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North Africa, Italy, and the Islands of the Mediterranean
Justin M. Andrews, Sc. D.
Malaria reached its highest level in the North African theater in 1943. According to data obtained from tabulations of individual medical records, there were (excluding readmitted cases) 731 cases of malaria in 1942; 32,811 in 1943; 23,985 in 1944; and 5,765 in 1945. The total malaria attack rates (excluding readmitted cases) per annum per 1,000 average strength were 31.89 in 1942; 71.84 in 1943; 36.92 in 1944; and 16.29 in 1945. It is believed that the high rate in 1943 was due to poor malaria discipline, imperfect Atabrine (quinacrine hydrochloride) supply, and inadequate malaria organization By 1945, when these defects had been corrected, the rates had lessened considerably. 1
The most important vector of malaria was Anopheles labranchiae labranchiae. Principal gametocyte reservoirs were rural Arab populations and Italian prisoners of war in North Africa, civilian refugees, Italian prisoners of war, impressed Yugoslav laborers, and Italian cobelligerent troops in the remainder of the theater.
The special antimalaria organization as it finally developed was strongly centralized. The Malariologist, North African theater, commanded a detachment of malariologist officers. These were attached to major commands in which they gave technical direction to malaria survey and control detachments. An airplane dusting and spraying-flight detachment was responsible operationally to the theater malariologist.
In Africa and Sicily, main reliance was placed on the physical improvement of streams, oil larviciding, and spray killing with pyrethrum. In Sardinia, Corsica, and Italy, these measures were supplemented and finally overshadowed by the aerial application of paris green and DDT as larvicides and of DDT as a residual building spray. Insect-proofing of buildings was practiced as screening supplies permitted. Personal protective measures were directed throughout the theater and their use stimulated by special training and subsequent reminders. In 1943, all troops were ordered to take Atabrine in suppressive doses. That policy was liberalized in 1944 by exempting troops
1 Except as otherwise indicated, the data presented in this chapter are based on the following three sources: (1) Annual Report, Medical Section, North African Theater of Operations, U.S. Army, 1943. (2) Annual Report, Surgeon, Mediterranean Theater of Operations, U.S. Army, 1944, vols. 1 and 2. (3) Final Report of the Preventive Medicine Officer, Mediterranean Theater of Operations, U.S. Army, 1945.
in areas where the malaria hazard was negligible. During 1945, suppressive Atabrine therapy was directed only for troops in areas where malaria was an uncontrolled danger.
On 14 August 1942, Lt. Gen. (later General of the Army) Dwight D. Eisenhower was directed by the Combined Chiefs of Staff of the Allied Nations to accomplish the control of North Africa from the Atlantic to the Red Sea and thus to secure positions from which direct attacks could be launched against the southern flank of the European Fortress.
Allied Force Headquarters
The tactical planning for the initial operation was begun in London by British and U.S. staff strategists, the latter detailed from the Planning Section, Headquarters, ETOUSA (European Theater of Operations, U.S. Army). On 12 September 1942, this group was officially designated AFHQ (Allied Force Headquarters) and was expanded suitably to function thereafter as a general headquarters. It consisted of general and special staff sections, each of which included British and U.S. personnel and was intended primarily for policy making, planning, and coordination.
North African Theater of Operations, U.S. Army
The British, however, developed their component of AFHQ as an operating as well as a coordinating agency and, with the prompt capitulation of the North African countries and the establishment and expansion of base section organizations, it became apparent that Americans also would have to provide for the centralized administrative and operational supervision of troops. For that purpose, another headquarters known as NATOUSA (North African Theater of Operations, U.S. Army) (map 11) was activated on 4 February 1943. Both AFHQ (American Section) and NATOUSA headquarters operated with the same personnel, though the latter organization required many additional members. They were located initially at Algiers, but during the summer of 1944 they moved to Caserta, Italy.
Services of Supply and Communications Zone, NATOUSA
On 15 February 1943, all supply operations were delegated by NATOUSA to a service of supply echelon with headquarters in Oran. A year later, 24 February 1944, the functions of SOS (Services of Supply), NATOUSA, were expanded to include those of a communications zone organization, and NATOUSA became, from the standpoint of Medical Department function, a planning and consultative agency. Services of Supply, NATOUSA, moved to Caserta during the summer of 1944 and was redesignated COMZONE (Communications Zone), on 1 October 1944.
Mediterranean Theater of Operations, U.S. Army
Concurrent with the absorption of southern France into ETOUSA on 1 November 1944, the designation of the North African theater was changed to MTOUSA (Mediterranean Theater of Operations, U.S. Army). COMZONE, MTOUSA, was inactivated 20 November 1944, and MTOUSA thereafter assumed responsibility for all operational as well as planning functions.
The invasion and occupation of Morocco and Algeria, both malarious countries, involved American and British forces. Operations began on 8 November 1942; 3 days later they had been terminated successfully.
The campaign to the east started at once and again American and British troops participated. The struggle for Tunisia was fought over intensely malarious terrain and was not concluded until 12 May 1943.
Sicily, second only to Sardinia in malaria. morbidity according to Italian malariologists, was secured by the Seventh U.S. Army and the British Eighth Army. It was a short but bitter contest lasting 38 days, from 10 July to 17 August 1943.
Canadian and British forces started pouring across the Strait of Messina into Italy on 3 September, and, on 9 September, the Fifth U.S. Army landed on the Salerno-Paestum beaches. This was the first of a series of operations destined to lead U.S. soldiers through many highly malarious sections of Italy.
On 8 September, Italy surrendered to the Allied Forces and, within the following month, Sardinia, always the blackest spot on the Italian malaria maps,2 was liberated by Italian divisions. Corsica was taken at about the same time by Free French troops assisted by American Rangers. Both of these islands were developed intensively as bases from which Army Air Force and Royal Air Force airpower was beamed into Nazi-held northern Italy and southern France.
Fifth U.S. Army troops drove steadily northward up the west coast of Italy. Naples was occupied 1 October and the Volturno River was crossed during the month. The northern advance slowed down with the coming of winter. A firm but tight beachhead was established at Anzio-Nettuno on 22 January 1944. German defenses forced a stalemate until 11 May when a combined offensive launched by the Fifth U.S. Army and the British Eighth Army broke the deadlock.
The Fifth U.S. Army pushed on through the flooded plains of Fondi and Pontinia, historically famed for their malaria hyperendemicity, and, on 25 May, made contact with VI Corps troops from the northern beachhead. On 4 June, Rome was occupied. During the ensuing month, U.S. and British forces continued to drive the enemy northward to a point beyond Leghorn. By the end of the year, the two armies had engaged some 28 German divisions
2 War Department Technical Bulletin (TB MED) 178, July 1945.
in defense of a line extending across the Italian peninsula, roughly from La Spezia to Ravenna.
On 15 August, the Seventh U.S. Army, composed of U.S. divisions and attached French troops, invaded southern France successfully. The area occupied and exploited by U.S. troops was nonmalarious.
Allied Forces in Italy massed below the Gothic Line until the spring of 1945. On 14 April, their final offensive was launched which took them across the malarious Po River flood plains and into the industrialized areas of northern Italy. On 2 May, this operation was concluded. Contact was made with partisan troops from Yugoslavia, and on 7 May Nazi Germany surrendered unconditionally.
Numerous base sections, area commands, or equivalent organizations were developed for the support of the armies. They were occupied for varying periods of time. The more important ones were located at Casablanca, Morocco; Oran, Algiers, and Constantine, Algeria; Bizerte, Tunisia; Palermo, Sicily; Naples, Leghorn, and Bari, Italy; Cagliari, Sardinia; Ajaccio, Corsica; and Marseille, France (map 12).
Air Force Installations
Medium bomber facilities were developed mainly on the satellite airfields around Foggia. Light bombers also operated from that side of Italy and from the southwestern coast and from Sardinia and Corsica. Fighter fields were more transient and widespread. They were established throughout the occupied sections of the theater, moving forward as fast as security precautions permitted, though a few units were left in the rear areas to carry on shore patrol, air-sea rescue, and counteraerial combat duties.
The limits of NATOUSA were defined to include the Iberian Peninsula, southern France, Italy, Switzerland, Austria, the Balkans, Turkey, the areas of French, Spanish, and Portuguese influence in West and North Africa, and the intervening islands of the Mediterranean (map 11). The actual military operations occurred mainly in the coastal areas of Morocco, Algeria, Tunisia, Sicily, Sardinia, Corsica, Italy, and southern France. All points in the theater were within 900 air miles of Algeria. The entire area lies 30 degrees or more north of the Equator and is, therefore, within the Temperate Zone and has definite winter and summer seasons.
Temperatures suitable for the transmission of vivax malaria (daily average of 60o F., or higher) occur from late April to November in North Africa, Sicily, and Sardinia.
In Italy and Corsica, the season is shorter, commencing in May or June and ending in October. The presence of semihibernating anophelines in occupied houses and animal shelters throughout the winter months suggests the possibility that infections may be transmitted as late as December or early January.
Temperatures high enough for the development of falciparum malaria (daily averages of 70o F., or higher) ordinarily start in June in Morocco and Algeria and in May or June in Tunisia, Sicily, and probably Sardinia. This period terminates in September in Morocco, Algeria, and Sicily but not until October in Tunisia. In Italy, north of Rome, average daily temperatures of this magnitude are not frequent enough to permit the development of falciparum parasites in mosquitoes, and falciparum malaria in man is correspondingly rare.
Average yearly rainfalls vary from 15 to 30 inches throughout coastal North Africa, Sicily, and Sardinia. In Italy and Corsica, they may be slightly higher. The midsummer months--June, July, and August--are dry or nearly so, particularly in North Africa. Most of the rain falls from October through March.
The clay soil on the hillsides of North Africa is notable for its lack of ability to absorb water. Vegetation is scarce., evidence of erosion abundant. Water runoff is, therefore, sudden and of great volume. Rivers and streams are swollen, torrential, and fast moving in the spring. By July, they are mere trickles connecting occasional shallow pools or are dried up entirely. In Sicily, Sardinia, Corsica, and Italy, there is a larger proportion of perennially flowing streams, as the water-holding capacity of the earth is somewhat greater. Many of the mountains are higher, their slopes support more prolific plantlife, and snow remains on them for longer intervals. Seepage and runoff into ravines and streams continue over more extended periods of time than in North Africa.
Native Reservoirs of Infection
Ordinarily, some 90 percent of the inhabitants of the North African countries are Arabs. With the declaration of war, however, Europeans flocked to Africa to evade the ravages of the conflict. In some instances, the populations of the larger cities doubled in size. The normal European component is predominantly French, but Italians and Spaniards have come into North Africa in such numbers that Italian or Spanish is heard in certain places as
frequently as French. These immigrants and refugees contributed little, however, to the malaria potentialities of the region.
The indigenous Arabs of the coastal areas are predominantly plain dwellers, living in close association with agricultural pursuits. Thus, malarious natives--the reservoir of infection for mosquitoes--were most abundant in rural sections along the coast and on the fertile river flood plains extending between the ranges of the Atlas Mountains. Basic dissimilarities in languages, religion, personal hygiene, and other customs impose strong barriers against intermingling with foreigners. Even among themselves, the Arabs are very clannish and, except in cities, had little tendency to associate closely with U.S. troops.3 This tribal isolation protected U.S. troops against transmission of vermin and diseases ordinarily acquired by direct contact but had no effect in preventing malaria, as it was virtually impossible to avoid siting camps and bivouac areas within mosquito flight range of Arab villages.
While there was some evidence of Arabic participation in the racial stock of Sardinia, Sicily, and, to a less extent, southeast Italy, its influence was never sufficient to hinder fraternization with Allied personnel. The two islands were as much a part of the Fascist State as the peninsula itself and, like it, were peopled predominantly by its nationals. In spite of their previous political affiliations, the Italians as a group and as individuals manifested strong amity for the Americans and appeared to enjoy their company.
The bombing and shelling of cities had resulted in widespread destruction of homes and dislocation of the Italian population. The terrified inhabitants moved into underground shelters or out into the country where they lived in caves, bans, public buildings, under bridges, or wherever they could find protection from the weather and bombardment. Many of them had left their homes precipitately and were, therefore, destitute, hungry, and lacking in sufficient clothing. They had no medical service and were as accessible to mosquitoes as the beasts of the field. In time, they constituted a huge reservoir of gametocyte carriers. In their desperate efforts to obtain the necessities of life, they tended to come into close association with Allied troops and thus facilitated the transmission of malaria. In addition to refugees, the areas were jammed with thousands of demobilized Italian soldiers. Many of these had seen service in the Balkans, North Africa, Ethiopia, Italian East Africa, and Sardinia, where they had experienced malaria from which they relapsed repeatedly. A large proportion of these ex-soldiers and of other young male civilians were formed into Italian labor units which lived and worked in close proximity to U.S. and British bivouac areas. They required extensive and continued treatment for malaria and must have contributed largely to local mosquito infection (map 13).
3 Personal observations of the author who supervised malaria control activities on a theaterwide basis in North Africa, Sicily, Italy, Sardinia, and Corsica, from May 1943 to January 1945.
In Sardinia, the potentialities of the highly infected civilian population were enhanced by the presence of some 200,000 Italian troops and Yugoslav laborers impressed by the Axis. They had been there for two malaria seasons. Their military organization had disintegrated completely, and they were scattered all over the island, living from hand to mouth as best as they could.
They suffered severely from malaria, and numerous deaths were ascribed to this disease. Many were employed as guards and laborers by U.S. military organizations and thus increased the likelihood of local anopheline infection.4
The Corsicans are of French and Italian ancestry. They are extremely independent people and did not associate with U.S. and British soldiers as extensively as did the natives of Italy, Sicily, and Sardinia. Historically, the island is reputed to be highly malarious5 (map 13). It is the custom of coastal plain farmers to move their families from the lowlands up into the hillside and mountain villages to escape the heat and fever of the summer months. This suggests that a considerable number of gametocyte carriers exist normally among the native Corsicans. To this must be added the infection potentialities of the 5,000 Yugoslav laborers imported from Sardinia. Most of them arrived at the height of the relapse season, and many were taken directly from the ship to the hospital with malaria attacks. They were ordinarily quartered in small camps adjacent to Allied establishments.
Because of the paucity of malaria survey detachments in NATOUSA and the necessity of using them as malaria control units, no widespread systematic effort was made to determine spleen and parasite rates in native populations adjacent to U.S. troop installations. Occasional spot surveys supported the ever-present clinical evidence of malaria morbidity with which gametocytes and consequent local mosquito infection must have been associated.
The most important vector of malaria in the North African and Mediterranean theaters was Anopheles labranchiae labranchiae Falleroni 1926 (fig. 29). In North Africa and Sicily, the map of its distribution was virtually that of the river systems in the plains. It was found generally in permanent sunlit, vegetated, clear waters. Pools, backwaters, along the indented edges of streams and rivers, collecting basins, poorly maintained irrigation ditches, canals, seepages (especially from leaky irrigation systems over grassy areas), wells and cisterns, foxholes, founts, and freshwater lagoons with peripheral marshes, all supported larval growth of this species. During the early part of the season, this species was found predominantly in the flooded areas adjacent to permanent bodies of water. As these flooded areas contracted during the summer, the larvae were found mainly in pools, edges of rivers, streams, and seepages. As the process of natural drying went still further, A. 1. labranchiae invaded the neglected irrigation systems and wells. It is a versatile, adaptable species tenaciously maintaining itself in fresh and brackish water, being limited principally by low temperatures, shade, pollution, turbidity, high salt content, and brisk flow.
of the general practice of maintaining many of these infected individuals
close to U. S. troops, one harried malariologist referred to them as "our
mobile pool of gametocyte carriers."
FIGURE 29.- Adult female of Anopheles maculipennis Meigen. This mosquito is identical in appearance with Anopheles labranchiae labranchiae Falleroni, principal vector of malaria in the north African and Mediterranean areas. (From J. Hyg., Lond. 1: 451, 1901.)
In Italy and Sardinia, the larvae grew abundantly not only in rivers and streams but also in water held by unmaintained canals, ditches, tank traps, slit trenches, foxholes, shell and bomb craters, subterranean shelters, gun emplacements, and the extensive flooded areas purposely inundated by the Germans (figs. 30 and 31). This type of destruction resulted in flooding enormous areas of farmland, as shown in figure 31. Many of these areas became mosquito producing. The natural drainageways in Italy, Sardinia, and Corsica were obstructed by the residues of demolished bridges and hastily built bypasses and fords. These interferences with natural flow created many additional breeding places for A. 1. labranchiae. On the northeast coastal plain of Corsica, several large lakes with marginal swamps added to the breeding acreage.
The adults of this species bite both man and domestic animals and rest in houses and animal shelters. During the winter, they could be found in small numbers in houses in Morocco. In Italy and Sardinia, they were encountered frequently in houses (especially unoccupied upper rooms) and in concrete pillboxes and strongpoints. They were difficult to find in the winter months in Algeria and Tunisia. In the summer, they were excessively numerous in occupied houses, stables, pigsties, and poultry shelters, especially in untreated areas of Italy, Sardinia, and Morocco. On certain occasions, their densities were so great that estimates of their numbers would be as high as 1,000 or more per square yard of wall surface.
The only other anopheline species presumed to be of vectoral importance were Anopheles sacharovi (elutus) Favre 1903, and Anopheles superpictus
Grassi 1899. A. sacharovi is a coastal form which tolerates somewhat higher salt concentrations than does A. l. labranchiae. It was found in the vicinity of Naples and on Corsica but never in any abundance. A. superpictus, a species which breeds in highly aerated running streams in the mountains and foothills, was of negligible importance from a numerical standpoint.
The total monthly diagnosed malaria rates (provisional) per 1,000 per annum for the theater from 1942 through 1945 are shown in table 30. This portrays well defined but distinctly different trends in a series of three exceptionally interesting annual malaria experiences.
Experience in 1942
Malaria acquired during the last 2 months of the year was minimal, and most of this came from coastal Morocco north of Casablanca.
Experience in 1943
The situation in 1943 was one of a susceptible and inadequately prepared military population exposed to hyperendemic malaria. A suppressive treatment schedule of 0.2 gm. of Atabrine, on 2 nonconsecutive days per week, was
ordered on a theaterwide basis effective
as of 22 April.6 This order was not enforced for the following
Base sections in Morocco and Algeria achieved some measure of environmental protection against the disease, but combat troops were sorely beset by malaria.
By the time the Sicilian campaign started, hospital admissions for malaria in Tunisia were on the increase. For this reason, many troops scheduled to participate in the campaign failed to embark. Others reached Sicily, but some 700 to 800 of them came down with the disease within incubation periods too short to have been due to infection contracted on the island. During the Sicilian campaign, 9 July to 10 September 1943, hospital admissions for malaria (21,482) exceeded battle casualties (17,375). 8 The new cases could be attributed largely to the failure to call for more than one of the three malaria
No. 38, Headquarters, NATOUSA, 20 Mar. 1943.
survey and control units which had been earmarked and readied for the invasion. This one unit arrived on D+4, but the troops advanced so rapidly that no antimalaria operations could be organized en route. Even after they were established in Palermo, there was more work than one unit could handle effectively. As a result, the troops were denied adequate environmental protection against anophelines.
Poor malaria discipline in both North Africa and Sicily also accounted for much of the morbidity. The remainder was caused primarily by failures in Atabrine supply. These occurred on board ship (lack of coordination between Army and Navy), at rations' breakdown points (where Atabrine was to be issued with the rations), and among forward combat elements for tactical reasons. This last is always inevitable to some degree. Thus, the malaria debacle in Sicily was the result of inefficient malaria control supply, poor malaria discipline, and a quantitatively inadequate special antimalaria organization. The malariousness of Sicily was well known and control and survey units had been prepared to accompany the invading forces but the Seventh U.S. Army Command would not permit these units to proceed to Sicily in time to render effective aid during the invasion.
The malaria rate reached a maximum in August 1943 of 192 cases per 1,000 per annum which represented about 8,500 cases; this coincided more or less with the end of the Sicilian campaign on 17 August. This overall theater rate fails to reflect faithfully the extent of the malaria morbidity experienced by elements of the Seventh U.S. Army during the campaign. As shown in table 31, weekly rates of diagnosed malaria among II Corps troops are reported to have risen to over 1,700 per 1,000 per year. Corresponding rates of "fever
TABLE 31 .- Admission rates, by weeks, hospital and quarters, for malaria and FU0 (fever of undetermined origin) in the Seventh U.S. Army, by major command, during the Sicilian campaign, 16 July-20 August 1943 1
of undetermined origin," a collective diagnostic term which included indeterminate proportions of malaria, sandfly fever, and other unrecognized pyrogenic disorders, were as high as, or higher than, the malaria rates.
Because of the rapid increase in the number of cases, the Seventh U.S. Army adopted a suppressive treatment schedule of 0.1 gm. of Atabrine 7 days a week starting on 14 August 1943.9 This increased dosage was well administered and tolerated. It was continued for about 3 weeks and probably accounted for the drop in the rate in September to 130 per 1,000 per annum. The relatively high rate in October was the result of the Salerno landings made by the Fifth U.S. Army on 9 September; discipline in taking suppressive Atabrine became lax in the heat of battle and at a time when mosquito transmission was still occurring.
With the coming of cold weather, the rates dropped off rapidly. As will be pointed out in the following paragraphs, many more infections not manifested in 1943 undoubtedly were contracted during the fall months of that year but were suppressed by Atabrine and remained dormant during the winter months. By the end of the year, 32,811 new cases were recorded, an annual rate of about 72 per 1,000. The number of recurrent cases is not known, but it is surmised that the new cases constituted 90 percent or more of the total malaria attacks. Since the primary cases reported during the winter and spring months of 1944 were practically all contracted during the previous season, the rate of transmission in 1943 must have been much higher than the hospital admission rates indicated. About 19 percent of the years infection were falciparum malaria, 48 percent were vivax malaria, 1 percent were quartan, less than 1 percent were the mixed type, and 32 percent were undetermined as to type.
Experience in 1944
Troops were well established on the Italian mainland by 1944. Suppressive Atabrine, 0.6 or 0.7 gm, per week, was ordered as of 1 May on a theaterwide basis except in areas which were nonmalarious or where malaria was considered by the area surgeons to be under control.10 The breakthrough at Anzio on 25 May permitted troops to push north through the flooded Pontine marshes. The advance continued across highly malarious coastal lowlands, passing through Civitavecchia, Tarquinia, Orbetello, Grosseto, and Piomubino. DDT was sprayed in forward areas, sometimes in advance of artillery units. With the advent of winter, troops were operating in the mountains north of Pisa and Florence and were out of malarious country. Throughout this period, additional U.S. forces (largely Air Corps) were occupying the insalubrious islands of Sardinia and Corsica.
Table 30 shows a sharp rise in spring cases with a rate of 80 per 1,000 per annum in April 1944. While many of these cases were relapses of infections
9 See footnote
7, p. 262.
contracted the previous year, a large proportion (approximately 40 percent) gave histories of no previous malaria. A few of these may have been contracted during the spring months, but the majority of these primary attacks undoubtedly represented late 1943 infections either suppressed by Atabrine or showing extraordinarily long incubation periods typical of certain strains of vivax malaria. The proof of this assertion rests on the observation that little or no spring malaria occurred in divisions entering the theater during the late winter of 1943-44. Indeed, their early cases were invariably in replacement or attached personnel from other divisions which had seen service in the 1943 campaigns. Thus, while 40,682 represents the total number of cases recorded for the year, a rate of about 62 per 1,000 per annum, most, if not all, of the 15,348 cases occurring before June are attributable to infections acquired during the 1943 season. In all probability, many of the relapses appearing after the beginning of June also should be referred back to 1943. Of the laboratory-diagnosed cases, about 5 percent were falciparum malaria, 92 percent were vivax malaria, less than 1 percent were quartan, and the balance was of undetermined types. Only in Sardinia was the species distribution substantially different: 21 percent falciparum malaria, 72 percent vivax malaria, and the remainder undetermined. The farther north the troops went in Italy, the fewer falciparum cases were reported; they were rare north of Rome.
Experience in 1945
The 1945 season saw a marked reduction in the size of the Mediterranean theater. North Africa was split off and placed under the command of the U.S. Army Forces in the Middle East. The islands of Sicily, Sardinia, and Corsica ceased to be of operational importance, and their military personnel were returned to the Italian mainland. For all intents and purposes, malaria control operations were restricted to Italy in the vicinity of Naples and Rome, around the Army Air Force areas in the Foggia region, in the Arno Valley from Leghorn to Florence, in the Ancona-Timini sector on the northeast coast, and in certain sections of the Po River Valley. While the danger from malaria exposure was considerably less than during the previous two seasons, the fact that troops were generally scattered throughout the malarious areas of Italy during 1945 constituted a situation of potential seriousness.
The Atabrine policy for this year called for suppressive medication only in areas designated as malarious.11 With the exception of one instance in the Po River Valley where the Fifth U.S. Army specified a few dangerous areas, suppressive treatment was limited to an occasional unit having an unduly high malaria rate or to individuals recovering from an attack.
The start of 1945 found Army troops ensconced in the Apennines north of Florence, preparing for the final offensive into the Po River Valley. After the highly satisfactory 1944 season, it was anticipated that the rise in cases
11 Circular No. 54, Headquarters., MTOUSA, 9 Apr. 1945
in the spring of 1945 would be less than in the preceding year. This prediction was fulfilled as the months passed. The peak appeared in May, when a rate of 31 per 1,000 per annum was recorded. Some apprehensiveness was felt concerning the possible effects of the Po River offensive, especially if it slowed down, on malaria prevalence in the troops. Fortunately, the campaign was a short one. The abrupt cessation of hostilities on 8 May 1945 permitted the Army to establish the bulk of its troops in the southern Alps, the remainder occupying isolated areas throughout the Po River Valley. Thus the rise in case number, which had been anticipated in June, failed to materialize. On the contrary, there was a steady drop in the incidence which was quite phenomenal in the light of existing conditions.
With the capitulation of the German armies in Europe, redeployment of U.S. troops to the United States and to the Pacific theaters was initiated promptly. However, while this movement was going on, approximately one-half the theater strength--Air Force and Service troops--was established in malarious areas. As the Army divisions were redeployed, they were required to occupy some of the more dangerous areas while staging. It is believed that the intensive work accomplished by the War Department malaria control units, in addition to the widespread use of DDT as a residual house spray, played a significant role in keeping malaria casualties to a minimum. During the 1945 malaria season, there was a total of 6,800 cases reported in the theater, a rate of 20.5 per 1,000 per annum. Again, as in 1944, the type of malaria was predominantly vivax as shown by the following species distribution for the year: 2 percent falciparum. malaria, 97 percent vivax malaria, quartan rare, and the remainder type unspecified.
Primary Malaria Rates
As reported previously, malaria control officers believe that the best appraisal of their efforts and fortune are the trends of new or primary malaria rates. Field malariologists gathered this information more or less independently in NATOUSA during 1943 and more systematically in MTOUSA during 1944 and 1945. On the basis of personal interviews with patients or from forms filled in by medical officers on the wards, they determined from each patient his unit assignment and history of previous malaria. On 1 July 1944, the Medical Section, COMZONE, NATOUSA, required its hospitals and separate dispensaries to use a supplemental communicable disease report in addition to the weekly statistical health report. The new form indicated whether or not patients were assigned to the command to which the hospital was responsible and whether or not the condition for which they were hospitalized (including malaria) was a primary or a subsequent episode. This relieved the base section malariologists of an onerous task and provided better and more extensive operational information for their use. The Medical Section continued to re-
quire this report from its base section hospitals and dispensaries after COMZONE had been inactivated.
Table 32 shows a comparison of primary and total malaria attack rates for the months where reasonably dependable data were available. It was admittedly not possible to ascertain the exact amounts of malaria transmitted each year; nevertheless, certain calculations based on reasonable assumptions indicate at least the relative degrees of transmission each year. According to the theater malariologists, the primary rate per 1,000 for 1943 was probably somewhere in the sixties; for 1944, somewhere in the thirties; and for 1945, it was probably less than ten.
Civilian Malaria Experience in Italy
The relatively favorable military malaria experience in Italy poses the question whether the low Army rates were due to effective control efforts or to nothing more than the good fortune of being present when the malaria potential was reduced abnormally. The answer to such an inquiry would be given by a determination of malaria prevalence in the civilian population at the time of Army occupation. Data concerning malaria morbidity and mortality in the years from 1939 to 1945 in Italy are meager and imperfect, but, such as they are, they tend to indicate a violent upsurge of epidemic malaria among civilians, particularly in the war-torn areas.
Before 1939, malaria was on the downgrade in Italy.12 At the turn of the century, annual case rates of about 1,000 and death rates of 40 to 50 per 100,000 prevailed. Their steady descent thereafter was interrupted by World War I but reached all time lows of 126 cases per 100,000 in 1939 and 1.1 deaths per 100,000 in 1940. This was due to the large-scale agricultural development of low, fertile coastal areas. Extensive land reclamation drainage (bonification) by gravity and pumping systems was practiced. This not only abolished large acreages of potential anopheline production but freshened the soil as a result of rainfall and drainage. Thus, it eliminated the dangerous carrier, A. sacharovi--a brackish-water breeder--from numerous sections where it had flourished previously. Furthermore, confining the water in these coastal lowlands to drainageways made it possible to apply paris green cheaply and effectively where this supplementary measure was indicated.
During the early years of the war, from 1939 to 1942, malaria increased as shown by the annual malaria morbidity rates per 100,000 reported as follows:
Actual rates were undoubtedly much higher as the imperfections of peacetime malaria case reporting are always enhanced during wars.
Official vital statistics for the country were not available after 1942; such figures as could be gathered were fragmentary and provisional. From them, it appears that the "heel" area of Italy showed little change in malariousness during the war years. This was the section of the country least disturbed by active warfare. On the other hand, the southwest coastal provinces and those in the northeast (Po River Valley) experienced reported increases of from 2 to 20 times their prewar malaria case burden. From Terracina, Fondi, Gaeta, Cassino, and neighboring rural settlements came reports of hyperendemic and fatal malaria. Similar accounts came from the provinces constituting the Veneto area through which the final offensive of the war was pushed. These are the areas where the hand of Mars was laid most heavily, where flooding, shelling, bombing, and digging in multiplied natural opportunities for anopheline production. Meteorologic influences also favored increased anophelism, but this effect was not productive of such high malaria morbidity rates in the Allied forces as occurred in the neighboring civilian population.
In summary, the evidence indicates that (1) in the face of epidemic malaria prevalence among the Italians in 1944 and 1945, the incidence of malaria in U.S. troops remained relatively low; and (2) the degree of success
12 Statistics and other information regarding malaria prevalence among Italians were supplied by the Istituto Superiore di Sanito, Roma.
achieved in military malaria control was accomplished in spite of and not because of natural forces.
ANTIMALARIA POLICY AND ORGANIZATION
As in all theaters, antimalaria policy and organization evolved slowly. Until the late spring months in 1943, the malaria control program was in the stage of planning, formulating, obtaining local malaria intelligence, liaison with civilian health agencies, and general development which necessarily precedes the physical organization phase.
A malaria advisory board was established by the Director of Medical Services, AFHQ, under the chairmanship of Brig. E. R. Boland, the consulting physician (British). 13 All nationalities locally concerned in the problem were represented in its membership which included Lt. Col. Perrin H. Long, MC, Consultant in Medicine, NATOUSA, and, later, the Preventive Medicine Officer and Malariologist, NATOUSA. This group inventoried and assessed malaria control facilities existing in the theater, set the policy for theaterwide suppressive medication, suggested that civilian health agencies be subsidized to provide environmental malaria control for Allied troops around camps and bivouac sites, considered the various malaria problems as they arose in the theater, and made recommendations regarding their solution.
During the early days, Colonel Long acted in the capacity of preventive medicine officer and concerned himself actively in laying the basis for the future antimalaria activities. He held conferences with British and French malaria control representatives and worked out an arrangement with civilian health agencies whereby they were to assume responsibility for the bulk of environmental malaria sanitation in extramilitary areas. Plans were made for a theaterwide suppressive Atabrine therapy program. Requests for special antimalaria personnel and supplies were placed with the War Department. Combat units commenced troop training in malaria control discipline. Exploratory survey operations were launched. Limited control activities--drainage and larviciding--were conducted in those areas where year-round anopheline production occurs. These were directed by Medical Corps or Sanitary Corps officers under the supervision of base section medical inspectors. By the end of May 1943, four survey and four control units had arrived from the United States and had been assigned to various base sections for duty. They immediately commenced malaria survey activities in and about Army installations and acted in advisory and inspectoral capacities with regard to antimalaria activities conducted by the various Army units within their own camps and those carried on by civil organizations insofar as they affected Army personnel.
See footnote 7, p. 262.
On 9 June 1943, a theater malariologist and an assistant theater malariologist were designated. The organization to which they belonged, a malaria control detachment recently arrived from Liberia, ultimately became the malaria control headquarters unit for the theater.
Policy Development and Expression
The pattern of administrative responsibility in malaria control as it finally developed was as follows: Malaria control policy and general administrative procedure in NATOUSA (MTOUSA) originated in the medical section of the theater headquarters, with the theater surgeon, the chief of preventive medicine, and the theater malariologist. These were expressed in circulars and administrative memorandums published from AFHQ and NATOUSA (MTOUSA) headquarters. They specified or clarified such considerations as (1) relative responsibilities of various commands in areas jointly occupied hr Al lied troops,14 (2) dates for the beginning and ending of malaria control operations,15 (3) personal preventive measures and suppressive medication, the basis for and method of issuing Atabrine and quinine for suppressive purposes to static and moving troops, (4) the designation of malarious and nonmalarious areas, the theater malaria control organization, (5) command responsibilities for malaria control, (6) allotment of malaria control supplies to individuals and units, (7) enlisted men antimalaria details, (8) malaria control instructions, (9) proper use of personal amid environmental preventive measures,16 the unrestricted use of DDT,17and (10) application for airplane dusting service. 18 These directives or pertinent parts of them were republished by subtheater commands.
Estimates of theater requirements for malaria control supplies were made and their distribution within the theater suggested in the Preventive Medicine Section of the Surgeon's Office. These were sent to the engineer and quartermaster sections of the theater headquarters, where unfailing cooperation in effecting the recommendations was always evidenced. During each month of the active malaria control season, supplies on hand, in transit, and due into various major depots were inventoried by the malariologist and were reported to the theater surgeon. By this means, a reasonably current picture of the status and the flow of supplies throughout the theater was maintained.
Memorandum No. 21, AFHQ, 17 May 1944, subject: Allocation of Responsibility
for Malaria Control Measures.
The theater malariologist administered the special malaria control organization.19 He was responsible to the Surgeon, NATOUSA, through the Chief, Preventive Medicine Section, Office of the Surgeon, NATOUSA, and maintained close operational liaison with Col. Paul F. Russell, MC, Chief, Malaria Control Branch, Allied Control Commission, and Brig. George MacDonald, RAMC, British Consultant, Malariologist, AFHQ. Special antimalaria unit situation-and-status reports were submitted to the theater surgeon each month by the malariologist. On his recommendation, malariologists and units were moved as needed from one theater subdivision to another. Efforts were made to distribute the antimalaria units' technical information pertaining to malaria and its control which arrived in the Medical Section, Headquarters, North African theater.
Special Organization for Malaria Control
The organization consisted of a provisional malaria control headquarters unit, War Department malaria survey and control detachments, and a section of a ferrying squadron used to operate dusting and spraying airplanes. In addition, each company, battery, or similar unit maintained enlisted-man malaria details as directed by War Department Circular No.223, dated 21 September 1943.
It is impossible to assign accurately the proper amount of credit due to the "enlisted-men" or unit antimalaria details for their malaria control achievements because no systematic accounting of their efforts is available. The details were trained and in many instances were supervised by the special malaria control organization. They were mentioned frequently in the local malariologists reports, but no routine recording of their activities--separate from malaria control accomplishments in general--was ever required or made. It is known, however, that while these were variable in quantity and quality, their aggregate effect must have been very considerable. This was true especially in Fifth U.S. Army areas and in Army Air Force installations.
It was interesting to note that, in the Air Force installations during 1944, these antimalaria details were made up exclusively of Medical Department personnel (except in antiaircraft artillery units) and they worked under the
19 On 9
June 1943, Col. Loren D. Moore, MC, commanding, and Lt. Col. Justin H. Andrews,
SnC, 2655th Malaria Control Detachment, were attached to the Medical Section,
Headquarters, NATOUSA, for duty as malariologist and assistant malariologist,
respectively. Shortly thereafter, Colonel Moore was incapacitated by rheumatoid
arthritis and ultimately returned to the Zone of Interior.
direct supervision of medical officers. 20 This practice was not in conformity with War Department Circular No. 223 which specifies that antimalaria details will be made up of Medical Department soldiers only in medical units. The circumstances which urged this departure from the directive were that: (1) Many Army Air Force units were composed entirely of special technicians with full-time duty responsibilities; (2) Army Air Force medical units were so generously manned that they could afford to supply the men without detrimental effect upon the fulfillment of their primary functions; and (3) the malaria survey and control units scheduled for the Army Air Force were delayed in arriving and it was essential for the Army Air Force malariologist to contrive some sort of working organization to take on the task of providing environmental malaria control. In spite of this contravention of Medical Department policy, the arrangement turned out to be an admirable one. Indeed, it is doubtful if as much work was accomplished, in proportion to total strength, by enlisted-men antimalaria details in other major or commands during 1944.
Headquarters unit . - This unit consisted of four officers and seven enlisted men. 21 In the early spring of 1944, it became a provisional NATOUSA organization with 13 officer and 20 enlisted-man position vacancies. Officer members were available for attachment to surgeons' offices in base section, Army, and Army Air Force headquarters for duty as malariologists. These malariologists had technical direction of the malaria survey and control units assigned or attached to their respective headquarters. As long as considerable numbers of U.S. troops were maintained in Africa, they coordinated the work of French health agencies doing malaria control in the neighborhood of military installations. Through the malariologists, malaria survey and control unit activities were reported in prescribed form to the surgeon of the organization to which the unit was attached or assigned. Each month, the weekly unit reports, together with accounts of malariologists' activities, were consolidated by the local malariologists and submitted to the local surgeon. These monthly reports were then sent by the latter through channels to the theater surgeon.
Local antimalaria units. - As of 1 July 1943, there were four malaria survey units and four malaria control units in the theater, in addition to the 2655th Malaria Control Detachment. There were no malariologists other than the theater and assistant theater malariologists. By the end of the year, one more survey unit and three more control units had arrived and eight officers (six Medical Corps and two Sanitary Corps) reported in the theater for duty as assistant malariologists. They were assigned to the 2655th Malaria Control Detachment as authorized overstrength pending approval of the revised table of organization for that unit.
20 See footnote
3, p. 256.
During 1944, 10 more control units were activated and trained in the theater. They were commanded by officers trained in the United States and sent over for that purpose. One more survey unit arrived completely trained. On 1 November, two control units were lost to the theater when ETOUSA took over all U.S. troops remaining in France. Thus, the antimalaria organization reached its maximal strength during the malaria season of 1944; as of 15 August, as shown in chart 8, it consisted of 6 survey units and 17 control units and 14 administrative malariologists, 12 of whom were assigned to the 2655th Malaria Control Detachment.
At the close of the 1944 season, when it was realized that the theater would no longer have commitments in North Africa, Sicily, Sardinia, or Corsica, it was decided to reduce the antimalaria organization both in personnel and units. The officer strength of the 2655th Malaria Control Detachment was cut from 13 to 6, and the antimalaria units were reduced from 17 to 10 control units and from 6 to 1 survey unit. Redeployment of officers took place during the winter months. The 10 oldest units were disbanded in February by War Department order, and all but three officers were returned to the United States. This drastic reduction occasioned considerable concern regarding the security of the malaria program. In order to safeguard it, authorization was obtained from MTOUSA to organize three provisional malaria control units. In addition, two of these units were authorized an overstrength of 14 enlisted men and 1 officer, making a total of 25 enlisted men and 2 officers. Where possible, an attempt was made to obtain men from the old units disbanded in the springs; this policy was successful in retaining about 30 percent of the trained personnel.
Airplane dusting and spraying detachment. - This detachment consisted of American and British pilots in the 327th Ferrying Squadron, Mediterranean Air Transport Service. They operated under the technical direction of the Malariologist, NATOUSA (MTOUSA), an arrangement requested by the Commanding General, Mediterranean Air Transport Service, and concurred in by the AFHQ committee of consulting malariologists consisting of the British Consultant Malariologist, AFHQ, the NATOUSA Malariologist, and the Tropical Disease Consultant, Royal Air Force. 22 In 1944, the U.S. contingent consisted of 9 pilots and 22 enlisted men; in 1945, of 9 pilots and 18 enlisted men; at no time were more than 6 pilots operating planes. They were equipped with two L-5 observation planes, three PT-17 (Stearman) trainers, all of which were equipped for dusting in 1944 with one modified for oiling in 1945, and ten A-20 (Boston) light bombers, four of which were equipped for oiling and six for dusting.
From administrative and operational viewpoints, it was advantageous to base aircraft and flying personnel at as few points as possible. In 1944, practically all the dusting and spraying in Italy was done from Capodichino Airport, though planes and pilots were attached for brief periods to Foggia Main
22 Letter. Commanding General, AFHQ. to Commanding General, Mediterranean Allied Air Forces, 18 June 1944, subject: Malaria control by Airplane Dusting.
Airport in east Italy and at Castiglione del Lago Airfield in central Italy. Other separate installations remained for the entire season in Sardinia and in Corsica. In 1945, a home base was maintained at Capodichino with advance bases set up in northern Italy in the Leghorn-Pisa sector and in the Rimini-Verona area.
The need for troop understanding of and familiarity with the procedures of malaria hygiene and sanitation was clearly recognized by Colonel Russell, theater malariologist, during the latter months of 1943. He urged the development of an Allied, theaterwide, malaria control teaching project as a winter activity for antimalaria personnel. This was directed forthwith 23 and the Allied Force Malaria Control School became an active entity in the early months of 1944 (fig. 32).
As finally established, this school was set up in three related but virtually autonomous sections, American, British, and French. Each section director outlined and supervised the presentation of courses suitable for personnel in his section. Some interchange of lectures was made among the British, American, and French schools held in Algiers. At the suggestion of the Surgeon, AFHQ (British), interallied dinners for the students of various nationalities were featured periodically in Algiers.
The basic faculty of the American Section of the Allied Force Malaria Control School was composed of members of the 2655th Malaria Control Detachment (Overhead). These officers were given a preliminary training course by the assistant theater malariologist in Algiers late in 1943. As they were attached to their respective posts, they conducted schools similar to the one in Algiers. Most of these were held during January, February, March, and April. All arrangements for announcements, issuing attendance orders, messing and billeting, and transporting student officers and men were made through regular channels by the malariologists, assisted in field and teaching duties by officers from malaria survey and control units. Certificates were generally awarded at the successful completion of these courses, so that suitable records might be made in the 201 files or service records of the individuals attending.
Three types of courses were given, modeled after those in Algiers, but with special divergencies and emphases as dictated by the situation. Course One was designed for officers of the medical-inspector type who had administrative interest in malaria control. This course dealt with clinical, epidemiologic, and preventive aspects of malaria. Guest lecturers were invited to participate and, especially in Algiers, strengthened the content of the presentation. Course Two was designed for laboratory officers and technicians. Train-
22 Training Memorandum No. 52, AFHQ, 22 Nov. 1943, subject: Allied Force Malaria Control School.
ing was given in the making and staining by various methods of thick blood films and the identification of the various stages and species of the malaria parasites. Course Three was designed primarily for enlisted men who were to serve as antimalaria details, although it was attended also by line officers detailed as antimalaria officers. It consisted of brief, didactic training in the principles and demonstration of the procedures used in malaria control practice.
American Section schools were held in Algiers, Oran, Bizerte, Palermo, Cagliari, Naples, Caserta, Foggia, Bari, San Severo, Cerignola, Spinazzola, Mandunia, and at the Anzio-Nettuno beachhead (fig. 33). 24 According to the local malariologists reports, 7,540 officers and enlisted men received training at these schools. This was about 1.2 percent of the total U.S. strength at the time the schools were conducted and represents a substantial troop contact. It was recognized that educational efforts should not stop with the expiration
24 The school at the Anzio-Nettuno beachhead deserves special comment. It was the largest (more than 2,000 officers and enlisted men were trained there) held in 1944 and was conducted literally under fire at all times. The hospital area seemed the least dangerous one available, so the didactic teaching was presented there in a double-ward tent liberally covered with red crosses. Not until the first days class arrived--armed to the teeth! --did it occur to the instructor that the picture of the completely accoutered students going in and out of the tent and lounging around it during the 10-minute "breaks," if taken by a German photoreconnaissance plane, might he justifiably interpreted as evidence of a breach of the Geneva conventions and serve as the basis for a deliberate attack on the hospital area! Nothing of the sort ever happened, but it took 3 long days to get the order countermanded requiring all combat soldiers to carry arms at all times--so that the students could come to school unarmed. This was the more remarkable because the hospital area, according to the uncannily accurate reports of Radio Rome, was under special surveillance at the time.
of a school project. Accordingly, some 51 miscellaneous lectures were given by assistant malariologists to military audiences totaling more than 6,500.
Inasmuch as so many persons connected with malaria control had received extensive schooling during 1944, comprehensive training was unwarranted in 1945 and a modified educational project was proposed. This consisted of 1-day schools held by local malariologists and assistants for (1) officers entrusted with antimalaria instruction of troops or who supervised the activities of enlisted-men antimalaria details, and (2) enlisted men of the unit antimalaria details. In the main, these schools were held during March and April just before the malaria season.
The courses for officers included the history of malaria in the theater, a prognosis of the malaria hazard and problems for 1945, the duties and interrelationships of antimalaria personnel, antimalaria education of troops, the training and use of unit antimalaria details, where and how to get supplies and equipment, and the 1945 theater policy for suppressive Atabrine therapy.
The courses for enlisted men dealt with the importance of malaria, utilizing the "Graphic Portfolio on Malaria"--War Department Graphic Training Aid 8-4, which gives a brief description of anopheline and culicine mosquitoes and their comparative bionomics, malaria control procedures to be practiced by enlisted-men antimalaria details, care and use of equipment, and demonstration of mosquito-collecting, house-spraying, oil-larviciding, and ditching techniques.
A special course was offered to officers and technicians in the Air Force Group Aid Dispensaries. These units were in the process of being equipped with microscopes, and a majority of the technical personnel assigned were
inexperienced in the preparation and interpretation of thick blood films for malaria diagnosis.
These schools were held in Naples, Rome, Grosseto, Siena, Leghorn, Pisa, Florence, Cattolica, Torre Maggiore, Foggia, Cerignola, Spinazzola, Ban, Manduria, and in the mountains of the Fifth U.S. Army sector, north and west of Florence.
According to the reports of local malariologists, 6,130 officers and enlisted men received training in these courses. This amounts to about the same troop contact as was achieved in 1944.
In addition to the formal training activities, awareness of the malaria problem and of the necessity for unremitting continuity in malaria control was stimulated by announcements and reminders conveyed both by radio and unit newssheets, by the use of roadside markers indicating the boundaries of malarious areas, by malaria control posters, and by the booklet entitled "This is Ann." Most of the posters came from the States (War Department, Medical Department Item Nos. 7J770-01 to 12, inclusive), although a few originated in the theater and were reproduced by engineer mapping units. Certain of the illustrations in "This is Ann" were enlarged and printed by civilian contract in Italy. The posters and pamphlets were usually in evidence in messhalls, dayrooms, and on company bulletin boards.
These were minimized in NATOUSA and MTOUSA from necessity rather than choice. The number of malaria control detachments in the theater was never great enough to provide and supervise environmental control measures on a really adequate scale. Consequently, it appeared advisable to use malaria survey detachments as malaria control detachments during the malaria seasons. In some instances, the malaria survey detachments were authorized to draw enough extra vehicles and equipment to make them operationally equivalent to control units; in others, provisional malaria control detachments were formed, by theater directive, from replacement personnel, commanded by the extra officer (parasitologist) from malaria survey detachments and equipped as malaria control detachments.
Furthermore, a considerable body of information regarding the distribution of malaria and anophelism existed in each country and island occupied. While these data were not always up to date, nor as nearly accurate as might be desired, they were generally useful. It seemed pointless, therefore, to engage in detailed explorational surveys except on those rare occasions when information from local civilian sources was not available. Consequently, the hulk of survey activities was inspectoral.
Splenometry . - Spleen palpation as a rapid measure of malaria endemicity was not widely employed, although limited and isolated observations were made in nearly all base sections, armies, and Army Air Forces. A total of
5,110 individuals, mostly children, were examined, of whom 12 percent were reported to have enlarged spleens. Local spleen rates varied from 2 to 43 percent.
Parasitology. - More parasite examinations were made in relation to either troop strength or the number of malaria survey detachments in 1943 than in either 1944 or 1945. This was due largely to the necessity of checking the blood-film examinations of hospital laboratories staffed with personnel not yet experienced in the recognition and identification of malaria parasites. Epidemiologic studies based on parasite-positive slides were not possible except on a small and unsatisfactory scale. The rapid movement of units and individuals and the possibility of protracted incubation periods (resulting from suppressive Atabrine therapy), during which multiple exposures in various places may have occurred, made these efforts unproductive in discovering where infections were contracted. They did point, however, to a rather selective prevalence among truckdrivers, railroad operators, cooks and kitchen helpers, attendants in antiaircraft, searchlight and locator posts, and among members of similar details in which duty exposure after dark was the common factor.
During 1943, more than 12,000 blood smears were examined by survey unit personnel in the theater. The lack of homogeneity as to time, place., sampling, and technique precludes drawing statistical conclusions from these data. As expected, tertian infections appeared to predominate in the early summer mouths and estivo-autumnal infections in the late summer and fall. About 75 percent of the total examined were survey slides made from troops, prisoners of war, or natives (mostly children). The remaining smears were from hospital patients, the majority of whom were suspected of having malaria from clinical evidence. Of the total, 11.5 percent of the blood films were positive.
In 1944, ever 14,000 smears were examined, of which only 3 percent were positive. Some of the examinations were from civilian or Italian military surveys; the others were made to check hospital laboratory malaria diagnoses.
In 1945, there were no parasitologic surveys due to the fact that all survey units but one were deactivated in the spring. The one remaining survey unit operated in the capacity of a control detachment. Accordingly, the control detachments were obliged to train their own mosquito inspection teams. In general, these consisted of two men per detachment. Lacking diagnostic equipment, it was impossible to differentiate anopheline larvae and adults.
. - As explained previously, most of the mosquito survey activities were
inspectoral rather than explorational. The following species of anophelines
were reported by various malaria survey units in the North African and Mediterranean
Other members of the maculipennis complex were probably encountered but were not recognized because of the paucity of survey personnel and equipment.
No environmental control measures of a truly permanent nature were attempted in NATOUSA except a relatively small amount of land fill. It is probable that much of the open ditching may have had certain semipermanent control values if the requisite maintenance work was done on it each year. Generally speaking, each Army unit was responsible for locating and controlling all anopheline breeding and performing other antimosquito measures within the limits of its installation, and, in many instances, for a mosquito flight-range radius beyond.
In North Africa, an effort was made during 1943 to utilize civilian health agencies for carrying on larviciding, clearing, and minor hand drainage beyond the military area limits to the extent of two kilometers. Base section commanders were authorized by NATOUSA directive to draw from U.S. military sources transportation, nonmedical supplies, and facilities for malaria control as dictated by circumstances in each base section and to expend up to 500,000 francs ($10,000) a month for civilian labor and miscellaneous items for the same purpose. This idea had merit, and where the base section commanders, surgeons, and preventive medicine officers took a constructive interpretation of the directive, the supplemental control activities thus generated had definite values both to military and local civilian populations.
Unfortunately, none of the North African health agencies, with the possible exception of the one in Morocco, had an experienced malaria control organization large enough to take on the task of environmental malaria control around Allied military installations. In Algeria, it was customary for larvicidal and drainage improvement operations to be performed by one national agency, the Service de la Colonisation et de l'Hydraulique, under the technical direction of another agency, the Service de la Santé Publique. The Eastern Base Section
25 (1) Russell, P. F., Rozeboom, L. E., and Stone, A. Keys to the Anopheline Mosquitoes of the World, With Notes on Their Identification, Distribution, Biology, and Relation to Malaria. Philadelphia: The American Entomological Society, The Academy of Natural Sciences, 1943, pp. 56-61. (2) Ross, E. S., and Roberts, H. R. : Mosquito Atlas. Part II, Eighteen Old World Anophelines Important to Malaria. Philadelphia: The American Entomological Society, The Academy of Natural Sciences, 1943, pp. 37-38.
included parts of both Algeria and Tunisia which made it. necessary to deal with two different national health departments. These circumstances naturally led to complications and misunderstandings in planning, responsibility, execution, and finally, in reimbursement.
Larviciding .- The treatment of anopheline breeding places to destroy larvae was practiced on a more extensive scale than any other single control method. The more frequent areas of mosquito production were small streams and ditches. In many of these areas, the entire water surface was covered by floating and emergent vegetation, and mosquito breeding extended from bank to bank; in others, plant growth was marginal, and larvae were found only along the edges, especially in relation to small vital floatage. In either case, supplementary clearing and cleaning were needed to make larviciding applications effective. These physical operations must have had considerable destructive effect upon the larvae themselves.
Petroleum oil, usually No. 2 diesel, was the larvicide of choice for ground application. Paris green was not generally available until 1944, but, in spite of considerable promotion and instruction in its use, the unit antimalaria details did not employ it to any great extent and showed a strong preference for oil. Probable reasons are that oil was much more available due to its general distribution for purposes other than larviciding, it required no mixing or trips to a mixing plant, it was not a poison, and the oil sprayers were mechanically superior to the rotary hand dusters usually supplied. In certain base sections, some paris green hand dusting was done by or immediately under the supervision of the special malaria control organization. An immense amount of paris green was spread by airplane in Italy, Sardinia, and Corsica during 1944 and in Italy in 1945. During the spring of 1944, DDT made its appearance in the theater. As a larvicide, it was used almost entirely in an experimental way both from the ground and by airplane. In 1945, 5 percent DDT in oil was used extensively as a larvicide applied both from the air and from the ground.
For the most part, various types of hand pressure sprayers were used to apply petroleum products. Continuous drip oilers were set up over streams in many parts of the theater. In one base section, a power oil sprayer was developed by utilizing a M3A1 Chemical Warfare decontaminating unit mounted on a 21/2-ton 6 x 6 truck chassis (fig. 34). This was actually a homogenizing pump developing up to 500 pounds pressure and was used to deliver a finely dispersed mixture of one part of oil in three parts water. Less oil was necessary for a given area when applied by this apparatus, the area was oiled in a shorter time than by hand-operated equipment, and the oil was forced below the water surface where it continued to come up under and around vegetation for periods of 2 or 3 weeks, so that its effect lasted longer than surface spraying.
Airplane larviciding . - Probably the first utilization of airplanes in dispersing larvicides in NATOUSA was made in Morocco during the summer of
FIGURE 34. - Power oil sprayer used to apply petroleum products. A. Decontaminating unit, mounted on a truck chassis, used to spray a mixture of diesel oil and water into mosquito breeding places. B. This method of oil-water application is especially effective and long-lasting in areas where emergent and floating vegetation is abundant, as the larvicide is forced into and below mats of vegetation.
1943.26 Planes and pilots for this purpose had been requested from the States early in the year. It was late September, however, before the six pilots--three of them experienced in crop dusting--reported for duty, and even later before the three PT-17 (Stearman) trainers, modified for dusting, were assembled and ready to fly. By that time, the mosquito-breeding season was nearly over so the planes were flown only for a small amount of experimental dusting. Some replacement parts for the dusting attachments had been sent over with them, but no repair or maintenance items for the aircraft arrived nor were there any in the theater. With the prospect of providing malaria protection in 1944 through the flooded Pontine and other bonifications and in malarious Sardinia and Corsica, it was necessary to enlarge the scope of the aerial-dusting facilities considerably beyond those afforded by three small trainer planes, any one of which might be grounded indefinitely by a cracked spark plug or a fiat tire. It was obviously desirable to provide more and larger planes which could be serviced within the theater. The A-20 (Boston) light bomber was finally selected because of its flying characteristics and availability (figs. 35 and 36), and a B-17 was dispatched to the States to obtain a load of PT-17 motors, tires, wheels, instruments, and other replacement parts.
26 The base section commander had forbidden use of paris green as a larvicide by Army personnel because he was misinformed as to its toxicity to men and domestic animals. The local stores of paris green were, therefore, made available to the Moroccan public health service, representatives of which proceeded to spread the paris-green-road-dust mixture with an old French bomber which had been condemned long before as unairworthy. The time came when this ancient aircraft could no longer get off the ground, whereupon the local Navy air surgeon took over the mission using a modified L-4 cub. He succeeded in getting in his flying time while he dusted effectively portions of two large swamp areas near Army campsites.
FIGURE 36.- A-20 dusting planes flying in formation. A. Planes flying over inundated Volturno bonification area. The speck at the upper right is an observation plane checking and directing the operation. B. Planes flying over the Plain of Cassino. The furthest plane is not yet discharging dust. The battered Monastery is atop the mountain peak to the left; at right, Hangman's Hill and numerous water-holding shell holes, bomb craters, and various other anopheline breeding places in foreground. Most of these were inaccessible because of landmines. The area required treatment because the road traversing it to the north was a vital supply line.
Theaterwide airplane dusting and spraying service was developed in 1944 and continued the following year. At the request of the Theater Surgeon, AFHQ directed the Mediterranean Allied Air Force to provide adequate planes and pilots for malaria control purposes.27 This responsibility was delegated by the Mediterranean Allied Air Force through the Army Air Force Service Command to the Mediterranean Air Transport Command. This organization placed a detachment of one of its ferrying squadrons virtually at the disposal of the theater malariologist. The crop dusting pilots, assisted by special malaria control organization personnel, supervised the structural modification of the A-20's to convert them to dusting and oiling planes.
Working arrangements were as follows: Requests for airplane dusting or spraying service were transmitted to the theater malariologist. As soon as practicable, he or one of his representatives visited the area and, accompanied by the local malariologist, made an aerial and ground inspection of the terrain to be treated. The amount of materials required for each week was then computed, and decisions were made regarding responsibility for transporting, mixing, and planeloading of larvicidal materials. The local malariologist provided a map for the pilot showing the exact area to be covered. The job was then scheduled for a particular day each week and copies of these arrangements circulated to all agencies concerned. Thereafter, the work proceeded as arranged until cancellation. Planeloading was generally handled by some element of the special malaria control organization.
In 1944, nearly 900,000 pounds of 25 percent paris green in lime and 7,000 gallons of oil (mostly No. 2 diesel with varying contents of DDT) were applied by airplane for American and British malaria control. During 1945, about 250,000 pounds of paris green mixed with diatomaceous earth (1: 3 for American use) or cement (1: 6 for British use) and roughly 72,000 gallons of 5 percent DDT in oil were dispersed by plane in the theater.
These quantities of paris green and DDT mixtures required large-scale mixing facilities. In 1944, they were contrived by base section engineers from an old Italian ammunition plant located in a cave near the Fair Grounds outside Naples (fig. 37). This factory was provided with motor-driven, steel tumblers loaded from a platform overhead. These containers discharged mixed dust into steel barrels on rollers below. Ample facilities were available for the dry storage of paris green and lime as well as mixed dust. Both 25 percent and 10 percent mixtures were prepared at this plant, the former for airplane and the latter for hand-duster applications. Plant capacity was 8 tons of mixed dust per 8-hour day.
In 1945, American larvicides were prepared by one of the malaria control units working in the Solvay plant at Rosignano (fig. 38). The 25 percent paris green mixture in diatomaceous earth was blended in revolving steel drums formerly used for manufacturing chloride of lime. The plant capacity was
27 Letter, the Commanding General, AFHQ, to the Commanding General, Mediterranean Allied Air Force. 23 Mar. 1944, subject: Malaria Control Dusting Airplanes for 1944.
5 to 15 tons per day. DDT solutions (5 percent in diesel oil or kerosene) were prepared in one of several large stills previously used for making trichlorethylene. Each of these had a capacity of 1,200 gallons and was equipped with a set of agitator paddles which rotated at the rate of 60 r.p.m. Oil or kerosene was pumped in through pipes connected to large storage tanks outside the building. DDT concentrate, dissolving in the proper amount, was added through a hatchway in the top of the still. After thorough mixing, the solution was drawn off through a tap at the bottom directly into 55-gallon drums. These stills had a capacity of about 2,400 gallons per day. Because of the ease of production, the malaria control unit also prepared large quantities of 5 percent DDT in kerosene for use as a residual insect-killing spray to be applied within houses by various units.
The MTOUSA airplane malaria control project abundantly demonstrated the feasibility of using large fast planes for applying larvicides. When the program was begun, this principle had not been employed to any extent, and its practicability was flatly denied by numerous "swivel-chair" pilots. The A-20 (Boston) light bomber 28 proved to be an admirable vehicle for dust and oil applications to large, unobstructed water areas. These planes were used
28 This bomber is powerful and surprisingly maneuverable in the hands of a skilled pilot and has visibility advantages over the B-25. Its radius of round-trip operation without refueling is about 200 miles. It can carry 8,000 pounds of dust, discharging it in 20 minutes, or 300 gallons of oil which can be discharged in from 3 to 15 minutes of dying time, according to the diameter of the discharge vent.
to dust large marshy and ponded areas in Corsica, vast inundated acreages in coastal Italy, the extensive canal systems in western Italy, and along the troopjammed highways of the Po River delta area (fig. 39).
The enthusiasm of theater malaria control personnel for the A-20 did not preclude the utilization of small planes for the precision treatment of small areas or winding streams, the course of which could not be followed by the larger aircraft. L-5 (Grasshopper) liaison planes, UC-61 (Fairchild) observation planes, and PT-17 (Stearman) trainers were all tried (fig. 40).29
29 Of these, the Stearman trainer plane was by all odds the best. It is powerful, tough, maneuverable, and has had excellent pilot visibility, as the cockpit is open. It has a work radius, without refueling, of from 100 to 150 miles. It carries 500 pounds of dust which it discharges in 7 minutes, or 55 gallons of oil which are released in about 6.5 minutes at a speed of 50 miles per hour. The L-5 was also satisfactory for minor plane dusting or spraying operations, but it lacked the power and maneuverability cf the PT-17. The UC-61 was considered undesirable for these purposes--though it was used more or less extensively by the British as it is underpowered and has limited pilot visibility.
Experience in 1944 demonstrated the desirability of covering large areas with several A-20's flying in echelon formation (fig. 36) so that an entire area could be covered with a single loading of larvicide. This avoided the necessity of having to leave for more dust or oil and returning to find different wind and air current conditions, as well as having to resume operations at an uncertain point somewhere near the place where the previous load ran out. Formation flying was found to be best directed from a liaison plane overhead, utilizing radio intercommunication with the pilots in the work planes. By this means, the effects of crosswinds could be noted, pilots ordered to the right or left, bare spots covered, and so on. The A-20 treatment of large canals was also performed more effectively under the direction of an aerial observer, as the A-20 pilot cannot see behind him to gage the effects of wind drift on the spray or dust cloud.
Airplane dusting was carried out at weekly intervals in accordance with the general principle of applying larvicides of temporary effectiveness at least once during each consecutive period of larval development. Aerial oiling schedules were placed on a weekly basis also, but this was because of administrative convenience. No data are available to show how long the DDT applications were effective in Italy. It is possible but unlikely, judging from experiences reported from other areas,30 that some residual effect was established after several weekly treatments on the same area.
Adult mosquito killing. - This activity was conducted systematically in Morocco during 1943, where it constituted a major and very effective means of mosquito reduction, especially when larvicidal measures were conducted simultaneously in the area.
This program was unique in that women were employed to conduct the spraying operations because of the ruling by the local pasha and the French civilian comptroller that men would not be permitted to enter Arab dwellings. Despite fear to the contrary, European women were easily obtained and proved to be more conscientious, careful, and steady sprayers than men. The total number of native dwellings involved in the inspection and spraying program in the whole sector is not known, but it must have been very large. The frequency with which the buildings were sprayed varied greatly, depending upon the findings of the inspectors. An indication of the cost and efficiency of this program is gained from data submitted from the Rabat area where, from 7 June to 31 July, five women sprayed 7,090 huts at a total labor cost of $564, or $0.08 per dwelling. Mosquito counts in these houses before the spraying program averaged 500 to 800 mosquitoes per hut.; at the end, 5 to 10 mosquitoes per hut.
Less extensive uses of spray killing both with liquid insecticide and Aerosol dispensers were made in other portions of the theater. While they could not be used in the most forward section of combat areas, they probably achieved
30 War Department Technical Bulletin (TB MED) 200, February 1946
their maximum utilization in Army areas where both the antimalaria units and the unit antimalaria details sprayed houses and animal shelters in newly occupied sections.
In the summer of 1944, the use of DDT as a residual house spray in Italy, Sardinia, and Corsica was begun. This measure came to be of increasing importance in malaria control technique, especially in areas where the possibilities of other environmental control practice were either not practicable or did not yield immediate health benefits. DDT residual spray was used for the control of all pest and disease-carrying insects. The DDT was mixed with kerosene to make a 5-percent solution and was packaged either in 5-gallon or 55-gallon containers at central points. The Fifth U.S. Army drew the mixed product from its supporting base section and distributed it with printed instructions as to its use to various units, a moiety of which made their own application. In virtually all other installations, the DDT solution was issued to units but was applied for them by specially- trained individuals or by teams using power sprayers. The latter arrangement was decidedly more efficient than the former, which was necessitated by the relatively vast dispersion of Army units. The basis of distribution in Air Corps units was 30 gallons per 1,000 men per month; in all other organizations, 5 gallons per company as needed, issue dates being determined by actual observations of insect prevalence. By NATOUSA directive, liquid insecticide and 5 percent DDT and kerosene were made available late in August "without restriction and in sufficient quantity to control disease-bearing insects throughout the theater." 31
Its spectacular success in 1944 as an adult mosquito killer led to its utilization on an even grander scale in 1945 in Italy, where it was credited by the theater malariologist as being the most important item in malaria control operations during the season. More than three and one-half times as much DDT was applied to walls by malaria control units in 1945 than had been used similarly during the previous year. Spraying was commenced in March to kill the overwintering anopheline females. After the initial application, unit buildings were resprayed every month and the surrounding civilian houses about every 3 months. Later in the season, it was felt that it would be more profitable to increase the protected zone by another half-mile to a mile rather than to respray previously treated houses; in this way very large areas of countryside were blanketed with DDT. It was also discovered that, in order to get adequate control, it was necessary to treat every shelter in the control zone, otherwise small foci of adults continued to exist in the untreated structures.32 Although DDT house spray was distributed on the basis of 30 gallons per 1,000 men per month in 1945, it was always available and units needing additional amounts could always draw them.
31 See footnote
17, p. 270.
DDT replaced Freon pyrethrum to a considerable extent as an insecticide in 1945. During the previous year, the special malaria control organization used 11,217 bombs, whereas in 1945 only 1,716 were reported to have been used and these by Army units during the Po River Valley offensive when it was necessary to treat houses quickly; later, the units went back and resprayed the houses with DDT.
Physical operations . - These were extensively conducted throughout the theater in 1943 to eliminate mosquito breeding and to permit more effective application of oil larvicides. Vegetation and obstructions were removed and residual pools often eliminated in order to enhance the speed of waterflow. In some instances, temporary dams were constructed to permit periodic flushing of streams. In 1944, the total amount of stream training, drainage, and land fill was greatly increased in Italy, Sardinia, and Corsica. In Corsica, a tremendous mileage of ditch and stream clearing, new ditching, and stream channelization was accomplished. Large areas were dewatered which, according to local inhabitants, had not been dry before in the memory of man. The mosquito population was so reduced that Corsican families moved from their summer homes in the hills down to the coastal plains before the advent of cold weather.
The enormous amount of physical operations was accomplished mainly by Italian and Yugoslav military labor. Companies of Italian infantry or quartermaster service troops were attached to malaria control units for operational control. These Italian organizations drew their own rations, messed, and sheltered themselves. The companies varied in size, averaging from 125 to 150 officers and men, but about a third were concerned in company administration and were not, therefore, available for work. In Corsica, Yugoslav labor companies were used similarly. The men in these units had been taken from their homes and country by the Germans as forced labor to work in Sardinia. When transported to Corsica, these labor companies were commanded by Italian officers and noncommissioned officers--whom they heartily detested--were malnourished, dispirited, and plagued by recurrent malaria. When the Italian officers were replaced with Americans and the Slays were well fed and given proper medical service, their morale rose rapidly and they became, by all accounts, the. most effective and dependable source of labor available in the theater. Italian civilian labor was employed on contract projects by the Allied Control Commission in Salerno and eastern Italy. Their work was also satisfactory as long as it was subject to U.S. officer inspection.
The responsibility of the Corps of Engineers for environmental control was accepted whenever its units were available from other duties.
Three Corps of Engineers projects were of considerable magnitude and were coordinated with the program of the special malaria control organization to such an extent that they merit particular mention.
During the spring months of 1944, while the Fifth U.S. Army headquarters were located at Sparanise (a small village located near Naples).
one battalion from each of five general service engineer regiments, together with the entire regimental heavy equipment, was made available for malaria control. One of the regimental officers, an experienced malaria control engineer, was detailed as liaison officer with the medical section of the Army headquarters. Together with the Commanding Officer, 28th Malaria Control Detachment, he surveyed the entire Army rear area north of the Volturno River, noting those situations where major earthmoving machinery and pumpage could be used to advantage. These jobs were then allotted to the various regiments by the Army engineer, and the indicated repairs were undertaken. This continued until engineers were needed for the push to Rome. No record of accomplishment is available, but the work included such operations as filling tank traps, shellholes, bomb craters; lowering culverts; removing obstructive bridge-demolition residues and bypasses; bridge improvement and construction; major canal repairs; and installation of heavy duty pumps which involved running electric powerlines for many miles. Much of this had to be done in heavily mined and boobytrapped areas. The engineers succeeded in reducing the water in the northern Volturno area to its normal level in time to permit civilians to plant the dewatered acres in the spring of 1944. It is no exaggeration to state that the U.S. Army engineers, with the tremendous manpower and equipment facilities at their disposal, accomplished more in a few weeks than the impoverished Italian citizenry could have hoped to do in as many years.
At the Anzio-Nettuno beachhead, the VI Corps engineer undertook responsibility not only for drainage improvement but for larviciding and spray killing in a considerable portion of that besieged area with the technical assistance of special malaria control organization representatives. This continued until the beachhead forces were joined with other elements of the Fifth U.S. Army on the advance to the north.
In the Salerno-Paestum area, where the invasion training center was situated during the summer of 1944, an engineer combat regiment cooperated with the special malaria control organization of the Army and the Navy in a joint program of malaria prevention. Men from this regiment, using explosives, carried out rapid but effective for a distance of several miles thus dewatering a large and potentially dangerous area. This could not have been accomplished otherwise with the facilities at hand in time to have favored the health of the troops training nearby.
Insect-proofing .- Since screening is virtually nonexistent in North Africa, all the buildings requisitioned by the Army in 1943 were without this protection. The scarcity of Army screening materials that year restricted their use to latrines, kitchens, messhalls, and breadboxes. Thus insect-proofing was employed primarily as an antifly rather than as an antimosquito measure. Some screening of hospitals was permitted, complete in certain instances, limited in others to spaces mentioned above and to one or two wards for patients with insect-borne diseases. Salvaged mosquito bars were used ex-
tensively for screening purposes. In 1944 and 1945, the situation was greatly improved. Screening materials were provided and used on an adequate scale throughout the theater.
Personal protective measures, except medication ,- Bed nets were utilized more faithfully than any other individual protective measure. By theater directive, they were available from 15 April to 30 November. 33 Some units requested them for use (against pest mosquitoes) during the winter months. They were not used by forward elements in combat as it was impracticable for these troops to carry or set up bed nets until they were back in rest areas. Where there was little or no supervision by officers, such as with truckdrivers or railroad operators on the road, it was not uncommon to find that bed nets and other essentials for personal protection against malaria were not in the possession of the individuals inspected. 34
The wearing of protective clothing was limited usually to long trousers and sleeves rolled down after dark. Shorts and shirts without sleeves were prohibited except during the hours of daylight. Some outfits wore leggings all the time. Head nets and mosquito gloves were rarely used and were not even nominally required by the theater in 1944 as items of personal protection.
Repellents were amply available but their maximum antimalaria values were never realized. Unless mosquitoes were numerous enough to constitute an annoyance, it was unusual for officers or enlisted men to use repellent as instructed. All kinds made their appearance at one time or another in the theater. Dimethyl phthalate or 6-2-2 appeared to be least objectionable to the soldiers and was effective against A. labranchiae labranchiae.
Much time and effort went into the indoctrination of officers and soldiers in NATOUSA regarding the use of personal protective measures against malaria, but in spite of all these endeavors it was known from night inspections that personal protection was more or less neglected except in those units where command interest enforced malaria discipline. This indifference was strikingly apparent as soon as the troops passed Rome advancing to the north. It was due, presumably, to the rumor that malaria did not exist north of the Eternal City.
An excellent feature of the Fifth U.S. Army malaria control program was the use of antimalaria officers and malaria control committees.
The antimalaria officers were appointed from nonmedical personnel in each corps, division, regiment, battalion, and separate company. It was the duty of the antimalaria officer to inform himself about the status of malaria and its control in his organization, to attend and participate in the deliberations of the malaria control committee to which he belonged, to acquaint his commanding officer with the malaria problem of the Unit, and to see that all necessary malaria control measures were being enforced.
23 See footnote
10, p. 264.
Malaria control committees were formed in each corps,. division, regiment, and battalion. The membership of each corps and division committee consisted of the medical inspector, the engineer, and the antimalaria officer of their respective echelons. Regimental and battalion committees were composed of their surgeons and antimalaria officers. The function of each committee was to bring together information concerning the phases of malaria control represented by the respective committee members. Thus, at periodic meetings, the medical inspector contributed information about current malaria prevalence and the activities of the Medical Department antimalaria personnel. The engineer was concerned primarily with environmental control and the mapping of malaria and malaria control data. The antimalaria officer discussed malaria control in general but was especially charged with noting how well the individual preventive measures were being enforced. Their findings were reported to the commanding general or officer. To an Army operating in a malarious area, this type of conference was most helpful as it brought together in all echelons the three branches of service--command, engineering, and medicine--most intimately concerned in the prevention of malaria. It is believed that this device did much to sustain malaria consciousness and integrated control effort while the Army was exposed to the military hazard of malaria. The various Army Air Force commands employed malaria-discipline officers in virtually the same capacity as the antimalaria officers mentioned previously.
Suppressive medication .- As indicated previously, the Malaria Advisory Board, AFHQ, was influential in formulating suppressive medication policy for the theater.35 The British were insistent upon universal, theaterwide administration of Atabrine (except to flying personnel who, they felt, should receive quinine) at a scheduled dosage of 0.2 gm. after the evening meal upon Monday and Thursday. This was contested in principle by the American membership for the following reasons: (1) It was American policy to depend primarily on environmental sanitation and not on chemical prophylaxis, except in active, tactical situations; (2) a high rate of toxic reactions, such as were manifested in the group of Ohio State University, Columbus, Ohio, students placed upon a controlled experiment of suppressive therapy under the auspices of the National Research Council, might occur, which, if true, would damage seriously the program of chemical suppression; and (3) with the numbers upon such therapy, the administrative details of providing the Atabrine to forward combat units would be difficult and the drug would arrive in an irregular manner and the program would suffer accordingly. The British minimized the force of these objectives, and the French agreed heartily with the British point of view. A compromise was finally effected whereby the procedures outlined above were to be followed, with the proviso that if environmental malaria control was found to be so effective in static areas that suppressive medication was
35 See footnote 7, p.262.
not needed, the commander in chief would decide whether or not the latter measure would be continued in main areas.
Suppressive Atabrine therapy was commenced 22 April 1943. 36 Practically no complaints of reactions were received following the first and second doses, but following the third, a well-nigh incredible wave of incapacitating, toxic episodes was reported. These involved nausea, vomiting, cramps, diarrhea, and, in some instances, febrile temperatures for a day or more following the third dose of Atabrine. All grades of severity were noted and many individuals experienced no symptoms whatever. A rather typical example of the incidence of toxic reactions encountered is shown in the following data recorded by the 59th Evacuation Hospital (table 33).
The experience in basic service troops was quite similar to that recorded in the officers and enlisted men in the detachment noted previously, with the exception that Negro troops showed a very low incidence of toxic reactions.
The experience in forward areas was very different from that in base sections. In II Corps troops, suppressive Atabrine therapy was begun 4 April 1943 because malaria was increasing in the 1st Infantry Division which was then engaged in combat.. The third dose was followed, in the 16th Infantry Division, by less than 5-percent moderate or severe toxic reactions, all of which passed off rapidly. In the 32d Field Artillery Battalion, about 10 percent of the personnel were affected, while in divisional headquarters some 25 percent suffered from toxic reactions. The reactions in II Corps troops were definitely less frequent than those in base section personnel. A similar story subsequently was gained from the 9th and 34th Infantry Divisions and the 1st Armored Division. The British reported similar toxic disturbances with the same curious tendency of having fewer reactions in units which were in forward areas.
36 See footnote 6, p. 262.
After this experience, the Malaria Advisory Board, AFHQ, was called into immediate session. It decided that 0.2 gm. was too large a dose of Atabrine and unanimously recommended that 0.1 gm. be taken on Monday, Tuesday, Wednesday, and Thursday of each week. Remarkable effects immediately were ascribed to this change in dosage, and many reports of decreased toxicity were received. However, the divisions in II Corps which had begun suppressive therapy early in April did not receive this order and continued upon the dosage of 0.2 gm. twice a week, on Tuesdays and Thursdays. This corps reported also an almost total lack of continued reactions so that the conclusion reached was that tolerance to suppressive Atabrine therapy was developed if the drug was continued, regardless of the type of dosage used.
The spring and summer experience with suppressive Atabrine had precisely the effect on the program of suppressive medication which the medical consultant had feared and expressed before the Malaria Advisory Board, AFHQ. For every individual who reacted physiologically to the early doses, there were several others who experienced similar psychogenic--but none the less incapacitating--episodes. Actually, when the smoke had cleared away, it was apparent that most of the affected people were able to develop a tolerance to the drug rather promptly if daily doses of 0.1 gm. or less per day were used. The proportion which remained continuously sensitive was less than 1 percent. Nevertheless, as a result of the widespread distress, numerous officers and men feared Atabrine and would go to any lengths to avoid taking it. They rationalized their deliberate and unauthorized discontinuance of the drug on many bases. The rumor spread that Atabrine was a cause of impotency. The yellow skin infiltration was regarded by the soldiers as jaundice and an indication of grave liver damage from which they might never recover.
Medical officers unconsciously sabotaged the program by expressing, in the presence of enlisted men, their doubts of the prophylactic value of Atabrine. Many of the troops worked and were quartered in large cities such as Algiers, Oran, and Casablanca, or in other areas where mosquitoes were scarce or absent. Neither officers nor enlisted men could see any use in taking Atabrine under these conditions, and the theater regulation was not enforced. These irregularities in taking suppressive Atabrine were evidenced abundantly by the frank admissions of malaria patients interviewed by malariologists and by the casual comments of officers in messes regarding the bottles of Atabrine on the tables before them. Thus, the proportion of troops taking Atabrine regularly in 1943 is not known nor, consequently, the role of chemical suppression in the picture of malaria morbidity which developed in 1943 and in early 1944.
A natural result of the uncertain, vacillating, poorly enforced Atabrine policy in 1943 was the evolution of a more rational directive for 1944.37 By
37 See footnote 10, p. 264.
this time, more information regarding the suppressive efficacy and lack of toxicity of Atabrine was available. The period 1 May to 15 October was designated as the malaria season. All areas were to be considered malarious unless otherwise designated, by the area commander concerned and upon the advice of his surgeon. Nonmalarious areas were designated as those in which malaria did not occur and areas where control measures had effectively removed the likelihood of malaria transmission. All military personnel were directed to take one 0.1 gm, tablet of Atabrine per day for either 6 or 7 consecutive days a week while in areas which had not been designated as nonmalarious.
The flexibility and adaptability of this directive, reinforced by troop training regarding the use of Atabrine, resulted in considerable improvement in Atabrine discipline during the first half of the 1944 malaria season. Some difficulty was experienced when soldiers who had been taking Atabrine regularly came into "nonmalarious" rest areas; that is, Rome, where Atabrine was not provided automatically with the rations. This defect was corrected promptly. The most serious impediment to the Atabrine program developed as the result of successful environmental control operations. The combination of low malaria rates and negligible anophelism made the enforcement of suppressive atabrinization--and other personal protective measures as well--seem useless to officers and enlisted men alike. Thus, during the late months of the malaria season in 1944, compliance with suppressive Atabrine regulations was not as extensive as earlier in the year.
In 1945, the policy was liberalized further by making Atabrine suppressive medication (0.1 gm, per day) compulsory only in specially designated areas.38 Several such areas in the Po River Valley were thus specified by the Commanding General, Fifth U.S. Army. Otherwise, Atabrine consumption during the year was limited to occasional units having unduly high malaria rates or to individuals recovering from attacks. The 1945 directive was thoroughly rational and enforceable and, judging from the results, the most successful of the suppressive Atabrine policies developed during the 3 years.
The personnel in the special malaria control organization were not able to devote much time to research. This was due not to any disinclination to engage in such activities but to a lack of opportunity. During the winter and early spring of the year, typhus control, malaria control training, and preseasonal control activities occupied the time of its members. After the transmission season commenced, no time for anything but control work remained. The theater was fortunate in having available in the Allied Control Commission (later Allied Commission) certain specialists (made possible through
38 See footnote 11, p. 265.
the cooperation of members of the field staff of the International Health Division of The Rockefeller Foundation), highly skilled in particular phases of malaria control, who were able to devote their entire time to working out problems suggested by individuals occupied with actual malaria control responsibilities. Reference is made to the monthly reports of the Demonstration Unit, Malaria Control Branch, Allied Control Commission.
The following abstracts are based upon investigations made during 1944 and 1945 by members of the special malaria control organization and the Allied Control Commission.
1. Determination of toxicity of 5 percent DDT in kerosene to 33 members of power spraying teams exposed 6 hours per day, 6 days per week, from 1 to 21 weeks each. No evidence of intoxication was adduced from histories, physical examinations, and laboratory tests in a general hospital.
2. Analysis of admission and disposition sheets to determine what proportion of cases originally diagnosed as fevers of undetermined origin and febricula were finally diagnosed as malaria. Of 150 cases in the Fifth U.S. Army discharged to duty during each of the following months--June, July, August--of 1944, 35 percent were definitely diagnosed as malaria, 19 percent remained as fevers of undetermined origin or febricula, and the remainder were distributed among respiratory, gastrointestinal, and miscellaneous disorders.
3. Development of the A-20 as a spray plane for the application of DDT in liquids. This involved experimentation: (1) with M-10 CWS wing tanks which were discarded because of their mechanical difficulties; (2) the utilization of auxiliary fuel cells (332-gallon capacity) and airscoops leading to an atomizing chamber whence the spray was conducted through a discharge tube to the tail of the ship and released; and (3) a special 300-gallon tank, from which equalized flows were obtained irrespective of variations in the hydraulic head within the tank, and an atomizing apparatus consisting of a truncated, conical airscoop fitted over a simple discharge pipe so that the distance between the end of the pipe and the terminal orifice of the scoop could be altered to vary droplet size and pattern.
4. Development of the PT-17 (Stearman) as a spray plane for the application of DDT in liquids. This utilized a 55-gallon steel drum as a reservoir with flow-equalizing equipment and with an atomizing apparatus similar to those used on the A-20.
5. The variable spray patterns and droplet spectra developed by the A-20 mind the PT-17 aircraft under varying conditions of temperature, wind direction, size of outlet, and adjustment of atomizer.
6. The dust pattern developed by the A-20 with 25 percent paris green-in-diatomaceous-earth mixtures under conditions of varying wind directions and amounts of dust in hopper. Great unevenness in spread, particularly of paris green particles, was noted.
7. A study of winter DDT house spraying and its concomitant effect on anophelines and malaria in an endemic area. 39 A single application of 5 percent DDT in kerosene (83 mg. of DDT per square foot) made in midwinter to all houses and outhouses in a certain area with virtually no other antimalaria measures in effect resulted in reduction in anopheline densities, frequency and size of enlarged spleens, and parasite rates (table 34).
During the winter months, the special malaria control organization was used predominantly for troop training in the principles of malaria prevention. Some of the malariologists and antimalaria units were employed in 1943-44 to combat the typhus epidemic which threatened Naples and the Fifth U.S. Army. At least one survey unit operated prophylactic stations in Naples during the winter. The remaining individuals and detachments were kept occupied in mapping, making watered-area surveys, overhauling equipment, consolidating records, and in accomplishing such preseasonal control operations as were possible. Thus during the season when malaria transmission was at its lowest ebb, the antimalaria personnel was serving usefully and in accordance with its prescribed functions.
As the theater malaria control organization expanded, increasing need was felt for discussing technical and administrative problems, for evaluating certain procedures, and for exchanging program information. To some degree, this was accomplished during the periodic visits of the theater malariologists to malaria control and survey units. It was evident, however, by the end of the 1944 malaria season, that a pooling of the highly specialized experiences
39 (1) Soper, F. L., Knipe, F. W., Casini, G., Riehl, L. A., and Rubino, A.: Reduction of Anopheles Density Effected by the Preseason Spraying of Building Interiors with DDT in Kerosene, at Castel Volturno, Italy, in 1944-45 and the Tiber Delta in 1945. Am. J. Trop. Med. 27: 177-200, March 1947. (2) Aitken, T. H. G.: A Study of Winter DDT House-Spraying and Its Concomitant Effect on Anophelines and Malaria in an Endemic Area. J. Nat. Malaria Soc. 5 : 169-187, June 1946.
of the malariologists attached to major commands would be invaluable toward making future operations more effective. With the object, therefore, of integrating, coordinating, and improving MTOUSA malaria control activities, of interchanging information, and of broadening the perspective of each malariologist by acquainting him with the experience of his fellows, the officer members of the 2655th Malaria Control Detachment were requested to attend and participate in a malaria control conference at Naples during November 1944. Sessions were held daily for 10 days. The program included a summary of theaterwide malaria control accomplishments and reviews of individual program experiences which were followed by group discussion and criticism. Presentations were also made concerning malaria control research projects which were being undertaken. A compilation of abstracts of the program was made and distributed later to those interested.
The results of the conference justified completely the time and expense involved in holding it. The participants had developed individual points of view which they propounded with great self-assurance and defended competently. The deliberate scrutiny and evaluation of each policy and procedure resulted in the resolution of certain generalizations concerning military malaria control which summarized the views of the malariologists. Some of them are presented in the following section.
CONCLUSIONS AND SUGGESTIONS FOR THE FUTURE
The following conclusions regarding NATOUSA (MTOUSA) malaria control experience and recommendations for future practice are not intended to reflect adversely on individuals concerned in their development. They are presented only with the object of improving military malaria prevention. Some of these reflect the deliberations of the malariologists at their 1944 meeting in Naples; others are the considered reflections of the author based upon his experience in NATOUSA and MTOUSA as assistant theater malariologist and then theater malariologist.
1. Physical noneffectiveness due to malaria did not threaten significantly the success of military operations in this theater. If the invasion of Sicily had been accomplished less swiftly, it is likely that malaria casualties might have become a source of embarrassment to the Commanding General in the fulfillment of his mission.
2. The principle of assigning command and operational responsibility to the theater malariologist in addition to his consultant duties worked very well in this theater. It centralized the program administratively as the theater malariologist was then in position to attach malariologists to major commands, to control essentially the attachment of antimalaria units, to supply airplane larviciding service where needed, and to advise concerning special malaria control supplies for the theater.
3. Military malaria control has all the diversity of practice inherent to civilian malaria control in addition to numerous other variable circumstances which do not occur in peacetime antimalaria operations; for example, static versus mobile populations, restricted versus expanding territories, service versus combat and flying troops, and the great increase in manmade mosquito breeding places due to topographic damage resulting from combat. Therefore, it is not feasible to plan or operate on a highly regimented basis; it is better in the long run to permit the local malariologists as much independence and liberty in developing and adapting their programs to prevailing conditions as is consistent with general theater coordination.
4. Didactic malaria control training is necessary as an initial incident in the educational process, but the process must be a continuous one in which the school is the beginning and not the end. Efforts at motivating military personnel to avoid exposure to malaria and of compensating for necessary risks must be maintained as long as the hazard of infection exists.
5. More malaria control enlightenment of line officers is needed, especially to promote a clear understanding of what their enlisted-men antimalaria details are supposed to do. This is especially true of commanding officers, particularly of company grade.
6. A greater utilization of medical supervision--perhaps through the medium of sanitary technicians--in unit malaria control would contribute greatly to the effectiveness of the program. By War Department Circular No. 223, dated 21 September 1943, enlisted-men details were to be composed mainly of nonmedical department personnel and were under the direct command of junior line officers who did not know how to use them. If the enlisted-men details could be placed under the technical direction of the medical officer, they might be used to much better advantage.
7. It was the considered opinion of the assembled malariologists, most of whom were medical officers, that, in MTOUSA, primary malaria control emphasis should be placed on: (1) Environmental control measures, (2) the use of bed nets, (3) protective clothing and repellents, and (4) suppressive medication. It is quite possible that groups of malariologists from other theaters would have given entirely different priorities to these activities.
8. The subject which provoked the most vigorous and sustained controversy in the malariologists' conference was the question of how much malaria control should be done for troops by the special malaria control organization and how much troops should do for themselves through the medium of enlisted-men antimalaria details. Except for the general proposition that both enlisted-men details and antimalaria units were needed, there was no general agreement as to their relative importance and dependability. In this theater, it was certainly true that malaria control could not be left entirely to enlisted-men details. The individuals assigned to this duty in many instances had little or no interest in it; many of them had other duty assignments that not infrequently superseded malaria control. Some of the men were inefficient and lazy. Frequent changes
occurred due to promotion, transfer, or the unpredictable notion of their commanding officers, so that there was much turnover and discontinuity in their work. They were commanded by officers who often were not well-indoctrinated with the importance and nature of their malaria control responsibilities.
Nevertheless, most of the environmental control (mainly DDT spray killing) in forward areas was done with enlisted-men details, and some of them performed magnificently under fire. The commanding officers of forward troops are rarely convinced of the urgency of malaria control units and are more prone to consider them unnecessary liabilities which have to be rationed, sheltered, and guarded. Thus, it is necessary under these conditions to depend primarily on the enlisted-men details, enhanced, where possible, by trained malaria unit personnel.
On the other hand, it was the general experience in this theater that in the relatively static rear areas a much higher quality of diversified malaria control program could be carried on through the use of native labor, labor troops, or of consolidated enlisted-men details working under the direction of malaria control unit personnel.
9. It was generally believed by the malariologic personnel in this theater that the malaria survey units and malaria control units as defined in 1944 were too small to accomplish their objectives efficiently. They were dependent upon larger units for rations and billets, and an unreasonably high proportion of their enlisted men component was needed for unit administration. It was suggested that several units might be attached to a higher coordinating headquarters for more effective utilization of unit personnel, or that larger, more self-sufficient units be organized. In 1945, the tables of organization and equipment for a medical battalion headquarters which might be used to consolidate antimalaria units were published, but this action was too late to be of use in MTOUSA. Since the end of the war, self-sufficient preventive medicine companies have been authorized, the functions of which include malaria survey and control. 40
40 (1) Tables of Organization and Equipment 8-500, 28 Apr. 1944. (2) Tables of Organization and Equipment 8-500, 18 Jan. 1945. (3) Tables of Organization and Equipment 8-117, 12 May 1950.