Prevalence and Clinical Management of Non-malarial Febrile Illnesses among Outpatients in the Era of Universal Malaria Testing in Malawi

Competing risks modeling of length of hospital stay enhances risk-stratification of patient care: application to under-five children hospitalized in Malawi

Introduction

Length of hospital stay (LOS), defined as the time from inpatient admission to discharge, death, referral, or abscondment, is one of the key indicators of quality in patient care. Reduced LOS lowers health care expenditure and minimizes the chance of in-hospital acquired infections. Conventional methods for estimating LOS such as the Kaplan-Meier survival curve and the Cox proportional hazards regression for time to discharge cannot account for competing risks such as death, referral, and abscondment. This study applied competing risk methods to investigate factors important for risk-stratifying patients based on LOS in order to enhance patient care.

Methods

This study analyzed data from ongoing safety surveillance of the malaria vaccine implementation program in Malawi's four district hospitals of Balaka, Machinga, Mchinji, and Ntchisi. Children aged 1-59 months who were hospitalized (spending at least one night in hospital) with a medical illness were consecutively enrolled between 1 November 2019 and 31 July 2021. Sub-distribution-hazard (SDH) ratios for the cumulative incidence of discharge were estimated using the Fine-Gray competing risk model.

Results

Among the 15,463 children hospitalized, 8,607 (55.7%) were male and 6,856 (44.3%) were female. The median age was 22 months [interquartile range (IQR): 12-33 months]. The cumulative incidence of discharge was 40% lower among HIV-positive children compared to HIV-negative (sub-distribution-hazard ratio [SDHR]: 0.60; [95% CI: 0.46-0.76]; P < 0.001); lower among children with severe and cerebral malaria [SDHR: 0.94; (95% CI: 0.86-0.97); P = 0.04], sepsis or septicemia [SDHR: 0.90; (95% CI: 0.82-0.98); P = 0.027], severe anemia related to malaria [SDHR: 0.54; (95% CI: 0.48-0.61); P < 0.001], and meningitis [SDHR: 0.18; (95% CI: 0.09-0.37); P < 0.001] when compared to non-severe malaria; and also 39% lower among malnourished children compared to those that were well-nourished [SDHR: 0.61; (95% CI: 0.55-0.68); P < 0.001].

Conclusions

This study applied the Fine-Gray competing risk approach to more accurately model LOS as the time to discharge when there were significant rates of in-hospital mortality, referrals, and abscondment. Patient care can be enhanced by risk-stratifying by LOS based on children's age, HIV status, diagnosis, and nutritional status.

Malaria diagnosis in rural healthcare facilities and treatment-seeking behavior in malaria endemic settings in western Kenya

Accurate malaria diagnosis and timely treatment are requirements for effective management of the disease. However, treatment efficacy may be significantly reduced in resource-constrained healthcare facilities with poorly equipped laboratories and frequent drug and rapid diagnostic test kit (RDT) stock-outs. Furthermore, patient may avoid seeking treatment from such facilities. The study's goal was to determine treatment-seeking behavior, malaria diagnosis and treatment quality, and likely treatment-seeking determinants in the local population. Passive case detection, which targeted all patients with suspected malaria cases, was conducted in ten public healthcare facilities over a three-month period. Monthly malaria cases, methods of diagnosis and antimalarial drug availability were assessed. A household-based survey was also carried out. Structured questionnaires were used to collect knowledge, attitude and practice (KAP) data from household heads. Malaria knowledge, treatment seeking behavior, and predictors of malaria treatment-seeking were all determined. Three of the seven dispensaries lacked a laboratory to conduct microscopy- diagnosis. These three dispensaries also experienced frequent RDT stock-outs, which resulted in depending on clinical signs as diagnosis for malaria. The majority of local residents with fever (50.3%) purchased antimalarial drugs from a chemist. About 37% of fever patients sought treatment at healthcare facility while the remaining 12.7% did not treat their fevers. In irrigated areas, 45.5% (46/64) of fever patients sought treatment at healthcare facilities, compared to 25% (18/64) in non-irrigated areas (p = 0.009). Most children aged below 5 who had fever (77.7%) were taken to healthcare facility for treatment compared to 31.4% of children aged 5-14 years or 20.9% of adults (0.0001). Predictors of treatment seeking included access to healthcare facility (OR = 16.23, 95% CI: 2.74-96.12), and ability to pay hospital bills (OR = 10.6, 95% CI: 1.97-57). Other factors that influenced health-seeking behavior included the severity of symptoms, the age of the patient and knowledge of malaria symptoms.

Trial-of-antibiotics to assist tuberculosis diagnosis in symptomatic adults in Malawi (ACT-TB study): a randomised controlled trial

BACKGROUND

Clinical practice and diagnostic algorithms often assume that tuberculosis can be ruled out in mycobacteriology-negative individuals whose symptoms improve with a trial-of-antibiotics. We aimed to investigate diagnostic performance, clinical benefit, and antimicrobial resistance using a randomised controlled trial.

METHODS

In this three-arm, individually randomised, open-label, controlled trial, we enrolled Malawian adults (aged ≥18 years) attending primary care who reported being unwell for at least 14 days (including cough) with no immediate indication for hospitalisation at Limbe and Ndirande Health Centres in Blantyre. Participants were randomly allocated (1:1:1) to azithromycin (500 mg taken once per day for 3 days), amoxicillin (1 g taken three times per day for 5 days), or standard of care with no immediate antibiotics, stratified by study site. Sputum at enrolment and day 8 was tested for tuberculosis (microscopy, Xpert MTB/RIF, and culture). The primary efficacy outcome was day 8 specificity (percentage with symptom improvement among mycobacteriology-negative participants), and day 29 clinical outcome (death, hospitalisation, or missed tuberculosis diagnosis) among all randomised participants. This study is registered with ClinicalTrials.gov, NCT03545373.

FINDINGS

Between Feb 25, 2019, and March 14, 2020, 5825 adults were screened and 1583 (mean age 36 years; 236 [14·9%] HIV positive) were randomly assigned to standard of care (530 participants), azithromycin (527 participants), or amoxicillin (526 participants) groups. Overall, 6·3% (100 of 1583 participants) had positive baseline sputum mycobacteriology. 310 (79·1%) of 392 patients receiving standard of care reported symptom improvement at day 8, compared with 340 (88·7%) of 383 patients receiving azithromycin (adjusted difference 8·6%, 95% CI 3·9-13·3%; p<0·0004) and 346 (89·4%) of 387 receiving amoxicillin (adjusted difference 8·8%, 4·0-13·6%; p=0·0003). The proportion of participants with day 29 composite clinical outcomes was similar between groups (standard of care 1% [7 of 530 participants], azithromycin 1% [6 of 527 participants], amoxicillin 2% [12 of 526 participants]).

INTERPRETATION

Routine outpatient trial-of-antibiotics during tuberculosis investigations modestly improved diagnostic specificity for mycobacteriologically confirmed tuberculosis but had no appreciable effect on death, hospitalisation, and missed tuberculosis diagnosis. These results confirm the limited benefit of trial-of-antibiotics, presenting an opportunity for discontinuation of trial-of-antibiotics and improved antimicrobial stewardship during tuberculosis screening, without affecting clinical outcomes.

FUNDING

Northern Norway Regional Health Authority (Helse Nord RHF), Commonwealth Scholarship Commission in the UK, Wellcome Trust, UK Medical Research Council, and the UK Department for International Development.

Understanding the Intransigence of Malaria in Malawi

Despite the scale-up of interventions against malaria over the past decade, this disease remains a leading threat to health in Malawi. To evaluate the epidemiology of both Plasmodium falciparum infection and malaria disease, the Malawi International Center of Excellence for Malaria Research (ICEMR) has developed and implemented diverse and robust surveillance and research projects. Descriptive studies in ICEMR Phase 1 increased our understanding of the declining effectiveness of long-lasting insecticidal nets (LLINs), the role of school-age children in malaria parasite transmission, and the complexity of host-parasite interactions leading to disease. These findings informed the design of ICEMR Phase 2 to test hypotheses about LLIN use and effectiveness, vector resistance to insecticides, demographic targets of malaria control, patterns and causes of asymptomatic to life-threatening disease, and the impacts of RTS,S vaccination plus piperonyl butoxide-treated LLINs on infection and disease in young children. These investigations are helping us to understand mosquito-to-human and human-to-mosquito transmission in the context of Malawi's intransigent malaria problem.

Non-Malaria Causes of Fever among under-5 Children with Negative Results for Malaria Rapid Diagnostic Test in South-Western Nigeria

BACKGROUND

Although the global malaria burden is decreasing, there are still concerns about overdiagnosis of malaria and the danger of misdiagnosis of non-malaria causes of fever. Clinicians continue to face the challenge of differentiating between these causes despite the introduction of malaria rapid diagnostic tests (mRDTs).

AIM

To determine the prevalence and causes of non-malaria-caused fever in children in South-Western Nigeria.

METHODS

Secondary analysis of data obtained to evaluate the effect of restricting antimalarial treatment to positive mRDT children in rural and urban areas of southwest Nigeria. Clinical examinations, laboratory tests for malaria parasites (including thick blood film and mRDT) and bacterial identification were performed on children aged 3-59 months (n = 511). The non-malaria group comprised febrile children who had both negative mRDT and microscopy results, while the malaria group included those who were positive for either mRDT or microscopy. We compared the causes of fever among children with non-malaria fever and those with malaria.

RESULTS

The prevalence of non-malaria fever and bacteria-malaria co-infection was 37.2% and 2.0%, respectively. Non-malarial pathogens identified were viral (54.7%) and bacterial (32.1%) infections. The bacterial infections included bacteriaemia (2.7%), urinary tract infections (21.6%), skin infections (11.6%) and otitis media (2.6%). The leading bacterial isolates were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumoniae.

CONCLUSION

The high prevalence and wide range of non-malarial infections reinforces the need for point-of-care tests to identify bacterial and viral infections to optimize the treatment of febrile illnesses in malaria-endemic areas.

Management of febrile illness in rural Guinea over a seven-year period: A retrospective study

INTRODUCTION

Febrile illnesses constitute a major clinical challenge in tropical settings. We aimed to assess the frequency, presentation and management of febrile illness at two health facilities in Forécariah, Guinea, with a focus on appropriateness of antibiotic prescription.

MATERIALS AND METHODS

This was a retrospective study conducted in patient files in a health center and a district hospital. Proportions of antibiotic prescription were determined by age group and syndromes as well as appropriateness of antibiotic prescription using the WHO model list (2019).

RESULTS

From 2014 to 2020, 23,583 of 62,185 (38.0%) visits were related to febrile illness. Most patients with fever were female (56.1%) and evaluated at the health center (81.0%). Gastrointestinal (40.6%) and respiratory syndromes (36.8%), and undifferentiated fever (30.0%) were the most common presentations. Malaria was confirmed in 61.3% of the cohort. Overall, the rate of antibiotic prescription was high (14,834/23,583, 62.9%), mostly among patients aged <5 years (5,285/7,566, 69.9%), those with respiratory (7,577/8,684, 87.3%) and gastrointestinal (6,324/9,585, 66.0%) syndromes. Moreover, 7,432/14,465 (51.4%) patients with malaria were also prescribed an antibiotic. Penicillin (42.0%), cotrimoxazole (26.3%) and quinolones (18.7%) were the most frequently prescribed antibiotics. Overall, appropriateness of antibiotic prescription was low (38.3%), and even more so in patients with respiratory (29.1%) and gastrointestinal (25.8%) syndromes.

CONCLUSIONS

Febrile illness is a major cause of consultation in rural Guinea. Rate of antibiotic prescription was high, even in confirmed malaria and was often considered inappropriate. There is a pressing need to investigate the etiological spectrum and improve the diagnostic approach of febrile illness in Guinea.

Overdiagnosis of Malaria Illness in an Endemic Setting: A Facility-Based Surveillance Study in Malawi

In endemic settings where asymptomatic malaria infections are common, malaria infection can complicate fever diagnosis. Factors influencing fever misdiagnosis, including accuracy of malaria rapid diagnostic tests (mRDTs) and the malaria-attributable fraction of fevers (MAF), require further investigation. We conducted facility-based surveillance in Malawi, from January 2012 through December 2013 in settings of high perennial (Chikhwawa), high seasonal (Thoylo), and moderate seasonal (Ndirande) malaria transmission. Consecutive patients presenting to outpatient departments were screened; those with suspected malaria illness were tested by mRDT or routine thick-smear microscopy. Test positivity rates (TPRs), positive predictive value (PPVs) of mRDTs, and MAFs were calculated by site, age, and season. Of 41,471 patients, 10,052 (24.2%) tested positive for malaria. The TPR was significantly greater in Chikhwawa (29.9%; 95% CI, 28.6-30.0) compared with Thyolo (13.2%; 95% CI, 12.5-13.7) and Ndirande (13.1%; 95% CI, 12.2-14.4). The overall PPV was 77.8% (95% CI, 76.8-78.7); it was lowest among infants (69.9%; 95% CI, 65.5-74.2) and highest among school-age children (81.9%; 95% CI, 80.3-83.4). Malaria infection accounted for about 50% of fevers in children younger than 5 years old with microscopy-confirmed Plasmodium falciparum infection, and less than 20% of such fevers in school-age children. Outpatient settings in Malawi had a high burden of malaria illness, but also possible overdiagnosis of malaria illness. Interventions to reduce malaria transmission and rapid testing for other common febrile illness may improve diagnostic clarity among outpatients in malaria endemic settings.