Skip to main content

Military Health System

Letter to the Editor: G6PD Deficiency in the Tafenoquine Era

Image of Female Anopheles funestus mosquito that had landed on a human skin surface and was in the process of obtaining its blood meal. This image shows a female Anopheles funestus mosquito that had landed on a human skin surface and was in the process of obtaining its blood meal. A. funestus is a known vector for the parasitic disease malaria.
CDC/James Gathany

Recommended Content:

Medical Surveillance Monthly Report

In the Dec. 2019 issue of the MSMR, Lee and Poitras reported a 2.2% prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency among active duty U.S. service members between 2004 and 2018.1 Their study utilized Health Level 7-formatted chemistry data archived in the Composite Health Care System (CHCS), but it did not stratify by quantitative or qualitative testing.

When tafenoquine was approved by the U.S. Food and Drug Administration in 2018 for chemoprophylaxis and radical cure of Plasmodium vivax,2 the distinction between quantitative and qualitative testing became clinically significant. Formerly, primaquine was the only approved medication to treat hypnozoites, the dormant form of the parasite in the liver stage of malaria. Its use required a “normal” G6PD activity level, the threshold of which on qualitative tests was usually established at 30%–40%. Tafenoquine, with its longer half-life of 14 days (compared to 6 hours for primaquine), provides a far simpler dosing regimen for malaria chemoprophylaxis and radical cure, but it may precipitate hemolytic anemia at higher levels of G6PD activity. Consequently, the U.S. Centers for Disease Control and Prevention recommends a quantitative G6PD assessment before tafenoquine prescription2 to ensure activity exceeding 70%.3,4

An X-linked genetic disorder, G6PD deficiency in males is usually severe (enzyme activity < 30%), meaning that a “deficient” result on qualitative testing contraindicates the use of both primaquine and tafenoquine. The same is true for females who are homozygous or double heterozygous for mutant alleles—both of which are rare. However, single heterozygous females usually have milder deficiency (enzyme activity 30%–80%),3 meaning they would have a “normal” result on qualitative testing and could safely take primaquine but potentially not tafenoquine.

Univeral G6PD deficiency screening is required across the U.S. Armed Forces, but current policy does not mandate quantitative testing.5 Since tafenoquine may improve medication adherence and thus become a preferable antimalarial option, it is important to understand how many service members have only been qualitatively tested. In the U.S. Air Force, 167,945 active duty members had at least 1 G6PD test performed and recorded in the CHCS between 1 Jan. 2015 and 31 Dec. 2019. Of these, only 4,325 (2.6%), including 1,602 females, had a normal qualitative test with no quantitative result. This low percentage should continue to decrease since quantitative testing is standard protocol for all new recruits at U.S. Air Force basic military training as well as new officer accessions at the U.S. Air Force Academy and Officer Training School (email communication, Maj Dianne Frankel and Lt Col Kevin Baldovich, Dec. 2019 and Jan. 2020, respectively).

While the article by Lee and Poitras provides valuable information, G6PD deficiency surveillance in the tafenoquine era should incorporate quantitative values. These values should also be documented in service members’ deployment readiness records. For example, the Aeromedical Services Information Management System, the U.S. Air Force’s readiness platform, defines G6PD status as either “normal” or “deficient”—essentially as a qualitative test, even if a quantitative enzyme activity level is available in the electronic health record. This may lead to improper prescription of tafenoquine to airmen, particularly females, who are coded as having “normal” G6PD activity levels but whose levels are in fact intermediate.

Author affiliations: Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD (Maj Sayers; Lt Col Webber); Public Health and Preventive Medicine Department, U.S. Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, OH (Lt Col Webber).

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Air Force, the Department of Defense, or the U.S. Government.

References

  1. Lee J, Poitras BT. Prevalence of glucose-6-phosphate dehydrogenase deficiency, U.S. Armed Forces, May 2004–Sept. 2018. MSMR. 2019;26(12):14–17.
  2. Haston JC, Hwang J, Tan KR. Guidance for using tafenoquine for prevention and antirelapse therapy for malaria—United States, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(46):1062–1068.
  3. Commons RJ, McCarthy JS, Price RN. Tafenoquine for the radical cure and prevention of malaria: the importance of testing for G6PD deficiency. Med J Aust. 2020;212(4):152–153.e1.
  4. Price RN, Commons RJ, Battle KE, Thriemer K, Mendis K. Plasmodium vivax in the era of the shrinking P. falciparum map. Trends Parasitol. 2020;36(6):560–570.
  5. Defense Health Agency, Department of Defense. Procedural Instruction 6025.14. Active Duty Service Members (ADSM) Erythrocyte Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency and Sickle Cell Trait (SCT) Screening. 6 Dec. 2018.

In reply:

We appreciate the response by Drs. Sayers and Webber to our article published in the Dec. 2019 issue of the MSMR on the prevalence of G6PD deficiency among active duty service members. We are in agreement that quantitative as well as qualitative testing for the genetic condition is imperative to prevent the potentially harmful side effects from the use of the 8-aminoquinoline (8-AQ) class of antimalarial drugs (tafenoquine and primaquine) for malaria chemoprophylaxis and radical cure. We applaud the Air Force for the implementation of quantitative screening of G6PD deficiency among new recruits.

Our article highlights the need for leadership awareness of G6PD deficiency diagnoses to reduce the possibility of adverse events from the use of the 8-AQ class of antimalarial drugs. The inclusion of quantitative G6PD testing is an important tool to further identify at-risk service members.

Respectfully,

MAJ Jangwoo Lee, PhD; Beth Poitras, MPH

You also may be interested in...

Musculoskeletal Injuries During U.S. Air Force Special Warfare Training Assessment and Selection, Fiscal Years 2019–2021.

Article
8/1/2022
U.S. Air Force Capt. Hopkins, 351st Special Warfare Training Squadron, Instructor Flight commander and Chief Combat Rescue Officer (CRO) instructor, conducts a military free fall equipment jump from a DHC-4 Caribou aircraft in Coolidge, Arizona, July 17, 2021. Hopkins is recognized as the 2020 USAF Special Warfare Instructor Company Grade Officer of the Year for his outstanding achievement from January 1 to December 31, 2020.

Musculoskeletal (MSK) injuries are costly and the leading cause of medical visits and disability in the U.S. military.1,2 Within training envi­ronments, MSK injuries may lead to a loss of training, deferment to a future class, or voluntary disenrollment from a training pipeline, all of which are impediments to maintaining full levels of manpower and resources for the Department of Defense.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Pain and Post-Traumatic Stress Disorder Screening Outcomes Among Military Personnel Injured During Combat Deployment.

Article
8/1/2022
U.S. Air Force Airman 1st Class Miranda Lugo, right, 18th Operational Medical Readiness Squadron mental health technician and Guardian Wingman trainer, and Maj. Joanna Ho, left, 18th OMRS director of psychological health, discuss the suicide prevention training program, Guardian Wingman, at Kadena Air Base, Japan, Aug. 20, 2021. Guardian Wingman aims to promote wingman culture and early help-seeking behavior. (U.S. Air Force photo by Airman 1st Class Anna Nolte)

The post-9/11 U.S. military conflicts in Iraq and Afghanistan lasted over a decade and yielded the most combat casualties since the Vietnam War. While patient survivability increased to the high­est level in history, a changing epidemiology of combat injuries emerged whereby focus shifted to addressing an array of long-term sequelae, including physical, psychologi­cal, and neurological issues.

Recommended Content:

Medical Surveillance Monthly Report

Prevalence and Distribution of Refractive Errors Among Members of the U.S. Armed Forces and the U.S. Coast Guard, 2019.

Article
8/1/2022
Ophthamologist Air Force Maj. Thuy Tran evaluates a patient during an eye exam. (U.S. Air Force photo by Tech. Sgt. John Hughel)

During calendar year 2019, the estimated prevalence of myopia, hyperopia, and astigmatism were 17.5%, 2.1%, and 11.2% in the active component of the U.S. Armed Forces and 10.1%, 1.2%, and 6.1% of the U.S. Coast Guard, respectively.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Phase I Results Using the Virtual Pooled Registry Cancer Linkage System (VPR-CLS) for Military Cancer Surveillance.

Article
7/1/2022
A patient at Naval Hospital Pensacola prepares to have a low-dose computed tomography test done to screen for lung cancer. Lung cancer is the leading cause of cancer-related deaths among men and women. Early detection can lower the risk of dying from this disease. (U.S. Navy photo by Jason Bortz)

The Armed Forces Health Surveillance Division, as part of its surveillance mission, periodically conducts studies of cancer incidence among U.S. military service members. However, service members are likely lost to follow-up from the Department of Defense cancer registry and Military Health System data sets after leaving service and during periods of time not on active duty.

Recommended Content:

Medical Surveillance Monthly Report

Establishment of SARS-CoV-2 Genomic Surveillance Within the Military Health System During 1 March–31 December 2020.

Article
7/1/2022
Dr. Peter Larson loads an Oxford Nanopore MinION sequencer in support of COVID-19 sequencing assay development at the U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. (Photo by John Braun Jr., USAMRIID.)

This report describes SARS-CoV-2 genomic surveillance conducted by the Department of Defense (DOD) Global Emerging Infections Surveillance Branch and the Next-Generation Sequencing and Bioinformatics Consortium (NGSBC) in response to the COVID-19 pandemic. Samples and sequence data were from SARS-CoV-2 infections occurring among Military Health System (MHS) beneficiaries from 1 March to 31 December 2020.

Recommended Content:

Medical Surveillance Monthly Report

Suicide Behavior Among Heterosexual, Lesbian/Gay, and Bisexual Active Component Service Members in the U.S. Armed Forces.

Article
7/1/2022
  The DOD’s theme for National Suicide Prevention Month is “Connect to Protect: Support is Within Reach.” Deployments, COVID-19 restrictions, and the upcoming winter season are all stressors and potential causes for depression that could lead to suicidal ideations. Options are available to individuals who are having thoughts of suicide and those around them (Photo by Kirk Frady, Regional Health Command Europe).

Lesbian, gay, and bisexual (LGB) individuals are at a particularly high risk for suicidal behavior in the general population of the United States. This study aims to determine if there are differences in the frequency of lifetime suicide ideation and suicide attempts between heterosexual, lesbian/gay, and bisexual service members in the active component of the U.S. Armed Forces. Self-reported data from the 2015 Department of Defense Health-Related Behaviors Survey were used in the analysis.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Trends for SARS-CoV-2 and Other Respiratory Pathogens Among U.S. Military Health System Beneficiaries, 27 September 2020–2 October 2021.

Article
7/1/2022
Staff Sgt. Misty Poitra and Senior Airman Chris Cornette, 119th Medical Group, collect throat swabs during voluntary COVID-19 rapid drive-thru testing for members of the community while North Dakota Army National Guard Soldiers gather test-subject data in the parking lot of the FargoDome in Fargo, N.D., May 3, 2020. The guardsmen partnered with the N.D. Department of Health and other civilian agencies in the mass-testing efforts of community volunteers. (U.S. Air National Guard photo by Chief Master Sgt. David H. Lipp)

Respiratory pathogens, such as influenza and adenovirus, have been the main focus of the Department of Defense Global Respiratory Pathogen Surveillance Program (DoDGRPSP) since 1976.1. However, DoDGRPSP also began focusing on SARS-CoV-2 when COVID-19 was declared a pandemic illness in early March 2020.2. Following this declaration, the DOD quickly adapted and organized its respiratory surveillance program, housed at the U.S. Air Force School of Aerospace Medicine (USAFSAM), in response to this emergent virus.

Recommended Content:

Medical Surveillance Monthly Report

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

Article
6/1/2022
Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

As in previous years, among service members deployed during 2021, injury/poisoning, musculoskeletal diseases and signs/symptoms accounted for more than half of the total health care burden during deployment. Compared to garrison disease burden, deployed service members had relatively higher proportions of encounters for respiratory infections, skin diseases, and infectious and parasitic diseases. The recent marked increase in the percentage of total medical encounters attributable to the ICD diagnostic category "other" (23.0% in 2017 to 44.4% in 2021) is likely due to increases in diagnostic testing and immunization associated with the response to the COVID-19 pandemic.

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2021

In 2021, mental health disorders accounted for the largest proportions of the morbidity and health care burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45–64 and those aged 65 or older, musculoskeletal diseases accounted for the most morbidity and health care burdens. As in previous years, this report documents a substantial majority of non-service member beneficiaries received care for current illness and injury from the Military Health System as outsourced services at non-military medical facilities.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Article
6/1/2022
Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

In 2021, as in prior years, the medical conditions associated with the most medical encounters, the largest number of affected service members, and the greatest number of hospital days were in the major categories of injuries, musculoskeletal disorders, and mental health disorders. Despite the pandemic, COVID-19 accounted for less than 2% of total medical encounters and bed days in active component service members.

Recommended Content:

Medical Surveillance Monthly Report

Hospitalizations, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Hospitalizations, Active Component, U.S. Armed Forces, 2021

The hospitalization rate in 2021 was 48.0 per 1,000 person-years (p-yrs), the second lowest rate of the most recent 10 years. For hospitalizations limited to military facilities, the rate in 2021 was the lowest for the entire period. As in prior years, the majority (71.2%) of hospitalizations were associated with diagnoses in the categories of mental health disorders, pregnancy-related conditions, injury/poisoning, and digestive system disorders.

Recommended Content:

Medical Surveillance Monthly Report

Ambulatory Visits, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Ambulatory Visits, Active Component, U.S. Armed Forces, 2021

In 2021, the overall numbers and rates of active component service member ambulatory care visits were the highest of any of the last 10 years. Most categories of illness and injury showed modest increases in numbers and rates. The proportions of ambulatory care visits that were accomplished via telehealth encounters fell to under 15% in 2021, compared to 19% in 2020.

Recommended Content:

Medical Surveillance Monthly Report

Medical Evacuations out of the U.S. Central and U.S. Africa Commands, Active and Reserve Components, U.S. Armed Forces, 2021

Article
6/1/2022
Medical Evacuations out of the U.S. Central and U.S. Africa Commands, Active and Reserve Components, U.S. Armed Forces, 2021

The proportions of evacuations out of USCENTCOM that were due to battle injuries declined substantially in 2021. For USCENTCOM, evacuations for mental health disorders were the most common, followed by non-battle injury and poisoning, and signs, symptoms, and ill-defined conditions. For USAFRICOM, evacuations for non-battle injury and poisoning were most common, followed by disorders of the digestive system and mental health disorders.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, recruit trainees, U.S. Armed Forces, 2021

Article
6/1/2022
Surveillance snapshot: Illness and injury burdens, recruit trainees, U.S. Armed Forces, 2021

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 13
Refine your search
Last Updated: October 24, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery