Factors Associated with Mortality in Febrile Patients in a Government Referral Hospital in the Kenema District of Sierra Leone

There is a paucity of data on the etiologies and outcomes of febrile illness in rural Sierra Leone, especially in the Lassa-endemic district of Kenema. We conducted a retrospective study of patients with subjective or documented fever (T ≥ 38.0°C) who were admitted to a rural tertiary care hospital in Kenema between November 1, 2011 and October 31, 2012. Of 854 patients admitted during the study period, 429 (50.2%) patients had fever on admission. The most common diagnoses were malaria (27.3%), pneumonia (5.1%), and Lassa fever (4.9%). However, 53.4% of febrile patients had no diagnosis at discharge. The in-hospital mortality rate was 18.9% and associated with documented temperature ≥ 38.0°C (adjusted odds ratio [AOR] = 2.89, P = 0.001) and lack of diagnosis at discharge (AOR = 2.04, P = 0.03). Failure to diagnose the majority of febrile adults and its association with increased mortality highlight the need for improved diagnostic capacity to improve patient outcomes.     

驻西非3例华人特殊疟疾病例诊疗体会

疟疾是对全球健康影响最大的传染病,西非是疟疾的高流行地区。本文通过报道我国援塞拉利昂军事医学专家组在塞拉利昂诊治的3例疟疾患者的经验和体会,以期为临床医生在诊治类似疾病时提供参考、借鉴。     

It all began with Ronald Ross: 100 years of malaria research and control in Sierra Leone (1899-1999)

It was in Sierra Leone, 100 years ago in 1899, that human malarial parasites were first observed in wild-caught Anopheles gambiae and An. funestus, the principal vectors of malaria in Africa. In the same year, Ronald Ross initiated the first antilarval measures for malaria control. This paper reviews 100 years of malaria field research and control in Sierra Leone, which became known as the 'White Man's Grave' in the 19th century largely because of the high malaria-related mortality amongst Europeans living there. The establishment of a field laboratory for the Liverpool School of Tropical Medicine in Freetown in 1920 made Sierra Leone the centre for malaria field research in Africa up to and during the Second World War. Eminent malariologists including Ronald Ross, Samuel Christophers, George Macdonald, Leonard Bruce-Chwatt, Brian Maegraith, Ian Macgregor, Brian Greenwood and Michael Service visited Sierra Leone for malaria-related activities. This review highlights the tremendous efforts made towards defining the epidemiological picture of the disease and the most effective means of combatting it. Malaria control in Sierra Leone, as in many other parts of the world, used to be based largely on mosquito eradication. However, experience gained over the past 100 years has shown that mosquito control is often not cost-effective in areas where the interruption of transmission cannot be sustained. Emphasis should now be on early diagnosis, treatment with effective antimalarials, and the selective use of preventive measures including vector control and insecticide-treated materials where they can be sustained.     

Poor Housing Construction Associated with Increased Malaria Incidence in a Cohort of Young Ugandan Children

Despite the use of accepted interventions to combat malaria, such as insecticide-treated bed nets and artemisinin-based combination therapy, malaria remains a leading cause of morbidity and mortality in Uganda. We investigated associations between household factors and malaria incidence in a cohort of children living in a highly endemic region of Uganda. Living in a modern house, defined as the use of non-earth floors, non-thatched roofs, and non-mud walls, was associated with approximately half malaria incidence compared with living in a traditional home (incidence rate ratio [IRR] = 0.54, P = 0.001). Other factors found to be associated with a lower incidence of malaria included living in town versus rural setting; sleeping in a room with openings to the outside (windows, eaves, and airbricks); and having an older and more educated primary caregiver. This study adds to the growing body of evidence that improved house construction may be associated with a lower risk of malaria.     

Apparent drug failure following artesunate treatment of Plasmodium falciparum malaria in Freetown, Sierra Leone: four case reports

Four cases of Plasmodium falciparum malaria who presented in Sierra Leone in November-December 2000 apparently failed to respond to treatment with artesunate. Three (75%) of the cases fulfilled the World Health Organization's criteria for late treatment failure. Although artesunate ranks only sixth as the first-line drug used by clinicians for the treatment of uncomplicated malaria in Sierra Leone, it is widely sold over the counter in pharmacies in the country. The indiscriminate and injudicious use of artesunate among the Sierra Leonean population is likely to increase the level and frequency of resistance among the local strains of P. falciparum. It is recommended that artesunate be reserved for patients who fail to respond to treatment with another of the antimalarial drugs available. Even then, the artesunate should preferably be used in combination with other, longer-acting antimalarial drugs, to slow the development of further resistance.     

塞拉利昂西区拉沙热血清流行病学调查

目的 了解拉沙热在塞拉利昂西区流行和分布情况。方法 用随机抽样的方式采集并检测了820份塞拉利昂西区人群血清中的拉沙热IgG抗体,并分析其分布特征。结果 总体拉沙热IgG抗体阳性率为 28.78%,95%可信区间(Confidence Interval, CI)为25.68%~31.88%。拉沙热阳性率西区郊区43.48%(80/184),高于西区城市24.82%(136/548)(χ²=23.06, P<0.05),差异有统计学意义;不同性别和不同年龄组之间拉沙热阳性率差异无统计学意义。结论 塞拉利昂西区拉沙热总体阳性率较高,且郊区和城市差异明显,应加强环境卫生的改善,加大防鼠灭鼠工作。     

Prevalence of diabetes in rural and urban populations in southern Sierra Leone: a preliminary survey

We conducted a preliminary community survey for diabetes in the Bo district of southern Sierra Leone. Five hundred and one subjects comprising 256 rural adults in two villages and 245 urban adults in Bo town were randomly selected and screened for diabetes using random capillary blood glucose according to WHO criteria. There were 6 diabetics, all in the urban area, giving a prevalence of 2.4% in the urban population, and 0% in the rural villages. The mean (s.d.) capillary random blood glucose (RBG) concentration was 5.7±1.7 mmol/l for the entire study population, while concentrations for the urban and rural populations were 5.8±2 and 5.5±1.4 mmol/l respectively ( P >0.05). RBG increased significantly with age. The mean (s.d.) body mass index (BMI) was 22.3±4.9 kg/m² for the total population while those for the urban and rural populations were 23.0±5.8 and 21.6±3.6 respectively ( P <0.01). Only 5% of the population were obese, i.e. BMI30 kg/m². Dietary habits were similar in both town and country. According to this survey, the prevalence of diabetes is very low in rural Sierra Leone, but urban areas may be experiencing increasing prevalence. Mechanisms for effective screening and promotion of proper diet and exercise must be incorporated into existing health services to prevent an escalation of diabetes in urban Sierra Leone.     

Malaria infection among pregnant women attending antenatal clinics in six Rwandan districts

OBJECTIVES: The aim of the study was to assess the knowledge, attitude and practices of pregnant women towards malaria and their association with malaria morbidity. METHODS: Cross-sectional malaria survey of 1432 pregnant women attending six health centres, each of them situated in a specific health district in Rwanda from September to October 2002. RESULTS: The overall prevalence of malaria infection was 13.6% and all infections but two were caused by Plasmodium falciparum. The six health districts were significantly different in terms of malaria prevalence, which varied between 11.5% and 15.4% in four and was <5% in the other two districts. The prevalence of anaemia and splenomegaly mirrored that of malaria infection. In three districts, the prevalence of infection was significantly higher in primigravidae than in secundigravidae and multigravidae (P = 0.01), while in two others it did not vary with parity. Bed net use was low - only 13.1% of the women had at least one bed net at home and 8.3% of them slept under it - and significantly different between districts. Most women knew that malaria might have serious consequences for their pregnancy and that insecticide-treated bed nets are useful for malaria prevention. However, the bed net market price [1525 Rwandan Francs (RFr), approximately 1.6] was much higher than that considered as affordable and acceptable (389 RFr, approximately 0.3). CONCLUSION: Malaria in pregnancy is a major problem in Rwanda, even in the districts of low transmission. Bed net use among pregnant women is low. The option of providing free insecticide-treated bed nets to pregnant women should be explored and possibly implemented; it could rapidly increase bed net use and earlier attendance to antenatal clinics with clear benefits for the women's health.     

Prevalence and distribution of spotted fever and typhus infections in Sierra Leone and Ivory Coast

A serosurvey for evidence of rickettsial infections was conducted in the rural populations of several tropical rain forest areas in Sierra Leone and Ivory Coast. Seropositivity rates were surprisingly high in both countries, with more than 7% of the individuals in some districts having antibodies to spotted fever-group rickettsiae. No significant difference was found in the overall prevalence of diagnostic antibody titers to spotted fever-group rickettsiae in Sierra Leone (5.3%) and Ivory Coast (6.2%). However, there was a significant difference (p less than 0.001) in the prevalence of diagnostic antibody titers to typhus rickettsiae in the two countries. There were no marked geographic differences within either country in overall prevalence of rickettsial infections, but there were possible area differences in specific seropositivity rates to typhus- and spotted fever-group rickettsiae in Sierra Leone. In both countries, age and sex differences were important in determining seropositivity, but there was no indication of an age-sex interaction. In Sierra Leone, 59 of the 80 positive sera (73.8%) were from persons age 15 or above (p less than 0.001), and 50 of the 80 (62.5%) were from males (p = 0.05). In Ivory Coast, 33 of the 37 positive sera (89.2%) were from the greater than or equal to 15-age group, and 28 of the 37 (75.7%) were from males (p less than 0.001 for both age and sex). The identification of specific areas endemic for these rickettsial diseases should facilitate the diagnosis and treatment of patients with rickettsial illnesses in West Africa.     

The role of traditional treatment on health care seeking by caregivers for sick children in Sierra Leone: Results of a baseline survey

In Sierra Leone, traditional treatment is at times used in lieu of seeking allopathic healthcare for major illnesses causing child death. This paper describes the nature of traditional treatment for diarrhea and fever (presumed malaria). Weighted analysis and multi-logistic regression was applied to a household cluster survey (n = 5951) conducted in 4 districts in June 2010. Using structured questionnaires, heads of households, and caregivers of children under five years of age were interviewed about child morbidity and care seeking. A thematic analysis of qualitative data based on focus group discussions and in-depth interviews with family members from twelve villages in these same four districts, was also done. Illness-specific herbal remedies were described by respondents. Among 1511 children with diarrhea, 31% used traditional treatment. Among 3851 children with fever, 22% used traditional treatment. Traditional treatment for diarrhea was associated with being from a tribe other than the Mende, using government recommended salt sugar solution, not having a vaccine card, having more than two illnesses, and not seeking any allopathic medical treatment for diarrhea. For fever, traditional treatment was associated with being a tribe other than the Mende, having more than two illnesses, not having a vaccine card, Muslim religion, and not seeking any allopathic medical treatment for fever. Qualitatively, respondents describe herbalists as trusted with remedies that are seen to be appropriate due to the perceived cause of illness and due to barriers to seeking care from government providers.The social determinants of traditional treatment use and the prominent role of herbalists in providing them need to be addressed to improve child survival in Sierra Leone.     

Short communication: An assessment of the use of malaria rapid tests by village health volunteers in rural Laos

Rapid malaria diagnosis, a key component of malaria control strategies, is hampered by the expense and training requirements of reliable microscopy. Rapid malaria antigen tests may improve the diagnosis of malaria in the rural tropics. After 1 h training 64 village health volunteers (VHVs) from rural Laos, with no previous laboratory experience, performed two malaria rapid diagnostic tests (ParacheckPf and OptiMAL) accurately. The reliability of six VHVs was assessed longitudinally, over 10 months with different frequencies of retraining. Compared with microscopy, error rates in dipstick interpretation were low (<2%) for both tests and were not associated with retraining frequency (P>0.2). Previously untrained Lao VHVs performed malaria rapid tests reliably with high sensitivity and specificity after minimal training.     

The Role of Laboratory Supervision in Improving the Quality of Malaria Diagnosis: A Pilot Study in Huambo,Angola

In 2006, the Angolan National Malaria Control Program introduced clinical guidelines for malaria case management, which included diagnostic confirmation of malaria before administration of treatment; however, diagnostic practices were inconsistent and of unknown quality. In 2009, a laboratory supervision program was implemented in Huambo Province, with the goal of assessing and improving diagnosis of malaria within the confines of available in-country resources. Supervisions were carried out from 2009 to 2014 using a standardized supervision tool by national laboratory trainers. Data from the first supervision were compared with that from the final supervision. Over the study period, the number and level of training of laboratory technicians increased, and there was a nonstatistically significant trend toward improved laboratory conditions. There was a significant reduction in false-positive microscopy slide reading (P = 0.0133). Laboratory infrastructural capacity to diagnose other communicable diseases, including syphilis, human immunodeficiency virus and hepatitis B virus infections (P = 0.0012, 0.0233 and 0.0026, respectively), also improved significantly. Laboratory supervision for malaria diagnosis found significant areas for improvement, and in combination with concurrent capacity-building activities, it improved the diagnostic capacity for malaria and other diseases. Importantly, this study demonstrates that locally available resources can be used to improve the accuracy of malaria diagnosis.     

Malaria: Diagnosis and treatment of falciparum malaria in travelers during and after travel

Plasmodium falciparum is responsible for most of the mortality in travelers related to imported malaria. Problems that occur during travel include the inaccuracy of a microscopic diagnosis of malaria, both false positives and false negatives, when ill travelers seek care while abroad. A false positive diagnosis can result in unnecessary parenteral injections that carry a risk of transmission of blood-borne pathogens, receipt of potentially dangerous drugs such as halofantrine, or receipt of fake, counterfeit drugs. Increased morbidity and mortality are associated with delays in diagnosis and initiation of prompt treatment for falciparum malaria. Availability of expert microscopy to confirm the diagnosis of malaria is limited. The presence of splenomegaly and thrombocytopenia are strongly associated with malaria and would justify empiric treatment. The availability of atovaquone-proguanil, a safe and well tolerated oral drug, should prompt a reconsideration of current treatment recommendations that discourage empiric treatment on clinical suspicion alone.     

Clinical predictors of malaria and other febrile illnesses in children under five on Pemba Island, Tanzania

Under the current guidelines of presumptive treatment of all children with reported fever, the risk of over-prescribing antimalarial drugs and missing other important causes of fever, like acute respiratory tract infection (ARI), is substantial. Clinical algorithms have been shown to be useful in diagnosing malaria, but often with differing results, due to regional variations. We set out to explore the clinical features associated with malaria compared with other febrile illnesses and specifically severe malaria with ARI in children under five in Pemba. Two hundred and seven children aged six months to five years presenting to a hospital clinic with fever were studied in Pemba. Clinical findings were related to the presence of malaria parasitaemia. Malaria accounted for 67.7% of the febrile episodes investigated. Five symptoms and signs, including pallor, drowsiness, splenomegaly, fever duration and no chest crackles, could accurately predict a case of malaria with a sensitivity of 91.3% and specificity of 53% and positive predictive value of 80.3%. Several clinical features were found to differentiate severe malaria from ARI. These results confirm that clinical algorithms can increase the diagnostic accuracy of malaria, although not sufficiently to replace microscopy, and by promoting the use of clinical skills other treatable causes of febrile illnesses may be identified.These findings could have implications in optimizing treatment and malaria control in children on Pemba.     

Burden of Malaria during Pregnancy at the Time of IPTp/SP Implementation in Gabon

The new recommendations to prevent malaria in pregnant women have recently been implemented in Gabon. There is little information on the pregnancy indicators that are useful for their evaluation. A cross-sectional study for the assessment of the prevalence of peripheral, placental, and cord malaria and anemia among delivering women was performed at the largest public hospital of Gabon. Malaria prevalence was 34.4%, 53.6%, and 18.2% for maternal peripheral, placental, and cord blood respectively, with no difference between primigravidae and multigravidae. Submicroscopic infections were frequent and concerned all the positive cord samples. Maternal peripheral, late placental, and cord infections were all associated with a reduced mean birth weight in primigravidae (P = 0.02). Anemia prevalence was 53%, low birth rate was 13%, and prematurity was 25%. The use of intermittent preventive treatment with sulfadoxine-pyrimethamine (greater than or equal to one dose) combined with bed net was associated with a reduction in infection only in multigravidae and with a reduced risk of maternal anemia.     

Challenges of hepatitis B treatment in rural Sub-Saharan Africa: Treatment initiation and outcomes from a public hospital-based clinic in Kono,Sierra Leone

Despite a high prevalence, there are few successful models for de-centralizing diagnosis and treatment of chronic hepatitis B virus (HBV) infection among rural communities in Sub-Saharan Africa. We report baseline characteristics and 1 year retention outcomes for patients enrolled in a HBV clinic integrated within chronic disease services in a rural district hospital in Sierra Leone. We conducted a retrospective cohort study of patients with HBV infection enrolled between 30 April 2019 and 30 April 2021. Patients were eligible for 1 year follow-up if enrolled before 28 February 2020. Treatment eligibility at baseline was defined as cirrhosis (diagnosed by clinical criteria of decompensated cirrhosis, ultrasonographic findings or aspartate-aminotransferase-to-platelet ratio >2) or co-infection with HIV or HCV. Retention in care was defined as a documented follow-up visit at least 1 year after enrolment. We enrolled 623 individuals in care, median age of 30 years (IQR 23–40). Of 617 patients with available data, 97 (15.7%) had cirrhosis. Treatment was indicated among 113 (18.3%) patients and initiated among 74 (65.5%). Of 39 patients eligible for 1 year follow-up on treatment at baseline, 20 (51.3%) were retained at 1 year, among whom 12 (60.0%) had documented viral suppression. Among the 232 patients not initiated on treatment eligible for 1 year follow-up, 75 (32.3%) were retained at 1 year. Although further interventions are required to improve outcomes, our findings demonstrated feasibility of retention and treatment of patients with HBV infection in a rural district in Sub-Saharan Africa, when integrated with other chronic disease services.     

Reactivity in Rapidly Collected Hygiene and Toilet Spot Check Measurements: A Cautionary Note for Longitudinal Studies

Malaria treatment policy has changed from presumptive treatment to targeted “test and treat” (T&T) with malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT). This transition involves changing behavior among health providers, meaning delays between introduction and full implementation are recorded in almost every instance. We investigated factors affecting successful transition, and suggest approaches for accelerating uptake of T&T. Records from 2000 to 2011 from health clinics in Senegal where malaria is mesoendemic were examined (96,166 cases). The study period encompassed the implementation of national T&T policy in 2006. Analysis showed that adherence to test results is the first indicator of T&T adoption and is dependent on accumulation of experience with positive RDTs (odds ratio [OR]: 0.55 [P ≤ 0.001], 95% confidence interval [CI]: 0.53–0.58). Reliance on tests for malaria diagnosis (rather than presumptive diagnosis) followed after test adherence is achieved, and was also associated with increased experience with positive RDTs (OR: 0.60 [P ≤ 0.001], 95% CI: 0.58–0.62). Logistic models suggest that full adoption of T&T clinical practices can occur within 2 years, that monitoring these behavioral responses rather than RDT or ACT consumption will improve evaluation of T&T uptake, and that accelerating T&T uptake by focusing training on adherence to test results will reduce overdiagnosis and associated health and economic costs in mesoendemic regions.     

Severe malaria and concomitant bacteraemia in children admitted to a rural Mozambican hospital

Objectives  To describe the prevalence, aetiology and prognostic implications of coexisting invasive bacterial disease in children admitted with severe malaria in a rural Mozambican Hospital.
Methods  Retrospective study of data systematically collected from June 2003 to May 2007 in a rural Mozambican hospital, from all children younger than 5 years admitted with severe malaria.
Results  Seven thousand and forty-three children were admitted with a diagnosis of malaria. 25.2% fulfilled the criteria for severe malaria. 5.4% of the children with severe malaria and valid blood culture results had a concomitant bacteraemia. Case fatality rates of severe malaria cases rose steeply when bacteraemia was also present (from 4.0% to 22.0%, P  < 0.0001), and bacteraemia was an independent risk factor for death among severe malaria patients (adjusted OR 6.2, 95% CI 2.8–13.7, P  = 0.0001). Streptococcus pneumoniae , Gram-negative bacteria, Staphilococcus aureus and non-typhoid Salmonella (NTS) were the most frequently isolated microorganisms among severe malaria cases. Their frequency and associated case fatality rates (CFR) varied according to age and to syndromic presentation. Streptococcus pneumoniae had a relatively low CFR, but was consistently associated with severe malaria syndromes, or anaemia severity groups. No clear-cut relationship between malarial anaemia and NTS bacteraemia was found.
Conclusions  The coexistence of malaria and invasive bacterial infections is a frequent and life-threatening condition in many endemic African settings. In Mozambique, S. pneumoniae is the leading pathogen in this interaction, possibly as a consequence of the high HIV prevalence in the area. Measures directed at reducing the burden of both those infections are urgently needed to reduce child mortality in Africa.     

The current malariological situation in the countries of western Africa. 1. The Republic of Guinea]

Favorable climatic conditions in the Republic of Guinea are conducive to a high prevalence of infectious and parasitic diseases, responsible for 70% of primary consultations of the population, malaria being diagnosed in 40% of cases. Five landscape malariologic zones were singled out in the country, that are characterized by a certain level of malariogenicity. In the lowland/river and mountain/river zones the parasite index of children aged 2 to 9 varied from 16.4 to 45%, and in some foci it reached 63.1%. Foci in the Guinea-Sudan type wet savanna zone are also referred to meso- and hyperendemic ones. The mountain/forest zones are mainly mesoendemic. Malaria foci in the forest/savanna zone in southern Guinea and in the Sierra Leone northern provinces are hyper- and holoendemic, with the parasite index of children aged 2 to 9 being 76.3-92%.