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|The relationship between reported fever and Plasmodium falciparum infection in African
||Emelda A Okiro and Robert W Snow
||Malaria Journal, 2010, 9:99
Multiple African Countries
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 diagnosisbased
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.
Conclusion: 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.
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