The relationship between reported fever and Plasmodium falciparum infection in African children.
BACKGROUND
Fever has traditionally served as the entry point for presumptive treatment of malaria in African children. However, recent changes in the epidemiology of malaria across many places in Africa would suggest that the predictive accuracy of a fever history as a marker of disease has changed prompting calls for the change to diagnosis-based treatment strategies.


METHODS
Using data from six national malaria indicator surveys undertaken between 2007 and 2009, the relationship between childhood (6-59 months) reported fever on the day of survey and the likelihood of coincidental Plasmodium falciparum infection recorded using a rapid diagnostic test was evaluated across a range of endemicities characteristic of Africa today.


RESULTS
Of 16,903 children surveyed, 3% were febrile and infected, 9% were febrile without infection, 12% were infected but were not febrile and 76% were uninfected and not febrile. Children with fever on the day of the survey had a 1.98 times greater chance of being infected with P. falciparum compared to children without a history of fever on the day of the survey after adjusting for age and location (OR 1.98; 95% CI 1.74-2.34). There was a strong linear relationship between the percentage of febrile children with infection and infection prevalence (R2 = 0.9147). The prevalence of infection in reported fevers was consistently greater than would be expected solely by chance and this increased with increasing transmission intensity. The data suggest that in areas where community-based infection prevalence in childhood is above 34-37%, 50% or more of fevers are likely to be associated with infection.


CONCLUSIONS
The potential benefits of diagnosis will depend on the prevalence of infection among children who report fever. The study has demonstrated a predictable relationship between parasite prevalence in the community and risks of infection among febrile children suggesting that current maps of parasite prevalence could be used to guide diagnostic strategies in Africa.
Okiro
Emelda A
EA
Malaria Public Health & Epidemiology Group, Centre for Geographic Medicine Research - Coast, Kenya Medical Research Institute/Wellcome Trust Research Programme, PO Box 43640, 00100 GPO, Nairobi, Kenya. eokiro@nairobi.kemri-wellcome.org
Snow
Robert W
RW
D000349:Africa; D000962:Antimalarials / Q000627:therapeutic use; D044383:Black People; D001831:Body Temperature; D002675:Child, Preschool; D005260:Female; D005334:Fever / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology / Q000469:parasitology; D008297:Male; D018512:Parasitemia / Q000453:epidemiology* / Q000469:parasitology; D010963:Plasmodium falciparum / Q000302:isolation & purification*; D011159:Population Surveillance
D000962:Antimalarials
P N G Med J. 1992 Dec;35(4):298-302
1341091
QJM. 2003 May;96(5):355-62
12702784
Trans R Soc Trop Med Hyg. 1998 Sep-Oct;92(5):527-31
9861370
J Trop Pediatr. 1992 Dec;38(6):295-8
1844088
J Trop Pediatr. 2001 Aug;47(4):230-8
11523765
BMJ. 2004 Nov 20;329(7476):1212
15542534
J Infect Dis. 2005 Jun 1;191(11):1932-9
15871128
PLoS Med. 2009 Mar 24;6(3):e1000048
19323591
Infect Immun. 2009 May;77(5):1917-23
19223480
Trop Med Int Health. 2001 Jun;6(6):423-8
11422955
Am J Trop Med Hyg. 2006 Jun;74(6):972-8
16760506
Trans R Soc Trop Med Hyg. 1993 Nov-Dec;87(6):662-5
8296367
Lancet. 2009 Jan 3;373(9657):58-67
19019422
Bull World Health Organ. 2001;79(1):28-32
11217664
Lancet. 1991 Nov 23;338(8778):1292-5
1682686
Trop Med Int Health. 2002 Jan;7(1):45-52
11851954
Lancet. 1996 Jan 27;347(8996):223-7
8551881
Acta Trop. 1994 Dec;58(3-4):267-73
7709865
Trans R Soc Trop Med Hyg. 1992 Sep-Oct;86(5):479-82
1475809
Am J Trop Med Hyg. 2009 Jun;80(6):882-8
19478243
Lancet. 1997 Sep 13;350(9080):781
9298000
Stat Med. 1994 Nov 30;13(22):2345-58
7855468
Pediatr Infect Dis J. 2008 Apr;27(4):319-24
18316995
Lancet. 2008 Nov 1;372(9649):1545-54
18984187
Lancet. 2008 Nov 1;372(9649):1555-62
18984188
Trans R Soc Trop Med Hyg. 1998 May-Jun;92(3):300-4
9861403
Am J Trop Med Hyg. 1999 Apr;60(4):641-8
10348241
Bull World Health Organ. 1997;75 Suppl 1:7-24
9529714
PLoS Med. 2009 Jan 6;6(1):e252
19127974
Am J Trop Med Hyg. 2009 Jan;80(1):133-40
19141851
Trop Med Int Health. 2008 Feb;13(2):218-28
18304268
Am J Trop Med Hyg. 2010 Feb;82(2):215-8
20133994
Trop Med Int Health. 2008 Sep;13(9):1131-42
18631313
Acta Trop. 2004 Apr;90(2):211-4
15177148
BMJ. 1998 Aug 1;317(7154):321
9685279
Trop Med Int Health. 2000 Dec;5(12):876-81
11169277