[Management of the COVID-19 epidemic in the carrier battle group (January-April 2020) by the Armed Forces Epidemiology and Public Health Center]. / Gestion de l'épidémie de COVID-19 au sein du groupe aéronaval (janvier­avril 2020) par le Centre d'épidémiologie et de santé publique des armées.

Objectives: Faced with the COVID-19 epidemic that occurred within the naval air group and the nuclear aircraft carrier Charles de Gaulle, the French Armed Forces Epidemiology and Public Health Center (CESPA) carried out an investigation (January - April 2020) whose objectives were: to identify the possible routes of introduction of the virus ; to describe the characteristics of the epidemic and to describe and model the dynamics of the epidemic's spread. Methods: A telephone survey was conducted. The biological diagnoses were transmitted by the medical antennas. A time/place/population analysis was carried out, as well as the description of the clinical pictures with their exposure factors. The instantaneous reproduction rate Rt of the epidemic was modeled. A spatial analysis of the epidemic on board was carried out. Forty-three viral genomes were sequenced and compared to the reference bases. Results: 0f 1767 sailors, 1568 (89%) participated in the telephone survey and 1064 (67.9%) were confirmed cases. Four patient profiles have been described: asymptomatic (13.0%); non-specific symptomatic (8.1%); specific symptomatic (76.3%); severe cases (2.6%). In univariate and multivariate analysis, age, overweight and obesity were significantly associated with the risk of having a severe form. Smoking was a protective factor. The evolution kinetics of Rt was in favor of an introduction of the virus at the end of February with a reintroduction during the stopover in Brest. Analysis of viral genomes ruled out introduction and spread of a single strain. Conclusion: Despite the control measures taken, an epidemic occurred. The often pauci-symptomatic clinical pictures resulted in a delay in identification. CESPA was able to carry out this epidemiological investigation within a highly constrained timeframe, showing all the interest of its integrated public health model.

Collection and sharing of medical information and medical intelligence (M2I) in NATO: a transversal survey.

INTRODUCTION: There is a requirement for adequate medical expertise to be available throughout the range of potential future operations involving members of the North Atlantic Treaty Organization (NATO). The aim of this study was to assess the collection and sharing of medical intelligence and medical information (M2I) by NATO Nations, Partner Nations and NATO Command Structure and NATO Force Structure Headquarters (NCS/NFS HQs). MATERIALS AND METHODS: A transversal survey was conducted between December 2014 and March 2015 using a survey form on M2I sent to NATO Nations and Partnership for Peace (PfP) Nations as well as NCS/NFS HQs. RESULTS: Correctly completed responses were received from 15/40 (37.5%) of the possible NATO and PfP Nations (37.5%) and 7/8 (87.5%) of the NCS/NFS HQs (100.0%). Deficiencies in the collection of M2I data were found due to lack of specific doctrines, networks, tools, structures and organisation. CONCLUSIONS: The survey provided an indication even though the participation rate was low for Nations. Part of the problem is thought to be that medical information and medical intelligence often lie in different chains of command. Future directions for this research could include studying the possibilities of a new specific information technology (IT) system to collect and to share M2I. Collection and sharing of M2I within the NATO/PfP community requires facilitation in order to strengthen the basis for decision-making and force health protection. The development of a dedicated NATO IT system may be a precondition for the implementation of an efficient M2I network.

[Social representations of public health among healthcare workers within the French Armed Forces]. / Les représentations sociales de la santé publique chez les professionnels de santé dans les armées françaises.

BACKGROUND: Public health is a multidisciplinary activity whose fields of action are acquiring an increasingly broad. The Service de santé des armées (SSA) has always had a culture of public health problems thanks to doctors specialized in the treatment of major diseases. Often involved in public health activities, health professionals nevertheless have a fragmented vision. The objective was to describe the social representations of public health of military healthcare workers. METHOD: The responders were doctors, nurses, veterinarians and pharmacists practicing in different areas of SSA (caregivers, administrators, policy makers) and were interviewed by telephone. A question of spontaneous evocation on the representations of public health in the army was asked. The overall lexical analysis was performed according to the method of rank-frequency. Categorical analysis was conducted to better understand the whole lexical field use. RESULTS: There were 90 responders. The most salient terms were "prevention, epidemiological surveillance and vaccination". The categorical analysis showed that doctors used a lexical field primarily focused on diseases and risk behaviors, nurses on the specifics of military surveillance and policy makers about the cross-discipline. CONCLUSION: Public health in the army is mainly represented by epidemiological surveillance and prevention. Given the non-mentioned fields, a strengthening of communication on the current challenges of public health would probably improve adherence of healthcare professionals since public health takes on more and more importance in the development of the national health policy and management of health crises.

Surveillance of adverse events following vaccination in the French armed forces, 2011-2012.

OBJECTIVES: French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to present the results of surveillance of vaccine adverse events (VAEs) reported from 2011 to 2012 in the French armed forces. STUDY DESIGN: VAEs were surveyed among all French armed forces from 2011 to 2012 by the epidemiological departments of the military health service. For each case, a notification form providing patient and clinical information was provided. METHODS: Case definitions were derived from the French drug safety guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAEs to the number of vaccine doses delivered. RESULTS: In total, 161 VAE cases were reported. The overall VAE reporting rate was 24.6 VAEs per 100,000 doses, and the serious VAE rate was 1.3 per 100,000 doses (nine cases). The serious VAEs included two cases of Guillain-Barré syndrome, one case of optic neuritis, one case of a meningeal-like syndrome, one case of rheumatoid purpura, one case of acute asthma and three cases of fainting. The highest rates of VAE were observed with the Bacille Calmette-Guérin vaccine (BCG) (482.3 per 100,000 doses), inactivated diphtheria-tetanus-poliovirus with acellular pertussis vaccine (dTap-IPV) (106.1 per 100,000 doses) and meningococcal quadrivalent glycoconjugate vaccine (MenACWY-CRM) (39.3 per 100,000 doses). CONCLUSIONS: The global rates of VAE observed in 2011 and 2012 confirm the increase that has been observed since 2009 in the French armed forces, which could reflect improved practitioner awareness about VAEs and the use of certain vaccines added to the vaccination schedule recently (dTap-IPV in 2008 and MenACWY-CRM in 2010). VAEs appear to be relatively rare, particularly serious VAEs, which indicates acceptable tolerance of vaccines.

Feedback on the management of the 2011 measles outbreak by French military general practitioners: an evaluation study.

OBJECTIVE: Preventive measures were implemented in the French armed forces to limit the measles outbreak that occurred in 2010 and 2011. This study aimed to obtain feedback concerning the management of this outbreak by the French military general practitioners. METHOD: A cross-sectional study was conducted among the general practitioners (GPs) in military units located in metropolitan France. The 60 military units that reported at least one measles case in 2011 were included. Data were collected using self-administered questionnaires. RESULTS: The acceptance of preventive measures against measles was good (measures "totally justified" for 77.8%) and most of the military GPs considered that the outbreak had no significant impact on their activities. The management of measles cases was perceived as not very problematic but difficulties were encountered in the identification of contacts around cases (48.1% of respondents) and in the identification of vaccine recipients among these contacts (more than 80% of respondents reporting difficulties in the collection of measles and vaccination histories). The organization of vaccination around cases was also perceived as difficult. CONCLUSIONS: Preventive measures around measles cases were well accepted by the military GPs, which could reflect their preparedness in the face of the outbreak. However, vaccination did not seem to be well understood or accepted by military patients, underlining the essential role of military GPs in patient information. Difficulties in the collection of vaccination and measles histories among contacts could be overcome by an early transcription of individual medical records in the military medical files of newly enlisted personnel. A more generalized use of oral fluid testing devices, which can be shipped at ambient temperature, would simplify diagnosis in the armed forces.

Adverse events following vaccination in the French armed forces: An overview of surveillance conducted from 2002 to 2010.

French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to describe vaccine adverse events (VAE) reported from 2002 to 2010 in armed forces. VAE are routinely surveyed by the military Centre for epidemiology and public health. For each case, military practitioners fill a notification form, providing patient characteristics, clinical information and vaccines administered. For this study, VAE following influenza A(H1N1)pdm09 vaccination were excluded. Among the 473 cases retained, 442 (93%) corresponded to non-severe VAE,including local, regional and systemic events, while 31 corresponded to severe VAE, with two leading to significant disability. The global VAE reporting rate (RR) was 14.0 per 100,000 injections. While stationary from 2002 to 2008, the RR increased from 2009. The most important observations were a marked increase of VAE attributed to Bacillus Calmette-Guérin (BCG) vaccine from 2005 to 2008, a high RR observed with the inactivated diphtheria-tetanus (toxoids)-poliovirus vaccine combined with acellular pertussis vaccine (dTap-IPV) from 2008 and an increase in RR for seasonal influenza vaccine VAE in 2009. Our RR for severe VAE (1.1 VAEper 100,000) appears comparable with rates observed among United States civilians and military personnel. The increase observed from 2009 could be partly explained by the influenza A(H1N1)pdm09 pandemic which increased practitioner awareness towards VAE. In conclusion, the tolerance of the vaccines used in French armed forces appears acceptable.

Increase in reported adverse events following seasonal influenza vaccination among the French armed forces, 2008-2009: possible role of stimulated reporting and background cases of influenza-like infection.

OBJECTIVES: In September 2009, an increase in seasonal influenza vaccine adverse events (VAE), compared with reports for previous years, was detected among the French armed forces in the setting of an extended immunization campaign. This work presents the results of this investigation. STUDY DESIGN: VAE were surveyed among all French military personnel from 2008 to 2009 by Epidemiological Departments of the French Military Health Service. For each case, a notification form was completed, providing patient and clinical information. METHODS: Case definitions were derived from the French drug vigilance guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAE to the number of vaccine doses injected. RESULTS: Forty-seven seasonal influenza VAE were reported in continental France: 18 in 2008 and 29 in 2009. The annual reporting rate was higher in 2009 (31.6 vs 16.6 VAE per 100,000 injections, respectively). The highest monthly incidence was observed in September 2009 (60.8 events per 100,000 injections). Two other peaks were observed in February 2008 and March 2009. The incidence in September 2009 was not significantly different from the incidences in February 2008 and March 2009. It was observed that incidence peaks occurred during influenza epidemic periods. One serious neurological VAE was observed. CONCLUSIONS: The increase in seasonal influenza VAE in late 2009 mainly involved non-serious events, and could reflect stimulated reporting in the context of the A(H1N1)pdm09 pandemic. VAE reporting rates were highest during influenza epidemic periods, which could be explained by VAE being wrongly attributed to the vaccine when symptoms could reflect coincident background cases of viral infection.

Resurgence of measles in the French military forces in 2010.

Since the start of 2010 there has been a flare-up of measles in France, following on the resurgence observed in 2008. The aim of this study was to present results of the epidemiological surveillance of measles in the French armed forces and to describe the increase in incidence. Measles was surveyed from 1992 to 2010. Criteria for report were those used for French national compulsory notification. The data, concerning active military personnel, were provided by the physicians in the armed forces using anonymous data collection forms. Between 1992 and July 2010, 689 cases of measles were notified. Since 2002, the mean incidence rate was 1 case per 100,000. A significant increase has been observed for 2010 (13.9 cases per 100,000 in 2010 versus 1.8 in 2009). The 28 cases reported in 2010 involved five clusters and three isolated cases. The mean age of affected subjects was 27 years. Only 30% of cases had been vaccinated. The epidemic resurgence of measles observed in 2010 in the French armed forces follows the same pattern as that observed nationally and at European level, and can be seen as the likely consequence of inadequate vaccination cover.

Novel influenza A(H1N1) outbreak among French armed forces in 2009: results of Military Influenza Surveillance System.

OBJECTIVES: An outbreak of novel A(H1N1) virus influenza, detected in Mexico in April 2009, spread worldwide in 9 weeks. The aim of this paper is to present the monitoring results of this influenza outbreak among French armed forces. STUDY DESIGN: The period of monitoring by the Military Influenza Surveillance System (MISS) was 9 months, from May 2009 to April 2010. METHODS: The main monitored events were acute respiratory infection (ARI), defined by oral temperature ≥38.5 °C and cough, and laboratory-confirmed influenza. Weekly incidence rates were calculated by relating cases to the number of servicepersons monitored. RESULTS: In continental France, the incidence of ARI increased from September 2009, with a weekly maxima of 401 cases per 100,000 in early December 2009 according to MISS. Estimations of the incidence of consultations which could be related to novel A(H1N1) influenza ranged from 48 to 57 cases per 100,000. CONCLUSIONS: The trends observed by MISS are compatible with French national estimations. The incidence of consultations which could be related to A(H1N1) influenza at the peak of the epidemic (194 cases per 100,000) was much lower than the national estimate (1321 cases per 100,000). This may be due to servicepersons who consulted in civilian facilities and were not monitored. Other explanations are the healthy worker effect and the younger age of the military population.

[Importance of a regional observatory of malarial chemoresistance, an emerging public health problem in the Guyanas region]. / Intérêt d'un observatoire régional de la chimiorésistance du paludisme, problème émergent de santé publique dans la région des Guyanes.

A regular implementation of prophylactic and therapeutic decision trees was organized on a consensus basis in Cayenne, French Guiana in 1990, 1995 and 2002. The updated recommendations were based on the knowledge of the in vitro chemosensitivity profiles of the local isolates, mainly coming from big rivers (Maroni and Oyapock, frontiers with Suriname and Brazil, respectively; and more recently Approuague). Most of the patients infected by Plasmodium falciparum were followed by the medical staff of the main hospitals (Cayenne and Saint-Laurent) and of the peripheral health centers in remote areas. Consequently the epidemiological situation and evolution of chemoresistance have been widely observed on a long-term (since 1994) basis in the Maroni region. Yet, we have only partial information coming from the Oyapock valley, even though an important (most of the time) illegal immigration has been developing since the 90s' leading to a notable modification of the epidemiological status of malaria in this eastern region, including a regular increase of P. vivax infections. Presently very little P. vivax chloroquine (and mefloquine) resistance has been identified but this result could lead to a real public health problem in a near future. As such, the National Reference Center on Plasmodium Chemoresistance in the French West Indies and Guiana (CNRCP-AG in French) is a unique observatory of malaria chemoresistance in the Guyanese shield which works with research laboratories of the Institut Pasteur, Paris. This network strategy offers a very attractive perspective for applications of modern tools, including the validation of chemoresistance molecular markers, for malaria control at both medical and public health levels. Some examples related to chloroquine and artemether resistance are given.

High acquisition rate of extended-spectrum ß-lactamase-producing Enterobacteriaceae among French military personnel on mission abroad, without evidence of inter-individual transmission.

OBJECTIVES: Acquisition of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) by Europeans travelling individually in high-endemicity countries is common. However, how the different ESBL-E strains circulate in groups of travellers has not been studied. We investigated ESBL-E transmission within several groups of French military personnel serving overseas for 4-6 months. METHODS: We conducted a prospective study among French military personnel assigned to Afghanistan, French Guiana or Côte d'Ivoire for 4-6 months. Faecal samples provided by volunteers before leaving and after returning were screened for ESBL-E isolates. ESBL Escherichia coli from each military group was characterized by repetitive element palindromic polymerase chain reaction (rep-PCR) fingerprinting followed, in the Afghanistan group, by whole-genome sequencing (WGS) if similarity was ≥97%. RESULTS: Among the 189 volunteers whose samples were negative before departure, 72 (38%) were positive after return. The highest acquisition rates were observed in the Afghanistan (29/33, 88%) and Côte d'Ivoire (39/80, 49%) groups. Acquisition rates on return from French Guiana were much lower (4/76, 5%). WGS of the 20 strains from the Afghanistan group that clustered by rep-PCR identified differences in sequence type, serotype, resistance genes and plasmid replicons. Moreover, single-nucleotide polymorphism (SNP) differences across acquired strains from a given cluster ranged from 30 to 3641, suggesting absence of direct transmission. CONCLUSIONS: ESBL-E. coli acquisition was common among military personnel posted overseas. Many strains clustered by rep-PCR but differed by WGS and SNP analysis, suggesting acquisition from common external sources rather than direct person-to-person transmission.

[Real time epidemiological surveillance within the armed forces: concepts, realities and prospects in France]. / Surveillance épidémiologique en temps réel dans les armées; concepts, réalités et perspectives en France.

BACKGROUND: In 2002, the North Atlantic Treaty Organization took five initiatives in order to enhance the defence capacities against the massive destruction weapons, one of them concerned the development of an interoperable surveillance system, giving in real time some informations permitting early warning to the commanders. Thoughts in France to improve the military surveillance system, methodological constraints and first results are shown. METHODS: Medical, technological, human and organisational aspects had to be taken into account to develop real time surveillance within the armed forces, and also specific military constraints. In order to evaluate the validity of its methodology, the "Institut de médecine tropicale du service de santé des armées" developed a prototype, set up in French Guyana and which took part in a second time at a multinational exercise. RESULTS: The "surveillance spatiale des épidémies au sein des forces armées de Guyane" has been set up in 2004, formed by both a recording and an analysis networks. This system permits to provide in real time some dashboards directly operational for the commanders. The exhaustiveness rate has been evaluated at 104%, compared to the traditional surveillance. It permitted three times to detect outbreaks several weeks before the other systems. Some limits have been identified, as the use of personal digitalized assistants. The involvement in a multinational exercise showed the system's efficacy, by detecting two simulated outbreaks, but also its interoperability. In 2006, it has been decided to extend the concept by deploying its second generation within the French armed forces in Djibouti. The "alerte et surveillance en temps réel" disposal permitted to take into account multiple geographical localizations. CONCLUSION: A real time surveillance system is an essential alarm disposal, however it is only an information tool within the complex activity of piloting the sanitary situation. It must be integrated within the whole situation expertise supports, represented also by medical intelligence, epidemiological investigations and prediction of the epidemiological phenomenon evolution.

Zika virus infections.

Since its discovery in 1947 in Uganda, the Zika virus (ZIKV) remained in the shadows emerging in 2007 in Micronesia, where hundreds of dengue-like syndromes were reported. Then, in 2013-2014, it was rife in French Polynesia, where the first neurological effects were observed. More recently, its arrival in Brazil was accompanied by an unusually high number of children with microcephaly born to mothers infected with ZIKV during the first trimester of pregnancy. In 2016, the World Health Organization declared ZIKV infection to be a public health emergency and now talks about a ZIKV pandemic. This review aims to summarize the current knowledge about ZIKV infection, successively addressing its transmission, epidemiology, clinical aspects, diagnosis, treatment, and prevention before discussing some perspectives.

[Contribution of the French Armed Forces Health Services to relief in Indonesia following the tsunami on December 26, 2004]. / Principales actions menées par le Service de santé des armées en Indonésie au décours du tsunami du 26 décembre 2004.

As of early January 2005, the French Armed Forces Health Services were on the ground in Indonesia to contribute to relief operations following the tsunami in Indonesia on December 26, 2004. Findings of preliminary investigation performed upon deployment of the first French elements demonstrated that a major priority was to speed up vaccination against measles in children between the ages of 6 months and 15 years. A vaccination campaign was planned in cooperation with Indonesian authorities and UNICEF. Implementation involved training of personnel and setting up vaccination clinics in refugee camps, schools, and neighborhoods in the city of Meulaboh. The vaccination campaign was hampered by a number of problems in particular involving logistics and required constant supervision. A survey to evaluate the results of the campaign in terms of vaccination coverage showed that the objective of vaccinating 70% of children in refugee camps was achieved. The survey provided other child health indicators that will be helpful to local authorities taking over after the departure of the French Armed Forces Health Services.

[Correlation between rainfall and meningococcal meningitis in Niger]. / Corrélation entre la pluviométrie et la méningite a méningocoque au Niger.

The term "meningitis belt" was coined by Lapeyssonnie in 1963 to describe a zone in Africa where epidemic meningitis occurs sporadically during the dry season. The purpose of this study was to evaluate the relationship between the recorded rainfall and reported incidence of meningococcal meningitis in Niger from 1996 to 2002. A total of 58 277 cases of meningococcal meningitis were reported in Niger during the study period. The mean annual incidence was 82.2 per 10(5) inhabitants. Two epidemic years occurred during the study period, i.e., 1996 with 183 cases per 105 inhabitants and 2000 with 140 cases per 10(5). The incidence increased during the dry season and decreased at the beginning of the rainy season. Calculation of the correlation coefficient between rainfall and incidence of meningococcal meningitis showed a statistically significant negative correlation (r = -0.27; P = 0.01). Neisseria meningitidis sero-group A was predominant but strains of Neisseria meningitidis sero-group W135 have been found in specimens collected since 2002. Outbreaks of meningococcal meningitis epidemics are multi-factorial. Multivariate analysis of all factors would allow implementation of preventive measures earlier than the epidemic prediction strategy based on threshold rates proposed by the World Health Organization.

[Fall in the seroprevalence of hepatitis A in French youth]. / Effondrement de la séroprévalence de l'hépatite virale A chez les jeunes français.

OBJECTIVE: An anti-hepatitis A virus seroprevalence survey was performed in 1997 in 1052 French army recruits (mean age: 21.2 years). To describe epidemiological trends, the current pattern was compared to previous results obtained by similar methods in 1985, 1990 and 1993. RESULTS: In 1997, overall anti-hepatitis A virus seroprevalence was 11.5%. The greatest risk factor of hepatitis A infection was related to travel in intermediate or highly endemic areas for hepatitis A virus: 46% of overseas residents (odds ratio = 10.3), 28% of recruits who had travelled in developing countries (odds ratio = 3.7) and 7.65% of French living in industrialised countries are anti-hepatitis A virus antibody positive. Moreover, seroprevalence was higher in subjects with a history of icteria (adjusted odds ratio = 3.5) and families with at least 3 children (adjusted odds ratio = 3). No association was found with drinking water, socioeconomic status such as baccalaureat degree, or parents profession. The seroepidemiological shift of hepatitis A, as assessed in three previous studies, shows a marked decrease of 20% in 12 years from 30.4% in 1985, to 21.3% in 1990, to 16.3% in 1993, and to 11.5% in 1997. The decrease in the prevalence of anti-hepatitis A virus was more marked in young adults who had never travelled in endemic countries (decrease of 20%) than those who had visited or lived in developing countries (decrease of 10%). CONCLUSION: Although France is not highly endemic for hepatitis A thanks to improved hygiene and housing conditions over the past 20 years, a pattern of intermediate endemicity was seen in French overseas areas in which the risk of outbreaks of hepatitis A was higher. The decrease in anti-hepatitis A virus seroprevalence in French youth can be used to draft a public health policy for hepatitis A control.

[Communicating about risks to public health]. / Communiquer sur les risques en santé publique.

The goals of public health risk communication are to explain the risks, to inform a community without causing a crisis, to implicate the population in decision-making, and to improve dialogue between organizations and communities. Based on a document entitled "Communicating about risks to public health: pointers to good practice", the authors of this article review the main principles relevant to health risk communication and present a list of key points for effective management of this communication.

[Antimalarial chemoprophylaxis in the French army: development from 1986 to 2001]. / La chimioprophylaxie antipaludique dans les armées françaises: évolution de 1986 à 2001.

In 1999, almost 25,000 French soldiers were deployed in malaria transmission areas. With an incidence of 4.5 p. 100 men.year, malaria infection remains a serious problem requiring priority status for control in military personnel. Epidemiological surveillance provides data necessary to assess morbidity due to malaria, monitor changing patterns of Plasmodium falciparum drug-sensitivity, and evaluate the efficacy of malaria control measures. In 1990, the French army replaced chemoprophylaxis using chloroquine alone with combination treatment using a single capsule containing 100 mg of chloroquine base and 200 mg of proguanil chlorhydrate. This measure in association with the use deltamethrine impregnated bed-nets led to a significant decrease in incidence. However a comeback was observed from 1993 to 1997. Since 1995, the effectiveness of the chloroquine-proguanil combination has diminished mainly in the stable malaria areas. In response to increasing Plasmodium falciparum resistance to chloroquine-proguanil chemoprophylaxis, it was necessary to find an alternative. Two studies carried out among French soldiers in Sub-Saharian Africa between 1996 and 1998 demonstrated that a daily dose 100 mg doxycycline was more effective than the chloroquine-proguanil combination. In addition the 1998 study showed that doxycycline monohydrate in the form of a multiparticle tablet was better tolerated. In 2001 four drugs are used for malaria chemoprophylaxis in the army personnel, i.e., chloroquine and proguanil in combination, mefloquine, and doxycycline, depending on location and duration of mission. The chloroquine-proguanil combination is used in countries with chloroquine-resistant strains, e.g., Chad and Senegal. Mefloquine and doxycycline are used in countries with chloroquine-resistant strains. Due to increasing resistance, it will be necessary to evaluate other drugs or antipaludian combinations.