Mefloquine: suitable for use by the Military?

Whilst we must be encouraged by news this week of a further, successful, claim in damages for the British Military’s substandard care around the prescription of mefloquine as an anti-malarial prophylaxis, we cannot be surprised.

Hilary Meredith Solicitors Ltd specialises in representing members of the Armed Forces, were actively involved in Parliament’s Defence Committee investigation in 2015/16, and regularly campaign for their safety and wellbeing on a wide range of issues.

Having launched a campaign around the Military’s use of this dangerous drug for this indication, we have been flooded with enquiries from service personnel who, having been unaware of the longer-term effects of the drug, have described military processes for its administration which would certainly be considered substandard in law.

As of today, we are retained to investigate 330 such cases.

Risks, Contraindications & Dangerous Side Effects

Mefloquine has long been associated with risks of neuropsychiatric injury.

It is not to be prescribed to anyone with a family history of certain conditions or personal medical history neuropsychiatric disturbance (including depression).

Furthermore, the common adverse side-effects are considered prodromal to a more serious (neuropsychiatric) event.

It is for these reasons that it should not have been taken by some service members at all and, where it has been “reasonable” to prescribe it, it should have been discontinued as soon as those adverse effects were experienced in the hope of avoiding a more serious problem.

There is also a risk of dizziness and disturbed balance which, whether it be repairing school roofs in Kenya or handling weapons in battle, hardly seems appropriate for military deployments.

It therefore seems to us incredulous that perfectly suitable, adequate and safe alternative anti-malarial prophylactics have long been available to the Military, even for high-risk malaria areas of the world.

Findings of Fact

Having now examined the service medical records for hundreds of members and veterans, we have found that, inter alia:

Mefloquine has been given where the geographical location of the deployment is not a high-risk malaria zone;
anti-malarial prophylaxis has been given for areas with low or even no malaria risk;
in contrast to alternative anti-malarial prescriptions, there is a regular failure to record an assessment, prescription or dispensing of mefloquine;
no contraindications, is often recorded….only to see that there were, in fact, contraindications!
We have not seen any recorded advice warning  of the prodromal nature of side-effects or to discontinue the drug should they arise;
we have rarely seen records of any discussion about alternative antimalarial prophylactics;
information sheets referring to anti-malarials often appear to downplay the controversy and the  prevalence of side effects, and sometimes contains data which may not be accurately or genuinely set out.
Having examined many military recipients of the drug, we have very rarely found one who recalls being advised of the contraindications, the prodromal nature of side-effects, or the need to discontinue when they occur. Many have therefore been given Lariam when they should not have been, and many have (dangerously) tried to tolerate the side-effects whilst continuing to dutifully administer it.

Injuries

Although unlawfully exposed to the risks of this drug, some service members have been fortunate enough to have avoided any persisting effects. It is, however, to be noted that they appear to have been unnecessarily exposed to the serious risks posed by mefloquine.

Regrettably, our clients say they have not been quite so lucky. They report a variety of injuries of varying severity, including (but not limited to):

changes in temperament, personality, and emotion which have impacted upon work and relationships;
depression and anxiety;
sleep disorders;
nocturnal and frontal lobe epilepsy;
psychotic illness;
suicidal ideation.

It is also concerning to note, particularly in a military setting, that the symptoms of mefloquine toxicity can mimic typical symptoms of PTSD and evidence of the toxicity is considered (by some experts) to confound the diagnosis of PTSD.

The MoD’s Response

Having fully investigated the generic issues, we served a Letter of Claim upon the MoD.

The Response has not only provided disclosure on the MoD’s position on guidance for the use of mefloquine and its policies on anti-malarial prophylaxis since mefloquine was first used, but admissions that they have owed a duty of care to:

adequately assess the appropriate antimalarial regime for a specific exercise or deployment;
adequately assess the individual; and
obtain the individual’s informed consent to take it in accordance with the common law.
The common law (at Montgomery v Lanarkshire Health Board (2015)) makes clear that informed consent includes informing the recipient of:

the risks likely to be considered significant;
the side-effects (which, certainly as far as mefloquine is concerned, would include advice to discontinue the drug on certain side-effects); and
the options of alternative anti-malarial prophylactics.

It has also been acknowledged that this duty arises regardless of whether the drug has been prescribed under a face-to-face assessment with the individual or a group assessment (although we continue to question the practicality of delivering the requisite information in a group setting).

We are, of course, expected to the prove facts and the medical link between mefloquine and the injuries complained of in each of our individual cases.

Furthermore, there are still wider concerns about the MoD’s apparent ambivalence around the dangers of this drug.

Ultimately, the most important question might be: is mefloquine at all suitable for use by the Military?

Justin Glenister