Lariam

Jeremy Lefroy Excerpts

Thursday 27th October 2016 Westminster Hall

[Jeremy Lefroy (Stafford) (Con)]

It is a great privilege to speak under your chairmanship, Mr Rosindell. I congratulate the Defence Committee, under the excellent chairmanship of my right hon. Friend the Member for New Forest East (Dr Lewis), and all previous speakers in this debate.

I declare an interest as chair of the all-party parliamentary group on malaria and neglected tropical diseases and as a trustee of the Liverpool School of Tropical Medicine. I have a large MOD base in my constituency, MOD Stafford, which has three signals regiments and the RAF’s tactical supply wing. Many members of those units spend quite a lot of time on deployment in countries where malaria is a problem.

Malaria, as my hon. Friend the Member for Plymouth, Moor View (Johnny Mercer) said, is a killer. It used to kill well over 1 million people a year, but thankfully that figure is now down to 438,000 a year, according to the World Health Organisation in 2015. I hope the figure is still falling, but it is an awful lot of people. I have had friends die from malaria, which is a serious disease.

It is absolutely right that the Ministry of Defence should take every precaution to protect its personnel from the depredations of malaria, but the question, of course, is how to do it. I had experience of Lariam when I lived in a tropical country. I took it when I was diagnosed with malaria—I took it not as a prophylactic but as a curative—and they were four of the worst days of my life, and not because of the malaria. Lariam produces extraordinary dreams that leave those who take it completely debilitated. The next time I had malaria—I have had malaria four times—I took a different drug, artemether, and the experience was quite different. Within 12 hours I was back on my feet, back at work and able to continue. The side effects were almost zero.

We are talking about Lariam as prophylaxis, but several alternatives are mentioned in the report. There is Malarone, which for many years was quite expensive, but it is a lot cheaper now that it is off patent—that is the one I use whenever I go to tropical countries. There is doxycycline, which is effective and cheap, and of course chloroquine and proguanil, which have been used for decades. Those two drugs have some side effects, particularly proguanil, which can cause mouth ulcers if taken over an extended period—proguanil is also an ingredient of Malarone.

On the curative side there is Lariam, but artemisinin-based combination therapies are also incredibly effective and are the recommended curative drugs for malaria across the world—I will talk about those in my conclusion.

The Committee’s recommendations for using Lariam are spot on. First, the MOD should find out whether service personnel are unable to tolerate alternatives. Secondly, individual risk assessments should be conducted and, thirdly, the patient should be aware of alternatives. I am delighted that the Committee has come up with those recommendations, which are all absolutely right, but they need to be put into effect. I am delighted to hear that the Ministry of Defence has taken the report seriously.

I finish by issuing a warning. We think that we have come a long way with both prophylactic and curative drugs against malaria, and that is indeed the case. All the research funding over the past decade and a half has partially resulted in halving the number of deaths, although a substantial part of that is also due to the use of mosquito nets. Has the Committee looked at how many service personnel are provided with insecticide-treated mosquito nets? A recent study by Oxford University found that almost two thirds of the reduction in deaths from malaria since 2000 is the result of insecticide-treated bed nets, not the improved drugs.

Be that as it may, it is vital that research into improved drugs continues because, unfortunately, we are beginning to see resistance to the artemisinin-based combination therapies—ACTs are the best drugs available at the moment—in south-east Asia, particularly on the Myanmar-Thai border. The worry is that resistance to all the previous effective antimalarials, first chloroquine and then sulfadoxine-pyrimethamine, started in that same area. The fact that resistance to ACTs is starting there gives us great cause for concern. The Department for International Development is putting a lot of effort into research on that subject, which I welcome, but it is important that we continue to focus research on antimalarials both as prophylaxis and as curative.

I am grateful for the opportunity to speak in this debate, and I thank my hon. and right hon. Friends on the Defence Committee for their excellent work, which I hope results in better treatment for our servicemen and women across the world.

--- Later in debate ---

[Dr Lewis]

That is probably the single strongest point that one could make in the course of this entire debate. Particularly in the macho military environment—I use that term in a non-sexist way—people are unlikely to disclose mental troubles in their past, meaning that either they may take a drug that is inappropriate for them or they may throw it away, rendering themselves vulnerable to contracting malaria.

[Jeremy Lefroy]

Did the Committee have any idea why there is such a particular emphasis on Lariam when other drugs are available, such as doxycycline or Malarone, that many of us take whenever we go to countries affected? The emphasis on Lariam seems to me extraordinary. I absolutely applaud my right hon. Friend’s point about the importance of encouraging Roche to continue its research in this area; we do not want it put off. Roche has been excellent in its clarity about what Lariam is about and what precautions need to be taken.

[Dr Lewis]

Other Committee members may correct me, but I have a feeling that we never quite got to the bottom of why the MOD is so fixated on that particular drug. What I am about to say is sheer speculation, but it could have something to do with the relative cost of different types of drug, or with concern about compensation claims. If the drug were given up completely, it might be easier to bring claims on that basis: “You don’t prescribe this drug at all now, so therefore you were wrong ever to have prescribed it.”

We sought to give the MOD a bit of wriggle room, for want of a better term, by saying that all we wanted it to do was designate Lariam as a drug of last resort. I do not see why it should not do that. It is obviously a drug of last resort, because the MOD accepts the fact that it should now be issued only under the most strictly defined conditions. What is that if not making it a drug of last resort? So why does the MOD not say so?

Similarly, there has been reluctance to acknowledge the experience of other countries. The MOD asserted that Lariam was

“considered by US CDC”—

the Centers for Disease Control and Prevention, which is the US equivalent of Public Health England—

“to be equally suitable (with an individual clinical assessment) as each of the other drugs”.

However, Dr Remington Nevin—one of the two doctors to whom we owe a great deal of gratitude for their consistent campaigning on this issue and for the evidence they brought to the Committee—described that as a “misinterpretation of CDC’s position”. The section entitled “Special Considerations for US Military Deployments” in chapter 8 of the CDC’s publication “Yellow Book” states:

“The military should be considered a special population with demographics, destinations, and needs that may differ from those of civilian travelers.”

In respect of the use of Lariam in other states’ armed forces, Dr Nevin argued that

“many of our Western allies have all but abandoned the use of the drug”,

and that the US and Australian military use it only for

“those rare service members who cannot tolerate…two safer and equally effective alternatives”.

That is why we made the point that Lariam should really be used only for such people, because we are not convinced that there is any geographical area where some other drug could not be used.

Dr Nevin also referred to the US Army Special Operations Command having taken the

“very wise step of banning it altogether”.

He said that the decision by the US military was made

“primarily on clinical grounds”

and was intended to

“decrease the risk of negative drug-related side-effects”.

The MOD’s response commits merely to updating the information held on the use by our allies of Lariam and other antimalarial drugs, including the extent to which Lariam is used and the circumstances in which it is supplied. It still does not appear to accept that its policy on Lariam is increasingly out of step with that of our allies.

We have made considerable progress by focusing on the terrible situation in which a drug designed for very specific issuing to very specific people after a very specific interview was doled out en masse as a routine prophylactic to our service personnel who were about to go to malaria-infested areas. That really was a scandal, and it would be another scandal if it ever happened again.