Vector-Borne Disease Control in Peacekeeping and Combat Operations MAJ Elizabeth Wanja Armed Forces Research Institute of Medical Sciences (AFRIMS) Asia Pacific Military Health Exchange Da Nang, Vietnam September 2015

Disclaimer The views expressed in this presentation are those of the author and do not represent the official policy or position of AFRIMS, the US Department of the Army, Department of Defense, or US Government. This work was funded by the United States Africa Command (US-AFRICOM) and Armed Forces Health Surveillance Center, Global Emerging Infections Surveillance and Response System (AFHSC-GEIS)

“ This will be a long war, if for every Division I have facing the enemy, I must count on a second Division in the hospital with malaria, and a third Division convalescing from this debilitating disease” General Douglas MacArthur (1943) Introduction

Wartime epidemics severely reduce fighting strength Until WW1, infectious diseases rather than battle and non-battle injuries were main causes of morbidity and mortality Advances in military hygiene and disease-control measures has resulted in disease decline Unfortunately, these diseases remain of central importance in developing countries in terms of morbidity and mortality Introduction Cont…

Vector-borne diseases especially malaria and dengue fever remain top threats during contingency and combat deployments Most preventable with a combination of The right prophylaxis Proper use of personal protective measures (PPM) Vector control Proper sanitation Introduction Cont…

Example between 2004 & 2006 Swedish troops deployed to Liberia - no malaria cases Reason-Soldiers used DEET-based repellent, mosquito nets, and took anti-malaria tablets In contrast in Liberia, U.S. Marines evacuated- with confirmed or presumed P. falciparum malaria Reason: Failure to use PPE and inadequate adherence with chemo-prophylaxis Introduction Cont…

Major Issues For peace-keeping operations, issues include 1. PPE Availability- Limited Bed Nets DEET/ Topical repellents Treated Uniforms 2. PPE Acceptability Permethrin-treated uniforms / DEET-cause skin diseases to include cancer Malaria prophylaxis drugs cause psychiatric problems 3. Lack of education/ information on*** Proper application of PPE Importance of sanitation for vector disease control

Major Issues cont…

1.Ectoparasites: Diseases *Fleas– Plague, murine typhus *Ticks: encephalitis, Erlichiosis *Mites- Scrub typhus 2. Leptospirosis 3. Lassa fever virus Major Issues cont… 1.Diarrheal diseases 2. Myiasis * Trypanosomiasis * Onchocerciasis (river blindness) Protozoa: Malaria Viruses: Dengue, chikungunya, Rift Valley fever, Yellow fever Helminths: Filariasis Allergy Other protozoan parasite vector- borne disease 1. Visceral Leishmaniasis ( Somalia- 665 cases in 2013)

Africa and other developing nations bear the greatest burden of vector-borne diseases Required skills and capacity to control them remain adversely scarce Malaria -labeled the signature disease of concern by US Africa Command (AFRICOM) Surgeon Preventable through correct malaria diagnosis, vector surveillance, control, proper use of personal protective measures (PPM) Major Concern

AFRICOM established East/West African Malaria Task Force (E/WAMTF) To help partner nations create a unified front against vector-borne diseases Task force objectives Identify ways to encourage self-protection Promote improved surveillance, diagnosis and treatment Approach Training/capacity building Mitigation

Military personnel from E/WAMTF member countries attended Entomology training in Kisumu, Kenya Nepal engagement- GEIS funded AFRIMS Entomology Department conducted similar training August 2014 Aim was to develop participants’ ability To conduct surveillance, identify, prevent, control disease vectors Understand importance of sanitation in vector disease prevention Training

Outdoor collection Training cont… Indoor collection Vector identification

Understand importance of PPE & correct use of PPM Permethrin uniform treatment using Individual dynamic absorption application (IDAA) kits 0.5 Aerosol can 2- gallon sprayer Skin treatment using DEET Proper wear of uniform to prevent arthropod bites Protecting the ‘at Risk Soldier’ using PPM Training cont…

Training Cont… IDAA Kits 2-gallon sprayer

Skin treatment using DEET Training cont… DEET applied DEET not applied

After Training -Success Story After training in Iraq,  Increased acceptance and uptake of PPM application Uniform treatment Topical repellent use Proper wear of clothing Bed nets (where possible)  Vector habitat recognition, destruction & avoidance Vector surveillance Vector Control Exclusion 75% reduction in fly population More than 50% reported insect bites

References US Army Med Dep J Apr-Jun:56-64.US Army Med Dep J. FM (FM ) Unit Field Sanitation Team US Army Public Health Command-Human Bot Fly Myiasis. Just the facts…. January 2010 US Army Public Health Command-Ocular Myiasis. Just the facts…. June 2004 Diseases from rodents | Rodents | CDC. Jul 29, 2010 Diseases from rodents | Rodents | CDC Well-tolerated chemoprophylaxis uniformly prevented Swedish soldiers from Plasmodium falciparum malaria in Liberia, Mil Med Dec;173(12): Mil Med.

References cont… An Outbreak of Plasmodium falciparum Malaria in U.S. Marines Deployed to Liberia. Am J Trop Med Hyg Aug 5; 83(2): 258–265. WHO- World Health Day 2014: Vector-borne diseases in Somalia. health-day-2014-vector-borne-diseases-in- somalia.html health-day-2014-vector-borne-diseases-in- somalia.html Office of Medical History- US army. history.amedd.army.mil/booksdocs/wwii/Malaria/chapter I.htm. Jun 1, 2009.