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Musumeci S, Kruse A, Chappuis F, Ostergaard Jensen T, Alcoba G. Neglected etiologies of prolonged febrile illnesses in tropical and subtropical regions: A systematic review. PLoS Negl Trop Dis 2024; 18:e0011978. [PMID: 38905305 PMCID: PMC11221637 DOI: 10.1371/journal.pntd.0011978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 07/03/2024] [Accepted: 06/04/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Febrile illnesses that persist despite initial treatment are common clinical challenges in (sub)tropical low-resource settings. Our aim is to review infectious etiologies of "prolonged fevers" (persistent febrile illnesses, PFI) and to quantify relative contributions of selected neglected target diseases with limited diagnostic options, often overlooked, causing inadequate antibiotic prescriptions, or requiring prolonged and potentially toxic treatments. METHODS We performed a systematic review of articles addressing the infectious etiologies of PFI in adults and children in sub-/tropical low- and middle-income countries (LMICs) using the PRISMA guidelines. A list of target diseases, including neglected parasites and zoonotic bacteria (e.g., Leishmania and Brucella), were identified by infectious diseases and tropical medicine specialists and prioritized in the search. Malaria and tuberculosis (TB) were not included as target diseases due to well-established epidemiology and diagnostic options. Four co-investigators independently extracted data from the identified articles while assessing for risk of bias. RESULTS 196 articles from 52 countries were included, 117 from Africa (33 countries), 71 from Asia (16 countries), and 8 from Central and -South America (3 countries). Target diseases were reported as the cause of PFI in almost half of the articles, most frequently rickettsioses (including scrub typhus), relapsing fever borreliosis (RF-borreliosis), brucellosis, enteric fever, leptospirosis, Q fever and leishmaniasis. Among those, RF-borreliosis was by far the most frequently reported disease in Africa, particularly in Eastern Africa. Rickettsioses (including scrub typhus) were often described in both Africa and Asia. Leishmaniasis, toxoplasmosis and amoebiasis were the most frequent parasitic etiologies. Non-target diseases and non-tropical organisms (Streptococcus pneumoniae, Escherichia coli, and non-typhoidal Salmonella spp) were documented in a fifth of articles. CONCLUSIONS Clinicians faced with PFI in sub-/tropical LMICs should consider a wide differential diagnosis including enteric fever and zoonotic bacterial diseases (e.g., rickettsiosis, RF-borreliosis and brucellosis), or parasite infections (e.g., leishmaniasis) depending on geography and syndromes. In the absence of adequate diagnostic capacity, a trial of antibiotics targeting relevant intra-cellular bacteria, such as doxycycline or azithromycin, may be considered.
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Affiliation(s)
- Stefano Musumeci
- Division of Infectious Diseases, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Alexandra Kruse
- Médecins Sans Frontières (MSF) / Doctors Without Borders, Brussels, Belgium
- Department for Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - François Chappuis
- Division of Tropical and Humanitarian medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Tomas Ostergaard Jensen
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Médecins Sans Frontières (MSF) / Doctors Without Borders, Paris, France
| | - Gabriel Alcoba
- Médecins Sans Frontières (MSF) / Doctors Without Borders, Geneva, Switzerland
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Chew R, Painter C, Pan-ngum W, Day NPJ, Lubell Y. Cost-effectiveness analysis of a multiplex lateral flow rapid diagnostic test for acute non-malarial febrile illness in rural Cambodia and Bangladesh. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 23:100389. [PMID: 38523864 PMCID: PMC10958476 DOI: 10.1016/j.lansea.2024.100389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/12/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
Background Multiplex lateral flow rapid diagnostic tests (LF-RDTs) may aid management of patients with acute non-malarial febrile illness (NMFI) in rural south and southeast Asia. We aimed to evaluate the cost-effectiveness in Cambodia and Bangladesh of a putative, as-yet-undeveloped LF-RDT capable of diagnosing enteric fever and dengue, as well as measuring C-reactive protein (CRP) to guide antibiotic prescription, in primary care patients with acute NMFI. Methods A country-specific decision tree model-based cost-effectiveness analysis was conducted from a health system plus limited societal perspective considering the cost of antimicrobial resistance. Parameters were based on data from a large observational study on the regional epidemiology of acute febrile illness, published studies, and procurement price lists. Costs were expressed in US$ (value in 2022), and cost-effectiveness evaluated by comparing incremental cost-effectiveness ratios with conservative opportunity cost-based willingness-to-pay thresholds and the more widely used threshold of per capita gross domestic product (GDP). Findings Compared to standard of care, LF-RDT-augmented clinical assessment was dominant in Cambodia, being more effective and cost-saving. The cost per disability-adjusted life year (DALY) averted in Bangladesh was US$482, slightly above the conservative opportunity cost-based willingness-to-pay threshold of US$388 and considerably lower than the GDP-based threshold of US$2687. The intervention remained dominant in Cambodia and well below the GDP-based threshold in Bangladesh when antimicrobial resistance costs were disregarded. Interpretation These findings provide guidance for academic, industry, and policymaker stakeholders involved in acute NMFI diagnostics. While definitive conclusions cannot be made in the absence of established thresholds, our results suggest that similar results are highly likely in some target settings and possible in others. Funding Wellcome Trust, UK Government, Royal Australasian College of Physicians, and Rotary Foundation.
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Affiliation(s)
- Rusheng Chew
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Chris Painter
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Wirichada Pan-ngum
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicholas Philip John Day
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Asuquo DE, Attai KF, Johnson EA, Obot OU, Adeoye OS, Akwaowo CD, Ekpenyong N, Isiguzo C, Ekanem U, Motilewa O, Dan E, Umoh E, Ekpin V, Uzoka FME. Multi-criteria decision analysis method for differential diagnosis of tropical febrile diseases. Health Informatics J 2024; 30:14604582241260659. [PMID: 38860564 DOI: 10.1177/14604582241260659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
This paper employs the Analytical Hierarchy Process (AHP) to enhance the accuracy of differential diagnosis for febrile diseases, particularly prevalent in tropical regions where misdiagnosis may have severe consequences. The migration of health workers from developing countries has resulted in frontline health workers (FHWs) using inadequate protocols for the diagnosis of complex health conditions. The study introduces an innovative AHP-based Medical Decision Support System (MDSS) incorporating disease risk factors derived from physicians' experiential knowledge to address this challenge. The system's aggregate diagnostic factor index determines the likelihood of febrile illnesses. Compared to existing literature, AHP models with risk factors demonstrate superior prediction accuracy, closely aligning with physicians' suspected diagnoses. The model's accuracy ranges from 85.4% to 96.9% for various diseases, surpassing physicians' predictions for Lassa, Dengue, and Yellow Fevers. The MDSS is recommended for use by FHWs in communities lacking medical experts, facilitating timely and precise diagnoses, efficient application of diagnostic test kits, and reducing overhead expenses for administrators.
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Affiliation(s)
- Daniel E Asuquo
- Department of Information Systems, Faculty of Computing, University of Uyo, Uyo, Nigeria
| | - Kingsley F Attai
- Department of Mathematics & Computer Science, Ritman University, Ikot Ekpene, Nigeria
| | - Ekemini A Johnson
- Department of Mathematics & Computer Science, Ritman University, Ikot Ekpene, Nigeria
| | - Okure U Obot
- Department of Software Engineering, Faculty of Computing, University of Uyo, Uyo, Nigeria
| | - Olufemi S Adeoye
- Department of Data Science, Faculty of Computing, University of Uyo, Uyo, Nigeria
| | - Christie Divine Akwaowo
- Community Medicine Department, University of Uyo, Uyo, Nigeria
- Health Systems Research Hub, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Nnette Ekpenyong
- Community Health Department, University of Calabar, Calabar, Nigeria
| | | | - Uwemedimbuk Ekanem
- Community Medicine Department, University of Uyo, Uyo, Nigeria
- Institute of Health Research and Development, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Olugbemi Motilewa
- Community Medicine Department, University of Uyo, Uyo, Nigeria
- Health Systems Research Hub, University of Uyo Teaching Hospital, Uyo, Nigeria
- Institute of Health Research and Development, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Emem Dan
- Health Systems Research Hub, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Edidiong Umoh
- Health Systems Research Hub, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Victory Ekpin
- Health Systems Research Hub, University of Uyo Teaching Hospital, Uyo, Nigeria
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Calderon-Ruiz P, Haist G, Mascus A, Holguin-Rocha AF, Koliopoulos P, Daniel T, Velez G, Londono-Renteria B, Gröndahl B, Tobon-Castano A, Gehring S. Multiplex Reverse Transcription Polymerase Chain Reaction Combined with a Microwell Hybridization Assay Screening for Arbovirus and Parasitic Infections in Febrile Patients Living in Endemic Regions of Colombia. Trop Med Infect Dis 2023; 8:466. [PMID: 37888594 PMCID: PMC10610613 DOI: 10.3390/tropicalmed8100466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
Acute febrile syndrome is a frequent reason for medical consultations in tropical and subtropical countries where the cause could have an infectious origin. Malaria and dengue are the primary etiologies in Colombia. As such, constant epidemiological surveillance and new diagnostic tools are required to identify the causative agents. A descriptive cross-sectional study was conducted to evaluate the circulation and differential diagnosis of six pathogens in two regions of Colombia. The results obtained via multiplex reverse transcription polymerase chain reaction combined with a microwell hybridization assay (m-RT-PCR-ELISA) were comparable to those obtained using rapid tests conducted at the time of patient enrollment. Of 155 patients evaluated, 25 (16.1%) and 16 (10.3%) were positive for malaria and dengue, respectively; no samples were positive for any of the other infectious agents tested. In most cases, m-RT-PCR-ELISA confirmed the results previously obtained through rapid testing.
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Affiliation(s)
- Paula Calderon-Ruiz
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
- Malaria Group, Lab 610, Faculty of Medicine, University of Antioquia, Medellin 050010, Colombia; (G.V.); (A.T.-C.)
| | - Gregor Haist
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
| | - Annina Mascus
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
| | - Andres F. Holguin-Rocha
- Department of Entomology, College of Agriculture, Kansas State University, Manhattan, KS 66506, USA;
| | - Philip Koliopoulos
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
| | - Tim Daniel
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
| | - Gabriel Velez
- Malaria Group, Lab 610, Faculty of Medicine, University of Antioquia, Medellin 050010, Colombia; (G.V.); (A.T.-C.)
| | - Berlin Londono-Renteria
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA;
| | - Britta Gröndahl
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
| | - Alberto Tobon-Castano
- Malaria Group, Lab 610, Faculty of Medicine, University of Antioquia, Medellin 050010, Colombia; (G.V.); (A.T.-C.)
| | - Stephan Gehring
- Center of Pediatric and Adolescent Medicine, University Medical Center, 55131 Mainz, Germany; (G.H.); (A.M.); (P.K.); (T.D.); (B.G.); (S.G.)
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5
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Peñataro Yori P, Paredes Olórtegui M, Schiaffino F, Colston JM, Pinedo Vasquez T, Garcia Bardales PF, Shapiama Lopez V, Zegarra Paredes LF, Perez K, Curico G, Flynn T, Zhang J, Ramal Asayag C, Meza Sanchez G, Silva Delgado H, Casapia Morales M, Casanova W, Jiu B, Oberhelman R, Munayco Escate C, Silver R, Henao O, Cooper KK, Liu J, Houpt ER, Kosek MN. Etiology of acute febrile illness in the peruvian amazon as determined by modular formatted quantitative PCR: a protocol for RIVERA, a health facility-based case-control study. BMC Public Health 2023; 23:674. [PMID: 37041550 PMCID: PMC10088183 DOI: 10.1186/s12889-023-15619-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND The study of the etiology of acute febrile illness (AFI) has historically been designed as a prevalence of pathogens detected from a case series. This strategy has an inherent unrealistic assumption that all pathogen detection allows for causal attribution, despite known asymptomatic carriage of the principal causes of acute febrile illness in most low- and middle-income countries (LMICs). We designed a semi-quantitative PCR in a modular format to detect bloodborne agents of acute febrile illness that encompassed common etiologies of AFI in the region, etiologies of recent epidemics, etiologies that require an immediate public health response and additional pathogens of unknown endemicity. We then designed a study that would delineate background levels of transmission in the community in the absence of symptoms to provide corrected estimates of attribution for the principal determinants of AFI. METHODS A case-control study of acute febrile illness in patients ten years or older seeking health care in Iquitos, Loreto, Peru, was planned. Upon enrollment, we will obtain blood, saliva, and mid-turbinate nasal swabs at enrollment with a follow-up visit on day 21-28 following enrollment to attain vital status and convalescent saliva and blood samples, as well as a questionnaire including clinical, socio-demographic, occupational, travel, and animal contact information for each participant. Whole blood samples are to be simultaneously tested for 32 pathogens using TaqMan array cards. Mid-turbinate samples will be tested for SARS-CoV-2, Influenza A and Influenza B. Conditional logistic regression models will be fitted treating case/control status as the outcome and with pathogen-specific sample positivity as predictors to attain estimates of attributable pathogen fractions for AFI. DISCUSSION The modular PCR platforms will allow for reporting of all primary results of respiratory samples within 72 h and blood samples within one week, allowing for results to influence local medical practice and enable timely public health responses. The inclusion of controls will allow for a more accurate estimate of the importance of specific prevalent pathogens as a cause of acute illness. STUDY REGISTRATION Project 1791, Registro de Proyectos de Investigación en Salud Pública (PRISA), Instituto Nacional de Salud, Perú.
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Affiliation(s)
- Pablo Peñataro Yori
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Asociación Benefica PRISMA, Iquitos, Loreto, Peru
| | | | - Francesca Schiaffino
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Faculty of Veterinary Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Josh M Colston
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Karin Perez
- Asociación Benefica PRISMA, Iquitos, Loreto, Peru
| | | | - Thomas Flynn
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jixian Zhang
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Cesar Ramal Asayag
- Universidad Nacional de La Amazonia Peruana, Loreto, Peru
- Hospital Regional de Loreto, Iquitos, Loreto, Peru
| | - Graciela Meza Sanchez
- Universidad Nacional de La Amazonia Peruana, Loreto, Peru
- Direccion Regional de Salud, Loreto, Peru
| | | | - Martin Casapia Morales
- Universidad Nacional de La Amazonia Peruana, Loreto, Peru
- Hospital Regional de Loreto, Iquitos, Loreto, Peru
| | - Wilma Casanova
- Universidad Nacional de La Amazonia Peruana, Loreto, Peru
| | - Bruce Jiu
- Laboratorio de Referencia en Salud Publica de la Direccion Regional de Salud- Diresa, Loreto, Peru
| | - Richard Oberhelman
- Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Cesar Munayco Escate
- Centro Nacional de Epidemiologia, Prevencion, y Control de Enfermedades, Ministerio de Salud de Peru, Jesus Maria, Peru
| | - Rachel Silver
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Olga Henao
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kerry K Cooper
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, USA
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | - Eric R Houpt
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Margaret N Kosek
- Division of Infectious Disease and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA.
- Asociación Benefica PRISMA, Iquitos, Loreto, Peru.
- Division of Infectious Diseases and International Health, Public Health Sciences, 345 Crispell Dr, Rm 2525, Charlottesville, USA.
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Ndiaye O, Woolston K, Gaye A, Loucoubar C, Cocozza M, Fall C, Dia F, Adams ER, Samb M, Camara D, Sadio BD, Diagne CT, Weidmann M, Faye O, Fitchett JRA, Sall AA, Diagne CT. Laboratory Evaluation and Field Testing of Dengue NS1 and IgM/IgG Rapid Diagnostic Tests in an Epidemic Context in Senegal. Viruses 2023; 15:v15040904. [PMID: 37112887 PMCID: PMC10143717 DOI: 10.3390/v15040904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Abstract
In Senegal, the burden of dengue is increasing and expanding. As case management and traditional diagnostic techniques can be difficult to implement, rapid diagnostic tests (RDTs) deployed at point of care are ideal for investigating active outbreaks. The aim of this study was to evaluate the diagnostic performance of the Dengue NS1 and Dengue IgM/IgG RDTs on the serum/plasma samples in a laboratory setting and in the field. During laboratory evaluation, performance of the NS1 RDT was assessed using NS1 ELISA as the gold standard. Sensitivity and specificity were 88% [75–95%] and 100% [97–100%], respectively. Performance of the IgM/IG RDT was assessed using the IgM Antibody Capture (MAC) ELISA, indirect IgG, and PRNT as gold standards. The IgM and IgG test lines respectively displayed sensitivities of 94% [83–99%] and 70% [59–79%] and specificities of 91% [84–95%] and 91% [79–98%]. In the field, the Dengue NS1 RDT sensitivity and specificity was 82% [60–95%] and 75% [53–90%], respectively. The IgM and IgG test lines displayed sensitivities of 86% [42–100%] and 78% [64–88%], specificities of 85% [76–92%] and 55% [36–73%], respectively. These results demonstrate that RDTs are ideal for use in a context of high prevalence or outbreak setting and can be implemented in the absence of a confirmatory test for acute and convalescent patients.
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Affiliation(s)
- Oumar Ndiaye
- Diatropix Unit, Institut Pasteur de Dakar, Dakar BP 220, Senegal
- Virology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Kevin Woolston
- Global Access Diagnostics, Bedford Technology Park, Bedford MK44 2YA, Bedfordshire, UK
| | - Aboubacry Gaye
- Epidemiology Clinical Research and Data Science Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Cheikh Loucoubar
- Epidemiology Clinical Research and Data Science Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Michael Cocozza
- Global Access Diagnostics, Bedford Technology Park, Bedford MK44 2YA, Bedfordshire, UK
| | - Cheikh Fall
- Microbiology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Fatou Dia
- Diatropix Unit, Institut Pasteur de Dakar, Dakar BP 220, Senegal
- Virology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Emily R. Adams
- Global Access Diagnostics, Bedford Technology Park, Bedford MK44 2YA, Bedfordshire, UK
| | - Marième Samb
- Diatropix Unit, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Diogop Camara
- Virology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | | | - Cheikh T. Diagne
- Mivegec Infectious Diseases and Vector: Ecology, Genetics, Evolution and Control, Université Montpellier, IRD, CNRS, 34394 Montpellier, France
| | - Manfred Weidmann
- Institute of Microbiology and Virology, Medical School Brandenburg Theodor Fontane, D-01968 Senftenberg, Germany
| | - Oumar Faye
- Virology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | | | - Amadou Alpha Sall
- Virology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
| | - Cheikh Tidiane Diagne
- Diatropix Unit, Institut Pasteur de Dakar, Dakar BP 220, Senegal
- Virology Department, Institut Pasteur de Dakar, Dakar BP 220, Senegal
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7
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Peñataro Yori P, Paredes Olórtegui M, Schiaffino F, Perez K, Curico Huansi G, Flynn T, Zhang J, Ramal Asayag C, Meza Sanchez G, Silva Delgado H, Casapia Morales M, Casanova W, Jiu B, Munayco Escate C, Silver R, Henao O, Cooper KK, Liu J, Houpt E, Kosek MN, Colston JM, Oberhelman R, Pinedo Vasquez T, Garcia Bardales PF, Shapiama Lopez WV, Zegarra Paredes LF. Etiology of Acute Febrile Illness in the Peruvian Amazon as determined by modular formatted quantitative PCR: A Protocol for RIVERA, a Health Facility-Based Case-Control Study. RESEARCH SQUARE 2023:rs.3.rs-2635774. [PMID: 37034707 PMCID: PMC10081374 DOI: 10.21203/rs.3.rs-2635774/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background The study of the etiology of acute febrile illness (AFI) has historically been designed as a prevalence of pathogens detected from a case series. This strategy has an inherent unrealistic assumption that all pathogen detection allows for causal attribution, despite known asymptomatic carriage of the principal causes of acute febrile illness in most low- and middle-income countries (LMICs). We designed a semi-quantitative PCR in a modular format to detect bloodborne agents of acute febrile illness that encompassed common etiologies of AFI in the region, etiologies of recent epidemics, etiologies that require an immediate public health response and additional pathogens of unknown endemicity. We then designed a study that would delineate background levels of transmission in the community in the absence of symptoms to provide corrected estimates of attribution for the principal determinants of AFI. Methods A case-control study of acute febrile illness in patients ten years or older seeking health care in Iquitos, Loreto, Peru, was planned. Upon enrollment, we will obtain blood, saliva, and mid-turbinate nasal swabs at enrollment with a follow-up visit on day 21-28 following enrollment to attain vital status and convalescent saliva and blood samples, as well as a questionnaire including clinical, socio-demographic, occupational, travel, and animal contact information for each participant. Whole blood samples are to be simultaneously tested for 32 pathogens using TaqMan array cards. Mid-turbinate samples will be tested for SARS-CoV-2, Influenza A and Influenza B. Conditional logistic regression models will be fitted treating case/control status as the outcome and with pathogen-specific sample positivity as predictors to attain estimates of attributable pathogen fractions for AFI. Discussion The modular PCR platforms will allow for reporting of all primary results of respiratory samples within 72 hours and blood samples within one week, allowing for results to influence local medical practice and enable timely public health responses. The inclusion of controls will allow for a more accurate estimate of the importance of specific, prevalent pathogens as a cause of acute illness. Study Registration Project 1791, Registro de Proyectos de Investigación en Salud Pública (PRISA), Instituto Nacional de Salud, Perú.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Cesar Munayco Escate
- Centro de Epidemiologia, Prevencion, y Control de Enfermedades, Ministerio de Salud
| | | | - Olga Henao
- Centers for Disease Control and Prevention
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Perceptions and priorities for the development of multiplex rapid diagnostic tests for acute non-malarial fever in rural South and Southeast Asia: An international modified e-Delphi survey. PLoS Negl Trop Dis 2022; 16:e0010685. [DOI: 10.1371/journal.pntd.0010685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 11/23/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background
Fever is a common presenting symptom in low- and middle-income countries (LMICs). It was previously assumed that malaria was the cause in such patients, but its incidence has declined rapidly. The urgent need to develop point-of-care tests for the most important causes of non-malarial acute febrile illness is hampered by the lack of robust epidemiological data. We sought to obtain expert consensus on analytes which should be prioritized for inclusion in fingerprick blood-based multiplex lateral flow rapid diagnostic tests (LF-RDTs) targeted towards four categories of patients with acute non-malarial fever in South and Southeast Asian LMICs, stratified by age (paediatric vs. adult) and care setting (primary vs. secondary care).
Methodology/Principal findings
We conducted a two-round modified e-Delphi survey. A total of 84 panellists were invited, consisting of seven each from 12 countries, divided into three regional panels (Mainland Southeast Asia, Maritime Southeast Asia, and South Asia). Panellists were asked to rank their top seven analytes for inclusion in LF-RDTs to be used in each patient category, justify their choices, and indicate whether such LF-RDTs should be incorporated into algorithm-based clinical decision support tools. Thirty-six panellists (43%) participated in the first round and 44 (52%) in the second. There was consensus that such LF-RDTs should be incorporated into clinical decision support tools. At a minimum, these LF-RDTs should be able to diagnose dengue and enteric fever in all patient categories. There was a clear preference to develop LF-RDTs for pathogens not readily detected by existing technologies, and for direct diagnosis through antigen detection. Pathogen biomarkers were prioritized over host inflammatory biomarkers, with CRP being the only one ranked consistently highly.
Conclusions/Significance
Our results provide guidance on prioritizing analytes for inclusion in context-specific multiplex LF-RDTs and similar platforms for non-malarial acute febrile illness, for which there is an urgent unmet need.
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Van Duffel L, Yansouni CP, Jacobs J, Van Esbroeck M, Ramadan K, Buyze J, Tsoumanis A, Barbé B, Boelaert M, Verdonck K, Chappuis F, Bottieau E. ACCURACY OF C-REACTIVE PROTEIN AND PROCALCITONIN FOR DIAGNOSING BACTERIAL INFECTIONS AMONG SUBJECTS WITH PERSISTENT FEVER IN THE TROPICS. Open Forum Infect Dis 2022; 9:ofac434. [PMID: 36092831 PMCID: PMC9454028 DOI: 10.1093/ofid/ofac434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/22/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Lukas Van Duffel
- Infectious Diseases Unit, Morgagni-Pierantoni Hospital , AUSL of Romagna, Forlì , Italy
| | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre , Montreal , Canada
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
- Department of Microbiology, Immunology and Transplantation , KU Leuven, Leuven , Belgium
| | - Marjan Van Esbroeck
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Kadrie Ramadan
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Jozefien Buyze
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Achilleas Tsoumanis
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine , Antwerp , Belgium
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine , Antwerp , Belgium
| | - Francois Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva , Geneva , Switzerland
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
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10
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Bottieau E, Van Duffel L, El Safi S, Koirala KD, Khanal B, Rijal S, Bhattarai NR, Phe T, Lim K, Mukendi D, Kalo JRL, Lutumba P, Barbé B, Jacobs J, Van Esbroeck M, Foqué N, Tsoumanis A, Parola P, Yansouni CP, Boelaert M, Verdonck K, Chappuis F. Etiological spectrum of persistent fever in the tropics and predictors of ubiquitous infections: a prospective four-country study with pooled analysis. BMC Med 2022; 20:144. [PMID: 35491421 PMCID: PMC9059373 DOI: 10.1186/s12916-022-02347-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/21/2022] [Indexed: 12/15/2022] Open
Abstract
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-itTM Typhoid IgM Lateral Flow Assay, and SD Bioline Salmonella typhi IgG/IgM for Salmonella Typhi infection, and Test-itTM 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.
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Affiliation(s)
- Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Lukas Van Duffel
- Infectious Diseases Operative Unit, Santa Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Sayda El Safi
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | | | - Basudha Khanal
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Suman Rijal
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Thong Phe
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Kruy Lim
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Deby Mukendi
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo.,Service de neurologie, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jean-Roger Lilo Kalo
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Pascal Lutumba
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Marjan Van Esbroeck
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Nikki Foqué
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Achilleas Tsoumanis
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Philippe Parola
- IHU-Méditerranée Infection & Aix-Marseille University, Marseille, France
| | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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11
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Akelew Y, Pareyn M, Lemma M, Negash M, Bewket G, Derbew A, Belay G, Pollmann J, Adriaensen W, Peeters M, Ombelet S, Adane A, Mohammed R, van Griensven J, Cnops L. Etiologies of acute undifferentiated febrile illness at the emergency ward of the University of Gondar Hospital, Ethiopia. Trop Med Int Health 2022; 27:271-279. [PMID: 35029010 DOI: 10.1111/tmi.13721] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Causes of acute febrile illness (AFI) often remain undetermined in developing countries, due to overlap of symptoms and limited available diagnostics. We aimed to assess the etiology of AFI in adults in a referral hospital in northwest Ethiopia. METHODS While all participants were tested for malaria by rapid diagnostic test (RDT), microscopy was only done on physician's request. Dengue virus (DENV) infections were detected using an RDT and ELISAs and dengue, yellow fever and chikungunya cases were identified by PCR. Bacterial etiologies were investigated using blood culture and PCR. RESULTS The etiology of acute infection was identified for 20.5% of 200 patients enrolled. 11.0% tested positive for Plasmodium, while microscopy was only requested for half of the identified malaria cases. For 4.0% of the Plasmodium-infected patients, an acute or past DENV (co-)infection was detected. We found 7.5% acute and 13.0% past DENV - all serotype 3 - infections. Bacterial infections were observed in 4.5% of the patients. CONCLUSION Malaria is still a considerable etiology of AFI and dengue is underrecognized. There are areas where both diseases occur concomitantly, and the DENV-3 serotype spreads from Sudan to northern Ethiopia. As only 20.5% of the etiologies were identified, a broader testing platform is required.
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Affiliation(s)
- Yibeltal Akelew
- Department of Medical Laboratory Sciences, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Myrthe Pareyn
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Mulualem Lemma
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Markos Negash
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gezahegn Bewket
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Agegnehu Derbew
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Gizeaddis Belay
- Department of Medical Microbiology, University of Gondar, Gondar, Ethiopia
| | - Julia Pollmann
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Wim Adriaensen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marjan Peeters
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aynishet Adane
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Rezika Mohammed
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia.,Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | - Johan van Griensven
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lieselotte Cnops
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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12
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Goarant C, Dellagi K, Picardeau M. Ending the Neglect of Treatable Bacterial Zoonoses Responsible for Non-Malaria Fevers. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:351-360. [PMID: 34211354 PMCID: PMC8223548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bacterial zoonotic diseases such as leptospirosis, Q fever, melioidosis, spotted
fever group rickettsioses, and brucellosis are increasingly recognized causes of
non-malaria acute fevers. However, though readily treatable with antibiotics,
these diseases are commonly misdiagnosed resulting in poor outcomes in patients.
There is a considerable deficit in the understanding of basic aspects of the
epidemiology of these neglected diseases and diagnostic tests for these zoonotic
bacterial pathogens are not always available in resource-poor settings. Raising
awareness about these emerging bacterial zoonoses is directly beneficial to the
patients by allowing a test-and-treat approach and is essential to control these
life-threatening diseases.
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Affiliation(s)
- Cyrille Goarant
- Institut Pasteur de Nouvelle-Calédonie, Unité de Recherche et d'Expertise sur la Leptospirose, Nouméa, New Caledonia
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13
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Wang H, Zhao J, Xie N, Wang W, Qi R, Hao X, Liu Y, Sevalie S, Niu G, Zhang Y, Wu G, Lv X, Chen Y, Ye Y, Bi S, Moseray M, Cellessy S, Kalon K, Baika DI, Luo Q. A Prospective Study of Etiological Agents Among Febrile Patients in Sierra Leone. Infect Dis Ther 2021; 10:1645-1664. [PMID: 34173960 PMCID: PMC8234757 DOI: 10.1007/s40121-021-00474-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Sierra Leone has one of the highest burdens of febrile illnesses in the world. As the incidence of malaria diminishes, a better understanding of the spectrum of etiological agents was important for accurate diagnosis and empirical treatment of febrile illness. Methods Blood, nasopharyngeal, and fecal specimens were collected from febrile patients for serological, molecular detection, and microbiologic culture to identify potential pathogens. Results For this prospective study, 142 febrile patients were enrolled. The prevalence of malaria was higher in children aged 5–15 years old (P = 0.185) and adults (P = 0.018). Acute respiratory infection (ARI) presented more commonly in the under 5 years old group (P = 0.009). For diarrhea, all children groups (P = 0.024) were predominant. A total of 22.5% of the febrile patients had malaria infection, 19.7% had typhoid infection, and 2.8% were coinfected with malaria and typhoid. ARI was the most common causes of fever, accounting for 31.7% of patients, influenza A virus, Mycoplasma pneumoniae, and five other respiratory pathogens were found. Diarrhea accounted for 16.2%, and seven kinds of diarrhea bacteria were isolated. Hepatitis B accounted for 8.5%, including five cases of spontaneous bacterial peritonitis, and ascites smear staining were both Gram-negative bacteria. Tuberculous encephalitis, parasitic diseases (ascaris and filariasis), and skin infection caused by Staphylococcus aureus accounted for 0.7%, 2.1%, and 0.7%, respectively. Conclusions Evidence of a wide spectrum of febrile etiological agents other than malaria was identified. The spread of malaria rapid diagnostic tests (RDTs) out of hospital and establishment of a national standard for Widal test will reduce the misdiagnosis of febrile diseases. Antibiotics against Gram-negative bacteria are helpful for empirical treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00474-y. Sierra Leone has one of the highest burdens of febrile illnesses in the world. Evidence of a wide spectrum of febrile pathogens other than malaria has been proven in this study. We considered that the etiology of febrile patients was closely related to local geography, heredity, immune features, economic industry, living habits, air pollution, medical and health conditions, and this was fully analyzed and discussed. The screening process used in this study can further simplify and identify the etiological agents of fever in more than 70% of the study population. This laid the foundation for the establishment of a more simplified and efficient diagnosis and treatment process in the local area. We also found the characteristics of age distribution of different febrile diseases. Children were an important susceptible population to fever. This study indicated the importance of reliable diagnostic tests for febrile pathogens and provided the necessary information for RDT requirements. The spread of malaria RDTs out of hospital and establishment of a national standard for Widal test will reduce the misdiagnosis of febrile diseases. For empirical treatment, antimalarial treatment was still targeted at falciparum malaria in Sierra Leone. Antibiotics against Gram-negative bacteria contributed to the empirical treatment of febrile diseases. For patients with acute respiratory tract infection, Gram-positive coccal antibiotics could be candidates for treatment. In addition, systematic and professional treatment of liver diseases should be promoted to reduce infection complications.
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Affiliation(s)
- Han Wang
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China.
| | - Jing Zhao
- Department of Clinical Diagnostic Centre, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, The People's Republic of China
| | - Na Xie
- Department of Inpatient and Medical Record Management, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Wanxue Wang
- Nursing Department, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Ruping Qi
- Department of Radiology, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, The People's Republic of China
| | - Xiaogang Hao
- Department of Inpatient and Medical Record Management, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Yan Liu
- Department of Clinical Diagnostic Centre, North Hospital District, The Third Hospital of Peking University, Beijing, The People's Republic of China
| | - Stephen Sevalie
- Headquarters, 34 Military Hospital of Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone
| | - Guotao Niu
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Yangli Zhang
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Ge Wu
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Xiaona Lv
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Yuhao Chen
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Yanfei Ye
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Sheng Bi
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China
| | - Moses Moseray
- Department of Clinical Diagnostic Centre, 34 Military Hospital of Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone
| | - Saidu Cellessy
- Department of Clinical Diagnostic Centre, 34 Military Hospital of Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone
| | - Ksaidu Kalon
- Department of Clinical Diagnostic Centre, 34 Military Hospital of Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone
| | - Dawud Ibrahim Baika
- Department of Clinical Diagnostic Centre, 34 Military Hospital of Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone
| | - Qun Luo
- Department of Transfusion Medicine, The Fifth Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, People's Republic of China.
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14
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Chidzwondo F, Mutapi F. Challenge of diagnosing acute infections in poor resource settings in Africa. AAS Open Res 2021. [DOI: 10.12688/aasopenres.13234.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Frequent disease outbreaks and acute infections occur in rural and low-income urban areas of Africa, with many health systems unprepared to diagnose and control diseases that are recurrent, endemic or have extended their geographic zone. In this review, we focus on acute infections that can be characterized by sudden onset, rapid progression, severe symptoms and poor prognosis. Consequently, these infections require early diagnosis and intervention. While effective vaccines have been developed against some of these diseases, lack of compliance and accessibility, and the need for repeated or multiple vaccinations mean large populations can remain vulnerable to infection. It follows that there is a need for enhancement of national surveillance and diagnostic capacity to avert morbidity and mortality from acute infections. We discuss the limitations of traditional diagnostic methods and explore the relative merits and applicability of protein-, carbohydrate- and nucleic acid-based rapid diagnostic tests that have been trialled for some infectious diseases. We also discuss the utility and limitations of antibody-based serological diagnostics and explore how systems biology approaches can better inform diagnosis. Lastly, given the complexity and high cost associated with after-service support of emerging technologies, we propose that, for resource-limited settings in Africa, multiplex point-of-care diagnostic tools be tailor-made to detect both recurrent acute infections and endemic infections.
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15
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Hin S, Lopez-Jimena B, Bakheit M, Klein V, Stack S, Fall C, Sall A, Enan K, Mustafa M, Gillies L, Rusu V, Goethel S, Paust N, Zengerle R, Frischmann S, Weidmann M, Mitsakakis K. Fully automated point-of-care differential diagnosis of acute febrile illness. PLoS Negl Trop Dis 2021; 15:e0009177. [PMID: 33630852 PMCID: PMC7906357 DOI: 10.1371/journal.pntd.0009177] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background In this work, a platform was developed and tested to allow to detect a variety of candidate viral, bacterial and parasitic pathogens, for acute fever of unknown origin. The platform is based on a centrifugal microfluidic cartridge, the LabDisk (“FeverDisk” for the specific application), which integrates all necessary reagents for sample-to-answer analysis and is processed by a compact, point-of-care compatible device. Methodology/Principal findings A sample volume of 200 μL per FeverDisk was used. In situ extraction with pre-stored reagents was achieved by bind-wash-elute chemistry and magnetic particles. Enzymes for the loop-mediated isothermal amplification (LAMP) were pre-stored in lyopellet form providing stability and independence from the cold chain. The total time to result from sample inlet to read out was 2 h. The proof-of-principle was demonstrated in three small-scale feasibility studies: in Dakar, Senegal and Khartoum, Sudan we tested biobanked samples using 29 and 9 disks, respectively; in Reinfeld, Germany we tested spiked samples and analyzed the limit of detection using three bacteria simultaneously spiked in whole blood using 15 disks. Overall during the three studies, the FeverDisk detected dengue virus (different serotypes), chikungunya virus, Plasmodium falciparum, Salmonella enterica Typhi, Salmonella enterica Paratyphi A and Streptococcus pneumoniae. Conclusions/Significance The FeverDisk proved to be universally applicable as it successfully detected all different types of pathogens as single or co-infections, while it also managed to define the serotype of un-serotyped dengue samples. Thirty-eight FeverDisks at the two African sites provided 59 assay results, out of which 51 (86.4%) were confirmed with reference assay results. The results provide a promising outlook for future implementation of the platform in larger prospective clinical studies for defining its clinical sensitivity and specificity. The technology aims to provide multi-target diagnosis of the origins of fever, which will help fight lethal diseases and the incessant rise of antimicrobial resistance. Infectious diseases in tropical regions may have a variety of viral, bacterial or parasitic origins and a patient may suffer from several diseases simultaneously, each presenting with acute fever as a clinical symptom. This makes it difficult to determine the origin of the pathogen causing the disease(s). In addition to the endemic infectious diseases, outbreaks of epidemics frequently complicate diagnostic demands. Accurate diagnosis for proper patient management requires the utilization of highly sensitive and specific, rapid, easy-to-use diagnostic tools compatible with point-of-care settings. We describe the use of a disk-shaped microfluidic platform, the “FeverDisk”, for differential diagnosis of acute fever. Our FeverDisk platform demonstrated its capability to detect bacteria, viruses and parasites that are typical of tropical single and co-infections from biobanked samples within only 2 hours and in very good agreement with reference method results. This, in combination with its easy-to-use and point-of-care compatible nature, render our platform a promising candidate for detection of tropical diseases and precise identification of the cause of acute fever, in endemic and epidemic settings. Future work will involve extensive clinical characterization of the platform in prospective studies.
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Affiliation(s)
- Sebastian Hin
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - Benjamin Lopez-Jimena
- Institute of Aquaculture, University of Stirling, Scotland, United Kingdom
- Mast Group Ltd, Mast House, Bootle, Liverpool, United Kingdom
| | | | - Vanessa Klein
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - Seamus Stack
- Mast Group Ltd, Mast House, Bootle, Liverpool, United Kingdom
| | - Cheikh Fall
- Arbovirus and viral haemorrhagic fever unit, Institut Pasteur de Dakar, Dakar, Senegal
| | - Amadou Sall
- Arbovirus and viral haemorrhagic fever unit, Institut Pasteur de Dakar, Dakar, Senegal
| | - Khalid Enan
- Department of Virology, Central Laboratory-The Ministry of Higher Education and Scientific Research, Khartoum, Sudan
| | - Mohamed Mustafa
- Department of Virology, Central Laboratory-The Ministry of Higher Education and Scientific Research, Khartoum, Sudan
| | - Liz Gillies
- Mast Group Ltd, Mast House, Bootle, Liverpool, United Kingdom
| | - Viorel Rusu
- MagnaMedics Diagnostics BV, Geleen, The Netherlands
| | - Sven Goethel
- MagnaMedics Diagnostics BV, Geleen, The Netherlands
| | - Nils Paust
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
- Hahn-Schickard, Freiburg, Germany
| | - Roland Zengerle
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
- Hahn-Schickard, Freiburg, Germany
| | | | - Manfred Weidmann
- Institute of Aquaculture, University of Stirling, Scotland, United Kingdom
| | - Konstantinos Mitsakakis
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
- Hahn-Schickard, Freiburg, Germany
- * E-mail:
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16
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Krumkamp R, Struck NS, Lorenz E, Zimmermann M, Boahen KG, Sarpong N, Owusu-Dabo E, Pak GD, Jeon HJ, Marks F, Jacobs T, May J, Eibach D. Classification of invasive bloodstream infections and Plasmodium falciparum malaria using autoantibodies as biomarkers. Sci Rep 2020; 10:21168. [PMID: 33273605 PMCID: PMC7712777 DOI: 10.1038/s41598-020-78155-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/20/2020] [Indexed: 01/25/2023] Open
Abstract
A better understanding of disease-specific biomarker profiles during acute infections could guide the development of innovative diagnostic methods to differentiate between malaria and alternative causes of fever. We investigated autoantibody (AAb) profiles in febrile children (≤ 5 years) admitted to a hospital in rural Ghana. Serum samples from 30 children with a bacterial bloodstream infection and 35 children with Plasmodium falciparum malaria were analyzed using protein microarrays (Protoplex Immune Response Assay, ThermoFisher). A variable selection algorithm was applied to identify the smallest set of AAbs showing the best performance to classify malaria and bacteremia patients. The selection procedure identified 8 AAbs of which IFNGR2 and FBXW5 were selected in repeated model run. The classification error was 22%, which was mainly due to non-Typhi Salmonella (NTS) diagnoses being misclassified as malaria. Likewise, a cluster analysis grouped patients with NTS and malaria together, but separated malaria from non-NTS infections. Both current and recent malaria are a risk factor for NTS, therefore, a better understanding about the function of AAb in disease-specific immune responses is required in order to support their application for diagnostic purposes.
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Affiliation(s)
- Ralf Krumkamp
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359, Hamburg, Germany.,German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Nicole Sunaina Struck
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359, Hamburg, Germany. .,German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany.
| | - Eva Lorenz
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359, Hamburg, Germany.,German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Marlow Zimmermann
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359, Hamburg, Germany.,German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Kennedy Gyau Boahen
- Department of Infectious Disease Epidemiology, Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Nimako Sarpong
- Department of Infectious Disease Epidemiology, Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Ellis Owusu-Dabo
- School of Public Health, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Gi Deok Pak
- Epidemiology Unit, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Hyon Jin Jeon
- Epidemiology Unit, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Florian Marks
- Epidemiology Unit, International Vaccine Institute (IVI), Seoul, Republic of Korea.,The Department of Medicine, the University of Cambridge, Cambridge, UK
| | - Thomas Jacobs
- Research Group Protozoa Immunology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Jürgen May
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359, Hamburg, Germany.,German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany.,First Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Eibach
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359, Hamburg, Germany.,German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
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17
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Elven J, Dahal P, Ashley EA, Thomas NV, Shrestha P, Stepniewska K, Crump JA, Newton PN, Bell D, Reyburn H, Hopkins H, Guérin PJ. Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Africa, 1980-2015. BMC Med 2020; 18:279. [PMID: 32951596 PMCID: PMC7504660 DOI: 10.1186/s12916-020-01744-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/13/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The availability of reliable point-of-care tests for malaria has heralded a paradigm shift in the management of febrile illnesses away from presumptive antimalarial therapy. In the absence of a definitive diagnosis, health care providers are more likely to prescribe empirical antimicrobials to those who test negative for malaria. To improve management and guide further test development, better understanding is needed of the true causative agents and their geographic variability. METHODS A systematic review of published literature was undertaken to characterise the spectrum of pathogens causing non-malaria febrile illness in Africa (1980-2015). Literature searches were conducted in English and French languages in six databases: MEDLINE, EMBASE, Global Health (CABI), WHO Global Health Library, PASCAL, and Bulletin de la Société Française de Parasitologie (BDSP). Selection criteria included reporting on an infection or infections with a confirmed diagnosis, defined as pathogens detected in or cultured from samples from normally sterile sites, or serological evidence of current or past infection. A number of published articles (rather than incidence or prevalence) reporting a given pathogen were presented. RESULTS A total of 16,523 records from 48 African countries were screened, of which 1065 (6.4%) met selection criteria. Bacterial infections were reported in 564 (53.0%) records, viral infections in 374 (35.1%), parasitic infections in 47 (4.4%), fungal infections in nine (0.8%), and 71 (6.7%) publications reported more than one pathogen group. Age range of the study population was not specified in 233 (21.9%) publications. Staphylococcus aureus (18.2%), non-typhoidal Salmonella (17.3%), and Escherichia coli (15.4%) were the commonly reported bacterial infections whereas Rift Valley fever virus (7.4%), yellow fever virus (7.0%), and Ebola virus (6.7%) were the most commonly reported viral infections. Dengue virus infection, previously not thought to be widespread in Africa, was reported in 54 (5.1%) of articles. CONCLUSIONS This review summarises the published reports of non-malaria pathogens that may cause febrile illness in Africa. As the threat of antimicrobial resistance looms, knowledge of the distribution of infectious agents causing fever should facilitate priority setting in the development of new diagnostic tools and improved antimicrobial stewardship. TRIAL REGISTRATION PROSPERO, CRD42016049281.
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Affiliation(s)
- Jeanne Elven
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Mahosot Hospital, Vientiane, Laos
| | - Nigel V Thomas
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Poojan Shrestha
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Paul N Newton
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Mahosot Hospital, Vientiane, Laos
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - David Bell
- Independent consultant, Issaquah, Washington, USA
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
| | - Philippe J Guérin
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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18
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Shrestha P, Dahal P, Ogbonnaa-Njoku C, Das D, Stepniewska K, Thomas NV, Hopkins H, Crump JA, Bell D, Newton PN, Ashley EA, Guérin PJ. Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Southern Asia and South-eastern Asia, 1980-2015. BMC Med 2020; 18:299. [PMID: 32951591 PMCID: PMC7504862 DOI: 10.1186/s12916-020-01745-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/13/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In the absence of definitive diagnosis, healthcare providers are likely to prescribe empirical antibacterials to those who test negative for malaria. This problem is of critical importance in Southern Asia (SA) and South-eastern Asia (SEA) where high levels of antimicrobial consumption and high prevalence of antimicrobial resistance have been reported. To improve management and guide further diagnostic test development, better understanding is needed of the true causative agents of fever and their geographical variability. METHODS We conducted a systematic review of published literature (1980-2015) to characterise the spectrum of pathogens causing non-malarial febrile illness in SA and SEA. We searched six databases in English and French languages: MEDLINE, EMBASE, Global Health (CABI) database, WHO Global Health Library, PASCAL, and Bulletin de la Société Française de Parasitologie (BDSP). Selection criteria included reporting on an infection or infections with a confirmed diagnosis, defined as pathogens detected in or cultured from samples from normally sterile sites, or serological evidence of current or past infection. RESULTS A total of 29,558 records from 19 countries in SA and SEA were screened, of which 2410 (8.1%) met the selection criteria. Bacterial aetiologies were reported in 1235 (51.2%) articles, viral in 846 (35.1%), parasitic in 132 (5.5%), and fungal in 54 (2.2%), and 143 (6.0%) articles reported more than one pathogen group. In descending order of frequency, Salmonella Typhi, Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and coagulase negative Staphylococcus were the commonly reported bacteria, while dengue virus, chikungunya virus, Japanese encephalitis virus, hepatitis B virus, and hepatitis C virus were common viral pathogens reported. Reports of rarely reported or emerging pathogens included a case report of Borrelia burgdorferi (Lyme disease) in India in 2010 and reports of Nipah virus in Singapore and India. CONCLUSIONS This review summarises the reported non-malaria pathogens that may cause febrile illness in SA and SEA. The findings emphasise the need of standardising the reporting of aetiological studies to develop effective, evidence-based fever management and improved surveillance. Research and development of diagnostic tools would benefit from up-to-date epidemiological reporting of the regional diversities of non-malaria fever aetiologies. TRIAL REGISTRATION PROSPERO registration, CRD42016049281.
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Affiliation(s)
- Poojan Shrestha
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Chinwe Ogbonnaa-Njoku
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Debashish Das
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nigel V. Thomas
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | - John A. Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Paul N. Newton
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Philippe J. Guérin
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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19
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Baltzell KA, Kortz TB, Blair A, Scarr E, Mguntha AM, Bandawe G, Schell E, Rankin SH. A 14-day follow-up of adult non-malarial fever patients seen by mobile clinics in rural Malawi. Malawi Med J 2020; 32:31-36. [PMID: 32733657 PMCID: PMC7366163 DOI: 10.4314/mmj.v32i1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background While health providers consistently use malaria rapid diagnostic tests to rule out malaria, they often lack tools to guide treatment for those febrile patients who test negative. Without the tools to provide an alternative diagnosis, providers may prescribe unnecessary antibiotics or miss a more serious condition, potentially contributing to antibiotic resistance and/or poor patient outcomes. Methods This study ascertained which diagnoses and treatments might be associated with poor outcomes in adults who test negative for malaria. Adult patients for rapid diagnostic test of malaria seen in mobile health clinics in Mulanje and Phalombe districts were followed for 14 days. Participants were interviewed on sociodemographic characteristics, health-seeking behaviour, diagnosis, treatment and access to care. Mobile clinic medical charts were reviewed. Two weeks (±2 days) following clinic visit, follow-up interviews were conducted to assess whether symptoms had resolved. Results Initially, 115 adult patients were enrolled and 1 (0.88%) was lost to follow-up. Of the 114 adult patients remaining in the study, 55 (48%) were seen during the dry season and 59 (52%) during the wet season. Symptoms resolved in 90 (80%) patients at the 14-day follow-up visit (n=90) with the rest (n=24) reporting no change in symptoms. None of the patients in the study died or were referred for further care. Almost all patients received some type of medication during their clinic visit (98.2%). Antibiotics were given to 38.6% of patients, and virtually all patients received pain or fever relief (96.5%). However, no anti-malarials were prescribed. Conclusions Mobile clinics provide important health care where access to care is limited. Although rapid tests have guided appropriate treatment, challenges remain when a patient's presenting complaint is less well defined. In rural areas of southern Malawi, simple diagnostics are needed to guide treatment decisions.
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Affiliation(s)
- Kimberly A Baltzell
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA.,Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA, USA
| | - Teresa Bleakly Kortz
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Alden Blair
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Ellen Scarr
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA, USA
| | | | - Gama Bandawe
- Department of Biological Sciences, Malawi University of Science and Technology, Malawi
| | - Ellen Schell
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA, USA.,Global AIDS Interfaith Alliance, San Rafael, CA, USA
| | - Sally H Rankin
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA, USA
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20
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Kapito-Tembo A, Mathanga D, Bauleni A, Nyirenda O, Pensulo P, Ali D, Valim C, Taylor TE, Laufer MK. Prevalence and Clinical Management of Non-malarial Febrile Illnesses among Outpatients in the Era of Universal Malaria Testing in Malawi. Am J Trop Med Hyg 2020; 103:887-893. [PMID: 32588795 DOI: 10.4269/ajtmh.18-0800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Atupele Kapito-Tembo
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre, Malawi
| | - Don Mathanga
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre, Malawi
| | - Andrew Bauleni
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Paul Pensulo
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Doreen Ali
- Malawi National Malaria Control Program, Lilongwe, Malawi
| | - Clarissa Valim
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts
| | - Terrie E Taylor
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland
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21
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Pokharel S, White LJ, Aguas R, Celhay O, Pellé KG, Dittrich S. Algorithm in the Diagnosis of Febrile Illness Using Pathogen-specific Rapid Diagnostic Tests. Clin Infect Dis 2020; 70:2262-2269. [PMID: 31313805 PMCID: PMC7245147 DOI: 10.1093/cid/ciz665] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/16/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In the absence of proper guidelines and algorithms, available rapid diagnostic tests (RDTs) for common acute undifferentiated febrile illnesses are often used inappropriately. METHODS Using prevalence data of 5 common febrile illnesses from India and Cambodia, and performance characteristics (sensitivity and specificity) of relevant pathogen-specific RDTs, we used a mathematical model to predict the probability of correct identification of each disease when diagnostic testing occurs either simultaneously or sequentially in various algorithms. We developed a web-based application of the model so as to visualize and compare output diagnostic algorithms when different disease prevalence and test performance characteristics are introduced. RESULTS Diagnostic algorithms with appropriate sequential testing predicted correct identification of etiology in 74% and 89% of patients in India and Cambodia, respectively, compared with 46% and 49% with simultaneous testing. The optimally performing sequential diagnostic algorithms differed in India and Cambodia due to varying disease prevalence. CONCLUSIONS Simultaneous testing is not appropriate for the diagnosis of acute undifferentiated febrile illnesses with presently available tests, which should deter the unsupervised use of multiplex diagnostic tests. The implementation of adaptive algorithms can predict better diagnosis and add value to the available RDTs. The web application of the model can serve as a tool to identify the optimal diagnostic algorithm in different epidemiological settings, while taking into account the local epidemiological variables and accuracy of available tests.
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Affiliation(s)
- Sunil Pokharel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Lisa J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ricardo Aguas
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Olivier Celhay
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Karell G Pellé
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Sabine Dittrich
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
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22
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Chilongola JO, Sabuni EJ, Kapyolo EP. Prevalence of plasmodium, leptospira and rickettsia species in Northern Tanzania: a community based survey. Afr Health Sci 2020; 20:199-207. [PMID: 33402908 PMCID: PMC7750093 DOI: 10.4314/ahs.v20i1.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The overlap of symptoms, geographic and seasonal co-occurrence of Plasmodium, Leptospira and Rickettsia infections makes malaria diagnosis difficult, increasing the chances of misdiagnosis. The paucity of data on the prevalence Plasmodium, Leptospira and Rickettsia infections contributes to an overly diagnosis of malaria. We aimed to determine the prevalence and distribution of Plasmodium, Leptospira and Rickettsia infections in northern Tanzania. METHODS A community based, cross sectional survey was conducted in two sites in Northern Tanzania. PCR was used to detect Plasmodium, Leptospira and Rickettsia infections. RESULTS The prevalence of P. falciparum and Leptospira spp were 31/128 (24.2%) and 3/128 (2.3%), respectively. No Rickettsia infection was detected in any of the two sites. Taking study sites separately, Plasmodium infection was detected in 31/63(49.2%) of participants in Bondo while Leptospira infection was detected in 3/65(4.6%) of participants in Magugu. Plasmodium was not detected in Magugu while no Leptospira infections were detected in Bondo. Fever was significantly associated with Plasmodium infection (χ2= 12.44, p<0.001) and age (χ2=17.44, p=0.000). CONCLUSION Results from this study indicate Plasmodium infection as the main cause of fever in the studied sites. While Plasmodium and Leptospira contribute to fevers, Rickettsia infection is an insignificant cause of fever in Northern Tanzania.
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Affiliation(s)
- Jaffu O Chilongola
- Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi Tanzania
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi Tanzania
| | - Elias J Sabuni
- Mawenzi Regional Referral Hospital, P.O. Box 3054, Moshi Tanzania
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Prevalence of Neglected Tropical Diseases (Leishmaniasis and Lymphatic Filariasis) and Malaria Among a Migrant Labour Settlement in Kerala, India. J Immigr Minor Health 2019; 21:563-569. [PMID: 29860672 DOI: 10.1007/s10903-018-0767-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Neglected tropical diseases (visceral leismaniasis, lymphatic filariasis) and malaria are endemic in northern states of India. Kerala has become a hub of construction activities employing a large number of migrants from these endemic states. Studies on morbidity pattern among migrants in Kerala are lacking. It is essential to look into the burden of these infections among migrant laborers who can act as reservoirs and are a threat to native population. A cross sectional study was done among migrant laborers in Ernakulam district, Kerala. After getting informed consent, a questionnaire was administered to each participant to collect sociodemographic details and 5 ml of blood was collected for detection of antigens using rapid diagnostic tests (RDT). Of the 309 migrants tested, none of them were positive for leishmaniasis, while 3.8% were positive for malaria and 3.6% for filariasis. With 2.5 million migrant laborers in Kerala, the magnitude of the problem in absolute numbers is enormous. Active surveillance and treatment is needed to prevent the reemergence of these diseases in Kerala.
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Bhaskaran D, Chadha SS, Sarin S, Sen R, Arafah S, Dittrich S. Diagnostic tools used in the evaluation of acute febrile illness in South India: a scoping review. BMC Infect Dis 2019; 19:970. [PMID: 31722678 PMCID: PMC6854686 DOI: 10.1186/s12879-019-4589-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/22/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Acute febrile illness (AFI) is characterized by malaise, myalgia and a raised temperature that is a nonspecific manifestation of infectious diseases in the tropics. The lack of appropriate diagnostics for the evaluation of AFI leads to increased morbidity and mortality in resource-limited settings, specifically low-income countries like India. The review aimed to identify the number, type and quality of diagnostics used for AFI evaluation during passive case detection at health care centres in South India. METHODS A scoping review of peer-reviewed English language original research articles published between 1946-July 2018 from four databases was undertaken to assess the type and number of diagnostics used in AFI evaluation in South India. Results were stratified according to types of pathogen-specific tests used in AFI management. RESULTS The review included a total of 40 studies, all conducted in tertiary care centres (80% in private settings). The studies demonstrated the use of 5-22 tests per patient for the evaluation of AFI. Among 25 studies evaluating possible causes of AFI, 96% tested for malaria followed by 80% for dengue, 72% for scrub typhus, 68% for typhoid and 60% for leptospirosis identifying these as commonly suspected causes of AFI. 54% studies diagnosed malaria with smear microscopy while others diagnosed dengue, scrub typhus, typhoid and leptospirosis using antibody or antigen detection assays. 39% studies used the Weil-Felix test (WFT) for scrub typhus diagnosis and 82% studies used the Widal test for diagnosing typhoid. CONCLUSIONS The review demonstrated the use of five or more pathogen-specific tests in evaluating AFI as well as described the widespread use of suboptimal tests like the WFT and Widal in fever evaluation. It identified the need for the development of better-quality tests for aetiological diagnosis and improved standardised testing guidelines for AFI.
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Affiliation(s)
- Divyalakshmi Bhaskaran
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics (FIND), New Delhi, India
| | - Rajashree Sen
- Foundation for Innovative New Diagnostics (FIND), New Delhi, India
| | - Sonia Arafah
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Smith S, Koech R, Nzorubara D, Otieno M, Wong L, Bhat G, van den Bogaart E, Thuranira M, Onchonga D, Rinke de Wit TF. Connected diagnostics: linking digital rapid diagnostic tests and mobile health wallets to diagnose and treat brucellosis in Samburu, Kenya. BMC Med Inform Decis Mak 2019; 19:139. [PMID: 31331394 PMCID: PMC6647279 DOI: 10.1186/s12911-019-0854-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 06/26/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Despite WHO guidelines for testing all suspected cases of malaria before initiating treatment, presumptive malaria treatment remains common practice among some clinicians and in certain low-resource settings the capacity for microscopic testing is limited. This can lead to misdiagnosis, resulting in increased morbidity due to lack of treatment for undetected conditions, increased healthcare costs, and potential for drug resistance. This is particularly an issue as multiple conditions share the similar etiologies to malaria, including brucellosis, a rare, under-detected zoonosis. Linking rapid diagnostic tests (RDTs) and digital test readers for the detection of febrile illnesses can mitigate this risk and improve case management of febrile illness. METHODS This technical advance study examines Connected Diagnostics, an approach that combines the use of point-of-care RDTs for malaria and brucellosis, digitally interpreted by a rapid diagnostic test reader (Deki Reader) and connected to mobile payment mechanisms to facilitate the diagnosis and treatment of febrile illness in nomadic populations in Samburu County, Kenya. Consenting febrile patients were tested with RDTs and patient diagnosis and risk information were uploaded to a cloud database via the Deki Reader. Patients with positive diagnoses were provided digital vouchers for transportation to the clinic and treatment via their health wallet on their mobile phones. RESULTS In total, 288 patients were tested during outreach visits, with 9% testing positive for brucellosis and 0.6% testing positive for malaria. All patients, regardless of diagnosis were provided with a mobile health wallet on their cellular phones to facilitate their transport to the clinic, and for patients testing positive for brucellosis or malaria, the wallet funded their treatment. The use of the Deki Reader in addition to quality diagnostics at point of care also facilitated geographic mapping of patient diagnoses in relation to key risk areas for brucellosis transmission. CONCLUSIONS This study demonstrates that the Connected Dx approach can be effective even when addressing a remote, nomadic population and a rare disease, indicating that this approach to diagnosing, treatment, and payment for healthcare costs is feasible and can be scaled to address more prevalent diseases and conditions in more populous contexts.
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Affiliation(s)
- S Smith
- PharmAccess Foundation, AHTC Tower 4C, Paasheuvelweg 25, 1105 BP, Amsterdam, The Netherlands.
| | - R Koech
- PharmAccess Foundation Kenya, New Rehema House, Rhamta Road, Westlands, Nairobi, Kenya
| | - D Nzorubara
- PharmAccess Foundation Kenya, New Rehema House, Rhamta Road, Westlands, Nairobi, Kenya
| | - M Otieno
- PharmAccess Foundation Kenya, New Rehema House, Rhamta Road, Westlands, Nairobi, Kenya
| | - L Wong
- Fio Corporation, 111 Queen Street East Suite 500, Toronto, Ontario, M5C 1S2, Canada
| | - G Bhat
- Fio Corporation, 111 Queen Street East Suite 500, Toronto, Ontario, M5C 1S2, Canada
| | - E van den Bogaart
- Mondial Diagnostics, Meibergdreef 39, 1105 AZ, Amsterdam, The Netherlands
| | - M Thuranira
- Samburu County Government, C77, P.O. Box 3 - 20600, Maralal, Samburu County, Kenya
| | - D Onchonga
- Samburu County Government, C77, P.O. Box 3 - 20600, Maralal, Samburu County, Kenya
| | - T F Rinke de Wit
- PharmAccess Foundation, AHTC Tower 4C, Paasheuvelweg 25, 1105 BP, Amsterdam, The Netherlands
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Koirala KD, Chappuis F, Verdonck K, Rijal S, Boelaert M. Persistent febrile illnesses in Nepal: A systematic review. Indian J Med Res 2019; 148:385-395. [PMID: 30666001 PMCID: PMC6362719 DOI: 10.4103/ijmr.ijmr_505_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background & objectives Although febrile illnesses are a frequent cause of consultation and hospitalization in low- and middle-income countries (LMICs), research has mainly focused on acute febrile illnesses (AFIs). In contrast, there are limited data on the causes of persistent febrile illnesses (PFIs) in LMIC. Lack of clarity on the differential diagnosis of PFIs in the rural tropics leads to the absence of diagnostic guidance tools. Methods In this study, a review of the potential causes of persistent fever defined as fever of more than seven days was done in Nepal, with a focus on nine pathogen-specific conditions. The current knowledge on their burden, distribution and diagnosis was summarized. Results Limited data were found on the incidence and public health burden of leptospirosis, murine typhus and brucellosis due to the absence of diagnostic tools outside reference laboratories and the overlap of signs and symptoms with other febrile conditions. The incidence of malaria and visceral leishmaniasis (VL) was found to be decreasing in Nepal, with some changes of the geographical areas at risk. Interpretation & conclusions This review indicates a need for more research on the causes of PFIs in Nepal and in the region and for the development of clinical guidance tailored to current local epidemiology. Guidance tools should include specific clinical features (e.g. eschar), results of rapid diagnostic tests (e.g. malaria, VL), appropriate indications for more sophisticated tests (e.g. abdominal ultrasound, polymerase chain reaction) and recommendations for adequate use of empirical treatment.
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Affiliation(s)
- Kanika Deshpande Koirala
- Department of Medicine, B.P. Koirala Institute of Health Science, Dharan, Nepal; Epidemiology and Control of Neglected Tropical Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium; Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - François Chappuis
- Institute of Global Health, University of Geneva; Division of Tropical & Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Kristien Verdonck
- Epidemiology and Control of Neglected Tropical Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Suman Rijal
- Department of Medicine, B.P. Koirala Institute of Health Science, Dharan, Nepal
| | - Marleen Boelaert
- Epidemiology and Control of Neglected Tropical Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium
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Bottger C, Bernard L, Briand V, Bougouma C, Triendebeogo J, Ridde V. Primary healthcare providers' practices related to non-malarial acute febrile illness in Burkina Faso. Trans R Soc Trop Med Hyg 2019; 111:555-563. [PMID: 29509953 DOI: 10.1093/trstmh/try009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 01/19/2018] [Indexed: 11/13/2022] Open
Abstract
Background In Africa, fever is the main reason for consultation, with malaria playing a prominent role. Studies have reported that the widespread use of rapid diagnostic tests for malaria, implemented since 2010, has revealed an increasing proportion of non-malaria acute febrile illnesses (NMAFI). It is an important public health issue because evidence shows that mortality is higher among patients presenting with non-malarial fever than among those with malaria. Methods This cross-sectional study assessed the professional practices of healthcare providers in the management of NMAFI in urban and rural sites in Burkina Faso. Data was collected from 286 healthcare providers through a questionnaire based on the clinical situation in 2014. Factors have been associated using a hierarchical linear mixed model with random intercepts to model dependence of outcomes for healthcare providers working on the same site. Results Survey results showed limited knowledge about management of NMAFI, global survey score on General Practice Indicator being 60% (36.02/60.00). This gap was more evident at the admission and diagnosis level. The study's population from rural areas had better survey score than that of urban areas concerning the respect of adequacy diagnosis, treatment and use of antibiotics in NMAFI, 15.71 vs 13.93 mean score (p=0.01) (75 vs 66% on a 0 to 100% scale, with 100% being the best). Overall, more educated participants performed relatively better. A total of 46% (134/286) of participants felt that they needed training in at least one of the fever-related issues. Conclusions Increased awareness and knowledge of management for NMAFI are urgently required in Burkina Faso. This must be done through regular supervision and training courses targeted specifically at primary healthcare providers.
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Affiliation(s)
- C Bottger
- School of Public Health, Université de Montréal (ESPUM), C.P. 6128, Succ. C.V., Montreal, Qc, H3C 3J7.,Université de Montréal Public Health Research Institute (IRSPUM), C.P. 6128, Succ. CV., Montréal, Qc., H3C 3J7, Canada
| | - L Bernard
- Faculty of Nursing, Université de Montréal, C.P. 6128, Succ. CV., Montreal, Qc, H3C 3J7, Canada
| | - V Briand
- UMR216-MERIT, French National Research Institute for Sustainable Development (IRD), Université Paris Descartes, Paris, France
| | - C Bougouma
- Ministère de la santé du Burkina Faso, Programme national de lutte contre les Maladies Tropicales Négligées, 03 BP: 7009 OUAGADOUGOU 03
| | - J Triendebeogo
- Jhpiego an affiliate of John Hopkins University, Burkina Faso
| | - V Ridde
- Université de Montréal Public Health Research Institute (IRSPUM), C.P. 6128, Succ. CV., Montréal, Qc., H3C 3J7, Canada.,IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, France
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28
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Pulford J, Saweri OPM, Jeffery C, Siba PM, Mueller I, Hetzel MW. Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea. BMJ Glob Health 2018; 3:e000915. [PMID: 30498587 PMCID: PMC6254749 DOI: 10.1136/bmjgh-2018-000915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction The presumptive treatment of febrile illness with antimalarial medication is becoming less common in low-income and middle-income countries as access to reliable diagnostic tests improves. We explore whether the shift towards test-based antimalarial prescription, and the introduction of highly efficacious artemisinin combination therapies (ACTs), reduces critical delays in seeking treatment for febrile illness or increases patient satisfaction. Methods We conducted countrywide repeat, cross-sectional surveys in 118 randomly selected primary healthcare services in Papua New Guinea. The clinical case management of 1765 consecutively presenting febrile patients was observed and exit interviews were completed at discharge. This was done prior to implementation of test-based ACT prescription (2011) and at 12 (2012) and 60 months (2016) postimplementation. We conducted multiple logistic regressions. Treatment response time was dichotomised as <24 hours from symptom onset vs 24+ hours. Satisfaction was dichotomised as a ‘high’ vs ‘low’ rating based on participant response to a visual, 7-point Likert-type scale. Results 62% (322/517) of febrile patients reported seeking treatment within 24 hours of symptom onset in 2011 compared with 53% (230/434) in 2012 and 42% (339/814) in 2016. Adjusted ORs for reporting a treatment response time <24 hours in the postimplementation surveys were 0.77 (95% CI 0.48 to 1.26) and 0.45 (95% CI 0.31 to 0.65), respectively when compared with the preimplementation period. 53% (230/533) of febrile patients reported ‘high’ satisfaction with the service received in 2011 compared with 32% (143/449) in 2012 and 35% (278/803) in 2016. Adjusted ORs for reporting high satisfaction in the postimplementation surveys were 0.52 (95% CI 0.32 to 0.85) and 0.65 (95% CI 0.39 to 1.10), respectively when compared with the preimplementation period. Conclusion Nationwide implementation of test-based ACT prescription in Papua New Guinea has increased the likelihood of critical treatment seeking delays and decreased patient satisfaction with the service received.
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Affiliation(s)
- Justin Pulford
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Olga P M Saweri
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Caroline Jeffery
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Institut Pasteur, Paris, France
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Zongo S, Carabali M, Munoz M, Ridde V. Dengue rapid diagnostic tests: Health professionals' practices and challenges in Burkina Faso. SAGE Open Med 2018; 6:2050312118794589. [PMID: 30147936 PMCID: PMC6100125 DOI: 10.1177/2050312118794589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/23/2018] [Indexed: 12/23/2022] Open
Abstract
Objectives Dengue fever remains unrecognized and under-reported in Africa due to several factors, including health professionals' lack of awareness, important prevalence of other febrile illnesses, most of which are treated presumptively as malaria, and the absence of surveillance systems. In Burkina Faso, health centers have no diagnostic tools to identify and manage dengue, which remains ignored, despite the evidence of seasonal outbreaks in recent years. A qualitative study was conducted to analyze the use of rapid diagnostic tests in six health and social promotion centers (i.e. health-care centers, from the French Centers de Santé et de Promotion Sociale) of Ouagadougou (Burkina Faso) in an exploratory research context. Methods Dengue rapid diagnostic tests were introduced into fever-related consultations from December 2013 to January 2014. In-depth individual interviews were conducted in May and June 2014 with 32 health professionals. Results Prior to the introduction of the tests, dengue was not well known or diagnosed by health professionals during consultations. Most febrile cases were routinely presumed to be malaria and treated accordingly. With training and routine use of rapid diagnostic tests, health professionals became more knowledgeable about dengue, improving the diagnosis of non-malaria febrile cases and its management, and better prescription practices. Conclusions In a context of dengue re-emergence and high prevalence of other febrile illnesses, having rapid diagnostic tools available, especially during epidemics reinforces health professionals' diagnostic and prescribing capacities, allowing an opportune and accurate case management and facilitates diseases surveillance.
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Affiliation(s)
- Sylvie Zongo
- Département Socio-économie et Anthropologie du Développement, Institut des Sciences des Sociétés, Centre National de la Recherche Scientifique et Technologique, Ouagadougou, Burkina Faso
| | - Mabel Carabali
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University Health Centre, Montreal, QC, Canada
| | - Marie Munoz
- Faculté de médicine, Université de Montréal, Montreal, QC, Canada
| | - Valéry Ridde
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
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30
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Bottieau E, Yansouni CP. Fever in the tropics: the ultimate clinical challenge? Clin Microbiol Infect 2018; 24:806-807. [PMID: 29940346 DOI: 10.1016/j.cmi.2018.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/11/2018] [Accepted: 06/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- E Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - C P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
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31
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Moreira J, Bressan CS, Brasil P, Siqueira AM. Epidemiology of acute febrile illness in Latin America. Clin Microbiol Infect 2018; 24:827-835. [PMID: 29777926 PMCID: PMC7172187 DOI: 10.1016/j.cmi.2018.05.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
Background The causes of acute febrile illness (AFI) in Latin America are diverse and their complexity increases as the proportion of fever due to malaria decreases, as malaria control measures and new pathogens emerge in the region. In this context, it is important to shed light on the gaps in the epidemiological characteristics and the geographic range for many AFI aetiologies. Objectives To review studies on community-acquired fever aetiology other than malaria in Latin America, and to highlight knowledge gaps and challenges needing further investigation. Sources PubMed from 2012 to April 2018. Content We found 17 eligible studies describing 13 539 patients. The median number of pathogens tested per individual was 3.5 (range 2–17). A causative pathogen could be determined for 6661 (49.2%) individuals. The most frequently reported pathogen during the study periods was dengue virus (DENV) (14 studies), followed by chikungunya virus (nine studies) and Zika virus (seven studies). Among the studies reporting concurrent infections, 296 individuals (2.2%) were found to have co-infections. In-hospital mortality was reported in eight (47%) studies, ranging between 0% and 18%. Implications DENV fever is the febrile illness most frequently reported, reflecting its importance, while chikungunya and zika viruses present increasing trends since their emergence in the region. Studies with systematic and harmonized approaches for detection of multiple pathogens are needed and would probably reveal a higher burden of neglected pathogens such as Rickettsia spp. and arenaviruses. The lack of point-of-care tests and harmonized approach limits the care provided by health professionals and the efficacy of surveillance for AFI in the region.
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Affiliation(s)
- J Moreira
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil; Programa de Pós-Graduação em Pesquisa Clínica, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
| | - C S Bressan
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil; Programa de Pós-Graduação em Pesquisa Clínica, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
| | - P Brasil
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil; Programa de Pós-Graduação em Pesquisa Clínica, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
| | - A M Siqueira
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil; Programa de Pós-Graduação em Pesquisa Clínica, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil.
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Pulford J, Kurumop S, Mueller I, Siba PM, Hetzel MW. The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness: a series of repeated cross-sectional studies in Papua New Guinea. Malar J 2018; 17:202. [PMID: 29769128 PMCID: PMC5956836 DOI: 10.1186/s12936-018-2351-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper examines the impact of the scale-up of malaria rapid diagnostic tests (RDT) on routine clinical diagnosis procedures for febrile illness in primary healthcare settings in Papua New Guinea. METHODS Repeat, cross-sectional surveys in randomly selected primary healthcare services were conducted. Surveys included passive observation of consecutive febrile case management cases and were completed immediately prior to RDT scale-up (2011) and at 12- (2012) and 60-months (2016) post scale-up. The frequency with which specified diagnostic questions and procedures were observed to occur, with corresponding 95% CIs, was calculated for febrile patients prescribed anti-malarials pre- and post-RDT scale-up and between febrile patients who tested either negative or positive for malaria infection by RDT (post scale-up only). RESULTS A total of 1809 observations from 120 health facilities were completed across the three survey periods of which 915 (51%) were prescribed an anti-malarial. The mean number of diagnostic questions and procedures asked or performed, leading to anti-malarial prescription, remained consistent pre- and post-RDT scale-up (range 7.4-7.7). However, alterations in diagnostic content were evident with the RDT replacing body temperature as the primary diagnostic procedure performed (observed in 5.3 and 84.4% of cases, respectively, in 2011 vs. 77.9 and 58.2% of cases in 2016). Verbal questioning, especially experience of fever, cough and duration of symptoms, remained the most common feature of a diagnostic examination leading to anti-malarial prescription irrespective of RDT use (observed in 96.1, 86.8 and 84.8% of cases, respectively, in 2011 vs. 97.5, 76.6 and 85.7% of cases in 2016). Diagnostic content did not vary substantially by RDT result. CONCLUSIONS Rapid diagnostic tests scale-up has led to a reduction in body temperature measurement. Investigations are very limited when malaria infection is ruled out as a cause of febrile illness by RDT.
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Affiliation(s)
- Justin Pulford
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Serah Kurumop
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Barcelona Centre for International Health Research, Barcelona, Spain
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Wangrangsimakul T, Althaus T, Mukaka M, Kantipong P, Wuthiekanun V, Chierakul W, Blacksell SD, Day NP, Laongnualpanich A, Paris DH. Causes of acute undifferentiated fever and the utility of biomarkers in Chiangrai, northern Thailand. PLoS Negl Trop Dis 2018; 12:e0006477. [PMID: 29852003 PMCID: PMC5978881 DOI: 10.1371/journal.pntd.0006477] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 04/24/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tropical infectious diseases like dengue, scrub typhus, murine typhus, leptospirosis, and enteric fever continue to contribute substantially to the febrile disease burden throughout Southeast Asia while malaria is declining. Recently, there has been increasing focus on biomarkers (i.e. C-reactive protein (CRP) and procalcitonin) in delineating bacterial from viral infections. METHODOLOGY/PRINCIPAL FINDINGS A prospective observational study was performed to investigate the causes of acute undifferentiated fever (AUF) in adults admitted to Chiangrai Prachanukroh hospital, northern Thailand, which included an evaluation of CRP and procalcitonin as diagnostic tools. In total, 200 patients with AUF were recruited. Scrub typhus was the leading bacterial cause of AUF (45/200, 22.5%) followed by leptospirosis (15/200, 7.5%) and murine typhus (7/200, 3.5%), while dengue was the leading viral cause (23/200, 11.5%). Bloodstream infections contributed to 7/200 (3.5%) of the study cohort. There were 9 deaths during this study (4.5%): 3 cases of scrub typhus, 2 with septicaemia (Talaromyces marneffei and Haemophilus influenzae), and 4 of unknown aetiologies. Rickettsioses, leptospirosis and culture-attributed bacterial infections, received a combination of 3rd generation cephalosporin plus a rickettsia-active drug in 53%, 73% and 67% of cases, respectively. Low CRP and white blood count were significant predictors of a viral infection (mainly dengue) while the presence of an eschar and elevated aspartate aminotransferase and alkaline phosphatase were important predictors of scrub typhus. INTERPRETATION Scrub typhus and dengue are the leading causes of AUF in Chiangrai, Thailand. Eschar, white blood count and CRP were beneficial in differentiating between bacterial and viral infections in this study. CRP outperformed procalcitonin although cut-offs for positivity require further assessment. The study provides evidence that accurate, pathogen-specific rapid diagnostic tests coupled with biomarker point-of-care tests such as CRP can inform the correct use of antibiotics and improve antimicrobial stewardship in this setting.
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Affiliation(s)
- Tri Wangrangsimakul
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Mavuto Mukaka
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Pacharee Kantipong
- Department of Medicine, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas P. Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Daniel H. Paris
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Semret M, Ndao M, Jacobs J, Yansouni CP. Point-of-care and point-of-'can': leveraging reference-laboratory capacity for integrated diagnosis of fever syndromes in the tropics. Clin Microbiol Infect 2018; 24:836-844. [PMID: 29649602 DOI: 10.1016/j.cmi.2018.03.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is an urgent need for integrated diagnosis of febrile syndromes able to account for multiple pathogens and to inform decisions for clinical care and public health. AIMS To reflect on the evolving roles of laboratory-based testing for non-malarial febrile illnesses (NMFIs) in low-resource settings, and to consider how advances in diagnostics, in connectivity and transport, and in implementation of quality systems may substantially enhance the capacity of reference laboratories to bridge the current gap between remote passive surveillance and clinically meaningful integrated fever diagnosis. SOURCES Iterative search of PubMed databases, organizational reports, and expert consultation. CONTENT Implementation of new technologies-such as very broad molecular panels for surveillance and mass spectrometry-may considerably diminish capability gaps in reference laboratories in low-resource settings. Although the need for clinical bacteriology diagnostics is now recognized, the lack of new simple and rapid phenotypic tests for antimicrobial resistance remains a key deficiency. Several initiatives to strengthen diagnostic preparedness for infectious disease outbreaks have highlighted the need for functional tiered laboratory networks. Recently, dramatic headway in connectivity-such as combining automated readers with the image processing and data transmission capabilities of smartphones-now allows for more complex testing and interfacing with distant laboratory information systems while reducing workload and errors. Together with connectivity to transmit and receive results, new approaches to specimen collection and transport-such as the validation of rectal swabs and the use of aerial drones to transport specimens to distant laboratories-now make remote testing feasible. The above innovations also open up the possibility of implementing quality systems through community-level diagnostic stewardship. Finally, strengthened laboratory networks actively support the feasibility of implementing quality-assured point-of-care testing where it is needed. IMPLICATIONS Recent advances offer the present-day possibility of innovations to re-invent the relationship between distant reference laboratories and end-users for integrated diagnosis of NMFIs.
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Affiliation(s)
- M Semret
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - M Ndao
- National Reference Centre for Parasitology, Montreal, Canada
| | - J Jacobs
- Institute of Tropical Medicine, Antwerp, Belgium; KU Leuven, Department of Microbiology and Immunology, Leuven, Belgium
| | - C P Yansouni
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada.
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35
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Dittrich S, Boutthasavong L, Keokhamhoung D, Phuklia W, Craig SB, Tulsiani SM, Burns MA, Weier SL, Dance DAB, Davong V, Vongsouvath M, Mayxay M, Phetsouvanh R, Newton PN, Woods K. A Prospective Hospital Study to Evaluate the Diagnostic Accuracy of Rapid Diagnostic Tests for the Early Detection of Leptospirosis in Laos. Am J Trop Med Hyg 2018; 98:1056-1060. [PMID: 29488460 PMCID: PMC5928825 DOI: 10.4269/ajtmh.17-0702] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Leptospirosis is a globally important cause of acute febrile illness, and a common cause of non-malarial fever in Asia, Africa, and Latin America. Simple rapid diagnostic tests (RDTs) are needed to enable health-care workers, particularly in low resource settings, to diagnose leptospirosis early and give timely targeted treatment. This study compared four commercially available RDTs to detect human IgM against Leptospira spp. in a head-to-head prospective evaluation in Mahosot Hospital, Lao PDR. Patients with an acute febrile illness consistent with leptospirosis (N = 695) were included in the study during the 2014 rainy season. Samples were tested with four RDTs: (“Test-it” [Life Assay, Cape Town, South Africa; N = 418]; “Leptorapide” [Linnodee, Ballyclare, Northern Ireland; N = 492]; “Dual Path Platform” [DPP] [Chembio, Medford, NY; N = 530]; and “SD-IgM” [Standard Diagnostics, Yongin, South Korea; N = 481]). Diagnostic performance characteristics were calculated and compared with a composite reference standard combining polymerase chain reaction (PCR) (rrs), microscopic agglutination tests (MATs), and culture. Of all patients investigated, 39/695 (5.6%) were positive by culture, PCR, or MAT. The sensitivity and specificity of the RDTs ranged greatly from 17.9% to 63.6% and 62.1% to 96.8%, respectively. None of the investigated RDTs reached a sensitivity or specificity of > 90% for detecting Leptospira infections on admission. In conclusion, our investigation highlights the challenges associated with Leptospira diagnostics, particularly in populations with multiple exposures. These findings emphasize the need for extensive prospective evaluations in multiple endemic settings to establish the value of rapid tools for diagnosing fevers to allow targeting of antibiotics.
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Affiliation(s)
- Sabine Dittrich
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Latsaniphone Boutthasavong
- Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Dala Keokhamhoung
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Weerawat Phuklia
- Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Scott B Craig
- Queensland Health Forensic and Scientific Service, WHO Collaborating Centre for Reference and Research on Leptospirosis, Brisbane, Australia.,Faculty of Science Health, Education and Engineering, University of the Sunshine Coast, Sippy Downs, Australia
| | - Suhella M Tulsiani
- Section for Global Health, Department of Public Health, Copenhagen Centre for Disaster Research, University of Copenhagen, Copenhagen, Denmark.,Queensland Health Forensic and Scientific Service, WHO Collaborating Centre for Reference and Research on Leptospirosis, Brisbane, Australia
| | - Mary-Anne Burns
- Queensland Health Forensic and Scientific Service, WHO Collaborating Centre for Reference and Research on Leptospirosis, Brisbane, Australia
| | - Steven L Weier
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - David A B Dance
- Faculty of Tropical and Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Viengmon Davong
- Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Manivanh Vongsouvath
- Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Mayfong Mayxay
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao PDR.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Rattanaphone Phetsouvanh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Paul N Newton
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - Kate Woods
- National Infection Service (NIS), Public Health England (PHE), London, United Kingdom.,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
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36
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Darton TC, Jones C, Dongol S, Voysey M, Blohmke CJ, Shrestha R, Karkey A, Shakya M, Arjyal A, Waddington CS, Gibani M, Carter MJ, Basnyat B, Baker S, Pollard AJ. Assessment and Translation of the Antibody-in-Lymphocyte Supernatant (ALS) Assay to Improve the Diagnosis of Enteric Fever in Two Controlled Human Infection Models and an Endemic Area of Nepal. Front Microbiol 2017; 8:2031. [PMID: 29109704 PMCID: PMC5660281 DOI: 10.3389/fmicb.2017.02031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 10/04/2017] [Indexed: 11/17/2022] Open
Abstract
New diagnostic tests for enteric fever are urgently needed to assist with timely antimicrobial treatment of patients and to measure the efficacy of prevention measures such as vaccination. In a novel translational approach, here we use two recently developed controlled human infection models (CHIM) of enteric fever to evaluate an antibody-in-lymphocyte supernatant (ALS) assay, which can detect recent IgA antibody production by circulating B cells in ex vivo mononuclear cell culture. We calculated the discriminative ability of the ALS assay to distinguish diagnosed cases in the two CHIM studies in Oxford, prior to evaluating blood culture-confirmed diagnoses of patients presenting with fever to hospital in an endemic areas of Kathmandu, Nepal. Antibody responses to membrane preparations and lipopolysaccharide provided good sensitivity (>90%) for diagnosing systemic infection after oral challenge with Salmonella Typhi or S. Paratyphi A. Assay specificity was moderate (~60%) due to imperfect sensitivity of blood culture as the reference standard and likely unrecognized subclinical infection. These findings were augmented through the translation of the assay into the endemic setting in Nepal. Anti-MP IgA responses again exhibited good sensitivity (86%) but poor specificity (51%) for detecting blood culture-confirmed enteric fever cases (ROC AUC 0.79, 95%CI 0.70–0.88). Patients with anti-MP IgA ALS titers in the upper quartile exhibited a clinical syndrome synonymous with enteric fever. While better reference standards are need to assess enteric fever diagnostics, routine use of this ALS assay could be used to rule out infection and has the potential to double the laboratory detection rate of enteric fever in this setting over blood culture alone.
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Affiliation(s)
- Thomas C Darton
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Merryn Voysey
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Christoph J Blohmke
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Rajendra Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Abhilasha Karkey
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Mila Shakya
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Amit Arjyal
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Claire S Waddington
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Malick Gibani
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Michael J Carter
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Andrew J Pollard
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
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37
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Dalrymple U, Cameron E, Bhatt S, Weiss DJ, Gupta S, Gething PW. Quantifying the contribution of Plasmodium falciparum malaria to febrile illness amongst African children. eLife 2017; 6:29198. [PMID: 29034876 PMCID: PMC5665646 DOI: 10.7554/elife.29198] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/12/2017] [Indexed: 12/31/2022] Open
Abstract
Suspected malaria cases in Africa increasingly receive a rapid diagnostic test (RDT) before antimalarials are prescribed. While this ensures efficient use of resources to clear parasites, the underlying cause of the individual's fever remains unknown due to potential coinfection with a non-malarial febrile illness. Widespread use of RDTs does not necessarily prevent over-estimation of clinical malaria cases or sub-optimal case management of febrile patients. We present a new approach that allows inference of the spatiotemporal prevalence of both Plasmodium falciparum malaria-attributable and non-malarial fever in sub-Saharan African children from 2006 to 2014. We estimate that 35.7% of all self-reported fevers were accompanied by a malaria infection in 2014, but that only 28.0% of those (10.0% of all fevers) were causally attributable to malaria. Most fevers among malaria-positive children are therefore caused by non-malaria illnesses. This refined understanding can help improve interpretation of the burden of febrile illness and shape policy on fever case management.
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Affiliation(s)
- Ursula Dalrymple
- Department of Zoology, University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
| | - Ewan Cameron
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
| | - Samir Bhatt
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom.,Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Daniel J Weiss
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
| | - Sunetra Gupta
- Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Peter W Gething
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
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38
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Tomashek KM, Lorenzi OD, Andújar-Pérez DA, Torres-Velásquez BC, Hunsperger EA, Munoz-Jordan JL, Perez-Padilla J, Rivera A, Gonzalez-Zeno GE, Sharp TM, Galloway RL, Glass Elrod M, Mathis DL, Oberste MS, Nix WA, Henderson E, McQuiston J, Singleton J, Kato C, García Gubern C, Santiago-Rivera W, Cruz-Correa J, Muns-Sosa R, Ortiz-Rivera JD, Jiménez G, Galarza IE, Horiuchi K, Margolis HS, Alvarado LI. Clinical and epidemiologic characteristics of dengue and other etiologic agents among patients with acute febrile illness, Puerto Rico, 2012-2015. PLoS Negl Trop Dis 2017; 11:e0005859. [PMID: 28902845 PMCID: PMC5597097 DOI: 10.1371/journal.pntd.0005859] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022] Open
Abstract
Identifying etiologies of acute febrile illnesses (AFI) is challenging due to non-specific presentation and limited availability of diagnostics. Prospective AFI studies provide a methodology to describe the syndrome by age and etiology, findings that can be used to develop case definitions and multiplexed diagnostics to optimize management. We conducted a 3-year prospective AFI study in Puerto Rico. Patients with fever ≤7 days were offered enrollment, and clinical data and specimens were collected at enrollment and upon discharge or follow-up. Blood and oro-nasopharyngeal specimens were tested by RT-PCR and immunodiagnostic methods for infection with dengue viruses (DENV) 1–4, chikungunya virus (CHIKV), influenza A and B viruses (FLU A/B), 12 other respiratory viruses (ORV), enterovirus, Leptospira spp., and Burkholderia pseudomallei. Clinical presentation and laboratory findings of participants infected with DENV were compared to those infected with CHIKV, FLU A/B, and ORV. Clinical predictors of laboratory-positive dengue compared to all other AFI etiologies were determined by age and day post-illness onset (DPO) at presentation. Of 8,996 participants enrolled from May 7, 2012 through May 6, 2015, more than half (54.8%, 4,930) had a pathogen detected. Pathogens most frequently detected were CHIKV (1,635, 18.2%), FLU A/B (1,074, 11.9%), DENV 1–4 (970, 10.8%), and ORV (904, 10.3%). Participants with DENV infection presented later and a higher proportion were hospitalized than those with other diagnoses (46.7% versus 27.3% with ORV, 18.8% with FLU A/B, and 11.2% with CHIKV). Predictors of dengue in participants presenting <3 DPO included leukopenia, thrombocytopenia, headache, eye pain, nausea, and dizziness, while negative predictors were irritability and rhinorrhea. Predictors of dengue in participants presenting 3–5 DPO were leukopenia, thrombocytopenia, facial/neck erythema, nausea, eye pain, signs of poor circulation, and diarrhea; presence of rhinorrhea, cough, and red conjunctiva predicted non-dengue AFI. By enrolling febrile patients at clinical presentation, we identified unbiased predictors of laboratory-positive dengue as compared to other common causes of AFI. These findings can be used to assist in early identification of dengue patients, as well as direct anticipatory guidance and timely initiation of correct clinical management. We conducted a prospective study of acute febrile illness (AFI) in Puerto Rico to better understand the etiology of AFI among all age groups in the tropics. Such findings could assist clinicians to identify disease-specific characteristics, which can then be used to initiate proper patient management. We enrolled 8,996 AFI patients and tested them for dengue viruses 1–4 (DENV 1–4) and 21 other pathogens. A pathogen was detected in 55% of patients, most frequently chikungunya virus (CHIKV, 18%), influenza A or B virus (FLU A/B, 12%), DENV 1–4 (11%), or another respiratory virus (ORV, 10%). Participants with dengue presented later after symptom onset and were hospitalized more often (47%) than patients with another etiology of AFI (27% with ORV, 19% with FLU A/B, and 11% with CHIKV). Predictors of patients with dengue differed by timing of presentation but included eye pain, nausea, and low white blood cell or platelet counts; negative predictors included symptoms of respiratory illness. By enrolling febrile patients at clinical presentation, we identified unbiased predictors of patients with dengue as compared to other common AFI. Findings can be used to diagnose dengue patients to provide early and appropriate clinical management.
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Affiliation(s)
- Kay M. Tomashek
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
- * E-mail:
| | - Olga D. Lorenzi
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Doris A. Andújar-Pérez
- Ponce Health Sciences University/Saint Luke's Episcopal Hospital, Ponce, Puerto Rico, United States of America
| | - Brenda C. Torres-Velásquez
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Elizabeth A. Hunsperger
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Jorge Luis Munoz-Jordan
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Janice Perez-Padilla
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Aidsa Rivera
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Gladys E. Gonzalez-Zeno
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Tyler M. Sharp
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Renee L. Galloway
- Bacterial Special Pathogens Branch, Zoonoses and Select Agent Laboratory, CDC, Atlanta, Georgia, United States of America
| | - Mindy Glass Elrod
- Bacterial Special Pathogens Branch, Zoonoses and Select Agent Laboratory, CDC, Atlanta, Georgia, United States of America
| | - Demetrius L. Mathis
- Bacterial Special Pathogens Branch, Zoonoses and Select Agent Laboratory, CDC, Atlanta, Georgia, United States of America
| | - M. Steven Oberste
- Polio and Picornavirus Laboratory Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, United States of America
| | - W. Allan Nix
- Polio and Picornavirus Laboratory Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, United States of America
| | - Elizabeth Henderson
- Polio and Picornavirus Laboratory Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, United States of America
| | - Jennifer McQuiston
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, CDC, Atlanta, Georgia, United States of America
| | - Joseph Singleton
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, CDC, Atlanta, Georgia, United States of America
| | - Cecilia Kato
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, CDC, Atlanta, Georgia, United States of America
| | - Carlos García Gubern
- Ponce Health Sciences University/Saint Luke's Episcopal Hospital, Ponce, Puerto Rico, United States of America
| | - William Santiago-Rivera
- Ponce Health Sciences University/Saint Luke's Episcopal Hospital, Ponce, Puerto Rico, United States of America
| | - Jesús Cruz-Correa
- Ponce Health Sciences University/Saint Luke's Episcopal Hospital, Ponce, Puerto Rico, United States of America
| | - Robert Muns-Sosa
- Saint Luke’s Episcopal Hospital, Guayama, Puerto Rico, United States of America
| | | | - Gerson Jiménez
- Saint Luke’s Episcopal Hospital, Guayama, Puerto Rico, United States of America
| | - Ivonne E. Galarza
- Ponce Health Sciences University/Saint Luke's Episcopal Hospital, Ponce, Puerto Rico, United States of America
| | - Kalanthe Horiuchi
- Office of the Director, Division of Vector-Borne Diseases, CDC, Fort Collins, Colorado, United States of America
| | - Harold S. Margolis
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico, United States of America
| | - Luisa I. Alvarado
- Ponce Health Sciences University/Saint Luke's Episcopal Hospital, Ponce, Puerto Rico, United States of America
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39
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Saweri OPM, Hetzel MW, Mueller I, Siba PM, Pulford J. The treatment of non-malarial febrile illness in Papua New Guinea: findings from cross sectional and longitudinal studies of health worker practice. BMC Health Serv Res 2017; 17:10. [PMID: 28056949 PMCID: PMC5217620 DOI: 10.1186/s12913-016-1965-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background The Papua New Guinea Department of Health recently shifted from a presumptive to a ‘test and treat’ malaria case management policy. This shift was supported by the widespread introduction of malaria rapid diagnostic tests in health facilities across the country. Health workers received training and job-aids detailing how to conduct and interpret a malaria rapid diagnostic test and how to treat test positive cases; however, little instruction on treating non-malaria febrile cases was provided. Accordingly, this study examined health worker case management of non-malarial febrile patients in the 12-month period immediately following the introduction of the revised malaria case management policy. Methods Data were collected from a country-wide cross-sectional survey of febrile case management at randomly selected health facilities and from longitudinal surveillance at sentinel health facilities. Analysis was restricted to febrile patients who tested negative for malaria infection by rapid diagnostic test (N=303 and 5705 outpatients, respectively). Results and Discussion 96.8% of non-malarial febrile patients received a diagnosis in the longitudinal sample, compared to 52.4% of the cross-sectional sample. Respiratory tract infections were the most commonly reported diagnoses. Over 90% of patients in both samples were prescribed one or more medications, most commonly an analgesic (71.3 & 72.9% of the longitudinal and cross-sectional samples, respectively), some form of antibiotic (72.7 & 73.4%, respectively) and/or an anthelminthic (17.9 & 16.5%, respectively). Prescribing behaviour was adherent with the recommendations in the standard treatment guidelines in fewer than 20% of cases (longitudinal sample only). Conclusion Many non-malarial febrile patients are not provided with a diagnosis. When diagnoses are provided they are typically some form of respiratory tract infection. Antibiotics and analgesics are widely prescribed, although medications prescribed rarely adhere to the Papua New Guinea standard treatment guidelines. These findings indicate that Papua New Guinea health workers require support for non-malarial febrile illness case management. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1965-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga P M Saweri
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, PO Box, 4002, Basel, Switzerland.,University of Basel, Petersplatz 1, 4003, Basel, Switzerland
| | - Ivo Mueller
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
| | - Justin Pulford
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea. .,Liverpool School of Tropical Medicine, Liverpool, UK.
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40
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Stoler J, Awandare GA. Febrile illness diagnostics and the malaria-industrial complex: a socio-environmental perspective. BMC Infect Dis 2016; 16:683. [PMID: 27855644 PMCID: PMC5114833 DOI: 10.1186/s12879-016-2025-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/14/2016] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Justin Stoler
- Department of Geography and Regional Studies, University of Miami, Coral Gables, FL USA
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL USA
- Abess Center for Ecosystem Science and Policy, University of Miami, Coral Gables, FL USA
| | - Gordon A. Awandare
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Legon, Ghana
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Ghana
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Achonduh-Atijegbe OA, Mfuh KO, Mbange AHE, Chedjou JP, Taylor DW, Nerurkar VR, Mbacham WF, Leke R. Prevalence of malaria, typhoid, toxoplasmosis and rubella among febrile children in Cameroon. BMC Infect Dis 2016; 16:658. [PMID: 27825318 PMCID: PMC5101675 DOI: 10.1186/s12879-016-1996-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 10/28/2016] [Indexed: 01/21/2023] Open
Abstract
Background The current roll-out of rapid diagnostic tests (RDTs) in many endemic countries has resulted in the reporting of fewer cases of malaria-attributed illnesses. However, lack of knowledge of the prevalence of other febrile illnesses and affordable diagnostic tests means that febrile patients are not managed optimally. This study assessed the prevalence of commonly treatable or preventable febrile illnesses in children between 6 months and 15 years using rapid diagnostic tests at the point-of-care. Methods Febrile children were enrolled between February-April 2014 at a health facility after obtaining informed consent from parent. Eligible participants were aged 6 months-15 years with a history of fever in the last 24 h or axillary temperature ≥38 °C at consultation. All participants were tested using RDTs for malaria, typhoid, toxoplasmosis and rubella. Malaria parasites were further identified by microscopy and PCR. Clinical and household characteristics were recorded and association with pathogens determined. Results Of the 315 children enrolled, the mean age was 5.8 ± 3.8 years. Stomach pain (41.2 %) was the most reported symptom. Prior to attending the health facility, 70.8 % had taken antipyretics, 27.9 % antimalarials, 11.4 % antibiotics and 13.3 % antifungal drugs. Among 315 children with fever, based on RDTs, 56.8 % were infected with malaria, 4.4 % with typhoid, 3.2 % with acute toxoplasmosis, and 1.3 % with rubella (all positive for rubella were in the same family and not vaccinated). All non-malarial infections were co-infections and approximately 30 % of the fever cases went un-diagnosed. Malaria prevalence by microscopy and PCR was 43.4 and 70.2 % respectively. The sensitivity and specificity of RDTs for the diagnosis of malaria were 75.98 and 100 % respectively, with 0.73 measurement agreement between RDTs and microscopy while that of RDT and PCR were 81 and 100 % respectively with a K value of 0.72. The use of Insecticide Treated Bednets was 44 %. There was a significant association between ITN non-usage and malaria (p = 0. 029) as well as drinking water and presence of typhoid (p = 0.047). No association was observed between type of housing and malaria, or toxoplasmosis and raising cats. Conclusion Though malaria still remains the major cause of fever in children, using RDTs for other treatable febrile illnesses like typhoid and toxoplasmosis could facilitate the optimal management of febrile illnesses in children especially when these occur as co-infections with malaria Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1996-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olivia A Achonduh-Atijegbe
- The Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon. .,North Pacific Global Health Program, University of Hawaii, Hawaii, USA.
| | - Kenji O Mfuh
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii, Hawaii, USA
| | | | - Jean P Chedjou
- The Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon
| | - Diane W Taylor
- North Pacific Global Health Program, University of Hawaii, Hawaii, USA.,Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii, Hawaii, USA
| | - Vivek R Nerurkar
- North Pacific Global Health Program, University of Hawaii, Hawaii, USA.,Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii, Hawaii, USA
| | - Wilfred F Mbacham
- The Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon
| | - Rose Leke
- The Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon.,North Pacific Global Health Program, University of Hawaii, Hawaii, USA
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Rapid Diagnostic Tests for Neglected Infectious Diseases: Case Study Highlights Need for Customer Awareness and Postmarket Surveillance. PLoS Negl Trop Dis 2016; 10:e0004655. [PMID: 27812099 PMCID: PMC5094593 DOI: 10.1371/journal.pntd.0004655] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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43
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Alirol E, Horie NS, Barbé B, Lejon V, Verdonck K, Gillet P, Jacobs J, Büscher P, Kanal B, Bhattarai NR, El Safi S, Phe T, Lim K, Leng L, Lutumba P, Mukendi D, Bottieau E, Boelaert M, Rijal S, Chappuis F. Diagnosis of Persistent Fever in the Tropics: Set of Standard Operating Procedures Used in the NIDIAG Febrile Syndrome Study. PLoS Negl Trop Dis 2016; 10:e0004749. [PMID: 27812090 PMCID: PMC5094701 DOI: 10.1371/journal.pntd.0004749] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In resource-limited settings, the scarcity of skilled personnel and adequate laboratory facilities makes the differential diagnosis of fevers complex [1–5]. Febrile illnesses are diagnosed clinically in most rural centers, and both Rapid Diagnostic Tests (RDTs) and clinical algorithms can be valuable aids to health workers and facilitate therapeutic decisions [6,7]. The persistent fever syndrome targeted by NIDIAG is defined as presence of fever for at least one week. The NIDIAG clinical research consortium focused on potentially severe and treatable infections and therefore targeted the following conditions as differential diagnosis of persistent fever: visceral leishmaniasis (VL), human African trypanosomiasis (HAT), enteric (typhoid and paratyphoid) fever, brucellosis, melioidosis, leptospirosis, malaria, tuberculosis, amoebic liver abscess, relapsing fever, HIV/AIDS, rickettsiosis, and other infectious diseases (e.g., pneumonia). From January 2013 to October 2014, a prospective clinical phase III diagnostic accuracy study was conducted in one site in Cambodia, two sites in Nepal, two sites in Democratic Republic of the Congo (DRC), and one site in Sudan (clinicaltrials.gov no. NCT01766830). The study objectives were to (1) determine the prevalence of the target diseases in patients presenting with persistent fever, (2) assess the predictive value of clinical and first-line laboratory features, and (3) assess the diagnostic accuracy of several RDTs for the diagnosis of the different target conditions.
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Affiliation(s)
- Emilie Alirol
- Clinical Research Centre, Geneva University Hospitals, Geneva, Switzerland
- * E-mail:
| | - Ninon Seiko Horie
- Clinical Research Centre, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva Switzerland
| | | | - Veerle Lejon
- Institut de Recherche pour le Développement (IRD), Unité Mixte de Recherche IRD-CIRAD 177, Montpellier, France
| | | | | | - Jan Jacobs
- Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | | | - Basudha Kanal
- B.P. Koirala Institute of Health Science, Dharan, Nepal
| | | | - Sayda El Safi
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Thong Phe
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Kruy Lim
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Long Leng
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Pascal Lutumba
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo
- Département de Médecine Tropicale, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Deby Mukendi
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo
- Département de Médecine Tropicale, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | | | - Suman Rijal
- B.P. Koirala Institute of Health Science, Dharan, Nepal
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva Switzerland
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45
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Nkonya DN, Tarimo DS, Kishimba RS. Accuracy of clinical diagnosis and malaria rapid diagnostic test and its influence on the management of children with fever under reduced malaria burden in Misungwi district, Mwanza Tanzania. Pan Afr Med J 2016; 25:48. [PMID: 28250872 PMCID: PMC5321141 DOI: 10.11604/pamj.2016.25.48.9401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 04/14/2016] [Indexed: 11/24/2022] Open
Abstract
Introduction Malaria diagnosis is known to be non-specific because of the overlap of symptoms of malaria with other infectious diseases that is made worse with declining malaria burden. Though the use of malaria rapid diagnostic test (mRDT) for malaria confirmation has universally been adopted, malaria decline may alter performance of mRDT. This study examined accuracy of clinical diagnosis and mRDT and its influence on prescription for febrile underfives. Methods A cross-sectional study of 600 underfives was carried out in 6 randomly selected health facilities in Misungwi district, Mwanza; from November - December 2014. Consecutive underfives with a fever consultation were recruited: for each fever and the clinical diagnosis entertained were recorded. Parasitological confirmation of malaria was done by mRDT and microscopic examination of finger prick blood samples. Treatment was based on mRDT results, drugs prescribed recorded. Accuracy of clinical diagnosis and mRDT in predicting malaria was assessed by performance indices against microscopy. Antimalarial and antibiotics prescriptions were assessed against parasitological findings. Results Clinically, 37.2% had malaria; 32.8% were mRDTpositive and 17.0% microscopically positive. Sensitivity of clinical diagnosis was very high (97.0% [95%CI: 91.0-99.2]); specificity 66.7% [95%CI: 62.3-70.8], and positive predictive value 37.4% (95%CI: 31.6-43.5). Sensitivity of mRDTwas very high (99.0% [95%CI: 93.9-99.9]), specificity (80.7% [95%CI: 76.9-84.0]), positive predictive value 51.3% [95% CI: 44.1-58.4]) and negative predictive 99.75% [95%CI: 99.4-100.0]. Those receiving antimalarial prescription, 75.0% were mRDT positive; 39.4% microscopically positive. Those receiving antibiotic, 78.8% were mRDT negative; 90.1% microscopically negative. Conclusion Decline in malaria lowered specificity of mRDT to < 95% against WHO recommendation. Though adherence to mRDT results was high, there was over prescription of antibiotics.
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Affiliation(s)
| | - Donath Samuel Tarimo
- Department of Parasitology, School of Public Health & Social Sciences, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania
| | - Rogath Saika Kishimba
- Tanzania Field Epidemiology and Laboratory Training Program; Tanzania Ministry of Health, Community Development, Gender, Elderly and Children
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Dittrich S, Tadesse BT, Moussy F, Chua A, Zorzet A, Tängdén T, Dolinger DL, Page AL, Crump JA, D’Acremont V, Bassat Q, Lubell Y, Newton PN, Heinrich N, Rodwell TJ, González IJ. Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus. PLoS One 2016; 11:e0161721. [PMID: 27559728 PMCID: PMC4999186 DOI: 10.1371/journal.pone.0161721] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022] Open
Abstract
Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP). To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i) time-to-result <10 min (but maximally <2 hrs); ii) storage conditions at 0–40°C, ≤90% non-condensing humidity with a minimal shelf life of 12 months; iii) operational conditions of 5–40°C, ≤90% non-condensing humidity; and iv) minimal sample collection needs (50–100μL, capillary blood). This expert approach to define assay requirements for a bacterial vs. non-bacterial assay should guide product development, and enable targeted and timely efforts by industry partners and academic institutions.
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Affiliation(s)
- Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- * E-mail:
| | - Birkneh Tilahun Tadesse
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- Special Programme for Research & Training in Tropical Diseases (TDR), World Health Organization, Avenue Appia 20, 1211, Geneva 27, Switzerland
- Hawassa University, College of Medicine and Health Sciences, Department of Pediatrics, Hawassa, Ethiopia
| | - Francis Moussy
- World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
| | - Arlene Chua
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anna Zorzet
- ReAct Europe, Uppsala University, Box 256, 751 05, Uppsala, Sweden
| | - Thomas Tängdén
- ReAct Europe, Uppsala University, Box 256, 751 05, Uppsala, Sweden
| | - David L. Dolinger
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anne-Laure Page
- Epidemiology and Population Health, Epicentre, Paris, France
| | - John A. Crump
- Centre for International Health, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
- Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, United States of America
- Division of Infectious Diseases and International Health, Box 102359, Duke University Medical Center, Durham, NC, 27710, United States of America
| | - Valerie D’Acremont
- Swiss Tropical and Public Health Institute, 4002 Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Bugnon 44, 1011, Lausanne, Switzerland
| | - Quique Bassat
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao PDR
| | - Norbert Heinrich
- Division for Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany; German Center for Infection Research, Munich partner site, Leopoldstr 5, D-80802, Munich, Germany
| | - Timothy J. Rodwell
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Iveth J. González
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
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Lee S, Mehta S, Erickson D. Two-Color Lateral Flow Assay for Multiplex Detection of Causative Agents Behind Acute Febrile Illnesses. Anal Chem 2016; 88:8359-63. [PMID: 27490379 DOI: 10.1021/acs.analchem.6b01828] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Acute undifferentiated febrile illnesses (AFIs) represent a significant health burden worldwide. AFIs can be caused by infection with a number of different pathogens including dengue (DENV) and Chikungunya viruses (CHIKV), and their differential diagnosis is critical to the proper patient management. While rapid diagnostic tests (RDTs) for the detection of IgG/IgM against a single pathogen have played a significant role in enabling the rapid diagnosis in the point-of-care settings, the state-of-the-art assay scheme is incompatible with the multiplex detection of IgG/IgM to more than one pathogen. In this paper, we present a novel assay scheme that uses two-color latex labels for rapid multiplex detection of IgG/IgM. Adapting this assay scheme, we show that 4-plex detection of the IgG/IgM antibodies to DENV and CHIKV is possible in 10 min by using it to correctly identify 12 different diagnostic scenarios. We also show that blue, mixed, and red colorimetric signals corresponding to IgG, IgG/IgM, and IgM positive cases, respectively, can be associated with distinct ranges of hue intensities, which could be exploited by analyzer systems in the future for making accurate, automated diagnosis. This represents the first steps toward the development of a single RDT-based system for the differential diagnosis of numerous AFIs of interest.
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Affiliation(s)
- Seoho Lee
- Sibley School of Mechanical and Aerospace Engineering, Cornell University , Ithaca, New York 14853, United States.,Institute for Nutritional Sciences, Global Health, and Technology (INSiGHT), Cornell University , Ithaca, New York 14853, United States
| | - Saurabh Mehta
- Institute for Nutritional Sciences, Global Health, and Technology (INSiGHT), Cornell University , Ithaca, New York 14853, United States.,Division of Nutritional Sciences, Cornell University , Ithaca, New York 14853, United States
| | - David Erickson
- Sibley School of Mechanical and Aerospace Engineering, Cornell University , Ithaca, New York 14853, United States.,Institute for Nutritional Sciences, Global Health, and Technology (INSiGHT), Cornell University , Ithaca, New York 14853, United States.,Division of Nutritional Sciences, Cornell University , Ithaca, New York 14853, United States
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Kapasi AJ, Dittrich S, González IJ, Rodwell TC. Host Biomarkers for Distinguishing Bacterial from Non-Bacterial Causes of Acute Febrile Illness: A Comprehensive Review. PLoS One 2016; 11:e0160278. [PMID: 27486746 PMCID: PMC4972355 DOI: 10.1371/journal.pone.0160278] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/15/2016] [Indexed: 12/17/2022] Open
Abstract
Background In resource limited settings acute febrile illnesses are often treated empirically due to a lack of reliable, rapid point-of-care diagnostics. This contributes to the indiscriminate use of antimicrobial drugs and poor treatment outcomes. The aim of this comprehensive review was to summarize the diagnostic performance of host biomarkers capable of differentiating bacterial from non-bacterial infections to guide the use of antibiotics. Methods Online databases of published literature were searched from January 2010 through April 2015. English language studies that evaluated the performance of one or more host biomarker in differentiating bacterial from non-bacterial infection in patients were included. Key information extracted included author information, study methods, population, pathogens, clinical information, and biomarker performance data. Study quality was assessed using a combination of validated criteria from the QUADAS and Lijmer checklists. Biomarkers were categorized as hematologic factors, inflammatory molecules, cytokines, cell surface or metabolic markers, other host biomarkers, host transcripts, clinical biometrics, and combinations of markers. Findings Of the 193 citations identified, 59 studies that evaluated over 112 host biomarkers were selected. Most studies involved patient populations from high-income countries, while 19% involved populations from low- and middle-income countries. The most frequently evaluated host biomarkers were C-reactive protein (61%), white blood cell count (44%) and procalcitonin (34%). Study quality scores ranged from 23.1% to 92.3%. There were 9 high performance host biomarkers or combinations, with sensitivity and specificity of ≥85% or either sensitivity or specificity was reported to be 100%. Five host biomarkers were considered weak markers as they lacked statistically significant performance in discriminating between bacterial and non-bacterial infections. Discussion This manuscript provides a summary of host biomarkers to differentiate bacterial from non-bacterial infections in patients with acute febrile illness. Findings provide a basis for prioritizing efforts for further research, assay development and eventual commercialization of rapid point-of-care tests to guide use of antimicrobials. This review also highlights gaps in current knowledge that should be addressed to further improve management of febrile patients.
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Affiliation(s)
- Anokhi J. Kapasi
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Iveth J. González
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Timothy C. Rodwell
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
- * E-mail:
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Pulford J, Smith I, Mueller I, Siba PM, Hetzel MW. Health Worker Compliance with a 'Test And Treat' Malaria Case Management Protocol in Papua New Guinea. PLoS One 2016; 11:e0158780. [PMID: 27391594 PMCID: PMC4938505 DOI: 10.1371/journal.pone.0158780] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/21/2016] [Indexed: 12/05/2022] Open
Abstract
The Papua New Guinea (PNG) Department of Health introduced a ‘test and treat’ malaria case management protocol in 2011. This study assesses health worker compliance with the test and treat protocol on a wide range of measures, examines self-reported barriers to health worker compliance as well as health worker attitudes towards the test and treat protocol. Data were collected by cross-sectional survey conducted in randomly selected primary health care facilities in 2012 and repeated in 2014. The combined survey data included passive observation of current or recently febrile patients (N = 771) and interviewer administered questionnaires completed with health workers (N = 265). Across the two surveys, 77.6% of patients were tested for malaria infection by rapid diagnostic test (RDT) or microscopy, 65.6% of confirmed malaria cases were prescribed the correct antimalarials and 15.3% of febrile patients who tested negative for malaria infection were incorrectly prescribed an antimalarial. Overall compliance with a strictly defined test and treat protocol was 62.8%. A reluctance to test current/recently febrile patients for malaria infection by RDT or microscopy in the absence of acute malaria symptoms, reserving recommended antimalarials for confirmed malaria cases only and choosing to clinically diagnose a malaria infection, despite a negative RDT result were the most frequently reported barriers to protocol compliance. Attitudinal support for the test and treat protocol, as assessed by a nine-item measure, improved across time. In conclusion, health worker compliance with the full test and treat malaria protocol requires improvement in PNG and additional health worker support will likely be required to achieve this. The broader evidence base would suggest any such support should be delivered over a longer period of time, be multi-dimensional and multi-modal.
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Affiliation(s)
- Justin Pulford
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Iso Smith
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Barcelona Centre for International Health Research, Barcelona, Spain
| | - Peter M. Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Manuel W. Hetzel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Lubell Y, Althaus T, Blacksell SD, Paris DH, Mayxay M, Pan-Ngum W, White LJ, Day NPJ, Newton PN. Modelling the Impact and Cost-Effectiveness of Biomarker Tests as Compared with Pathogen-Specific Diagnostics in the Management of Undifferentiated Fever in Remote Tropical Settings. PLoS One 2016; 11:e0152420. [PMID: 27027303 PMCID: PMC4814092 DOI: 10.1371/journal.pone.0152420] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 03/14/2016] [Indexed: 01/21/2023] Open
Abstract
Background Malaria accounts for a small fraction of febrile cases in increasingly large areas of the malaria endemic world. Point-of-care tests to improve the management of non-malarial fevers appropriate for primary care are few, consisting of either diagnostic tests for specific pathogens or testing for biomarkers of host response that indicate whether antibiotics might be required. The impact and cost-effectiveness of these approaches are relatively unexplored and methods to do so are not well-developed. Methods We model the ability of dengue and scrub typhus rapid tests to inform antibiotic treatment, as compared with testing for elevated C-Reactive Protein (CRP), a biomarker of host-inflammation. Using data on causes of fever in rural Laos, we estimate the proportion of outpatients that would be correctly classified as requiring an antibiotic and the likely cost-effectiveness of the approaches. Results Use of either pathogen-specific test slightly increased the proportion of patients correctly classified as requiring antibiotics. CRP testing was consistently superior to the pathogen-specific tests, despite heterogeneity in causes of fever. All testing strategies are likely to result in higher average costs, but only the scrub typhus and CRP tests are likely to be cost-effective when considering direct health benefits, with median cost per disability adjusted life year averted of approximately $48 USD and $94 USD, respectively. Conclusions Testing for viral infections is unlikely to be cost-effective when considering only direct health benefits to patients. Testing for prevalent bacterial pathogens can be cost-effective, having the benefit of informing not only whether treatment is required, but also as to the most appropriate antibiotic; this advantage, however, varies widely in response to heterogeneity in causes of fever. Testing for biomarkers of host inflammation is likely to be consistently cost-effective despite high heterogeneity, and can also offer substantial reductions in over-use of antimicrobials in viral infections.
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Affiliation(s)
- Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Daniel H. Paris
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Laos
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
| | - Wirichada Pan-Ngum
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lisa J. White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Laos
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