Causes of fever in Tanzanian adults attending outpatient clinics: a prospective cohort study

N Boillat-Blanco; Z Mbarack; J Samaka; T Mlaganile; T Kazimoto; A Mamin; B Genton; L Kaiser; V D'Acremont

doi:10.1016/j.cmi.2020.08.031

Causes of fever in Tanzanian adults attending outpatient clinics: a prospective cohort study

Clin Microbiol Infect. 2021 Jun;27(6):913.e1-913.e7. doi: 10.1016/j.cmi.2020.08.031. Epub 2020 Sep 4.

Authors

N Boillat-Blanco¹, Z Mbarack², J Samaka³, T Mlaganile³, T Kazimoto³, A Mamin⁴, B Genton⁵, L Kaiser⁴, V D'Acremont⁵

Affiliations

¹ Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania; Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; Infectious Diseases Service, University Hospital of Lausanne, Lausanne, Switzerland. Electronic address: noemie.boillat@chuv.ch.
² Mwananyamala Hospital, Dar Es Salaam, United Republic of Tanzania.
³ Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania.
⁴ Division of Infectious Diseases and Centre for Emerging Viral Diseases, University of Geneva Hospitals, And Faculty of Medicine, Geneva, Switzerland.
⁵ Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland.

Abstract

Objectives: Exploring fever aetiologies improves patient management. Most febrile adults are outpatients, but all previous studies were conducted in inpatients. This study describes the spectrum of diseases in adults attending outpatient clinics in urban Tanzania.

Methods: We recruited consecutive adults with temperature ≥38°C in a prospective cohort study. We collected medical history and performed a clinical examination. We performed 27 364 microbiological diagnostic tests (rapid tests, serologies, cultures and molecular analyses) for a large range of pathogens on blood and nasopharyngeal samples. We based our diagnosis on predefined clinical and microbiological criteria.

Results: Of 519 individuals, 469 (89%) had a clinically or microbiologically documented infection and 128 (25%) were human immunodeficiency virus (HIV) -infected. We identified 643 diagnoses: 264 (41%) acute respiratory infections (36 (5.6%) pneumonia, 39 (6.1%) tuberculosis), 71 (11%) infections with another focus (31 (4.8%) gastrointestinal, 26 (4.0%) urogenital, 8 (1.2%) central nervous system) and 252 (39%) infections without focus (134 (21%) dengue, 30 (4.7%) malaria, 28 (4.4%) typhoid). Of the 519 individuals, 318 (61%), 179 (34%), 30 (6%) and 15 (3%), respectively, had a viral, bacterial, parasitic and fungal acute infection. HIV-infected individuals had more bacterial infections than HIV-negative (80/122 (66%) versus 100/391 (26%); p < 0.001). Patients with advanced HIV disease had a higher proportion of bacterial infections (55/76 (72%) if CD4 ≤200 cells/mm³ and 25/52 (48%) if CD4 >200 cells/mm³, p 0.02).

Conclusions: Viral diseases caused most febrile episodes in adults attending outpatient clinics except in HIV-infected patients. HIV status and a low CD4 level strongly determined the need for antibiotics. Systematic HIV screening is essential to appropriately manage febrile patients.

Keywords: Aetiologies of fever; Dengue; Human immunodeficiency virus; Outbreak; Sub-Saharan Africa.

MeSH terms

Adult
Ambulatory Care Facilities
Bacterial Infections / complications*
Bacterial Infections / diagnosis*
Cohort Studies
Female
Fever / etiology*
HIV Infections / complications*
HIV Infections / diagnosis*
HIV-1
Humans
Male
Prospective Studies
Tanzania
Young Adult