Comparing actual and perceived causes of fever among community members in a low malaria transmission setting in northern Tanzania

Understanding psychosocial determinants of malaria behaviours in low-transmission settings: a scoping review

BACKGROUND

Recent estimates show progress toward malaria elimination is slowing in many settings, underscoring the need for tailored approaches to fight the disease. In addition to essential structural changes, human behaviour plays an important role in elimination. Engagement in malaria behaviours depends in part on psychosocial determinants such as knowledge, perceived risk, and community norms. Understanding the state of research on psychosocial determinants in low malaria transmission settings is important to augment social and behaviour change practice. This review synthesizes research on psychosocial factors and malaria behaviours in low-transmission settings.

METHODS

A systematic search of peer-reviewed literature and supplemental manual search of grey literature was conducted using key terms and eligibility criteria defined a priori. Publications from 2000-2020 in the English language were identified, screened, and analysed using inductive methods to determine the relationship between the measured psychosocial factors and malaria behaviours.

RESULTS

Screening of 961 publications yielded 96 for inclusion. Nineteen articles collected data among subpopulations that are at increased risk of malaria exposure in low-transmission settings. Purposive and cluster randomized sampling were common sampling approaches. Quantitative, qualitative, and mixed-methods study designs were used. Knowledge, attitudes, and perceived risk were commonly measured psychosocial factors. Perceived response-efficacy, perceived self-efficacy, and community norms were rarely measured. Results indicate positive associations between malaria knowledge and attitudes, and preventive and care-seeking behaviour. Studies generally report high rates of correct knowledge, although it is comparatively lower among studies of high-risk groups. There does not appear to be sufficient extant evidence to determine the relationship between other psychosocial variables and behaviour.

CONCLUSIONS

The review highlights the need to deploy more consistent, comprehensive measures of psychosocial factors and the importance of reaching subpopulations at higher risk of transmission in low transmission contexts. Malaria-related knowledge is generally high, even in settings of low transmission. Programmes and research should work to better understand the psychosocial factors that have been positively associated with prevention and care-seeking behaviours, such as norms, perceived response efficacy, perceived self-efficacy, and interpersonal communication. These factors are not necessarily distinct from that which research has shown are important in settings of high malaria transmission. However, the importance of each factor and application to malaria behaviour change programming in low-transmission settings is an area in need of further research. Existing instruments and approaches are available to support more systematic collection of psychosocial determinants and improved sampling approaches and should be applied more widely. Finally, while human behaviour is critical, health systems strengthening, and structural interventions are essential to achieve malaria elimination goals.

Fever and health-seeking behaviour among migrants living along the Thai-Myanmar border: a mixed-methods study

BACKGROUND

Fever is a common reason to seek healthcare in Southeast Asia, and the decline of malaria has complexified how is perceived, and what actions are taken towards it. We investigated the concept of fever and the determinants influencing health-seeking behaviours among migrants on the Thai-Myanmar border, where rapid economic development collides with precarious political and socio-economic conditions.

METHODS

We implemented a mixed-methods study between August to December 2019. Phase I used a qualitative approach, with in-depth interviews and focus group discussions. Phase II used a quantitative approach with a close-ended questionnaire based on Phase I findings. A conditional inference tree (CIT) model first identified geographic and socio-demographic determinants, which were then tested using a logistic regression model.

RESULTS

Fever corresponded to a high diversity of conceptions, symptoms and believed causes. Self-medication was the commonest behaviour at fever onset. If fever persisted, migrants primarily sought care in humanitarian cost-free clinics (45.5%, 92/202), followed by private clinics (43.1%, 87/202), health posts (36.1%, 73/202), public hospitals (33.7%, 68/202) and primary care units (30, 14.9%). The qualitative analysis identified distance and legal status as key barriers for accessing health care. The quantitative analysis further investigated determinants influencing health-seeking behaviour: living near a town where a cost-free clinic operated was inversely associated with seeking care at health posts (adjusted odds ratio [aOR], 0.40, 95% confidence interval [95% CI] [0.19-0.86]), and public hospital attendance (aOR 0.31, 95% CI [0.14-0.67]). Living further away from the nearest town was associated with health posts attendance (aOR 1.05, 95% CI [1.00-1.10] per 1 km). Having legal status was inversely associated with cost-free clinics attendance (aOR 0.27, 95% CI [0.10-0.71]), and positively associated with private clinic and public hospital attendance (aOR 2.56, 95% CI [1.00-6.54] and 5.15, 95% CI [1.80-14.71], respectively).

CONCLUSIONS

Fever conception and believed causes are context-specific and should be investigated prior to any intervention. Distance to care and legal status were key determinants influencing health-seeking behaviour. Current economic upheavals are accelerating the unregulated flow of undocumented migrants from Myanmar to Thailand, warranting further inclusiveness and investments in the public health system.

Facility-based disease surveillance and Bayesian hierarchical modeling to estimate endemic typhoid fever incidence, Kilimanjaro Region, Tanzania, 2007–2018

Growing evidence suggests considerable variation in endemic typhoid fever incidence at some locations over time, yet few settings have multi-year incidence estimates to inform typhoid control measures. We sought to describe a decade of typhoid fever incidence in the Kilimanjaro Region of Tanzania. Cases of blood culture confirmed typhoid were identified among febrile patients at two sentinel hospitals during three study periods: 2007–08, 2011–14, and 2016–18. To account for under-ascertainment at sentinel facilities, we derived adjustment multipliers from healthcare utilization surveys done in the hospital catchment area. Incidence estimates and credible intervals (CrI) were derived using a Bayesian hierarchical incidence model that incorporated uncertainty of our observed typhoid fever prevalence, of healthcare seeking adjustment multipliers, and of blood culture diagnostic sensitivity. Among 3,556 total participants, 50 typhoid fever cases were identified. Of typhoid cases, 26 (52%) were male and the median (range) age was 22 (<1–60) years; 4 (8%) were aged <5 years and 10 (20%) were aged 5 to 14 years. Annual typhoid fever incidence was estimated as 61.5 (95% CrI 14.9–181.9), 6.5 (95% CrI 1.4–20.4), and 4.0 (95% CrI 0.6–13.9) per 100,000 persons in 2007–08, 2011–14, and 2016–18, respectively. There were no deaths among typhoid cases. We estimated moderate typhoid incidence (≥10 per 100 000) in 2007–08 and low (<10 per 100 000) incidence during later surveillance periods, but with overlapping credible intervals across study periods. Although consistent with falling typhoid incidence, we interpret this as showing substantial variation over the study periods. Given potential variation, multi-year surveillance may be warranted in locations making decisions about typhoid conjugate vaccine introduction and other control measures.

There is evidence that typhoid fever incidence may vary over time, but there are few longitudinal studies estimating incidence. This is especially true in Sub-Saharan Africa, where recent estimates show wide variation in incidence across different settings, but very limited longitudinal descriptions from those settings. Incidence estimates were generated using facility-based surveillance data from three study periods that was adjusted for health-seeking behavior established through healthcare utilization surveys performed in the catchment area. In addition to coupling facility-based surveillance data with healthcare utilization data, we utilized a Bayesian statistical methodology in order to estimate incidence and characterize uncertainty around the estimates. Our results demonstrate moderate typhoid incidence in 2007–08 and low incidence during 2012–14 and 2016–18, but with overlapping credible intervals across study periods. Our data are consistent with evidence that endemic typhoid may vary substantially over time. Given potential variation, multi-year surveillance may be warranted in locations making decisions about typhoid conjugate vaccine introduction and other control measures.

The knowledge, attitude and practice of community people on dengue fever in Central Nepal: a cross-sectional study

Background

Since 2006, Nepal has experienced frequent Dengue fever (DF) outbreaks. Up to now, there have been no knowledge, attitude and practice (KAP) studies carried out on DF in Nepal that have included qualitative in-depth and quantitative data. Thus, we aimed to explore and compare the KAP of people residing in the lowland (< 1500 m) and highland (> 1500 m) areas of Nepal.

Methods

A cross-sectional mixed-method study was conducted in six districts of central Nepal in September–October 2018 including both quantitative (660 household surveys) and qualitative data (12 focus group discussions and 27 in-depth interviews). The KAP assessment was executed using a scoring system and defined as high or low based on 80% cut-off point. Logistic regression was used to investigate the associated factors, in quantitative analysis. The deductive followed by inductive approach was adopted to identify the themes in the qualitative data.

Results

The study revealed that both the awareness about DF and prevention measures were low. Among the surveyed participants, 40.6% had previously heard about DF with a significantly higher number in the lowland areas. Similarly, IDI and FGD participants from the lowland areas were aware about DF, and it’s associated symptoms, hence they were adopting better preventive practices against DF. The findings of both the qualitative and quantitative data indicate that people residing in the lowland areas had better knowledge on DF compared to people in highland areas. All IDI participants perceived a higher chance of increasing future dengue outbreaks due to increasing temperature and the mobility of infected people from endemic to non-endemic areas. The most quoted sources of information were the television (71.8%) and radio (51.5%). Overall, only 2.3% of the HHS participants obtained high knowledge scores, 74.1% obtained high attitude scores and 21.2% obtained high preventive practice scores on DF. Among the socio-demographic variables, the area of residence, educational level, age, monthly income, SES and occupation were independent predictors of knowledge level, while the education level of the participants was an independent predictor of the attitude level.

Conclusions

Our study found a very low level of knowledge and insufficient preventive practices. This highlights an urgent need for extensive dengue prevention programs in both highland and lowland communities of Nepal.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07404-4.

Dengue and Chikungunya virus circulation in Cameroon and Gabon: molecular evidence among symptomatic individuals

We report the molecular evidence of dengue virus (DENV) and chikungunya virus (CHIKV) infection in symptomatic individuals in Cameroon and Gabon, respectively. Arthropod-borne viruses (arboviruses) are distributed in the tropical or subtropical regions, with DENV having the highest burden. The morbidity and mortality related to arboviral diseases raise the concern of timely and efficient surveillance and care. Our aim was to assess the circulation of arboviruses [DENV, CHIKV, Zika virus (ZIKV)] among febrile patients in Dschang (West Cameroon) and Kyé-ossi (South Cameroon, border with Gabon and Equatorial Guinea). Dried blood spots were collected from 601 consenting febrile patients, and 194 Plasmodium spp.-negative samples were tested for the molecular detection of cases of DENV, CHIKV and ZIKV infection. Overall, no case of ZIKV infection was found, whereas one case of DENV infection and one case of CHIKV infection were detected in Dschang and Kyé-ossi, respectively, with the CHIKV-infected patient being resident in Gabon. Our findings suggest the need to establish an active surveillance of arbovirus transmission in Cameroon and bordering countries.

Using Intersectionality to Identify Gendered Barriers to Health-Seeking for Febrile Illness in Agro-Pastoralist Settings in Tanzania

Background

Research has shown that gender is a significant determinant of health-seeking behavior around the world. Gender power relations and lay etiologies of illness can influence the distribution of household resources, including for healthcare. In some rural settings in Africa, gender intersects with multiple forms of health inequities, from proximal socio-cultural factors to more “upstream” or distal health system determinants which can amplify barriers to health-seeking for specific groups in specific contexts.

Aim

We used an intersectionality approach to determine how women in particular, experience gendered barriers to accessing healthcare among Maa and non-Maa speaking agro-pastoralists in northern Tanzania. We also explored lay etiologies of febrile illness, perceptions of health providers and rural health-seeking behavior in order to identify the most common barriers to accessing healthcare in these settings.

Methods

Mixed method ethnographic approaches were used to collect data between 2016 and 2018 from four Maa-speaking and two Swahili-speaking agro-pastoralist villages in northern Tanzania. Maa-speaking villages were based in Naiti, Monduli district while non-Maa speaking villages were selected from Msitu in Babati district. Data on health seeking behaviors was collected through semi-structured questionnaires, in-depth interviews, focus group discussions, and home and facility-based participant observation.

Findings

The results primarily focus on the qualitative outcomes of both studies. We found that febrile illness was locally categorized across a spectrum of severity ranging from normal and expected illness to serious illness that required hospital treatment. Remedial actions taken to treat febrile illness included attending local health facilities, obtaining medicines from drug sellers and use of herbal remedies. We found barriers to health-seeking played out at different scales, from the health system, community (inter-household decision making) and household (intra-household decision making). Gender-based barriers at the household had a profound effect on health-seeking. Younger married women delayed seeking healthcare the most, as they often had to negotiate health-seeking with husbands and extended family members, including co-wives and mothers-in-law who make the majority of health-related decisions.

Conclusion

An intersectional approach enabled us to gain a nuanced understanding of determinants of health-seeking behavior beyond the commonly assumed barriers such lack of public health infrastructure. We propose tapping into the potential of senior older women involved in local therapy-management groups, to explore gender-transformative approaches to health-seeking, including tackling gender-based barriers at the community level. While these social factors are important, ultimately, improving the public health infrastructure in these settings is a first step toward addressing structural determinants of treatment-seeking.

Comparing the accuracy of lay diagnosis of childhood malaria and pneumonia with that of the revised IMCI guidelines in Nigeria

BACKGROUND

Improving caregivers' recognition of childhood malaria and pneumonia is crucial to early treatment and improving outcomes. The objective of this study was to assess the accuracy and reliability of caregivers' recognition of malaria and pneumonia (lay diagnosis) as compared to the revised IMCI guidelines.

METHODS

A cross-sectional study design was used to recruit 903 children aged 2-59 months who were assessed for malaria and pneumonia by health workers at five primary healthcare centres in Benin City, Nigeria. Accuracy of lay diagnosis as compared to the revised IMCI guidelines was assessed using sensitivity, specificity, positive and negative predictive values and area under the receiver operating characteristic curve (AUROC) values.

RESULTS

The accuracy of caregivers' ability to recognise malaria (AUROC: 0.60; 95% CI: 0.57-0.64) and pneumonia (AUROC: 0.54; 95% CI: 0.50-0.58) was, respectively, moderate and poor as compared to the IMCI guidelines. Caregivers were better able to identify children without than those with malaria and pneumonia. Agreement between caregivers and the IMCI guidelines for malaria and pneumonia diagnosis was poor (k = 0.14, 95% CI: 0.09-0.19; P = 0.0001).

CONCLUSION

Caregivers' ability to recognise these childhood diseases as compared to the IMCI guidelines was poor overall, which was partly due to the approach used to ascertain lay diagnosis.

Management and Follow-up Practices of Children with Unclassified Fever in Rural Ethiopia: Experiences of Health Extension Workers and Caregivers

Different health-care management guidelines by the World Health Organization exist to help health workers in resource-limited settings treat patients. However, for children with unclassified fever and no danger signs, management guidelines are less clear and follow-up recommendations differ. Both a "universal follow-up" for all children, irrespective of health status, and a "conditional follow-up" only for children whose fever persists are recommended in different guidelines. It is unclear how feasible and acceptable these two different follow-up guidelines are among community health workers and caregivers of the sick child. This qualitative study was conducted in Ethiopia and was nested within a cluster-randomized controlled trial (cRCT). It aimed to determine health extension workers' (HEWs') and caregivers' experiences of the management of febrile children and their perceptions of universal versus conditional follow-up recommendations. Seventeen HEWs and 20 caregivers were interviewed. The interviews revealed that HEWs' understanding of how to handle an unclassified fever diagnosis increased with the implementation of the cRCT in both study arms (universal versus conditional follow-up). This enabled HEWs to withhold medicines from children with this condition and avoid referral to health centers. Both follow-up recommendations had perceived advantages, while the universal follow-up provided an opportunity to see the child's health progress, the conditional follow-up advice allowed saving time and costs. The findings suggest that improved awareness of the unclassified fever condition can make HEWs feel more comfortable in managing these febrile children themselves and omitting unnecessary medication. Future community-level management guidelines should provide clearer instructions on managing fever where no malaria, pneumonia, diarrhea, or danger signs are present.

Health Beliefs and Patient Perspectives of Febrile Illness in Kilombero, Tanzania

This qualitative study assessed the knowledge and beliefs surrounding fever syndrome among adult febrile patients seeking health care in Kilombero, Tanzania. From June 11 to July 13, 2014, 10% of all adult (≥ 15 years) febrile patients enrolled in the larger syndromic study, who presented with an axillary temperature ≥ 37.5°C and symptom onset ≤ 5 days prior, were randomly selected to participate in an in-depth physician-patient interview, informed by Health Belief Model constructs. Interviews were audio recorded, translated, and transcribed. Transcripts were coded using NVivo Version 11.1, and the thematic content was analyzed by two separate researchers. Blood and nasopharyngeal/oralpharyngeal specimens were collected and analyzed using both acute febrile illness and respiratory TaqMan Array Cards for multipathogen detection of 56 potential causative agents. A total of 18 participants provided 188 discrete comments. When asked to speculate the causative agent of febrile illness, 33.3% cited malaria and the other 66.6% offered nonbiomedical responses, such as "mosquitoes" and "weather." Major themes emerging related to severity and susceptibility to health hazards included lack of bed net use, misconceptions about bed nets, and mosquito infestation. Certain barriers to treatment were cited, including dependence on traditional healers, high cost of drugs, and poor dispensary services. Overall, we demonstrate low concurrence in speculations of fever etiology according to patients, clinicians, and laboratory testing. Our findings contribute to the important, yet limited, base of knowledge surrounding patient risk perceptions of febrile illness and underscore the potential utility of community-based participatory research to inform disease control programs.

Knowledge of myocardial infarction symptoms and perceptions of self-risk in Tanzania

Background

Little is known about community knowledge of myocardial infarction symptoms and perceptions of self-risk in sub-Saharan Africa.

Methods

A community survey was conducted in northern Tanzania, where the prevalence of cardiovascular risk factors is high. Households were selected randomly in a population-weighted fashion and surveys were administered to self-identified household healthcare decision-makers. Respondents were asked to list all symptoms of a heart attack and asked whether they thought they had a chance of suffering a heart attack. Associations between participant sociodemographic features and responses to these questions were assessed with Pearson's chi-squared and the Student t test.

Results

There were 718 survey participants, with median (IQR) age 48 (32, 62) years. Of these, 115 (16.0%) were able to identify any conventional symptom of a heart attack, including 24 (3.3%) respondents who cited chest pain as a possible symptom. There was no association between ability to identify a conventional symptom and gender, level of education, socioeconomic status, urban residence, or age. Of respondents, 198 (27.6%) thought they had a chance of suffering a heart attack. Older respondents were more likely to perceive themselves to be at risk (P < .001), but there was no association between perception of self-risk and gender, level of education, socioeconomic status, or urban residence.

Conclusions

In northern Tanzania, knowledge of myocardial infarction symptoms is poor among all segments of the population and only a minority of residents perceive themselves to be at risk of this disease. Educational interventions regarding ischemic heart disease are urgently needed.

Effect of Supportive Supervision on Competency of Febrile Clinical Case Management in Sub-Saharan Africa

Since 2010, the WHO has recommended that clinical decision-making for malaria case management be performed based on the results of a parasitological test result. Between 2015 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported the implementation of this practice in eight sub-Saharan African countries through 5,382 outreach training and supportive supervision visits to 3,563 health facilities. During these visits, trained government supervisors used a 25-point checklist to observe clinicians' performance in outpatient departments, and then provided structured mentoring and action planning. At baseline, more than 90% of facilities demonstrated a good understanding of WHO recommendations-when tests should be ordered, using test results to develop an accurate final diagnosis, severity assessment, and providing the correct prescription. However, significant deficits were found in history taking, conducting a physical examination, and communicating with patients and their caregivers. After three visits, worker performance demonstrated steady improvement-in particular, with checking for factors associated with increased morbidity and mortality: one sign of severe malaria (72.9-85.5%), pregnancy (81.1-87.4%), and anemia (77.2-86.4%). A regression analysis predicted an overall improvement in clinical performance of 6.3% (P < 0.001) by the third visit. These findings indicate that in most health facilities, there is good baseline knowledge on the processes of quality clinical management, but further training and on-site mentoring are needed to improve the clinical interaction that focuses on second-order decision-making, such as severity of illness, management of non-malarial fever, and completing the patient-provider communication loop.

Perceptions of chest pain and healthcare seeking behavior for chest pain in northern Tanzania: A community-based survey

Background

Little is known about community perceptions of chest pain and healthcare seeking behavior for chest pain in sub-Saharan Africa.

Methods

A two-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household healthcare decision-makers from randomly selected households were asked to list all possible causes of chest pain in an adult and asked where they would go if an adult household member had chest pain.

Results

Of 718 respondents, 485 (67.5%) were females. The most commonly cited causes of chest pain were weather and exercise, identified by 342 (47.6%) and 318 (44.3%) respondents. Two (0.3%) respondents identified ‘heart attack’ as a possible cause of chest pain. A hospital was selected as the preferred healthcare facility for an adult with chest pain by 277 (38.6%) respondents. Females were less likely to prefer a hospital than males (OR 0.65, 95% CI 0.47–0.90, p = 0.008).

Conclusions

There is little community awareness of cardiac causes of chest pain in northern Tanzania, and most adults reported that they would not present to a hospital for this symptom. There is an urgent need for educational interventions to address this knowledge deficit and guide appropriate care-seeking behavior.

Knowledge and perception of pastoral community members about brucellosis as a cause of abortion in animals and its zoonotic importance in Amibara district, Afar Region, Ethiopia

Sero-epidemiological studies of brucellosis in the Afar Region showed that the disease is prevalent in livestock. However, there is little information regarding the pastoral community members’ awareness about brucellosis as a cause of abortion in animals and its zoonotic importance. In this study, we assessed knowledge and perception of pastoral community members about brucellosis as a cause of abortion in animals and its zoonotic importance in Amibara district, Afar Region, Ethiopia. Between October and December 2016, a total of 475 study participants (age range 18–80 years, mean age 35.9 years) were interviewed about abortion in their animals, its causes, and diseases that can be transmitted to humans through consumption of raw milk. Almost all (97.7%) of the study participants reported that abortion in animals, especially in goats, is a major problem in the area, and they mentioned that disease (44.6%), drought (58.4%) and fly bites (29.5%) as the main causes of abortion. The study participantsalso thought that malaria (42.9%) and bovine tuberculosis (19.3%) can be transmitted to humans through consuming raw milk. Five respondents (4.2%) mentioned brucellosis (locally known as “hahayita”) as a disease that can be transmitted through frequent consumption of raw milk. The majority (91.9%) mentioned malaria as a cause of febrile illness in humans and 16 (4.4%) participants mentioned brucellosis as a cause of febrile illness. Some participants also mentioned brucellosis as a cause of joint swelling (hygroma) in cattle. In conclusion, the pastoral community members in the present study area lack clear understanding about brucellosis as one of the diseases that cause abortion in their animals and its zoonotic importance. There is a need to create awareness about the zoonotic and animal health importance of brucellosis through various means such as community health extension/veterinary workers and community leaders.

Community-based prevalence of typhoid fever, typhus, brucellosis and malaria among symptomatic individuals in Afar Region, Ethiopia

BACKGROUND

In sub-Saharan Africa, where there is the scarcity of proper diagnostic tools, febrile illness related symptoms are often misdiagnosed as malaria. Information on causative agents of febrile illness related symptoms among pastoral communities in Ethiopia have rarely been described.

METHODS

In this a community based cross-sectional survey, we assessed the prevalence of typhoid fever, typhus, brucellosis and malaria among individuals with a set of given symptoms in Amibara district, Afar Region, Ethiopia. Blood samples were collected from 650 study participants, and examined by Widal and Weilfelix direct card agglutination test (DCAT) as well as test tube based titration test for Salmonella enterica serotype Typhi (S. Typhi) and Rickettsia infections. Rose Bengal Plate Test (RBPT) and Complement Fixation Test (CFT) were used to screen Brucella infection. Thin and thick blood smears were used to diagnosis malaria.

RESULTS

Out of 630 sera screened by DCAT, 83 (13.2%) were reactive to H and/or O antigens for S. Typhi infection. Among these, 46 (55.4%) were reactive by the titration test at the cut off value ≥ 1:80. The combined sero-prevalence for S. Typhi by the two tests was 7.3% (46/630). The seroprevalence for Rickettsia infection was 26.2% (165/630) by DCAT and 53.3% (88/165) by the titration test at the cut off value ≥ 1:80. The combined sero-prevalence for Rickettsia infection by the two tests was 14.0% (88/630). The sero-prevalence for Brucella infection was 12.7% (80/630) by RBPT, of which 28/80 (35%) were positive by CFT. The combined sero-prevalence for Brucella infection by the two tests was 4.4% (28/630). Out 650 suspected individuals for malaria, 16 (2.5%) were found positive for P. falciparum infection.

CONCLUSION

In this study, typhoid fever, typhus, brucellosis and malaria were observed among symptomatic individuals. The study also highlighted that brucellosis cases can be misdiagnosed as malaria or other disease based solely on clinical diagnosis. Therefore, efforts are needed to improve disease awareness and laboratory services for the diagnosis of brucellosis and other zoonotic diseases to identify other causes of febrile illness in this pastoral setting.

Patient reported symptoms, body temperature and hospital mortality: an observational study in a low resource healthcare environment

BACKGROUND

Fever is a common presenting complaint of patients, especially in sub-Saharan Africa. Although most medical authorities consider fever to be synonymous with an elevated body temperature the relationship of the complaint of fever made by patients to temperature has not been well defined.

AIM

This study examined the relationship of the complaint of fever to temperature on and after admission and in-hospital mortality.

METHOD

Observational study in a low-resource Ugandan mission hospital.

RESULTS

Out of 2122 alert patients admitted between 9 August 2016 and 5 January 2018, 349 (16.4%) complained of fever: these patients were no more likely to have an abnormal temperature or die in-hospital than those not complaining of fever. Of the 707 alert patients admitted after 1 July 2017, 422 were interviewed in detail about their symptoms: only rigors, feeling intermittently hot and cold, and anorexia were statistically related to the complaint of fever, and only rigors to an admission temperature >38°C. No symptom or sign was associated with a temperature ≤36°C: cold and clammy skin was the only finding associated with in-hospital death. On logistic regression the only independent predictors of mortality were: the National Early Warning Score, impaired mobility on presentation and cold and clammy skin.

CONCLUSION

In this study, the term fever used by patients and raised body temperature were not synonymous. Although fever and related symptoms reported by patients are common presenting complaints only the finding of cold and clammy skin was associated with in-hospital mortality.

Predictors of residual antimalarial drugs in the blood in community surveys in Tanzania

Background

Understanding pattern of antimalarials use at large scale helps ensuring appropriate use of treatments and preventing the spread of resistant parasites. We estimated the proportion of individuals in community surveys with residual antimalarials in their blood and identified the factors associated with the presence of the most commonly detected drugs, lumefantrine and/or desbutyl-lumefantrine (LF/DLF) or sulfadoxine-pyrimethamine (SP).

Methods

A cross-sectional survey was conducted in 2015 in three regions of Tanzania with different levels of malaria endemicity. Interviews were conducted and blood samples collected through household surveys for further antimalarial measurements using liquid chromatography coupled to tandem mass spectrometry. In addition, diagnosis and treatment availability was investigated through outlet surveys. Multilevel mixed effects logistic regression models were used to estimate odds ratios for having LF/DLF or SP in the blood.

Results

Amongst 6391 participants, 12.4% (792/6391) had LF/DLF and 8.0% (510/6391) SP in the blood. Factors associated with higher odds of detecting LF/DLF in the blood included fever in the previous two weeks (OR = 2.6, p<0.001), living in districts of higher malaria prevalence (OR = 1.5, p<0.001) and living in a ward in which all visited drug stores had artemisinin-based combination therapies in stocks (OR = 2.7, p = 0.020). Participants in older age groups were less likely to have LF/DLF in the blood (OR = 0.9, p<0.001). Factors associated with higher odds of having SP in the blood included being pregnant (OR = 4.6, p<0.001), living in Mwanza (OR = 3.9, p<0.001 compared to Mbeya), fever in the previous two weeks (OR = 1.7, p<0.001) and belonging to older age groups (OR = 1.2, p<0.001).

Conclusion

The most significant predictors identified were expected. History of fever in the past two weeks and young age were significant predictors of LF/DLF in the blood, which is encouraging. Antimalarial drug pressure was high and hence the use of recommended first-line drugs in combination with malaria Rapid Diagnostics Tests should be promoted to ensure appropriate treatment.

Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in the Democratic Republic of the Congo: A cluster-randomized, community-based non-inferiority trial

BACKGROUND

The World Health Organization's integrated community case management (iCCM) guidelines recommend that all children presenting with uncomplicated fever and no danger signs return for follow-up on day 3 following the initial consultation on day 1. Such fevers often resolve rapidly, however, and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. We aimed to determine if a conditional follow-up visit was non-inferior to a universal follow-up visit for these children.

METHODS AND FINDINGS

We conducted a cluster-randomized, community-based non-inferiority trial among children 2-59 months old presenting to community health workers (CHWs) with non-severe unclassified fever in Tanganyika Province, Democratic Republic of the Congo. Clusters (n = 28) of CHWs were randomized to advise caregivers to either (1) return for a follow-up visit on day 3 following the initial consultation on day 1, regardless of illness resolution (as per current WHO guidelines; universal follow-up group) or (2) return for a follow-up visit on day 3 only if illness continued (conditional follow-up group). Children in both arms were assessed again at day 8, and classified as a clinical failure if fever (caregiver-reported), malaria, diarrhea, pneumonia, or decline of health status (development of danger signs, hospitalization, or death) was noted (failure definition 1). Alternative failure definitions were examined, whereby caregiver-reported fever was first restricted to caregiver-reported fever of at least 3 days (failure definition 2) and then replaced with fever measured via axillary temperature (failure definition 3). Study participants, providers, and investigators were not masked. Among 4,434 enrolled children, 4,141 (93.4%) met the per-protocol definition of receipt of the arm-specific advice from the CHW and a timely day 8 assessment (universal follow-up group: 2,210; conditional follow-up group: 1,931). Failure was similar (difference: -0.7%) in the conditional follow-up group (n = 188, 9.7%) compared to the universal follow-up group (n = 230, 10.4%); however, the upper bound of a 1-sided 95% confidence interval around this difference (-∞, 5.1%) exceeded the prespecified non-inferiority margin of 4.0% (non-inferiority p = 0.089). When caregiver-reported fever was restricted to fevers lasting ≥3 days, failure in the conditional follow-up group (n = 159, 8.2%) was similar to that in the universal follow-up group (n = 200, 9.1%) (difference: -0.8%; 95% CI: -∞, 4.1%; p = 0.053). If caregiver-reported fever was replaced by axillary temperature measurement in the definition of failure, failure in the conditional follow-up group (n = 113, 5.9%) was non-inferior to that in the universal follow-up group (n = 160, 7.2%) (difference: -1.4%; 95% CI: -∞, 2.5%; p = 0.012). In post hoc analysis, when the definition of failure was limited to malaria, diarrhea, pneumonia, development of danger signs, hospitalization, or death, failure in the conditional follow-up group (n = 108, 5.6%) was similar to that in the universal follow-up group (n = 147, 6.7%), and within the non-inferiority margin (95% CI: -∞, 2.9%; p = 0.017). Limitations include initial underestimation of the proportion of clinical failures as well as substantial variance in cluster-specific failure rates, reducing the precision of our estimates. In addition, heightened security concerns slowed recruitment in the final months of the study.

CONCLUSIONS

We found that advising caregivers to return only if children worsened or remained ill on day 3 resulted in similar rates of caregiver-reported fever and other clinical outcomes on day 8, compared to advising all caregivers to return on day 3. Policy-makers could consider revising guidelines for management of uncomplicated fever within the iCCM framework.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02595827.

A Combined Syndromic Approach to Examine Viral, Bacterial, and Parasitic Agents among Febrile Patients: A Pilot Study in Kilombero, Tanzania

The use of fever syndromic surveillance in sub-Saharan Africa is an effective approach to determine the prevalence of both malarial and nonmalarial infectious agents. We collected both blood and naso/oro-pharyngeal (NP/OP) swabs from consecutive consenting patients ≥ 1 year of age, with an axillary temperature ≥ 37.5°C, and symptom onset of ≤ 5 days. Specimens were analyzed using both acute febrile illness (AFI) and respiratory TaqMan array cards (Resp TAC) for multiagent detection of 56 different bloodstream and respiratory agents. In addition, we collected epidemiologic data to further characterize our patient population. We enrolled 205 febrile patients, including 70 children (1 < 15 years of age; 34%) and 135 adults (≥ 15 years of age; 66%). AFI TAC and Resp TAC were performed on 191 whole blood specimens and 115 NP/OP specimens, respectively. We detected nucleic acid for Plasmodium (57%), Leptospira (2%), and dengue virus (1%) among blood specimens. In addition, we detected 17 different respiratory agents, most notably, Haemophilus influenzae (64%), Streptococcus pneumonia (56%), Moraxella catarrhalis (39%), and respiratory syncytial virus (11%) among NP/OP specimens. Overall median cycle threshold was measured at 26.5. This study provides a proof-of-concept for the use of a multiagent diagnostic approach for exploratory research on febrile illness and underscores the utility of quantitative molecular diagnostics in complex epidemiologic settings of sub-Saharan Africa.

Emergence of Lassa Fever Disease in Northern Togo: Report of Two Cases in Oti District in 2016

Background

Lassa fever belongs to the group of potentially fatal hemorrhagic fevers, never reported in Togo. The aim of this paper is to report the first two cases of Lassa fever infection in Togo.

Case Presentation

The two first Lassa fever cases occurred in two expatriate's health professionals working in Togo for more than two years. The symptoms appeared among two health professionals of a clinic located in Oti district in the north of the country. The absence of clinical improvement after antimalarial treatment and the worsening of clinical symptoms led to the medical evacuation. The delayed diagnosis of the first case led to a fatal outcome. The second case recovered under ribavirin treatment.

Conclusion

The emergence of this hemorrhagic fever confirms the existence of Lassa fever virus in Togo. After a period of intensive Ebola virus transmission from 2013 to 2015, this is an additional call for the establishment and enhancement of infection prevention and control measures in the health care setting in West Africa.

Quantifying the contribution of Plasmodium falciparum malaria to febrile illness amongst African children

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.

"It is good to take her early to the doctor" - mothers' understanding of childhood pneumonia symptoms and health care seeking in Kilimanjaro region, Tanzania

Background

Pneumonia is among the leading causes of avoidable deaths for young children globally. The main burden of mortality falls on children from poor and rural families who are less likely to obtain the treatment they need, highlighting inequities in access to effective care and treatment. Caretakers’ illness perceptions and care-seeking practices are of major importance for children with pneumonia to receive adequate care. This study qualitatively explores the caretaker concepts of childhood pneumonia in relation to treatment seeking behaviour and health worker management in Moshi urban district, Tanzania.

Methods

In May - July 2013 data was gathered through different qualitative data collection techniques including five focus group discussions (FGDs) with mothers of children under-five years of age. The FGDs involved free listing of pneumonia symptoms and video presentations of children with respiratory symptoms done, these were triangulated with ten case narratives with mothers of children admitted with pneumonia and eleven in-depth interviews with hospital health workers. Transcripts were coded and analysed using qualitative content analysis.

Results

Mothers demonstrated good awareness of common childhood illnesses including pneumonia, which was often associated with symptoms such as cough, flu, chest tightness, fever, and difficulty in breathing. Mothers had mixed views on causative factors and treatments options but generally preferred modern medicine for persisting and severe symptoms. However, all respondent reported access to health facilities as a barrier to care, associated with transport, personal safety and economic constraints.

Conclusion

Local illness concepts and traditional treatment options did not constitute barriers to care for pneumonia symptoms. Poor access to health facilities was the main barrier. Decentralisation of care through community health workers may improve access to care but needs to be combined with strengthened referral systems and accessible hospital care for those in need.

Universal versus conditional three-day follow up visit for children with uncomplicated fever at the community level: design of a cluster-randomized, community-based, non-inferiority trial in Tanganyika, Democratic Republic of Congo

Background

The current recommendation within integrated Community Case Management guidelines that all children presenting with uncomplicated fever and no danger signs be followed up after three days may not be necessary. Such fevers often resolve rapidly (usually within 48–96 h), and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. We aim to determine the non-inferiority of a conditional versus a universal follow-up visit for these children.

Methods

We are conducting a cluster-randomized, community-based, non-inferiority trial enrolling ~4300 children (ages 2–59 months) presenting to community health workers (CHWs) with uncomplicated fever in Tanganyika Province, Democratic Republic of the Congo. Clusters (n = 28) of CHWs are randomized to advise caretakers of such children to either 1) return for a follow-up visit on Day 3 following the initial consultation (Day 1), regardless of illness resolution (as per current guidelines) or 2) return for a follow-up visit on Day 3 only if the child’s signs have not resolved. Enrolled children are followed up at Day 7 for a repeat assessment and recording of the primary outcome of the study, “failure”, which is defined as having fever, diarrhea, pneumonia or decline of health status (e.g. hospitalization, presenting danger signs, or death).

Discussion

The results of this trial will be interpreted in conjunction with a similarly designed trial currently ongoing in Ethiopia. If a follow-up visit conditional on continued illness is shown to be non-inferior to current guidelines stipulating universal follow-up, appropriate updating of such guidelines could reduce time and human resource pressures on both providers and caregivers throughout communities of sub-Saharan Africa and South Asia.

Trial registration

This trial was registered at ClinicalTrials.gov (NCT02595827) on November 2nd, 2015

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

BACKGROUND

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

MAIN BODY

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

CONCLUSION

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

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania's Health System

INTRODUCTION

People in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.

METHODS

Using mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child's respiratory symptoms.

RESULTS AND DISCUSSION

Of 614 household members with a recent acute illness, 73% sought outside care-30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. Although health facilities and ADDOs had similar availability of antimicrobials, ADDOs had more pediatric formulations available (p<0.001). The common perception was that drugs from ADDOs are more expensive, but the difference in the median cost to treat pneumonia was relatively minimal (US$0.26 in a public facility and US$0.30 in an ADDO). Over 20% of households said they had someone with a chronic condition, with 93% taking medication, but ADDOs are allowed to sell very few chronic care-related medicines. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child.

CONCLUSION

ADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.

Malaria and HIV among pediatric inpatients in two Tanzanian referral hospitals: A prospective study

Malaria remains common in sub-Saharan Africa, but it is frequently over-diagnosed and over-treated in hospitalized children. HIV is prevalent in many malaria endemic areas and may delay parasite clearance and increase mortality among children with malaria. This prospective cohort study enrolled children with suspected malaria between 3 months and 12 years of age hospitalized at two referral hospitals in Tanzania. Both a thick blood smear (BS) and a malaria rapid diagnostic test (mRDT) were performed. If discordant results were obtained, PCR was performed for Plasmodium falciparum. Malaria was confirmed if two out of three tests were positive. Malaria parasite densities were determined for two consecutive days after diagnosis and treatment of malaria. All participants were tested for HIV. Among 1492 hospitalized children, 400 (26.8%) were enrolled with suspected malaria infection. There were 196/400 (49.0%) males, and the median age was 18 [9-36] months. BS was positive in 95/400 (23.8%), and mRDT was positive in 70/400 (17.5%), with moderate agreement (Kappa=0.598). Concordant results excluded malaria in 291/400 (72.8%) and confirmed malaria in 56/400 (14.0%). PCR performed on 53 discordant results confirmed malaria in 1/39 of the BS-positive/mRDT-negative cases, and 6/14 of the BS-negative/mRDT-positive cases. The prevalence of confirmed malaria was 63/400 (15.8%). In multivariable logistic regression, malaria was associated with HIV (OR 3.45 [1.65-7.20], p=0.001). Current breastfeeding (OR 0.25 [0.11-0.56], p=0.001) and higher hemoglobin (OR 0.70 [0.60-0.81], p<0.001 per 1g/dL) were associated with decreased odds of malaria. Malaria parasite clearance was delayed in HIV-infected participants (p<0.001). Malaria is over-diagnosed even at referral centers in high transmission areas. Hospitalized HIV-infected children are more likely to have malaria and exhibit delayed clearance of parasites. Hospitals should consider using mRDTs as a first step for malaria testing among hospitalized children in sub-Saharan Africa.

Accuracy of commercially available c-reactive protein rapid tests in the context of undifferentiated fevers in rural Laos

BACKGROUND

C-Reactive Protein (CRP) has been shown to be an accurate biomarker for discriminating bacterial from viral infections in febrile patients in Southeast Asia. Here we investigate the accuracy of existing rapid qualitative and semi-quantitative tests as compared with a quantitative reference test to assess their potential for use in remote tropical settings.

METHODS

Blood samples were obtained from consecutive patients recruited to a prospective fever study at three sites in rural Laos. At each site, one of three rapid qualitative or semi-quantitative tests was performed, as well as a corresponding quantitative NycoCard Reader II as a reference test. We estimate the sensitivity and specificity of the three tests against a threshold of 10 mg/L and kappa values for the agreement of the two semi-quantitative tests with the results of the reference test.

RESULTS

All three tests showed high sensitivity, specificity and kappa values as compared with the NycoCard Reader II. With a threshold of 10 mg/L the sensitivity of the tests ranged from 87-98 % and the specificity from 91-98 %. The weighted kappa values for the semi-quantitative tests were 0.7 and 0.8.

CONCLUSION

The use of CRP rapid tests could offer an inexpensive and effective approach to improve the targeting of antibiotics in remote settings where health facilities are basic and laboratories are absent. This study demonstrates that accurate CRP rapid tests are commercially available; evaluations of their clinical impact and cost-effectiveness at point of care is warranted.

Community prevalence of fever and relationship with malaria among infants and children in low-resource areas

We used Demographic and Health Survey data to describe the 2-week period prevalence of fever, cough, and diarrhea among children aged < 5 years in low-resources areas. We then explored the relationship between prevalence of isolated fever and national malaria risk. Fever and isolated fever occurred in 26.7% and 7.0% of children, respectively, and was not fully explained by malaria.

Aetiology of acute febrile episodes in children attending Korogwe District Hospital in north-eastern Tanzania

Introduction

Although the burden of malaria in many parts of Tanzania has declined, the proportion of children with fever has not changed. This situation underscores the need to explore the possible causes of febrile episodes in patients presenting with symptoms at the Korogwe District Hospital (KDH).

Methods

A hospital based cross-sectional study was conducted at KDH, north-eastern Tanzania. Patients aged 2 to 59 months presenting at the outpatient department with an acute medical condition and fever (measured axillary temperature ≥37.5°C) were enrolled. Blood samples were examined for malaria parasites, human immunodeficiency virus (HIV) and bacterial infections. A urine culture was performed in selected cases to test for bacterial infection and a chest radiograph was requested if pneumonia was suspected. Diagnosis was based on both clinical and laboratory investigations.

Results

A total of 867 patients with a median age of 15.1 months (Interquartile range 8.6–29.9) were enrolled from January 2013 to October 2013. Respiratory tract infections were the leading clinical diagnosis with 406/867 (46.8%) of patients diagnosed with upper respiratory tract infection and 130/867 (15.0%) with pneumonia. Gastroenteritis was diagnosed in 184/867 (21.2%) of patients. Malaria infection was confirmed in 72/867 (8.3%) of patients. Bacterial infection in blood and urine accounted for 26/808 (3.2%) infections in the former, and 66/373 (17.7%) infections in the latter. HIV infection was confirmed in 10/824 (1.2%) of patients. Respiratory tract infections and gastroenteritis were frequent in patients under 36 months of age (87.3% and 91.3% respectively). Co-infections were seen in 221/867 (25.5%) of patients. The cause of fever was not identified in 65/867 (7.5%) of these patients.

Conclusions

The different proportions of infections found among febrile children reflect the causes of fever in the study area. These findings indicate the need to optimise patient management by developing malaria and non-malaria febrile illnesses management protocols.

Deconstructing "malaria": West Africa as the next front for dengue fever surveillance and control

Presumptive treatment of febrile illness patients for malaria remains the norm in endemic areas of West Africa, and "malaria" remains the top source of health facility outpatient visits in many West African nations. Many other febrile illnesses, including bacterial, viral, and fungal infections, share a similar symptomatology as malaria and are routinely misdiagnosed as such; yet growing evidence suggests that much of the burden of febrile illness is often not attributable to malaria. Dengue fever is one of several viral diseases with symptoms similar to malaria, and the combination of rapid globalization, the long-standing presence of Aedes mosquitoes, case reports from travelers, and recent seroprevalence surveys all implicate West Africa as an emerging front for dengue surveillance and control. This paper integrates recent vector ecology, public health, and clinical medicine literature about dengue in West Africa across community, regional, and global geographic scales. We present a holistic argument for greater attention to dengue fever surveillance in West Africa and renew the call for improving differential diagnosis of febrile illness patients in the region.