title: Etiology of severe non-malaria febrile illness in Northern Tanzania: a prospective cohort study.
abstract: BACKGROUND
  The syndrome of fever is a commonly presenting complaint among persons seeking healthcare in low-resource areas, yet the public health community has not approached fever in a comprehensive manner. In many areas, malaria is over-diagnosed, and patients without malaria have poor outcomes.
  
  
  RESULTS
  We prospectively studied a cohort of 870 pediatric and adult febrile admissions to two hospitals in northern Tanzania over the period of one year using conventional standard diagnostic tests to establish fever etiology. Malaria was the clinical diagnosis for 528 (60.7%), but was the actual cause of fever in only 14 (1.6%). By contrast, bacterial, mycobacterial, and fungal bloodstream infections accounted for 85 (9.8%), 14 (1.6%), and 25 (2.9%) febrile admissions, respectively. Acute bacterial zoonoses were identified among 118 (26.2%) of febrile admissions; 16 (13.6%) had brucellosis, 40 (33.9%) leptospirosis, 24 (20.3%) had Q fever, 36 (30.5%) had spotted fever group rickettsioses, and 2 (1.8%) had typhus group rickettsioses. In addition, 55 (7.9%) participants had a confirmed acute arbovirus infection, all due to chikungunya. No patient had a bacterial zoonosis or an arbovirus infection included in the admission differential diagnosis.
  
  
  CONCLUSIONS
  Malaria was uncommon and over-diagnosed, whereas invasive infections were underappreciated. Bacterial zoonoses and arbovirus infections were highly prevalent yet overlooked. An integrated approach to the syndrome of fever in resource-limited areas is needed to improve patient outcomes and to rationally target disease control efforts.
authors.affiliation: Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA. john.crump@duke.edu
authors.forename: John A
authors.initials: JA
authors.lastname: Crump
authors.forename: Anne B
authors.initials: AB
authors.lastname: Morrissey
authors.forename: William L
authors.initials: WL
authors.lastname: Nicholson
authors.forename: Robert F
authors.initials: RF
authors.lastname: Massung
authors.forename: Robyn A
authors.initials: RA
authors.lastname: Stoddard
authors.forename: Renee L
authors.initials: RL
authors.lastname: Galloway
authors.forename: Eng Eong
authors.initials: EE
authors.lastname: Ooi
authors.forename: Venance P
authors.initials: VP
authors.lastname: Maro
authors.forename: Wilbrod
authors.initials: W
authors.lastname: Saganda
authors.forename: Grace D
authors.initials: GD
authors.lastname: Kinabo
authors.forename: Charles
authors.initials: C
authors.lastname: Muiruri
authors.forename: John A
authors.initials: JA
authors.lastname: Bartlett
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001419:Bacteria / Q000145:classification / Q000302:isolation & purification; D001424:Bacterial Infections / Q000453:epidemiology*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005335:Fever of Unknown Origin / Q000453:epidemiology* / Q000209:etiology*; D005658:Fungi / Q000145:classification / Q000302:isolation & purification; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000453:epidemiology*; D011446:Prospective Studies; D013636:Tanzania / Q000453:epidemiology; D014777:Virus Diseases / Q000453:epidemiology*; D014780:Viruses / Q000145:classification / Q000302:isolation & purification; D055815:Young Adult