Key findings:

The key findings of this abstract include the predominance of malaria among healthcare workers with acute febrile illness, particularly during the months of August, September, and October. Clinical features such as myalgia and abdominal pain were common, with leukocytosis observed in 75% of cases. Vigilance and prompt treatment are essential.

What is known and what is new?

The abstract elucidates the clinical features and epidemiological trends of malaria among healthcare workers with acute febrile illness, emphasizing the importance of vigilance in diagnosis and treatment. While the prevalence of malaria is known, the specific data regarding its occurrence among healthcare workers and associated clinical manifestations provide new insights for targeted interventions and preventive strategies.

What is the implication, and what should change now?

The study highlights the prevalence and clinical manifestations of malaria among healthcare workers presenting with acute undifferentiated febrile illness. Improved awareness, early recognition, and prompt treatment of malaria are essential for reducing morbidity and preventing outbreaks among healthcare providers. Enhanced training and adherence to preventive measures are crucial in healthcare settings.

 Acute febrile illness (AFI) is defined as a patient with fever of 38°C or higher at presentation or history of fever that persisted for 2–7 days with no localizing source [1].  Acute febrile illness is a common cause of patients seeking health care settings posing a diagnostic and therapeutic challenge to the health care workers [2]. Field studies on fever aetiology in India are few, and surveillance is limited by lack of accessibility to health facilities. 

Some fever syndromes have a more clear localization to skin and soft tissue (abscess or cellulitis), meninges or neural tissue (headache, neck-stiffness, altered sensorium with or without focal neurological signs), respiratory tract (cough, breathlessness), or urinary tract (dysuria, hematuria). These syndromes have better developed guidelines for their management. On the other hand, AUF-syndromes (such as fever-rash, fever-myalgia, fever-arthralgia, fever-hemorrhage, and fever-jaundice) have overlapping etiologies, which makes their diagnosis and management even more challenging. [3]

In this article we describe the clinical, laboratory, serological and radiological features of Malaria as a cause of Acute Undifferentiated Febrile Illness among the patients admitted in the Department of Medicine at Indira Gandhi Medical College, Shimla, Himachal Pradesh, India.

[1] Oishr K, A Maputa C, Carlos CC, Cinco-Abanes MT, Saoto M, Inoue S, Morita K, Natividad FF. Dengue and other Febric illnesses among Children in the Philippines.

[2] Reller ME, Bodinayake C, Nagahawatte A, Devasiri V, Kodikara-Arachichi W, Strouse JJ, Flom JE, Dumler JS, Woods CW. Leptospirosis as frequent cause of acute febrile illness in southern Sri Lanka. Emerging infectious diseases. 2011 Sep;17(9):1678.

[3] Ray P, Ratagiri VH, Kabra SK, Lodha R, Sharma S, Sharma BS, Kalaivani M, Wig N. Chikungunya infection in India: results of a prospective hospital based multi-centric study. PloS one. 2012 Feb 17;7(2):e30025.

It was a hospital-based cross-sectional observational study that was conducted in the Department of Internal Medicine at Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. The study was conducted over a period of one year. All patients who were admitted with Malaria as a cause of Acute Undifferentiated Fever were defined as temperature ≥ 100°F and history of febrile illness of 2–14 days duration, with no other localized cause were included in the study. The data was collected, cleaned and entered into Microsoft Excel spreadsheet and transferred to Epi info version 7.2.1.0 software. The categorical variables were expressed in terms of frequencies, proportions, and percentages with 95% confidence intervals. The continuous variables were expressed as means ± standard deviation. (Table 1)

We found that the mean age of the study participants suffering from malaria was found to be 35 years and a standard deviation of 12.2 years. Their duration of stay in the hospital was found to be 3.8 days on an average with a standard deviation of 1.6 days. The duration of fever of the patients suffering from malaria in our study participants was found to be 3.6 days with standard deviation of 2.1 days. The majority of cases of malaria were positive in the month of August followed by September and October. (Fig. 1)

Table 1: Malaria

Fig.1: Monthly Distribution of Cases of Malaria

Table 2 gives a description of clinical parameters of the study participants who presented with malaria as an acute undifferentiated illness. Among the patients of malaria 38% of the study participants presented with arthralgia whereas 88% of the study participants presented with myalgia. Half of the participants presented with nausea and vomiting whereas 25% of the study participants had retrobulbar pain. However 50% of the study participants presented with an icterus at the time of admission. While 38% of the study participants suffering from malaria presented with cough only 50% of the study participants had dyspnea. No patient presented with hemoptysis. 50% of the participants diagnosed with malaria-like illness had headache. Whereas 50% of the individuals were found to have splenomegaly but only 25% of the individuals suffering from malaria had hepatomegaly. 63% of the individuals presented with pain in the abdomen but 38% of the individuals presented with loose stools among the patients suffering from Malaria.

Table 2: Clinical parameters associated with Acute Undifferentiated Febrile Illness due to Malaria (N=8)

Among all the cases of malaria admitted in the department of general medicine 25% of the individuals were found to have anemia, 75% of the individuals had leukocytosis and none had leukopenia. 13% of the individuals had thrombocytopenia and half of the individuals had raised haematocrit. Serum creatinine was found to be raised in only one patient  and none had raised serum total bilirubin. Elevated serum ALT and serum AST were found in only 25% and 38% individuals respectively while 13% of the individuals suffering from malaria had deranged serum albumin. (Table 3)

Among all the cases only 37% of the individuals had abnormal chest X-Ray while none of the individuals had abnormal ultrasonographic findings in the abdomen.

Table 3: Laboratory, Serological and Radiological parameters associated with Acute Undifferentiated Febrile Illness due to Malaria (N=8)

Signs and symptoms of malaria are often nonspecific, but fever is usually present. Other symptoms include headache, chills, increased sweating, back pain, myalgia, diarrhea, nausea, vomiting, and cough [1]. Prompt diagnosis requires that malaria be included in the differential diagnosis of illness in a febrile person with a history of travel to a malarious area. Clinicians should ask all febrile patients for a travel history, including when evaluating febrile illnesses among international visitors, immigrants, refugees, migrant laborers, and international travelers. [2]

The importance of taking correct precautions and chemoprophylaxis is underscored by the eight fatal cases of malaria that occurred in the United States in 2002 [6]. An earlier review of deaths attributed to malaria in the United States identified specific risk factors for fatal malaria, including failure to take recommended antimalarial chemoprophylaxis, refusal of or delay in seeking medical care, and misdiagnosis. [7]

Prompt treatment of suspected malaria is essential, because persons with P. falciparum infection are at risk for experiencing life-threatening complications soon after the onset of illness. Ideally, therapy for malaria should be initiated immediately after the diagnosis has been confirmed by a positive blood film. Treatment should be determined on the basis of the infecting Plasmodium species, the probable geographic origin of the parasite, the parasite density, and the patient's clinical status.^[5] If the diagnosis of malaria is suspected and cannot be confirmed, or if a diagnosis of malaria is confirmed but species determination is not possible, antimalarial treatment should be initiated that is effective against P. falciparum. Resistance of P. falciparum to chloroquine is worldwide, with the exception of a limited number of geographic regions. Therefore, therapy for presumed P. falciparum malaria should usually entail use of a drug effective against such resistant strains.

[1] World Health Organization. World malaria situation in 1994. Wkly Epidemiol Rec 1997;72:269--76. https://doi.org/10.1016/S0140-6736(96)12085-2.

[2] Breman JG. Ears of the hippopotamus: manifestations, determinants, and estimates of the malaria burden. The Intolerable Burden of Malaria: A New Look at the Numbers: Supplement to Volume 64 (1) of the American Journal of Tropical Medicine and Hygiene. 2001 Jan.

[3] Zucker JR. Changing patterns of autochthonous malaria transmission in the United States: a review of recent outbreaks. Emerging infectious diseases. 1996 Jan;2(1):37.

[4] Greenberg AE, Lobel HO. Mortality from Plasmodium falciparum malaria in travelers from the United States, 1959 to 1987. Annals of Internal Medicine. 1990 Aug 15;113(4):326-7.

[5] Zucker JR, Campbell CC. Malaria. Principles of prevention and treatment. Infectious disease clinics of North America. 1993 Sep 1;7(3):547-67.

Health-care providers should be familiar with prevention, recognition, and treatment of malaria and are encouraged to consult appropriate sources for malaria prevention and treatment recommendations.

No funding sources

None declared

The study was approved by the Institutional Ethics Committee of Indira Gandhi Medical College.

1. Oishr, Kazunori, et al. "Dengue and other Febric illnesses among Children in the Philippines." (2006). https://apps.who.int/iris/bitstream/handle/10665/170219/db2006v30p26.pdf 

2. Reller, Megan E., et al. "Leptospirosis as frequent cause of acute febrile illness in southern Sri Lanka." Emerging infectious diseases 17.9 (2011): 1678. https://doi.org/10.3201%2Feid1709.100915 

3. Ray, Pratima, et al. "Chikungunya infection in India: results of a prospective hospital based multi-centric study." PloS one 7.2 (2012): e30025. https://doi.org/10.1371/journal.pone.0030025 

4. World Health Organization. World malaria situation in 1994. Wkly Epidemiol Rec 1997;72:269--76. https://doi.org/10.1016/S0140-6736(96)12085-2.

5. Breman, Joel G. "Ears of the hippopotamus: manifestations, determinants, and estimates of the malaria burden." The Intolerable Burden of Malaria: A New Look at the Numbers: Supplement to Volume 64 (1) of the American Journal of Tropical Medicine and Hygiene (2001). https://www.ncbi.nlm.nih.gov/books/NBK2615/?report=reader 

6. Zucker, Jane R. "Changing patterns of autochthonous malaria transmission in the United States: a review of recent outbreaks." Emerging infectious diseases 2.1 (1996): 37. https://doi.org/10.3201%2Feid0201.960104 

7. Greenberg, Alan E., and Hans O. Lobel. "Mortality from Plasmodium falciparum malaria in travelers from the United States, 1959 to 1987." Annals of Internal Medicine 113.4 (1990): 326-327. https://doi.org/10.7326/0003-4819-113-4-326