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Chapter 6

Contents

CHAPTER VI

Africa-Middle East Theater

John W. H. Rehn, Ph. D.

    In Africa and the Middle East, U.S. military strength was small, and troops were spread over an enormous territory. Although some combat occurred within the area, American activities, with the exception of air combat forces, were fundamentally those of transport, supply, and liaison. Tortuous supply routes, particularly for air transport, necessitated numerous bases. Many of them were of an emergency or secondary character, and were lightly staffed. While some portions of the area were as malarious as any in the world, others were nonmalarious. As geographic, climatologic, and biologic conditions were very diverse, the programs developed were, in general, to meet local conditions. Administrative commands and boundaries were frequently changed, so that a decentralized method of malaria control and prevention was followed.

    The discussion of malaria in the Africa-Middle East theater 1 is divided into a general consideration, supplemented by more detailed accounts of activities in Liberia and in the Persian Gulf. This division has been made because of biologic and administrative differences in these areas and because of limitations of available information.

    The Liberian area had considerable contact with Central and other West African areas. Moreover, more detailed information is available for it and certain other small areas than is obtainable for the whole region. The Persian Gulf area, in addition to its geographic separation, differs significantly from all the other areas and within itself shows considerable diversity. Each of these areas was an independent command for at least a portion of the period covered.

    In addition to a discussion of the general development there has been appended a brief résumé of the growth of the Air Transport Command and associated service commands. Because of their virtually independent development, a combined account might present a confused picture.

1Except as otherwise indicated, data in this chapter are derived from: Billick, E. W., and Vickery, E. L. : History of the Medical Section. Africa-Middle East Theater, September 1941 to September 1945, vols. I and II [Official record.]


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MILITARY DEVELOPMENT

General Considerations

    On 13 September 1941, the President of the United States, in a memorandum to the Secretary of War, requested that arrangements be made at the earliest practicable time for the establishment and operation of depots in the Middle East for the maintenance and supply of American aircraft and all types of ordnance furnished the British in that area. The U.S. Military North African Mission was immediately formed and sent to Egypt, where it arrived in Cairo on 22 November 1941. Contact was made to select housing, develop plans, and choose sites for bases. British, civilian, and captured records and reconnaissance surveys of Eritrea, Egypt, Anglo-Egyptian Sudan, and Palestine were utilized. In Egypt, the projects included ordnance shops as well as engineer and signal repair installations. Smaller scale activities of a similar type were planned for Palestine. At Port Sudan and in Eritrea, it was proposed to have Air Corps repair depots, ordnance repair shops, a naval base, and port facilities.

    Since the United States was at that time a nonbelligerent, the Army could not build and staff the proposed installations itself, but it was responsible for the planning and supervision. The President had written: "The British authorities should be consulted on all details as to location, size and the character of depot and transport facilities. Their needs should govern."

    The Japanese attack on Pearl Harbor changed the status of all U.S. Army activities. Construction was accelerated, militarization of the Mission between 10 April and 19 June 1942 was accomplished, and the region was consolidated into a theater of operations known as USAFIME (U.S. Army Forces in the Middle East). Service commands were organized in the various areas. The Iranian Mission was included among USAFIME. When Egypt was jeopardized by the campaign in the desert in June 1942, the Trans-Africa Road Reconnaissance Party made an investigation of a supply route across Africa on the southern fringe of the Sahara Desert from Khartoum in the Anglo-Egyptian Sudan to Lagos, Nigeria. Seven out of ten of the reconnaissance party contracted malaria. Fortunately it was not necessary to develop this alternate route.

The U.S. Army Middle East Air Force was established on 28 June 1942 and on 12 November was designated the Ninth Army Air Force, while the U.S. Army Ground Forces in the Middle East was organized on 16 August 1942.

    A reorganization on 11 August 1942 resulted in the forming of the Eritrea, Delta, Levant, and Persian Gulf Service Commands (map 14). The Libyan Service Command, which originated on 7 December 1942, functioned until the end of May 1943 (map 15) and was then divided into base commands.


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MAP 14.- U.S. Army Forces in the Middle East, jurisdictional map, 1942.

    By 13 May 1943, all organized resistance in North Africa had ended. Preventive medicine, with the problem of malaria control topping the list, had been of the greatest importance in all operations.

    The base commands established in the former Libyan Service Command were disbanded in September and November 1943. The Suez Canal Port Command was discontinued as a separate entity, and all were reabsorbed into the Delta Service Command.

    In September 1943, the U.S. Army Forces in Central Africa were incorporated into the USAFIME and redesignated the West African Service Command. U.S. Forces in Liberia came into the theater without a change of name. The Persian Gulf Service Command was split off to form an independent command in December 1943 (map 16). Thus, activities were spread from Senegal in the west to Iran in the east. The Air Transport Command,


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MAP 15.- U.S. Army Forces in the Middle East, jurisdictional map, 1943.

with its isolated bases across the continent of Africa, added to the malaria problems of the theater.

    General retrenchment followed in 1944. Malaria was under control in most of the theater. Active fighting had moved far enough from the Middle East to render the theater of USAFIME one of communications rather than of combat. The original Delta Service Command changed into the Middle East Service Command on 16 February 1944. U.S. Forces in Eritrea regained a certain amount of independence later in the year, when they were again designated the Eritrea Base Command (map 16)

Early in 1945, the jurisdiction of USAFIME was greatly expanded. The-


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MAP 16.- U.S. Armed Forces in the Middle East, jurisdictional map, 1944.

ater boundaries were extended to include not only the whole continent of Africa and the Middle East but also a sector of Antarctica with its apex at the South Pole. The name of the theater was changed on 1 March 1945 to the Africa-Middle East theater. Those installations in French Morocco, Algeria, and Tunisia which joined the theater in March were organized into the North African Service Command.

    A reduction of theater activities occurred as a result of victory in Europe, but it did not eliminate air traffic to India and China. It greatly stimulated air travel from Europe to the United States by way of North Africa.

    After 2 September 1945, V-J Day, the Africa-Middle East theater proceeded on a rapid reorganization program, and by the end of the year most of the troops had been withdrawn.


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Air Transport Command in Africa

MAP 17.- Air communications, U.S. Army Forces, Africa and the Middle East, 1941-45.

    The U.S. Government was interested in the delivery of airplanes to the Allies in the Middle and Far East. For this purpose, Pan-American Airways had been commissioned to establish a route for the transportation of aircraft by way of Africa to the Middle East. The route passed from Brazil to Liberia, through the Gold Coast, Nigeria, Anglo-Egyptian Sudan, Egypt, and Eritrea (map 17). Later, it was extended through Aden to India. By 15 December 1942, the Air Transport Command was operating the full route.

When the British Eighth Army was driven eastward to the Nile Delta


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in the spring of 1942, the vulnerability of this air route became apparent. The War Department decided to find an alternate route and chose one which extended from Natal, Brazil, to Ascension Island, to French Equatorial Africa, the Belgian Congo, Uganda, and Abyssinia to Aden, and this grouping of airbases was organized as the U.S. Army Forces in Central Africa.

    During 1943, the Air Transport Command grew and became more firmly established in Africa and Asia Minor. The Africa-Middle East Wing was reorganized into a North African Wing and a Central African Wing.

    U.S. Army Forces in Central Africa closed the partly developed Southern Trans-African Air Route in 1943. Its activities came under the jurisdiction of USAFIME on 15 September 1943.

    The Central African Division, Air Transport Command, was inactivated and closed its stations in June and July 1945, and the West African Service Command was inactivated on 30 June 1945. Remaining activities were placed under control of the North African Service Command.

U.S. Army Forces in Liberia

    The mission of U.S. Army Forces in Liberia was to construct and maintain airfields and associated transport facilities. In August 1941, the U.S. Government contracted to establish aerial service through points in Africa. Construction was started at Roberts Field, Liberia, and continued until 31 December 1942, when all material was turned over to the U.S. Army Forces. The original plan to use Bathurst and Gambia, British West Africa, was abandoned in late 1941, and material was directed to the shores of Fisherman Lake, Liberia.

    A defense agreement was signed by representatives of the United States and the Liberian Government on 31 March 1942. The first task force arrived in June 1942 and was concerned with airfield construction and with preparing for the larger defense force. The other task force arrived on 11 March 1943. In addition, the Liberian Government was assisted in reorganizing, training, and equipping the Liberian Frontier Force.

    On 28 February 1946, the U.S. Army Forces in Liberia was inactivated.

Persian Gulf Command

    On 27 September 1941, as the result of a Presidential directive, the U.S. Military Iranian Mission was established to include the Iranian Engineer District, North Atlantic Division, and to supplement the efforts of the British in the Persian corridor. The mission arrived in Baghdad, Iraq, on 30 November 1941.

    Entry of the United States into the war did not at first alter the organization setup, but the territory of the U.S. Iranian Mission was changed to exclude India on 4 April 1942.


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    The activities of the U.S. Military Iranian Mission included the construction or reconstruction of approximately 1,000 miles of all-weather road; the building and operation of airplane, truck, and barge assembly plants; and the development of port facilities.

    The U.S. Military Iranian Mission was discontinued on 24 June 1942, and the area was redesignated and established as the Iran-Iraq Service Command of USAFIME. On 13 August 1942, the Iran-Iraq Service Command was redesignated and established as the Persian Gulf Service Command with its geographic limits fixed as embracing Iraq, Iran, and those parts of Arabia that border on the Persian Gulf. In order to facilitate control and supervision, it was divided into territorial areas on 1 September 1942. The Persian Gulf Service Command was put under the jurisdiction of the Services of Supply, USAFIME, when the latter was established on 4 November 1942, and was relieved of this assignment on 20 January 1943.

    After the Teheran Conference, the Persian Gulf Service Command was redesignated the Persian Gulf Command and was removed from the jurisdiction of USAFIME. At this time, U.S. military activities in all of Saudi Arabia came within the jurisdiction of USAFIME.

    The mission of the Persian Gulf Command--the transportation of materiel to the U.S.S.R. from Persian Gulf ports across Iran--was declared accomplished on 1 June 1945. Effective on 1 October 1945, this command became a subcommand of the Africa-Middle East theater known as the Persian Gulf Service Command. The Persian Gulf Service Command closed suddenly, and all personnel were evacuated on 31 December 1945.

AREA CHARACTERISTICS

    The Africa-Middle East area may be divided for purposes of description into two regions, Ethiopian (Africa) and Palaearctic (map 18).

Ethiopian Region

    The tropical African area may be divided into a number of distinct biologic areas. 2 The most important of these is the immense West African region. Within this and the East and South African regions, secondary divisions are readily evident. Because of the large number of distinct biologic areas and the sparse troop population present, detailed statements concerning all these divisions are not required here. However, generalizations and discussion of features at souse points of troop concentration may be of interest.

    The coast of West Africa is bordered by a wide belt of virgin tropical forest, which, however, is broken by the clearings of the local population. To the north, the forests continue in open savanna woodlands, grassland interspersed

2 Geographical Handbook Series, French Equatorial Africa and Cameroons, Great Britain Admiralty, Naval Intelligence Division, December 1942.


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MAP 18.- Regional map of Africa.

with isolated groups of trees, and forest-fringed river courses. The region then passes into the Sudan Plain which is covered with deciduous brush and thorn.3

    In the Sudan itself, there are two distinct areas, the southern forest, which has an average rainfall of 40 to 50 inches a year and which is composed of plains overgrown with deciduous trees, and the more northern districts, with rainfall of 20 to 40 inches a year, characterized by thornbush-covered plains.

    The rainy season begins in the coastal districts in April and continues to the middle of July. This, in turn, is followed by gradually decreasing rains succeeded in October by a short rainy season. The driest period of the year is from December to March.

3 Martens, O., and Karstedk, O. (editors) : The African Handbook, A Guide to West, South, and East Africa. 2d edition. London: George Allen and Unwin, Ltd., 1938.


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    In the Dakar area, French West Africa, rainfall is relatively light (from 25 to 30 inches a year), and summers are warm.

    In Liberia, the humidity generally is high. The dry season, extending from December to March, definitely is the hottest. The wet season, which extends from April to November, while not cool, is less hot. Throughout this area, seasonal differentiation is into the wet and dry seasons, rather than into summer and winter. 4

    The Gold Coast has a hot and damp climate. Rainfall, however, is less than in other regions of the coast. The dry and rainy seasons are clearly defined. The latter starts in March and continues until about the end of June. A short and comparatively dry season ensues until the beginning of September, when the rains recommence and continue until the end of October. The dry season lasts from November to March.5

    In Nigeria, the coastline is backed by a belt of swamp and mangrove forest from 10 to 60 miles in breadth which is intersected by the various arms of the Niger and other large rivers and streams. Beyond the forest zone is a broad section of more or less open country, consisting of savanna and parklike land. Most of the country is an undulating plateau which rises to an average of about 2, 000 feet and is interspersed with isolated hills.

    The Belgian Congo is a broad belt of almost impenetrable primitive forest stretching with scarcely a break to about the fourth degree of south latitude. This virgin forest is bounded to the north and south by parklike land, brush, and grass savannas.

Palaearctic Region

    In the Palaearctic Region of the Africa-Middle East area, a number of distinct zones may be recognized. In a general broad category can be placed all the area bounding the southern and eastern shores of the Mediterranean. This semiarid land occupies a strip between the coast and the interior deserts. As exemplified by Palestine, although the actual time of arrival of the rains varies from place to place, conditions are as follows: There is seasonal rainfall, beginning about the middle of October and lasting until the middle or end of March. During April, there are a few spring showers, and from then until the end of October there is practically no rain. The country has really only two seasons--winter and summer. Throughout this country, January is the coldest, and August the hottest, month of the year. In general, the relative humidity is highest during the rainy season and lowest in May and October. Along the actual coast, the humidity is high throughout most of the year.

4 Strong, Richard P. (editor) : The African Republic of Liberia and The Belgian Congo, Based on the Observations Made and Material Collected During the Harvard African Expedition, 1926-1927. Cambridge: Harvard University Press, 1930, vol. I.
5 Fitzgerald, Walter: Africa: Economic and Political Geography of Its Major Regions. New York: E. P. Dutton and Co., Inc., 1939.


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    The general Nile drainage area, at least that portion occurring in Egypt, is an intensely agricultural section which has numerous problems peculiar to itself. Irrigation undoubtedly is one of the main factors contributing to the presence of malaria in this region.

    In the Persian Gulf area, three major distinctions may be made. The first of these is the actual coastal area, where littoral conditions contribute greatly to the malaria problem. Inland, one first finds large reaches of arid or semiarid lands in which malaria is not widespread but is confined to those areas in which irrigation is practiced or in the vicinity of oases and wells. Continuing further inland, one reaches the mountainous and plateau section. In this area of the country, which is well watered, malaria is present but usually not hyperendemic. Irrigation, as well as the many natural waterways and basins, supplies the potential and actual breeding location for the various Anopheles vectors of malaria.

    Tables 35 and 36 show average temperature and precipitation at selected localities. These give some approximation of meteorologic conditions at some of the more important centers of troop concentration.

LOCAL POPULATION

    Throughout the areas, local populations represented several races and numerous distinct tribal stocks. In West and Central Africa, various indigenous tribes of Negroid stock, employed as unskilled labor, ware closely associated with American troops. The degree of association varied from intermittent to almost constant, depending upon the condition at the particular base. In some cases, local residents were not allowed in the controlled areas except while working, but in other localities entire villages lay in close proximity to troop quarters.

    In Northeast Africa, posts and camps were usually situated along transport and communication lines, in or near towns or cities. Here, again, the resident population (Egyptian, Arabian, and Hamitic) was utilized for labor. There must have been considerable contact during working hours under a variety of conditions. In the Levant, conditions resembled those in northeast Africa.

    The Persian Gulf area, with its problems of transport and supply, necessitated close contact with the resident population. Here, labor forces and such skilled personnel as were available were utilized by the Army. Without doubt here, too, there was close contact with the indigenous population.

    Living conditions among all types of population, whether Negroid, Arabian, Persian, or other, were generally substandard. There was a lack of even the most elementary sanitation, and health conditions were, in general, poor. Malaria control was usually nonexistent. In some areas, malaria was looked upon as the will of Allah and, therefore, beyond the means of mere mortals to comprehend or control. Adding to this the diversity of Anopheles vectors and their varied breeding habits, one can understand why malaria was a major


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TABLE 35.- Average rainfall in inches at selected localities,1 for various time periods

TABLE 36.- Average temperature in degrees Fahrenheit at selected localities 1


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problem in much of the area. Because of lack of education, information, and initiative, many other diseases were also widespread.

MALARIA ENDEMICITY AND POTENTIALITIES

    Africa and the Middle East are well known for their areas of malaria endemicity. Before American occupation, antimalaria work and malaria surveys had been carried on throughout considerable portions of this territory; however, there is not sufficient information to present an accurate map. The effect of malaria on this area is difficult to measure.6 Enough work has been done and enough experience gained to show that malaria occupies a high place, if not the foremost, among the infective diseases causing mortality and morbidity in the indigenous populations. It plays an outstanding part in hindering the progress and social development of the people and in retarding the advancement of industry and trade. Up to the time of World War II, the prevention or control of malaria, with some notable exceptions, had been attempted only in populations inhabiting comparatively circumscribed areas, in urban districts, in large engineering or industrial projects, or in some areas of European farming settlements. In British colonial territories antimosquito measures had been practiced in the main townships.7 In and around airports, considerable antimosquito measures were attempted.8 Elsewhere, some steps had been taken to break the mosquito-man-mosquito cycle of the parasite in European homes by the use of screening, bed nets, and insecticidal sprays.

    Africa as a whole is highly malarious. There are, however, portions of the Union of South Africa, vast stretches of the Sahara Desert, and various mountain areas in which malaria is definitely absent. Falciparum malaria is the most important variety in tropical Africa.

    The entire Mediterranean coast of Africa is malarious, ranging in degree from low to high endemicity. Malaria extends southward into the great desert in several isolated oases. Throughout the huge Nile drainage system, malaria is endemic. Around the Suez Canal and on both shores of the Red Sea, it is also endemic. This condition extends down most of the coastal lowlands of east Africa. One main exception is the desert area of British and Italian Somaliland. The West Coast of Africa is also notoriously subject to malaria.

    Throughout the great west African region, which encompasses primarily the Guinea forest belts and associated savanna land, malaria reaches hyperendemic proportions. Endemicity gradually tapers off until it is completely absent in the southern reaches of the Sahara Desert. West Africa has a sinister

6 Malaria Under African conditions. Quart. Bull. Health Organ., League of Nations 5: 110-112, March 1936.
7 Lord Hailey: African Survey, A study of Problems Arising South of the Sahara. Issued by the Committee of the African Research Survey Under Auspices of The Royal Institute of International Affairs. New York: Oxford University Press, 1939.
8 Development of a Medical Service for Airline Operations in Africa. War Med. 3: 484-497 619-634, May-June 1943.


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reputation in the matter of health. In this area, malaria is probably the most important cause of morbidity, inefficiency, and premature deaths. Nearly every member of the indigenous population is infected with malaria early in life.

    Throughout British East Africa, malaria is prevalent but does not reach the proportions found in west Africa. The plateau section, although mildly malarious, does not offer suitable conditions for the hyperendemicity found further to the west. These conditions prevail in a southerly direction past the points where American troops were stationed.

    Throughout the Levant, malaria is present to a varying degree. Some areas of hyperendemicity are known, but for the most part, moderate to slight endemicity is the rule. A considerable amount of antimalaria work was done in these countries before they were occupied by American troops.

    In the Persian Gulf area, malaria is widely prevalent and often highly endemic, especially in the low coastal regions.

    In addition to these generalities, the following more detailed information on areas where troops were stationed is of interest.

French West Africa

    In the Dakar-Rufisque area of French West Africa, from 24 to 54 percent of blood smears from local residents were positive for Plasmodium.Gametocyte indices averaged 6 percent in total examined and 28 percent in children between the ages of 5 and 10 years. On the Yoff Peninsula, surveys among the indigenous population showed 90 percent infectivity with a 6-percent gametocyte index. Of 407 positive blood smears, P. falciparum was identified in 388, P. malariae in 25, and P. vivax in 6. Twelve blood smears showed mixed infections.

Liberia

    Liberia is a country where malaria reaches hyperendemic proportions. Parasite surveys 10 included individuals living on or near the Firestone Rubber Plantation, where control measures had been in effect (tables 37 and 38).

    Parasite surveys were made in 1942 in villages near troop installations, 11 and, of 2,648 blood smears studied, 50 percent showed P. falciparum; 5.2 percent, P. malariae; and 2 percent, P. vivax. Similar examinations made in August 1953 revealed 161 out of 687 smears, or 23 percent, positive for malaria parasites.

9 Report, Maj. Alva J. Floyd, MC, Asst. Malariologist, USAFIME, to Commanding General, USAFIME, Cairo, Egypt, attention: The Chief Surgeon, 4 Nov. 1944, subject: Report of Malaria Control Activities at U.S. Army Installations in West Africa, 1941-1944. Part IV, French West Africa
10 (1) Barber, M. A., Rice, J. B., and Brown, J. Y. : Malaria Studies on the Firestone Rubber Plantation in Liberia, West Africa. Am. J. Hyg. 15: 601-633, May 1932. (2) Medical and Sanitary Data on Liberia. compiled by Medical Intelligence Branch, Preventive Medicine Division, Office of The Surgeon General, U.S. Army, 17 Nov. 1942.
11 Annual Report, U.S. Army Forces in Liberia, 1943.


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TABLE 37 . - Malaria parasite index, Liberia, 1931

TABLE 38 . - Malaria parasite index, Liberia, 1942

    In accordance with the usual findings in hyperendemic areas, 12 a high proportion of the infants (83 percent) and children (71 percent) were found infected, the adults having a materially lower parasite rate (34 percent). Similar relationships were observed between gametocyte prevalence and age. The infants showed a much higher prevalence (50 percent) than children (3 percent) or adults (1 percent). Numerous other surveys substantiated these findings. 13

British West Africa

    The Gold Coast is also subject to hyperendemic malaria. Surveys of children in the region have shown about two-thirds of them to be infected with P. falciparum and to have gametocyte rates exceeding 15 percent.14

    The annual malaria rate for European personnel of the British Army in the Accra District in the period from 1 September 1941 to 31 August 1942

12 Report, Maj. Justin M. Andrews, SnC, to Chief Health Officer, 5 July 1948, subject: Malaria Investigations and Recommendations for Malaria Control at Roberts Field Area.
13 Annual Malaria Report, 1944. (Report of Malaria Control at U.S. Army Installations in West Africa, 1941-1944, Part III: Liberia, West Africa, Headquarters, Medical Composite Units (Malaria Survey and Control Units), 15 Jan. 1945.)
14 Report, Maj. Elliston Farrell, MC, to the Commanding General, USAFIME, Cairo, Egypt, attention: The Chief Surgeon, 1 Nov. 1944, subject: Report of Malaria Control at U.S. Army Installations in Blest Africa, 1941-1944. Part II Gold Coast British West Africa.


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was 102.6.15 From 50 to 75 percent of the children from 2 to 10 years of age in the district villages had enlarged spleens. Children under 5 years of age invariably were found to have gametocyte rates of 90 percent or more.

Egypt

    During the period from August to December 1936, a survey was made of three general areas in Egypt: 16 The valley of the Nile, including Fayum; the Oasis of Siwa in the Western Desert; and the Suez Canal Zone. Malaria was found to be widespread in the Nile Valley; no locality of Lower Egypt proved to be malaria free. Both the parasite rates and the percentage of enlarged spleens were low in many places, but in villages near rice plantations or large bodies of fresh water they were usually high. High parasite and spleen indices were found in the Siwa Oasis and in the Suez Canal Zone. P. vivax predominated in the majority of localities, but P. falciparum occurred in nearly all pars of the territory. P. malariae was not found in the Nile Valley and was rare in other Egyptian areas. The spleen index was generally lower than the parasite index. The villages in Lower Egypt (the Delta., between Cairo and the Mediterranean) had an average parasite index of 7.2. The average parasite index of all examinations was 21.1 percent--an index probably too high to be representative of the whole valley.

Palestine

    General surveys throughout various portions of the country obtained the following figures: 17 Among Jews, the Plasmodium index was 4.6 percent and the enlarged spleen index, 20.1 percent; among Arabs, the Plasmodium index was 12.5 percent and the enlarged spleen index, 62.5 percent; among Bedouins, the Plasmodium index was 32.5 percent and the enlarged spleen index, 58.8 percent. In Palestine, surveys made between 1922 and 1924 showed the relative frequency of various types of malaria to be: P. vivax, 69.13 percent; P. falciparum, 29.30 percent; and P. malariae, 1.57 percent. In epidemic periods, however, as for instance in 1922, the findings were: P. vivax, 58.6 percent; P. falciparum, 40.3 percent; and P. malariae, 1.1 percent.

Iran

    In Iran,18 blood surveys in 1934 showed from 10 to 25 percent of the population to be harboring malaria parasites. Examination of 5,000 patients during a 6-month period (from the middle of May to the middle of November)

15 Report, Maj. O. J. S. Macdonald, Indian Medical Service, to Brig. Gen. James S. Simmons, MC, Director, Preventive Medicine Division, Office of the Surgeon General, 1 Dec. 1943, subject: Summary of Report on Malaria in the Accra District.
16 Barber, M. A., and Rice, J. B.: Survey of Malaria in Egypt. Am. J. Trop. Med. 17: 413-436, May 1947.
17 Kligler, Israel J. : Epidemiology and Control of Malaria in Palestine. Chicago : The University of Chicago Press, 1930.
18 Greenfleld, G.: Beitrag zur Frage der Malaria in Persien. Arch. f. Schiffs-u.Tropen-Hyg. 39:257-260, June 1935.


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disclosed 48 percent as having had malaria, 75 percent of which was caused by P. vivax, 20 percent by P. malariae, and 5 percent by P. falciparum. Surveys made while American troops were present showed the proportions of the various kinds of malarial infection as follows: 19 P. vivax, 80 percent; P. falciparum, 14 percent; P. malariae, mixed, and unclassified infections, 6 percent. No surveys were permitted in Azerbaijan and Caspian areas of northern Iran which were under Russian control.

VECTORS

    In the Africa-Middle East area, at least 75 species of Anopheles have been recognized. Some of these are rare, and many do not transmit malaria. The malaria vectors have received considerable study, and a wealth of information about them has been published. The following species of Anopheles are believed to be of importance in the transmission of malaria in Africa-Middle East areas occupied by American troops:

    Anopheles claviger bifurcatus Meigen 1904 is found in Europe, northern Africa, Asia Minor, and Turkestan. Larvae breed in marshes, rock pools, wells, and cisterns. In Palestine, this species commonly enters houses and bites humans freely. Elsewhere, it rarely enters houses or feeds on man. It is the most important urban vector of malaria in Palestine and Syria but is not considered important in other areas.

    Anopheles funestus Giles 1900 is widely distributed throughout tropical and South Africa, occurs as far north as Abyssinia, and is found on Madagascar and Mauritius.

    A. funestus usually breeds in large or fairly permanent bodies of clear water, such as swamps, weedy banks of streams, rivers, ditches, protected lake shores, or long-standing seepages. Some shade is usually preferred, but not deep forest shade. As the breeding places of A. funestus are often more permanent than those of A. gambiae, the former tends to be associated with endemic rather than epidemic malaria.

    The adults readily enter houses in large numbers where they feed on human blood. Work in Kenya has revealed that 40.8 percent of the blood meals examined were positive for human blood and that over 58 percent of those showing any definite reaction reacted only to human blood.  Preference for the blood of Africans was suggested by the results of some experiments. Other work has shown that A. funestus is attracted more strongly to a human sleeping in a confined space than in the open. In all-night catches, it was found that the greatest number of females entered quarters at about 2300. Although A. funestus adults may be taken as far as 4½ miles from the nearest breeding place, 80 percent are found within a ½-mile radius of this site.

19 A Narrative History of Medical Activities in the Persian Gulf Command. [Official record.]


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    A. funestus is an important vector of malaria, although often secondary to A. gambiae, where both occur. The following natural infectivity rates represent the percentage positive for sporozoites in the salivary glands: Sierra Leone: Kissy, 4.1 percent; Liberia: Firestone Plantation, 1.9 percent; Nigeria: Gadau, 3.5 percent; Ibadan, 6.9 percent; Lagos and vicinity, 12.8 percent; and Belgian Congo: Stanleyville, 4.2 percent. Many areas in East and South Africa show rates which vary from 0.2 to 27 percent.

    Anopheles gambiae Giles 1902 is found throughout tropical Africa and in South Africa except in the desert regions and high mountains; it is also found in Arabia, Madagascar, Reunion, and Mauritius. It has invaded and has been driven out of Egypt and Brazil.

    A. gambiae larvae are found in puddles, shallow ponds, borrow pits, hoof-prints, and ditches in sun or light shade.

    A. gambiae feeds mainly on human blood, and enters dwellings in large numbers in most regions where it is prevalent. In some towns, it is the only domestic Anopheles, and, in many areas, it may represent 95 percent of the domestic Anopheles population. In regions where A. funestus is also common, the two species together usually constitute 90 percent or more of this population.

    Much research work on A. gambiae indicates a strong preference of resting females for inhabited dwellings. However, appreciable numbers may enter houses unsuitable as resting places, in order to feed and then leave. Observations in Kenya determined that this species had an anthropophilic index of 78 percent. At Lagos, 82 percent gave positive reactions for human blood even examinations made of specimens caught in buildings in which both cattle and humans were sheltered. It has been found that where the species is abundant it frequently feeds in the early hours of the evening. At Lagos, all-night catches showed that while biting took place from sunset until sunrise, the peak of biting activities occurred between 0200 and 0400. This species has been found biting freely out of doors during the time of activity. Adult dispersal of at least one-half a mile is common, and at times individuals have been found as far as 3 miles from their breeding place.

    A. gambiae and A. funestus are the two most important malaria vectors in the Ethiopian region. (Both are also important vectors of filariasis.) The following records show natural infectivity rates for this species and represent the percentage positive for Plasmodium sporozoites in the salivary glands: Sierra Leone: Freetown, 8 percent; Kissy, 11.2 percent; Liberia: Firestone Plantation, 3.5 percent; Nigeria: from 7.4 to 9.6 percent; Yaba, 4.6 percent; Lagos and vicinity, 6.6 percent; Ibadan, 13.1 percent; and central and east Africa, various stations, 0.7 to 11.5 percent.

    Anopheles gambiae melas Theobald 1901 is found breeding in brackish water along the littoral of Sierra Leone and the Gold Coast in tidal swamps and coastal streams. Adults are house haunting and take human blood freely. Melas an important vector in some localities.


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    Anopheles hancocki Edwards 1929 is found in parts of west and central Africa, from Sierra Leone to Uganda and southward to Angola.

    The adults of this species are commonly found in human habitations, particularly in Liberia and Uganda. Near Freetown, they have been taken in outdoor biting experiments, with local boys as bait. The larvae are found in clear water in grassy holes, wells, streams, and swamps in sunny places.

    This species is an important malaria vector wherever prevalent. A considerable number of dissections in Uganda revealed an average monthly infection rate of 11.4 percent and an average sporozoite rate of 2.7 percent. The monthly sporozoite rate fluctuated from zero to a maximum of 7 percent. In Liberia, this species is still suspected on epidemiologic grounds, although no positive findings were obtained in a small number of dissections.

    Anopheles hargreavesi Evans 1927 is found in Liberia, Sierra Leone, Gold Coast, southern Nigeria and northern Belgian Congo.

    Adults are common in huts in Nigeria. Females were attracted in large numbers to human bait during night experiments at Lagos. The peak of activity is midnight or later. Larvae are found in shady places of swamps and stream margins in open jungle.

    This is an important malaria vector in certain areas of west Africa where it is common. In southern Nigeria, a sporozoite rate of 5.4 percent has been found.

    Anopheles moucheti moucheti Evans 1925 is found in the Belgian Congo, Uganda, and Cameroons.

    In localities where this species is prevalent, females have been found indoors in considerable numbers. Larvae are found among vegetation of pools, streams, and swamps in sun to light shade.

    This species, where common, has considerable importance as a vector of malaria. The total infection rate averages 8.3 percent, with the sporozoite rate fluctuating between 1.6 and 4.1 percent. Near Stanleyville, an oocyst and sporozoite rate of 4.5 percent has been found among females collected from huts.

    Anopheles moucheti nigeriensis Evans 1931 is found only in southern Nigeria. Adults were found in considerable numbers in huts in villages near Lagos. Larvae are found in clear, sunny water in swamps.

    This form is of importance wherever it is common. A sporozoite rate of 1.1 percent was found among females taken in huts near Lagos.

    Anopheles multicolor Cambouliu 1902 is a desert species found in North Africa, Egypt, Sudan, Palestine, eastern Iran, and Baluchistan.

    The adults of this species may disperse, with prevailing winds, as far as 8 miles and readily enter houses to bite humans. Larvae are found in pools, flowing or stagnant drains, and shallow wells, and tolerate desert salinity up to 5.96 percent.

    This species is considered on epidemiologic grounds to be a vector of malaria.


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    Anopheles nili Theobald 1904 is widely distributed through west and central Africa and extends into British East Africa.

    Adults are rare in houses but have been found in large numbers in huts and camps in limited areas. Larvae are found in shade among vegetation along stream edges.

    Where prevalent in dwellings this species may be an important vector. Dissections have been made with negative findings in some areas, but when positive the rates were usually high. Representative findings are: In villages in Stanleyville District, oocyst rate 10 percent and sporozoite rate 5.3 percent; camps on rubber plantation, Liberia, oocyst rate 14.6 percent and sporozoite rate 0.8 percent; houses near Freetown, oocyst rate 18.2 percent and sporozoite rate 9.1 percent.

    Anopheles pharoensis Theobald 1901 is widespread throughout tropical Africa and is also found in Egypt and Palestine.

    In certain localities where this species is prevalent, the adults may enter houses and tents in appreciable numbers. It is described as a domestic species in Egypt. In other areas, the number of females captured indoors is relatively small in comparison with those of the other important vectors. Although A. pharoensis feeds readily on man, the results of precipitin tests reveal a marked preference for cattle blood. Larvae are found in swamps and rice-fields.

    Much evidence has been accumulated to indicate that A. pharoensis is an efficient vector of malaria. Many individuals have been found naturally infected in nature, with oocysts and a few with sporozoites. The species has been infected experimentally with both P. falciparum and P. vivax. In the Nile Delta, distribution of the species correlates closely with that of malaria prevalence. It is believed to be one of the chief vectors in the Upper Nile Province. In most parts of Africa, it appears to be of less importance than A. gambiae and A. funestus. However, sporozoite rates up to 6 percent have been found. In southern Nigeria, a malaria positive rate of 1.8 percent and sporozoite rate of 0.7 percent were encountered; while in Egypt, oocysts rates of 6.7 percent to 10.8 percent and a sporozoite rate of 0.5 percent were found.

    Anopheles pretoriensis Theobald 1903 is found in parts of West and Central Africa.

    Adults in some areas frequent houses while in others outside resting places are preferred. Larvae are found in rock pools, hoofprints, and semistagnant pools in streams and ditches.

    Although 1.7 percent of one series were found to be naturally infected, it is doubtful whether this species is of much importance as a malaria vector.

    Anopheles pulcherrimus Theobald 1902 is a dominant species in regions of the lower Persian Gulf area and is also found in Pakistan and central Asia. Some observers have found it to be a bold feeder, often taken in houses. It is a strong flier and may be carried long distances by the wind. In some


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areas, it has been found naturally infected, but usually it is not an important vector.

    Anopheles sacharovi (elutus) Favre 1903 is chiefly a European and northern Asiatic species but it is of importance as a vector in portions of the Levant and Persian Gulf.

    Sacharovi is an indiscriminate feeder on both man and domestic animals. Adults enter human habitations to feed. Observations in Palestine indicate that there it shows house preference. Its flight range is from 1 1/4 miles to more than 1 1/2 miles.  Larvae are found in open inland marshes and also in brackish waters.  2 miles. Larvae are found in open inland marshes and also in brackish waters.

    This species is considered to be an important vector in the Balkans, Palestine, and Iran. An infective rate of 1.2 percent has been found in Palestine.

    Anopheles sergenti Theobald 1907 is found through Northern Africa, Egypt, and Palestine. Larvae are found in riceflelds, irrigation channels, borrow pits, river edges, and seepages. Adults feed indoors or outdoors but do not rest inside houses in Palestine, preferring rocky caves.

    This species is a vector in Egypt and especially in Palestine.

    Anopheles stephensi stephensi Listor 1901 is found in the Persian Gulf area, Iraq, Iran, Pakistan, and India. Larvae are found in wells, cisterns, flowerpots, and roof gutters. Adults are thoroughly domestic, feeding readily on man.

    Stephensi stephensi is an important vector in certain urban areas and is responsible for much of the malaria in southern Iraq and Iran.

    Anopheles superpictus Grassi 1899 is widely distributed in Southern Europe and Asia Minor and is found eastward to northwestern India. Larvae are found in fresh-water pools, streams, and seepages, especially in hilly areas. Adults readily enter and rest. in houses, taking human blood freely.

    This species is a vector in Southern Europe, Mesopotamia, Iraq, Iran, and Baluchistan.

MALARIA EXPERIENCE

    Chart 9 and table 39 show the malaria rates from 1942 through 1945 for the Africa-Middle East area. Table 39 also shows the rates for fever of undetermined origin for the same period. The overall picture shows the general effect of various methods of environmental control and suppressive medication. Moreover, it illustrates to some extent the seasonal distribution of malaria in these areas. Owing to diverse conditions, further conclusions are not warranted.

    Table 40 and chart 10 show the malaria rates in forces stationed in west and central Africa during portions of 1942 and 1943. In addition, table 40 shows the rates for fever of undetermined origin among these forces for the same period. In some of this region, suppressive medication was used to supplement physical control measures.


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CHART 9.- Attack rates for malaria among U.S. Army personnel, Africa-Middle East area,11942-45


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CHART 10.- Attack rates for malaria among U.S. Army personnel in Africa 1 and the Middle East,2 June 1942-August 1943


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TABLE 39.- Attack rates for malaria and fever of undetermined origin, among U.S. Army personnel, Africa-Middle East area,1 1942-45

TABLE 40.- Attack rates for malaria and fever of undetermined origin, among U.S. Army personnel in Africa,1 1942-43


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    The Liberian Force was given suppressive medication from before landing until October and November 1942. Then in late December, after a great increase of the disease, suppressive treatment was reinstituted and continued until late February 1943, when it was again stopped. In June, this force was again placed on suppressive medication. At least in the Accra district, suppressive medication was in force from December 1942 through March 1943. The U.S. Army Forces in central Africa were placed on suppressive medication in November 1942. It seems probable that other areas were similarly treated, but definite information other than that summarized in the section on suppressive medication is not available.

    Comparable rates, for the same period, in the Middle East are shown in table 41 and chart 10. Whether suppressive medication was used to supplement other control measures is not known. The figures may represent simply the incidence as influenced by physical control measures.

TABLE 41.- Attack rates for malaria and fever of undetermined origin, among U.S. Army personnel in Middle East,1 1942-43

    Tables 42 and 43 show malaria rates in various areas in West Africa, for varying lengths of time in the period 1942 through 1944. Whether suppressive medication was authorized in other than the Accra district of the Gold Coast and those parts administered by U.S. Army Forces in central Africa is not known. In certain of these areas, all physical control measures were the responsibility of our Allies, while in others, American forces supple-


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TABLE 42.- Attack rates for malaria among U.S. Army troops, French West Africa, January 1943-December 1944

TABLE 43.- Attack rates for malaria among U.S. Army troops, in the Gold Coast and Nigeria, British West Africa, January 1943-December 1944


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mented or took over these operations. These stations were in some of the classic malarious areas of the world, and a large percentage of the troops contracted the disease at some time during their stay.

Chart 11 and tables 44 and 45, respectively, show the malaria rate for 1944 and 1945 in the Middle East, excluding Persian Gulf Command, and in the Persian Gulf Command; in addition, the tables also show the fever of undetermined origin rate for the same period. These figures indicate the total effect of the various control measures used. It should be noted that rates in the Persian Gulf area at the beginning of the period were appreciably lower than in Africa. No further conclusions from these figures are warranted.

CHART 11.- Attack rates for malaria among U.S. Army personnel in the Africa-Middle East area (excluding Persian Gulf Command) and in the Persian Gulf Command, 1944-45


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    Chart 12 and table 46 show the malaria rate from 1942 through 1945, in Liberia.

    For 2 weeks before the arrival of the first task force in Liberia in late June and July 1942 and until late October or early November, personnel were under quinine suppressive medication. At the time they landed, bed nets were not available for all personnel and many infections undoubtedly occurred. It is believed that the figures from October on show the result of activated latent malaria. From late December 1942 through February 1943, all troops were on Atabrine suppression. After 10 March 1943, no prophylactic treatment was administered and at this time the second task force arrived. Rates rose rapidly, and on 21 June 1943, Atabrine suppressive medication was reintro-

CHART 12.- Attack rates for malaria among U.S. Army personnel in Liberia, 1942-45


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TABLE 44.- Attack rates for malaria and fever of undetermined origin, among U.S. Army personnel, Africa-Middle East area, 1 January 1944-December 1945

TABLE 45 .- Attack rates for malaria and fever of undetermined origin, among U.S. Army personnel, Persian Gulf Command, January 1944-December 1945


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duces. This was discontinued early in 1944, but after 4 months (24 July 1944), all troops were again placed on suppressive medication. This policy continued through the remainder of that year and all of 1945. It is not known definitely, but it is believed that this treatment continued until the area was finally evacuated. In June and July 1943, over one-quarter of the force had malaria. The fluctuations in the rates apparently correlate with seasonal prevalence, exposure factors, arrival of new personnel, effectiveness of physical control measures, and the achieving of various degrees of suppression by the administration of antimalarial drugs.

TABLE 46.- Attack rates for malaria among U.S. Army personnel, Liberia, 1942-45

    Statistics, making it possible to contrast experience in various areas or types of troops, other than those given are not available. Considerable detailed information on the Liberian Force is on file but other comparable records are not at hand. Some reports have given figures to illustrate malaria incidence at particular points and times, but how these figures were compiled and their degree of accuracy is not known.

    Although excessive prevalence of malaria was noted in several areas, the disease responded to control and preventive measures. In some areas when troops were released from suppressive medication, rate rose alarmingly, but when this medication was reintroduced reductions were quickly evident. In all cases, when incidence was exceptionally high, troops had either recently arrived in hyperendemic areas or been released from suppressive medication.

    The malaria rate among local population in controlled area showed some response to control activities. Representative findings are given in the section on surveys. No information concerning prisoners of war is available.


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ANTIMALARIA ORGANIZATION

    From available information, it would seem that the antimalaria organization was not strongly centralized. For example, it is not easy to ascertain the degree of interrelationship between such areas as the Persian Gulf Command and the U.S. Army Forces in Liberia, both of which were at times independent commands. There was a central supervisory administration, but considerable freedom of action was allowed to the various commands.

    During the first months of the war in this region it would seem that each command approached the problem without reference to other headquarters. This divided authority clearly interfered with malaria control and discipline. After a study of the problems, in November 1943, by several officers from the Surgeon Generals Office and by the Medical Inspector, USAFIME, the organization was overhauled and responsibility was assumed by the theater. At the close of 1943, the Medical Section, Headquarters, USAFIME, had a Preventive Medicine Section with medical inspectors and a malariologist. The latter was given the duty of technical supervision of malaria control.

    The surgeon and other special staff officers performed in a dual capacity. They were the special staff of both services of supply and the theater.

    Cooperation with the British resulted in the formation of an inter-Allied malaria control group for the purpose of providing a coordinated antimalaria program in British West Africa. This resulted in control operations at numerous bases being the responsibility of the Royal Air Force or other Allied groups. In some of this area and particularly at Accra, Gold Coast, the unfortunate experience of American forces, depending on malaria control by other agencies, necessitated constant inspection and initiation of local control activities similar to those carried out routinely elsewhere among American troops. In other areas, American personnel took over full control at their own installations and also supplemented the work of other agencies. In some cases, complete responsibility for control of the area passed to American forces. Moreover, as the various civilian contractors and Pan-American Airways withdrew, the Army assumed responsibility for control operations that they had begun.

    In each of the commands, various programs were developed. Antimalaria units were organized in each service command in 1942. General malaria control measures were strengthened by the designation of one man per hundred for malaria control work within units as directed by Circular No. 31, USAFIME, 2 September 1942.

    In February 1943, the surgeon of the U.S. Army Forces in Liberia was given the general responsibility for malaria control and sanitation. When theater supervision was unified under USAFIME, late in 1943, all malaria control became the responsibility of the theater.

    In the Gold Coast,. until 1944, U.S. Army authorities failed to organize and implement an adequate malaria control program. Local commanders


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had not supported antimalaria measures recommended by their own medical staff and as required by Army Regulations. Furthermore, integration of British and American malaria control efforts did not promptly achieve the coordinated program which was essential to success.

    Mention should be made of the Egyptian gambiae eradication project that began early in 1943 and continued until August 1945. Anopheles gambiae had invaded Egypt as far north as Asyut by November 1942 and was causing devastating epidemics along the path of the invasion down the Nile. Allied military forces, the Rockefeller Foundation, and the Egyptian Government cooperated in a campaign that made full use of therapeutic and suppressive Atabrine, paris green larvicide, and pyrethrum adulticide. The invasion was finally halted and the invader was eradicated. The last A. gambiae in Egypt was found on 19 February 1945.

    In 1943, the Brazilian Government reported that A. gambiae had been brought to Brazil by aircraft from West Africa. This was strongly deplored by the Brazilian Government as they had just finished a long and costly campaign to eradicate this mosquito from their country. To investigate the problem, a committee from the Office of The Surgeon General, the malariologist for the North African Theater of Operations, U.S. Army, and the medical inspector of the USAFIME went to West Africa.

    In the first place, this group noted the following:

    The large-scale malaria control program undertaken jointly by the British Army, the RAF, the American Army, and the civil authorities at Accra is considered to be sound and gives every promise of being successful if supported by all agencies concerned, and if vigorously pushed to completion and maintained. Proposed malaria organization is excellent.

    The committee recommended that full American support be given to the proposed inter-Allied mosquito control program at Accra.

    In the second place, the committee made numerous recommendations which resulted in several changes, described as follows:

    There was formed at Accra in the inter-Allied malaria control group, a team which formulated policies and methods of control and obtained necessary supplies and equipment. All the individuals involved cooperated fully in attempting to break the man-mosquito-man cycle at as many points as possible. To this end, the following practices were put into effect: (1) Destroying Anopheles larvae, (2) attacking adult Anopheles, (3) preventing infested Anopheles from biting the population at risk, and (4) administering suppressive medication.

    Furthermore, to combat any possible reintroduction of A. gambiae into Brazil, special disinsectization methods were started both at the African air-bases and at the various Brazilian points of entry. In addition, it was decided that Brazilian authorities would help to supervise mosquito control procedures at the various African airports. Under this new plan, Brazilian authorities were in key positions on both sides of the Atlantic to safeguard their country


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from airborne African insects. This was a welcome procedure to all concerned, as it allowed the sharing of duties and responsibility with representatives of the Brazilian Government.

    Throughout the theater, unit antimalaria details were formed to supplement the control programs organized by the malariologists and control detachments.

    Indigenous labor was utilized at all military establishments to install and maintain the control program. In many instances, it was necessary to use large numbers of laborers to achieve adequate drainage, larviciding, and pyrethrum spraying.

    No definite information concerning dusting and spraying from airplanes is available except that such dusting with paris green was carried out in Egypt in 1943 and that of three light planes in British West Africa the first became operational on 24 August 1944.20 The only other recorded statement concerning this phase of the work is that up until November 1944 no aircraft were available for air spray operations in Liberia.21 A Stearman biplane (PT-17) had been allocated.

Training and Propaganda

    Practically no information is available regarding training and propaganda for malaria control and prevention purposes in the Africa-Middle East Command.

    Personnel of locally activated malaria detachments were trained in the field while those arriving as complete units had been trained before entering the area. The methods and time spent on these operations is not known.

    One active educational program was developed in Liberia. In this, a series of lectures was given, microscopic demonstrations were prepared, and posters were displayed.

    No doubt, in connection with the strengthening of malaria control and prevention measures just mentioned, some training was carried out, and some aids, such as posters, radio reminders, and bulletins, were utilized.

Other Duties of Antimalaria Organizations

    Antimalaria organizations and personnel in the Africa-Middle East area were used for other duties than malaria control in a number of instances. For example, in an outbreak of bubonic plague in Dakar, malaria personnel experimented in the use of DDT against fleas. It was found in controlled experiments that DDT not only killed fleas within a matter of hours after contact but that it inhibited their host-seeking and biting activities within 10 minutes after direct spraying or within 15 minutes after a 10- to 25-second contact

20 See footnote 14, p. 317.
21 See footnote 13, p. 317.


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with a DDT sprayed surface. It did not act as a repellent as did dimethyl phthalate.

    African sleeping sickness or trypanosomiasis was present in a portion of the occupied territory. The vector Glossina palpalis was common at some installations and particularly along the Farmington River in Liberia. Here, antimalaria personnel found that 5 percent of the flies caught and dissected were infected. Of 200 natives examined for sleeping sickness, 20 had enlarged glands; but gland punctures gave negative results. In view of the results of inquiries and of the extensive clearing along the riverbanks for malaria control purposes, no special precautions or control measures against Glossina were considered necessary.

    In addition to usual activities, the malaria units were on the lookout for Wuchereria bancrofti, the cause of filariasis. Both A. funestus and A. gambiae are efficient vectors of this organism. As these species were being controlled for antimalaria purposes, no special additional measures were needed. In Liberia, 7.95 percent of 1,182 natives examined were found to harbor W. bancrofti, and 4 percent of 220 A. gambiae dissected were found to contain larvae of W. bancrofti. In Nigeria, the incidence was somewhat less; in fact, Loa loa was found more frequently than W. bancrofti.

    Yellow fever prevention had to be continued without relaxation. By careful disinsectization of aircraft to kill all mosquitoes, it was hoped to prevent the spread of the vector from yellow fever areas in the path of the Central African air routes to other parts of the theater, or to India. The control of Aedes aegypti along with other mosquitoes helped to reduce the incidence of dengue among U.S. Army personnel. The antimalaria units often in practice performed as insect control units; for the comfort and protection of the commands, they attacked many problems which were not strictly concerned with malaria prevention. The units were also used to control sandflies, bedbugs, and other insects. Disinsectization was carried out not only in the field, but also in theaters, halls, barracks, and billets. Such general insect control activities were particularly useful in Egypt where units were not faced with malaria hazards so severe as those on the west coast of Africa.

SURVEY ACTIVITIES

Entomological Investigations

    In all areas, survey activities were an important part of the antimalaria program. At first, the surveys were made to find out which species of Anopheles were present, which were acting as vectors of malaria, and where they were breeding. When control measures were in operation, adult and larva surveys were made to assess the results. A certain amount of research was also undertaken after control had been established.

    Some results of surveys are cited to illustrate their scope and importance in relation to control operations. For instance, in the Rufisque district of


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    French West Africa, despite what appeared to be an adequate larviciding program, large numbers of Anopheles mosquitoes, including malaria vectors, were present in the camp area. It became evident that the flight of such local vectors as A. gambiae was long enough to break through the 1-mile control zone. The zone was therefore extended to 1½ miles, and there was an immediate drop in the number of Anopheles mosquitoes in the protected area.

    A survey of the off Peninsula, near Dakar, French West Africa, was made during January and February 1944, to obtain data regarding malaria problems. Control operations were then started. In July 1944, however, an unforeseen problem was encountered. Previously, control had easily been maintained during the dry season, but now a large number of Anopheles mosquitoes appeared. Surveys disclosed that they were being blown into the controlled area from the north and northwest. As a result, it became necessary to extend the control zone out to 7 or 8 miles.

    Extensive survey activities in Liberia were made to determine adult mosquito densities in occupied military quarters. As control measures improved, these densities became lower, allowance being made for seasonal prevalence, as indicated by checking the huts of the local population in uncontrolled areas. Such figures were used to determine the effectiveness of control. Similarly, larval searches were made. The following figures illustrate the size of this program: In 1944, over 26,000 poo1s were searched. In the 251 found positive for Anopheles, there were 894 A. gambiae larvae and 28 larvae of other species of Anopheles. Over 18,000 rooms were searched with 3,100 positives, and a total of 9,914 adult anophelines were collected. In 1945, among some 43,000 pools that were searched, 138 were positive and 1,030 larvae were found. In over 22,000 rooms searched, 792 were positive, yielding 1,920 Anopheles. Larvae and adults were identified and several series of A. gambiae were dissected for malaria parasites.22

    On the Yoff Peninsula, special studies were made to determine the effect of desiccation on the viability of A. gambiae eggs, and the length of the breeding cycle in this section of Senegal. Eggs kept dry for 24 hours had a little higher than 50 percent hatching rate; those kept for 48 hours, 19.8 percent; for 72 hours, 6.1 percent; and those that were dry for 96 hours, 0.7 percent. Obviously, even if only 0.7 percent of the eggs of A. gambiae could hatch after 96 hours of desiccation, one could not depend on the temporary drying of pools for control of this species. Other studies of the life cycle disclosed that it took only from 7 to 12 days for the eggs of A. gambiae to develop into adults in this area. This information was utilized in scheduling larviciding activities.

    The same organization in French West Africa performed DDT experiments in 1944, when a small quantity of this material was received. The application of 150 milligrams of DDT per square foot of surface was found to give satisfactory mosquito control under certain conditions for 2 months

22 (1) See footnote 13, p.317. (2) Annual Report, 27th Malaria Control Detachment, 1945.


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Tests of the length of time of exposure to DDT-treated surfaces necessary to kill mosquitoes revealed that only 5 seconds contact with a surface treated at the rate of 100 to 125 milligrams per square foot were required to permit A. gambiae adults to acquire a lethal dose of DDT. Further studies demonstrated that there was a marked and slowly declining residual action of DDT upon A. gambiae larvae.

    In Liberia, also, experiments with DDT were undertaken.

Parasitological Investigations

    Numerous blood surveys were made in all areas where troops were stationed. In some places, the surveys were continued long enough to give some indication of the effects of control operations. An example of this is the following, reported from Dakar:

    Surveys in villages surrounding American installations, made in January 1944, revealed a parasite index of 58.7 percent and a gametocytic index of 5.2 percent. By January 1945, these indexes had dropped to 11 percent and 0.6 percent, respectively, and, by July 1945, a further drop to 5 percent and 0.5 percent was noted.

    In Liberia, 23 in 1943, blood smear surveys among the local populations near camps revealed from 23 to 68 percent positive for malaria parasites. Gametocytes were found in 2.3 to 10 percent of the total. The higher percentages in the surveys included both children and women. In 90 to 98 percent of blood smears examined, the parasite was P. falciparum.

    During the period from 16 June through 25 December 1942,24 538 positive examinations for malaria parasites in military personnel and white civilians in the Roberts Field area of Liberia showed the following: 95.4 percent P. falciparum, with 1.7 percent showing gametocytes; P. vivax, 0.6 percent; P. ovale, 0.2 percent; and undetermined, 2.1 percent.

    In early 1943, 25 thick blood smears among U.S. Army troops in Liberia revealed that 1 percent of the command was positive for malaria parasites and that half of these were gametocyte carriers. No microfilariae were found. Two other blood surveys were conducted on troops; one in December 1943 and January 1944 which showed 1.9 percent with malaria infections, with 0.3 percent of the positive smears having gametocytes; and a survey in January 1945 that revealed only one man having trophozoites and one with gametocytes of P. falciparum.

    Numerous blood surveys of the local population near camps in other areas were also made in an effort to evaluate the malaria problem.

23 See footnote 13, p. 317.
24 Report, Lt. Col. Justin M. Andrews, SnC, to Chief Health Officer, Roberts Field, Liberia, 5 Jan. 1943, subject: Malaria Investigation and Control Activities in the Roberts Field Area during December 1942, with Brief Summaries for the year 1942.
25 Annual Report, Malaria Control Activities at Roberts Field, Liberia, 1943.


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ANTIMOSQUITO MEASURES

    In all the occupied areas of Africa and the Middle East, various methods of physical control aimed at the elimination of breeding places and the destruction of larvae and adults were used. The establishment of adequate drainage, larviciding with oil or paris green, and spraying with pyrethrum and Aerosol bombs, and finally the use of DDT were major methods utilized. At first, many difficulties were encountered in obtaining supplies, but subsequently adequate material was available. Malaria control was established at an effective level throughout the region in 1944 and was improved in 1945. The most important factor in the 1944 control program was the arrival of sufficient quantities of DDT for large-scale use. It was used in a hand-larviciding mixture of sand and waste oil and in larvicides and kerosene as a residual spray (fig. 41). The fight against malaria was a difficult and prolonged one, but in the end it resulted in one of the quiet victories of the war.

    In general, the control program consisted of permanent draining or filling of low areas in and around bases; larviciding of mosquito-breeding waters within flight range of camps; extensive systems of ditching for draining valleys; when possible, removing villages away from proximity of camps;

FIGURE 41.- DDT residual spraying with power spray.


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and controlling of ocean lagoons through a combination of larviciding and intermittent flooding.

    Drainage was the method favored by the British Army authorities, because, despite its drawbacks of expense and time, it had some permanency. Water was diverted to well-defined channels which could readily be controlled. Before the drainage system was completed, larvae were killed by larvicides.

    Adult mosquitoes were killed in military quarters and in the houses of the indigenous population by spraying with pyrethrum and DDT. Repeated sprayings in houses and Army installations were carried out throughout 1944 and 1945.

    The Yoff Peninsula, where a comprehensive program of insecticiding was carried on, will serve as an example of this type of control operation. Routine spraying of over 2,400 dwellings in villages within a mile of American installations was undertaken. Here, it was found easier to apply the DDT-kerosene solution with knapsack sprayers than with the hand or power sprays. For larval control, a power-driven unit for paris green dusting was developed (figs. 42 and 43). This consisted of a motor-driven propeller into which lime and paris green were fed from a hopper. The whole apparatus was mounted on a plank and bolted to a platform on a truck. Under favor-

FIGURE 42.- Improvised paris green duster.


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FIGURE 43.- Dusting with paris green.

able conditions, this machine could dust as many as 25 acres of water surface in an hour and a half.

    A campsite near the city of Rufisque 26 presented the problem of interrupting the transfer of malaria from an infected local population to the Army personnel. To do so, the mosquito vectors had to be eradicated for a distance of 2 miles or more from troop concentrations. It was not feasible to remove infected residents from the area. The eradication of breeding sites without disturbing the districts limited water supply was essential. Destroying Anopheles larvae within a radius of 3 miles by larviciding, and the killing of adults by insecticiding all buildings, insofar as possible, within a 2-mile radius of camp was the solution. In addition, malaria discipline was essential for the protection of troops.

    Information concerning supplies used in Liberia illustrates the extent of control activities. With an average of a 5-day oiling cycle, the following quantities of oil were used as larvicide: 27 7,550 gallons in 1942, 51,823 gallons in 1943, 106,220 gallons in 1944, and 73,852 gallons in 1945. The quantities of insecticide, Aerosol bombs, and DDT used in connection with the antimalaria program were similarly large.

26 See footnote 9, p. 316.
27 See footnote 22 (2), p. 337.


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    At this base, local labor was excellent for unskilled work, such as digging, chopping, and channel cleaning, but it was, with rare exceptions, almost futile to employ it for operations requiring any degree of skill, judgment, or independent responsibility, such as oiling and spray killing. In 1942, spray killing in village quarters took 147 local labor man-days, drainage operations, 1,450 man-days, and village construction--resettlement for gametocyte removal--1,521 man-days.

    Drainage operations in Liberia, in 1943,28 completed the following tasks: 51,863 yards of new ditching, 80,304 yards of maintenance of old ditching, 9,294 yards of reconstruction of old ditches, 23,130 cubic yards of filling, 76,185 square yards of brush removal, and construction of 31 spillways. This work used 60,638 local labor man-days and 2,235 soldier man-days. During 1944, 29 the following was accomplished: 9,370 yards of old ditch reconstruction, 58,338 yards of old ditch maintenance, 36,745 yards of new ditching, 92,917 square yards of brush removal, 14,010 cubic yards of fill, and construction of 14 spill-ways. Spray killing was carried on extensively; 6,402 gallons of insecticide and 8,407 Freon dispensers were used. An average of 270 laborers per month were employed during the first 7 months of 1944, and 390 per month for the remaining 5 months.

    During 1945, 30 in Liberia, larviciding alone required 15,374 man-days. Spray killing utilized 4,889 gallons of ready-mixed insecticide and 3,738 Freon bombs. A 5-percent solution of DDT in kerosene was available in sufficient quantities for application in and around the base as a residual spray. A total of 7,072 gallons of this mixture was dispersed. The drainage system was completed, and in the end there were approximately 55 miles of major ditches in the sanitated area. The following engineer operations were carried out: 1,035 yards of new ditch construction, 6,360 yards of old ditch reconstruction, 71,891 yards of old ditch maintenance, 85,874 square yards of brush removal, and 2,852 cubic yards of fill. For the first 8 months of the year, an average of 310 laborers were employed and for the last 4 months only 150. The drop was due to the reduction in personnel and to the completion of large-scale drainage projects.

    A much needed powerboat for larviciding finally arrived in Liberia in 1945. Considerable difficulty was encountered in obtaining suitable equipment from engineer depots in the United States. In spite of repeated specifications supplied by the Liberian base regarding the proper type of oil sprayers for larviciding, the equipment received consisted of knapsack firefighting sprayers. These were not only unsuitable for handling oil larvicides but were not even complete for use in spraying water.

    The Deversoir Air Base, between Port Said and Suez, had a high initial incidence of malaria. A problem was presented by the swamps, lakes, and

28 See footnote 25, p. 338.
29 See footnote 13. p. 317.
30 See footnote 22 (2), p. 337.


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irrigation ditches with which the airdrome was surrounded. With local labor, these ditches were cleared, and the swamps and lakes were drained. Paris green and oil larvicides were employed. After the program had been completed in January 1944, very few cases of malaria developed, and many or all of these may have been contracted elsewhere.

    In the Persian Gulf area, malaria control operations were delayed because of insufficient personnel and equipment. Essential malaria control equipment was lacking during most of 1943. A few knapsack sprayers were taken over from. a construction company, but they were in a bad state of repair and few of them could be used. Eventually, sprinkling cans were procured from local sources to spread oil on water surfaces. These were of poor construction, did not last long, and results were not too favorable. There was some dusting equipment for application of paris green, but as local road dust was the only available diluent the equipment was soon ruined. After this, a paris green mixture was broadcast by hand. In the latter part of 1943, the first "flit guns" were available. Eventually, in the fall of 1943, two portable air compressors arrived.

    Supplies of insecticide were inadequate, and during the summer of 1943 they were completely exhausted. Materials were not available for spraying nearby native villages until August 1943, when equipment was secured from British Army stocks in the Middle East. The British released 5,000 gallons of Flysol (a pyrethrum insecticide), 6,000 pounds of pyrethrum powder, 3,000 flit guns, and 5,000 pounds of paris green. At about this time, the malaria control units began to prepare their own insecticide by soaking pyrethrum powder in kerosene. Fortunately, there was plenty of fuel oil No. 2 for the malaria control needs. It was not until the 1945 season had begun that the 5 percent DDT kerosene residual spray became available for general use within the command.31

    In 1944, in the Persian Gulf area, the following was accomplished: 32 Over 600 acres cleared; over 1,500,000 lineal yards of ditching cleared or straightened; over 40,000 yards of new ditching installed; and over 2,600 water acres, over 3,300,000 lineal yards of small ditches, and over 100,000 square feet. of other water surfaces larvicided. Over 17,000 gallons of kerosene-pyrethrum spray, 167,000 gallons of oil, and 470,000 pounds of mixed paris green dust as well as 3,600 gallons of 2 percent DDT were used. Over 850,000 man-hours of labor were needed for these operations.

    For the period from January to September 1945,33 inclusive, the following was accomplished: Over 59,000 lineal yards of channel or ditch cleaning, over 1,000 lineal yards of new ditching, more than 600 cubic. yards of fill, and over

31 Report, Capt. Manning A. Price, SnC, to Commanding General, Persian Gulf Command, subject: Report of Malaria Control Activities for Month of September 1945.
32 Letter. Capt. Manning A. Price, SnC, to Commanding General, Persian Gulf Command, 10 Jan. 1945, subject: The Malaria Problem and a Summary of Malaria Control Operations for 1944 in the Persian Gulf Command.
33 See footnote 31.


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575 water areas and over 25,000 lineal feet of small streams (less than 5 feet wide) larvicided. These operations required over 45,000 man-hours of labor for spraying and over 250,000 man-hours for other aspects of the control program.

PERSONAL PREVENTIVE MEASURES AND MALARIA DISCIPLINE

    The use of personal preventive measures, such as repellents, bed nets, and proper clothing, was directed by various War Department publications and in addition was supported by directives and circulars issued by the various headquarters. Remarks to the effect that malaria discipline was enforced, or strengthened, are found in many of the documents dealing with malaria. It is not possible to obtain a clear picture of this aspect of the program for the entire area. Some typical illustrations of conditions are cited to show the general trends.

    At Eknes Field and Dakar, Senegal, until about June 1943, barracks were not sprayed regularly, and there was no malaria discipline. After that time, all barracks were sprayed nightly, but none of the buildings were adequately mosquitoproofed. Protective clothing was required, suppressive Atabrine was administered, and mosquito repellent was issued to all personnel.

    In Liberia, military quarters were sprayed once nightly, and bed nets were lowered and tucked in by 1600. The wearing of proper clothing at night out of doors was enforced, but the wearing of head nets was discontinued when mosquito repellent was issued to the troops in May 1943. Standing orders at Roberts Field prescribed the wearing of protective clothing after 1800 when out of doors. Military police were stationed in the theater and at other points to enforce the regulations.

    At some of the Air Transport Command bases in 1943, enlisted personnel were restricted to the base from 1800 to 0600 to reduce exposure to malaria.

    Although, at first, in the Gold Coast, there were unscreened quarters and theaters and malaria discipline was lax, the situation was corrected. Most of the necessary screening had been installed by the middle of September 1943. At this time, malaria discipline was strengthened.

    After this time, in the Accra area the U.S. Army camp and the Royal Air Force camp were well screened and well maintained (fig. 44). The usual protective clothing was worn, mosquito nets were used, and the American outdoor movie was screened.

    A report on the status of malaria control at Central African Stations in August 1943 34 tells of the following general policies: All barracks and quarters were sprayed regularly with liquid insecticide. Nearby villages were sprayed daily with insecticide, and British Army authorities sprayed other villages three or more times a week. The majority of American soldiers were

34 Report Col. Arch A. Fall, A.G.D., United States Army Forces in Central Africa, to The Surgeon General, 20 Aug. 1943, subject: Present Status of Malaria Control at USAFICA Stations.


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FIGURE 44.- Type of barracks housing U.S. troops at Accra Airport, showing the single mosquito trap entrance to building.

housed in mosquitoproofed barracks, and all men were supplied with mosquito bars (bed nets). The maintenance of these bars was each man's responsibility, and most of the bars were kept in good repair. Atabrine for suppressive medication was taken regularly. The usual protective clothing measures were enforced. However, mechanics working at the airport at night could not repair aircraft while their arms were covered. To obviate this difficulty, mosquito repellent was issued to each man.

    In the Delta Service Command area, normal mosquito control measures were carried out, but emphasis was placed upon individual protective measures. Proper emphasis and strict supervision of individual protective measures were the rule.

    Lack of malaria discipline in the Persian Gulf area was not solely a local characteristic, as American troops often slept without mosquito nets. This was particularly true of motor transport drivers. Maintenance and repair of bed nets and the supplying of them for transients was a constant problem.

    Although, throughout all occupied areas of the Africa-Middle East, personal preventive measures were stressed, the degree of compliance with, and therefore the effectiveness of, the program varied considerably at the different installations.


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SUPPRESSIVE MEDICATION

    Quinine and, later, Atabrine were used for suppressive medication in the Africa-Middle East area. In practically all areas of high or hyperendemicity, this method of combating malaria was used for at least limited periods of time, but whether the entire region was on suppressive medication is not known.

    In the various stations in French West Africa, Atabrine suppressive medication was authorized in June 1943. In March 1944, the Dakar area was relieved from this medication for the dry season.

    In Liberia, suppressive medication was used at various times. Two weeks before debarkation of the original task force, all troops were placed on quinine prophylaxis. After the arrival of Circular Letter No. 135, Office of the Surgeon General, dated 21 October 1942, most of the troops were taken off suppressive treatment. About half the troops were ordered off quinine prophylaxis on 2 December and the remainder on 16 December 1942. Subsequently, the number of hospital admissions for malaria increased considerably. On 24 December, a radiogram was received from Headquarters, U.S. Army Forces in Central Africa, which read:

     *  *  * Your stations have been taken off antimalaria prophylaxis. Request confirmation and reason. The administration of Atabrine to all troops in prophylactic doses is directed. Request information as to cause of increase in malaria rate.

    On 27 December, orders were issued for the restoration of prophylaxis, using Atabrine instead of quinine.

    From the first of the year through February 1943, all troops were on Atabrine prophylaxis, but the defense force which arrived on 10 and 11 March was not placed on prophylaxis. In June, the number of malaria cases surpassed all previous records, and the institution of Atabrine suppressive medication was begun on 21 June. This prophylactic treatment was continued as far as is known, except for 4 months early in 1944, for the remainder of the occupation.

    At Accra, on the Gold Coast, American troops were placed on voluntary quinine suppressive treatment until 3 November 1942, when Atabrine suppressive medication was substituted. From then on, at least through 1944, Atabrine suppression was required in compliance with several directives. All base unit personnel were issued Atabrine cards to be punched daily when the tablet was given in the mess. At the end of each week, those whose cards lacked the requisite seven punches reported to the dispensary to receive the remainder of their weeks Atabrine quota. By the end of November 1944, the malaria rates in all forces were at the lowest point for the Accra area.

    In Nigeria, 35 Atabrine suppressive medication was administered in accordance with the provisions of Air Transport Command Regulations No. 25-8 dated 12 July 1944.

35 Report, Maj. Elliston Farrell, MC, to Commanding General, USAFIME, Cairo, Egypt, attention: The Chief Surgeon, 1 Nov. 1944, subject: Malaria Control at U.S. Army Installations in West Africa, 1941-44. Part I: Nigeria, British West Africa.