Health and Safety Tips for Madagascar from the U.S. Army

These tips from the army appear to be a bit dated and not specific to Madagascar (poisonous snakes are not really an issue). I'd say these tips are a bit excessive.


Prepared by Tripler Army Medical Center Aug 2002/ Reviewed May 2003

Per USCINCPACINST 6200.2: Commanders are responsible for an effective Force Health Protection Plan for personnel deploying to locations within the USCP AOR, ensuring implementation of the Plan, for appointing a FHP Officer and assistant who will serve as the Commander's focal point for the planning, coordination, and execution of "real world" force health protection planning for a specific deployment. This is applicable to all assigned and attached personnel, all Department of Defense personnel performing official duties within locations in the AOR, and all U.S. contractor personnel employed directly by the DOD in locations in the AOR.

Note: This FHP document provides general and country-specific guidance for developing a FHP deployment plan. Specific requirements may vary depending on the deployment activities and conditions. Any operation or exercise-specific guidelines supersede this.

FHP Planning must include the following elements:

1. Health Threat Assessment: This assessment must evaluate known and anticipated health threats/hazards (including endemic diseases, injuries, industrial toxins, and climatic extremes) and the appropriate countermeasures to be taken for each.

The standards of medical facilities vary and many are below U.S. standards, particularly in remote areas. Crime is a concern in Madagascar. Significant health risks exist in Madagascar. The following illnesses are of military concern (in order of greatest health threat):

Food-borne and water-borne illness: Diarrheal Diseases are highly endemic throughout the area, in particular cholera and other watery diarrheas, the dysenteries, typhoid fever, viral hepatitis, and helminthic (parasitic worm) infections.
Insect/arthropod-borne illness: Malaria, West Nile Fever, Rift Valley Fevers, Sindbis Virus Disease, Crimean-Congo hemorrhagic fever and filariasis are prevalent. Plague and other diseases occur.
Other illnesses: Schistosomiasis is present and is transmitted in freshwater lakes and rivers by larvae, which penetrate intact skin. Sporadic, rare Ebola activity occurs. Transmission is via direct contact with blood or body fluids of acutely ill patients. Influenza risk extends throughout the year. Rabies in animals is a hazard in most areas.

2. Health Record and Readiness Screening: Performed prior to deployment. Items identified for screening include: immunizations, HIV testing, TB skin testing, DNA sample on file, current physical exam, dental class I or II, prescription medications on hand, extra pair of eye glasses, and unresolved health problems (i.e., limited duty, pregnancy, mental health, etc.) which could disqualify the service member for deployment.

3. Updated immunization record: Service members should have a copy of the updated immunization record (a PHS-731 yellow immunization card is preferred).

4. Pre-deployment health assessment: All personnel deploying as a result of a JCS/Unified Command Deployment Order for 30 continuous days or greater to a land-based location outside the United States that does not have a permanent US military medical treatment facility must complete a pre-deployment health assessment questionnaire (available at the web site of the Army Medical Surveillance Activity (AMSA) A copy should be sent to AMSA, and the original placed in the member?s medical record. Post-deployment health assessments must be completed upon return.

5. Health Threat Briefing: Must be performed prior to deployment. Attendance must be documented. Minimum contents of a Health Threat Briefing for Madagascar are included in sections 5.1 ? 5.11.

5.1 Immunizations:

    (a) Routine immunizations: All routine immunizations must be up to date for personnel on deployable or mobility status: tetanus booster, hepatitis A, hepatitis B (for health care providers, graves registration, and those likely to contact blood), typhoid, MMR, polio, influenza.

    (b) Current influenza vaccine. Even if local flu season is past and new vaccine is not yet available.

    (c) Special immunizations: Yellow Fever.

    (d) Yellow Fever vaccination certificate is required if coming from a yellow fever infected area.

    (e) Cholera. Cholera is present in Madagascar. There is no FDA approved cholera vaccine at present.

Malaria Chemoprophylaxis:
Risk exists in all areas, with highest risk in coastal areas. In addition to DEET and permethrin-treated BDU/uniform, chemoprophylaxis is recommended. Medicines that protect against malaria in this area include mefloquine (Lariam), and doxycycline.

Recommended regimens for personnel deployed ashore:
    (a) Doxycycline 100 mg PO QD, beginning 2 days before potential exposure, continuing during exposure, and for 28 days after, PLUS primaquine phosphate 15 base mg PO QD for 14 days beginning the day of departure from the malarious area (must ensure normal G6PD level prior to prescribing).

    (b) Alternative regimen is Mefloquine 250 mg PO Q week beginning 2 weeks pre-exposure through 4 weeks post-exposure, PLUS terminal primaquine as above. Mefloquine is contra-indicated for flight-status personnel.

5.4 Tuberculosis: Tuberculosis is highly endemic throughout Madagascar. This country has a prevalence of over 100 cases per 100,000 population, the highest WHO risk category. All service members should have a tuberculin skin test (PPD) done and results recorded within twelve months prior to deploying. A follow-up PPD should be done approximately 3 months after returning.

5.5 Personal Protective Measures: The most important personal protective measures against insect- or arthropod-borne diseases (e.g., list major country-specific ones here) are avoiding vector exposure as much as possible, using appropriate arthropod repellent, properly wearing permethrin-treated field uniforms, and sleeping under a treated, properly installed bed net.
    (a) Avoid vector exposure: Anopheles mosquitoes (malaria and filariasis) breeds in semipermanent and permanent bodies of clear water with emergent vegetation. It can be found at altitudes of up to 1,800 meters (3,300 ft). It feeds indoors or out at night, and rests indoors after feeding. Anopheles (malaria) species of mosquitoes are primarily rural dwelling, nighttime feeders (dusk to dawn). Aedes spp. (yellow fever and dengue) are primarily daytime feeders, and both urban and rural dwellers (indoors/outdoors). Fleas carried on rats can transmit plague. Avoid any unnecessary fresh water entry (leptospirosis).

    (b) 33% extended-duration DEET (NSN 6840-01-284-3982) or an equivalent should be applied to all exposed skin surfaces 30 minutes before potential exposure and should be reapplied every four to six hours, especially if there is significant sweating. When using both DEET and sunscreen, DEET should be applied approximately 30 minutes before the sunscreen. DEET decreases the effectiveness of the sunscreen by approximately 35%, therefore, sunscreen with SPF 30 is recommended. Sunscreen should not be applied first since that may decrease the effectiveness of the DEET.

    (c) Permethrin treatment of uniforms and bed nets before departure (preferably with permethrin concentrate/compressed air sprayer technique, which lasts the life of the uniform).

    (d) Sleep under a permethrin-treated bed net with the edges tucked in under the bedding on all sides. Net should be suspended from poles (poles on outside of net to prevent gapping) so net does not come in contact with occupant.

5.6 Safe Food and Water: Contamination of food and water supplies in Madagascar is widespread and diarrheal illnesses pose a very high threat to military personnel. To minimize risk:
    (a) Wash hands before eating, smoking, or handling food and after using latrines

    (b) CONSUME only approved food and water
If not available:
    (c) Eat piping hot, freshly cooked food from reputable sources

    (d) Eat no salads or fresh fruit/vegetables (except intact fruit which you wash and peel yourself

    (e) Eat no food from street vendors or stalls

    (f) Drink bottled or canned water/beverages without ice cubes.

5.7 Sexually transmitted diseases: STDs are prevalent and can be serious or FATAL (i.e. HIV, hepatitis B).
    (a) Abstinence is the only perfectly safe practice and is recommended.

    (b) Barrier protection with latex condoms is the only other acceptable option (but can be just as dangerous in case of breakage).

5.8 Motor Vehicle and General Safety.

(a) Motor vehicle accidents pose a great health risk for travelers. Seat belt use and extreme caution in and around vehicles must be practiced.

(b) General safety. Exercise caution in ALL activities to avoid injury of any type. If you are seriously injured, there may be no option other than medical care in a facility where sterility of equipment and safety of blood products are far below those in the U.S.

5.9 Environmental Factors
    The climate in Madagascar is generally tropical in coastal areas, but cooler temperatures prevail in uplands. Dry weather prevails from May through September.

    (a) Heat injury precautions. Climate can be hot and humid, making injuries such as heat exhaustion and heat stroke more likely. Factors that increase heat injury risk include: alcohol consumption, skin trauma, diarrhea, certain medications, and poor physical conditioning. Necessary precautions include drinking water and other fluids frequently, on a schedule, to avoid dehydration; adhering to safe work-rest cycles during extreme conditions; and careful observation of teammates to detect warning signs of heat injury such as mental status changes and cessation of sweating.

    (b) Sun injury precautions. Sun exposure can be intense. Sun glasses, wide-brimmed hats, long sleeves and trousers, and liberal use of sunscreen (SPF 30 or greater) and lip balm are recommended precautions. Sunscreen should be applied to all sun-exposed skin (especially if taking Doxycycline to protect against malaria) approximately 30 minutes after applying DEET.

    (c) Environmental and industrial pollution. Insignificant.

5.10 Hazardous Plants and Animals:
    (a) Plants: Madagascar has numerous plants that cause skin irritation, an allergic reaction, or are poisonous. Avoid contact whenever possible.

    (b) Animals: Rabid animals, especially dogs, are not uncommon. For extended stays in remote areas without medical support, pre-exposure immunization with rabies vaccine may be needed. Animal bites of any type should be scrubbed vigorously with soap and water for 15 minutes, and should then be evaluated as soon as possible by a competent healthcare provider.

    (c) Venomous snakes: There are venomous snakes in Madagascar, although only a small number are commonly encountered and likely to inflict a bite. It is important to avoid all interactions with snakes, as some have extremely toxic venom and anti-venom may not be readily available. First aid for snake bites:
Have the victim lie down and rest quietly;
Immobilize the affected part by splinting it as if it were fractured and keep it lower than the heart;
Remove all jewelry (including from unaffected limbs);
Arrange for urgent medevac to a medical treatment facility.
NO ONE SHOULD ATTEMPT TO KILL OR CATCH THE SNAKE (dead snakes and severed heads have been known to bite up to several hours post-mortem)

5.11 Personal Health and Fitness. Try as much as possible to maintain a healthful regimen of hygiene and fitness. Regular bathing and frequent changes of undergarments, including socks, are important. When exercising outdoors, be aware that shorts and tank tops will make you more susceptible to diseases carried by mosquitoes and other insects. Apply DEET repellent to exposed skin prior to exercising outdoors.

5.12 Other comments.

Special Concerns
The difficult political situation that gripped Madagascar since the presidential election in late 2001 is essentially over. The government of President Ravalomanana now controls all of Madagascar, and the prospect of violent clashes between opposing political camps is unlikely. The six-month political crisis severely damaged the economy, affecting virtually every sector, and it will take at least a few months for the overall economic situation to return to normal. Air and highway travel can still be problematic, there are shortages of medical and food supplies in all parts of the country, and some areas have curfews.
The major concerns for visitors to Antananarivo are street crime and theft from residences and vehicles. Although not generally violent, incidents involving violence by assailants, particularly when the victim resists, are on the rise. There has been an increase in the number of travelers being pickpocketed at the airport. Organized gangs of bandits are known to patrol areas where foreigners who are perceived to be wealthy congregate. Walking at night, whether alone or in a group, is not considered safe in urban areas, including in the vicinity of western-standard hotels. Wearing expensive jewelry or carrying other expensive items while on foot or using public transportation is strongly discouraged.

Except for Antananarivo's main streets and a few well-maintained routes to outlying cities, most roads are in disrepair. For those traveling by road between cities, travel at night is not recommended. Roads tend to be narrow and winding with many one-lane bridges and blind curves. Most vehicles tend to drive in the center of the road unless another vehicle is present. Local practice is to blow the horn before going around a curve to let others know of one's presence. Few pedestrian crosswalks or working traffic signals exist.

Obtain the latest State Department advisory and Consular Information Sheet prior to travel at:

5.13 Assistance with Health Threat Assessments, Health Threat Briefings, and countermeasures planning can be obtained from the following sources:

    (a) Department of Preventive Medicine, Tripler Army Medical Center, phone DSN or 808 433-6693

    (b) Epidemiology Department, Navy Environmental and Preventive Medicine Unit 6, phone (DSN or 808) 473-0555; email:

    (c) Pacific Air Forces Public Health Officer, Hickam Air Force Base, phone (DSN or 808) 449-2332, x269

This document is available from the Tripler Army Medical Center