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N Engl J Med. 2014 Feb 27;370(9):809-17. doi: 10.1056/NEJMoa1214482.

Beyond malaria--causes of fever in outpatient Tanzanian children.

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From the Swiss Tropical and Public Health Institute and University of Basel, Basel (V.D., J.K.-M., C.L., B.G.), the Department of Ambulatory Care and Community Medicine, University of Lausanne (V.D., B.G.), and the Infectious Diseases Service, University Hospital (B.G.), Lausanne, and the Laboratory of Virology, Division of Infectious Diseases and Division of Laboratory Medicine, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva (P.C., L.K.) - all in Switzerland; the City Medical Office of Health, Dar es Salaam City Council (V.D., J.K.M.), and Amana Hospital (M.K., W.S.), Dar es Salaam, Ifakara Health Institute, Dar es Salaam and Ifakara (B.G.), and St. Francis Hospital, Ifakara (E.K., S.P.) - all in Tanzania.



As the incidence of malaria diminishes, a better understanding of nonmalarial fever is important for effective management of illness in children. In this study, we explored the spectrum of causes of fever in African children.


We recruited children younger than 10 years of age with a temperature of 38°C or higher at two outpatient clinics--one rural and one urban--in Tanzania. Medical histories were obtained and clinical examinations conducted by means of systematic procedures. Blood and nasopharyngeal specimens were collected to perform rapid diagnostic tests, serologic tests, culture, and molecular tests for potential pathogens causing acute fever. Final diagnoses were determined with the use of algorithms and a set of prespecified criteria.


Analyses of data derived from clinical presentation and from 25,743 laboratory investigations yielded 1232 diagnoses. Of 1005 children (22.6% of whom had multiple diagnoses), 62.2% had an acute respiratory infection; 5.0% of these infections were radiologically confirmed pneumonia. A systemic bacterial, viral, or parasitic infection other than malaria or typhoid fever was found in 13.3% of children, nasopharyngeal viral infection (without respiratory symptoms or signs) in 11.9%, malaria in 10.5%, gastroenteritis in 10.3%, urinary tract infection in 5.9%, typhoid fever in 3.7%, skin or mucosal infection in 1.5%, and meningitis in 0.2%. The cause of fever was undetermined in 3.2% of the children. A total of 70.5% of the children had viral disease, 22.0% had bacterial disease, and 10.9% had parasitic disease.


These results provide a description of the numerous causes of fever in African children in two representative settings. Evidence of a viral process was found more commonly than evidence of a bacterial or parasitic process. (Funded by the Swiss National Science Foundation and others.).

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