Blackwater Fever in West Africa, 1941–45

Tolerance May Be More Appropriate Than Immunity When Describing Chronic Malaria Infections

“…Asymptomatic parasitemia would likely have been very high in West African soldiers who would not have had their blood examined. 6 Infection pressure in West Africa remained very high, so the differences between British and West African soldiers' malaria rates (shown in Figure 1B) would not have been due to lack of exposure. 7 Chemoprophylaxis was given only to the British soldiers, suppressing the blood infections with varying degrees of success, which improved over time with better use of atabrine/quinacrine.…”

“…7 Chemoprophylaxis was given only to the British soldiers, suppressing the blood infections with varying degrees of success, which improved over time with better use of atabrine/quinacrine. 8 It is possible that the dramatic decreases in British soldiers' malaria rates shown across four West African countries during the Second World War are actually due to accelerated acquisition of tolerance. By 1945, constant infection of British soldiers with variable drug suppression would have gradually produced a state of tolerance with sub-patent parasitemias that approximated that seen in West African soldiers whose low-level parasitemias were controlled without chemoprophylaxis.…”

Historical Review: Problematic Malaria Prophylaxis with Quinine

“…It was reported that blackwater fever subsequently disappeared from British soldiers except for a few stubborn individuals that insisted on continuing to self-administer quinine regardless. 35 Interestingly, it was after the switch to atabrine that hemolytic episodes in African soldiers began to increase, perhaps due to glucose-6-phosphate dehydrogenase (G6PD) deficiency. 36 Blackwater fever cases are still seen in circumstances when physicians revert to chronic quinine use, but its actual cause remains poorly understood as some complex interaction between falciparum malaria, G6PD deficiency, and quinine.…”

The Multifactorial Epidemiology of Blackwater Fever

“…3 When synthetic antimalarial drugs such as quinacrine became available and chronic suppression with quinine was discontinued, blackwater fever largely disappeared. 4 When chloroquine resistance led to a revival of quinine for malaria treatment, occasional cases of blackwater fever were observed in U.S. soldiers, African children, and expatriates. [5][6][7] Blackwater fever was never mechanistically understood and remains largely a mystery because of the rarity of modern cases.…”

“…Australian records were supplemented by unpublished data from the Basser Library in Canberra. 4,16 Although the precise definition of blackwater fever, the quality of malaria incidence data, and the time period covered varied, it was possible to construct epidemiological graphs for the four groups which are shown in Figure 1. Despite having decades of preceding malaria information, blackwater fever was not reported from the Andaman Islands Penal Colony until 1908.…”