Travel Medicine and Infectious Disease (2014) 12, 307e317

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid

Malaria control strategies in French armed forces R. Migliani a,*, B. Pradines b,c, R. Michel d, O. Aoun e, A. Dia d, X. Deparis a,d, C. Rapp a,e a

Ecole du Val de Graˆce, Paris, France Institut de recherche biome´dicale des arme´es, Bre´tigny-sur-Orge, France c Aix Marseille Universite´, Unite´ de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, UM 63, CNRS 7278, IRD 198, Inserm 1095, Marseille, France d Centre d’e´pide´miologie et de sante´ publique des arme´es, Marseille, France e Service des maladies infectieuses et tropicales, Hoˆpital d’instruction des arme´es Be´gin, Saint-Mande´, France b

Received 26 December 2013; received in revised form 11 May 2014; accepted 13 May 2014

Available online 25 June 2014

KEYWORDS Malaria; Control strategy; French armed forces

Summary Each year, 40,000 French soldiers deploy or travel through malaria-endemic areas. Despite the effective control measures that were successively implemented, malaria remains a public health concern in French armed forces with several important outbreaks and one lethal case every two years. This article describes the malaria control strategy in French armed forces which is based on three combined strategies: i) Anopheles vector control to prevent infection with the implementation of personal protection against vectors (PPAV) adapted to the field living conditions of the troops. ii) Chemoprophylaxis (CP) to prevent the disease based on prescription of effective and well tolerated doxycycline. iii) Management of cases through early diagnosis and appropriate treatment to prevent death. In isolated conditions in endemic areas, rapid diagnosis tests (RDT) are used as first-line tests by military doctors. Treatment of uncomplicated Plasmodium falciparum (P. falciparum) malaria is based either on the piperaquine tetraphosphateedihydroartemisinin association since 2013, or on the atovaquoneproguanil association. First-line treatment of severe P. falciparum malaria is based on IV artesunate. These measures are associated with constant education of the military, epidemiological surveillance of malaria cases and monitoring of parasite chemosensitivity. ª 2014 Published by Elsevier Ltd.

* Corresponding author. Direction centrale du service de sante ´ des arme ´es, Fort-Neuf de Vincennes, Alle ´e des Mare ´chaux, 75614 Paris cedex 12, France. Tel.: þ33 6 17 30 87 84. E-mail address: [email protected] (R. Migliani). http://dx.doi.org/10.1016/j.tmaid.2014.05.008 1477-8939/ª 2014 Published by Elsevier Ltd.

308

1. Introduction Among the infectious risks to which the French military are exposed, malaria, the first parasitic world endemic in inter and subtropical zones [1], has long held an important place. Two major events etched malaria into the history of armed forces and the memory of the Service de Sante ´ des Arme ´es (SSA): the conquest of Madagascar in 1895 with approximately 6000 malaria-related deaths for less than 30 killed in action [2] and the Macedonian front line in 1916 with 50% of French forces infected by malaria and more than 600 dead [3]. During this incident, military malaria control measures were implemented with success until the end of the «Great war» [4] and are still currently used. Since the occurrence of Plasmodium falciparum resistance to chloroquine in Africa in the nineteen eighties [5] and the rise of deployments overseas in the last decade, malaria is once again a public health concern in French armed forces with several important outbreaks [6e9] and an average of one death every two years. As a result, a new strategic plan for controlling malaria was established.

2. Context of French armed forces’ exposure to malaria Approximately 40,000 French soldiers (Army, Navy, Air Force and Gendarmerie) are deployed to over a dozen malaria-endemic destinations each year. On average, 16,000 are stationed either isolated or in established units according to two different settings. The first corresponds to long length stays (two years in general) as part of defense agreement with African countries like Gabon, Senegal and Djibouti, or as part of French sovereignty in the overseas territories like French Guiana and Mayotte. The second corresponds to short time stays, planned or not, from a few days to a few months, as part of a port of call or training missions, short military missions, maneuvers with allied countries, peace keeping or security operations, as part of national, European, North Atlantic Treaty Organization, or United Nations decisions. Operational deployments expose soldiers living in crowded and poor sanitary conditions to several epidemiological risks including malaria. Prevention of this risk requires medical readiness before deployment, compliance with antimalarial measures during deployment and with chemoprophylaxis upon return.

3. Objectives The primary objective of the of the SSA in malaria control is ambitious: “reaching zero malaria-related deaths in French armed forces”. The secondary objective is to maintain troop readiness by reducing the number of malaria cases.

4. Organization of malaria control in the armed forces A committee of experts from the French Health Corps annually updates a malaria control document based on World Health Organization and French national recommendations [10].

R. Migliani et al. In addition, the latest scientific advances in malaria control and results of research conducted by the Service de Sante ´ des Arme ´es are included. This document describes the strategies required to implement malaria control procedures and is distributed as a ministerial circular to all military physicians. The Service de Sante ´ des Arme ´es is responsible for the supply and prescription of antimalarials. Logistical units of the armed forces are in charge of providing the vector control tools. SSA and commanding officers ensure implementation and good compliance with control measures.

5. Implemented antimalarial measures in the armed forces Malaria control in the armed forces is based on the three classical strategies conducted jointly: anopheles vector control to prevent infection, chemoprophylaxis to prevent the disease and management of cases through early diagnosis and appropriate treatment to prevent death. These measures are associated with actions that encourage good compliance with protection measures and verify their efficacy: initial and continuous training of healthcare providers, constant education of the military, epidemiological surveillance of malaria cases completed by specific surveys in exposed units and monitoring of parasite chemosensitivity. Research is conducted simultaneously to better understand the risks taken by servicemen and identify the factors impacting compliance. These works will allow the development of relevant and appropriate prophylactic tools.

5.1. Anopheles vector control Vector control is the primary prevention tool in rolling back malaria and other vector-borne diseases. It combines individual and group measures adapted to the field living conditions of the soldiers [11]. 5.1.1. Individual measures The means available for each serviceman are aimed to reduce contact with the Anopheles vector by mechanical and/or chemical barriers thus insuring individual vectorbite protection. This latter rests upon the use, each night, of deltamethrin-impregnated cotton bed nets during sleep or 1.25 mg/m2 industrially permethrin-treated combat suit associated with skin repellents application on exposed body parts. These repellents represented by CITRIODIOL (oil of lemon eucalyptus containing paramenthane-3,8-diol), icaridin, IR3535 and diethyltoluamide (DEET) have a protection time varying from 4 to 8 h depending on the applied molecule. Mosquito bed nets are the best protection tool against malaria only if they stay in good condition and are properly used each night throughout the entire stay. They have a maximum impregnation duration of 4 months. Hence they must be retreated (with 25 mg/m2 deltamethrin) beyond this time or after washing. Impregnated combat suits and repellents act as complements to bed nets when required (in the beginning of the evening, late night, during patrols, guards or combat). Their combined appropriate use guarantees a nearly 100% protection [12]. Industrial

Malaria control strategies in the French army impregnation of combat suits lasts 4 months with usual washing rhythm and should be renewed beyond this time by sprinkling a 4% permethrin solution. As permethrin does not adhere to the fabric, its protective qualities end after four washings. This individual vector-bite protection equipment is provided to each soldier before departure (three impregnated combat suits and a spray bottle of skin repellents), upon arrival to endemic zone (impregnated bed net) and during all the stay (repellents). Re-impregnations are usually made collectively by medical staff or military units’ harbingers. Supplying troops with permanent impregnation bed nets made of synthetic fibers and impregnated canvas cover is planned at medium term [12]. Surveys carried out on the field during recent outbreaks showed poor compliance with the implementation of these individual protection measures, regarding either wearing appropriate clothing (long-sleeved shirts and trousers) every night or using skin repellents or mosquito bed nets [6e9]. Combat environment is an important unfavorable factor [8,12]. 5.1.2. Group measures These measures are part of the protection of military sites and personnel from mosquito vectoring diseases (Anopheles sp., Aedes sp., Culex sp.). They aim at decreasing density and/or life expectancy of vectors in contact with the military. Three actions are conducted: selection of installation sites, protection of premises and execution of procedures around accommodations [11,12]. An assessment of the entomological risk level (vectors, resistance level) is permanently carried out by a defense sanitary watch system based on continuous collection of health data on troops’ deployment zones or potential operations [13]. This evaluation source remains insufficient for knowing the real vector risk level because collected information is sometimes old and often fragmented [12]. These last years, entomological risk field assessments were led in French military positions in some African capitals (Abidjan, Dakar, Libreville), in French Guiana and during deployments (Co ˆte d’Ivoire) [12,14e18]. The selection of settlement sites by the field military command, apart from camps already built and when military requirements allow it, takes into account, after consulting the Medical Corps, malaria risk. In order to limit this risk, the camp should be established far (more than 1 km) from potential larval sources and local populations, in a clear and ventilated zone [11,12]. Living places (habitations, guardrooms, toilets) are sealed to vectors to the strongest extent, by setting mechanical barriers (mosquito nets) at openings and spraying persistent insecticides on walls (25 mg/m2 deltamethrin) using portable manual pressure sprayers (like Matabi). Air conditioning, when available, reduces mosquito intrusion possibilities by closing rooms [19]. However, it creates a false safety in many situations especially in requisitioned facilities due to malfunctioning equipment (ie poor installation or maintenance, no electricity). Therefore, soldiers are recommended to sleep under bed nets if air conditioning quality is poor. Mosquito numbers are limited by constant and organized larval source management in camps. This action is extended when possible to immediate surroundings in

309 collaboration with locals and their authorities, in particular, to farming areas which act as suppliers of Anopheles larval sources [12]. Larval control is physical and chemical. Physical control targets the three mosquito species by methodical destruction of larval habitats with establishments of drainage systems to stop the creation of new sources, maintenance of drains (gutters, pipes .) and protection of artificial water storages. Large larval habitats are treated by spreading chemical (temephos) or biological (Bacillus thuringiensis israelensis [Bti]) larvicides. Vegetation caring (weeding, mowing, destruction of thickets, trimming bushes, banning sheathed plants) completes these « around accommodations » measures by making military sites unfavorable to adult mosquitoes’ survival by eliminating their rest areas and stopping their movements [12]. Chemical actions against adult mosquitoes consist of spatial insecticide spraying (deltamethrin), using low volume-treatment sprayers. It is reserved for situations with important nuisance or for outbreak risks. In order to be effective, spatial spraying should be done during the activity hours of vectors. Thus, for night or late night Anopheles, day spraying is effectless [12]. Insecticides and sprayers are supplied for the troops in vector control packages. Field vector control is organized by mosquito control task forces led by the local French military commander.

5.2. Malaria chemoprophylaxis Completing mosquito protection measures, chemoprophylaxis is prescribed to servicemen after a medical consultation for ruling out possible contraindications. The physician will also have to assess individual factors (history of antimalarial drug side effects, female personnel, and medical history), destination (endemicity level, P. falciparum resistance level), type of stay (permanent, short time mission, operation) and occupation. Before 1990, chemoprophylaxis was based on chloroquine and from 1990 to 2000 on chloroquineeproguanil association (SSA antimalarial capsule). Between 2001 and 2002 two schemes were used: chloroquineeproguanil association for long duration deployments (two years) and mefloquine for short time missions. In 2003, after utilization in Co ˆte d’Ivoire from the end of 2002, doxycycline monohydrate progressively replaced the other prophylactic drugs. Its prophylactic efficacy was demonstrated in several studies conducted in different countries [20]. Considering deployment context and resistances development and in order to optimize compliance with homogeneous prescription, 100 mg daily doxycycline remains the first line chemoprophylaxis in 2013. However certain rules should be respected for limiting the gastro-intestinal side effects [7,21]. The pill should be taken during lunch with a large glass of water. In case of omission, doxycycline can be taken during dinner. This chemoprophylaxis should start upon departure day, be continued during all the stay and four weeks after leaving the endemic zone. A once weekly 250 mg mefloquine dose is indicated in case of contraindications or doxycycline side-effects. The drug should be ingested upon day 10 and day 3 before deploying, then once a week during deployment and finally for three additional

310 weeks upon return from the endemic destination. For subjects weighing less than 45 kg, in particular women, who represent 15% of the French armed forces numbers, dose is adapted (5 mg/kg). For deployments shorter than 7 days in low transmissionrisk zones (stay in downtown in air conditioned hotel, airport transit area, port of call), chemoprophylaxis is not mandatory. Strict execution of mosquito bite avoidance individual measures is strongly recommended as well as consulting a physician rapidly in case of symptoms (fever, headaches, asthenia) for a swift and appropriate treatment management. This scheme is defined as « standby emergency treatment strategy ». The 100 mg doxycycline monohydrate dose is well tolerated. Several surveys conducted in French military units confirmed it with 72%e81% of subjects stating no side effect. Side effects were benign and mainly gastro-intestinal [7,21,22]. Doxycycline half-life being short (one day), some omissions can facilitate the occurrence of malaria attack if the subject does not execute well the individual mosquito bite avoidance measures, thus exposing himself to bites of infected Anopheles. Since September 2002, French troops have been participating in the peace-keeping operation Licorne (Unicorn), in Co ˆte d’Ivoire. Thirteen thousands and five hundred forty three cases of malaria have thus been reported but most of these cases are believed to be the result of poor compliance with doxycycline [7,8]. Furthermore, several studies were carried out in the last years to assess the determining factors of chemoprophylaxis compliance in healthy service members during short or long term deployments in African endemic areas. One of these was a large prospective study on 19 military units regarding their compliance 15 days before the return to France and 15 days after return. The average prevalence rate of appropriate compliance was 46.2% (range: 9.6e76.6) according to units and destination). Poor compliance was significantly associated with evening activities, malaria medical history and awareness of mosquito attractiveness. Appropriate compliance was associated with routine use of vector control protection measures, type of operations and other individual factors » [23]. Hence, from 2002 to 2006, 1787 falciparum malaria cases were observed in French soldiers who were expected to take doxycycline. A surge in the number of malaria cases within three weeks after discontinuation of doxycycline prophylaxis is often observed after return [7,8]. This lack of compliance is particularly critical after return, as showed in a study carried out in 2006 in a unit which deployed four months to Co ˆte d’Ivoire and in which 17 malaria cases occurred in the first three weeks following the return. Chemoprophylaxis lack of compliance was reported 54.7% three weeks after return by history taking and 63.4% by measuring serum doxycycline [24]. Radical cure strategy upon return using an efficacious antimalarial is a possible solution for overcoming the lack of compliance upon return. It is based on the absence of P. falciparum liver hypnozoites. Routine treatment upon return from an endemic zone can eradicate plasmodial strains, henceforth preventing travel-related P. falciparum malaria cases. Its efficacy was demonstrated by the French Health Corps in a trial conducted in 1989 using halofantrine [25,26]. From 1992, severe halofantrine-related cardiac side effects were

R. Migliani et al. reported, cancelling this strategy. It could be again reconsidered if an antimalarial with no major side effects were available [25,26]. Direct observation therapy is not currently used in French armed forces. Close commanding staff is encouraged to verify if their men are taking their chemoprophylaxis but they do not have orders to directly observe their subordinates’ intake. In 2004, cutaneous infections as furuncles were observed, in soldiers returning from deployments. These reports allowed the identification of virulent doxycycline resistant Staphylococcus aureus strains with positive Panton-Valentine leukocidin circulating among troops. This emergence was related to the selection of pre-existing resistant strains in carriers under doxycycline chemoprophylaxis. The spreading of these strains in military units was facilitated by crowded and poor sanitary conditions [27]. One of the important limitations of our malaria prevention strategy is essentially due to the compliance and resistance of the service members regarding prevention messages. Thus, more effective actions are required in the fields of information, education and communication based on appropriate social and anthropological research.

5.3. Management of malaria cases Malaria prognosis is determined by early diagnosis and appropriate treatment. If fever is the major symptom, chills are absent in half of cases and other non-specific symptoms (digestive disorders, influenza-like syndrome) are frequently associated. This causes diagnosis confusions and late management. Henceforth, every fever, whatever associated symptoms are, after a stay in a malaria-endemic zone, requires an immediate medical consultation for malaria testing. Malaria biological diagnosis is an emergency and is based on the two «gold standard» associated techniques, thin and thick blood smears [28,29]. Malaria rapid diagnosis tests (RDT) are used as a complement to the reference techniques, they do not replace them [29]. These tests had good performances for detecting P. falciparum and Plasmodium vivax, but not for Plasmodium ovale or Plasmodium malariae species [30]. Two immunochromatographic tests are used in the armed forces, one since 2002 detecting Histidine Rich Protein-II (HRP2) antigen (BinaxNOW Malaria test,) and the other since 2004 screening for plasmodial lactate dehydrogenase (pLDH) (Core Malaria Pan/Pv/Pf) [31]. In isolated conditions in endemic zones, RDT are used as first-line tests by military doctors. However, many factors related either to the parasite or to the test may affect the performance of malaria RDTs. Although pLDH appears to be highly conserved, it has been reported that P. falciparum HRP2 (PfHRP2) sequence variations, particularly with regard to certain amino acid repeats, can affect the sensitivity of HRP2-based RDTs [31,32]. In addition, misdiagnosis may also arise from gene deletions that prevent the expression of proteins by the parasite. More recently, the deletions of PfHRP2 were reported as the causes of false negative diagnoses in populations from Senegal [33] and Mali [34]. Treatment management of malaria-infected soldiers in France or overseas follows the 2007 revised French national

Malaria control strategies in the French army recommendations [28] in appropriate and safe medical facilities. In isolated conditions, especially in deployed medical outpost, treatment of non-complicated P. falciparum malaria forms in the absence of gastro-intestinal side effects is based either on the piperaquine tetraphosphateedihydroartemisinin association since 2013, if no contraindications and with electrocardiographic monitoring, or on the atovaquone-proguanil association or on the artemetherelumefantrine association. This latter is only prescribed in hospitals. Injectable quinine, first-line treatment on the field since 2002 [7], is now reserved to noncomplicated forms in case of vomiting. P. falciparum malaria severe forms are medevaced to resuscitation units (intensive care units or operational medical units deployed overseas in military field hospitals). Since July 2013, first-line treatment is based on 60 mg IV artesunate, currently available by dispensation in deployed medical units (initial supply of 24 vials) provided that the therapeutic utilization protocol and the information collection is respected with a minimal 28 day follow-up. Injectable quinine loading dose is used when artesunate is unavailable. A switch to oral treatment should be done as soon as ingestion is possible. In the absence of vomiting, the treatment of Plasmodium vivax malaria contracted in French Guiana or in areas with low or nil prevalence of chloroquine resistance, is based on oral chloroquine. In areas with high prevalence of chloroquine resistance, treatment rests upon either per os quinine associated with an antibiotic possessing antimalarial activity (doxycycline or clindamycin) or recommended artemisininbased combined associations (ACT) for treating P. falciparum malaria. In case of vomiting, only IV quinine infusion with no loading dose is possible with oral switch as soon as possible. Severe forms are managed like P. falciparum severe forms. P. ovale attack treatment is similar to P. vivax. Radical treatment of P. vivax and P. ovale relapses is to be initiated upon the first attack and is based on 30 mg primaquine per day during 14 days [34,35]. Glucose-6-phosphate dehydrogenase deficiency screening is mandatory before starting treatment. P. malariae infection treatment rests upon chloroquine. Plasmodium knowlesi malaria treatment is identical to the one recommended for P. falciparum. No P. knowlesi malaria case was diagnosed in French forces.

5.4. Other measures for controlling malaria 5.4.1. Healthcare providers training Since the end of the eighties, physicians and nurses serving within the armed forces in malaria-endemic zones have been attending initial and continuing training on malaria control in the Val-de-Gra ˆce military health school and in civilian medical universities. During trainings on malaria control, physicians and nurses are informed about the importance of organizing additional information sessions on preventive measures to apply on the field during outbreaks, before transmission seasons, upon the occurrence of malaria-related fatality and when they notice a slackening of measures during the deployment. 5.4.2. Continuous education of servicemen Health education topics are addressed during the periodic health assessments of soldiers and during educational group

311 sessions prior to deployments. Special emphasis is made on educating officers and non-commissioned officers. Further sessions are recommended during deployment particularly before high-risk missions, after observing noncompliance with prophylactic measures or after occurrence of cases, during rotations or just after return to prevent postdeployment malaria attacks. Delivered educational messages emphasize on four essential attitudes: i) information on malaria and its prevention prior to departure, ii) execution during all the stay of individual mosquito bite protection measures each night from sunset to sunrise, iii) chemoprophylaxis uptake without omission starting from departure day, during all deployment and four weeks after return; iv) immediate consultation in case of malaria suggestive signs during mission and after return, especially fever. A survey conducted in 2005, on a representative sample of military doctors and nurses, showed that educational group sessions in military units were lectured by the majority of physicians (79%) and approximately half of nurses (51%) [36]. Most addressed topic was vector-borne diseases among which malaria. Doctors and nurses in charge of health education can refer to information brochures and posters designed by the SSA, available in the Health Corps supply units (Fig. 1) [37]. The reminder of malaria chemoprophylaxis uptake upon return by daily text messaging was assessed. No significant impact of this reminding method was observed. However, this study showed that this method is feasible and accepted and should be reevaluated [38]. 5.4.3. Epidemiological surveillance Since 1986, this surveillance rests upon military units’ physicians who must notify every Monday by email the malaria cases occurring the previous week in France and abroad, among the soldiers they medically support [39]. Malaria cases have a standardized definition: « every pathological manifestation associated with the presence of Plasmodium on thin or thick blood smears or positive QBC test or positive RDT ». RDTs were included in the definition in 2002. For each case, an anonymous form completes the emailed notification. It includes patient’s characteristics, place of occurrence, conditions and quality of chemoprophylaxis, clinical presentation, parasitological diagnosis, management details and course of the disease. Three clinical presentations are notified by physicians: simple attack with neither clinical nor biological severity signs, severe attack with at least one severity criterion (WHO classification) and atypical form which does not match one of these two definitions. Field investigations complete, if needed, the information collected by the routine notification system. The analysis of reported cases is made by the French JMHC center of epidemiology and public health (CESPA in French) which distributes weekly information bulletin to military doctors and analysis reports of malaria situation in armed forces every year. Fig. 2 shows the course of malaria incidence notified in French armed forces from 1982 to 2011. There was a first important increase of malaria due to the spread of P. falciparum chloroquine-resistant strains in West Africa at the end of the eighties. Several measures were rapidly implemented to control malaria: reinforcement of mosquito bites individual protection measures (repellents and insecticideimpregnated bed nets), substitution of chloroquine

312

R. Migliani et al.

Fig. 1

Set of educational posters on malaria designed by the French Medical Health Corps in 2006.

chemoprophylaxis with chloroquine (100 mg) e proguanil (200 mg) association daily intake. The efficacy of this combination was demonstrated by a study carried out by the health corps in many military units in 1989 [40]. After the reduction of malaria cases’ incidence, showing the efficacy of applied measures, a second important outbreak occurred during a military and humanitarian intervention in Africa [6]. Vector control measures were again reinforced with the creation of mosquito control task forces in 1997

and distribution of insecticide-treated combat suits to the troops in 1998 which effectiveness was also demonstrated by studies led by the SSA [41,42]. For troops deployed for short length missions, mefloquine (250 mg weekly uptake) was used as first-line chemoprophylaxis from 2001 to 2002. Malaria incidence was, at this period, at the same level as in the beginning of the eighties. This respite was of short time since the incidence increased again importantly at the end of 2002 with the start of the deployment in Co ˆte

Malaria control strategies in the French army

313

1200

1000

1000

202

Notified cases incidence

100

276 103 164

600

329

102 97

400

863 782

657

79 440

159 377 170

132

279

10 164 163

88 548 435

327

266 283 172

284

524

501 497

220

141

106

126

200

127

93

171

42

394 273

147

435

67 127

111

ncidence rate p 1000

195 800

305 279 180

105 95 256 267 165 174

171

0

1 1982

1984

1986

1988

1990

1992

1994

1996

Number of notified cases

1998

2000

Return incidence

2002

2004

2006

2008

2010

Incidence rate p.1000

Fig. 2 Reported number of malaria cases in endemic areas in French armed forces from 1982 to 2011** (Source: Department of epidemiology and public health of the French armed forces).* The numbers of persons exposed to risk are unavailable for incidence rate calculation before 1986.

d’Ivoire [7] and illegal gold panning control operations in French Guiana [9]. This phase was marked by the highest frequency of malaria cases occurring upon return particularly from Co ˆte d’Ivoire. The importance of deployed forces in this country (up to 4500 soldiers) and the cycle of rotations (every four months) explain partially this increased frequency of malaria cases. Since the end of 2002, daily uptake of doxycycline monohydrate (100 mg) has been used for chemoprophylaxis. From 2008, due to decreased

sensitivity of P. falciparum strains to chloroquineeproguanil association especially in Africa [43], doxycycline became the first line prophylaxis for all French forces in endemic zones. The incidence is currently stable at a level close to the one in early eighties, due to the major withdrawal from Co ˆte d’Ivoire. Regarding the evolution of reported malaria incidence in the French military in main endemic countries or territories (Figs. 3 and 4), there has been a global decreasing tendency

1000 Sénégal

Incidence p 1000 persons

Côte d'Ivoire

100 Tchad

Cameroun

10 Centrafrique

Gabon

1 1994

1996

1998

2000

2002

2004

2006

2008

2010

Fig. 3 Reported incidence of malaria according to the presumed location of infection in French armed forces from 1994 to 2011 in west and central African countries (Source: Department of epidemiology and public health of the French armed forces).

314

R. Migliani et al. 1000

DjibouƟ

100

Incidence p 1000 persons

MayoƩe

10

Guyane

1 1994

1996

1998

2000

2002

2004

2006

2008

2010 Afghanistan

0

Fig. 4 Reported incidence of malaria according to the presumed location of infection in French armed forces from 1994 to 2011 in other countries (Source: Department of epidemiology and public health of the French armed forces).

since 1994 except in French Guiana where an augmentation of P. vivax [44] cases was observed. Disparities have also been described between the areas with countries where incidence is respectively high (Co ˆte d’Ivoire, Gabon, Central African Republic, Cameroon), intermediate (Chad, Senegal) or low (Djibouti, Afghanistan, Mayotte) associated with malaria endemicity level. From 1986 to 2011, 13,543 malaria cases were identified in the armed forces out of which 71% occurred in endemic zones. Upon return, 80% of attacks happened in the first four weeks. Simple malaria attacks with favorable outcome represented 95.1% of all cases and severe presentations 2.2% with eleven deaths out of which five occurred in Gabon or upon return from this country. The remaining 2.7% of patients presented with atypical manifestations of malaria. P. falciparum species was responsible for 78.1% of attacks, P. vivax 16.4%, P. ovale 4.5% and P. malariae 1.0%. Between 2002 and 2006, we observed a frequency step-up of P. ovale attacks due to the deployment to Co ˆte d’Ivoire [45]. From 1998, incidence of French Guiana-related P. vivax cases rose. This was a consequence of concomitant arrival of populations from bordering Brazil and Surinam where P. vivax infection prevalences are high and intensification of illegal gold panning control operations by French troops in French Guiana [44]. Since 2004, the French Medical corps has been developing a space surveillance system of epidemics, first in French Guiana then in Djibouti, in order to currently form a global surveillance system during deployments named ASTER which in French stands for Alerte et surveillance en temps re ´el (real time alert and surveillance) [46]. This system, in the development process, allows an early detection of outbreaks in armed forces, particularly the vector-borne diseases. As a consequence, it leads to rapid and appropriate reactions as in French Guiana in 2006 [47] or in Djibouti in 2011.

5.4.4. Surveillance of parasite chemosensitivity When a P. falciparum malaria case is confirmed, a venous blood sample must be taken, and transported, at þ4  C, in less than 24 h, to the South National reference center in Marseille for the chemosensitivity analysis of the strain. This transportation time is often difficult to respect and few strains are screened each year. Thus, for example, only 3% of blood samples were analyzed out of the 1776 Co ˆte d’Ivoire-related malaria cases between 2003 and 2006 [48]. The methods used for strain testing are standardized. The in vitro resistance to several antimalarials is estimated according to threshold values [49,50]. Another possibility to assess the level of in vitro resistance to antimalarial drugs is to conduct studies on field P. falciparum isolates in areas in where are deployed French soldiers, such as Gabon, Senegal or Djibouti [51e54]. The surveillance of P. falciparum and P. vivax susceptibility to antimalarials can also be assessed by the evaluation of molecular markers of resistance to chloroquine, proguanil, atovaquone or doxycycline [55e58]. 5.4.5. Research activities Malaria-related research in armed forces aims to compensate for deficits in prevention, diagnosis and treatment. Civil research has its limits regarding the specificities of malaria control in the military. This is why the military medical corps has created in 1980 a research unit dedicated to malaria at the Institute of tropical medicine of the SSA (IMTSSA in French) e Le Pharo in Marseille (which has been closed permanently since July 2013). Many tasks were accomplished in more than 30 years. The main studies conducted by this unit were the assessment of P. falciparum chemosensitivity with the establishment in 1987 of in vitro tests, the measuring of antimalarials plasma levels, clinical trials on doxycycline as a prophylactic drug, screening for new antimalarials and search for novel

Malaria control strategies in the French army therapeutic and prophylactic targets [50]. As an example, receptors were discovered for the design of a vaccine blocking cytoadherence of invaded red cells [59]. A second research unit in parasite biology and epidemiology, created in 2004, has also initiated studies on the evaluation and prediction of vector-borne diseases’ impact and on the epidemiological determinants of P. falciparum population dynamics in order to deduce implications in malaria control and resistance limitation [60e64]. This unit works on identification and validation of new molecular markers of resistance to antimalarial drugs such as quinine, artemisinin derivatives, piperaquine, pyronaridine or pyrimethamine [65e70] and evaluates in vitro activity and efficacy of potential antimalarial drugs such as ferrocene derivatives and ferroquine now in clinical trial [67] or piperaquine and pyronaridine now commonly used [71] or drugs effective in experimental cerebral malaria murine model such as methylene blue or atorvastatin [72e74]. Regarding malaria-related research in the armed forces, two projects are currently in the works. The first one is a consequence of the increased malaria incidence in soldiers deployed to French Guiana in the last decade [44]. It is a three-year cohort study launched in January 2013 that will include 2000 soldiers and gendarmes deployed in malariaendemic zones. This research project aims to understand the determinants of malaria infection and of compliance with preventive measures. It is coordinated by two military doctors, a researcher of the biomedical research institute of armed forces (IRBA in French) and an epidemiologist from the CESPA. The second project is the development of a dipstick that identifies antimalarial drugs’ urinary metabolites, among which doxycycline, to monitor on the field the compliance with chemoprophylaxis [75]. An evaluation of this test’s validity will be carried out in the forces deployed to French Guiana.

6. Conclusion The French SSA has a long experience in malaria control dating from the 19th century due to the deeds of two military physicians, Franc ¸ois Cle ´ment MAILLOT and Alphonse LAVERAN. The first one revolutionized malaria treatment by using quinine during the conquest of Algeria and the second one discovered the parasite in 1880 in Constantine, Algeria. These last 30 years, at each increase of malaria incidence in the French armed forces, the French SSA responded with a significant impact. However, these successes have remained frail due to possible resistance of parasites to antimalarial drugs, of mosquito vectors to insecticides and of men to the good use of provided protection measures. This strongly emphasizes the relevance of maintaining research and expertise in tropical medicine regarding malaria and entomology within the French SSA. It also highlights the importance of multidisciplinary approach to malaria control, such as illustrated by the cohort project in French Guiana. Field general practitioners, infectiologists, microbiologists, epidemiologists, entomologists, sociologists, anthropologists, researchers as well as military users, all united, form the essential elements of the efforts for controlling malaria. Only this organized approach through coordinated union of experts, participation of the military

315 community and evidence-based preventive measures can roll back malaria in armed forces.

Conflict of interest This work was never published. The authors state no conflict of interest.

References [1] Boutin JP, Pradines B, Page `s F, Legros F, Rogier C, Migliani R. Epide ´miologie du paludisme. La revue du praticien 2005;55: 833e40. [2] Aubry P. L’expe ¸aise de Madagascar de 1895. Un ´dition franc de ´sastre sanitaire. Pourquoi. Med Armees 1979;7:745e51. [3] Sergent Ed, Sergent Et. L’arme ´e d’Orient de ´livre ´e du paludisme. Paris: Charles-Lavauzelle ed.; 1932. p. 91. [4] Sergent Ed, Sergent Et. La prophylaxie antipaludique d’une arme ´e en campagne (Arme ´e d’Orient 1917). Bull Soc Path Exot 1918;11:641e8. [5] Adubofour KO. Drug resistance in malaria: a review of the West African situation. J Natl Med Assoc 1992;84:1025e9. [6] Pascal B, Baudon D, Keundjian A, Fusai T, Cochet P, Soupault JF, et al. Epide ´mie de paludisme au cours d’une intervention militaro-humanitaire en Afrique. Med Trop 1997;57:253e5. [7] Migliani R, Josse R, Hovette P, Keundjian A, Pages F, Meynard JB, et al. Le paludisme vu des tranche ´es, le cas de la Co ˆte d’Ivoire en 2002e2003. Med Trop 2003;63:282e6. [8] Migliani R, Page `s F, Josse R, Michel R, Pascal B, Baudon D. Epide ´mies de paludisme sur les the ´a ˆtres d’ope ´rations. Med Armees 2004;32:293e9. [9] Michel R, Ollivier L, Meynard JB, Guette C, Migliani R, Boutin JP. Outbreak of malaria among policemen in French Guiana. Mil Med 2007;172:977e81. [10] BEH 22-23/2013 Recommandations sanitaires pour les voyageurs; 2013. pp. 249e56. [11] Deparis X, Boutin JP, Michel R, Galoisy-Guibal L, Meynard JB, Page `s F, et al. La strate ´gie de lutte antivectorielle dans les Arme ¸aises. Med Trop 2001;61:87e90. ´es Franc [12] Page `s F. La lutte antivectorielle dans les arme ´es, une ne ´cessite ´ historique, une adaptation indispensable. Med Trop 2009;69:165e72. [13] Boutin JP, Ribie `re O, Van Cuyck H, Malosse D. Pour une veille sanitaire de de ´fense. Med Armees 2004;32:366e72. [14] Coffinet T, Rogier C, Page `s F. Evaluation de l’agressivite ´ des anophe `les et du risque de transmission du paludisme: me ¸aises. Med Trop ´thodes utilise ´es dans les Arme ´es franc 2009;69:109e22. [15] Girod R, Orlandi-Pradines E, Rogier C, Page `s C. Malaria transmission and insecticide resistance of Anopheles gambiae (Diptera: Culicidae) in the French military camp of PortBoue ¨t, Abidjan (Co ˆte d’Ivoire): implication for vector control. J Med Entomol 2006;43:1082e7. [16] Gadiaga L, Machault V, Page `s F, Gaye A, Jarjaval F, Godefroy L, et al. Conditions of malaria transmission in Dakar from 2007 to 2010. Malar J 2011;10:312. [17] Mourou JR, Coffinet T, Jarjaval F, Cotteaux C, Pradines B, Godefroy L, et al. Malaria transmission in Libreville: results of a one year survey. Malar J 2012;11:40. [18] Orlandi-Pradines E, Rogier C, Koffi B, Jarjaval F, Bell M, Machault V, et al. Major variations in malaria exposure of travellers in rural areas: an entomological cohort study in western Co ˆte d’Ivoire. Malar J 2009;8:171. [19] PPAV Working Groups. Personnal protection against biting insects and ticks. Parasite 2011;18:93e111.

316 [20] Briolant S, Almeras L, Fusaı¨ T, Rogier C, Pradines B. Cyclines et paludisme. Med Trop 2007;67:86e96. [21] Page `s F, Boutin JP, Meynard JB, Keundjian A, Ryfer S, Giuriato I, et al. Tolerability of doxycycline monohydrate salt vs chloroquine-proguanil in malaria prophylaxis. Trop Med Int Health 2002;7:919e24. [22] Meynard JB, Bouton JE, Chapoix N, Ce ´sar JF, Thomas E, ´valuation de l’observance et de la tole Ollivier L, et al. E ´rance de la chimioprophylaxie antipalustre au sein des forces franc ¸aises en Co ˆte d’Ivoire. Med Armees 2005;33:57e60. [23] Resseguier N, Machault V, Ollivier L, Orlandi-Pradines E, Texier G, Pradines B, et al. Determinants of compliance with malaria chemoprophylaxis among French soldiers during missions in inter-tropical Africa. Malar J 2010;9:41. [24] Ollivier L, Michel R, Carlotti MP, Mahe ´ P, Romand O, Todesco A, et al. Chemoprophylaxis compliance in a French battalion after returning from malaria-endemic area. J Travel Med 2008;15:355e7. [25] Baudon D, Bernard J, Mouliat-Pelat JP, Martet G, Sarrouy J, Touze JE, et al. Efficacite ´ de la cure radicale d’halofantrine sur la pre ´vention du paludisme importe ´ a ` Plasmodium falciparum. Ann Soc Belg Med Trop 1992;72:263e70. [26] Touze JE, Peyron F, Mojon M, Fourcade L. Halofantrine: vers des nouvelles re ´gles de prescriptions. Presse Med 1995;24: 366e9. [27] Lesens O, Haus-Cheymol R, Dubrous P, Verret C, Spiegel A, Bonnet R, et al. Methicillin-susceptible, Doxycyclineresistant Staphylococcus aureus, Co ˆte d’Ivoire. Emerg Infect Dis 2007;13:488e90. [28] Stahl JP, Chidiac C, Bru JP, choutet P, Decazes JM, Dubreuil L, et al. Prise en charge et pre ´vention du paludisme d’importation a ` Plasmodium falciparum. Recommandations pour la pratique clinique 2007 (Re ´vision de la Confe ´rence de consensus de 1999). Med Mal Infect 2008;38:68e117. [29] http://www.cdc.gov/malaria/diagnosis_treatment/ microscopy.html. [30] Marx A, Pewsner D, Egger M, Nu ¨esch R, Bucher HC, Genton B, et al. Meta-analysis: accuracy of rapid tests for malaria in travelers returning from endemic areas. Ann Intern Med 2005;142:836e46. [31] De Pina JJ, Garnotel E, Hance P, Vedy S, Rogier C, Morillon M. Diagnostic du paludisme d’importation en France. Med Mal Infect 2007;37:710e5. [32] Wurtz N, Briolant S, Lemarie ´ D, Pommier de Santi V, Pascual A, Roodt T, et al. Retard de diagnostic d’un acce `s palustre a ` Plasmodium falciparum chez un militaire en Ouganda : ne ´gativite ´ des tests de diagnostic rapide associe ´e a ` un polymorphisme de l’antige `ne HRP2. Med Sante Trop 2013;23:181e4. [33] Wurtz N, Fall B, Bui K, Pascual A, Fall M, Camara C, et al. Pfhrp2 and pfhrp3 polymorphisms in Plasmodium falciparum isolates from Dakar, Senegal: impact on rapid malaria diagnostic tests. Malar J 2013;12:34. [34] Koita OA, Doumbo OK, Ouattara A, Tall LK, Konare ´ A, Diakite ´ M, et al. False-negative rapid diagnosis tests for malaria and deletion of the histidine-rich repeat region of the hrp2 gene. Am J Trop Med Hyg 2012;86:194e8. [35] Oliver M, Simon F, de Monbrison F, Beavogui AH, Pradines B, Ragot C, et al. Le nouvel a ˆge de la primaquine contre le paludisme. Med Mal Inf 2008;38:169e79. [36] de Laval F, Oliver M, Rapp C, Pommier de Santi V, Mendibil A, Deparis X, et al. The challenge of diagnosing Plasmodium ovale malaria in travellers: report of six clustered cases in French soldiers returning from West Africa. Malar J 2010;9: 358. [37] Migliani R, Ollivier L, Queyriaux B, Mare ´chal M, Michel R, ´valuation des pratiques, des attentes et des Boutin JP. E

R. Migliani et al.

[38]

[39]

[40]

[41]

[42] [43]

[44]

[45]

[46]

[47]

[48]

[49]

[50]

[51]

[52]

besoins en matie `re d’e ´ducation sanitaire collective dans les arme ´es en 2005. Med Trop 2008;36:55e60. Migliani R, Michel R, Ollivier L, Queyriaux B, Richard V, Martin P, et al. De nouveaux outils de pre ´vention du paludisme dans les arme ´es. XXIIes Actualite ´s du Pharo (CA-72). Med Trop 2006;66:399. Ollivier L, Romand O, Marimoutou C, Michel R, Pognant C, Todesco A, et al. Use of short message service (SMS) to improve malaria chemoprophylaxis compliance after returning from a malaria endemic area. Malar J 2009;8: 236e43. Ollivier L, Romand O, Pommier de santi V, Todesco A, Page `s F, Haus-Cheymol R, et al. Surveillance e ´pide ´miologique du paludisme dans les arme ´es. Bull Epidemiol Hebdo 2006;2008(23e24):206e9. Sarrouy J, Cellier C, Migliani R, Todesco A, Favier G, Linden L, et al. Chimioprophylaxie du paludisme a ` Plasmodium falciparum par une association de 100 mg de chloroquine et de 200 mg de proguanil par jour dans une zone III de chloroquino-re ´sistance (Gabon). Etude chez 431 militaires franc ¸ais. Bull Soc Path Exot 1991;84: 80e93. Deparis X. L’expe ´rience des tenues de combat impre ´gne ´es. Bull Soc Path Exot 2001;94:166e7. Deparis X, Frere B, Lamizana M, N’Guessan R, Leroux F, Lefevre P, et al. Efficacy of permethrin-treated uniforms in combination with DEET topical repellent for protection of French military troops in Co ˆte d’Ivoire. J Med Entomol 2004; 41:914e21. Centre national de re ´fe ´rence du Paludisme. Proposition de modification des recommandations de pre ´vention du paludisme pour cinq pays d’Afrique de l’Ouest. Bull Epidemiol Hebdo 2008;19:167. Queyriaux B, Texier G, Ollivier L, Galoisy-Guibal L, Michel R, Meynard JB, et al. Plasmodium vivax malaria among military personnel, French Guiana, 1988e2008. Emerg Infect Dis 2011;17:1280e2. Migliani R, Ollivier L, Romand O, Verret C, Haus-Cheymol R, Todesco A, et al. Paludisme chez les militaires franc ¸ais en Co ˆte-d’Ivoire de 1998 a ` 2006. Bull Epidemiol Hebdo 2008;2324:209e12. Meynard JB, Chaudet H, Texier G, Dupuy B, Queyriaux B, Pellegrin L, et al. Militaires franc ¸ais en ope ´rations exte ´rieures : avantages et limites de la surveillance en temps re ´el. Bull Epidemiol Hebdo 2008;23-24:213e7. Meynard JB, Chaudet H, Texier G, Ardillon V, Ravachol F, Deparis X, et al. Value of syndromic surveillance within the armed forces for early warning during a dengue fever outbreak in French Guiana in 2006. BMC Med Inform Decis Mak 2008;8:29. Briolant S, Baragatti M, Parola P, Simon F, Tall A, Sokhna C, et al. Multinormal in vitro distribution model suitable for the distribution of Plasmodium falciparum chemosusceptibility to doxycycline. Antimicrob Agents Chemother 2009;53: 688e95. Pradines B, Hovette P, Fusai TH, Atanda L, Baret E, Cheval P, et al. Prevalence in vitro resistance to eleven standard or new antimicrobial drugs among Plasmodium falciparum isolates from Pointe-Noire, Republic of Congo. J Clin Microbiol 2006;44:2404e8. Parzy D, Rogier C, Keundjian A, Fusaı¨ T, Pradines B, Sinou V. Recherche sur le paludisme a ` l’IMTSSA Le Pharo. Med Trop 2001;61:11e4. Fall B, Pascual A, Sarr FD, Wurtz N, Richard V, Baret E, et al. Plasmodium falciparum susceptibility to anti-malarial drugs in Dakar, Senegal, in 2010: an ex vivo and drug resistance molecular markers study. Malar J 2013;12:107.

Malaria control strategies in the French army [53] Pradines B, Mamfoumbi MM, Tall A, Sokhna C, Koeck JL, Fusai T, et al. In vitro activity of tafenoquine against the asexual blood stages of Plasmodium falciparum isolates from Gabon, Senegal, and Djibouti. Antimicrob Agents Chemother 2006;50:3225e6. [54] Rogier C, Pradines B, Bogreau H, Koeck JL, Kamil MA, Mercereau-Puijalon O. Malaria epidemic and drug resistance, Djibouti. Emerg Infect Dis 2005;11:317e21. [55] Pradines B, Fusai T, Daries W, Laloge V, Rogier C, Millet P, et al. Ferrocene-chloroquine analogues as antimalarial agents: in vitro activity of ferrochloroquine against 103 Gabonese isolates of Plasmodium falciparum. J Antimicrob Chemother 2001;48:179e84. [56] Wurtz N, Fall B, Pascual A, Diawara S, Sow K, Baret E, et al. Prevalence of molecular markers of Plasmodium falciparum drug resistance in Dakar, Senegal. Malar J 2012;11:197. [57] Wurtz N, Pascual A, Marin-Jauffre A, Bouchiba H, Benoit N, Desbordes M, et al. Early treatment failure during treatment of Plasmodium falciparum malaria with atovaquoneproguanil in the Republic of Ivory Coast. Antimicrob Agents Chemother 2012;56:3467e9. [58] Briolant S, Wurtz N, Zettor A, Rogier C, Pradines B. Susceptibility of Plasmodium falciparum isolates to doxycycline is associated with pftetQ sequence polymorphisms and pftetQ and pfmdt copy numbers. J Infect Dis 2010;201:153e9. [59] Mint Lekweiry K, Ould Mohamed Salem Boukhary A, Gaillard T, Wurtz N, Bogreau H, Hafid JE, et al. Molecular surveillance of drug-resistant Plasmodium vivax using pvdhfr, pvdhps and pvmdr1 markers in Nouakchott, Mauritania. J Antimicrob Chemother 2012;67:367e74. [60] Parzy D, Fusaı¨ T, Pouvelle B, Torrentino M, Eustacchio F, Le ´polard C, et al. Recombinant human thrombomodulin (csaþ): a tool for analyzing Plasmodium falciparum adhesion to chondroitin-4-sulfate. Microb Infect 2000;2:779e88. [61] Machault V, Orlandi-Pradines E, Michel R, Pages F, Texier G, Pradines B, et al. Remote sensing and malaria risk for military personnel in Africa. J Travel Med 2008;15:216e20. [62] Sagui E, Resseguier N, Machault V, Ollivier L, OrlandiPradines E, Texier G, et al. Determinants of compliance with anti-vectorial protective measures among non-immune travellers during missions to tropical Africa. Malar J 2011; 10:232. [63] Texier G, Machault V, Barragi M, Boutin JP, Rogier C. Environmental determinant of malaria cases among travellers. Malar J 2013;12:87. [64] Eboumbou Moukoko EC, Bogreau H, Briolant S, Pradines B, Rogier C. Distinguabilite ´ des populations de Plasmodium falciparum pour la recherche clinique. Med Trop 2009;69: 613e7.

317 [65] Abdi Khaireh B, Assefa A, Guessod HH, Basco LK, Abdi Khaireh M, Pascual A, et al. Population genetics analysis during the elimination process of Plasmodium falciparum in Djibouti. Malar J 2013;12:201. [66] Henry M, Briolant S, Zettor A, Pelleau S, Baragatti M, Baret E, et al. Plasmodium falciparum Naþ/Hþ exchanger 1 transporter is involved in reduced susceptibility to quinine. Antimicrob Agents Chemother 2009;53:1926e30. [67] Deplaine G, Lavazec C, Bischoff E, Natalang O, Perrot S, Guillotte-Blisnick M, et al. Artesunate tolerance in transgenic Plasmodium falciparum parasites overexpressing a tryptophan-rich protein. Antimicrob Agents Chemother 2011; 55:2576e84. [68] Briolant S, Henry M, Oeuvray C, Amalvict R, Baret E, Didillon E, et al. Absence of association between piperaquine in vitro responses and polymorphisms in the pfcrt, pfmdr1, pfmrp, and pfnhe genes in Plasmodium falciparum. Antimicrob Agents Chemother 2010;54:3537e44. [69] Briolant S, Bogreau H, Gil M, Bouchiba H, Baret E, Amalvict R, et al. The F423Y mutation in the pfmdr2 gene and mutations N51I, C59R, and S108N in the pfdhfr gene are independently associated with pyrimethamine resistance in Plasmodium falciparum isolates. Antimicrob Agents Chemother 2012;56: 2750e2. [70] Andrianatsoanirina V, Durand R, Pradines B, Baret E, Bouchier C, Ratsimbasoa A, et al. In vitro susceptibility to pyrimethamine of DHFR I164L single mutant Plasmodium falciparum. Malar J 2011;10:283. [71] Dubar F, Egan TJ, Pradines B, Kuter D, Ncokazi KK, Forge D, et al. The antimalarial ferroquine: role of the metal and intramolecular hydrogen bond in activity and resistance. ACS Chem Biol 2011;6:275e87. [72] Pascual A, Parola P, Benoit-Vical F, Simon F, Malvy D, Picot S, et al. Ex vivo activity of the ACT new components pyronaridine and piperaquine in comparison with conventional ACT drugs against isolates of Plasmodium falciparum. Malar J 2012;11:45. [73] Dormoi J, Briolant S, Pascual A, Desgrouas C, Travaille ´ C, Pradines B. Improvement of the efficacy of dihydroartemisinin with atorvastatin in an experimental cerebral malaria murine model. Malar J 2013;12:302. [74] Dormoi J, Pradines B. Dose responses of proveblue methylene blue in an experimental murine cerebral malaria model. Antimicrob Agents Chemother 2013;57:4080e1. [75] Fusaı¨ T, Egglete TA, Pascual A, Bourdon S, Durand C, Martelloni M, et al. De ´tection des mole ´cules antipaludiques utilise ´es en chimioprophylaxie par immunocapture : un nouvel outil de terrain pour l’analyse de l’observance. XXIIIes Actualite ´s du Pharo (CO-Y07). Med Trop 2007;67:376.