Persistent febrile illnesses in Nepal: A systematic review

Review on Scrub Typhus: An Important Etiology of Acute Undifferentiated Fever Illness

One of India's predominant public health issues is acute undifferentiated fever illness (AUFI), a typical response to an infectious agent. Diagnosis becomes challenging when the disease has been reported with fever as the primary symptom. Among the cases presenting at a tertiary care hospital in central India, 88% had an acute undifferentiated fever, the most common being dengue infection. In India, rural communities are at more risk from AUFI than cities. Most of those in danger are those who reside in remote areas, and one of the most significant risks is for those who reside close to forests. AUFI is a complex condition for physicians to deal with and is one of the most frequent clinical conditions for which empirical treatment is required. Nowadays, AUFI can be managed by a syndromic approach with the judicial use of antibiotics. Symptoms of AUFI, along with myalgia, headache, and anorexia, can be caused by various illnesses. Patients are recommended to undertake a battery of investigations, which may delay the therapy and increase expenses because many diseases may present with the same symptoms. In the developed world, viral illness is the primary cause of AUFI. However, in developing countries like India, it can also be brought on by potentially curable but life-threatening conditions such as malaria, leptospirosis, hantavirus infection, and Japanese encephalitis. Lack of knowledge of the locally prevalent illnesses, which might be the cause of AUFI, and lack of preliminary screening and diagnostics at the point of care to identify the etiologies make it difficult to control these generally curable causes of the burden of AUFI, especially in tropical and subtropical countries. A deeper understanding of AUFI is required to develop better diagnostics and cures for various etiologies, especially scrub typhus.

Visceral leishmaniasis in new foci areas of Nepal: Sources and extent of infection

Background & objectives

The successful elimination program of visceral leishmaniasis (VL) in Nepal decreased the incidence to less than 1 per 10,000 population leading to the consolidation phase. However, new VL cases have been recorded from new districts, threatening the elimination goal. This study monitors the geographical spread of VL and identifies potential risk factors.

Methods

VL data of 2017-2020 were obtained from the Epidemiology and Disease Control Division (EDCD) of Nepal and mapped. Telephonic interviews with 13 VL patients were conducted.

Results

The incidence maps indicate that VL is spreading to new areas. The target incidence exceeded four times in hilly and twice in mountainous districts. VL cases occurred in 64 of 77 districts in all three regions (mountainous, hilly and Terai). Interviews showed a correlation between travel history (private, commercial and for studies) and the spread of VL cases to new foci.

Interpretation & conclusion

One major challenge of VL elimination in the maintenance phase is the spread of infection through travelers to new foci areas, which needs to be under continuous surveillance accompanied by vector control activities. This should be confirmed by a large-scale analytical study.

ACCURACY OF C-REACTIVE PROTEIN AND PROCALCITONIN FOR DIAGNOSING BACTERIAL INFECTIONS AMONG SUBJECTS WITH PERSISTENT FEVER IN THE TROPICS

Background

In low-resource settings, inflammatory biomarkers can help identify patients with acute febrile illness who do not require antibiotics. Their use has not been studied in persistent fever (defined as fever lasting for ≥7 days at presentation).

Methods

C-reactive protein (CRP) and procalcitonin (PCT) levels were measured in stored serum samples of patients with persistent fever prospectively enrolled in Cambodia, the Democratic Republic of Congo, Nepal, and Sudan. Diagnostic accuracy was assessed for identifying all bacterial infections and the subcategory of severe infections judged to require immediate antibiotics.

Results

Among 1838 participants, CRP and PCT levels were determined in 1777 (96.7%) and 1711 (93.1%) samples, respectively, while white blood cell (WBC) count was available for 1762 (95.9%). Areas under the receiver operating characteristic curve for bacterial infections were higher for CRP (0.669) and WBC count (0.651) as compared with PCT (0.600; P <.001). Sensitivity for overall and severe bacterial infections was 76.3% (469/615) and 88.2% (194/220) for CRP >10 mg/L, 62.4% (380/609) and 76.8% (169/220) for PCT >0.1 µg/L, and 30.5% (184/604) and 43.7% (94/215) for WBC >11 000/µL, respectively. Initial CRP level was <10 mg/L in 45% of the participants who received antibiotics at first presentation.

Conclusions

In patients with persistent fever, CRP and PCT showed higher sensitivity for bacterial infections than WBC count, applying commonly used cutoffs for normal values. A normal CRP value excluded the vast majority of severe infections and could therefore assist in deciding whether to withhold empiric antibiotics after cautious clinical assessment.

Etiological spectrum of persistent fever in the tropics and predictors of ubiquitous infections: a prospective four-country study with pooled analysis

BACKGROUND

Persistent fever, defined as fever lasting for 7 days or more at first medical evaluation, has been hardly investigated as a separate clinical entity in the tropics. This study aimed at exploring the frequencies and diagnostic predictors of the ubiquitous priority (i.e., severe and treatable) infections causing persistent fever in the tropics.

METHODS

In six different health settings across four countries in Africa and Asia (Sudan, Democratic Republic of Congo [DRC], Nepal, and Cambodia), consecutive patients aged 5 years or older with persistent fever were prospectively recruited from January 2013 to October 2014. Participants underwent a reference diagnostic workup targeting a pre-established list of 12 epidemiologically relevant priority infections (i.e., malaria, tuberculosis, HIV, enteric fever, leptospirosis, rickettsiosis, brucellosis, melioidosis, relapsing fever, visceral leishmaniasis, human African trypanosomiasis, amebic liver abscess). The likelihood ratios (LRs) of clinical and basic laboratory features were determined by pooling all cases of each identified ubiquitous infection (i.e., found in all countries). In addition, we assessed the diagnostic accuracy of five antibody-based rapid diagnostic tests (RDTs): Typhidot Rapid IgM, Test-it^TM Typhoid IgM Lateral Flow Assay, and SD Bioline Salmonella typhi IgG/IgM for Salmonella Typhi infection, and Test-it^TM Leptospira IgM Lateral Flow Assay and SD Bioline Leptospira IgG/IgM for leptospirosis.

RESULTS

A total of 1922 patients (median age: 35 years; female: 51%) were enrolled (Sudan, n = 667; DRC, n = 300; Nepal, n = 577; Cambodia, n = 378). Ubiquitous priority infections were diagnosed in 452 (23.5%) participants and included malaria 8.0% (n = 154), tuberculosis 6.7% (n = 129), leptospirosis 4.0% (n = 77), rickettsiosis 2.3% (n = 44), enteric fever 1.8% (n = 34), and new HIV diagnosis 0.7% (n = 14). The other priority infections were limited to one or two countries. The only features with a positive LR ≥ 3 were diarrhea for enteric fever and elevated alanine aminotransferase level for enteric fever and rickettsiosis. Sensitivities ranged from 29 to 67% for the three RDTs targeting S. Typhi and were 9% and 16% for the two RDTs targeting leptospirosis. Specificities ranged from 86 to 99% for S. Typhi detecting RDTs and were 96% and 97% for leptospirosis RDTs.

CONCLUSIONS

Leptospirosis, rickettsiosis, and enteric fever accounted each for a substantial proportion of the persistent fever caseload across all tropical areas, in addition to malaria, tuberculosis, and HIV. Very few discriminative features were however identified, and RDTs for leptospirosis and Salmonella Typhi infection performed poorly. Improved field diagnostics are urgently needed for these challenging infections.

TRIAL REGISTRATION

NCT01766830 at ClinicalTrials.gov.

Seroprevalence and Associated Risk Factors of Leptospira interrogans Serogroup Sejroe Serovar Hardjo in Dairy Farms in and around Jimma Town, Southwestern Ethiopia

A cross-sectional study was conducted on selected dairy farms in and around Jimma town, Oromia, southwestern Ethiopia from November 2019 to May 2020 to determine the seroprevalence of Leptospira interrogans serogroup Sejroe serovar Hardjo (L. hardjo). Furthermore, information was gathered on individual animal and herd level by using pretested semistructured questionnaire to assess associated risk factors. A stratified and simple random sampling procedure was used for the selection of dairy farms and individual animal's, respectively. Indirect enzyme-linked immunosorbent assay (I-ELISA) was used in this study to detect antibody against L. hardjo. Out of 384 animal's sera, 94 animals were seropositive against L. hardjo antibodies. From 77 dairy farms selected for the study, 57 of them were distinguished as positive for L. hardjo. The overall seroprevalence of leptospirosis caused by L. hardjo was 24.48% (95% CI: 20.18%–28.78%) and 74.03% (95% CI: 64.23%–83.82%) at individual animal and farm level, respectively. The result of multilogistic regression analysis revealed that management system (p < 0.05; OR = 4.25 (95% CI: 2.31–7.82)), hygienic status of the farm (p < 0.05; OR = 0.35 (95% CI: 0.20–0.61)), age of animals (p < 0.05; OR = 8.30 (95% CI: 1.87–36.89)), history of abortion (p < 0.05; OR = 8.37 (95% CI: 1.73–40.42)), herd size (p < 0.05; OR = 2.32 (95% CI: 1.17–4.61)), and access of rodents to the farm (p < 0.05; OR = 0.17 (95% CI: 0.03–0.86)) were significantly associated with the occurrence of L. hardjo infection. However, breed, parity, and introduction of new animals to the farm were insignificantly associated (p > 0.05). Management system of the animal, hygienic status of the farm, herd size, age of animals, previous history of abortion, and access of rodents to the farm were identified as potential risk factors of L. hardjo disease occurrence. Thus, limiting rodents contact with cattle and their feed and water as well as good sanitary practices and husbandry management should be undertaken.

Primary cutaneous melioidosis acquired in Nepal - Case report and literature review

A 27 years-old Dutch male returning from Nepal presented with a painful abscess on the left forearm without fever or other systemic complications. Signs and symptoms consisted of culture of the abscess material revealed Burkholderia pseudomallei. Laboratory results, chest X-ray and CT scan of the abdomen were without abnormalities. The patient was initially treated with 2 weeks of ceftazidime and continued with a 6-week oral eradication phase with trimethoprim-sulfamethoxazole. The patient recovered without complications. Melioidosis is encountered relatively infrequently as an imported condition, mainly from Southeast Asia with focus on Thailand. Melioidosis from Nepal is a rarity and has previously been described in only four cases, with possible acquisition abroad in three of those.

Livestock and Poultry Production in Nepal and Current Status of Vaccine Development

The livestock and poultry sectors are an integral part of Nepalese economy and lifestyle. Livestock and poultry populations have continuously been increasing in the last decade in Nepal and are likely to follow that trend as the interests in this field is growing. Infectious diseases such as Foot and Mouth Disease (FMD), Peste des Petits Ruminants (PPR), hemorrhagic septicemia (HS), black quarter (BQ), swine fever, avian influenza, and Newcastle disease (ND) constitute one of the major health challenges to the Nepalese livestock and poultry industry. Vaccinations are an efficient means of preventing the occurrence and spread of several diseases in animals and birds. Considering this fact, the government of Nepal began the production of veterinary vaccines in the 1960s. Nepal is self-reliant in producing several vaccines for cattle and buffaloes, sheep and goats, pigs, and poultry. Despite these efforts, the demand for vaccines is not met, especially in the commercial poultry sector, as Nepal spends billions of rupees in vaccine imports each year. There is a need of strengthening laboratory facilities for the isolation and characterization of field strains of pathogens and capacity building for the production of different types of vaccines using the latest technologies to be self-reliant in veterinary vaccine production in the future in Nepal.