Fever episodes in a holoendemic malaria area of Tanzania: parasitological and clinical findings and diagnostic aspects related to malaria.

All episodes of acute illness, in children aged 0-9 years, were registered during 3 years in a health clinic in a village of about 500 inhabitants in a malaria holoendemic area on the Tanzanian coast. Of 668 clinical episodes, 395 were diagnosed as malaria. There was no death. Only 5% of the children with malaria episodes came to the clinic after more than 3 d of symptoms. All 11 severe anaemias occurred among these children. Fever was reported in 98%, vomiting in 15%, and diarrhoea in 8% of the malaria episodes. Intermittent fever was reported in 98% of the malaria patients with more than one day of fever, compared to 4% of those with other febrile illnesses. Parasite densities > or = 10,000/microliters were found in 48% of the malaria episodes. Densities > or = 400/microliters were found in 96% of the malaria episodes and in only 8% of the other febrile illnesses. The 16 malaria episodes (4%) with densities below that level were all in children under one year of age. The ability of the rural medical aid or the doctor to differentiate malaria episodes from other febrile illnesses without microscopical examination was limited. Although very few malaria episodes were missed, substantial over-diagnosis resulted in specificity values of only 13% and 52% for their respective malaria diagnoses. It is concluded that intermittent fever was strongly associated with malaria, but a high accuracy of malaria diagnosis in febrile children requires microscopical examination.(ABSTRACT TRUNCATED AT 250 WORDS)     

Assessment of the underestimation of childhood diarrhoeal disease burden in Israel

We determined the extent by which mandatory reporting on isolates of Shigella and Salmonella underestimates the burden of diarrhoeal diseases in individuals aged <17 years in Israel and examined paediatricians' knowledge, attitudes and practices related to patient visits with diarrhoeal diseases. Sources of data were a nationwide population-based telephone survey for presence of diarrhoeal diseases, Maccabi Healthcare Services databases and a mail survey among its paediatricians. Monte Carlo simulation and rate estimates for all stages, from visit to physician to reporting on a culture-confirmed case of shigellosis or salmonellosis, were used to determine the underestimation factor. Of 1492 children, 5·7% reported a diarrhoeal episode during the 2 weeks prior to interview. The rate of visiting a physician with and without fever was 86% and 16%, respectively. A stool culture was performed for around 20% of patients and the isolation rates were 7·1% for Shigella and 2·1% for Salmonella. Paediatricians (n=214) ranked very young age of patient and the complaint 'bloody diarrhoea' as the most important determinants. We estimated that one reported isolate of Shigella or Salmonella represented 152 diarrhoeal episodes of all aetiologies. This estimate is important for further assessments of the true burden of diarrhoeal diseases.     

我国15省0~6岁儿童两周患病情况分析

目的 通过调查我国0~6岁儿童常见疾病及症状的发生情况,分析我国儿童目前的健康水平及存在的主要健康问题,为儿童疾病的预防、保健措施制定提供依据。方法 通过多阶段分层随机抽样在全国15个省抽取43 370名6岁以下儿童,采用家长问卷进行调查,采用SPSS 13.0对数据进行统计分析。结果 我国0~6岁儿童家长自报两周患病率为22.35%,男童高于女童,城市高于农村,不同年龄组、东中西部地区间差异有统计学意义。呼吸系统疾病的两周患病率为4.48%,占各系统两周患病总和的74.68%;发热、咳嗽、腹泻等是儿童常见的疾病症状,两周发生率分别为9.62%、9.39%和6.43%。结论 0~6岁儿童两周患病率在不同年龄、城乡、地区间差异提示应加强婴儿常见病的防治,针对儿童呼吸和消化系统疾病防治以及发热、咳嗽、腹泻等疾病症状的处理,开展有针对性的防治工作。     

Childhood mortality and probable causes of death using verbal autopsy in Niakhar, Senegal, 1989-2000

BACKGROUND: In African rural settings, medically certified information on causes of death is largely lacking. The authors applied the verbal autopsy to identify causes of death before 15 years old in a rural area of Senegal where a demographic surveillance system is operating. METHODS: Between 1989 and 2000, a postmortem interview was conducted using a standardized questionnaire which was independently reviewed by two physicians who assigned the probable underlying cause of death. Discordant diagnoses were discussed by a panel of physicians. Causes of death were grouped into a few categories; cause-specific mortality rates and fractions were generated. RESULTS: Between 1989 and 1997, all-cause mortality fluctuated. Diarrhoeal diseases, malaria and acute respiratory infections explained between 30% and 70% of the mortality before 10 years of age. In children 1-9 years old, malaria death rate increased between 1989 and 1994 and thereafter did not change. The 1998-2000 years were marked by a peak in mortality, attributed to a meningitis outbreak in children more than one year old paralleled by an increase in death rate from fever of unknown origin, diarrhoeal diseases, and acute respiratory infections in children under 5 years. CONCLUSIONS: Verbal autopsy provided useful information on the mortality structure responsible for the 1998-2000 peak in mortality. It underlined that, outside outbreak situations, malaria was a leading cause of death for 1-9 year old children and that diarrhoea, acute respiratory infections, or fever from unknown origin accounted for up to 50% of the deaths among the children under 5 years.     

Lifestyles and Practices that Enhance Malaria and Typhoid Fever in Njoro District, Kenya

Unhygienic practices have been associated with the spread of parasitic and bacterial infections in rural areas. This study was designed to verify the link between the frequencies of malaria and typhoid fever with selected rural practices in Njoro District, Kenya. A cross-sectional study involving observations, questionnaires and interviews was conducted to determine the socio-economic variables and practices/lifestyles in 336 randomly selected homesteads. Frequencies of malaria and typhoid fever in two randomly selected health centers were determined through a retrospective study for the period from 2004 to 2009. The respondents had large families (68%), low education level (67%) and high responsibility burden (67%). Individuals who did not boil drinking water constituted 61%. Boiling drinking water was less common among the poor, Odds Ratio (OR) of 2.36, χ² = 9.88, 95% Confidence Interval (CI) of 1.38–4.03. Respondents who washed their hands in a basin after using the latrines comprised 79.8% while 4.8% did not. 18.5% of the respondents did not use a soap to wash their hands after using the latrine. One third (33.6%) of the homesteads had dirty and inappropriate pit latrines while 2.7% of the homesteads lacked latrines. Failure to use mosquito bed nets was more likely to occur among the poor respondents, OR of 1.44, χ² = 1.74, 95% CI of 0.84–2.48. The frequencies of malaria and typhoid fever were an average of 29 and 24% respectively. Malaria and typhoid fever cases were relatively frequent due to adoption of inappropriate lifestyles and practices that predisposed the residents to infectious agents. Poverty seemed to play a significant role in the spread of malaria and typhoid fever.     

A comparative study of the nutritional status,parasitic infections and health of male roadworkers in four areas of Kenya

The nutritional status, parasitic infections and general health of 801 male roadworkers living in four different areas of Kenya, namely, the highlands, coastal lowlands, Lake Victoria basin and the semiarid north-west, were investigated. Undernutrition was common in all areas but was most marked among men in the semi-arid area. Anaemia was most prevalent in the coastal lowlands where 41% of men had a haemoglobin level less than 13·0 g/dl. Hookworm eggs were seen in the faeces of 40% of all men and in 69% of samples collected in the coastal lowlands. The Lake Victoria basin was a significant focus of infection with Schistosoma mansoni, 51% of faecal samples containing its eggs; S. haematobium also occurred but was most common in the coastal lowlands. Stages of Plasmodium spp. were most commonly observed in blood smears collected from men near Lake Victoria and the coast, two significant foci of malaria. An analysis of variance was used to examine the relationship between variables and indicated that the most significant association was between hookworm infections and low haemoglobin levels.     

Differing health and health-seeking behaviour: ethnic minorities of the Chittagong Hill Tracts,Bangladesh

This study investigates the health and health-seeking behaviour of the indigenous population of Chittagong Hill Tracts, Bangladesh by surveying 2,550 randomly selected households from five major ethnic groups residing in the region. A structured questionnaire was used for collecting data. Morbidity prevalence (23%) and child malnutrition (19%) was highest among Bangalis. Fever (40%), diarrhoeal diseases (37%) and malaria (16%) were the three most common illnesses reported among the study population. Around fifteen percent of the Bangalis sought care from the paraprofessionals while 'unqualified' allopaths were consulted more frequently by the Tripuras, Chakmas and the Marmas (60-70%). Qualified allopaths were mostly consulted by the Bangalis (26%). Sex, types of illness, ethnicity, household head's education and household's landholding were significant predictors of seeking treatment, and allopathic treatment in particular. The findings on the differential health and health-seeking behaviour among ethnic groups should help in the designing of any future health interventions in the area.     

Does malnutrition predispose to diarrhoea during childhood? Evidence from a longitudinal study in Matlab, Bangladesh

It is posited that diarrhoeal illness during one period has influence on diarrhoeal illness in a subsequent period. This relationship may potentially mask the association between malnutrition and subsequent diarrhoea. To test this, we analysed data on cross-sectional anthropometry in combination with data on diarrhoeal morbidity collected longitudinally in a community-based study of 1262 children (aged 6-60 months) during March-December, 1976, in Matlab, Bangladesh. The results confirmed the posited relationship between diarrhoeal morbidities in two consecutive periods and showed that the risks of diarrhoeal attack and longer diarrhoeal illness increased more than threefold during the 2 months following diarrhoeal illness during the preceding 2 months (previous diarrhoea). Children with no previous diarrhoea indicated a positive association between malnutrition and subsequent diarrhoea, but the pattern found among children with previous diarrhoea was not understandable. Logistic regression analyses performed separately for younger and older children showed that controlling for effects of previous diarrhoea, maternal illiteracy and household poverty, severe malnutrition as assessed by weight-for-age was found to be strongly associated with the risk of longer diarrhoeal illness in a 2-month interval in the age group 24-60 months; in the same age group the association with the risk of diarrhoeal attack was significant at the 10 per cent level. No such association for malnutrition, however, was found in the age group 6-23 months.     

Malaria: knowledge and behaviour in an endemic rural area of Turkey

This cross-sectional study was conducted to determine the knowledge and behaviour of people in the Sanliurfa province of Turkey regarding the prevention of malaria. A modified 30-cluster sampling method based on the traditional Expanded Programme for Immunization coverage surveys was employed to select a representative sample from 210 households. A questionnaire that focused on sociodemographic characteristics, knowledge and behaviour of malaria prevention, treatment-seeking behaviour and the use of antimalarials was applied. Eighty-nine percent of respondents knew at least one of the classical symptoms of malaria, and fever and chills were the most commonly reported symptoms (78.6%). Of the people interviewed, 33% believed that malaria can be acquired from dirty water, by changing place of residence, by working in cotton or tomato fields, or from malaria patients' belongings. None of the respondents knew how mosquitoes acquire the parasite. Twenty-five percent of respondents believed that elimination of breeding sites was one way to prevent malaria, and 8% identified the use of bednets. Fifty-five percent of respondents reported protective behaviours that are not directly associated with malaria transmission. Almost 47% of respondents reported that they completed their antimalarials, and only 21% of respondents indicated that they would seek treatment for febrile disease from physicians or a malaria unit. Understanding community perceptions of aetiology, symptom identification and treatment of malaria is an important step towards disease control.     

Child mortality in a collapsing African society.

A cohort study of mortality among under-5-year-olds was carried out in two Somali villages in 1987-89, a period of economic and political collapse in the rural parts of the country. Analysed was the relative importance of the social characteristics for under-5-year-old mortality against a background of deteriorating political and economic conditions. Mortality increased among under-5-year-olds from 1987 (211 per 1000) to 1988 (323 per 1000) to 1989 (414 per 1000). The mortality risk was more pronounced for boys than girls and was more so for infants than children aged 1-4 years. The major signs prior to death were respiratory infections, diarrhoeal diseases, fever/malaria and tetanus in the neonatal period. Over the 3-year study period mortality rates for diarrhoeal diseases increased significantly, while those for respiratory infections and diseases preventable by immunization increased more slowly. The increasing trend in under-5-year-old mortality was more pronounced in instances when the mother derived her major income from sources other than farming and in larger households.     

Risk factors for drowning and near-drowning among children in Hillsborough County,Florida.

The authors obtained data from 700 households in Hillsborough County, FL, in a telephone random survey to determine risk factors for incidents of drowning and near-drowning among children in the county. The survey was conducted from August through December 1991. A combination of forced-choice and open-ended questions was used to assess adults'' drowning-related knowledge, attitudes, and prevention behaviors, as well as the incidence of and the circumstances surrounding drowning and near-drowning among children who lived in those households. The results showed that although most respondents had some knowledge of the epidemiology of drowning and near-drowning among children, deficits were noted in their knowledge of the importance of adult supervision and the recommended age at which to begin children''s swimming instruction. Results showed a need for isolation fencing, that which separates a swimming pool from a house and yard. Most respondents reported that they did not know how to perform cardiopulmonary resuscitation (CPR) on an infant or child. More than 40 percent reported not knowing how to perform CPR on an adult. Respondents reported no drowning or near-drowning incidents among children of their household within the last 3 years. However, the respondents did describe water-related immersions that involved children who experienced difficulty in the water, but recovered by themselves or with the aid of a nearby person. In some instances the child''s breathing pattern was altered. There were three episodes during which difficulty in breathing occurred. The respondents reported a total of nine childhood water-immersion episodes within their families, none of which had been reported to treatment facilities. Recommendations are provided for programs for prevention of childhood drowning.     

Diagnosis and management of febrile children using the WHO/UNICEF guidelines for IMCI in Dhaka, Bangladesh.

OBJECTIVE: To determine whether the fever module in the WHO/UNICEF guidelines for the integrated management of childhood illness (IMCI) identifies children with bacterial infections in an area of low malaria prevalence. METHODS: Physicians assessed a systematic sample of 669 sick children aged 2-59 months who presented to the outpatient department of Dhaka Shishu Hospital, Bangladesh. FINDINGS: Had IMCI guidelines been used to evaluate the children, 78% of those with bacterial infections would have received antibiotics: the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%) and urinary tract infection (83%); and 50% or less of children with bacteraemia (50%), dysentery (48%), and skin infections (30%). The current fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot, and have a history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current IMCI module. CONCLUSIONS: In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.     

Self-reported influenza-like illness during the 2009 H1N1 influenza pandemic--United States, September 2009 - March 2010

CDC identified the first case of 2009 H1N1 pandemic influenza on April 15, 2009. During the first 3 months of the outbreak, approximately 43,000 cases were reported to CDC. In June 2009, the World Health Organization declared the outbreak an influenza pandemic. Because no existing influenza surveillance system in the United States monitored influenza-like illness (ILI) among persons with ILI who did not seek health care, CDC initiated community-based surveillance of self-reported ILI (defined as the presence of fever with cough or sore throat) and health-care--seeking behavior through a supplementary module of the Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes results from BRFSS surveys conducted during September 2009--March 2010. Among 216,431 adults and 43,511 children (aged <18 years), the average monthly percentage of respondents reporting ILI in the 30 days preceding the interview was 8.1% among adults (range: 5.5% for September interviews to 9.5% for November) and 28.4% among children (range: 20.4% for September interviews to 35.9% for November). Health care was sought by 40% of adults and 56% of children with self-reported ILI. The results indicate that reported symptoms of ILI were widespread during the 2009--10 influenza season, with a substantial percentage of those reporting ILI seeking health care.     

Mother-father concordance on treatment choices in the care of sick children under five years of age in Osun state, Nigeria

Communication and agreement between spouses has been found to be an important factor in terms of acceptance and use of family planning services and supplies. Therefore, it is likely that agreement between spouses may play an important role in other aspects of family health, including care of childhood illness. This study, based in a rural and an urban community in Osun State, Nigeria, set out to determine the agreement between mothers and fathers on the illness experience and care provided to their preschool age children. Among the 550 couples studied, most mothers (98%) and fathers (94%) reported that they "did something" to help during their child's recent illness. The illness was recognized first by the mothers according to 83% of respondents. Overall, 81% of couples concurred that the mother was the first to discover the illness. Concurrence was greater in urban areas and where fathers read a newspaper frequently. Only 45% concurred on who took the decision for first action to address the illness, which again was greater in the urban area and in families where the father read a newspaper frequently. Parents also were not in full agreement about the name of the child's illness, but concurrence was greater in the case of malaria/fever. Finally, concurrence on the actual first form of treatment care reached only 36%. Most concurrent couples and non-concurrent mothers mentioned drug shops/chemists as the first source of care, while non-concurrent fathers placed government clinics first. While mothers are likely to be the main caregivers, fathers do have decision making and financial roles. Not only should health education for appropriate and prompt care of child illnesses be aimed equally are both parents, it should also recognize that fathers may have different perceptions from mothers. Education should also encourage better couple communication.     

前往疟疾疫区的出国劳工对疟疾相关知识、态度及行为调查

〔目的〕了解前往疟疾疫区的出国劳工对疟疾防治知识的知晓状况,为建立有效的疟疾宣传教育模式提供依据。〔方法〕对2009年6—11月到广东国际旅行卫生保健中心进行出国体检的265名前往疟疾疫区的劳工(不含船员)采用自行设计的问卷进行调查。〔结果〕前往疟疾疫区的劳工265人中初中及初中以下文化程度占46.7%,高中以上文化程度占37.9%。出国后将从事野外和户外工作占46.4%。有6.9%的人认为疟疾为非传染病,36.0%不清楚疟疾是否有传染性;仅49.4%知道蚊虫与疟疾相关;47.5%知道发热为疟疾的主要临床表现;仅22.9%的人知道目前常用的防疟方法是防蚊和携带紧急情况下使用的治疗药物,19.2%的人知道可口服药物进行疟疾预防。〔结论〕出国劳工对疟疾防治知识认识匮乏,在出国劳工中开展疟疾宣传教育活动是十分必要的。     

Evaluating a malaria intervention strategy using knowledge, practices and coverage surveys in rural Bolifamba, southwest Cameroon

We evaluated the impact of a malaria intervention in Bolifamba in rural Cameroon. The intervention consisted of educating the community on management of malaria and provision of a dispensary for early diagnosis and treatment. In July 2001, prior to the intervention, a questionnaire was used to obtain information on knowledge of and practices toward childhood malaria of 185 mothers of children aged 0-5 years. The same questionnaire was administered to 120 of the 185 mothers, one-year post-intervention. Clinical and laboratory investigations were carried out on children whose mothers were interviewed. A comparison of pre- and post-intervention data indicated significant changes in (i) the use of appropriate malaria treatment (from 50% to 81.7%); (ii) recognition of splenomegaly as a feature of malaria (from 18.4% to 80.8%); (iii) prevalence of splenomegaly (from 26.5% to 13.3%); (iv) prevalence of fever (from 27.8% to 13.3%); (v) parasite prevalence (from 60.5% to 44.2%) and (vi) severe malaria anaemia (from 2.6% to 0.0%). These findings revealed that proper education of villagers, particularly mothers, on malaria and the presence of health facilities, where treatment is readily available at affordable cost, close to villages, are important strategies that would reduce malaria morbidity and mortality significantly.     

Tumor necrosis factor-alpha promoter variant 2 (TNF2) is associated with pre-term delivery, infant mortality, and malaria morbidity in western Kenya: Asembo Bay Cohort Project IX.

A polymorphism in the promoter region of the tumor necrosis factor-alpha (TNF-alpha) gene, with a guanine to adenine nucleotide change at position -308, TNF2 is associated with increased TNF-alpha production. TNF2 homozygotes have a higher risk of severe disease and/or death due to cerebral malaria and other infectious diseases. We investigated the impact of this allele on malaria morbidity and mortality in young children who participated in an immuno-epidemiologic cohort study of malaria in an area of intense perennial Plasmodium falciparum transmission in western Kenya. A total of 1,048 children were genotyped. Poisson regression and Cox proportional hazards models were used to determine the relationship between TNF-308 variants and morbidity and mortality. The gene frequencies of the TNF1 and TNF2 alleles were 0.90 and 0.10, respectively. TNF2 homozygosity was associated with pre-term birth when compared with TNF1 homozygotes [relative risk (RR) 7.3, 95% CI, 2.85-18.9, P = 0.002) and heterozygotes (RR 6.7, 95% CI 2.0-23.0, P = 0.008). Among children born prematurely, the TNF2 allele was significantly associated with a higher risk of death in infancy compared with TNF1 (RR 7.47, 95% CI 2.36-23.6). The risk of death was higher among TNF2 homozygotes than among heterozygotes. The TNF2 allele was significantly associated with high density P. falciparum parasitemia (RR 1.11, 95% CI 1.0-1.24). Among low birth weight children, the TNF2 allele was associated with severe anemia (RR 2.16, 95% CI 1.17-4.01) and showed a trend toward a risk for severe malaria anemia (RR 1.99, 95% CI 0.89-4.46). These data suggest that TNF2 is a risk factor for pre-term birth and early childhood mortality and malaria morbidity in children in this region. Further understanding of the pathogenic mechanisms underlying this association is required.     

Childhood malaria in Africa

300-400 million acute cases of malaria occur annually worldwide. There are 1-2 million deaths per year globally, primarily in children. Over 80% of the world's cases of malaria occur in Africa. Early diagnosis and prompt treatment are essential. Since 92% of childhood deaths occur at home, mothers and caretakers must be informed about the symptoms of malaria and seek treatment. Cumbersome diagnostic policies, unstable supplies of drugs, high costs (time, transport, and fees), and traditional beliefs about malaria discourage people who are seeking treatment. Since many childhood diseases that cause fever overlap with malaria, a single therapy treating both illnesses is recommended. Prompt diagnosis can be achieved by better training in recognition of clinical signs and by improved laboratory testing. Simple, effective guidelines on the management of malaria are needed by the health services and the private sector. Laboratory diagnosis is important because of drug resistance and seasonal differences. Based on clinical symptoms alone, 54.2% of cases were correctly diagnosed in the Sahel during the rainy season; 3.6% were in the dry season. Hospitalization is recommended for severe cases of malaria; however, most people in Africa are unable to afford the cost of transportation and hospitalization. Because of this, preliminary treatment should begin at the health facility. For children, intramuscular quinine is as effective as that given intravenously. Alternate injection sites are required. An alternative antimalarial is sulfadoxine-pyrimethamine. Clinical improvement is maintained and the increase in hemoglobin is greater than with chloroquine. In areas where R-III resistance to chloroquine exists (more than 5-10% of cases do not show clinical improvement that lasts more than 14 days or sufficient hematological recovery), the therapy for Plasmodium falciparum malaria should be changed. The aforementioned combination therapy is more expensive than chloroquine, but the savings achieved due to the decreased need for repeated treatment and patient transport, the less severe anemia, and the reduced morbidity and mortality would offset the cost. National guidelines need to be developed.     

The treatment of falciparum malaria in African children

More than 80% of all cases of malaria and malaria-related mortality worldwide occur in Africa, due mostly to infection with Plasmodium falciparum. Up to half of all mortality among African children aged 6 months to 5 years may be due to malaria. While prevention measures against malaria infection remain important, the prompt diagnosis and treatment of the disease remain key to reducing the high incidence of malaria-related mortality. It is possible that any patient with a febrile illness in a malaria-endemic area and parasites on the peripheral blood film has malaria. All patients who present with fever and parasites on peripheral blood film need to be carefully clinically assessed, with care given to exclude other causes of fever which could be mistaken for malaria. Both microscopy and the available dipstick tests to detect malaria have limited practical use in diagnosing malaria in febrile African children. First-line treatment, severe malaria, and the future are discussed. A cheap, effective, and safe alternative to chloroquine, Fansidar, and amodiaquine is needed to treat malaria in children in Africa. Multi-drug therapy may be necessary to reduce the emergence of drug-resistant organisms.