**4. Engage security forces to prevent disease spread and support elimination operations**

## **4.1. Security forces as a neglected population contributing to the malaria transmission reservoir and spread of drug-resistant parasites**

The GMS security forces are a neglected population group that are at greater risk of contracting malaria, [22, 63] and serving as a transmission reservoir [20, 66]. They are certainly spreading the disease in the region and are the most obvious direct conduit of the current parasites to Africa [10]. In Africa, peacekeeping forces, deployed from many malaria endemic countries, work together, which could cause rapid spread of the new drug-resistant parasites. PCR-based screening of UN peacekeeping troops from Cambodia was initiated in 2015 (PCR is the only method sensitive enough to detect asymptomatic parasite carriers). In 2017, it was learnt that this practice had been discontinued at some point, but with inputs from key leaders to WHO, this was fortunately re-initiated. This process must be monitored so that lapses in screening do not recur. It must also be extended to include other militaries in the region that soon will also be at risk of spreading these parasites.

We have evidence that the Cambodian army has high malaria infection rates, and not been receiving optimal malaria prevention or treatment, and are serving as the primary malaria transmission reservoir in an area of Northwestern Cambodia [67, 68]. In 2010, 5% of troops were reported positive for Pf by PCR during a malaria screening [68]. The study for which the screening was done provided direct evidence, although with small numbers, early warning that dihydroartemisinin-piperaquine was failing as treatment. The lead author urged the US Army to act to stop transmission in these troops, but to no avail. He then contacted BMGF in 2012 to provide funding to stop transmission in these troops; funding was awarded, but not used until 2016, by which time the number positive for Pf had doubled to 10% [20]. It is unclear why the US Army does not act much more quickly given the threat to US troops.

In the 2016 intervention study, Pf transmission was stopped, providing direct evidence that the Cambodian army was the primary Pf transmission reservoir in the area of the study [20]. We believe there is sufficient evidence to scale the interventions that were proven to be effective (e.g., permethrin-treated uniforms, see **Table 2**). The impressive results from the study, however, have unfortunately not yet been acted upon.

the "National Strategy for Malaria Control and Elimination 2011-2020 and Vision for 2030" [65]. This critical window includes the following factors: (1) efficacious antimalarial combinations still exist but are failing fast; (2) potent tools for vector control are available but could be undermined quickly by the development of insecticide resistance; and (3) financial support from external funding partners continues to flow but is likely time bound. The Government of Vietnam will also need to take bold steps and intensify national malaria elimination efforts to ensure that malaria is eliminated from Vietnam for good before this window of opportunity

In summary, with a new leadership team, given a passion for the mission, along with authority, expertise and sufficient/effective funding, we believe WHO's Pf elimination goals can be achieved near the set target date of 2020. Vietnam is an example of a success story, which can serve as a model for other country programs. However, Vietnam cannot eliminate malaria until neighboring countries also do so. We urge BMGF, Asian Development Bank (ADB), PMI, the US military and other philanthropists to take action to address the challenges presented

The GMS security forces are a neglected population group that are at greater risk of contracting malaria, [22, 63] and serving as a transmission reservoir [20, 66]. They are certainly spreading the disease in the region and are the most obvious direct conduit of the current parasites to Africa [10]. In Africa, peacekeeping forces, deployed from many malaria endemic countries, work together, which could cause rapid spread of the new drug-resistant parasites. PCR-based screening of UN peacekeeping troops from Cambodia was initiated in 2015 (PCR is the only method sensitive enough to detect asymptomatic parasite carriers). In 2017, it was learnt that this practice had been discontinued at some point, but with inputs from key leaders to WHO, this was fortunately re-initiated. This process must be monitored so that lapses in screening do not recur. It must also be extended to include other militaries in the region that

We have evidence that the Cambodian army has high malaria infection rates, and not been receiving optimal malaria prevention or treatment, and are serving as the primary malaria transmission reservoir in an area of Northwestern Cambodia [67, 68]. In 2010, 5% of troops were reported positive for Pf by PCR during a malaria screening [68]. The study for which the screening was done provided direct evidence, although with small numbers, early warning that dihydroartemisinin-piperaquine was failing as treatment. The lead author urged the US Army to act to stop transmission in these troops, but to no avail. He then contacted BMGF in 2012 to provide funding to stop transmission in these troops; funding was awarded, but not used until 2016, by which time the number positive for Pf had doubled to 10% [20]. It is unclear why the US Army does not act much more quickly given the threat to US troops.

**4. Engage security forces to prevent disease spread and support** 

**4.1. Security forces as a neglected population contributing to the malaria** 

**transmission reservoir and spread of drug-resistant parasites**

soon will also be at risk of spreading these parasites.

here in order to drive malaria elimination in the region.

**elimination operations**

52 Towards Malaria Elimination - A Leap Forward

closes.

Additional evidence of security forces being a transmission reservoir comes from the area where the most resistant parasites cross-border into Vietnam. Forest rangers in the Bu Gia Map National Park screened positive for Pf malaria at about ~11% for Pf (very similar to the Cambodian army in Northwestern Cambodia, see above) [66]. This population is probably a significant malaria transmission reservoir in this area. From the publication, the rangers appear neither to be receiving effective prevention measures nor routine screening and treatment. No funding in the GF 2018–2020 budget was allocated for such activities in this population. The only way it will be possible is to request unused GF year-end funding be reallocated, which is not an easy process (CO, personal communication). Furthermore, since permethrintreated uniforms are not yet WHO-prequalified (despite standard of care in Western militaries and recent impressive evidence in the Cambodian army), GF funding may not be able to be used for this intervention (CO, personal communications).

Permethrin is very inexpensive, well-tolerated, and widely used for uniform treatment by Western militaries for malaria prevention [69]. The evidence for efficacy of treated uniforms/ clothing is summarized in **Table 2**. Based on available evidence, and in light of emerging incurable parasites and pyrethroid sensitivity of the main transmitting mosquitoes (M. Macdonald, personal communication), we believe treated uniforms should be rapidly scaled up for all security forces in the GMS as one component of an integrated vector control package.

In Cambodia, there are three types of government security personnel working in the forest army, forest rangers, and border police; each falling under different ministries. We are aware of a pilot project in Northwestern Cambodia where an ADB-funded project is working with all of these groups for malaria prevention and treatment (CO, personal communications). We believe this initiative should be taken to scale as quickly as possible in the region.

#### **4.2. GMS security forces can provide direct support if given a mission and properly resourced**

The Vietnam People's Army, including the Vietnam Border Defense Force, provides an excellent model for security personnel supporting health interventions. From 2005 to 2015, the Combined Military Medical Program contributed to improve health, hunger elimination and poverty reduction [75]. Example accomplishments for health include: (1) vaccination of 5.1 million children with Ministry of Health-recommended vaccines, (2) family planning for more than 3.7 million people, (3) malaria prevention education for more than 1.8 million people, and (4) IRS of nearly 26 million square meters of housing with National Malaria Control Program with provided pyrethroids.

More than 1300 health stations were strengthened with military staffing, including 1044 health stations in remote and isolated areas (>10% of all nationwide; in locations where it is hard to recruit civilian staff). The system includes 152 border clinics, which also serves as a border surveillance system for early detection of epidemics.


**First author** 

**Level of** 

**Study** 

**Study Designb**

**(n)**

**Intervention groups** 

**Control group (n)**

**% Failure** 

**%** 

**Protective** 

**Reference/**

**interventionc**

**Failure** 

**efficacy (95%** 

**notese**

**control**

**CI)d**

**evidencea**

**population**

**and study** 

**location**

Eamsila (1994),

6

Military

Unclear,

Permethrin-treated

Placebo-treated

27%

29%

4%

[73] 5

(−23–26%)

uniforms (n = 414)

probably CR

uniforms (n = 249)

Thailand

Most (2016),

7

Military

Unclear

Long-lasting polymercoated permethrinimpregnated uniforms

Untreated uniforms

0%

9%

100%

[74]

(NA)

(n = 125)

"conditions

identical"

(n = 25)

French Guiana

a1 is strongest, 7 least strong.

cNYA: Not yet available.

dNA: Not available.

events reported, (4) <

 20 uniforms had more malaria than placebo in one area).

**Table 2.**

Review of protective efficacy of permethrin treated clothing for malaria prevention.

Preparing for the Next Global Threat: A Call for Targeted, Immediate Decisive Action…

http://dx.doi.org/10.5772/intechopen.78261

55

eReference in [], notes by number: (1) Trial planned to execute in 2018, (2) True efficacy higher as estimate is confounded with *Plasmodium vivax* (Pv) relapses; efficacy only

for Pv as Pf transmission was interrupted by interventions; final clinical study report pending. (3) Instructed to wear their uniforms day and night; under garments also

treated, two adverse events in the permethrin arm requiring topical treatment but able to continue in study, no treatment needed in placebo arm; only trial with adverse

years had ~64% Pf protective efficacy, pooled efficacy underestimated because of Pv relapses, headscarf's were worn by women outside during

waking hours and used by the family as bed sheets at night, noted efficacy almost as good a treated bed nets in a prior trial in the same population. (5) Pv cases despite CQ

prophylaxis indicated non-adherence; noted incomplete ability to monitoring uniform use, possible randomization leading to unequal exposure (e.g. permethrin-treated

bCR: Cluster randomized trial, RDBCT: randomized, double blind clinical trial.


**First author** 

**Level of** 

**Study** 

**Study Designb**

**(n)**

**Intervention groups** 

**Control group (n)**

**% Failure** 

**%** 

**Protective** 

**Reference/**

**interventionc**

**Failure** 

**efficacy (95%** 

**notese**

**control**

**CI)d**

**evidencea**

**population**

**and study** 

**location**

Moore (2019),

1

Public

CR

Permethrin-treated

Untreated uniforms

NYA

NYA

NYA

1

(n~500), DEET

placebo (N~250)

Untreated uniforms

10%

24%

56%

[20] 2

54 Towards Malaria Elimination - A Leap Forward

(21–76%)

uniforms (n~500),

DEET (N~250)

Service

Corps

Tanzania

Wojnarski

2

Military

CR

Permethrin-treated

uniforms (n = 125)

(n = 143)

(2016),

Cambodia

Additional arm

'"

""

""

Permethrin-treated

Untreated uniforms

15%

24%

35%

[20] 2

(−7–61%)

uniforms + partially

(n = 143)

effective prophylaxis

(n = 130)

in Wojnarski

(2016)

Soto (1995),

3

Military

RDBCT

Permethrin-treated

Water-treatment of

3%

14%

75%

[70] 3

(15–93%)

the same (n = 86)

uniforms, socks and hat

(n = 86)

Columbia

Rowland

4

Afghan

RCT (to

Permethrinimpregnated

Placebo EC

25%

38%

36%

[71] 4

(21–48%)

formulation

headscarves/top sheets

(n = 387, 51

families)

(n =

438, 51 families)

household)

refugees

(1999),

Pakistan

Kimani (2006),

5

Somali

CR

Permethrin-

Plain waterimpregnated

38%

66%

43%

[72]

(22–58%)

impregnated clothing

& sheets (n = 90)

clothing & sheets

(n = 91)

refugees

Kenya

dNA: Not available.

eReference in [], notes by number: (1) Trial planned to execute in 2018, (2) True efficacy higher as estimate is confounded with *Plasmodium vivax* (Pv) relapses; efficacy only for Pv as Pf transmission was interrupted by interventions; final clinical study report pending. (3) Instructed to wear their uniforms day and night; under garments also treated, two adverse events in the permethrin arm requiring topical treatment but able to continue in study, no treatment needed in placebo arm; only trial with adverse events reported, (4) < 20 years had ~64% Pf protective efficacy, pooled efficacy underestimated because of Pv relapses, headscarf's were worn by women outside during waking hours and used by the family as bed sheets at night, noted efficacy almost as good a treated bed nets in a prior trial in the same population. (5) Pv cases despite CQ prophylaxis indicated non-adherence; noted incomplete ability to monitoring uniform use, possible randomization leading to unequal exposure (e.g. permethrin-treated uniforms had more malaria than placebo in one area).

**Table 2.** Review of protective efficacy of permethrin treated clothing for malaria prevention. In conclusion, we urge donors and NMCEPs to help supporting security forces take action. This should include first to make sure security forces are using appropriate prevention and treatment packages. GMS security forces absolutely can directly support elimination operations. They best understand the mobile and migrant populations (MMPs) and terrain of the remaining forest in the region, understand military planning and have a structured workforce in many of the challenging areas. We call on donors to provide the leadership and funding by making sure that security forces are not a transmission reservoir and are engaged in the fight against malaria.
