1 5A U G U S T
Rapid Diagnostic Tests for a
Coordinated Approach to
Fever Syndromes in Low-
To THE EDITOR—We read with interest
the editorial commentary by Crump ,
which emphasizes the need for a syn-
dromic approach to fever in low-resource
settings—citing 2 recent epidemics of Sal-
monella Typhi [2, 3], the decreasing pro-
portion of malaria-attributable illness in
many areas, and changing vaccination
patterns as arguments. We strongly agree
with this point and wish to emphasize
the role of microbiologic diagnostic tests
in this process.
Although the benefits of parasitologi-
cal diagnosis of malaria are widely em-
phasized , using malaria diagnosis
alone as the cornerstone of linking
febrile patients to appropriate care is
dangerous. For example, the Institute of
Tropical Medicine, Antwerp, was recent-
ly asked for assistance by colleagues in
the remote Bwamanda health zone of
the Democratic Republic of the Congo,
which was facing an outbreak of severe
malarial anemia in the second half of
2011. A dramatic increase in blood
transfusion requirements and in-hospital
mortality was observed among children
<5 years of age with parasitologically
confirmed malaria. Intensified surveil-
lance of bloodstream infections in De-
cember 2011 via the national reference
laboratory in Kinshasa recovered 57
nontyphoidal Salmonella isolates among
135 blood cultures in severely ill chil-
dren (42%). This large unrecognized
outbreak of severe disease from a clonal
strain of Salmonella illustrates the pitfalls
of focusing on a single pathogen, such
as malaria, in patients presenting with
febrile illnesses in low-resource settings.
malaria rapid diagnostic tests (RDT) has
resulted in dramatic increases in empiric
antibacterial use among the three-quar-
ters of febrile patients in whom no
malaria is found . This dichotomous
emerging antimicrobial resistance in the
settings that can least afford it .
Choosing rational empiric therapy for
patients with febrile syndromes in low-
resource settings is complicated by the
fact that a large proportion of them may
be caused by any of several geographi-
cally restricted infections and neglected
tropical diseases, such as tick-borne bor-
reliosis , visceral leishmaniasis ,
and human African trypanosomiasis.
Such infections are severe and treatable
matters worse, very little epidemiologic
data underpin clinicians’ assessment of
prior probability in vast areas of Africa
A syndromic approach to patients with
fever that integrates relevant combina-
tions of RDT is urgently needed in many
parts of the world. This will require (1)
using reference standard techniques to
determine the prevalence of priority dis-
eases that are severe and treatable; (2)
validation of existing RDT in field set-
tings and development of new RDT for
key pathogens of epidemiologic impor-
tance; and (3) evidence-based algorithms
incorporating local epidemiological data
and setting-specific RDT diagnostic con-
tributions, because the latter can vary
substantially by locality [9,10].
We are working as part of the EU-
funded NIDIAG (Neglected Infectious
develop such an approach to persistent
fever in 4 low-resource countries, with
the aim of achieving patient-centered
care pathways that will accelerate diag-
nosis and improve outcomes.
Financial support. The NIDIAG consortium
is supported by the European Commission under
the Health Cooperation Work Programme of the
7th Framework Programme (FP7).
Potential conflicts of interest.
No reported conflicts.
All authors have submitted the ICMJE Form
for Disclosure of Potential Conflicts of Interest.
Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
Cedric P. Yansouni,1Emmanuel Bottieau,1
François Chappuis,2Marie-France Phoba,3
Octavie Lunguya,3Billy Bongoso Ifeka,4and
1Department of Clinical Sciences, Institute of Tropical
Medicine, Antwerp, Belgium;2Division of
International and Humanitarian Medicine, Geneva
University Hospitals, Switzerland;3Institut National
de Recherche Biomédicale, Kinshasa, and4Zone de
Santé Rurale de Bwamanda, Democratic Republic of
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Correspondence: Cedric P. Yansouni, MD, Department of
Clinical Sciences, Institute of Tropical Medicine, Nationales-
traat 155, 2000 Antwerp, Belgium (cedric.yansouni@mail.
Clinical Infectious Diseases
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