Aetiologies of non-malaria febrile episodes in children under 5 years in sub-Saharan Africa

Could combined rapid diagnostic testing for malaria and c-reactive protein be helpful for the diagnosis and management of febrile illnesses in children under-5 years of age in rural Burkina Faso?

BACKGROUND

Febrile illnesses are among the most important reasons for medical consultation in sub-Saharan Africa and are frequently treated with antimicrobials due to the unavailability of appropriate diagnostic tools. This practice leads to antimicrobial resistance, with increasing mortality and morbidity as result. One of the few accessible diagnostic tools available in low resource settings is malaria rapid diagnostic tests (mRDTs) which contributed to reducing the over-prescription of anti-malarials, but cannot guide antibiotic prescriptions. To circumvent this problem, we explored whether combined testing with mRDT and c-reactive protein (CRP) could improve the diagnosis of febrile illnesses and subsequent prescription of antibiotics.

METHODS

Clinical specimens (blood, stool and urine) collected from 396 febrile children (axillary temperature of ≥ 37.5 °C) were analyzed with rapid diagnostic tests (malaria and CRP) and microbiology culture to establish the possible cause of fever. Actual antimicrobial prescriptions given to the children were compared with those that could be given based on combined CRP-malaria testing.

RESULTS

In total, 68.7% (272/396) of malaria cases were diagnosed by mRDT-Pf-HRP-2. CRP test was positive in 84.3% (334/396) of the children, but bacterial infections were confirmed in 12.4% (49/396) of them. A possible cause of fever could not be established in 20.5% (81/396) of cases. Based on the diagnostic practice in place, 265 of the children with a positive mRDT-Pf-HRP-2 received anti-malarial treatment. Furthermore, 89.5% (111/124) of negative mRDT results received antibiotic treatment and 37.1% (46/124) received antimalarial treatment. Of these 124 cases, 80 had positive CRP tests and 44 negative CRP tests. If the results of CRP testing are considered, 44 CRP/mRDT negative children would not get antibiotic treatment, resulting in a 35.5% reduction in antibiotic prescriptions. However, 2 cases with a bacterial infection would be denied appropriate treatment.

CONCLUSION

Combining mRDT-PfHRP2 with CRP testing is particularly useful in children for whom both tests are negative as it results in a reduction of antibiotics prescriptions. However, there is a risk to miss potential severe bacterial infections and a close follow-up of these cases is strongly recommended.

A systematic review and meta-analysis of the aetiological agents of non-malarial febrile illnesses in Africa

Background

The awareness of non-malarial febrile illnesses (NMFIs) has been on the rise over the last decades. Therefore, we undertook a systematic literature review and meta-analysis of causative agents of non-malarial fevers on the African continent.

Methodology

We searched for literature in African Journals Online, EMBASE, PubMed, Scopus, and Web of Science databases to identify aetiologic agents that had been reported and to determine summary estimates of the proportional morbidity rates (PMr) associated with these pathogens among fever patients.

Findings

A total of 133 studies comprising 391,835 patients from 25 of the 54 African countries were eligible. A wide array of aetiologic agents were described with considerable regional differences among the leading agents. Overall, bacterial pathogens tested from blood samples accounted for the largest proportion. The summary estimates from the meta-analysis were low for most of the agents. This may have resulted from a true low prevalence of the agents, the failure to test for many agents or the low sensitivity of the diagnostic methods applied. Our meta-regression analysis of study and population variables showed that diagnostic methods determined the PMr estimates of typhoidal Salmonella and Dengue virus. An increase in the PMr of Klebsiella spp. infections was observed over time. Furthermore, the status of patients as either inpatient or outpatient predicted the PMr of Haemophilus spp. infections.

Conclusion

The small number of epidemiological studies and the variety of NMFI agents on the African continent emphasizes the need for harmonized studies with larger sample sizes. In particular, diagnostic procedures for NMFIs should be standardized to facilitate comparability of study results and to improve future meta-analyses. Reliable NMFI burden estimates will inform regional public health strategies.

Previous systematic reviews have highlighted the research priorities of causative agents for non-malarial febrile illnesses by counting the number of publications attributed to an agent. However, proportional morbidity rates are calculated by dividing the number of cases with a specific disease (numerator) by the total number of diagnosed fever cases (denominator) and are better indicators of the relative importance of aetiological agents in a population. Therefore, we present the leading causes of non-malarial febrile illnesses in African patients in both healthcare and community settings. Preference is given to HIV-negative patients when data could be found. We also determined summary estimates of Brucella spp., Chikungunya virus, Dengue virus, Haemophilus spp., Klebsiella spp., Leptospira spp., non-typhoidal Salmonella spp., typhoidal Salmonella spp., Staphylococcus spp., and Streptococcus spp.

The wide array of aetiological agents causing febrile illnesses on the African continent does not only complicate malaria control programs but may also hamper response to epidemic and pandemic illnesses such as Ebola and COVID-19. The harmonisation of diagnostics and study designs will reduce between-study differences, which may result in better estimates of disease burden on the continent and in the different African regions. This information is important for Pan-African surveillance and control efforts.

Relationship between symptoms, barriers to care and healthcare utilisation among children under five in rural Mali

Objectives

To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high‐mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation.

Methods

Using baseline household survey data from a cluster‐randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio‐demographic factors, symptoms and utilisation outcomes in mixed‐effect logistic regressions.

Results

Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one‐quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider.

Conclusions

Even distances as short as 2–5 km significantly reduced children’s likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

Extensive Antibiotic and Antimalarial Prescription Rate among Children with Acute Febrile Diseases in the Lake Victoria Region, Tanzania

OBJECTIVES

Acute mosquito-borne febrile diseases pose a threat to children in the Sub-Saharan-Africa with ∼272 000 children dying worldwide from malaria in 2018. Although the awareness for malaria in this area has increased due to improved health education, the apparent decline of actual malaria cases has not affected clinical practice significantly. This study collected clinical and epidemiologic data of children presenting with acute febrile diseases in order delineate their diagnostic and therapeutic management.

METHODS

A hospital-based cross-sectional clinical study was conducted at the Sekou Toure Regional Referral Hospital in Tanzania. Children between 1 month and 12 years of age with an axillary temperature ≥ 37.5°C were recruited from August 2016 to December 2016. Children received full clinical examination. In addition, file data about diagnostics and treatment were collected and malaria rapid diagnostic tests (mRDTs) were performed. Confirmatory malaria polymerase chain reaction was performed from dry blood spots.

RESULTS

From 1381 children presented in the pediatric outpatient department, 133 met the inclusion criteria. Out of 133 febrile children, 10.5% were malaria positive. Treatment data indicate the prescription of antimalarials in 35.3% and antibiotics in 63.9% of the children with an overlap of 24.1% receiving both. Despite a negative mRDT, 36 patients received antimalarials.

CONCLUSIONS

The findings of this study confirm a significant decline of malaria cases in the Lake Victoria region. The discrepancy between the valuable results provided by mRDTs and the high prescription rates of antibiotics and antimalarials call for an enforced diagnostic and therapeutic algorithm.

LAY SUMMARY

The aim of the study was to take a closer look at reported cases of febrile diseases in the Lake Victoria region and assess the relationship between clinical as well as diagnostic findings and the resulting therapeutic concept. Based on these findings the prescription rate of antimalarial and antibiotic drugs was analyzed. The results showed an overall high prescription rate of antimalarials and antibiotics in both diagnosed malaria cases and cases with diagnosed bacterial infections.Not only with regards to the possible side effects of these medications but also keeping in mind the apparent misuse of resources this practice poses a serious burden to the health care system in this low resource country.

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

Increasing access to rapid diagnostic tests for malaria (mRDTs) has raised awareness of the challenges healthcare workers face in managing non-malarial febrile illnesses (NMFIs). We examined NMFI prevalence, clinical diagnoses, and prescribing practices in outpatient clinics across different malaria transmission settings in Malawi. Standardized facility-based malaria surveillance was conducted at three facilities one of every 4 weeks over 2 years. Information on demographics, presenting symptoms, temperature, clinical diagnosis, and treatment were collected from outpatients presenting with malaria-like symptoms. Of the 25,486 patients with fever, 69% had NMFI. Non-malarial febrile illness prevalence was lower in 5- to 15-year-old patients (55%) than in children < 5 years (72%) and adults > 15 years of age (77%). The most common clinical diagnoses among febrile patients with negative mRDTs in all age-groups and settings were respiratory infections (46%), sepsis (29%), gastroenteritis (13%), musculoskeletal pain (9%), and malaria (5%). Antibiotic prescribing was high in all age-groups and settings. Trimethoprim-sulfamethoxazole (40%) and amoxicillin (29%) were the most commonly prescribed antibiotics and were used for nearly all clinical diagnoses. In these settings with minimal access to diagnostic tools, patients with fever and a negative mRDT received a limited number of clinical diagnoses. Many were likely to be inaccurate and were associated with the inappropriate use of the limited range of available antibiotics. Prescription and diagnostic practices for NMFIs in the facilities require research and policy input. Resource-limited malaria-endemic countries urgently need more point-of-care diagnostic tools and evidence-based diagnosis and treatment algorithms to provide effective and cost-efficient care.

Host-Based Prognostic Biomarkers to Improve Risk Stratification and Outcome of Febrile Children in Low- and Middle-Income Countries

Fever is one of the leading causes for pediatric medical consultation and the most common symptom at clinical presentation in low- and middle-income countries (LMICs). Most febrile episodes are due to self-limited infections, but a small proportion of children will develop life-threatening infections. The early recognition of children who have or are progressing to a critical illness among all febrile cases is challenging, and there are currently no objective and quantitative tools to do so. This results in increased morbidity and mortality among children with impending life-threatening infections, whilst contributing to the unnecessary prescription of antibiotics, overwhelming health care facilities, and harm to patients receiving avoidable antimicrobial treatment. Specific fever origin is difficult to ascertain and co-infections in LMICs are common. However, many severe infections share common pathways of host injury irrespective of etiology, including immune and endothelial activation that contribute to the pathobiology of sepsis (i.e., pathogen "agnostic" mechanisms of disease). Importantly, mediators of these pathways are independent markers of disease severity and outcome. We propose that measuring circulating levels of these factors can provide quantitative and objective evidence to: enable early recognition of severe infection; guide patient triage and management; enhance post-discharge risk stratification and follow up; and mitigate potential gender bias in clinical decisions. Here, we review the clinical and biological evidence supporting the clinical utility of host immune and endothelial activation biomarkers as components of novel rapid triage tests, and discuss the challenges and needs for developing and implementing such tools.

Vaccine impact on antimicrobial resistance to inform Gavi, the Vaccine Alliance's 2018 Vaccine Investment Strategy: report from an expert survey

Background: While the rise of antimicrobial resistance (AMR) has been recognised as a major public health problem, the value of vaccines to control AMR is poorly defined. This expert survey was launched with the aim of informing the 2018 Vaccine Investment Strategy through which Gavi, the Vaccine Alliance prioritises future vaccine funding. This exercise focused on both vaccines currently supported by Gavi and under consideration for future funding. Methods: The relative importance of pre-defined criteria as drivers of overall value of vaccines as a tool/ intervention to control AMR was assessed by 18 experts: prevention of mortality and morbidity due to resistant pathogens, antibiotic use prevented, societal impact, ethical importance and sense of urgency. For each vaccine, experts attributed scores reflecting the estimated value for each criterion, and overall value relative to AMR was derived from the value assigned to each criterion and their relative importance for each vaccine. Results: Mortality, morbidity due to targeted resistant pathogens, and antibiotic use prevented were considered the most important determinants of overall value. Pneumococcal, typhoid and malaria vaccines were assigned highest value relative to antimicrobial resistance. Intermediate value was estimated for specific rotavirus, cholera, respiratory syncytial virus (RSV), influenza, dengue, measles, meningitis and Haemophilus influenza type b- (Hib-) containing pentavalent vaccines. Lowest value relative to AMR was estimated for Japanese encephalitis, hepatitis A, yellow fever, rabies and human papilloma virus vaccine. Conclusions: In the future, more evidence-based, data-driven, robust methodologies should be developed to guide coordinated, rational decision making on priority actions aimed at strengthening the use of vaccines against AMR.

A cross-sectional survey on the seroprevalence of dengue fever in febrile patients attending health facilities in Cross River State, Nigeria

Background

In Nigeria, recent reports suggest that dengue viruses could be a major cause of acute fevers. We sought to make a cross-sectional estimate of the prevalence of current and previous dengue infections in patients presenting with fever to healthcare centres in Cross River State Nigeria.

Methodology/Principal findings

This cross-sectional health facility survey recruited persons with temperature ≥38°C. Dengue virus immunoglobulin M (IgM)/immunoglobulin G (IgG) antibody testing using Onsite Duo dengue Ag-IgG/IgM lateral flow immunoassay cassettes was done. Samples which tested positive were further confirmed using the RecombiLISA dengue IgM and IgG enzyme linked immunosorbent assay kits and classified into primary and secondary dengue infection. Malaria testing was carried out using microscopy. Between 4 January 2017 and 24 August 2017 a total of 420 participants were sampled across 11 health centres. The mean age was 34 (range = 1–99), 63% were female, 49% reported sleeping under a treated mosquito net in the past week and 44% reported taking an antimalarial prior to seeking care. The mean number of days fever was present prior to seeking care was 8, and many of the participants presented with symptoms indicative of respiratory or urinary tract infections. Testing indicated that 6% (95% CI: 2, 13; n = 24) had either a primary or secondary dengue infection with or without co-existing malaria, while 4% (95% CI: 2, 9; n = 16) had either a primary or secondary dengue infection without co-existing malaria. 52% (95% CI: 46, 58; n = 218) had a malaria infection with or without any dengue infection, and 50% (95% CI: 44, 57; n = 210) had a malaria infection without any dengue infection.

Conclusion

Our study confirms the presence of dengue at not insignificant levels in patients attending health centres with fever in this south eastern province of Nigeria. These data highlight the danger of the common presumption in this setting that fever is due to malaria. Surveillance for dengue is vital in this setting.

Can clinical signs or symptoms combined with basic hematology data be used to predict the presence of bacterial infections in febrile children under - 5 years?

BACKGROUND

Infectious diseases in children living in resource-limited settings are often presumptively managed on the basis of clinical signs and symptoms. Malaria is an exception. However, the interpretation of clinical signs and symptoms in relation to bacterial infections is often challenging, which may lead to an over prescription of antibiotics when a malaria infection is excluded. The present study aims to determine the association between clinical signs and symptoms and basic hematology data, with laboratory confirmed bacterial infections.

METHODS

A health survey was done by study nurses to collect clinical signs/symptoms in febrile (axillary temperature ≥ 37.5 °C) children under - 5 years of age. In addition, blood, stool and urine specimen were systematically collected from each child to perform bacterial culture and full blood cell counts. To determine the association between a bacterial infection with clinical signs/symptoms, and if possible supported by basic hematology data (hemoglobin and leucocyte rates), a univariate analysis was done. This was followed by a multivariate analysis only on those variables with a p-value p < 0.1 in the univariate analysis. Only a p-value of < 0.05 was considered as significant for multivariate analysis.

RESULTS

In total, 1099 febrile children were included. Bacteria were isolated from clinical specimens (blood-, stool- and urine- culture) of 127 (11.6%) febrile children. Multivariate logistical regression analysis revealed that a general bacterial infection (irrespective of the site of infection) was significantly associated with the following clinical signs/symptoms: diarrhea (p = 0.003), edema (p = 0.010) and convulsion (p = 0.021). Bacterial bloodstream infection was significantly associated with fever> 39.5 °C (p = 0.002), diarrhea (p = 0.019) and edema (p = 0.017). There was no association found between bacterial infections and basic haematological findings. If diarrhea and edema were absent, a good negative predictive value (100%) of a bacterial bloodstream infection was found, but the positive predictive value was low (33.3%) and the confidence interval was very large (2.5-100; 7.5-70.1).

CONCLUSION

Our study demonstrates that clinical signs and symptoms, combined with basic hematology data only, cannot predict bacterial infections in febrile children under - 5 years of age. The development of practical and easy deployable diagnostic tools to diagnose bacterial infections remains a priority.

Treatable causes of fever among children under five years in a seasonal malaria transmission area in Burkina Faso

BACKGROUND

Fever remains a major public health problem. In Burkina Faso, more than half of febrile children are considered not to be infected by malaria. This study prospectively assessed probable (treatable) causes of fever in Burkinabe children.

METHODS

A prospective study was conducted among febrile children (≥37.5 °C) under 5 years of age presenting at four health facilities and one referral hospital in rural Burkina Faso. From each participant, blood was collected for malaria microscopy and culture, urine for dipstick testing and culturing if tested positive for leucocytes and nitrite, stool for rotavirus/adenovirus testing, culture and parasitology, and a nasopharyngeal swab for culture.

RESULTS

In total 684 febrile children were included in the study. Plasmodium falciparum malaria was found in 49.7% (340/684) of the participants and non-malaria infections in 49.1% (336/684) of children. The non-nalaria infections included gastro-intestinal infections (37.0%), common bacterial pathogens of nasopharynx (24.3%), bacterial bloodstream infections (6.0%) and urinary tract infections (1.8%). Nearly 45% (154/340) of the malaria infected children were co-infected with non-nalaria infections, but only 3.2% (11/340) of these co-infections could be considered as a possible alternative cause of fever. In contrast, in the malaria microscopy negative children 18.0% (62/344) of the infections could be the probable cause of the fever. Pathogens were not isolated from 23.7% (162/684) of the febrile cases.

CONCLUSIONS

Malaria remains the most common pathogen found in febrile children in Burkina Faso. However, a relative high number of febrile children had non-malaria infections. The correct diagnosis of these non-malaria fevers is a major concern, and there is an urgent need to develop more point-of-care diagnostic tests and capacities to identify and treat the causes of these fevers.

Febrile illness diagnostics and the malaria-industrial complex: a socio-environmental perspective

Background

Global prioritization of single-disease eradication programs over improvements to basic diagnostic capacity in the Global South have left the world unprepared for epidemics of chikungunya, Ebola, Zika, and whatever lies on the horizon. The medical establishment is slowly realizing that in many parts of sub-Saharan Africa (SSA), particularly urban areas, up to a third of patients suffering from acute fever do not receive a correct diagnosis of their infection.

Main body

Malaria is the most common diagnosis for febrile patients in low-resource health care settings, and malaria misdiagnosis has soared due to the institutionalization of malaria as the primary febrile illness of SSA by international development organizations and national malaria control programs. This has inadvertently created a “malaria-industrial complex” and historically obstructed our complete understanding of the continent’s complex communicable disease epidemiology, which is currently dominated by a mélange of undiagnosed febrile illnesses. We synthesize interdisciplinary literature from Ghana to highlight the complexity of communicable disease care in SSA from biomedical, social, and environmental perspectives, and suggest a way forward.

Conclusion

A socio-environmental approach to acute febrile illness etiology, diagnostics, and management would lead to substantial health gains in Africa, including more efficient malaria control. Such an approach would also improve global preparedness for future epidemics of emerging pathogens such as chikungunya, Ebola, and Zika, all of which originated in SSA with limited baseline understanding of their epidemiology despite clinical recognition of these viruses for many decades. Impending ACT resistance, new vaccine delays, and climate change all beckon our attention to proper diagnosis of fevers in order to maximize limited health care resources.