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Fever in Africa and WHO recommendation
THE LANCET
accurate screening tests for malaria are urgently needed.3 This study was supported by the Medical Research Council and the Department for International Development, UK.
*Dilys Morgan, James A G Whitworth, Amanda Ross, Nicholas Omoding, Henry Eotu Medical Research Programme on AIDS, PO Box 49, Entebbe, Uganda 1
2
3
Einterz EM, Bates ME. Fever in Africa: do patients know when they are hot? Lancet 1997; 350: 781. Morgan D, Malamba S, Maude M, et al. An HIV-1 natural history cohort and survival times in rural Uganda. AIDS 1997; 11: 633–40. WHO. A rapid dipstick antigen capture assay for the diagnosis of falciparum malaria. Geneva: WHO, WHO/MAL/95.1072.
SIR—Our experiences from Ghana do not support the conclusions of Ellen M Einterz and Myra E Bates1 who report the unreliability of patients’ assessment of fever in Africa and question the validity of histories of fever in epidemiological studies based on symptom reports. Ahorlu and colleagues’ study2 of malaria-related beliefs and behaviour in southern Ghana documented one of the most important symptoms of malaria observed in children by their caretakers as “hot body”. But this observation was a report of the children’s caretakers’ own assessment since clinical thermometers were not used at local home. So we investigated the likelihood that a sick child reported as having “hot body” has fever (肁37·5°C). Between April and June, 1995, we followed up 130 children, aged 1–9 years, from two communities— Dodowa, a forest-type zone, and Prampram, which is in a coastal savannah—for the occurrence of fever. Each child was visited at home once every week by a trained field assistant who recorded any symptoms of malaria, as observed and reported in the local language (Dangme) by caretakers, and took the child’s axillary temperature with an electronic thermometer. We deemed a temperature of 37·5°C or higher to be raised. Hedorla is the Dangme term for “hot body” or fever. A caretaker was defined as the parent or guardian who provided daily care for the child, such as bathing, feeding, clothing,
sending to school or to hospital when sick. We combined data from both communities (as a result of the high level of consensus) and after the exclusion of 121 child-weeks of followup, for which records on age were missing, there were a total of 3021 childweeks of follow-up. Of 76 records in which caretakers reported “hot body” in their children, 79% were febrile, and of 2824 visits during which caretakers denied any “hot body” in the children 99·3% did not have fever (table). Our findings indicate that a report of “hot body” in children obtained from caretakers in the home is a reliable marker of fever. The unreliability of patients’ assessment of fever, as reported by Einterz and Bates, is not reflected in our data. These conflicting results could reflect differences in study design. Einterz and Bates collected their data from the outpatient department of a district hospital, whereas we recorded the symptoms as they were observed and reported in the home setting. In rural Ghanian communities, the earliest recognition of a febrile illness suspected to be malaria begins in the home where treatment is also started with homeprepared herbs or analgesics and often inadequate doses of chloroquine purchased at local drug shops without prescription are also given.2 The final recourse, if the illness does not respond to home treatment is the formal health sector; a pattern that Einterz and Bates have also observed in Cameroon.3 Thus, the constellation of symptoms and their predictive value as observed in the clinic can be influenced by various factors. For example, antipyretics and antimalarials might have been taken before a clinic visit to reduce the fever and a change in body temperature at the time a patient arrives in hospital can also be expected as part of the disease process of malaria or diurnal rhythm.4 Febrile episodes are often the starting point for malaria and most other endemic diseases in children in tropical countries and serve as useful diagnostic and prognostic markers. Thus, we believe that a report of fever, especially in children, in combination with other symptoms that suggest malaria, should initiate treatment since the benefits (such as prevention of severe and life-threatening malaria) are
Temperature 肁37·5ºC
Temperature 聿37·5ºC
Correct responses
Incorrect responses
% correct
Correct responses
Age-group (years) <2 2–5 6–9
24 23 13
3 10 3
89 70 81
563 1077 1165
5 9 5
99 99 99·6
Total
60
16
79
2805
19
99·3
Caretakers’ assessment of fever in children in southern Ghana
1550
Incorrect responses
% correct
obvious and outweigh the disadvantage of indiscriminate use of antimalarials, which is often blamed for the development and spread of drugresistant malaria. *Samuel K Dunyo, Kwadwo A Koram, Francis K Nkrumah Noguchi Memorial Institute for Medical Research, University of Ghana, PO Box 25, Legon, Accra, Ghana 1
2
3
4
Einterz EM, Bates ME. Fever in Africa: do patients know when they are hot? Lancet 1997; 350: 781. Ahorlu CK, Dunyo SK, Afari EA, et al. Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control. Trop Med Int Health 1997; 2: 488–99. Einterz EM, Bates ME. Infant disease patterns in northern Cameroon. Trans R Soc Med Hyg 1993; 87: 418–20. Armstrong Schellenberg JRM, Greenwood BM, Gomex P, et al. Diurnal variation in body temperature of Gambian children. Trans R Soc Med Hyg 1994; 88: 429–31.
Sir—I was disappointed that Ellen Einterz and Myra Bates1 do not acknowledge the local traditional and cultural meanings of the symptom “being hot” in Africa. Their study was conducted in Northern Cameroon, where most people use local, traditional health-care delivery, and the words patients use to describe symptoms and diseases must be understood within that cultural context. When a patient says that he or she has fever or heat inside them, it can be due to various causes and can manifest itself in a range of symptoms, one of which may be a rise in bodily temperature. Einterz and Bates conclude that “a patient’s or carer’s report of fever is not reliable”. Their work usefully highlights the proportion of patients who said they are hot and who actually had an increase in temperature. But the symptomatology of the patients who were incorrect should not be derided. If a patient complains that they have fever, then appropriate questions and instruments should be used to assess and understand the symptom, rather than just depending on the explanation from western medicine of a rise in temperature. The same word can have different meanings between lay and professional circles, as well as between different cultures. The question in Africa is not only do patients know when they are hot, but also do western-trained doctors know what patients mean when they say they are hot? Farhang Tahzib Department of Public Health Medicine, Croydon Health Authority, Knollys House, Croydon CR0 6SR, UK 1
Einterz EM, Bates ME. Fever in Africa: do patients know when they are hot? Lancet 1997; 350: 781.
Vol 350 • November 22, 1997
accurate screening tests for malaria are urgently needed.3 This study was supported by the Medical Research Council and the Department for International Development, UK.
*Dilys Morgan, James A G Whitworth, Amanda Ross, Nicholas Omoding, Henry Eotu Medical Research Programme on AIDS, PO Box 49, Entebbe, Uganda 1
2
3
Einterz EM, Bates ME. Fever in Africa: do patients know when they are hot? Lancet 1997; 350: 781. Morgan D, Malamba S, Maude M, et al. An HIV-1 natural history cohort and survival times in rural Uganda. AIDS 1997; 11: 633–40. WHO. A rapid dipstick antigen capture assay for the diagnosis of falciparum malaria. Geneva: WHO, WHO/MAL/95.1072.
SIR—Our experiences from Ghana do not support the conclusions of Ellen M Einterz and Myra E Bates1 who report the unreliability of patients’ assessment of fever in Africa and question the validity of histories of fever in epidemiological studies based on symptom reports. Ahorlu and colleagues’ study2 of malaria-related beliefs and behaviour in southern Ghana documented one of the most important symptoms of malaria observed in children by their caretakers as “hot body”. But this observation was a report of the children’s caretakers’ own assessment since clinical thermometers were not used at local home. So we investigated the likelihood that a sick child reported as having “hot body” has fever (肁37·5°C). Between April and June, 1995, we followed up 130 children, aged 1–9 years, from two communities— Dodowa, a forest-type zone, and Prampram, which is in a coastal savannah—for the occurrence of fever. Each child was visited at home once every week by a trained field assistant who recorded any symptoms of malaria, as observed and reported in the local language (Dangme) by caretakers, and took the child’s axillary temperature with an electronic thermometer. We deemed a temperature of 37·5°C or higher to be raised. Hedorla is the Dangme term for “hot body” or fever. A caretaker was defined as the parent or guardian who provided daily care for the child, such as bathing, feeding, clothing,
sending to school or to hospital when sick. We combined data from both communities (as a result of the high level of consensus) and after the exclusion of 121 child-weeks of followup, for which records on age were missing, there were a total of 3021 childweeks of follow-up. Of 76 records in which caretakers reported “hot body” in their children, 79% were febrile, and of 2824 visits during which caretakers denied any “hot body” in the children 99·3% did not have fever (table). Our findings indicate that a report of “hot body” in children obtained from caretakers in the home is a reliable marker of fever. The unreliability of patients’ assessment of fever, as reported by Einterz and Bates, is not reflected in our data. These conflicting results could reflect differences in study design. Einterz and Bates collected their data from the outpatient department of a district hospital, whereas we recorded the symptoms as they were observed and reported in the home setting. In rural Ghanian communities, the earliest recognition of a febrile illness suspected to be malaria begins in the home where treatment is also started with homeprepared herbs or analgesics and often inadequate doses of chloroquine purchased at local drug shops without prescription are also given.2 The final recourse, if the illness does not respond to home treatment is the formal health sector; a pattern that Einterz and Bates have also observed in Cameroon.3 Thus, the constellation of symptoms and their predictive value as observed in the clinic can be influenced by various factors. For example, antipyretics and antimalarials might have been taken before a clinic visit to reduce the fever and a change in body temperature at the time a patient arrives in hospital can also be expected as part of the disease process of malaria or diurnal rhythm.4 Febrile episodes are often the starting point for malaria and most other endemic diseases in children in tropical countries and serve as useful diagnostic and prognostic markers. Thus, we believe that a report of fever, especially in children, in combination with other symptoms that suggest malaria, should initiate treatment since the benefits (such as prevention of severe and life-threatening malaria) are
Temperature 肁37·5ºC
Temperature 聿37·5ºC
Correct responses
Incorrect responses
% correct
Correct responses
Age-group (years) <2 2–5 6–9
24 23 13
3 10 3
89 70 81
563 1077 1165
5 9 5
99 99 99·6
Total
60
16
79
2805
19
99·3
Caretakers’ assessment of fever in children in southern Ghana
1550
Incorrect responses
% correct
obvious and outweigh the disadvantage of indiscriminate use of antimalarials, which is often blamed for the development and spread of drugresistant malaria. *Samuel K Dunyo, Kwadwo A Koram, Francis K Nkrumah Noguchi Memorial Institute for Medical Research, University of Ghana, PO Box 25, Legon, Accra, Ghana 1
2
3
4
Einterz EM, Bates ME. Fever in Africa: do patients know when they are hot? Lancet 1997; 350: 781. Ahorlu CK, Dunyo SK, Afari EA, et al. Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control. Trop Med Int Health 1997; 2: 488–99. Einterz EM, Bates ME. Infant disease patterns in northern Cameroon. Trans R Soc Med Hyg 1993; 87: 418–20. Armstrong Schellenberg JRM, Greenwood BM, Gomex P, et al. Diurnal variation in body temperature of Gambian children. Trans R Soc Med Hyg 1994; 88: 429–31.
Sir—I was disappointed that Ellen Einterz and Myra Bates1 do not acknowledge the local traditional and cultural meanings of the symptom “being hot” in Africa. Their study was conducted in Northern Cameroon, where most people use local, traditional health-care delivery, and the words patients use to describe symptoms and diseases must be understood within that cultural context. When a patient says that he or she has fever or heat inside them, it can be due to various causes and can manifest itself in a range of symptoms, one of which may be a rise in bodily temperature. Einterz and Bates conclude that “a patient’s or carer’s report of fever is not reliable”. Their work usefully highlights the proportion of patients who said they are hot and who actually had an increase in temperature. But the symptomatology of the patients who were incorrect should not be derided. If a patient complains that they have fever, then appropriate questions and instruments should be used to assess and understand the symptom, rather than just depending on the explanation from western medicine of a rise in temperature. The same word can have different meanings between lay and professional circles, as well as between different cultures. The question in Africa is not only do patients know when they are hot, but also do western-trained doctors know what patients mean when they say they are hot? Farhang Tahzib Department of Public Health Medicine, Croydon Health Authority, Knollys House, Croydon CR0 6SR, UK 1
Einterz EM, Bates ME. Fever in Africa: do patients know when they are hot? Lancet 1997; 350: 781.
Vol 350 • November 22, 1997