Regarding the death, the victim was a 38-year-old airman who did not take chemoprophylaxis due to gastrointestinal side effects. He presented with nausea and vomiting for two days and was diagnosed with falciparum malaria based on the rapid diagnostic test. Treatment was commenced for uncomplicated falciparum malaria with oral quinine and doxycycline, but his condition worsened within the next 24 h. Intravenous quinine was started immediately (without a loading dose). No clinical improvement was observed in the next 24 h, and he was transferred to a higher-tier hospital where he developed atrial fibrillation, which was probably influenced by the high quinine dose. The attending doctors recommended an urgent blood transfusion (no record of the hemoglobin level at this point), but no facilities were available for transfusions in that hospital. The patient was being airlifted to a higher-tier hospital in Uganda when he suffered a cardiac arrest and passed away on the 4th day of the illness.
During the focus group discussions, some important themes emerged. Knowledge regarding the need for chemoprophylaxis to prevent malaria was adequate amongst the troops. However, the circumstances of the working environment were such that they could not put the knowledge into practice. The recommended chemoprophylaxis (mefloquine) was not available in adequate quantities and artemether-lumefantrine, which is the recommended drug for the treatment of malaria, was unavailable at the destination. Of the recommended drugs, only quinine was available for the treatment of severe falciparum malaria. Only primary care facilities were available on-site near the camps. The primary care center was well-staffed, with 2 doctors, 8 nurses and a pharmacist. Patients with severe illness were transferred to a higher tier hospital, but the recommended treatment recourses were limited in these hospitals as well. Prior to departure, the troops were advised regarding the prevention of, and the prophylaxis for, malaria and HIV/AIDS. All were aware of other malaria preventive strategies such as the use of repellents, wearing long-sleeved clothes, etc., but many admitted that most of these measures were not practiced even after an outbreak due to the nature of the occupation. They also had a false sense of security, since the camps were sprayed with an insecticide (permethrin) once every three months. In addition, during the first 4 months of the deployment, the troops were housed within temporary shelters and they worked outdoors, constructing their permanent shelters while being exposed to mosquito bites. The number of cases had declined by December 2014 when the permanent shelters were completed.
Upon the return of this group to Sri Lanka in November 2015, the malaria screening program conducted by the anti-malaria campaign at the Bandaranaike International Airport detected two further falciparum malaria cases by rapid diagnostic testing, which were later confirmed as being positive for malaria by microscopy. The recovery of both individuals was uneventful. Thereafter, all returnees were screened 6 weeks after arrival to ensure diagnoses of asymptomatic malaria infections. All tested negative for malaria by rapid diagnostic (antigen) testing and microscopy. At the follow-up of these individuals 4 months later, another malaria-positive person was diagnosed by microscopy and the rapid diagnostic test despite testing negative in previous screenings. This was a relapse infection due to P.ovale.