Malaria misdiagnosis and the re-emergence of viral fevers: The case for improved surveillance and diagnostics of acute undifferentiated febrile illness in West Africa

Presumptive treatment of febrile illness patients for malaria remains the norm in endemic areas of West Africa, and “malaria” remains the top source of health facility outpatient visits in many West African nations. Many other febrile illnesses, including bacterial, viral, and fungal infections, share a similar symptomatology as malaria and are routinely misdiagnosed as such; yet growing evidence suggests that much of the burden of febrile illness is often not attributable to malaria. Dengue fever is one of several viral diseases with symptoms similar to malaria, and the combination of rapid globalization, the long-standing presence of Aedes mosquitoes, case reports from travelers, and recent seroprevalence surveys all implicate West Africa as an emerging front for dengue surveillance and control. We tested blood samples of 218 children, aged 2-14 years, with confirmed malaria in hospitals across Ghana for dengue virus exposure. We detected dengue-specific IgM antibodies in 3.2% of the children, indicating possible co-infection, and IgG antibodies in 21.6% of them, which suggests previous exposure. We discuss correlates of exposure, and recap recent vector ecology, public health, and clinical medicine literature about dengue in West Africa. We present a holistic argument for greater attention to viral fever surveillance in West Africa and renew the call for improving differential diagnosis of acute undifferentiated febrile illness (AUFI) patients in the region.