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Private Members’ Business—Dáil Éireann
Motion on Anti-Malaria Drug Lariam
Speech by Mr. Paul Kehoe, TD
Minister with Responsibility for Defence
Ceann Comhairle, at the outset, while I appreciate that there are concerns with the prescribing of Lariam and that these concerns should be discussed, I would like to state, that because a High Court case is due to commence next week, I am restricted in what I can say.
A total of fifty five claims have been received. The first case is due for hearing next Tuesday in the High Court.
There are elements of the Motion that are problematic as it seeks to draw out the defence that will be put forward in the High Court during the forthcoming case.
As such I am constrained in what I can say and there is a need to ensure that anything said in the House does not prejudice either party’s right to a fair hearing.
I am mindful of not encroaching on the Court’s role in considering these matters. Members need to be very mindful of the separation of powers and the process in which the Courts are already involved. This House should exercise caution before debating matters that are central to an imminent court case.
Let me start by making it very clear to the House that the health and welfare of the men and women of the Oglaigh na hÉireann is a high priority for me and the Defence Forces.
The Motion before us tonight asks the House to direct doctors as to what medications to prescribe. Fundamentally, this is a medical matter that should be decided by qualified medical professionals, not politicians. In the Defence Forces these are decisions for highly qualified Medical Officers, having regard to the specific circumstances of the mission and the individual member of the Defence Forces.
There are three anti-malarial drugs in use in the Defence Forces, namely, Lariam (mefloquine), Malarone and Doxycycline. The selection by a Medical Officer of the most appropriate drug for use is a complex one and dependent upon a number of factors. All of these anti-malaria drugs have contraindications and side effects. Indeed the World Health Organisation (WHO) recognises this very issue. In its’ WHO International Travel and Health Handbook it provides for a range of anti-malarials which includes mefloquine (Lariam). The WHO Handbook notes that there are specific contraindications and possible side effects for ALL anti-malarial drugs.
It is the policy of the Defence Forces that individuals are screened by a Medical Officer who will consider a number of things. For example, the medical profile of the individual and his/her suitability to take a particular medication, duration of the travel, operational profile of the mission, dosing regimen and resistance in the region to particular drugs.
It is wholly inappropriate that any Government would be called upon to instruct the military authorities to over-rule the advice of medical professionals on what anti-malaria medications should be used in the Defence Forces.
This is not a political decision. It is a medical decision.
We should be very cautious about instructing doctors on what medications to prescribe. Patient safety and care is best left to the medical experts.
We are all aware that malaria is a serious disease and can be fatal. The reason the Defence Forces prescribes malaria chemoprophylaxis in the first instance is to protect its personnel. In all the years of Defence Forces overseas service in areas where malaria is present not one member has died from malaria. The World Health Organization’s World Malaria Report 2016 indicates that there were 212 million new cases of malaria worldwide in 2015 with an estimated 429,000 malaria deaths. It is a serious threat to any military force operating in an area where the disease is prevalent.
I have indicated time and again that significant precautions are taken by Defence Forces Medical Officers in assessing the medical suitability of members of our Defence Forces to take any of the anti-malarial medications.
In terms of the three anti-malarial drugs, in use in the Defence Forces, I am advised there are specific reasons as to why Malarone and Doxycycline are not prescribed for typical deployments in sub-Saharan Africa.
Doxycycline has to be taken in the absence of dairy products for maximum effect. It can cause troublesome, mainly gastrointestinal side effects, and it can also produce sun-sensitivity skin rashes (akin to severe sun burn) in some individuals. This is particularly significant when used in very sunny climes. For these reasons it is not generally prescribed for first line use by the Defence Forces in sub-Saharan Africa.
Up to September 2012, Malarone was only licensed for up to 28 days, this was removed in September 2012. However, I am advised by Military Authorities that there is limited evidence as to the safety and effectiveness of Malarone usage for longer periods. On this basis the Defence Forces medical policy, to use Malarone up to the 27 day limit, remains unchanged.
As Doxycycline and Malarone have to be taken daily, there is an increased risk of missing a dose on operational deployments. Lariam has the advantage of being taken weekly, and on operational deployments this reduces the risk of a missed dose exposing the individual to contracting malaria.
I am informed that these are amongst the reasons why Lariam, as opposed to the alternatives, is usually prescribed to members of the Defence Forces on certain operational deployments in areas where the predominant species of malaria is plasmodium Falciparum. In all cases, the primary focus is to protect personnel to the greatest extent possible from contracting malaria.
The medical procedures involved in assessing personnel before deployment are designed to ensure that a person who may be vulnerable to depression or other mental health issues is not prescribed Lariam.
In general terms, where the Defence Forces medical assessment is that Lariam is required to mitigate the risk of contracting malaria, those individuals for whom Lariam is contraindicated or not tolerated, are generally not deployed. However, I am advised that in such circumstances there are occasions when alternative malaria chemoprophylaxis agents are prescribed. This can relate to whether the deployment of an individual is critical for the mission; where an individual has to deploy without sufficient lead time to take Lariam; or where an individual who is already deployed subsequently develops a sensitivity to Lariam.
A Working Goup is currently examining issues arising in relation to the use of Lariam. In its earlier work in 2013, the Group investigated all the various issues surrounding the use of Lariam and obtained advice from leading medical experts both national and international. Those experts concurred with the practices followed by the Defence Forces in prescribing Lariam.
The Group is examining developments in the context of the Defence Forces use of malaria chemoprophylaxis with particular focus on updated patient safety information, changes to Summary Product Characteristics, changes in product licensing/authorization, identification of any new anti-malarial medications on the market and national and international expert advices on the use of malaria chemoprophylaxis and its usage in other Armed Forces.
Reference has been made to Dr Croft and retired Major Dr. Remington Nevin. Both accepted an invitation and made submissions to the Second Report of the Working Group.
The Group is continuing to engage with national and international experts and met again this morning. I anticipate receiving its Report shortly.
I understand that the Working Group are considering options to formalise the provision of ongoing external expert medical advice to the Defence Forces in relation to a range of medical matters, including malaria chemoprophylaxis.
I want to assure the House that when I have received the Group’s report I will carefully consider its recommendations.
I would also like to point out that there is a range of support services, both medical and non medical, available to Defence Forces Personnel. These include access to Defence Forces Medical Officers, Psychiatric, Psychological, Social Work and Personnel Support Services. A strictly confidential 24 hour care-line, manned by trained counsellors is also available to Defence Forces personnel.
For close to 60 years now, our Defence Forces have played a vital role as peacekeepers all over the world in Europe, Africa and the Middle East. At present Ireland is contributing 657 Defence Forces personnel to 10 different missions throughout the world. Reflecting the Government’s continued commitment to our responsibilities in the area of international peace and security. The Defence Forces have brought great honour on Ireland through their participation in peace support operations and have never hesitated to deploy into some of the world’s most dangerous conflict zones. In this regard, we should recall the 86 members of the Permanent Defence Force who have paid the ultimate price in the cause of peace. Our thoughts and prayers are with those peacekeepers and their families.
I would like to take this opportunity to pay tribute to those serving and former members of the Defence Forces for the important role they have played in Ireland’s contribution to peacekeeping missions abroad. Their dedication and service contributes in no small measure to the excellent reputation that Ireland holds as a member of the international community.
This afternoon I was delighted to attend the launch by the Organisation of National Ex-Service Men and Women of its annual Fuchsia Appeal. The work of O.N.E. is an important support in the lives of many former members of the Defence Forces.
Finally, I want to re-iterate the health and welfare of the Defence Forces is a high priority for me and the military authorities; this will continue to inform the approach to the issue of protecting our personnel from the significant risks posed by malaria.
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