Clare Daly (Dublin Fingal, Independent)
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48. To ask the Taoiseach and Minister for Defence if he will provide the detailed medical advice given by the medical corps and the medical officer of the Defence Forces that states Lariam is the most suitable drug for members of the Defence Forces in sub-Saharan Africa. [33808/16]

Paul Kehoe (Wexford, Fine Gael)
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I already provided the information sought by the Deputy to this question on 18 October, 2016 in written PQ 20561/16. I am happy to provide the information to the Deputy again.

The health and welfare of the men and women of the Defence Forces is a high priority for me and the Defence Forces.

Malaria is a serious disease which killed approximately 438,000 people in 2015, with 90% of deaths occurring in sub-Saharan Africa as reported by the World Health Organisation.  It is a serious threat to any military force operating in the area.

There are three anti-malarial drugs, in use in the Defence Forces:

- Lariam (Mefloquine);

- Malarone; and

- Doxycycline.

The choice of medication is a medical decision made by Medical Officers in the Defence Forces having regard to the specific circumstances of the mission and the individual member of the Defence Forces. That position has not changed.

  The Defence Forces Director Medical Branch issues instructions on matters of medical policy. Current DMB Instruction No. 52 amendment No. 1, dated 24 August 2016 provides for Vaccinations and Other preparations for Overseas Deployments. Paragraphs 5 to 8 deal specifically with the use of malaria prophylaxis and provides for the following:

5. Please note that the ‘default’ chemoprophylaxis against Malaria, in Sub-Saharan missions and other areas where the predominant species is Plasmodium falciparum and where there is no evidence of resistance to it in the region, is Mefloquine (Lariam) 250mg weekly. Mefloquine is the only ‘once weekly’ medication currently available as a chemoprophylactic agent for Malaria. The dosing regimen is particularly suitable for the deployed soldier, given that he/she has minimal control over the operational environment on a day to day basis, thus increasing the risk of missing a dose of a daily medication. To be effective Mefloquine must be started two (2) weeks prior to deployment and should, if possible, be started four (4) weeks prior to departure in order to allow accommodation to minor and tolerable side-effects or to determine the appearance of intolerable side-effects or contraindications. Where operational imperatives demand immediate deployment without any ‘lead-in’ period, Mefloquine is not appropriate as a chemoprophylactic agent and one of the daily medications (Doxycycline or Malarone) should be used instead. All Medical Officers should familiarise themselves in detail with the contraindications and side-effect of all prescribed medications. To this end, the Health Products Regulatory Authority (HPRA) website can be consulted. Where an individual has an intolerance or sensitivity or contraindication to the use of Mefloquine, he/she should not be prescribed Mefloquine and should be ‘stood down’ from that particular deployment. In the event of there being no other person available within the Defence Forces with the particular skills set required for the mission, derogation may be sought from the appropriate authority to permit use of an alternative medication. As in all such circumstances the risk benefit ratio will become the determining factor in the recommendation from the Office of DMB to DCOS Sp.

6. In all other areas where troops are to be deployed and where malaria is endemic, the chemoprophylactic agent(s) will be dictated by the predominant species of plasmodium in the area as well as the resistance patterns to the various agents. For example, currently Doxycycline is the recommended first line chemoprophylactic agent for the malaria season in Afghanistan.

7. Irrespective of which agent is used, all deploying personnel should be made aware of the steps to be taken to minimise mosquito bites in the first place e.g. long sleeves, unexposed legs, use of insect repellant on face and neck and other exposed areas, mosquito nets etc etc.

8. There is a requirement for personnel returning to Ireland from deployment in a malarious and/or tropical or Sub Saharan mission/area to be provided with the following medications on repatriation and to be advised on the importance and necessity of course completion:

a. Primaquine 15mgs twice daily for 14 days.

b. Mefloquine (Lariam) 250mgs weekly for 4 weeks.

c. Mebendazole 100mgs twice daily for 3 days.

The above regime should commence following repatriation so that the Primaquine and Mebendazole regime is taken concurrently with the last 2 weeks of the Lariam prophylaxis regime.”

Defence Forces Regulations A.12. (Medical Treatment) provides for medical examination of all members of the Permanent Defence Force. The Defence Forces Director Medical Branch instruction No. 40 Medical Examinations amendment No. 3, dated 6 September, 2012 paragraph 5 provides for individual screening and assessment of members of the Defence Force who present for Overseas Medical Examinations. This paragraph provides that the individual member will be:

“subjected to a full medical examination with particular emphasis being given to the physical and psychological demands of the mission and the patient’s age and suitability for the specific environment, the proposed vaccinations and any relevant chemo prophylactic agent which may be required.”

  The current policy is consistent with previous policy in relation to malaria prophylaxis. The Defence Forces policy, in relation to the use of anti-malaria medication, including Lariam, is in line with current summary of product characteristics and product manufacturer’s guidelines.

  Where malaria has been identified as a risk in a particular mission area, the choice of chemoprophylaxis medication is dependent on a number of factors including the type of malaria in the destination, resistance to particular drugs, the profile of the traveller (contra-indications, underlying health conditions, purpose of travel), the duration of travel and adherence issues.

  Significant precautions are taken by Defence Forces Medical Officers in assessing the medical suitability of members of our Defence Forces to take any of the anti-malarial medications. It is the policy of the Defence Forces that personnel are individually screened for fitness for service overseas and medical suitability.

The use of and the information on medications is kept under ongoing review. As I already indicated, the health and welfare of the Defence Forces is a priority for me and the Defence Forces and this will continue to inform the approach to the issue of Lariam.