Fever: Like Malaria, Like Dengue

It is here again. The season of acute febrile illness.

Everywhere you turn and, in every household, there is a child or adult suffering from fever. The fever is usually very high and accompanied by headaches, body pains and sometimes tummy aches. Some people complain of additional symptoms of cough and catarrh, but the common denominator is always fever.

We blame it on the mosquitoes and rainy season. Every year, like clockwork, we have this season where there is an increase incidence of febrile illness that grips the country. And because Nigeria is a country where humour reigns supreme- we even give the fever nicknames. In Kano, some years ago, it was called ‘merger’; when Kwankwaso’s new PDP faction merged with APC.

The fever is persistent and often difficult to treat, as it does not respond to ACTs. In desperation, people turn to injectables as I have often heard people say, ‘the fever does not respond to medicine fa, just go and do malaria injection for 3 days.’

In most cases, that is not the case. Investigations are now showing that, this fever that we are calling Malaria, is not in fact Malaria.

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In Africa, misdiagnosis of Dengue fever as Malaria is a common scenario.

Malaria and Dengue are two very common vector-borne and mosquito-borne diseases in certain parts of the world, meaning that they are both transmitted by mosquitoes. They are responsible for over 600,000 deaths and have been reported in over 80 countries. The diseases can also be present in the same countries, which can be problematic if there is an outbreak of both diseases at the same time. Misdiagnosis between the two is common and contributes to the prevalence of co-infection.

Both malaria and dengue are transmitted by female mosquitoes and cause severe fevers in humans. Because of this similarity, they can be confused by patients and medical personnel.

However, there the similarity ends.

While we all know that Malaria is a parasitic illness (Plasmodium spp) transmitted by the anopheles mosquito, Dengue infections are caused by four closely related viruses named DEN-1, DEN-2, DEN-3, and DEN-4 and transmitted by the mosquito – Aedes specie. This mosquito also transmits chikungunya, yellow fever and zika infection.

Most people with Dengue have mild or no symptoms and will get better in 1–2 weeks. Rarely, Dengue can be severe and lead to death. If symptoms occur, they usually begin 4–10 days after infection and last for 2–7 days. Symptoms may include high fever (40°C/104°F), severe headache, pain behind the eyes, muscle and joint pains, nausea, vomiting, swollen glands, and rash. Individuals who are infected for the second time are at greater risk of severe Dengue.

After a slight decline of cases between the year 2020-2022 due to the COVID-19 pandemic and lower reporting rate, the global incidence of dengue has markedly increased over the past two decades, posing a substantial public health challenge. From 2000 to 2023, the World Health Organisation (WHO) documented a ten-fold surge in reported cases worldwide increasing from 500,000 to 6.5 million, characterised by a significant increase in the number, scale, and simultaneous occurrence of multiple outbreaks, spreading into regions previously unaffected by Dengue. Major reasons for this upsurge include urbanisation, international travel, climate change, and low socioeconomic status.

So, if this is the case- why are we still hammering on Malaria fever?

Firstly, we know Malaria. Malaria is our main man. Parasitic illnesses like Malaria are easier to test and treat. It is also cheaper. And because of this, we always hold on to our main culprit. A simple rapid diagnostic test will tell you whether it is Malaria. These test kits are available in every nook and cranny of Nigeria. Unlike Dengue. Dengue is tested via blood samples using antibody testing or PCR tests. Currently, there is a diagnostics capacity for the Dengue virus (DENV) at the NCDC National Reference Laboratory (NRL) in Abuja and the Usman Dan Fodio University Sokoto Teaching Hospital Laboratory Centre for Human and Zoonotic Virology (UDUTH).

You see the problem? So, it easier to start with Malaria.

Secondly and more importantly, like many viral illnesses, there is no specific treatment for Dengue. Appropriate supportive medical care frequently saves the lives of patients with severe Dengue, otherwise, the mild form of Dengue fever is usually self-limiting, meaning that, even without treatment, the person usually gets better on his own. This fact is especially important in patients who have fever.

Typical scenario- you have fever and go for a Malaria test. This is what the WHO recommends, test before treating. If positive- treat with any of the Artemisinin Combination Therapies. If negative- please look for other causes of fever. If you are practicing where you can test for Dengue, please do so. If not, look for other causes like urinary tract infections, enteric fever etc. Chances are, if it is Dengue, the fever will resolve on its own while you are busy running tests.

Indiscriminate prescribing of ACT leads to antimicrobial resistance. But that is a story for another day.