Group | Management of Fevers

In tropical primary care facilities, fever is by far the most frequent complaint presented by patients. Malaria is declining globally viral infections have become the leading cause of fever. Due to the lack of diagnostic tools for non-malaria causes of fever, antibiotics are prescribed for the majority of cases when the malaria test is negative. This over-prescription of antibiotics at primary care level fuels antibiotic resistance, a major public health threat. Health workers urgently need novel point-of-care tests and evidence-based guidelines to better take care of patients with fever.

Our research on management of fevers aims to improve ways of diagnosing and treating patients with common infections in primary care in an integrated way, and to increase rational antimicrobial use.

Causes of Fever

Deployment of malaria diagnostic tests should go hand-in-hand with providing evidence-based guidelines for the management of the ‘negative syndrome’ – that is, detecting other causes of fever when the malaria test is negative. A first important step is to understand causes of acute febrile episodes, which is the subject of our research on fever etiology.

Further information

Interactive Electronic Decision Support Tools

Treating patients with fever in primary care can be challenging for health workers; adequate diagnostics and disease management tools are often lacking. We seek to support the current IMCI strategy through increasing the evidence base on the diagnosis and management of common infections and through the development and validation of novel, integrated disease management tools. This includes electronic, smartphone-based, decision trees.

Further information

Host Biomarkers

Host biomarkers are promising tools to improve care for patients with fever; examples include oxygen saturation or hemoglobin to detect patients with severe disease requiring hospital referral, and C-reactive protein or procalcitonin to identify patients in need for antibiotic treatment. We seek to integrate existing host biomarkers point-of-care tests into innovative disease management tools, and to evaluate their use in the tropical primary care setting. We also aim at identifying novel host biomarkers that can help manage patients with infections.

Further information

Our work on electronic decision support tools aims at improving the quality of health care through the development and validation of interactive, smartphone-based tools that promote evidence-based medicine and rational medicine use.

For developing such electronic decision support tools, we aim to improve the evidence base for the diagnosis and management of common childhood conditions. This includes the characterization of causes of fever at primary care level, finding new combinations of easy-to-assess clinical predictors for serious infections, assessing the impact of integrating existing host biomarkers point-of-care tests into disease management algorithms, and identifying novel host biomarkers that can help manage patients with infections.

Our first generation interactive electronic decision tree, ALMANACH, builds on the IMCI flowchart but also integrates additional clinical predictors and a urinary dipstick test to improve identification of children with serious infections. ALMANACH is now being implemented through a collaboration of Swiss TPH with ICRC.

Our next generation interactive electronic decision tree, e-POCT, seeks to further improve the diagnosis and management of common infections through the integration of host biomarker point-of care test results: oximetry, hemoglobin to identify severe anemia, as well as biomarkers of inflammation (procalcitonin and C-reactive protein) that help identifying patients with bacterial infection requiring antibiotic treatment. We recently assessed the e-POCT tool in a clinical trial in Tanzania. Further validation and implementation studies are planned.

With malaria transmission declining in many parts of Africa, there is increasing awareness that most acute febrile episodes are due to other pathogens, such as viral and bacterial infections. As some of these are life-threatening and may cause epidemic outbreaks, they must be identified and treated appropriately.  

In 2008 our group conducted the first comprehensive study on causes of fever in children presenting to outpatient care in Sub-Saharan Africa. 

We continue to characterize causes of fevers in a more recent adult and pediatric Tanzanian outpatient cohort through the SAFIA project (funded by the Gates Foundation), a collaboration between the Policlinique Médicale Universitaire in Lausanne and the University Hospital of Geneva Virology Laboratory. The project uses cutting-edge next-generation sequencing techniques.  

We are particularly interest in translating evidence on causes of fever into clinical practice and public health interventions. This includes the development and validation of electronic disease management tools, the identification and assessment of host biomarkers, and the integration of surveillance strategies with disease management programs.

Host biomarkers are great prospects to improve the management of fevers; they can help children with serious infections requiring antibiotic treatment and sometimes hospital-based management. Like the malaria rapid diagnostic test, such point-of-care biomarkers are important assets in increasing the rational use of drugs when used in conjunction with a clinical assessment.

For existing host biomarkers, we are particularly interested on how such tools can be integrated in patient management tools, such as e-POCT. We also aim at finding novel, better host biomarkers through a collaboration with the University of Toronto. Such novel biomarkers would eventually become available as point-of-care tests suitable for low resource settings.

Keitel K et al. A novel electronic algorithm using host biomarker point-of-care tests for the management of febrile illnesses in Tanzanian children (e-POCT): a randomized, controlled non-inferiority trial. PLoS Med. 2017;14(10):e1002411. DOI: 10.1371/journal.pmed.1002411

Shao A.F et al. New algorithm for managing childhood illness using mobile technology (ALMANACH): a controlled non-inferiority study on clinical outcome and antibiotic use in Tanzania. PLoS One. 2015;10(7):e0132316. DOI: 10.1371/journal.pone.0132316

D'Acremont V et al. Beyond malaria: causes of fever in outpatient Tanzanian children. N Engl J Med. 2014;370(9):809-817. DOI: 10.1056/NEJMoa1214482