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PubMed2002

Yellow fever in Africa: public health impact and prospects for control in the 21st century.

In the last two decades, yellow fever re-emerged with vehemence to constitute a major public health problem in Africa. The disease has brought untold hardship and indescribable misery among different populations in Africa. It is one of Africa's stumbling blocks to economic and social development. Despite landmark achievements made in the understanding of the epidemiology of yellow fever disease and the availability of a safe and efficacious vaccine, yellow fever remains a major public health problem in both Africa and America where the disease affects annually an estimated 200,000 persons causing an estimated 30,000 deaths. Africa contributes more than 90% of global yellow fever morbidity and mortality. Apart from the severity in morbidity and mortality, which are grossly under reported, successive outbreaks of yellow fever and control measures have disrupted existing health care delivery services, overstretched scarce internal resources, fatigued donor assistance and resulted in gross wastage of vaccines. Recent epidemics of yellow fever in Africa have affected predominantly children under the age of fifteen years. Yellow fever disease can be easily controlled. Two examples from Africa suffice to illustrate this point. Between 1939 and 1952, yellow fever virtually disappeared in parts of Africa, where a systematic mass vaccination programme was in place. More recently, following the 1978-1979 yellow fever epidemic in the Gambia, a mass yellow fever vaccination programme was carried out, with a 97% coverage of the population over 6 months of age. Subsequently, yellow fever vaccination was added to the EPI Programme. The Gambia has since then maintained a coverage of over 80%, without a reported case of yellow fever, despite being surrounded by Senegal which experienced yellow fever outbreaks in 1995 and 1996. The resurgence of yellow fever in Africa and failure to control the disease has resulted from a combination of several factors, including: 1) collapse of health care delivery systems; 2) lack of appreciation of the full impact of yellow fever disease on the social and economic development of the affected communities; 3) insufficient political commitment to yellow fever control by governments of endemic countries; 4) poor or inadequate disease surveillance; 5) inappropriate disease control measures, and 6) preventable poverty coupled with misplaced priorities in resource allocation. Yellow fever can be controlled in Africa within the next 10 years, if African governments seize the initiative for yellow fever control by declaring an uncompromising resolve to control the disease, the governments back up their resolve with an unrelenting commitment and unwavering political will through adequate budgetary allocations for yellow fever control activities, and international organisations, such as WHO, UNICEF, GAVI, etc., provide support and technical leadership and guidance to yellow fever at risk countries. Over a ten-year period, of stage-by-stage mass yellow fever vaccination campaigns, integrated with successful routine immunisation, Africa can bring yellow fever under control. Subsequently, for yellow fever to cease being a public health problem, Africa must maintain at least an annual 80% yellow fever vaccine coverage of children under the age of 1 year, and sustain a reliable disease surveillance system with a responsive disease control programme. This can be achieved at an affordable annual expenditure of less than US$1.00 per person per year, with a reordering of priorities.

Africa↗
PubMed1999

Aetiology of fever in patients with acute stroke.

OBJECTIVE: Fever in patients with acute stroke is usually related to infectious complications. In some cases, a focus of infection cannot be identified, fever does not respond to empirical antibiotic treatment and is thought to be due to the central nervous system lesion. The aim of this study was to determine the frequency and origin of fever in patients with acute stroke and the characteristics associated with the presence of fever. DESIGN: A retrospective study of 36 months' duration. SETTING: The study was carried out at 'Alexandra' Hospital, a tertiary care teaching centre in Athens, Greece. SUBJECTS: A total of 330 patients hospitalized for acute stroke from June 1992 until July 1994. RESULTS: In 37.6% of 330 patients, fever was noted; 22.7% had a documented infection and 14.8% had fever without a documented infection. In univariate analysis, older age was associated with the presence of fever (P = 0.001). The development of fever was associated with intracerebral haemorrhage versus ischaemic infarct (P < 0.001) and with the presence of mass effect (P < 0.001), transtentorial herniation (P < 0.001), intraventricular blood (P < 0. 001), and larger size of ischaemic infarct (P = 0.0001) and of haemorrhage (P = 0.0002). Patients with fever had lower scores on admission on the Glasgow Coma Scale (P = 0.0001) and the Scandinavian Stroke Scale (P = 0.0001). The development of fever was associated with prior use of an invasive technique (P < 0.001) and more specifically with urinary catheterization (P < 0.001), but not with the presence of risk factors for infection. Patients with fever had a worse outcome assessed by the Modified Rankin Scale (P = 0. 0001) and the Barthel Index (P = 0.0001). In multivariate analysis, age, Scandinavian Stroke Scale score and mass effect were found to be significantly associated with fever (P = 0.035, P = 0.0001 and P = 0.0004, respectively). Patients with fever without documented infection had an earlier onset of fever than those with infection (P = 0.0061). In a logistic regression analysis, the only factor predictive of fever without documented infection versus infection was earlier onset of fever (P = 0.029). CONCLUSION: Patients with acute stroke who develop fever are older, suffer severe stroke, their fever is associated with the use of invasive techniques, and they have a poor outcome. In patients with fever without a focus of infection, the only characteristic that is different from patients with known infection is earlier onset of fever.

Acute Disease↗
PubMed2003

Risk factors for fever in the neurologic intensive care unit.

OBJECTIVE: To identify risk factors for fever among patients treated in a neurologic intensive care unit (NICU). METHODS: The authors prospectively studied the frequency and causes of fever, defined as a patient's first temperature > or =101 degrees F (38.3 degrees C), among 387 patients consecutively admitted to their NICU. After identifying risk factors for 1) any fever, 2) infectious fever, and 3) unexplained fever using logistic regression, they calculated disease-specific adjusted odds ratios for developing these types of fever among 12 diagnostic groups. RESULTS: Fever occurred in 23% (87/387) of patients. Fifty-two percent of fevers were explained by infection (predominantly pneumonia or bronchitis), and 28% were unexplained despite a complete diagnostic evaluation. NICU length of stay was a risk factor for all three types of fever (all p < 0.004); other risk factors included depressed level of consciousness for any fever (p = 0.005) and infectious fever (p = 0.048), endotracheal intubation for infectious fever (p = 0.01), and intraventricular catheterization for unexplained fever (p = 0.004). Subarachnoid hemorrhage increased the risk of both infectious and unexplained fever, even after adjusting for these risk factors (p = 0.006). CONCLUSION: Fever occurs in nearly 25% of NICU patients, and is associated with increased length of stay and depressed level of consciousness. Endotracheal intubation is a risk factor for infectious fever, whereas intraventricular catheterization is a risk factor for unexplained fever, which suggests a role for ventricular hemorrhage in the pathogenesis of "central" fever. Subarachnoid hemorrhage increases the risk of developing fever of all types.

Adolescent↗
PubMed1989

Clinical study of drug fever induced by parenteral administration of antibiotics.

The incidence and clinical features of drug fever induced by antibiotics were investigated. Of a total of 390 patients analyzed, 193 had malignant diseases (lung cancer in most cases) and the remaining 197 had non-malignant diseases, of which the majority comprised pulmonary infectious diseases such as pneumonia, lung abscess and chronic infections. beta-Lactams most frequently induced drug fever. Piperacillin induced drug fever in 18 of 108 (17%), cefotaxime in 11 of 72 (15%), ceftizoxime in 7 of 49 (14%) and cefoperazone in 6 of 74 patients (8%). In contrast, the incidence of drug fever caused by ampicillin and that by cefazolin were in one of 39 (3%) and in none of 44 (0%), respectively. On the other hand, antimicrobial agents other than beta-lactams only rarely induced drug fever. The higher incidence of drug fever caused by newer derivatives of beta-lactam antibiotic suggests that the side chain attached to their core moiety might be involved in the mechanism of drug fever. In patients with malignancy who were on antibiotics, respiratory infection was the most frequent cause of fever exceeding 38 degrees C. In contrast, in patients with non-malignant diseases, the use of antibiotic per se was the most frequent cause of the fever which recurred during antibiotic therapy after a previous febrile episode had subsided. The most common feature of drug fever induced by the use of an antibiotic was as follows: A low-grade fever at the time of onset is followed by a high and remittent fever. The highest diurnal body temperature rises gradually, and then the fever subsides promptly after cessation of the causative antibiotic. The fever of this type accounted for 70% of all the drug fever in this study. A transient elevation of serum level of lactic dehydrogenase was associated with drug fever in one half (25/49, 51%) of the patients. A transient and slight decrease from the normal range in counts of neutrophils and platelets were observed in 11 (23%) and in 4 (8%) of 48 patients with drug fever, respectively. These changes in laboratory findings were considered as the possible consequence of allergic processes involved in the development of drug fever and thus seem to be a helpful index for establishing the diagnosis of drug fever.

Adult↗
PubMed2004

Risk factors for typhoid and paratyphoid fever in Jakarta, Indonesia.

CONTEXT: The proportion of paratyphoid fever cases to typhoid fever cases may change due to urbanization and increased dependency on food purchased from street vendors. For containment of paratyphoid a different strategy may be needed than for typhoid, because risk factors for disease may not coincide and current typhoid vaccines do not protect against paratyphoid fever. OBJECTIVE: To determine risk factors for typhoid and paratyphoid fever in an endemic area. DESIGN, SETTING, AND PARTICIPANTS: Community-based case-control study conducted from June 2001 to February 2003 in hospitals and outpatient health centers in Jatinegara district, Jakarta, Indonesia. Enrolled participants were 1019 consecutive patients with fever lasting 3 or more days, from which 69 blood culture-confirmed typhoid cases, 24 confirmed paratyphoid cases, and 289 control patients with fever but without Salmonella bacteremia were interviewed, plus 378 randomly selected community controls. MAIN OUTCOME MEASURES: Blood culture-confirmed typhoid or paratyphoid fever; risk factors for both diseases. RESULTS: In 1019 fever patients we identified 88 (9%) Salmonella typhi and 26 (3%) Salmonella paratyphi A infections. Paratyphoid fever among cases was independently associated with consumption of food from street vendors (comparison with community controls: odds ratio [OR], 3.34; 95% confidence interval [CI], 1.41-7.91; with fever controls: OR, 5.17; 95% CI, 2.12-12.60) and flooding (comparison with community controls: OR, 4.52; 95% CI, 1.90-10.73; with fever controls: OR, 3.25; 95% CI, 1.31-8.02). By contrast, independent risk factors for typhoid fever using the community control group were mostly related to the household, ie, to recent typhoid fever in the household (OR, 2.38; 95% CI, 1.03-5.48); no use of soap for handwashing (OR, 1.91; 95% CI, 1.06-3.46); sharing food from the same plate (OR, 1.93; 95% CI, 1.10-3.37), and no toilet in the household (OR, 2.20; 95% CI, 1.06-4.55). Also, typhoid fever was associated with young age in years (OR, 0.96; 95% CI, 0.94-0.98). In comparison with fever controls, risk factors for typhoid fever were use of ice cubes (OR, 2.27; 95% CI, 1.31-3.93) and female sex (OR, 1.79; 95% CI, 1.04-3.06). Fecal contamination of drinking water was not associated with typhoid or paratyphoid fever. We did not detect fecal carriers among food handlers in the households. CONCLUSIONS: In Jakarta, typhoid and paratyphoid fever are associated with distinct routes of transmission, with the risk factors for disease either mainly within the household (typhoid) or outside the household (paratyphoid).

Adolescent↗
PubMed2003

[Evaluation on the functions and cost of 'fever clinics' during the period of severe acute respiratory syndrome epidemics in Beijing].

OBJECTIVE: To identify the experiences and lessons learned on 'fever clinics' during the severe acute respiratory syndrome (SARS) epidemic in Beijing and to propose a better model in monitoring SARS to fit the 'fever clinics' into current situation. METHODS: Both qualitative and quantitative methods were used in data collection and analyses. Quantitative surveys would include 1. The setting, functions and administration of current 63 'fever clinics' in Beijing; 2. Survey on patients with fever who had visited 'fever clinics' and randomly selected from the 63 fever clinics; 3. Survey on physicians working in the 'fever clinics'. Qualitative studies would include discussion or interview with administrators, physicians working in the 'fever clinics' and field studies on 23 randomly selected 'fever clinics' as well as telephone interview to the staff working in the hospitals that did not have the 'fever clinics'. RESULTS: A couple of significant problems raised during the study including: 1. Low coverage of current surveillance system. 89% of the hospitals were not covered by the surveillance system which reflecting the misjudgment on the patients with fever that they would only attend 'fever clinics' to seek for medical help. The fact was that most of the hospitals where 'fever clinics' had not been set also received patients with fever. 2. Information related to patients with fever needs to improve regarding its completeness and accuracy. 3. Significant unbalance in daily cost and effectiveness in most of the 'fever clinics' was noticed. CONCLUSION: 'Fever clinics' needs to be adjusted to meet the possible SARS epidemic in coming winter and spring. Short-term and long-term suggestions were proposed regarding SARS monitoring through the functions of 'fever clinics' in Beijing.

China↗
PubMed1998

Maternal fever and birth outcome: a prospective study.

Although maternal fever has been implicated as a human teratogen in several studies, no prospective study has adequately addressed the full spectrum of birth outcomes following such exposure in pregnancy. The purpose of this study was to determine whether or not maternal fever is associated with an increased risk for structural malformations, prematurity, growth retardation, or pregnancy loss. Using a prospective cohort study design, we ascertained women who had called the California Teratogen Information Service and Clinical Research Program between 1979-1996 with questions regarding fever in a current pregnancy. Of these women, 115 who reported a fever of at least 38.9 degrees C lasting for at least 24 h (high fever group) and 147 women who reported a fever of either less than 38.9 degrees C or lasting less than 24 h (low fever group) were enrolled in the cohort. An additional 298 pregnant women who reported having no fever at any time in pregnancy were enrolled in a control group. All pregnancies were followed in a similar fashion, and outcomes were compared among the three groups. The combined prevalence of all major structural malformations was increased, but not significantly so, in the offspring of women who had a high fever in the first trimester of pregnancy compared to those with a lower fever or to controls (relative risk 1.80 for high fever group compared to controls; 95% confidence interval, 0.54, 6.03; relative risk 1.21 for low fever group compared to controls; 95% confidence interval, 0.36, 4.03). However, 2/34 or 5.9% of women who had a high fever during the critical period for neural tube closure carried fetuses with anencephaly compared to none in the low fever group or controls. Specific minor defects were found more frequently in the high fever group compared to controls and were consistent with the pattern of defects previously reported in a retrospective case series. In addition, stillbirth occurred more frequently in the high fever group compared to controls (2.6% vs. 0%). These data support the conclusion that high maternal fever early in pregnancy is a human teratogen. Women who experience fevers of 38.9 degrees C or higher for extended periods of time in the first month of pregnancy should be considered at increased risk for neural tube defects and should be provided appropriate counseling.

Cohort Studies↗
PubMed2004

Causes and consequences of fever complicating critical surgical illness.

BACKGROUND: Fever may have malign consequences in the postoperative period. This study was performed to determine the causes and consequences of fever in critically ill surgical patients. The specific hypothesis tested is that postoperative fever is associated with adverse clinical outcomes, including increased organ dysfunction and risk of death. METHODS: Inception-cohort study of critically ill surgical patients who manifested a core temperature of >/=38.2 degrees C for the first time. The episode of fever was monitored until resolution, which was defined as a core temperature of <38.2 degrees C for at least 72 consecutive h. Demographic data collected included age, gender, admission diagnosis, admission status (elective/emergency), severity of illness (APACHE III), the systemic inflammatory response syndrome (SIRS) score, the cumulative multiple organ dysfunction score, cause of fever (infectious/non-infectious), ICU and hospital length of stay, and mortality. The day of onset of fever in the ICU, peak temperature, ICU day of peak temperature, and duration of fever episode were recorded. All diagnostic and therapeutic interventions were recorded, including the type and duration of antibiotic therapy. Univariate results of possible significance (alpha < 0.15) were tested in logistic regression models for independence of effect upon mortality after auto-correlation was excluded by matrix correlations and the Durbin-Watson statistic. Cases where both non-infectious and infectious causes of fever were present were analyzed as part of the infectious group, whereas the cumulative MOD score was dichotomized (< 5, >/=5 points) at a value known to be associated with increased mortality. RESULTS: Among 2,419 screened patients, 626 patients (26%) developed fever. Febrile patients were older, sicker, more likely to have undergone emergency surgery, more likely to develop organ dysfunction, and more likely to die (all, p < 0.0001). The mean day of onset of fever was day 1 and the mean peak temperature for the episode was 39.1 +/- 0.1 degrees C. For most patients, it was their only episode of fever, with a mean of 1.4 +/- 0.1 episodes/patient. Forty-six percent of febrile patients were found to have an infectious cause of fever. Nearly all patients had SIRS, and nearly all developed organ dysfunction to some degree. By logistic regression, the presence of SIRS (as opposed to fever in isolation), emergency status, higher APACHE III score and the peak temperature were associated with increased mortality, with peak temperature being the most powerful predictor in the model (OR 2.20, 95% Cl 1.57-3.19). Gender had no bearing on outcome, and there was a trend toward a protective effect from an infectious etiology of fever. CONCLUSIONS: Postoperative fever is deleterious to critically ill patients. The magnitude of fever is a determinant of mortality, whereas an infectious etiology of fever may not be. The impacts of nosocomial infection and suppression of fever on critically surgical patients deserve further study.

APACHE↗