Malaria’s contribution to World War One – the unexpected adversary

Abstract

Malaria in the First World War was an unexpected adversary. In 1914, the scientific community had access to new knowledge on transmission of malaria parasites and their control, but the military were unprepared, and underestimated the nature, magnitude and dispersion of this enemy. In summarizing available information for allied and axis military forces, this review contextualizes the challenge posed by malaria, because although data exist across historical, medical and military documents, descriptions are fragmented, often addressing context specific issues. Military malaria surveillance statistics have, therefore, been summarized for all theatres of the War, where available. These indicated that at least 1.5 million solders were infected, with case fatality ranging from 0.2 -5.0%. As more countries became engaged in the War, the problem grew in size, leading to major epidemics in Macedonia, Palestine, Mesopotamia and Italy. Trans-continental passages of parasites and human reservoirs of infection created ideal circumstances for parasite evolution. Details of these epidemics are reviewed, including major epidemics in England and Italy, which developed following home troop evacuations, and disruption of malaria control activities in Italy. Elsewhere, in sub-Saharan Africa many casualties resulted from high malaria exposure combined with minimal control efforts for soldiers considered semi-immune. Prevention activities eventually started but were initially poorly organized and dependent on local enthusiasm and initiative. Nets had to be designed for field use and were fundamental for personal protection. Multiple prevention approaches adopted in different settings and their relative utility are described. Clinical treatment primarily depended on quinine, although efficacy was poor as relapsing Plasmodium vivax and recrudescent Plasmodium falciparum infections were not distinguished and managed appropriately. Reasons for this are discussed and the clinical trial data summarized, as are controversies that arose from attempts at quinine prophylaxis (quininization). In essence, the First World War was a vast experiment in political, demographic, and medical practice which exposed large gaps in knowledge of tropical medicine and unfortunately, of malaria. Research efforts eventually commenced late in the War to address important clinical questions which established a platform for more effective strategies, but in 1918 this relentless foe had outwitted and weakened both allied and axis powers.

Camillo Golgi (1843-1926): scientist extraordinaire and pioneer figure of modern neurology

“…In this way he identified the complete life cycle of Plasmo- www.acbjournal.org dium (malarial parasite) in human erythrocyte, which is eponymous as Golgi cycle. He also discovered the cardinal correlation between the segmentation of malarial parasite in human blood (pathological phenomenon) with the occurrence of febrile bouts in patients [27].…”

Design insights for socially-led interventions

“…This requires the contextualisation that syringes, in the developing world especially, are re-used multiple times, and are a transmission boost for virulent viruses between patients in hospitals (Clark, 2015). This is not a new thing; it was first observed back in 1931, with malaria spreading throughout a couple of regiments in the British Army (Brabin, 2014).…”

The Fever Tree: from Malaria to Neurological Diseases

“…Ronald Ross, consultant Physician to the Mediterranean Expeditionary Force who discovered the mosquito transmission of malaria, created quinine concentration camps in England and France for intensive enforced drug treatment. Under those treatment protocols, blood-stage parasites could be eliminated, yet the drug did not affect the hepatic forms of the parasite (largely Plasmodium vivax ) and efficacy of the treatment was not clear [20,21]. In 1917, Sir William Osler commented that “the man who could not treat malaria successfully with quinine should give up the practice of medicine” [21].…”

“…Under those treatment protocols, blood-stage parasites could be eliminated, yet the drug did not affect the hepatic forms of the parasite (largely Plasmodium vivax ) and efficacy of the treatment was not clear [20,21]. In 1917, Sir William Osler commented that “the man who could not treat malaria successfully with quinine should give up the practice of medicine” [21]. Quinine was the main treatment of malaria until the 1920s, when chloroquine was introduced.…”