CHAPTER V
North Africa, Italy, and the Islands of the Mediterranean
Justin M. Andrews, Sc. D.
Malaria reached its highest level in the North African theater in 1943. According to data obtained from tabulations of individual medical records, there were (excluding readmitted cases) 731 cases of malaria in 1942; 32,811 in 1943; 23,985 in 1944; and 5,765 in 1945. The total malaria attack rates (excluding readmitted cases) per annum per 1,000 average strength were 31.89 in 1942; 71.84 in 1943; 36.92 in 1944; and 16.29 in 1945. It is believed that the high rate in 1943 was due to poor malaria discipline, imperfect Atabrine (quinacrine hydrochloride) supply, and inadequate malaria organization By 1945, when thesedefects had been corrected, the rates had lessened considerably. 1
The most important vector of malaria was Anopheles labranchiae labranchiae. Principal gametocyte reservoirs were rural Arab populations and Italian prisonersof war in North Africa, civilian refugees, Italian prisoners of war, impressed Yugoslav laborers, and Italian cobelligerent troops in the remainder ofthe theater.
The special antimalaria organization as it finally developed was strongly centralized. The Malariologist, North African theater, commanded a detachment of malariologist officers. These were attached to major commands in which they gave technical direction to malaria survey and control detachments. An airplane dusting and spraying-flight detachment was responsible operationally to the theater malariologist.
In Africa and Sicily, main reliance was placed on the physical improvement of streams, oil larviciding, and spray killing with pyrethrum. In Sardinia, Corsica, and Italy, these measures were supplemented and finally overshadowed by the aerial application of paris green and DDT as larvicides and of DDT as a residual building spray. Insect-proofing of buildings was practiced as screening supplies permitted. Personal protective measures were directed throughout the theater and their use stimulated by special training and subsequent reminders. In 1943, all troops were ordered to take Atabrine in suppressive doses. That policy was liberalized in 1944 by exempting troops
1 Except as otherwise indicated, the data presented in this chapter are based onthe following three sources: (1) Annual Report, Medical Section, North African Theater of Operations, U.S. Army, 1943. (2) Annual Report, Surgeon, Mediterranean Theater of Operations, U.S. Army, 1944, vols. 1 and 2. (3) Final Report of the Preventive Medicine Officer, Mediterranean Theater of Operations, U.S. Army, 1945.
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in areas where the malaria hazard was negligible. During 1945, suppressive Atabrine therapy was directed only for troops in areas where malaria was an uncontrolled danger.
MILITARY DEVELOPMENT
On 14 August 1942, Lt. Gen. (later General of the Army) Dwight D. Eisenhower was directedby the Combined Chiefs of Staff of the Allied Nations to accomplish thecontrol of North Africa from the Atlantic to the Red Sea and thus to securepositions from which direct attacks could be launched against the southernflank of the European Fortress.
Allied Force Headquarters
The tactical planning for the initial operation was begun in London by British and U.S. staffstrategists, the latter detailed from the Planning Section, Headquarters,ETOUSA (European Theater of Operations, U.S. Army). On 12 September 1942,this group was officially designated AFHQ (Allied Force Headquarters) andwas expanded suitably to function thereafter as a general headquarters. Itconsisted of general and special staff sections, each of which included Britishand U.S. personnel and was intended primarily for policy making, planning,and coordination.
North African Theater of Operations, U.S. Army
The British, however, developed their component of AFHQ as an operating as well as a coordinating agency and, with the prompt capitulation of the North African countriesand the establishment and expansion of base section organizations, it becameapparent that Americans also would have to provide for the centralized administrative and operational supervision of troops. For that purpose, another headquarters known as NATOUSA (North African Theater of Operations, U.S. Army) (map 11) was activated on 4 February 1943. Both AFHQ (American Section) and NATOUSA headquarters operated with the same personnel, though the latter organization required many additional members. They were located initially at Algiers, but during the summer of 1944 they moved to Caserta, Italy.
Services of Supply and Communications Zone, NATOUSA
On 15 February 1943, all supply operations were delegated by NATOUSA to a service of supply echelon with headquarters in Oran. A year later, 24 February 1944, the functions of SOS (Services of Supply), NATOUSA, were expanded to include those of a communications zone organization, and NATOUSA became, from the standpoint of Medical Department function, a planning and consultative agency. Services of Supply, NATOUSA, moved to Caserta during the summer of 1944 and was redesignated COMZONE (Communications Zone), on 1 October 1944.
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MAP 11.- North African Theater of Operations, 1944
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Mediterranean Theater of Operations, U.S. Army
Concurrent withthe absorption of southern France into ETOUSA on 1 November 1944, the designation of the North African theater was changed to MTOUSA (Mediterranean Theater of Operations, U.S. Army). COMZONE, MTOUSA, was inactivated 20 November1944, and MTOUSA thereafter assumed responsibility for all operational aswell as planning functions.
Operations
The invasion and occupation of Morocco and Algeria, both malarious countries, involved American and British forces. Operations began on 8 November 1942; 3 days later they had been terminated successfully.
The campaign tothe east started at once and again American and British troops participated.The struggle for Tunisia was fought over intensely malarious terrain andwas not concluded until 12 May 1943.
Sicily, second only to Sardinia inmalaria. morbidity according to Italian malariologists, was secured by theSeventh U.S. Army and the British Eighth Army. It was a short but bittercontest lasting 38 days, from 10 July to 17 August 1943.
Canadian and British forces started pouring across the Strait of Messina into Italy on 3 September, and, on 9 September, the Fifth U.S. Army landed on the Salerno-Paestumbeaches. This was the first of a series of operations destined to lead U.S.soldiers through many highly malarious sections of Italy.
On 8 September,Italy surrendered to the Allied Forces and, within the following month, Sardinia, always the blackest spot on the Italian malaria maps,2 was liberated by Italian divisions. Corsica was taken at about the same time by Free French troops assisted by American Rangers. Both of these islands were developed intensively as bases from which Army Air Force and Royal Air Force airpower was beamed into Nazi-held northern Italy and southern France.
Fifth U.S. Armytroops drove steadily northward up the west coast of Italy. Naples was occupied 1 October and the Volturno River was crossed during the month. The northern advance slowed down with the coming of winter. A firm but tight beachhead was established at Anzio-Nettuno on 22 January 1944. German defenses forced a stalemate until 11 May when a combined offensive launched by the Fifth U.S. Army and the British Eighth Army broke the deadlock.
The Fifth U.S. Army pushed on through the flooded plains of Fondi and Pontinia, historically famed for their malaria hyperendemicity, and, on 25 May, made contact with VI Corps troops from the northern beachhead. On 4 June, Rome was occupied. During the ensuing month, U.S. and British forces continued to drive theenemy northward to a point beyond Leghorn. By the end of the year, the twoarmies had engaged some 28 German divisions
2 War Department Technical Bulletin (TB MED) 178, July 1945.
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in defense of a line extending across the Italian peninsula, roughly from La Spezia to Ravenna.
On 15 August, the Seventh U.S. Army, composed of U.S. divisions and attached French troops, invaded southern France successfully. The area occupied and exploited by U.S. troops was nonmalarious.
Allied Forces in Italy massed below the Gothic Line until the spring of 1945. On 14 April, their final offensive was launched which took them across the malariousPo River flood plains and into the industrialized areas of northern Italy.On 2 May, this operation was concluded. Contact was made with partisan troops from Yugoslavia, and on 7 May Nazi Germany surrendered unconditionally.
Base Sections
Numerous base sections, area commands, or equivalent organizations were developed for the support of the armies. They were occupied for varying periods of time. The more important ones were located at Casablanca, Morocco; Oran, Algiers, and Constantine, Algeria; Bizerte, Tunisia; Palermo, Sicily; Naples, Leghorn, and Bari, Italy; Cagliari, Sardinia; Ajaccio, Corsica; and Marseille, France (map 12).
Air Force Installations
Medium bomber facilities were developed mainly on the satellite airfields around Foggia. Light bombers also operated from that side of Italy and from the southwestern coast and from Sardinia and Corsica. Fighter fields were more transient and widespread. They were established throughout the occupied sections of the theater, moving forward as fast as security precautions permitted, though a few units were left in the rear areas to carry on shore patrol, air-sea rescue, and counteraerial combat duties.
AREA CHARACTERISTICS
Geography
The limits of NATOUSA were defined to include the Iberian Peninsula, southern France, Italy, Switzerland, Austria, the Balkans, Turkey, the areas of French, Spanish, and Portuguese influence in West and North Africa, and the intervening islands of the Mediterranean (map 11). The actual military operations occurred mainly in the coastal areas of Morocco, Algeria, Tunisia, Sicily, Sardinia, Corsica, Italy, and southern France. All points in the theater were within 900 air miles of Algeria.The entire area lies 30 degrees or more north of the Equator and is, therefore, within the Temperate Zone and has definite winter and summer seasons.
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Climate
Temperatures suitable for the transmission of vivax malaria (daily average of 60o F., or higher) occur from late April to November in North Africa, Sicily, and Sardinia.
In Italy and Corsica, the season is shorter, commencing in May or June and ending in October.The presence of semihibernating anophelines in occupied houses and animalshelters throughout the winter months suggests the possibility that infectionsmay be transmitted as late as December or early January.
Temperatures high enough for the development of falciparum malaria (daily averagesof 70o F., or higher) ordinarily start in June in Morocco andAlgeria and in May or June in Tunisia, Sicily, and probably Sardinia. Thisperiod terminates in September in Morocco, Algeria, and Sicily but not untilOctober in Tunisia. In Italy, north of Rome, average daily temperatures ofthis magnitude are not frequent enough to permit the development of falciparumparasites in mosquitoes, and falciparum malaria in man is correspondinglyrare.
Average yearly rainfalls vary from 15 to 30 inches throughout coastal North Africa, Sicily, and Sardinia. In Italy and Corsica, they may be slightly higher. The midsummer months--June, July, and August--are dry or nearly so, particularly in North Africa. Most of the rain falls from October through March.
Surface
The clay soil on the hillsides of North Africa is notable for its lack of ability to absorb water. Vegetation is scarce., evidence of erosion abundant. Water runoff is, therefore, sudden and of great volume. Rivers and streams are swollen, torrential, and fast moving in the spring. By July, they are mere trickles connecting occasional shallow pools or are dried up entirely. In Sicily, Sardinia,Corsica, and Italy, there is a larger proportion of perennially flowing streams,as the water-holding capacity of the earth is somewhat greater. Many of themountains are higher, their slopes support more prolific plantlife, and snowremains on them for longer intervals. Seepage and runoff into ravines andstreams continue over more extended periods of time than in North Africa.
Native Reservoirs of Infection
Ordinarily, some 90 percent of the inhabitants of the North African countries are Arabs.With the declaration of war, however, Europeans flocked to Africa to evadethe ravages of the conflict. In some instances, the populations of the larger cities doubled in size. The normal European component is predominantly French, but Italians and Spaniards have come into North Africa in such numbers that Italian or Spanish is heard in certain places as
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frequently as French. These immigrants and refugees contributed little, however, to the malaria potentialitiesof the region.
The indigenous Arabs of the coastal areas are predominantly plain dwellers, living in close association with agricultural pursuits. Thus, malarious natives--the reservoir of infection for mosquitoes--were most abundant in rural sections along the coast and on the fertile river flood plains extending between the ranges of the Atlas Mountains. Basic dissimilarities in languages, religion, personal hygiene, and other customs impose strong barriers against intermingling with foreigners. Even among themselves, the Arabs are very clannish and, except in cities, had little tendency to associate closely with U.S. troops.3 This tribal isolation protected U.S. troops against transmission of vermin and diseases ordinarily acquired by direct contact but had no effect in preventing malaria, as it was virtually impossible to avoid siting camps and bivouac areas within mosquito flight range of Arab villages.
While there wassome evidence of Arabic participation in the racial stock of Sardinia, Sicily, and, to a less extent, southeast Italy, its influence was never sufficient to hinder fraternization with Allied personnel. The two islands were as much a part of the Fascist State as the peninsula itself and, like it, were peopled predominantly by its nationals. In spite of their previous political affiliations, the Italians as a group and as individuals manifested strong amity for the Americans and appeared to enjoy their company.
The bombing andshelling of cities had resulted in widespread destruction of homes and dislocation of the Italian population. The terrified inhabitants moved into underground shelters or out into the country where they lived in caves, bans, public buildings, under bridges, or wherever they could find protection from the weather and bombardment. Many of them had left their homes precipitately andwere, therefore, destitute, hungry, and lacking in sufficient clothing. Theyhad no medical service and were as accessible to mosquitoes as the beasts of the field. In time, they constituted a huge reservoir of gametocyte carriers. In their desperate efforts to obtain the necessities of life, they tended to come into close association with Allied troops and thus facilitated the transmission of malaria. In addition to refugees, the areas were jammed with thousands of demobilized Italian soldiers. Many of these had seen service in the Balkans, North Africa, Ethiopia, Italian East Africa, and Sardinia, where they had experienced malaria from which they relapsed repeatedly. A large proportion of these ex-soldiers and of other young male civilians were formed into Italian labor units which lived and worked in close proximity to U.S. and British bivouac areas. They required extensive and continued treatmentfor malaria and must have contributed largely to local mosquito infection(map 13).
3 Personal observations of the author who supervised malaria control activities ona theaterwide basis in North Africa, Sicily, Italy, Sardinia, and Corsica,from May 1943 to January 1945.
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MAP 13.- Distribution of malaria in Italy, Sicily, and Sardinia, 1944, and in Corsica, 1925.
In Sardinia, the potentialities of the highly infected civilian population were enhancedby the presence of some 200,000 Italian troops and Yugoslav laborers impressed by the Axis. They had been there for two malaria seasons. Their military organization had disintegrated completely, and they were scattered all over the island, living from hand to mouth as best as they could.
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They suffered severely from malaria, and numerous deaths were ascribed to this disease. Many were employed as guards and laborers by U.S. military organizations and thus increased the likelihood of local anopheline infection.4
The Corsicans are of French and Italian ancestry. They are extremely independent people and did not associate with U.S. and British soldiers as extensively as did the natives of Italy, Sicily, and Sardinia. Historically, the island is reputed to be highly malarious5 (map 13). It is the custom of coastal plain farmers to move their families from the lowlands up into the hillside and mountain villages to escape the heat and fever of the summer months.This suggests that a considerable number of gametocyte carriers exist normally among the native Corsicans. To this must be added the infection potentialities of the 5,000 Yugoslav laborers imported from Sardinia. Most of them arrived at the height of the relapse season, and many were taken directly fromthe ship to the hospital with malaria attacks. They were ordinarily quartered in small camps adjacent to Allied establishments.
Because of the paucity of malaria survey detachments in NATOUSA and the necessity of using them as malaria control units, no widespread systematic effort was made to determine spleen and parasite rates in native populations adjacent to U.S. troop installations. Occasional spot surveys supported the ever-present clinical evidence of malaria morbidity with which gametocytes and consequent local mosquito infection must have been associated.
Vectors
The most important vector of malaria in the North African and Mediterranean theaters was Anopheles labranchiae labranchiae Falleroni 1926 (fig. 29). In North Africa and Sicily, the map of its distribution was virtually that of the river systems in the plains. It was found generally in permanent sunlit, vegetated,clear waters. Pools, backwaters, along the indented edges of streams andrivers, collecting basins, poorly maintained irrigation ditches, canals, seepages(especially from leaky irrigation systems over grassy areas), wells and cisterns,foxholes, founts, and freshwater lagoons with peripheral marshes, all supportedlarval growth of this species. During the early part of the season, thisspecies was found predominantly in the flooded areas adjacent to permanentbodies of water. As these flooded areas contracted during the summer, thelarvae were found mainly in pools, edges of rivers, streams, and seepages.As the process of natural drying went still further, A. 1. labranchiae invaded the neglected irrigation systems and wells. It is a versatile, adaptable species tenaciously maintaining itself in fresh and brackish water, being limited principally by low temperatures, shade, pollution, turbidity, high salt content, and brisk flow.
4 Because of the general practice of maintaining many of these infected individuals close to U. S. troops, one harried malariologist referred to them as "our mobile pool of gametocyte carriers."
5 War Department Technical Bulletin (TB MED) 125, December 1944.
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FIGURE 30.- Enemy-demolished pumping station near Licola, northwest of Naples.
In Italy and Sardinia, the larvae grew abundantly not only in rivers and streams but also in water held by unmaintained canals, ditches, tank traps, slit trenches, foxholes, shell and bomb craters, subterranean shelters, gun emplacements, and the extensive flooded areas purposely inundated by the Germans (figs. 30 and31). This type of destruction resulted in flooding enormous areas of farmland, as shown in figure 31. Many of these areas became mosquito producing. The natural drainageways in Italy, Sardinia, and Corsica were obstructed bythe residues of demolished bridges and hastily built bypasses and fords.These interferences with natural flow created many additional breeding placesfor A. 1. labranchiae. On the northeast coastal plain of Corsica,several large lakes with marginal swamps added to the breeding acreage.
The adults of this species bite both man and domestic animals and rest in houses and animal shelters. During the winter, they could be found in small numbers in houses in Morocco. In Italy and Sardinia, they were encountered frequently in houses (especially unoccupied upper rooms) and in concrete pillboxes and strongpoints. They were difficult to find in the winter months in Algeria and Tunisia. Inthe summer, they were excessively numerous in occupied houses, stables, pigsties,and poultry shelters, especially in untreated areas of Italy, Sardinia, andMorocco. On certain occasions, their densities were so great that estimates of their numbers would be as high as 1,000 or more per square yard of wall surface.
The only other anopheline species presumed to be of vectoral importance were Anopheles sacharovi (elutus) Favre 1903, and Anopheles superpictus
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FIGURE 31.- Flooded area near Licola, showing high water mark on the side of the farmhouse.
Grassi 1899. A. sacharovi is a coastal form which tolerates somewhat higher salt concentrations thandoes A. l. labranchiae. It was found in the vicinity of Naples andon Corsica but never in any abundance. A. superpictus, a species whichbreeds in highly aerated running streams in the mountains and foothills,was of negligible importance from a numerical standpoint.
MALARIA EXPERIENCE
The total monthly diagnosed malaria rates (provisional) per 1,000 per annum for the theater from 1942 through 1945 are shown in table 30. This portrays well defined but distinctly different trends in a series of three exceptionally interesting annual malaria experiences.
Experience in 1942
Malaria acquired during the last 2 months of the year was minimal, and most of this camefrom coastal Morocco north of Casablanca.
Experience in 1943
The situation in 1943 was one of a susceptible and inadequately prepared military population exposed to hyperendemic malaria. A suppressive treatment schedule of 0.2 gm. of Atabrine, on 2 nonconsecutive days per week, was
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ordered on a theaterwide basis effective as of 22 April.6 This order was not enforced for the following reasons:7
1. The widespread prevalence of acute intestinal manifestations following the third close.
2. Misinformation regarding its effects.
3. A lack of comprehension as to its value.
Base sections in Morocco and Algeria achieved some measure of environmental protection against the disease, but combat troops were sorely beset by malaria.
By the time theSicilian campaign started, hospital admissions for malaria in Tunisia wereon the increase. For this reason, many troops scheduled to participate inthe campaign failed to embark. Others reached Sicily, but some 700 to 800of them came down with the disease within incubation periods too short tohave been due to infection contracted on the island. During the Siciliancampaign, 9 July to 10 September 1943, hospital admissions for malaria (21,482)exceeded battle casualties (17,375). 8 The new cases could beattributed largely to the failure to call for more than one of the threemalaria
6 Circular No. 38, Headquarters, NATOUSA, 20 Mar. 1943.
7 Long,Perrin H: A Historical Survey of the Activities of the section of PreventiveMedicine, Office of the Surgeon, MTOUSA, 3 Jan. 1943 to 15 Aug. 1943. [Officialrecord.]
8 Report Malaria in the Sicilian Campaign 9 July to 10 Sept. 1943, Office of the Surgeon,AFHQ, 21 Oct. 1943.
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survey and control units which hadbeen earmarked and readied for the invasion. This one unit arrived on D+4,but the troops advanced so rapidly that no antimalaria operations could beorganized en route. Even after they were established in Palermo, there wasmore work than one unit could handle effectively. As a result, the troopswere denied adequate environmental protection against anophelines.
Poor malaria discipline in both North Africa and Sicily also accounted for much of the morbidity. The remainder was caused primarily by failures in Atabrine supply. These occurred on board ship (lack of coordination between Army and Navy), atrations' breakdown points (where Atabrine was to be issued with the rations),and among forward combat elements for tactical reasons. This last is alwaysinevitable to some degree. Thus, the malaria debacle in Sicily was the resultof inefficient malaria control supply, poor malaria discipline, and a quantitativelyinadequate special antimalaria organization. The malariousness of Sicilywas well known and control and survey units had been prepared to accompanythe invading forces but the Seventh U.S. Army Command would not permit theseunits to proceed to Sicily in time to render effective aid during the invasion.
The malaria rate reached a maximum in August 1943 of 192 cases per 1,000 per annum whichrepresented about 8,500 cases; this coincided more or less with the end ofthe Sicilian campaign on 17 August. This overall theater rate fails to reflectfaithfully the extent of the malaria morbidity experienced by elements ofthe Seventh U.S. Army during the campaign. As shown in table 31, weekly ratesof diagnosed malaria among II Corps troops are reported to have risen toover 1,700 per 1,000 per year. Corresponding rates of "fever
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of undetermined origin," a collective diagnostic term which included indeterminate proportions of malaria, sandfly fever, and other unrecognized pyrogenic disorders, were as high as, orhigher than, the malaria rates.
Because of the rapid increase in the number of cases, the Seventh U.S. Army adopted a suppressive treatment schedule of 0.1 gm. of Atabrine 7 days a week starting on 14 August 1943.9 This increased dosage was well administered and tolerated. It was continued for about 3 weeks and probably accounted for the drop in the rate in September to 130 per 1,000 per annum. The relatively high rate in October was theresult of the Salerno landings made by the Fifth U.S. Army on 9 September;discipline in taking suppressive Atabrine became lax in the heat of battleand at a time when mosquito transmission was still occurring.
With the comingof cold weather, the rates dropped off rapidly. As will be pointed out inthe following paragraphs, many more infections not manifested in 1943 undoubtedly were contracted during the fall months of that year but were suppressed by Atabrine and remained dormant during the winter months. By the end of the year, 32,811 new cases were recorded, an annual rate of about 72 per 1,000. The number of recurrent cases is not known, but it is surmised that thenew cases constituted 90 percent or more of the total malaria attacks. Sincethe primary cases reported during the winter and spring months of 1944 werepractically all contracted during the previous season, the rate of transmission in 1943 must have been much higher than the hospital admission rates indicated. About 19 percent of the years infection were falciparum malaria, 48 percent were vivax malaria, 1 percent were quartan, less than 1 percent were the mixed type, and 32 percent were undetermined as to type.
Experience in 1944
Troops were well established on the Italian mainland by 1944. Suppressive Atabrine, 0.6or 0.7 gm, per week, was ordered as of 1 May on a theaterwide basis except in areas which were nonmalarious or where malaria was considered by the area surgeons to be under control.10 The breakthrough at Anzio on25 May permitted troops to push north through the flooded Pontine marshes. The advance continued across highly malarious coastal lowlands, passing through Civitavecchia, Tarquinia, Orbetello, Grosseto, and Piomubino. DDT was sprayed in forward areas, sometimes in advance of artillery units. With the advent of winter, troops were operating in the mountains north of Pisa and Florence and were out of malarious country. Throughout this period, additional U.S. forces (largely Air Corps) were occupying the insalubrious islands of Sardinia and Corsica.
Table 30 shows a sharp rise in spring cases with a rate of 80 per 1,000 per annum in April 1944. While many of these cases were relapses of infections
9 See footnote 7, p. 262.
10 Circular No. 12, Headquarters, NATOUSA, 28 Jan. 1944.
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contracted the previous year, a large proportion (approximately 40 percent) gave histories of no previous malaria. A few of these may have been contracted during the spring months, but the majority of these primary attacks undoubtedly represented late 1943 infections either suppressed by Atabrine or showing extraordinarily long incubation periods typical of certain strains of vivax malaria. The proof ofthis assertion rests on the observation that little or no spring malariaoccurred in divisions entering the theater during the late winter of 1943-44.Indeed, their early cases were invariably in replacement or attached personnelfrom other divisions which had seen service in the 1943 campaigns. Thus,while 40,682 represents the total number of cases recorded for the year,a rate of about 62 per 1,000 per annum, most, if not all, of the 15,348 casesoccurring before June are attributable to infections acquired during the1943 season. In all probability, many of the relapses appearing after thebeginning of June also should be referred back to 1943. Of the laboratory-diagnosedcases, about 5 percent were falciparum malaria, 92 percent were vivax malaria, less than 1 percent were quartan, and the balance wasof undetermined types. Only in Sardinia was the species distribution substantiallydifferent: 21 percent falciparum malaria, 72 percent vivax malaria, and the remainder undetermined. The farther north the troops wentin Italy, the fewer falciparum cases were reported; they were rarenorth of Rome.
Experience in 1945
The 1945 seasonsaw a marked reduction in the size of the Mediterranean theater. North Africa was split off and placed under the command of the U.S. Army Forces in the Middle East. The islands of Sicily, Sardinia, and Corsica ceased to be of operational importance, and their military personnel were returned to the Italian mainland. For all intents and purposes, malaria control operations were restricted to Italy in the vicinity of Naples and Rome, around the Army Air Force areas in the Foggia region, in the Arno Valley from Leghorn toFlorence, in the Ancona-Timini sector on the northeast coast, and in certain sections of the Po River Valley. While the danger from malaria exposure was considerably less than during the previous two seasons, the fact that troops were generally scattered throughout the malarious areas of Italy during 1945 constituted a situation of potential seriousness.
The Atabrine policy for this year called for suppressive medication only in areas designated as malarious.11 With the exception of one instance in the PoRiver Valley where the Fifth U.S. Army specified a few dangerous areas,suppressive treatment was limited to an occasional unit having an undulyhigh malaria rate or to individuals recovering from an attack.
The start of 1945 found Army troops ensconced in the Apennines north of Florence, preparing for the final offensive into the Po River Valley. After the highly satisfactory 1944 season, it was anticipated that the rise in cases
11 Circular No. 54, Headquarters., MTOUSA, 9 Apr. 1945
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in the spring of 1945 would be less than in the preceding year. This prediction was fulfilled as the monthspassed. The peak appeared in May, when a rate of 31 per 1,000 per annum wasrecorded. Some apprehensiveness was felt concerning the possible effectsof the Po River offensive, especially if it slowed down, on malaria prevalencein the troops. Fortunately, the campaign was a short one. The abrupt cessationof hostilities on 8 May 1945 permitted the Army to establish the bulk ofits troops in the southern Alps, the remainder occupying isolated areas throughout the Po River Valley. Thus the rise in case number, which had been anticipated in June, failed to materialize. On the contrary, there was a steady drop in the incidence which was quite phenomenal in the light of existing conditions.
With the capitulation of the German armies in Europe, redeployment of U.S. troops to the United States and to the Pacific theaters was initiated promptly. However, while this movement was going on, approximately one-half the theater strength--Air Force and Service troops--was established in malarious areas. As the Army divisions were redeployed, they were required to occupy some of the more dangerous areas while staging. It is believed that the intensive work accomplished by the War Department malaria control units, in addition to the widespread use of DDT as a residual house spray, played a significant role in keeping malaria casualties to a minimum. During the 1945 malaria season, there was a total of 6,800 cases reported in the theater, a rate of 20.5 per 1,000per annum. Again, as in 1944, the type of malaria was predominantly vivax as shown by the following species distribution for the year: 2 percent falciparum. malaria, 97 percent vivax malaria, quartan rare,and the remainder type unspecified.
Primary MalariaRates
As reported previously, malaria control officers believe that the best appraisal of their efforts and fortune are the trends of new or primary malaria rates. Field malariologists gathered this information more or less independently in NATOUSA during1943 and more systematically in MTOUSA during 1944 and 1945. On the basisof personal interviews with patients or from forms filled in by medicalofficers on the wards, they determined from each patient his unit assignmentand history of previous malaria. On 1 July 1944, the Medical Section, COMZONE, NATOUSA, required its hospitals and separate dispensaries to use a supplemental communicable disease report in addition to the weekly statistical health report. The new form indicated whether or not patients were assigned to thecommand to which the hospital was responsible and whether or not the conditionfor which they were hospitalized (including malaria) was a primary or asubsequent episode. This relieved the base section malariologists of anonerous task and provided better and more extensive operational information for their use. The Medical Section continued to re-
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quire this report from its base section hospitals and dispensaries after COMZONE had been inactivated.
Table 32 shows a comparison of primary and total malaria attack rates for the months where reasonably dependable data were available. It was admittedly not possible to ascertain the exact amounts of malaria transmitted each year; nevertheless, certain calculations based on reasonable assumptions indicate at leastthe relative degrees of transmission each year. According to the theatermalariologists, the primary rate per 1,000 for 1943 was probably somewherein the sixties; for 1944, somewhere in the thirties; and for 1945, it wasprobably less than ten.
Civilian Malaria Experience in Italy
The relatively favorable military malaria experience in Italy poses the question whether the low Army rates were due to effective control efforts or to nothing more than thegood fortune of being present when the malaria potential was reduced abnormally. The answer to such an inquiry would be given by a determination of malaria prevalence in the civilian population at the time of Army occupation. Data concerning malaria morbidity and mortality in the years from 1939 to 1945 in Italy are meager and imperfect, but, such as they are, they tend to indicate a violent upsurge of epidemic malaria among civilians, particularly in the war-torn areas.
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Before 1939, malaria was on the downgrade in Italy.12 At the turn of the century,annual case rates of about 1,000 and death rates of 40 to 50 per 100,000prevailed. Their steady descent thereafter was interrupted by World War Ibut reached all time lows of 126 cases per 100,000 in 1939 and 1.1 deathsper 100,000 in 1940. This was due to the large-scale agricultural developmentof low, fertile coastal areas. Extensive land reclamation drainage (bonification) by gravity and pumping systems was practiced. This not only abolished large acreages of potential anopheline production but freshened the soil as aresult of rainfall and drainage. Thus, it eliminated the dangerous carrier,A. sacharovi--a brackish-water breeder--from numerous sections whereit had flourished previously. Furthermore, confining the water in these coastal lowlands to drainageways made it possible to apply paris green cheaply and effectively where this supplementary measure was indicated.
During the early years of the war, from 1939 to 1942, malaria increased as shown by theannual malaria morbidity rates per 100,000 reported as follows:
Year Rate
1939..........................................................................126
1940..........................................................................137
1941..........................................................................141
1942..........................................................................178
Actual rates were undoubtedly much higher as the imperfections of peacetime malaria casereporting are always enhanced during wars.
Official vital statistics for the country were not available after 1942; such figures as could be gathered were fragmentary and provisional. From them, it appears that the "heel"area of Italy showed little change in malariousness during the war years.This was the section of the country least disturbed by active warfare. Onthe other hand, the southwest coastal provinces and those in the northeast (Po River Valley) experienced reported increases of from 2 to 20 times their prewar malaria case burden. From Terracina, Fondi, Gaeta, Cassino, and neighboring rural settlements came reports of hyperendemic and fatal malaria. Similar accounts came from the provinces constituting the Veneto area through which the final offensive of the war was pushed. These are the areas where the hand of Mars was laid most heavily, where flooding, shelling, bombing, and digging in multiplied natural opportunities for anopheline production. Meteorologic influences also favored increased anophelism, but this effect was not productive of such high malaria morbidity rates in the Allied forces as occurred in the neighboring civilian population.
In summary, theevidence indicates that (1) in the face of epidemic malaria prevalence amongthe Italians in 1944 and 1945, the incidence of malaria in U.S. troops remainedrelatively low; and (2) the degree of success
12 Statistics and other information regarding malaria prevalence among Italians weresupplied by the Istituto Superiore di Sanito, Roma.
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achieved in military malaria control was accomplished in spite of and not because of natural forces.
ANTIMALARIA POLICY AND ORGANIZATION
As in all theaters, antimalaria policy and organization evolved slowly. Until the late spring months in 1943, the malaria control program was in the stage of planning, formulating, obtaining local malaria intelligence, liaison with civilian health agencies, and general development which necessarily precedes thephysical organization phase.
Initial Stage
A malaria advisory board was established by the Director of Medical Services, AFHQ, underthe chairmanship of Brig. E. R. Boland, the consulting physician (British). 13 All nationalities locally concerned in the problem were represented in its membership which included Lt. Col. Perrin H. Long, MC, Consultant in Medicine, NATOUSA, and, later, the Preventive Medicine Officer and Malariologist, NATOUSA. This group inventoried and assessed malaria control facilitiesexisting in the theater, set the policy for theaterwide suppressive medication,suggested that civilian health agencies be subsidized to provide environmentalmalaria control for Allied troops around camps and bivouac sites, consideredthe various malaria problems as they arose in the theater, and made recommendations regarding their solution.
During the early days, Colonel Long acted in the capacity of preventive medicine officerand concerned himself actively in laying the basis for the future antimalaria activities. He held conferences with British and French malaria controlrepresentatives and worked out an arrangement with civilian health agencieswhereby they were to assume responsibility for the bulk of environmentalmalaria sanitation in extramilitary areas. Plans were made for a theaterwidesuppressive Atabrine therapy program. Requests for special antimalaria personneland supplies were placed with the War Department. Combat units commencedtroop training in malaria control discipline. Exploratory survey operationswere launched. Limited control activities--drainage and larviciding--wereconducted in those areas where year-round anopheline production occurs. Thesewere directed by Medical Corps or Sanitary Corps officers under the supervisionof base section medical inspectors. By the end of May 1943, four survey andfour control units had arrived from the United States and had been assignedto various base sections for duty. They immediately commenced malaria survey activities in and about Army installations and acted in advisory and inspectoral capacities with regard to antimalaria activities conducted by the various Army units within their own camps and those carried on by civil organizations insofar as they affected Army personnel.
13 See footnote 7, p. 262.
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On 9 June 1943,a theater malariologist and an assistant theater malariologist were designated. The organization to which they belonged, a malaria control detachment recently arrived from Liberia, ultimately became the malaria control headquarters unit for the theater.
Policy Development and Expression
The pattern of administrative responsibility in malaria control as it finally developed was as follows: Malaria control policy and general administrative procedure in NATOUSA (MTOUSA) originated in the medical section of the theater headquarters, with the theater surgeon, the chief of preventive medicine, and the theater malariologist. These were expressed in circulars and administrative memorandums published from AFHQ and NATOUSA (MTOUSA) headquarters. They specified or clarified such considerations as (1) relative responsibilities of various commands inareas jointly occupied hr Al lied troops,14 (2) dates for the beginningand ending of malaria control operations,15 (3) personal preventivemeasures and suppressive medication, the basis for and method of issuingAtabrine and quinine for suppressive purposes to static and moving troops,(4) the designation of malarious and nonmalarious areas, the theater malariacontrol organization, (5) command responsibilities for malaria control, (6)allotment of malaria control supplies to individuals and units, (7) enlisted men antimalaria details, (8) malaria control instructions, (9) proper use of personal amid environmental preventive measures,16 the unrestricted use of DDT,17and (10) application for airplane dusting service. 18 These directives or pertinent parts of them were republishedby subtheater commands.
Supplies
Estimates of theater requirements for malaria control supplies were made and their distribution within the theater suggested in the Preventive Medicine Section of theSurgeon's Office. These were sent to the engineer and quartermaster sectionsof the theater headquarters, where unfailing cooperation in effecting therecommendations was always evidenced. During each month of the active malariacontrol season, supplies on hand, in transit, and due into various majordepots were inventoried by the malariologist and were reported to the theatersurgeon. By this means, a reasonably current picture of the status and theflow of supplies throughout the theater was maintained.
14Administrative Memorandum No. 21, AFHQ, 17 May 1944, subject: Allocation of Responsibility for Malaria Control Measures.
15 See footnote 10, p. 264.
16 Circular No. 72, Headquarters, NATOUSA, 20 May 1944.
17 Letter Order to all concerned, by command of Lt. Gen. Jacob L. Devers, 29 Aug.1944, subject: Insecticides.
18 Administrative Memorandum No. 23, AFHQ, 28 May 1944, subject: Allocation of Responsibility for Malaria Control Measures.
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Theater Malariologist
The theater malariologist administered the special malaria control organization.19 Hewas responsible to the Surgeon, NATOUSA, through the Chief, Preventive Medicine Section, Office of the Surgeon, NATOUSA, and maintained close operational liaison with Col. Paul F. Russell, MC, Chief, Malaria Control Branch, Allied Control Commission, and Brig. George MacDonald, RAMC, British Consultant, Malariologist, AFHQ. Special antimalaria unit situation-and-status reports were submitted to the theater surgeon each month by the malariologist. On his recommendation, malariologists and units were moved as needed from one theater subdivision to another. Efforts were made to distribute the antimalaria units' technical information pertaining to malaria and its control which arrived in the Medical Section, Headquarters, North African theater.
Special Organization for Malaria Control
The organization consisted of a provisional malaria control headquarters unit, War Department malaria survey and control detachments, and a section of a ferrying squadron used to operate dusting and spraying airplanes. In addition, each company, battery, or similar unit maintained enlisted-man malaria details as directed by War Department Circular No.223, dated 21 September 1943.
It is impossible to assign accurately the proper amount of credit due to the "enlisted-men" or unit antimalaria details for their malaria control achievements because no systematic accounting of their efforts is available. The details were trained and in many instances were supervised by the special malaria control organization. They were mentioned frequently in the local malariologistsreports, but no routine recording of their activities--separate from malariacontrol accomplishments in general--was ever required or made. It is known,however, that while these were variable in quantity and quality, their aggregateeffect must have been very considerable. This was true especially in FifthU.S. Army areas and in Army Air Force installations.
It was interesting to note that, in the Air Force installations during 1944, these antimalaria details were made up exclusively of Medical Department personnel (except in antiaircraft artillery units) and they worked under the
19 On 9June 1943, Col. Loren D. Moore, MC, commanding, and Lt. Col. Justin H. Andrews, SnC, 2655th Malaria Control Detachment, were attached to the Medical Section, Headquarters, NATOUSA, for duty as malariologist and assistant malariologist, respectively. Shortly thereafter, Colonel Moore was incapacitated by rheumatoid arthritis and ultimately returned to the Zone of Interior.
On 24 July 1943, Col. Louis L. Williams, Jr., USPHS, arrived and was designated theater malariologist. He was stricken with coronary disease on 31 Julyand thus became unavailable for duty.
On 21 September 1943, Col. Paul F. Russell, MC, arrived and was designated theater malariologist.
On 4 March 1944, Colonel Russell left theater headquarters to become Chief, Malaria Control Branch, Allied Control Commission, and Colonel Andrews was designated theater malariologist.
On 9 January 1945, Colonel Andrews was returned to the Zone of Interiorfor redeployment. Maj. Thomas H. G. Aitken, SnC, was designated theater malariologist, a position which he retained until after the capitulation of the enemy troops in northern Italy on 9 May 1945
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direct supervision of medical officers. 20 This practice was not in conformity with War Department Circular No. 223 which specifies that antimalaria details will be made up of Medical Department soldiers only in medical units. The circumstances which urged this departure from the directive were that: (1) Many Army Air Force units were composed entirely of special technicians with full-time duty responsibilities; (2) Army Air Force medical units were so generously manned that they could afford to supply the men without detrimental effect upon the fulfillment of their primary functions; and (3) the malaria survey and control unitsscheduled for the Army Air Force were delayed in arriving and it was essentialfor the Army Air Force malariologist to contrive some sort of working organization to take on the task of providing environmental malaria control. In spite of this contravention of Medical Department policy, the arrangement turned out to be an admirable one. Indeed, it is doubtful if as much work was accomplished, in proportion to total strength, by enlisted-men antimalaria details in other major or commands during 1944.
Headquartersunit . - This unit consisted of four officers and seven enlisted men. 21 In the early spring of 1944, it became a provisional NATOUSAorganization with 13 officer and 20 enlisted-man position vacancies. Officermembers were available for attachment to surgeons' offices in base section,Army, and Army Air Force headquarters for duty as malariologists. These malariologists had technical direction of the malaria survey and control units assigned or attached to their respective headquarters. As long as considerable numbers of U.S. troops were maintained in Africa, they coordinated the work ofFrench health agencies doing malaria control in the neighborhood of militaryinstallations. Through the malariologists, malaria survey and control unitactivities were reported in prescribed form to the surgeon of the organizationto which the unit was attached or assigned. Each month, the weekly unitreports, together with accounts of malariologists' activities, were consolidated by the local malariologists and submitted to the local surgeon. These monthly reports were then sent by the latter through channels to the theater surgeon.
Local antimalaria units. - As of 1 July 1943, there were four malaria survey units and four malaria control units inthe theater, in addition to the 2655th Malaria Control Detachment. Therewere no malariologists other than the theater and assistant theater malariologists. By the end of the year, one more survey unit and three more control units had arrived and eight officers (six Medical Corps and two Sanitary Corps) reported in the theater for duty as assistant malariologists. They wereassigned to the 2655th Malaria Control Detachment as authorized overstrengthpending approval of the revised table of organization for that unit.
20 See footnote 3, p. 256.
21 The 2655th Malaria Control Detachment (Ovhd) was originally activated by the War Department as Medical Detachment 2655 to supervise malaria control activities in and around Army installations in Liberia.
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During 1944, 10more control units were activated and trained in the theater. They were commanded by officers trained in the United States and sent over for that purpose. One more survey unit arrived completely trained. On 1 November, two control units were lost to the theater when ETOUSA took over all U.S. troops remaining in France. Thus, the antimalaria organization reached its maximal strength during the malaria season of 1944; as of 15 August, as shown in chart 8, itconsisted of 6 survey units and 17 control units and 14 administrative malariologists,12 of whom were assigned to the 2655th Malaria Control Detachment.
At the close ofthe 1944 season, when it was realized that the theater would no longer havecommitments in North Africa, Sicily, Sardinia, or Corsica, it was decidedto reduce the antimalaria organization both in personnel and units. The officerstrength of the 2655th Malaria Control Detachment was cut from 13 to 6, andthe antimalaria units were reduced from 17 to 10 control units and from 6to 1 survey unit. Redeployment of officers took place during the winter months.The 10 oldest units were disbanded in February by War Department order, andall but three officers were returned to the United States. This drastic reductionoccasioned considerable concern regarding the security of the malaria program.In order to safeguard it, authorization was obtained from MTOUSA to organizethree provisional malaria control units. In addition, two of these unitswere authorized an overstrength of 14 enlisted men and 1 officer, makinga total of 25 enlisted men and 2 officers. Where possible, an attempt wasmade to obtain men from the old units disbanded in the springs; this policywas successful in retaining about 30 percent of the trained personnel.
Airplane dusting and spraying detachment. - This detachment consisted of American and British pilots in the 327th Ferrying Squadron, Mediterranean Air Transport Service. They operated under the technical direction of the Malariologist, NATOUSA (MTOUSA), an arrangement requested by the Commanding General, Mediterranean Air Transport Service, and concurred in by the AFHQ committee of consulting malariologists consisting of the British Consultant Malariologist, AFHQ, the NATOUSA Malariologist, and the Tropical Disease Consultant, Royal Air Force. 22 In 1944, the U.S. contingent consisted of 9 pilotsand 22 enlisted men; in 1945, of 9 pilots and 18 enlisted men; at no timewere more than 6 pilots operating planes. They were equipped with two L-5observation planes, three PT-17 (Stearman) trainers, all of which were equippedfor dusting in 1944 with one modified for oiling in 1945, and ten A-20 (Boston)light bombers, four of which were equipped for oiling and six for dusting.
From administrative and operational viewpoints, it was advantageous to base aircraft and flying personnel at as few points as possible. In 1944, practically all the dusting and spraying in Italy was done from Capodichino Airport, though planesand pilots were attached for brief periods to Foggia Main
22 Letter. Commanding General, AFHQ. to Commanding General, Mediterranean Allied Air Forces, 18 June 1944, subject: Malaria control by Airplane Dusting.
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CHART8. - Special malaria control organization,North African theater, 15 August 1944 1
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Airport in eastItaly and at Castiglione del Lago Airfield in central Italy. Other separateinstallations remained for the entire season in Sardinia and in Corsica.In 1945, a home base was maintained at Capodichino with advance bases setup in northern Italy in the Leghorn-Pisa sector and in the Rimini-Veronaarea.
ANTIMALARIA ACTIVITIES
Training
The need for troop understanding of and familiarity with the procedures of malaria hygieneand sanitation was clearly recognized by Colonel Russell, theater malariologist, during the latter months of 1943. He urged the development of an Allied, theaterwide, malaria control teaching project as a winter activity for antimalaria personnel. This was directed forthwith 23 and the Allied Force Malaria Control School became an active entity in the early months of 1944 (fig. 32).
As finally established, this school was set up in three related but virtually autonomous sections, American, British, and French. Each section director outlined and supervised the presentation of courses suitable for personnel in his section. Someinterchange of lectures was made among the British, American, and Frenchschools held in Algiers. At the suggestion of the Surgeon, AFHQ (British),interallied dinners for the students of various nationalities were featuredperiodically in Algiers.
The basic faculty of the American Section of the Allied Force Malaria Control School wascomposed of members of the 2655th Malaria Control Detachment (Overhead).These officers were given a preliminary training course by the assistanttheater malariologist in Algiers late in 1943. As they were attached totheir respective posts, they conducted schools similar to the one in Algiers.Most of these were held during January, February, March, and April. All arrangementsfor announcements, issuing attendance orders, messing and billeting, andtransporting student officers and men were made through regular channelsby the malariologists, assisted in field and teaching duties by officersfrom malaria survey and control units. Certificates were generally awardedat the successful completion of these courses, so that suitable recordsmight be made in the 201 files or service records of the individuals attending.
Three types of courses were given, modeled after those in Algiers, but with special divergencies and emphases as dictated by the situation. Course One was designed forofficers of the medical-inspector type who had administrative interest inmalaria control. This course dealt with clinical, epidemiologic, and preventiveaspects of malaria. Guest lecturers were invited to participate and, especiallyin Algiers, strengthened the content of the presentation. Course Two wasdesigned for laboratory officers and technicians. Train-
22 Training Memorandum No. 52, AFHQ, 22 Nov. 1943, subject: Allied Force Malaria Control School.
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FIGURE 32.- Allied Force Malaria Control School at Anzio-Nettuno beachhead.
ing was given in the making and staining by various methods of thick blood films and the identification of the various stages and species of the malaria parasites. Course Three was designedprimarily for enlisted men who were to serve as antimalaria details, althoughit was attended also by line officers detailed as antimalaria officers.It consisted of brief, didactic training in the principles and demonstrationof the procedures used in malaria control practice.
American Section schools were held in Algiers, Oran, Bizerte, Palermo, Cagliari, Naples,Caserta, Foggia, Bari, San Severo, Cerignola, Spinazzola, Mandunia, and atthe Anzio-Nettuno beachhead (fig. 33). 24 According to the localmalariologists reports, 7,540 officers and enlisted men received trainingat these schools. This was about 1.2 percent of the total U.S. strength atthe time the schools were conducted and represents a substantial troop contact.It was recognized that educational efforts should not stop with the expiration
24 The school at the Anzio-Nettuno beachhead deserves special comment. It was the largest (more than 2,000 officers and enlisted men were trained there) held in1944 and was conducted literally under fire at all times. The hospital areaseemed the least dangerous one available, so the didactic teaching was presented there in a double-ward tent liberally covered with red crosses. Not until the first days class arrived--armed to the teeth! --did it occur to the instructor that the picture of the completely accoutered students going in and outof the tent and lounging around it during the 10-minute "breaks," if takenby a German photoreconnaissance plane, might he justifiably interpreted asevidence of a breach of the Geneva conventions and serve as the basis fora deliberate attack on the hospital area! Nothing of the sort ever happened, but it took 3 long days to get the order countermanded requiring all combat soldiers to carry arms at all times--so that the students could come to school unarmed. This was the more remarkable because the hospital area, according to the uncannily accurate reports of Radio Rome, was under special surveillance at the time.
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of a school project. Accordingly, some 51 miscellaneous lectures were given by assistant malariologists to military audiences totaling more than 6,500.
Inasmuch as so many persons connected with malaria control had received extensive schooling during 1944, comprehensive training was unwarranted in 1945 and a modified educational project was proposed. This consisted of 1-day schools held by local malariologists and assistants for (1) officers entrusted with antimalaria instruction of troops or who supervised the activities of enlisted-men antimalaria details, and (2) enlisted men of the unit antimalaria details. In the main, theseschools were held during March and April just before the malaria season.
The courses forofficers included the history of malaria in the theater, a prognosis of themalaria hazard and problems for 1945, the duties and interrelationships ofantimalaria personnel, antimalaria education of troops, the training anduse of unit antimalaria details, where and how to get supplies and equipment,and the 1945 theater policy for suppressive Atabrine therapy.
The courses forenlisted men dealt with the importance of malaria, utilizing the "GraphicPortfolio on Malaria"--War Department Graphic Training Aid 8-4, which givesa brief description of anopheline and culicine mosquitoes and their comparativebionomics, malaria control procedures to be practiced by enlisted-men antimalariadetails, care and use of equipment, and demonstration of mosquito-collecting,house-spraying, oil-larviciding, and ditching techniques.
A special course was offered to officers and technicians in the Air Force Group Aid Dispensaries. These units were in the process of being equipped with microscopes, anda majority of the technical personnel assigned were
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inexperienced in the preparation and interpretation of thick blood films for malaria diagnosis.
These schools were held in Naples, Rome, Grosseto, Siena, Leghorn, Pisa, Florence, Cattolica, Torre Maggiore, Foggia, Cerignola, Spinazzola, Ban, Manduria, and in the mountains of the Fifth U.S. Army sector, north and west of Florence.
According to the reports of local malariologists, 6,130 officers and enlisted men received training in these courses. This amounts to about the same troop contactas was achieved in 1944.
In addition to the formal training activities, awareness of the malaria problem and of the necessity for unremitting continuity in malaria control was stimulated by announcements and reminders conveyed both by radio and unit newssheets, by the use ofroadside markers indicating the boundaries of malarious areas, by malariacontrol posters, and by the booklet entitled "This is Ann." Most of the posterscame from the States (War Department, Medical Department Item Nos. 7J770-01to 12, inclusive), although a few originated in the theater and were reproducedby engineer mapping units. Certain of the illustrations in "This is Ann"were enlarged and printed by civilian contract in Italy. The posters andpamphlets were usually in evidence in messhalls, dayrooms, and on companybulletin boards.
Survey Activities
These were minimized in NATOUSA and MTOUSA from necessity rather than choice. The number ofmalaria control detachments in the theater was never great enough to provideand supervise environmental control measures on a really adequate scale.Consequently, it appeared advisable to use malaria survey detachments asmalaria control detachments during the malaria seasons. In some instances,the malaria survey detachments were authorized to draw enough extra vehiclesand equipment to make them operationally equivalent to control units; inothers, provisional malaria control detachments were formed, by theater directive,from replacement personnel, commanded by the extra officer (parasitologist)from malaria survey detachments and equipped as malaria control detachments.
Furthermore, a considerable body of information regarding the distribution of malaria and anophelism existed in each country and island occupied. While these data were not always up to date, nor as nearly accurate as might be desired, they were generally useful. It seemed pointless, therefore, to engage in detailed explorational surveys except on those rare occasions when information from local civilian sources was not available. Consequently, the hulk of survey activities was inspectoral.
Splenometry . - Spleen palpation as a rapid measure of malaria endemicity was notwidely employed, although limited and isolated observations were made innearly all base sections, armies, and Army Air Forces. A total of
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5,110 individuals, mostly children, were examined, of whom 12 percent were reported to have enlarged spleens. Local spleen rates varied from 2 to 43 percent.
Parasitology. - More parasite examinations were made in relation to either troop strength or the number of malaria survey detachments in 1943 than in either 1944 or 1945. Thiswas due largely to the necessity of checking the blood-film examinationsof hospital laboratories staffed with personnel not yet experienced in therecognition and identification of malaria parasites. Epidemiologic studiesbased on parasite-positive slides were not possible except on a small andunsatisfactory scale. The rapid movement of units and individuals and thepossibility of protracted incubation periods (resulting from suppressiveAtabrine therapy), during which multiple exposures in various places mayhave occurred, made these efforts unproductive in discovering where infectionswere contracted. They did point, however, to a rather selective prevalenceamong truckdrivers, railroad operators, cooks and kitchen helpers, attendantsin antiaircraft, searchlight and locator posts, and among members of similardetails in which duty exposure after dark was the common factor.
During 1943, more than 12,000 blood smears were examined by survey unit personnel in thetheater. The lack of homogeneity as to time, place., sampling, and techniqueprecludes drawing statistical conclusions from these data. As expected,tertian infections appeared to predominate in the early summer mouths andestivo-autumnal infections in the late summer and fall. About 75 percentof the total examined were survey slides made from troops, prisoners of war,or natives (mostly children). The remaining smears were from hospital patients,the majority of whom were suspected of having malaria from clinical evidence.Of the total, 11.5 percent of the blood films were positive.
In 1944, ever 14,000 smears were examined, of which only 3 percent were positive. Some of the examinations were from civilian or Italian military surveys; the others were made to check hospital laboratory malaria diagnoses.
In 1945, there were no parasitologic surveys due to the fact that all survey units but one were deactivated in the spring. The one remaining survey unit operated in the capacity of a control detachment. Accordingly, the control detachments were obliged to train their own mosquito inspection teams. In general, these consisted of two men per detachment. Lacking diagnostic equipment, it was impossible to differentiate anopheline larvae and adults.
Entomology . - As explained previously, most of the mosquito survey activities were inspectoral rather than explorational. The following species of anophelines were reported by various malaria survey units in the North African and Mediterranean theaters:
Anopheles algeriensis Theobald
Anopheles claviger bifurcatus Meigen
Anopheles hyrcanus pseudopictus Grassi
Anopheles labranchiae atroparvus van Thiel
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Anopheles labranchiae labranchiae Falleroni
Anopheles maculipennis maculipennis Meigen
Anopheles marteri Senevet and Prunelle
Anopheles melanoon melanoon Hackett
Anopheles plumbeus Stephens
Anopheles sacharovi (elutus) Favre
Anopheles superpictus Grassi
Anopheles turkhudi (hispaniola) Liston 25
Other members of the maculipennis complex were probably encountered but were not recognized because of the paucity of survey personnel and equipment.
Control Activities
No environmental control measures of a truly permanent nature were attempted in NATOUSAexcept a relatively small amount of land fill. It is probable that muchof the open ditching may have had certain semipermanent control values ifthe requisite maintenance work was done on it each year. Generally speaking,each Army unit was responsible for locating and controlling all anophelinebreeding and performing other antimosquito measures within the limits ofits installation, and, in many instances, for a mosquito flight-range radiusbeyond.
In North Africa, an effort was made during 1943 to utilize civilian health agencies forcarrying on larviciding, clearing, and minor hand drainage beyond the militaryarea limits to the extent of two kilometers. Base section commanders wereauthorized by NATOUSA directive to draw from U.S. military sources transportation, nonmedical supplies, and facilities for malaria control as dictated by circumstances in each base section and to expend up to 500,000 francs ($10,000) a month for civilian labor and miscellaneous items for the same purpose. This idea had merit, and where the base section commanders, surgeons, and preventive medicine officers took a constructive interpretation of the directive, the supplemental control activities thus generated had definite values both to military and local civilian populations.
Unfortunately, none of the North African health agencies, with the possible exception of the one in Morocco, had an experienced malaria control organization large enough to take on the task of environmental malaria control around Allied military installations. In Algeria, it was customary for larvicidal and drainage improvement operations to be performed by one national agency, the Service de la Colonisation et de l'Hydraulique, under the technical direction of another agency, the Service de la Santé Publique. The Eastern Base Section
25 (1) Russell, P. F., Rozeboom, L. E., and Stone, A. Keys to the Anopheline Mosquitoesof the World, With Notes on Their Identification, Distribution, Biology,and Relation to Malaria. Philadelphia: The American Entomological Society,The Academy of Natural Sciences, 1943, pp. 56-61. (2) Ross, E. S., and Roberts, H. R. : Mosquito Atlas. Part II, Eighteen Old World Anophelines Important to Malaria. Philadelphia: The American Entomological Society, The Academy of Natural Sciences, 1943, pp. 37-38.
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included parts of both Algeria andTunisia which made it. necessary to deal with two different national healthdepartments. These circumstances naturally led to complications and misunderstandingsin planning, responsibility, execution, and finally, in reimbursement.
Larviciding .- The treatment of anopheline breeding places to destroy larvae was practiced on a more extensive scale than any other single control method. The more frequent areas of mosquito production were small streams and ditches. Inmany of these areas, the entire water surface was covered by floating andemergent vegetation, and mosquito breeding extended from bank to bank; inothers, plant growth was marginal, and larvae were found only along the edges,especially in relation to small vital floatage. In either case, supplementaryclearing and cleaning were needed to make larviciding applications effective.These physical operations must have had considerable destructive effect uponthe larvae themselves.
Petroleum oil, usually No. 2 diesel, was the larvicide of choice for ground application. Paris green was not generally available until 1944, but, in spite of considerable promotion and instruction in its use, the unit antimalaria details did not employit to any great extent and showed a strong preference for oil. Probable reasons are that oil was much more available due to its general distribution forpurposes other than larviciding, it required no mixing or trips to a mixingplant, it was not a poison, and the oil sprayers were mechanically superiorto the rotary hand dusters usually supplied. In certain base sections, someparis green hand dusting was done by or immediately under the supervision of the special malaria control organization. An immense amount of paris green was spread by airplane in Italy, Sardinia, and Corsica during 1944 and in Italy in 1945. During the spring of 1944, DDT made its appearance in the theater.As a larvicide, it was used almost entirely in an experimental way both fromthe ground and by airplane. In 1945, 5 percent DDT in oil was used extensivelyas a larvicide applied both from the air and from the ground.
For the most part, various types of hand pressure sprayers were used to apply petroleum products. Continuous drip oilers were set up over streams in many parts of the theater. In one base section, a power oil sprayer was developed by utilizing a M3A1 Chemical Warfare decontaminating unit mounted on a 21/2-ton6 x 6 truck chassis (fig. 34). This was actually a homogenizing pump developing up to 500 pounds pressure and was used to deliver a finely dispersed mixture of one part of oil in three parts water. Less oil was necessary for a given area when applied by this apparatus, the area was oiled in a shorter time than by hand-operated equipment, and the oil was forced below the watersurface where it continued to come up under and around vegetation for periodsof 2 or 3 weeks, so that its effect lasted longer than surface spraying.
Airplane larviciding . - Probably the first utilization of airplanes in dispersing larvicides in NATOUSA was made in Morocco during the summer of
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FIGURE 35.- A-20 airplane dusting paris green over flooded areas northwest ofNaples.
1943.26 Planes and pilots for this purpose had been requested from the States early in the year.It was late September, however, before the six pilots--three of them experienced in crop dusting--reported for duty, and even later before the three PT-17 (Stearman) trainers, modified for dusting, were assembled and ready tofly. By that time, the mosquito-breeding season was nearly over so the planes were flown only for a small amount of experimental dusting. Some replacement parts for the dusting attachments had been sent over with them, but no repair or maintenance items for the aircraft arrived nor were there any in the theater. With the prospect of providing malaria protection in 1944 through the flooded Pontine and other bonifications and in malarious Sardinia and Corsica, it was necessary to enlarge the scope of the aerial-dusting facilities considerably beyond those afforded by three small trainer planes, any one of which might be grounded indefinitely by a cracked spark plug or a fiat tire. It was obviously desirable to provide more and larger planes which could be serviced within the theater. The A-20 (Boston) light bomber was finally selected becauseof its flying characteristics and availability (figs. 35 and 36), and a B-17 was dispatched to the States to obtain a load of PT-17 motors, tires, wheels, instruments, and other replacement parts.
26 The base section commander had forbidden use of paris green as a larvicide by Army personnel because he was misinformed as to its toxicity to men and domestic animals. The local stores of paris green were, therefore, made available to the Moroccan public health service, representatives of which proceeded to spread the paris-green-road-dust mixture with an old French bomber which had been condemned long before as unairworthy. The time came when this ancient aircraft could no longer get off the ground, whereupon the local Navy air surgeon took over the mission using a modified L-4 cub. He succeeded in getting in his flying time while he dusted effectively portions of two large swamp areas near Army campsites.
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Theaterwide airplane dusting and spraying service was developed in 1944 and continued the following year. At the request of the Theater Surgeon, AFHQ directed the Mediterranean Allied Air Force to provide adequate planes and pilots for malaria control purposes.27 This responsibility was delegated by the Mediterranean Allied Air Force through the Army Air Force Service Command to the Mediterranean Air Transport Command. This organization placed a detachment of one ofits ferrying squadrons virtually at the disposal of the theater malariologist. The crop dusting pilots, assisted by special malaria control organization personnel, supervised the structural modification of the A-20's to convert them to dusting and oiling planes.
Working arrangements were as follows: Requests for airplane dusting or spraying service weretransmitted to the theater malariologist. As soon as practicable, he or oneof his representatives visited the area and, accompanied by the local malariologist,made an aerial and ground inspection of the terrain to be treated. The amountof materials required for each week was then computed, and decisions weremade regarding responsibility for transporting, mixing, and planeloadingof larvicidal materials. The local malariologist provided a map for the pilotshowing the exact area to be covered. The job was then scheduled for a particularday each week and copies of these arrangements circulated to all agenciesconcerned. Thereafter, the work proceeded as arranged until cancellation.Planeloading was generally handled by some element of the special malariacontrol organization.
In 1944, nearly900,000 pounds of 25 percent paris green in lime and 7,000 gallons of oil(mostly No. 2 diesel with varying contents of DDT) were applied by airplanefor American and British malaria control. During 1945, about 250,000 poundsof paris green mixed with diatomaceous earth (1: 3 for American use) or cement(1: 6 for British use) and roughly 72,000 gallons of 5 percent DDT in oilwere dispersed by plane in the theater.
These quantities of paris green and DDT mixtures required large-scale mixing facilities.In 1944, they were contrived by base section engineers from an old Italianammunition plant located in a cave near the Fair Grounds outside Naples (fig.37). This factory was provided with motor-driven, steel tumblers loaded froma platform overhead. These containers discharged mixed dust into steel barrelson rollers below. Ample facilities were available for the dry storage ofparis green and lime as well as mixed dust. Both 25 percent and 10 percentmixtures were prepared at this plant, the former for airplane and the latterfor hand-duster applications. Plant capacity was 8 tons of mixed dust per8-hour day.
In 1945, American larvicides were prepared by one of the malaria control units working inthe Solvay plant at Rosignano (fig. 38). The 25 percent paris green mixturein diatomaceous earth was blended in revolving steel drums formerly usedfor manufacturing chloride of lime. The plant capacity was
27 Letter, the Commanding General, AFHQ, to the Commanding General, MediterraneanAllied Air Force. 23 Mar. 1944, subject: Malaria Control Dusting Airplanesfor 1944.
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FIGURE 37. - Paris green mixing plant near Naples.
5 to 15 tons per day. DDT solutions (5 percent in diesel oil or kerosene) were prepared in one of several large stills previously used for making trichlorethylene. Each of these had acapacity of 1,200 gallons and was equipped with a set of agitator paddleswhich rotated at the rate of 60 r.p.m. Oil or kerosene was pumped in throughpipes connected to large storage tanks outside the building. DDT concentrate,dissolving in the proper amount, was added through a hatchway in the topof the still. After thorough mixing, the solution was drawn off through atap at the bottom directly into 55-gallon drums. These stills had a capacityof about 2,400 gallons per day. Because of the ease of production, the malariacontrol unit also prepared large quantities of 5 percent DDT in kerosenefor use as a residual insect-killing spray to be applied within houses byvarious units.
The MTOUSA airplane malaria control project abundantly demonstrated the feasibility of using large fast planes for applying larvicides. When the program was begun, this principle had not been employed to any extent, and its practicability was flatly denied by numerous "swivel-chair" pilots. The A-20 (Boston) lightbomber 28 proved to be an admirable vehicle for dust and oilapplications to large, unobstructed water areas. These planes were used
28 Thisbomber is powerful and surprisingly maneuverable in the hands of a skilledpilot and has visibility advantages over the B-25. Its radius of round-tripoperation without refueling is about 200 miles. It can carry 8,000 poundsof dust, discharging it in 20 minutes, or 300 gallons of oil which can bedischarged in from 3 to 15 minutes of dying time, according to the diameterof the discharge vent.
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to dust large marshy and ponded areas in Corsica, vast inundated acreages in coastal Italy, the extensive canal systems in western Italy, and along the troopjammed highways of the PoRiver delta area (fig. 39).
The enthusiasm of theater malaria control personnel for the A-20 did not preclude the utilization of small planes for the precision treatment of small areas or winding streams, the course of which could not be followed by the larger aircraft. L-5 (Grasshopper) liaison planes, UC-61 (Fairchild) observation planes, and PT-17 (Stearman) trainers were all tried (fig. 40).29
29 Of these, the Stearman trainer plane was by all odds the best. It is powerful, tough, maneuverable, and has had excellent pilot visibility, as the cockpit isopen. It has a work radius, without refueling, of from 100 to 150 miles.It carries 500 pounds of dust which it discharges in 7 minutes, or 55 gallonsof oil which are released in about 6.5 minutes at a speed of 50 miles perhour. The L-5 was also satisfactory for minor plane dusting or spraying operations, but it lacked the power and maneuverability cf the PT-17. The UC-61 was considered undesirable for these purposes--though it was used more or less extensively by the British as it is underpowered and has limited pilot visibility.
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FIGURE 39.- A-20 airplane discharging DDT in oil over a small canal near Pisa.
FIGURE 40.- PT-17 (Stearman) spraying a canal in Italy with DDT in oil.
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Experience in 1944 demonstrated the desirability of covering large areas with several A-20's flying in echelon formation (fig. 36) so that an entire area could be covered with a single loading of larvicide. This avoided the necessity of having to leave for more dust or oil and returning to find different wind and air current conditions, as well as having to resume operations at an uncertain point somewhere near the place where the previous load ran out. Formation flying was found to be best directed from a liaison plane overhead, utilizing radio intercommunication with the pilots in the work planes. By this means, the effects of crosswinds could be noted, pilots ordered to the right or left,bare spots covered, and so on. The A-20 treatment of large canals was alsoperformed more effectively under the direction of an aerial observer, asthe A-20 pilot cannot see behind him to gage the effects of wind drift onthe spray or dust cloud.
Airplane dusting was carried out at weekly intervals in accordance with the general principle of applying larvicides of temporary effectiveness at least once duringeach consecutive period of larval development. Aerial oiling schedules wereplaced on a weekly basis also, but this was because of administrative convenience. No data are available to show how long the DDT applications were effective in Italy. It is possible but unlikely, judging from experiences reported from other areas,30 that some residual effect was established after several weekly treatments on the same area.
Adult mosquito killing. - This activity was conducted systematically in Morocco during 1943, where it constituted a major and very effective means of mosquitoreduction, especially when larvicidal measures were conducted simultaneouslyin the area.
This program was unique in that women were employed to conduct the spraying operations because of the ruling by the local pasha and the French civilian comptroller that men would not be permitted to enter Arab dwellings. Despite fear to thecontrary, European women were easily obtained and proved to be more conscientious,careful, and steady sprayers than men. The total number of native dwellingsinvolved in the inspection and spraying program in the whole sector is notknown, but it must have been very large. The frequency with which the buildings were sprayed varied greatly, depending upon the findings of the inspectors. An indication of the cost and efficiency of this program is gained from data submitted from the Rabat area where, from 7 June to 31 July, five women sprayed 7,090 huts at a total labor cost of $564, or $0.08 per dwelling. Mosquito counts in these houses before the spraying program averaged 500 to 800 mosquitoes per hut.; at the end, 5 to 10 mosquitoes per hut.
Less extensive uses of spray killing both with liquid insecticide and Aerosol dispensers were made in other portions of the theater. While they could not be used in the most forward section of combat areas, they probably achieved
30 War Department Technical Bulletin (TB MED) 200, February 1946
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their maximum utilization in Army areas where both the antimalaria units and the unit antimalaria details sprayed houses and animal shelters in newly occupied sections.
In the summer of 1944, the use of DDT as a residual house spray in Italy, Sardinia, and Corsica was begun. This measure came to be of increasing importance in malaria control technique, especially in areas where the possibilities of other environmental control practice were either not practicable or did not yield immediate health benefits. DDT residual spray was used for the control of all pest and disease-carrying insects. The DDT was mixed with kerosene to make a 5-percent solution and was packaged either in 5-gallon or 55-gallon containers at central points. The Fifth U.S. Army drew the mixed product from its supporting base section and distributed it with printed instructions as to its use to various units, a moiety of which made their own application. In virtually all other installations, the DDT solution was issued to units but was applied for them by specially- trained individuals or by teams using power sprayers. The latter arrangement was decidedly more efficient than the former, which was necessitated bythe relatively vast dispersion of Army units. The basis of distributionin Air Corps units was 30 gallons per 1,000 men per month; in all otherorganizations, 5 gallons per company as needed, issue dates being determinedby actual observations of insect prevalence. By NATOUSA directive, liquidinsecticide and 5 percent DDT and kerosene were made available late in August"without restriction and in sufficient quantity to control disease-bearinginsects throughout the theater." 31
Its spectacularsuccess in 1944 as an adult mosquito killer led to its utilization on aneven grander scale in 1945 in Italy, where it was credited by the theatermalariologist as being the most important item in malaria control operationsduring the season. More than three and one-half times as much DDT was appliedto walls by malaria control units in 1945 than had been used similarly duringthe previous year. Spraying was commenced in March to kill the overwinteringanopheline females. After the initial application, unit buildings were resprayedevery month and the surrounding civilian houses about every 3 months. Laterin the season, it was felt that it would be more profitable to increase the protected zone by another half-mile to a mile rather than to respray previously treated houses; in this way very large areas of countryside were blanketed with DDT. It was also discovered that, in order to get adequate control, it was necessary to treat every shelter in the control zone, otherwise small foci of adults continued to exist in the untreated structures.32 Although DDT house spray was distributed on the basis of 30 gallons per 1,000 men per month in 1945, it was always available and units needing additional amounts could always draw them.
31 See footnote 17, p. 270.
32 In afew instances, however, it was necessary to restrict the amount of spraying. Thus, in certain sections of the Po River valley where sericulture is practiced, DDT was applied only to civilian pigsties, stables, and other outhousesas the silkworms which were raised in the homes would have otherwise beendestroyed.
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DDT replaced Freon pyrethrum to a considerable extent as an insecticide in 1945. During the previous year, the special malaria control organization used 11,217 bombs, whereas in 1945 only 1,716 werereported to have been used and these by Army units during the Po River Valleyoffensive when it was necessary to treat houses quickly; later, the unitswent back and resprayed the houses with DDT.
Physical operations . - These were extensively conducted throughout the theater in 1943 to eliminate mosquito breeding and to permit more effective application of oillarvicides. Vegetation and obstructions were removed and residual pools ofteneliminated in order to enhance the speed of waterflow. In some instances, temporary dams were constructed to permit periodic flushing of streams. In 1944, the total amount of stream training, drainage, and land fill was greatly increased in Italy, Sardinia, and Corsica. In Corsica, a tremendous mileage of ditch and stream clearing, new ditching, and stream channelization was accomplished. Large areas were dewatered which, according to local inhabitants, had not been dry before in the memory of man. The mosquito population was so reduced that Corsican families moved from their summer homes in the hills down to the coastal plains before the advent of cold weather.
The enormous amount of physical operations was accomplished mainly by Italian and Yugoslavmilitary labor. Companies of Italian infantry or quartermaster service troopswere attached to malaria control units for operational control. These Italian organizations drew their own rations, messed, and sheltered themselves. The companies varied in size, averaging from 125 to 150 officers and men, but about a third were concerned in company administration and were not, therefore, available for work. In Corsica, Yugoslav labor companies were used similarly. The men in these units had been taken from their homes and country by the Germans as forced labor to work in Sardinia. When transported to Corsica, these labor companies were commanded by Italian officers and noncommissioned officers--whom they heartily detested--were malnourished, dispirited, and plagued by recurrent malaria. When the Italian officers were replaced with Americans and the Slays were well fed and given proper medical service, their morale rose rapidly and they became, by all accounts, the. most effective and dependable source of labor available in the theater. Italian civilian labor was employed on contract projects by the Allied Control Commission inSalerno and eastern Italy. Their work was also satisfactory as long as itwas subject to U.S. officer inspection.
The responsibility of the Corps of Engineers for environmental control was accepted whenever its units were available from other duties.
Three Corps of Engineers projects were of considerable magnitude and were coordinated with the program of the special malaria control organization to such an extent that they merit particular mention.
During the spring months of 1944, while the Fifth U.S. Army headquarters were located atSparanise (a small village located near Naples).
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one battalion from each of five general service engineer regiments, together with the entire regimental heavy equipment, was made available for malaria control. One of the regimental officers,an experienced malaria control engineer, was detailed as liaison officerwith the medical section of the Army headquarters. Together with the Commanding Officer, 28th Malaria Control Detachment, he surveyed the entire Army rear area north of the Volturno River, noting those situations where major earthmoving machinery and pumpage could be used to advantage. These jobs were thenallotted to the various regiments by the Army engineer, and the indicatedrepairs were undertaken. This continued until engineers were needed for thepush to Rome. No record of accomplishment is available, but the work included such operations as filling tank traps, shellholes, bomb craters; lowering culverts; removing obstructive bridge-demolition residues and bypasses; bridge improvement and construction; major canal repairs; and installation of heavy duty pumps which involved running electric powerlines for many miles. Much of this had to be done in heavily mined and boobytrapped areas. The engineers succeeded in reducing the water in the northern Volturno area to its normal level in time to permit civilians to plant the dewatered acres in the spring of 1944. It is no exaggeration to state that the U.S. Army engineers, with the tremendous manpower and equipment facilities at their disposal, accomplished more in a few weeks than the impoverished Italian citizenry could have hoped to do in as many years.
At the Anzio-Nettuno beachhead, the VI Corps engineer undertook responsibility not only fordrainage improvement but for larviciding and spray killing in a considerableportion of that besieged area with the technical assistance of special malariacontrol organization representatives. This continued until the beachheadforces were joined with other elements of the Fifth U.S. Army on the advanceto the north.
In the Salerno-Paestum area, where the invasion training center was situated during the summerof 1944, an engineer combat regiment cooperated with the special malariacontrol organization of the Army and the Navy in a joint program of malariaprevention. Men from this regiment, using explosives, carried out rapid buteffective for a distance of several miles thus dewatering a large and potentiallydangerous area. This could not have been accomplished otherwise with thefacilities at hand in time to have favored the health of the troops trainingnearby.
Insect-proofing .- Since screening is virtually nonexistent in North Africa, all the buildings requisitioned by the Army in 1943 were without this protection. The scarcity of Army screening materials that year restricted their use to latrines, kitchens, messhalls, and breadboxes. Thus insect-proofing was employed primarily as an antifly rather than as an antimosquito measure. Some screening of hospitals was permitted, complete in certain instances, limited in others to spaces mentioned above and to one or two wards for patients with insect-borne diseases. Salvaged mosquito bars were used ex-
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tensively for screening purposes. In 1944 and 1945, the situation was greatly improved. Screening materials were provided and used on an adequate scale throughout the theater.
Personal protective measures, except medication ,- Bed nets were utilized more faithfully than any other individual protective measure. By theater directive, they were available from 15 April to 30November. 33 Some units requested them for use (against pestmosquitoes) during the winter months. They were not used by forward elementsin combat as it was impracticable for these troops to carry or set up bednets until they were back in rest areas. Where there was little or no supervisionby officers, such as with truckdrivers or railroad operators on the road,it was not uncommon to find that bed nets and other essentials for personalprotection against malaria were not in the possession of the individualsinspected. 34
The wearing of protective clothing was limited usually to long trousers and sleeves rolled down after dark. Shorts and shirts without sleeves were prohibited except during the hours of daylight. Some outfits wore leggings all the time. Head nets and mosquito gloves were rarely used and were not even nominally required by the theater in 1944 as items of personal protection.
Repellents wereamply available but their maximum antimalaria values were never realized.Unless mosquitoes were numerous enough to constitute an annoyance, it wasunusual for officers or enlisted men to use repellent as instructed. Allkinds made their appearance at one time or another in the theater. Dimethylphthalate or 6-2-2 appeared to be least objectionable to the soldiers andwas effective against A. labranchiae labranchiae.
Much time and effort went into the indoctrination of officers and soldiers in NATOUSA regarding the use of personal protective measures against malaria, but in spite of all these endeavors it was known from night inspections that personal protection was more or less neglected except in those units where command interest enforced malaria discipline. This indifference was strikingly apparent as soon asthe troops passed Rome advancing to the north. It was due, presumably, tothe rumor that malaria did not exist north of the Eternal City.
An excellent feature of the Fifth U.S. Army malaria control program was the use of antimalaria officers and malaria control committees.
The antimalariaofficers were appointed from nonmedical personnel in each corps, division,regiment, battalion, and separate company. It was the duty of the antimalariaofficer to inform himself about the status of malaria and its control inhis organization, to attend and participate in the deliberations of the malariacontrol committee to which he belonged, to acquaint his commanding officerwith the malaria problem of the Unit, and to see that all necessary malariacontrol measures were being enforced.
23 See footnote 10, p. 264.
24 See footnote 3, p. 293.
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Malaria controlcommittees were formed in each corps,. division, regiment, and battalion.The membership of each corps and division committee consisted of the medicalinspector, the engineer, and the antimalaria officer of their respectiveechelons. Regimental and battalion committees were composed of their surgeonsand antimalaria officers. The function of each committee was to bring togetherinformation concerning the phases of malaria control represented by the respectivecommittee members. Thus, at periodic meetings, the medical inspector contributedinformation about current malaria prevalence and the activities of the MedicalDepartment antimalaria personnel. The engineer was concerned primarily withenvironmental control and the mapping of malaria and malaria control data.The antimalaria officer discussed malaria control in general but was especiallycharged with noting how well the individual preventive measures were beingenforced. Their findings were reported to the commanding general or officer.To an Army operating in a malarious area, this type of conference was mosthelpful as it brought together in all echelons the three branches of service--command,engineering, and medicine--most intimately concerned in the prevention ofmalaria. It is believed that this device did much to sustain malaria consciousnessand integrated control effort while the Army was exposed to the militaryhazard of malaria. The various Army Air Force commands employed malaria-discipline officers in virtually the same capacity as the antimalaria officers mentioned previously.
Suppressive medication .- As indicated previously, the Malaria Advisory Board, AFHQ, was influential in formulating suppressive medication policy for the theater.35 The British were insistent upon universal, theaterwide administrationof Atabrine (except to flying personnel who, they felt, should receive quinine) at a scheduled dosage of 0.2 gm. after the evening meal upon Monday and Thursday. This was contested in principle by the American membership for the following reasons: (1) It was American policy to depend primarily on environmentalsanitation and not on chemical prophylaxis, except in active, tactical situations;(2) a high rate of toxic reactions, such as were manifested in the groupof Ohio State University, Columbus, Ohio, students placed upon a controlledexperiment of suppressive therapy under the auspices of the National ResearchCouncil, might occur, which, if true, would damage seriously the programof chemical suppression; and (3) with the numbers upon such therapy, theadministrative details of providing the Atabrine to forward combat units would be difficult and the drug would arrive in an irregular manner andthe program would suffer accordingly. The British minimized the force ofthese objectives, and the French agreed heartily with the British pointof view. A compromise was finally effected whereby the procedures outlinedabove were to be followed, with the proviso that if environmental malariacontrol was found to be so effective in static areas that suppressive medicationwas
35 See footnote 7, p.262.
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not needed, the commander in chiefwould decide whether or not the latter measure would be continued in mainareas.
Suppressive Atabrine therapy was commenced 22 April 1943. 36 Practically no complaints of reactions were received following the first and second doses, but following the third, a well-nigh incredible wave of incapacitating, toxic episodes was reported. These involved nausea, vomiting, cramps, diarrhea, and, insome instances, febrile temperatures for a day or more following the thirddose of Atabrine. All grades of severity were noted and many individualsexperienced no symptoms whatever. A rather typical example of the incidenceof toxic reactions encountered is shown in the following data recorded bythe 59th Evacuation Hospital (table 33).
TABLE 33 - Incidence of toxic reactions from Atabrine at the 59th Evacuation Hospital, 1943
The experience in basic service troops was quite similar to that recorded in the officers and enlisted men in the detachment noted previously, with the exception thatNegro troops showed a very low incidence of toxic reactions.
The experience in forward areas was very different from that in base sections. In II Corps troops, suppressive Atabrine therapy was begun 4 April 1943 because malaria was increasing in the 1st Infantry Division which was then engaged in combat.. The third dose was followed, in the 16th Infantry Division, by less than5-percent moderate or severe toxic reactions, all of which passed off rapidly.In the 32d Field Artillery Battalion, about 10 percent of the personnel wereaffected, while in divisional headquarters some 25 percent suffered fromtoxic reactions. The reactions in II Corps troops were definitely less frequentthan those in base section personnel. A similar story subsequently was gainedfrom the 9th and 34th Infantry Divisions and the 1st Armored Division. TheBritish reported similar toxic disturbances with the same curious tendencyof having fewer reactions in units which were in forward areas.
36 See footnote 6, p. 262.
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After this experience, the Malaria Advisory Board, AFHQ, was called into immediate session. Itdecided that 0.2 gm. was too large a dose of Atabrine and unanimously recommended that 0.1 gm. be taken on Monday, Tuesday, Wednesday, and Thursday of each week. Remarkable effects immediately were ascribed to this change in dosage, and many reports of decreased toxicity were received. However, the divisions in II Corps which had begun suppressive therapy early in April did notreceive this order and continued upon the dosage of 0.2 gm. twice a week,on Tuesdays and Thursdays. This corps reported also an almost total lackof continued reactions so that the conclusion reached was that toleranceto suppressive Atabrine therapy was developed if the drug was continued,regardless of the type of dosage used.
The spring and summer experience with suppressive Atabrine had precisely the effect on the program of suppressive medication which the medical consultant had feared and expressed before the Malaria Advisory Board, AFHQ. For every individual who reacted physiologically to the early doses, there were several others who experienced similar psychogenic--but none the less incapacitating--episodes. Actually, when the smoke had cleared away, it was apparent that most of the affected people were able to develop a tolerance to the drug rather promptly if daily doses of 0.1 gm. or less per day were used. The proportion which remained continuously sensitive was less than 1 percent. Nevertheless, as a result of the widespread distress, numerous officers and men feared Atabrine and would go to any lengths to avoid taking it. They rationalized their deliberate and unauthorized discontinuance of the drug on many bases. The rumor spread that Atabrine was a cause of impotency. The yellow skin infiltration was regarded by the soldiers as jaundice and an indication of grave liver damage from which they might never recover.
Medical officers unconsciously sabotaged the program by expressing, in the presence of enlisted men, their doubts of the prophylactic value of Atabrine. Many of the troops worked and were quartered in large cities such as Algiers, Oran, and Casablanca, or in other areas where mosquitoes were scarce or absent. Neither officers nor enlisted men could see any use in taking Atabrine under these conditions, and the theater regulation was not enforced. These irregularities in taking suppressive Atabrine were evidenced abundantly by the frank admissionsof malaria patients interviewed by malariologists and by the casual comments of officers in messes regarding the bottles of Atabrine on the tables before them. Thus, the proportion of troops taking Atabrine regularly in 1943is not known nor, consequently, the role of chemical suppression in thepicture of malaria morbidity which developed in 1943 and in early 1944.
A natural result of the uncertain, vacillating, poorly enforced Atabrine policy in 1943was the evolution of a more rational directive for 1944.37 By
37 See footnote 10, p. 264.
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this time, more information regarding the suppressive efficacy and lack of toxicity of Atabrine was available. The period 1 May to 15 October was designated as the malaria season. Allareas were to be considered malarious unless otherwise designated, by thearea commander concerned and upon the advice of his surgeon. Nonmalariousareas were designated as those in which malaria did not occur and areas wherecontrol measures had effectively removed the likelihood of malaria transmission. All military personnel were directed to take one 0.1 gm, tablet of Atabrine per day for either 6 or 7 consecutive days a week while in areas which had not been designated as nonmalarious.
The flexibilityand adaptability of this directive, reinforced by troop training regardingthe use of Atabrine, resulted in considerable improvement in Atabrine discipline during the first half of the 1944 malaria season. Some difficulty was experienced when soldiers who had been taking Atabrine regularly came into "nonmalarious" rest areas; that is, Rome, where Atabrine was not provided automatically with the rations. This defect was corrected promptly. The most serious impediment to the Atabrine program developed as the result of successful environmental control operations. The combination of low malaria rates and negligible anophelism made the enforcement of suppressive atabrinization--and other personal protective measures as well--seem useless to officers and enlisted men alike. Thus,during the late months of the malaria season in 1944, compliance with suppressive Atabrine regulations was not as extensive as earlier in the year.
In 1945, the policy was liberalized further by making Atabrine suppressive medication (0.1gm, per day) compulsory only in specially designated areas.38 Several such areas in the Po River Valley were thus specified by the Commanding General, Fifth U.S. Army. Otherwise, Atabrine consumption during the year was limited to occasional units having unduly high malaria rates or to individuals recovering from attacks. The 1945 directive was thoroughly rational and enforceableand, judging from the results, the most successful of the suppressive Atabrine policies developed during the 3 years.
Research
The personnel in the special malaria control organization were not able to devote much time to research. This was due not to any disinclination to engage in such activities but to a lack of opportunity. During the winter and early spring of the year, typhus control, malaria control training, and preseasonal control activities occupied the time of its members. After the transmission season commenced, no time for anything but control work remained. The theater was fortunate in having available in the Allied Control Commission (later Allied Commission) certain specialists (made possible through
38 See footnote 11, p. 265.
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the cooperation of members of the field staff of the International Health Division of The Rockefeller Foundation), highly skilled in particular phases of malaria control, who were able to devote their entire time to working out problems suggested by individuals occupied with actual malaria control responsibilities. Reference is madeto the monthly reports of the Demonstration Unit, Malaria Control Branch,Allied Control Commission.
The following abstracts are based upon investigations made during 1944 and 1945 by members of the special malaria control organization and the Allied Control Commission.
1. Determination of toxicity of 5 percent DDT in kerosene to 33 members of power spraying teams exposed 6 hours per day, 6 days per week, from 1 to 21 weeks each.No evidence of intoxication was adduced from histories, physical examinations, and laboratory tests in a general hospital.
2. Analysis of admission and disposition sheets to determine what proportion of cases originally diagnosed as fevers of undetermined origin and febricula were finally diagnosed asmalaria. Of 150 cases in the Fifth U.S. Army discharged to duty during eachof the following months--June, July, August--of 1944, 35 percent were definitely diagnosed as malaria, 19 percent remained as fevers of undetermined origin or febricula, and the remainder were distributed among respiratory, gastrointestinal, and miscellaneous disorders.
3. Development of the A-20 as a spray plane for the application of DDT in liquids. This involved experimentation: (1) with M-10 CWS wing tanks which were discarded because of their mechanical difficulties; (2) the utilization of auxiliary fuel cells (332-gallon capacity) and airscoops leading to an atomizing chamber whence the spray was conducted through a discharge tube to the tail of the shipand released; and (3) a special 300-gallon tank, from which equalized flowswere obtained irrespective of variations in the hydraulic head within thetank, and an atomizing apparatus consisting of a truncated, conical airscoop fitted over a simple discharge pipe so that the distance between the end ofthe pipe and the terminal orifice of the scoop could be altered to vary dropletsize and pattern.
4. Development of the PT-17 (Stearman) as a spray plane for the application of DDT in liquids. This utilized a 55-gallon steel drum as a reservoir with flow-equalizing equipment and with an atomizing apparatus similar to those used on the A-20.
5. The variablespray patterns and droplet spectra developed by the A-20 mind the PT-17 aircraft under varying conditions of temperature, wind direction, size of outlet, and adjustment of atomizer.
6. The dust pattern developed by the A-20 with 25 percent paris green-in-diatomaceous-earthmixtures under conditions of varying wind directions and amounts of dustin hopper. Great unevenness in spread, particularly of paris green particles,was noted.
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7. A study of winter DDT house spraying and its concomitant effect on anophelines and malaria in an endemic area. 39 A single application of 5 percent DDT in kerosene (83 mg. of DDT per square foot) made in midwinter to all houses andouthouses in a certain area with virtually no other antimalaria measures ineffect resulted in reduction in anopheline densities, frequency and size ofenlarged spleens, and parasite rates (table 34).
TABLE 34 . - Results of winter DDT spraying in an endemic area, 1945
Other Activities
During the winter months, the special malaria control organization was used predominantlyfor troop training in the principles of malaria prevention. Some of the malariologists and antimalaria units were employed in 1943-44 to combat the typhus epidemic which threatened Naples and the Fifth U.S. Army. At least one survey unit operated prophylactic stations in Naples during the winter. The remaining individuals and detachments were kept occupied in mapping, making watered-area surveys, overhauling equipment, consolidating records, and in accomplishing such preseasonal control operations as were possible. Thus during the season when malaria transmission was at its lowest ebb, the antimalaria personnel was serving usefully and in accordance with its prescribed functions.
As the theater malaria control organization expanded, increasing need was felt for discussing technical and administrative problems, for evaluating certain procedures, and for exchanging program information. To some degree, this was accomplished during the periodic visits of the theater malariologists to malaria control and survey units. It was evident, however, by the end of the 1944 malaria season, that a pooling of the highly specialized experiences
39 (1) Soper, F. L., Knipe, F. W., Casini, G., Riehl, L. A., and Rubino, A.: Reduction of Anopheles Density Effected by the Preseason Spraying of Building Interiors with DDT in Kerosene, at Castel Volturno, Italy, in 1944-45 and the Tiber Delta in 1945. Am. J. Trop. Med. 27: 177-200, March 1947. (2) Aitken, T. H. G.: A Study of Winter DDT House-Spraying and Its Concomitant Effect on Anophelines and Malaria in an Endemic Area. J. Nat. Malaria Soc. 5 : 169-187, June 1946.
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of the malariologists attached to major commands would be invaluable toward making future operations more effective. With the object, therefore, of integrating, coordinating, and improving MTOUSA malaria control activities, of interchanging information, and of broadening the perspective of each malariologist by acquainting him with the experience of his fellows, the officer members of the 2655th Malaria Control Detachment were requested to attend and participate in a malaria control conferenceat Naples during November 1944. Sessions were held daily for 10 days. Theprogram included a summary of theaterwide malaria control accomplishmentsand reviews of individual program experiences which were followed by groupdiscussion and criticism. Presentations were also made concerning malariacontrol research projects which were being undertaken. A compilation of abstractsof the program was made and distributed later to those interested.
The results of the conference justified completely the time and expense involved in holding it. The participants had developed individual points of view which theypropounded with great self-assurance and defended competently. The deliberatescrutiny and evaluation of each policy and procedure resulted in the resolutionof certain generalizations concerning military malaria control which summarized the views of the malariologists. Some of them are presented in the following section.
CONCLUSIONS ANDSUGGESTIONS FOR THE FUTURE
The following conclusions regarding NATOUSA (MTOUSA) malaria control experience and recommendations for future practice are not intended to reflect adversely on individuals concerned in their development. They are presented only with the objectof improving military malaria prevention. Some of these reflect the deliberations of the malariologists at their 1944 meeting in Naples; others are the considered reflections of the author based upon his experience in NATOUSA and MTOUSA as assistant theater malariologist and then theater malariologist.
1. Physical noneffectiveness due to malaria did not threaten significantly the success of military operations in this theater. If the invasion of Sicily had been accomplished less swiftly, it is likely that malaria casualties might have become a source of embarrassment to the Commanding General in the fulfillment of his mission.
2. The principle of assigning command and operational responsibility to the theater malariologist in addition to his consultant duties worked very well in this theater.It centralized the program administratively as the theater malariologistwas then in position to attach malariologists to major commands, to control essentially the attachment of antimalaria units, to supply airplane larviciding service where needed, and to advise concerning special malaria control supplies for the theater.
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3. Military malaria control has all the diversity of practice inherent to civilian malariacontrol in addition to numerous other variable circumstances which do notoccur in peacetime antimalaria operations; for example, static versus mobilepopulations, restricted versus expanding territories, service versus combatand flying troops, and the great increase in manmade mosquito breeding placesdue to topographic damage resulting from combat. Therefore, it is not feasible to plan or operate on a highly regimented basis; it is better in the long run to permit the local malariologists as much independence and liberty indeveloping and adapting their programs to prevailing conditions as is consistentwith general theater coordination.
4. Didactic malaria control training is necessary as an initial incident in the educationalprocess, but the process must be a continuous one in which the school isthe beginning and not the end. Efforts at motivating military personnel toavoid exposure to malaria and of compensating for necessary risks must bemaintained as long as the hazard of infection exists.
5. More malariacontrol enlightenment of line officers is needed, especially to promote aclear understanding of what their enlisted-men antimalaria details are supposedto do. This is especially true of commanding officers, particularly of companygrade.
6. A greater utilization of medical supervision--perhaps through the medium of sanitary technicians--in unit malaria control would contribute greatly to the effectiveness of the program. By War Department Circular No. 223, dated 21 September 1943, enlisted-men details were to be composed mainly of nonmedical department personnel and were under the direct command of junior line officers who did not knowhow to use them. If the enlisted-men details could be placed under the technical direction of the medical officer, they might be used to much better advantage.
7. It was the considered opinion of the assembled malariologists, most of whom were medical officers, that, in MTOUSA, primary malaria control emphasis should be placed on: (1) Environmental control measures, (2) the use of bed nets, (3) protective clothing and repellents, and (4) suppressive medication. It is quite possible that groups of malariologists from other theaters would have given entirely different priorities to these activities.
8. The subject which provoked the most vigorous and sustained controversy in the malariologists' conference was the question of how much malaria control should be donefor troops by the special malaria control organization and how much troopsshould do for themselves through the medium of enlisted-men antimalariadetails. Except for the general proposition that both enlisted-mendetails and antimalaria units were needed, there was no general agreementas to their relative importance and dependability. In this theater, it wascertainly true that malaria control could not be left entirely to enlisted-mendetails. The individuals assigned to this duty in many instances had littleor no interest in it; many of them had other duty assignments that not infrequently superseded malaria control. Some of the men were inefficient and lazy. Frequent changes
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occurred due to promotion, transfer, or the unpredictable notion of their commanding officers, so that therewas much turnover and discontinuity in their work. They were commanded byofficers who often were not well-indoctrinated with the importance and natureof their malaria control responsibilities.
Nevertheless, most of the environmental control (mainly DDT spray killing) in forward areas was done with enlisted-men details, and some of them performed magnificently under fire. The commanding officers of forward troops are rarely convinced of the urgency of malaria control units and are more prone to considerthem unnecessary liabilities which have to be rationed, sheltered, and guarded. Thus, it is necessary under these conditions to depend primarily on the enlisted-men details, enhanced, where possible, by trained malaria unit personnel.
On the other hand, it was the general experience in this theater that in the relatively static rear areas a much higher quality of diversified malaria control programcould be carried on through the use of native labor, labor troops, or ofconsolidated enlisted-men details working under the direction of malariacontrol unit personnel.
9. It was generally believed by the malariologic personnel in this theater that the malariasurvey units and malaria control units as defined in 1944 were too smallto accomplish their objectives efficiently. They were dependent upon largerunits for rations and billets, and an unreasonably high proportion of theirenlisted men component was needed for unit administration. It was suggestedthat several units might be attached to a higher coordinating headquartersfor more effective utilization of unit personnel, or that larger, more self-sufficientunits be organized. In 1945, the tables of organization and equipment fora medical battalion headquarters which might be used to consolidate antimalariaunits were published, but this action was too late to be of use in MTOUSA.Since the end of the war, self-sufficient preventive medicine companies havebeen authorized, the functions of which include malaria survey and control. 40
40 (1) Tables of Organization and Equipment 8-500, 28 Apr. 1944. (2) Tables of Organization and Equipment 8-500, 18 Jan. 1945. (3) Tables of Organization and Equipment 8-117, 12 May 1950.
