Redd S C, Kazembe P N, Luby S P, Nwanyanwu O, Hightower A W, Ziba C, Wirima J J, Chitsulo L, Franco C, Olivar M
Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia, USA.
Lancet. 1996 Jan 27;347(8996):223-7. doi: 10.1016/s0140-6736(96)90404-3.
Identification of children who need antimalarial treatment is difficult in settings where confirmatory laboratory testing is not available, as in much of sub-Saharan Africa. The current national policy in Malawi is to treat all children with fever, usually defined as the mother's report of fever in the child, for presumed malaria. To assess this policy and to find out whether a better clinical case definition could be devised, we studied acutely ill children presenting to two hospital outpatient departments in Malawi.
The parent or guardian of each enrolled child (n = 1124) was asked a standard series of questions about the symptoms and duration of the child's illness. Each child was examined, axillary and rectal temperatures and blood haemoglobin concentrations were measured, and a giemsastained thick smear was examined for malaria parasites. Logistic regression procedures were used to identify clinical predictors of parasitaemia.
High temperature (37.7 degrees C or above), nailbed pallor, enlarged spleen, and being seen at one of the clinics rather than the other were associated with an increased risk of malaria parasitaemia in univariate analyses. A revised malaria case definition of rectal temperature of 37.7 degrees C or higher, splenomegaly, or nailbed pallor was 85% sensitive in identifying parasitaemic children and 41% specific; the corresponding sensitivity and specificity for the nationally recommended definition that equates mother's history of fever with malaria were 93% and 21%. The revised case definition had 89% sensitivity in identifying parasitaemic children with haemoglobin concentration below 80 g/L and 89% sensitivity in identifying children with parasite density greater than 10,000/microL, characteristics that indicate a clear need for antimalarial treatment.
These results suggest that better clinical definitions are feasible, that splenomegaly and pallor are helpful in identifying children with malaria, and that much overtreatment of children without parasitaemia could be avoided.
在撒哈拉以南非洲的大部分地区，由于无法进行确诊的实验室检测，识别需要抗疟治疗的儿童很困难。马拉维目前的国家政策是，对所有发烧儿童（通常定义为母亲报告孩子发烧）进行疟疾推定治疗。为了评估这一政策并找出是否可以制定出更好的临床病例定义，我们对马拉维两个医院门诊部门的急症患儿进行了研究。
询问了每名登记患儿（n = 1124）的家长或监护人一系列关于患儿症状和疾病持续时间的标准问题。对每个孩子进行检查，测量腋窝和直肠温度以及血液血红蛋白浓度，并检查经吉姆萨染色的厚涂片以查找疟原虫。采用逻辑回归程序来确定寄生虫血症的临床预测因素。
在单因素分析中，高温（37.7摄氏度或以上）、甲床苍白、脾脏肿大以及在其中一个诊所而非另一个诊所就诊与疟疾寄生虫血症风险增加相关。修订后的疟疾病例定义为直肠温度37.7摄氏度或更高、脾肿大或甲床苍白，在识别寄生虫血症患儿方面的敏感度为85%，特异度为41%；将母亲报告的发烧等同于疟疾的国家推荐定义的相应敏感度和特异度分别为93%和21%。修订后的病例定义在识别血红蛋白浓度低于80 g/L的寄生虫血症患儿方面敏感度为89%，在识别寄生虫密度大于10,000/微升的患儿方面敏感度为89%，这些特征表明明显需要进行抗疟治疗。
这些结果表明，更好的临床定义是可行的，脾肿大和苍白有助于识别疟疾患儿，并且可以避免对无寄生虫血症的儿童进行大量过度治疗。
