Volume 99, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Febrile illnesses are a major cause of mortality in sub-Saharan Africa. Early identification of patients at increased risk of death may avert adverse outcomes. We aimed to independently evaluate the performance of the Modified Early Warning Score, quick Sequential Organ Failure Assessment (qSOFA) score, and Integrated Management of Adolescent and Adult Illness (IMAI) emergency signs and severity criteria to predict in-hospital mortality among a prospective cohort of febrile patients in Tanzania. We evaluated 419 patients aged ≥ 10 years in the period 2007–2008. Of the 44 patients who died, 31 (70.5%) were human immunodeficiency virus (HIV) infected. On univariate analysis, in-hospital mortality was associated with HIV infection, oxygen saturation < 90%, respiratory distress, Glasgow Coma Scale < 15, neck stiffness, unconsciousness, convulsions, hemoglobin < 9 g/dL, absence of a systemic syndrome, and neurologic syndrome. A qSOFA score ≥ 2, the presence of at least one, two, or three IMAI emergency signs, and IMAI severe respiratory distress syndrome without shock were significantly associated with in-hospital mortality. The criterion “presence of at least one IMAI emergency sign” showed a good diagnostic accuracy, as highlighted by the high sensitivity, low negative likelihood ratio, and wide area under the receiver operating characteristics curve. The remaining scores showed a poor performance in predicting fatal outcomes in our study population. Further studies are needed to validate our findings and to derive early warning scores that have good clinical performance in settings throughout sub-Saharan Africa.


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  1. GBD 2015 Mortality Causes of Death Collaborators, 2016. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388: 14591544. [Google Scholar]
  2. Petit PL, van Ginneken JK, , 1995. Analysis of hospital records in four African countries, 1975–1990, with emphasis on infectious diseases. J Trop Med Hyg 98: 217227. [Google Scholar]
  3. Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA, , 2006. Laboratory medicine in Africa: a barrier to effective health care. Clin Infect Dis 42: 377382. [Google Scholar]
  4. Archibald LK, Reller LB, , 2001. Clinical microbiology in developing countries. Emerg Infect Dis 7: 302305. [Google Scholar]
  5. Crump JA, Gove S, Parry CM, , 2011. Management of adolescents and adults with febrile illness in resource limited areas. BMJ 343: d4847. [Google Scholar]
  6. Becker JU, Theodosis C, Jacob ST, Wira CR, Groce NE, , 2009. Surviving sepsis in low-income and middle-income countries: new directions for care and research. Lancet Infect Dis 9: 577582. [Google Scholar]
  7. Seymour CW, 2016. Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315: 762774. [Google Scholar]
  8. Subbe CP, Kruger M, Rutherford P, Gemmel L, , 2001. Validation of a modified early warning score in medical admissions. QJM 94: 521526. [Google Scholar]
  9. Singer M, 2016. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315: 801810. [Google Scholar]
  10. Kruisselbrink R, 2016. Modified Early Warning Score (MEWS) identifies critical illness among ward patients in a resource restricted setting in Kampala, Uganda: a prospective observational study. PLoS One 11: e0151408. [Google Scholar]
  11. Huson MA, Kalkman R, Grobusch MP, van der Poll T, , 2017. Predictive value of the qSOFA score in patients with suspected infection in a resource limited setting in Gabon. Travel Med Infect Dis 15: 7677. [Google Scholar]
  12. Wheeler I, Price C, Sitch A, Banda P, Kellett J, Nyirenda M, Rylance J, , 2013. Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study. PLoS One 8: e59830. [Google Scholar]
  13. Baker T, Blixt J, Lugazia E, Schell CO, Mulungu M, Milton A, Castegren M, Eriksen J, Konrad D, , 2015. Single deranged physiologic parameters are associated with mortality in a low-income country. Crit Care Med 43: 21712179. [Google Scholar]
  14. Opio MO, Nansubuga G, Kellett J, , 2013. Validation of the VitalPAC Early Warning Score (ViEWS) in acutely ill medical patients attending a resource-poor hospital in sub-Saharan Africa. Resuscitation 84: 743746. [Google Scholar]
  15. World Health Organization, 2011. IMAI District Clinician Manual: Hospital Care for Adolescents and Adults: Guidelines for the Management of Common Illness with Limited Resources. Available at: http://www.who.int/influenza/patient_care/DCM_Volume_1.pdf. Accessed August 23, 2017.
  16. World Health Organization, 2000. Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for Care at the First-Referral Level in Developing Countries. Geneva, Switzerland: World Health Organization.
  17. Clifton DC, Ramadhani HO, Msuya LJ, Njau BN, Kinabo GD, Buchanan AM, Crump JA, , 2012. Predicting mortality for paediatric inpatients where malaria is uncommon. Arch Dis Child 97: 889894. [Google Scholar]
  18. Paxton LA, Redd SC, Steketee RW, Otieno JO, Nahlen B, , 1996. An evaluation of clinical indicators for severe paediatric illness. Bull World Health Organ 74: 613618. [Google Scholar]
  19. National Bureau of Statistics, 2013. 2012 Population and Housing Census. Dar es Salaam, United Republic of Tanzania: National Bureau of Statistics.
  20. Hay SI, 2009. A world malaria map: Plasmodium falciparum endemicity in 2007. PLoS Med 6: e1000048. [Google Scholar]
  21. National Bureau of Statistics, 2008. Tanzania HIV/AIDS and Malaria Indicator Survey 2007–2008. Dar es Salaam, United Republic of Tanzania: National Bureau of Statistics.
  22. Crump JA, 2011. Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected children and infants in northern Tanzania. Trop Med Int Health 16: 830837. [Google Scholar]
  23. Crump JA, 2011. Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected adults and adolescents in northern Tanzania. Clin Infect Dis 52: 341348. [Google Scholar]
  24. D’Acremont V, Kilowoko M, Kyungu E, Philipina S, Sangu W, Kahama-Maro J, Lengeler C, Cherpillod P, Kaiser L, Genton B, , 2014. Beyond malaria—causes of fever in outpatient Tanzanian children. N Engl J Med 370: 809817. [Google Scholar]
  25. Southeast Asia Infectious Disease Clinical Research Network, 2017. Causes and outcomes of sepsis in southeast Asia: a multinational multicentre cross-sectional study. Lancet Glob Health 5: e157e167. [Google Scholar]
  26. Wang TH, Wei KC, Jiang DD, Chiu CH, Chang SC, Wang JD, , 2008. Unexplained deaths and critical illnesses of suspected infectious cause, Taiwan, 2000–2005. Emerg Infect Dis 14: 16531655. [Google Scholar]
  27. Asiimwe SB, Abdallah A, Ssekitoleko R, , 2015. A simple prognostic index based on admission vital signs data among patients with sepsis in a resource-limited setting. Crit Care 19: 86. [Google Scholar]
  28. Rhee KJ, Fisher CJ, Jr. Willitis NH, , 1987. The rapid acute physiology score. Am J Emerg Med 5: 278282. [Google Scholar]
  29. Olsson T, Terent A, Lind L, , 2004. Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. J Intern Med 255: 579587. [Google Scholar]
  30. Fernandez G, , 2010. Statistical Data Mining Using SAS Applications, 2nd edition. Boca Raton, FL: CRC Press Reference.
  31. Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, Edelson DP, , 2017. Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit. Am J Respir Crit Care Med 195: 906911. [Google Scholar]

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  • Received : 27 Aug 2017
  • Accepted : 14 Aug 2018
  • Published online : 17 Sep 2018

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