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

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.

Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

Figures

Fig. 1
Fig. 1
Flow chart of study participants.
Fig. 2
Fig. 2
Distribution of 643 diagnoses found in 519 adults attending outpatient clinics with fever in Tanzania. (a) All diagnoses; (b) diagnoses of lower respiratory tract infections; (c) diagnoses of infections without focus.
Fig. 3
Fig. 3
Overlap between types of pathogens causing fever in the 519 adults, overall and stratified by HIV status.
Fig. 4
Fig. 4
Proportion of patients diagnosed with malaria, dengue, influenza and fever of unknown origin over time. Representation of the rainy season by the volume of rain during the study period.
figs1
figs1
Distribution of diagnoses found in 391 HIV-negative and 128 HIV-infected febrile adults attending outpatient clinics in Tanzania.
figs2
figs2
Predicted linear temporal distribution of the major clinical syndromes (with and without dengue patients).
figs3
figs3
Overlap between types of pathogens before and during the dengue outbreak.

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