Memorandum from the Ministry of Defence
concerning medical preparedness for deployments to Sierra Leone
(25 July 2000)
In a letter of 27 June, we promised to let you
have a note on the outcome of the three Services' Boards of Inquiry
into medical preparedness for the deployment to Sierra Leone.
I now attach a paper that summarises the findings
of the three Boards.
1. The three Service Boards of Inquiry (BOI)
were tasked to investigate the apparent unpreparedness for deployment
of OP PALLISER, in particular to determine the true extent of
the problem, to examine the causes, to establish means of preventing
a recurrence and, if necessary, to take appropriate disciplinary
action. A summary is as follows:
True extent of the problem
2. The Army BOI found that some 200 personnel
arrived in theatre without anti-malaria tablets due to last minute
changes in the task organisation. This was quickly remedied by
procuring a French anti-malaria drug locally, which was subsequently
replaced by supplies of the preferred British drug, mefloquine.
3. As far as the number of malaria cases
is concerned, the RN BOI stated that "The current level of
malaria cases is well within the numbers that might be expected
when operating in this area, based on the assessed effectiveness
of prophylactic medication." The Surgeon General's Department
(SGD) has confirmed that no anti-malaria drugs can provide guaranteed
protection and it is likely that some personnel deployed to an
area of high risk
will contract the disease. 4,500 personnel were deployed at the
peak of the operation. Almost all of them came within malarial
propagation range of the shore at some stage. The total number
of personnel affected by malaria to date (19 July) is 82 (1.8%
of the total force). Data is only currently available on 59 of
these cases, but 58 of them were taking the malaria prophylaxis
of choice. There was no requirement for any unit to be on anti-malarial
prophylaxis before the operation but the order to commence the
anti-malarial regime was given by MoD as soon as was reasonably
practical, albeit not within the normal timescale. The Army BOI
believes that the decision to deploy before the medication could
become fully effective was a contributory factor to the number
of malaria cases.
4. The BOI have reported different levels
of immunisation in different ways. 594 RN personnel (19%) were
out of date for one or more immunisation prior to deployment,
of which only 38 personnel (1%) were out of date for more than
two immunisations. Army figures, including Special Forces, show
that 102 immunisations were out of date on deployment. This represents
less than 2% of the 5,750 mandated immunisations required by the
Spearhead Land Element (SLE). In the RAF, 15% of personnel who
deployed were not fully immunised. The PJHQ Medical Cell has confirmed
that, by 24 May, all personnel had been vaccinated in accordance
with current policy. There is a national shortage of UK licensed
Yellow Fever vaccine, but this did not have a significant impact.
There are currently no reported cases of illness that can be attributed
to overdue immunisation.
5. No single cause was identified, but there
were a number of contributory factors.
6. All service personnel are required to
be always in date for those immunisations which are set down in
the Surgeon General's Policy Letters (SGPLs). Commanding Officers'
responsibilities are laid down by the Surgeon General (SG) in
Joint Service Publication (JSP) 311. They are also made clear
in single Service instructions, for example Army General and Administrative
Instructions, Volume 2, chapter 66, paragraph 66 121 states "Commanding
Officers are responsible for ensuring that the immunisation states
of their units are up-to-date at all times." Despite the
clarity of their framework, and the fact that similar problems
were noted after Operation GRANBY, it was apparent that the monitoring
of immunisation status of personnel was being given insufficient
command attention. It is clear that there is no standard procedure
for the monitoring of immunisation status of personnel either
across the Services or even within Services, and these procedures
are unnecessarily complex.
7. The medical audit was made more difficult
in some cases by breaking the formal Notice to Move (NTM) and
by using personnel from both formed units and non-formed units.
Some personnel without any formal NTM were deployed with only
24 hours notice. If NTM had been respected, there might have been
time to catch up with the backlog of vaccinations. However, NTM
sometimes needs to be broken for operational reasons and, having
made a risk assessment, some commanders decided to deploy with
unprepared personnel. There are also problems in that readiness
is reported by ship/unit/aircraft and not by individuals. As far
as the RAF is concerned, this meant that some individuals were
not nominated until the aircraft were placed on standby. They
were therefore unaware of their specific needs and requirements
until the last moment.
8. Some individual responsibility is unclear.
For example, in the RAF, Queen's Regulations lay responsibility
on the individual to ensure that his vaccination state is current
while at the same time stating that immunisation is voluntary.
General awareness of malaria is also believed to be low.
9. The Commanders in Chief deliver a capability
to the Chief of Joint Operations and they must ensure that consideration
is given to the appropriate immunisation states of all personnel
that are likely to be deployed. Orders should be given to commence
anti-malarial regimes at the earliest possible opportunity.
10. Readiness procedures need to be reviewed
to ensure that all personnel likely to be deployed are at high
readiness, accepting that this may not be possible for non-formed
unit personnel. NTM should be reduced as early as possible and
last minute changes to task organisations should be avoided if
at all possible.
11. The SG's policy guidelines laid down
in JSP 311 and various SGLPs are not prescriptive and allow the
single Services scope to meet specific requirements. Single service
guidelines should be reviewed to ensure coherence with the SG's
12. General awareness of malaria and tropical
health risks is low and needs to be addressed, including the
issue of environmental health preparedness. The SGD believe that
their prophylaxis guidance in the event of short NTM could be
13. The question of a standard system of
monitoring immunisation across the Services needs to be investigated.
The current system also needs to be simplified. The SG has issued
instructions for post-deployment health screening of all those
deployed to Sierra Leone and the wider issue of a deployment health
surveillance strategy is being pursued in ongoing work by the
14. Recurrence of malaria cases cannot be
prevented, only minimised (see statistics in para 3). Health risks
of overseas deployments should always be brought to the attention
of senior Commanders and Ministers during the Defence Crisis Management
Organisation decision-making process.
9 If SE Asia or S America are taken as a baseline,
the risk of malaria in W Africa is 100 times higher. D/SG(Med
Pol)370/9 dated 4 July 2000. Back
D/VCDS/5/2/4 dated 15 June 2000. Sierra Leone: Health Surveillance. Back