Fever is an immune response capable of protecting the body from the effects of microbial infections.[1] In children, temperatures above 38°C measured rectally or 37.2°C measured under th
Trang 1Fever is an immune response capable of protecting
the body from the effects of microbial infections.[1] In
children, temperatures above 38°C measured rectally
or 37.2°C measured under the arm are indicative of
fever, which is frequently associated with infections.[2]
Annually, approximately 350-500 million cases of
malaria kill up to three million people, with more
than 90% of these deaths occurring in African children
under 5 years of age.[3] It also accounts for 10-30% of
all hospital admissions in malaria-endemic regions,
especially Sub-Saharan Africa.[4]
Despite recent progress leading to the reduction
of malaria morbidity and mortality, there are both
empirical and theoretical evidence that the current suite
of interventions is insufficient to eliminate malaria from those areas in Sub-Saharan Africa with high levels
of malaria transmission.[5] In order to achieve reduced morbidity and mortality resulting from malaria, the infection must be recognized quickly so that patients are treated promptly The clinical diagnosis of malaria
is usually based on the patient’s symptoms, which include fever, chills, sweats, headaches, muscle pains, nausea, and vomiting, which are also associated with other diseases This makes early diagnosis difficult, leading to delays in the commencement of treatment The World Health Organization (WHO) re commends that the treatment of malaria should be based on a laboratory-confirmed diagnosis, with the exception
of children less than 5 years of age in areas of high transmission in whom treatment may be provided
on the basis of a clinical diagnosis However, the high prevalence of asymptomatic infections and lack of resources such as microscopes and trained microscopists in highly endemic areas have led peripheral health facilities to use “presumptive treatment.” Children who suffer from a fever that does not have any obvious cause are presumed to have malaria and are treated for that disease Though
Correspondence:
Dr Adebola Onanuga, Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmacy, Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria E-mail: adebolaonanuga@gmail.com
Access this article online Quick Response Code: Website:
www.atmph.org
DOI:
10.4103/1755-6783.156668
A study of the relationship between the observation of fever
symptoms and parasitemia among children in the Federal Capital
Territory, Nigeria
Adebola Onanuga, Oluwatoyin A Igbeneghu 1 , Adebayo Lamikanra 1
Department of Pharmaceutical Microbiology and Biotechnology, Niger Delta University, Wilberforce Island, Bayelsa State, 1 Department of Pharmaceutics, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
ABSTRACT
Background: Fever is usually associated with malaria parasitemia, and it is recommended that febrile children
below the age of 5 years be treated with antimalarials This study was undertaken to obtain information concerning the relationship between fever and the prevalence of malaria parasitemia among Nigerian children
Materials and Methods: Blood specimens from deep inger pricks of 730 children aged 0-2 years were examined
for parasitemia using the Field’s stain method, and the axillary temperature of each subject was measured
Results: Malaria parasites were observed in 26.1% of the afebrile children and 40.6%, a statistically signi icant
difference, in febrile children Furthermore, 59.2% of the febrile subjects had no detectable malaria parasites in
their blood Conclusions: Fever is not always indicative of parasitemia, and subjects with asymptomatic infection
must be regarded as a signi icant reservoir of transmissible malaria parasites within the study environment
Key words: Antimalarial, asymptomatic, children, fever, malaria, parasitemia
Trang 2Onanuga, et al.: Relationship between observation of fever symptoms and parasitemia
Annals of Tropical Medicine and Public Health | Jan-Feb 2015 | Vol 8 | Issue 1
this allows the rapid treatment of a potentially
fatal disease, it can lead to incorrect diagnoses and
unnecessary use of antimalarial drugs.[6] A study of
the relationship between fever and the prevalence of
Plasmodium falciparum parasitemia among children
0-2 years of age will give information that can serve
as an important tool in the proper management of
malaria among children in this age group and, more
importantly, guide the judicious use of antimalarial
drugs
Materials and Methods
Study area
The study was carried out from April 1, 2008-March 31,
2009 in the Paediatric Out-patient Unit of the University
of Abuja Teaching Hospital, Gwagwalada and the
Immunization Unit of the Primary Health Care Centre,
Gwagwalada, Abuja, Nigeria, over a period of 1 year
(April 1, 2008-March 31, 2009) Appropriate ethical
clearance was obtained from both institutions
Subjects
Four categories of children of both sexes aged 0-2 years
were recruited into the study after informed consent
was obtained from their parents There were 244
children with a complaint of fever only, 153 children
with fever and diarrhea, 48 children with diarrhea only,
and 285 apparently healthy children, who came to the
health care facility for immunization, as controls The
axillary body temperatures of all the children were
measured and temperatures above 37.2°C were taken
as indicative of fever Demographic characteristics
of the children such as age, gender, and onset of the
symptoms in the children were recorded The presence
of asexual forms of P falciparum in a blood smear
of a child with symptoms led to the diagnosis of
uncomplicated clinical malaria.[7]
Collection of specimens and malaria parasite
density determination
Blood specimens were obtained from deep finger pricks
of all 730 children for the preparation of a thick blood
film The film slides were air-dried and stained with
Field’s stains A and B and then examined under a light
microscope using the oil immersions by an experienced
microscopist The number of parasites on each slide was
calculated per 200 white blood cells (WBC) assuming
8000 WBC/μL of blood.[8] The level of parasitemia
was designated as single (+) when 1-10 parasites
were counted per 100 microscopic fields (mild/scanty
parasitemia); or double (++) when 11-100 parasites
were counted per 100 fields; or triple (+++) when
101-1000 parasites were counted per 100 fields.[8]
Statistical analysis
Data obtained were compared using the chi-square test with the SPSS statistical program All reported
P values were two-sided and P ≤ 0.05 was considered
statistically significant
Results
Of the 730 children admitted into the study,
337 (46.2%) were female and 393 (53.8%) male Malaria parasites were detected in 75 (26.3%) of the apparently healthy children Twelve afebrile children were found to have malaria parasites in their blood, while 161 (40.6%) of the children presenting with fever had malaria parasites in their blood [Table 1] The prevalence of parasitemia among the febrile subjects was significantly higher than among the afebrile subjects, as indicated in Table 2 Two levels of parasitemia were observed among the study subjects
A total of 214 subjects had low level parasitemia (+) and 34 showed high level parasitemia (++) [Table 3] The distribution of levels of parasitemia and symptomatic manifestation among the subjects in different age groups are shown in Table 4
Table 1: Presence of malaria parasites among subjects
Category of subjects Sample no (%) No with malaria parasites (%)
Diarrhea with fever 153 (21.0) 59 (38.6)
Apparently healthy 285 (39.0) 75 (26.3)
Table 2: Degree of parasitemia among subjects
Degree of parasitemia
Subjects Total P value
With history of
fever (N = 397) (%)
Without fever
(N = 333) (%)
P.F + = Lower level of P falciparum in the blood; P.F ++ = High level of P falciparum in
the blood, *Statistically signifi cant (P < 0.05)
Table 3: Distribution of subjects after clinical diagnosis
Category of subjects No (%)
Febrile but without parasitemia 235 (59.2% of febrile subjects) Febrile with low-level parasitemia (+) 135 (34.0% of febrile subjects) Febrile with high-level parasitemia (++) 26 (6.6% of febrile subjects) Afebrile with low-level parasitemia (+) 79 (23.7% of afebrile subjects) Afebrile with high-level parasitemia (++) 8 (2.4% of afebrile subjects) Afebrile without parasitemia 247 (74.2% of afebrile subjects)
Trang 3Onanuga, et al.: Relationship between observation of fever symptoms and parasitemia
Discussion
The results of this study show that of the 397
children with a report of fever, only 161 (40.6%) had
parasitemia, suggesting that in about 60% of cases
of fever, malaria was not present This revelation
by microscopy that 60% of the febrile subjects had
no parasitemia is an indication that a fever is not
indicative of malaria parasitemia, suggesting that
the treatment of all patients presenting with a fever
with antimalarial drugs may be inappropriate This
observation is similar to other studies.[9-11] The
WHO recommends that all patients, especially
children, presenting at a health care facility with a
history of fever in the past 24 h should be treated
with antimalarial drugs.[12] The findings in this study
suggest that the treatment of every febrile child with
Coartem® tablets [a fixed dose of the oral combination
of artemether (20 mg) and lumefantrine (120 mg)],
which has been shown to be effective in the treatment
of chloroquine-resistant P falciparum malaria,
may be inappropriate.[13] As the use of antimalarial
drugs is allowed by WHO for children aged under
5 years in malaria-endemic regions because of their
vulnerability, the results of this study underscore
the need to follow up the treatment with laboratory
investigations and halting the treatment within 24 h
if investigations cannot demonstrate the presence
of malaria parasites Apart from the problem of the
development of antimalarial drug resistance, the
wrong diagnosis in febrile aparasitemic patients may
lead to an increase in the cost of hospital treatment
and, more seriously, mortalities could occur, as the
specific conditions responsible for their fever may go
undetected and untreated
The analysis of the density of parasitemia observed
among the study subjects shows that most of the
clinical malaria cases occurred in patients with
low-level parasitemia This suggests that most of the study
subjects have a low immune status or have other
underlying conditions that predispose them to clinical
malaria even at a low parasite density
Further analysis of the frequency of malaria among the
study subjects showed that children aged 0-6 months
had the lowest prevalence of malaria, followed by those aged 7-18 months The children aged 19-24 months had a significantly higher prevalence of malaria than other age groups The major difference between the children aged under 6 months and the others is that 67% of the youngest children were being breastfed, suggesting that the lower prevalence associated with these children could be the result of receiving protective antibodies from their mothers through breast milk This observation is comparable to what has been observed in children with diarrhea who also derive a significant level of protection from diarrheal pathogens.[14]
Research carried out at the Department of Microbiology,
La Trobe University has shown that various antibacterial, antiviral, and antiparasitic factors in human milk are active
in vitro against a wide range of pathogens, which includes
P falciparum In a study, breastfeeding was associated with
a signifi cantly lower risk of malaria in children 6-15 months old, while in children >15-24 months old, breastfeeding was not protective against malaria.[10] The fi nding in this study further underscores the need to continue counseling mothers
to breastfeed their babies for as long as possible but not for less than 6 months
The recorded prevalence of asymptomatic parasitemia among 26.1% of afebrile children is similar to the results from a previous study among Senegalese children aged less than 5 years, where a prevalence
of 25.4% asymptomatic malaria parasitemia was observed.[15] This proportion of children, though small,
is a significant potential source of malaria transmission This parasitemia may, however, be due to a situation in which the children had not begun to exhibit malaria symptoms or might have been recovering from an attack Furthermore, asymptomatic infections in areas of highly seasonal transmission may persist long enough through the dry season and reseed transmission when mosquito populations increase during the rainy season.[16] All these factors may be contributory to the difficulties in the correct diagnosis, control, and eradication of malaria in the malaria-endemic regions
of the world
Table 4: The distribution of levels of parasitemia and symptomatic manifestation among subjects in different age groups
Age group Sample number No (%) with
parasitemia
No (%) of HLP with malaria symptoms
No (%) of LLP with malaria symptoms
P value
HLP = High-level parasitemia; LLP = Low-level parasitemia, *Statistically signifi cant (P < 0.05)
Trang 4Onanuga, et al.: Relationship between observation of fever symptoms and parasitemia
Annals of Tropical Medicine and Public Health | Jan-Feb 2015 | Vol 8 | Issue 1
Conclusion
The results of this study suggest that fever is not always
indicative of malaria parasitemia and that subjects
with asymptomatic infection must be regarded as a
significant reservoir of transmissible malaria parasites
within the study environment It further suggests
that breast milk appears to offer a significant level of
protection against malaria parasites in young children
Acknowledgment
We thank the management and staff of the Department of
Medical Laboratory, University of Abuja Teaching Hospital,
Gwagwalada, Federal Capital Territory, for their support and
technical assistance in the collection and screening of the
blood samples for malaria parasitemia.
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Cite this article as: Onanuga A, Igbeneghu OA, Lamikanra A A study
of the relationship between the observation of fever symptoms and parasitemia among children in the Federal Capital Territory, Nigeria Ann Trop Med Public Health 2015;8:1-4.
Source of Support: This work was not supported by any agencies or
institutions, Confl ict of Interest: None declared.
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