Acute undifferentiated fever in Binh Thuan province, Vietnam: imprecise clinical diagnosis and...

Acute undifferentiated fever in Binh Thuan province, Vietnam:

imprecise clinical diagnosis and irrational pharmaco-therapy

Hoang L. Phuong1,2, Peter J. de Vries1, Nico Nagelkerke3, Phan T. Giao2, Le Q. Hung2, Tran Q. Binh2,

Tran. T. Thanh Nga1,4, Nguyen V. Nam5 and Piet A. Kager1

1 Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, Amsterdam, The Netherlands2 Department of Tropical Diseases, Cho Ray Hospital, Ho Chi Minh City, Vietnam3 Department of Community Medicine, United Arab Emirates University, Al Ain, United Arab Emirates4 Department of Microbiology, Cho Ray Hospital, Ho Chi Minh City, Vietnam5 Binh Thuan Malaria and Goiter Control Center, Phan Thiet, Vietnam

Summary objectives To describe the characteristics of patients consulting commune primary healthcare posts

for acute undifferentiated fever not being malaria (AUF), and to explore the diagnostic and therapeutic

responses of the healthcare workers.

methods All patients presenting with AUF at 12 commune health posts and one clinic at the provincial

malaria station, Binh Thuan, a dengue endemic province in southern Vietnam, were included. Record

forms were used to fill in patient and diseases characteristics, pre-referral treatment, signs and symptoms,

provisional diagnosis and installed treatment, referral and final outcome.

results Two thousand ninety-six patients were included from April 2001 to March 2002. The median

delay to attend the health posts was, 0.87 day for >5, 1.15 days for children aged 5–15 years and

1.41 days for adults (P < 0.001). Sixty-five per cent of patients took some measures before consulting

the health post, of whom 82% applied self-medication and 69% took antibiotics. Pre-referral medica-

tion with antibiotics increased with age (RR 1.012 per year of age; 95% CI: 1.004–1.019). The diag-

nostic and therapeutic response of healthcare workers was very unspecific. The tourniquet test was

inappropriately used as general discriminating test, not only for detecting dengue haemorrhagic fever.

Empiric antibiotic therapy was installed in 77.2% of cases.

conclusions Management of uncomplicated fever, not being malaria, at the primary healthcare level

in Vietnam is non-specific, dominated by searching signs of hemorrhagic dengue and empiric antibiotic

treatment. This can probably be improved by better education.

keywords fever, clinical diagnosis, treatment, Vietnam

Introduction

Vietnam has been highly successful in bringing malaria

under control during the last decade (Ettling 2002).

Despite the rapid decline of malaria (Ettling 2002; Hung

et al. 2002; Nam et al. 2005), fever remains a common

reason for seeking help at communal health posts. Unlike

malaria, for which microscopic confirmation has become

standard practice at many health posts, laboratory diag-

nosis of other infectious diseases is lacking, and diagnosis

and treatment are generally only based on signs and

symptoms.

Self-medication has become very common among febrile

subjects in Vietnam and many other developing countries,

similar to what was observed for malaria before the large-

scale introduction of early diagnosis and treatment of

malaria (EDTM) (Boonstra et al. 2002; Deressa et al.

2003). Unguided use of antibiotics has many disadvanta-

ges, such as selection of drug resistant micro-organisms,

adverse drug effects, drug interactions and increased health

expenditure (Larsson et al. 2000; Okumura et al. 2002).

In the case of malaria, we recently showed that

improving the public knowledge and offering early diag-

nosis and effective treatment diverted patients from self-

treatment towards professional help (Giao et al. 2005). We

wondered if this can be achieved for other fevers as well.

This requires further study into the interaction between

health-seeking behaviour and the provided care. Health-

seeking behaviour is frequently investigated by techniques,

which are common in social sciences or marketing research

Tropical Medicine and International Health doi:10.1111/j.1365-3156.2006.01636.x

volume 11 no 6 pp 869–879 june 2006

ª 2006 Blackwell Publishing Ltd 869

https://www.researchgate.net/publication/7928111_Malaria_control_in_Vietnam_The_Binh_Thuan_experience?el=1_x_8&enrichId=rgreq-3158172d322cd78f7acf8ebaabbf10c5-XXX&enrichSource=Y292ZXJQYWdlOzcwMTE2MDI7QVM6OTk5MDczMTg4NDU0NTBAMTQwMDgzMTE2OTU4Mw==

(Font et al. 2001; Giao et al. 2005). The response of the

healthcare provider is less well studied (Halfvarsson et al.

2000; Guyatt & Snow 2004).

Here we describe the characteristics of patients with

acute fever, not being malaria, who present to a public

primary health post and explore patterns in the healthcare

workers’ diagnostic and therapeutic response.

Methods

The study was performed in Binh Thuan province (Figure 1)

in southern Vietnam, starting in April 2001. Binh Thuan has

a population of approximately 1.1 million on an area of

7992 km2, wedged between the Truong Son forested

mountains (alt. 1100–1642 m) in the west and the South

Chinese sea in the east. The majority of the population lives

in rural areas, with approximately 187,042 people in and

around the capital, Phan Thiet. The majority of the popu-

lation (88%) is of Kinh (Vietnamese) origin, the others

belong to several ethnicminorities of varying population size

(Cham, K’Ho, Hoa, Tay, Nung, Ra Glai, Ta Lop and Ma)

often living in the more remote areas.

Until recently, Binh Thuan was a relatively poor region,

and especially the ethnic minorities were vulnerable. Over

the last decade the provincial annual income per capita

increased to US$278 in urban areas and US$230 in rural

areas (the national income per capita is US$374).

Healthcare is provided by a provincial hospital in Phan

Thiet, nine district hospitals and 115 commune posts for

primary healthcare and disease control (further called

health posts). In 2001 there were 483 medical doctors with

a university degree (MD) employed in the province. The

target of the national strategy to staff every health post

with at least one MD has almost completely been achieved

by postgraduate training at university level of medical

officers (the so-called second degree doctors). (Source:

Statistical Yearbook 2001 – Binh Thuan Statistics Office,

Phan Thiet) Additional professional training after formal

graduation is virtually non-existent let alone ‘continuous

education’.

This study took place in changing circumstances of

liberalization of the health sector giving rise to the

development of a private sector (Sepehri et al. 2003). To

attend a health post patients pay a small fee (±US$0.06)

37. Ham My (12731)

95. Duc Long (15255)

103. Ham Tien (11175)

11. Binh Tan (6588)

83. Vinh Hao (8344)

51. Tan Xuan (7169)

49. Tan Minh (14020)

78. Tra Tan (14960)

79. Me Pu (12152)

59. Huy Khiem (7747)

25. Ham Phu (6843)

7. Phan Tien (862)

• Hanoi

•

Ho Chi MinhCity

Figure 1 Administrative map of Binh Thuan indicating the communes (name and number) participating in the study. Between brackets the

population in 2000.

Tropical Medicine and International Health volume 11 no 6 pp 869–879 june 2006

H. L. Phuong et al. Acute undifferentiated fever in Binh Thuan province, Vietnam

870 ª 2006 Blackwell Publishing Ltd

https://www.researchgate.net/publication/10852936_If_They_Get_Sick_They_Are_in_Trouble_Health_Care_Restructuring_User_Charges_and_Equity_in_Vietnam?el=1_x_8&enrichId=rgreq-3158172d322cd78f7acf8ebaabbf10c5-XXX&enrichSource=Y292ZXJQYWdlOzcwMTE2MDI7QVM6OTk5MDczMTg4NDU0NTBAMTQwMDgzMTE2OTU4Mw==

and patients have to pay for examinations and drugs. Poor

subjects, including members of the ethnic minority groups,

are exempted from payment. The motives why patients

choose the public or private sector are largely unknown.

Twelve, not adjacent, health posts and one clinic at the

provincial malaria station, where febrile patients, suspect-

ing malaria, come for diagnosis and treatment, were

selected in a manner that would ensure a representative

selection of rural and (semi-)urban, lowland and highland

communes, and the province’s ethnic population structure.

The staff of the participating health posts were composed

of MDs and second degree doctors.

All patients presenting with acute undifferentiated fever

(AUF) were included in this study. AUF was defined as any

febrile illness of duration less than 14 days, confirmed by

an axillary temperature ‡38.0 �C, without any indication

for either severe systemic or organ specific disease. Malaria

was excluded by microscopic examination of a thick blood

smear.

Data collection

Record forms were filled in for all AUF patients recording

patient identifiers (age, sex, occupation and address),

history of recent exposure factors such as occupation, fresh

water contact, visiting forests, duration of disease and

invalidation, treatment taken, signs and symptoms at

presentation, provisional diagnosis and prescribed treat-

ment, referral and final outcome. Diagnoses such as ‘acute

fever’ and ‘viral infection’ were all reclassified to ‘undif-

ferentiated fever’.

Blood samples were collected for sero-diagnosis, results

of which will be presented elsewhere. All included subjects

were asked to come back after 2–4 weeks for re-assessment

and collection of a second blood sample.

Data were entered by the attending healthcare worker at

the first presentation of the patient. All health posts were

monitored at monthly visits by the research team from Cho

Ray Hospital, Ho Chi Minh City.

The study was approved by the Review Board of the Cho

Ray Hospital. The study was explained and discussed in

meetings with provincial authorities and staff of the health

posts. All patients (or, for children, the parents or

guardian) gave written informed consent.

Data analysis

Statistical analysis was done using SPSS (Version 11.5,

SPSS Inc., Ill.) and S-Plus 2000 (release 2, Mathsoft Inc,

MA). Frequencies and means or medians were calculated

to describe background variables. The chi-square test and

the median test were applied to assess the relation of

variables such as time of presentation at primary health

posts and age groups, time of presentation at primary

health posts and previous treatment, and season and

presumptive diagnosis. A logistic regression model was

used to explore the variables that related to antibiotic

use. Associations between the different indicators were

sought with explorative techniques such as correspon-

dence analysis, an explorative cluster analysis technique

and classification trees (Benzecri 1992; Venables &

Ripley 1999).

Results

From April 2001 until April 2002, 2096 patients with

undifferentiated fever (867 females and 1229 males,

female/male ¼ 1/1.3) were included. The median age was

18 years (range from 1 to 82). Their main occupation was

farming (820 adults, 39%) and school attendance (768

children, 37%). Other occupations included construction

and industrial labour (n ¼ 153; 7%), civil officer (n ¼ 39;

2%), child at home (n ¼ 163; 8%) and retirement (n ¼ 41;

2%).

Patients were divided into three age groups: adults

>15 years (n ¼ 1198; 57.2%), children from 5 to 15 years

(n ¼ 730; 34.8%) and >5 (n ¼ 166; 7.9%). The age

distribution of patients differed among health posts and is

shown in Table 1. Some health posts preferentially attrac-

ted children (health posts 25, 51 and 103), whereas others

were mainly visited by elderly subjects (e.g. Nos. 79 and

97).

Table 1 Distribution of age of patients with acute undifferenti-

ated fever who presented to 13 primary health posts in Binh Thuan

province, Vietnam

Health post(code)

Total patients(No.)

Age groups (years)

<5 (%) 5–15 (%) >15 (%)

7 451* 7.3 19.7 72.911 75 6.7 33.3 60.0

25 210 22.9 51.9 25.2

37 315 1.3 45.1 53.7

49 73 4.1 20.5 75.351 77 24.7 54.5 20.8

59 115 7.0 27.0 66.1

78 167 7.2 25.1 67.7

79 48 – 8.3 91.783 161 3.1 46.6 50.3

95 209 12.4 38.3 49.3

97 92 – 12.0 88.0103 101 3.0 64.4 32.7

Total 2094 7.9 34.9 57.2

* Two cases missing age.




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Patients attended the health post relatively soon after the

first symptoms. Themedian interval fromonset of illness and

of fever to presentation is shown in Table 2. The significant

difference in time between the three groups suggests that

parents seek help earlier for their children >5 than for their

children between 5 and 15 years or themselves.

Before attending the health posts, 1356 of 2096 (65%)

patients took some measure such as self-medication (82%)

or consulted a private clinic (11%) or a health post (5%).

The latter group mainly comprises patients who did not

meet the inclusion criterion of axillary temperature >38 �Cat the first visit and who were enrolled at a later visit when

fever persisted or recurred. Seeking healthcare at private

clinics, but not applying self-medication, increased the

patient delay (Table 2). Of these 1356 patients, 938

patients (69%) had already used antibiotics. Antibiotic use

was lower among those who applied self-treatment (65%),

compared with those who received treatment from a

private clinic (94%) or public health post (83%;

P < 0.001).

A logistic regression model was used to explore the

relation between antibiotic use before attending the health

posts and age, gender, season and health post. The relative

risk (RR, 95% CI) of using antibiotics increased slightly by

a factor 1.012 (1.004–1.019; P ¼ 0.003) per year of age.

The rainy season was also significantly associated with

higher use of antibiotics (RR 2.310, 95% CI 1.820–2.933;

P < 0.001). Neither gender nor health post appeared to be

associated with antibiotic use. The main signs and

symptoms of the patients are shown in Table 3.

The results of the tourniquet test, presented as the

number of petechiae per square inch, are not shown in this

Table. Petechiae appeared in 210 cases (10%; £9/squareinch: n ¼ 126; 10–19/square inch: n ¼ 50; ‡20/squareinch: n ¼ 34), and among all age groups [>5: n ¼ 20

Table 2 Patient delay in undifferentiated fever, presented to public primary healthcare posts in southern Vietnam, by age group and by

referral pattern

Patient delay in days (median, 90th percentile)

v2(d.f. ¼ 2)* P-value

Age groups (years)

<5 5–15 >15

From first symptom 1.43 (3.95) 1.64 (3.79) 2.28 (4.89) 61.03 <0.001

From onset of fever 0.87 (2.95) 1.15 (3.13) 1.41 (3.87) 26.22 <0.001Help seeking behaviour

Came directly to health post Consulted private clinic first After self-treatment

From first symptom 2.44 (5.40) 3.51 (7.52) 2.42 (4.69) 28.95 <0.001From onset of fever 1.77 (4.71) 2.68 (6.60) 1.64 (3.77) 42.47 <0.001

d.f., degrees of freedom.

* Calculated by the Median Test.

Table 3 Symptoms and signs of patients presenting with undif-

ferentiated fever to public primary healthcare posts in southern

Vietnam

All

Frequency (%)

Age groups (years)

<5 5–15 >15

Symptoms

Sore throat 89.5 46.4 88.2 96.3Anorexia 80.4 81.9 76.8 82.4

Myalgia 46.8 7.2 29.7 62.7

Headache 45.8 33.7 53.0 43.2

Running nose 35.8 48.8 36.4 33.6Cough 35.7 56 28.4 37.4

Nausea 23.6 11.4 24.1 25.0

Backache 21.2 0.6 7.5 32.4

Arthralgia 16.3 2.4 8.8 22.8Vomitus 11.7 17.5 13.2 9.9

Abdominal pain 10.4 9.0 8.9 11.4

Rash 2.9 0.6 1.8 3.8Haemorrhage 1.1 0.6 2.5 0.4

Signs

Pharyngitis 56.0 64.5 67.5 47.8

Myalgia 38.4 6.6 24.0 51.7Rhinitis 35.6 53 28.2 37.6

Pallor 17.8 10.8 15.2 20.3

Arthralgia 7.7 2.4 5.1 10.0

Dehydration 7.1 9.0 4.8 8.2Conjunctivitis 6.7 15.1 7.0 5.4

Tender liver 2.9 0.6 2.1 3.7

Dermal Rash 2.3 0.6 1.4 3.1Lymphadenopathy 2.1 2.4 2.5 1.8

Lymphadenitis 1.7 0.6 2.9 1.2

Jaundice 1.6 0 0.8 2.3

Bruise 1.6 2.4 2.1 1.2Hepatomegaly 1.0 0.6 0.7 1.3

Splenomegaly 0.5 0 0.3 0.8




(9.5%), 5–15 years: n ¼ 127 (60.5%) and >15 years:

n ¼ 63 (30%)].

The response of the healthcare worker was assessed in

two ways, viz. the presumptive diagnosis and the treatment

given. The frequency of the different presumptive diagno-

ses is shown in Table 4. Diagnoses varied by season at all

age groups. There were no significant differences between

males and females with respect to presumptive diagnosis.

The diagnostic process of the healthcare worker is

visualized in the classification tree in Figure 2. In this

model, diagnostic leads such as gender, age, season,

exposure factors, and signs and symptoms were entered as

independent variables and presumptive diagnosis was

taken as dependent variable. In most cases the diagnosis

was classified as ‘undifferentiated fever’ without an iden-

tifiable pattern of diagnostic leads. In 1968 cases the

presumptive diagnosis was made more specific by using one

or more diagnostic leads. In 962 of these, the tourniquet

test appeared to be the most significant factor for differ-

entiating between dengue and a group of other diagnoses.

The regression tree analysis chooses the best cut-off value

of the number of petechiae, observed with the tourniquet

test. This was very low: 1.5 per square inch. Other leads

used were the presence of a red pharynx on physical

examination, the complaint of diarrhoea, myalgia, cough

or abdominal pain and finding abdominal tenderness on

physical examination. However, many cases were still

misclassified, including less common diagnoses such as

typhoid, tonsillitis, leptospirosis and hepatitis.

Forty-six healthcare workers contributed to this study.

Their prescribed treatment was not uniform except that

antipyretics appeared in 98.3% (range 78–10%) of

prescriptions. Vitamins were prescribed in 87.2%

(39.3–100%) of cases, antibiotics in 68.7% (16.7–100%),

corticosteroids in 9.6% (0–33.1%), IV fluids in 20%

(0–83.3%), anti-tussants in 13.5% (0–46.5%) and oral

rehydration solution (ORS) in 10.3% (0–82.6%). The

distribution of prescriptions is shown in Table 5, divided

by age groups. There were significant differences among

age groups except for the prescription of corticosteroids.

Notably, no patient left the health post without a

prescription.

Table 6 shows the data of presumptive diagnoses and

treatments. It was recognized that antipyretics, vitamin,

antibiotics and fluid were prescribed for all of the

presumptive diagnoses but anti-tussant and corticoids were

used more frequently for a presumptive diagnosis of

pharyngitis and tonsillitis and ORS was used mostly for

diarrhoea and dengue fever. Combinations of different

antibiotics were found in 82 cases (5.4%). The most

frequently prescribed antibiotics were amoxicillin (43.2%)

and cephalexin (36%). In general, low dosages of

Table 4 Primary healthcare workers’ presumptive diagnosis of patients with undifferentiated fever, by age and season

Frequency of presumptive diagnoses (%)

Age group (years)*

<5� 5–15� >15§

Season

Dry, n ¼ 79 Rainy, n ¼ 87 Dry, n ¼ 330 Rainy, n ¼ 400 Dry, n ¼ 599 Rainy, n ¼ 599

Undiff. fever (n ¼ 1074) 34.2 43.7 36.1 44.0 58.3 60.9

Pharyngitis (n ¼ 500) 27.8 27.6 29.4 27.3 24.4 17.0Dengue fever (n ¼ 180) 5.1 14.9 10.0 16.5 4.5 6.2

Tonsillitis (n ¼ 147) 24.1 8.0 20.3 7.5 2.2 1.8

Typhoid fever (n ¼ 75) 1.3 0 1.2 2.0 3.7 6.7

Diarrhoea/enteritis (n ¼ 58) 6.3 3.4 1.2 1.0 3.5 3.5Leptospirosis (n ¼ 11) 0 0 0 0 0.7 1.2

Hepatitis (n ¼ 10) 0 0 0.3 0.5 0.3 0.8

Others– (n ¼ 39) 1.3 2.3 1.5 1.3 2.5 1.8

Undiff. fever, undifferentiated fever.

* Two cases missing age.Chi-square Test:

� v2 (4 d.f.) 12.23, P ¼ 0.016.

� v2 (5 d.f.) 31.78, P < 0.0001.

§ v2 (8 d.f.) 17.84, P ¼ 0.022.– Others: Allergy (8), Gastritis (7), Lymphadenitis (5), Arthritis (2), Mumps (2), Clinical malaria (2), Measles (1) and Varicella (1).




antibiotics were applied for short intervals. When these

regimens were compared with internationally used rec-

ommendations, e.g. the ‘Stanford Guide to Antimicrobial

Therapy’; 2003, it appeared that the dose was appropriate

in 88.6% of patients but the duration was appropriate in

only 54.4%. Both appropriate dose as well as treatment

duration was prescribed in 47.3%.

Table 6 does not show the interdependency between the

multiple outcomes. With correspondence analysis this can

be illustrated in a comprehensive manner. Correspondence

analysis is a rather old technique, which receives more

attention lately (Benzecri 1992). In correspondence analy-

sis the relative frequency of all outcomes is calculated and

expressed in terms of co-ordinates on scales of virtual

dimensions. These co-ordinates are calculated in such a

way that on a two-dimensional plot the correspondence of

different outcomes is expressed as the distance from the

origin (dimension 1 ¼ dimension 2 ¼ 0) in the same

Undiff. fever (962/1968; 49%)

Enteritis (22/65; 34%)

Enteritis (11/16; 69%)

Pharyngitis (132/318; 42%)


Undiff. fever (171/434; 39%)

< 1.5 / inch2

No Yes

Dengue (53/200; 27%)

Undiff. fever (148/705; 26%)

No YesNo Yes

No Yes

> 1.5 / inch2Petechiae on tourniquet test

Diarrhoea

Red pharynx(phys. ex.)

Myalgia

CoughNo Yes

Abdominal tenderness (Phys. Ex.)

Undiff. fever (785/1768; 44%)

Undiff. fever (202/770; 44%)

Pharyngitis(276/564; 59%)



Figure 2 Classification of primary healthcare workers’ strategies to make a presumptive diagnosis of patients with undifferentiated fever,

based on signs and symptoms. Classification tree of the presumptive diagnosis of 1968 of 2098 patients, based on their signs andsymptoms. This tree is not a clinical algorithm to guide diagnosis but an analytical tool for post hoc inference on the diagnostic strategy

used by the health workers. It identifies the relation between signs and symptoms and the presumptive diagnosis for fever patients. The tree

shows all decision nodes, i.e. the signs and symptoms used for making the presumptive diagnosis. Final nodes are depicted by rectangles.

The ratio in each node indicates the proportion of incorrect classifications. For example, if initially the presumptive diagnosis of all 1968patients would be classified as ‘undifferentiated fever’, the most common diagnosis, then 962 would be incorrect. The first and most

important discriminating sign used by the healthcare workers is the number of petechiae occurring in the tourniquet test. Below a cut-off

value of 1.5/square inch, the best possible classification would be 1768 cases of undifferentiated fever (of whom 785 would be incorrect);above the cut-off 200 cases would be classified as dengue (of whom 53 incorrect). At the bottom of the tree the total proportion of incorrect

classifications has decreased from an initial 962/1968 to 668/1968.




direction. The correspondence between presumptive diag-

nosis and prescribed treatment is shown in Figure 3. For

example, the relative frequency of diarrhoea corresponds

with that of ORS, indicating that healthcare workers

preferably prescribe ORS for diarrhoea.

Almost all patients returned home after consultation,

except 73 (3.5%) patients who were admitted to the health

post and 33 (1.6%) who were referred to a higher

healthcare level.

Discussion

This study shows that the case management of undiffer-

entiated fever at the public primary healthcare level in

Vietnam is characterized by very short patient delay, high

rates of prior self-treatment, unspecific diagnostic consid-

erations and poly-pharmacy with high prescription rates of

antibiotics.

The short patient delay is probably the result of the rigid

malaria control policy in this province, which stimulates

febrile patients to come to a health post immediately,

where they can receive microscopic diagnosis and adequate

treatment at low cost or free of charge. This feature is

rather unique to this region (Giao et al. 2005). Other

studies in developing countries have shown that patient

delay may be much longer (Khe et al. 2002).

Patient delay in children was shorter than in adults. This

is a very common feature. Parents are probably more

alarmed about the health of their children than they are

about themselves. This has been found in other studies also

(Larsson et al. 2000; Giao et al. 2005). However, some

recall bias may play a role here, since there may be a time

span between onset of fever and the moment on which the

parent or guardian notices that a child, especially an infant

who cannot talk, is ill.

Self-medication is very common in countries where

drugs can be obtained over the counter (Kamat & Nichter

1998; Deressa et al. 2003; Nam et al. 2005). In Vietnam

the effectiveness of national and provincial malaria control

programmes is probably the reason why febrile patients

Table 5 Distribution of treatment for patients

Treatment All age n (%)

Age groups (years)

v2, (d.f. ¼ 2) P-value<5 5–15 >15n (%) n (%) n (%)

Antipiretic 1976 (94.3) 159 (95.8) 705 (96.6) 1110 (92.7) 13.673 0.001Vitamin 1683 (80.3) 110 (66.3) 621 (85.1) 950 (79.3) 31.894 0.000

Antibiotic 1524 (72.7) 122 (73.5) 581 (79.6) 819 (68.4) 28.847 0.000

Fluid 359 (17.1) 7 (4.2) 101 (13.8) 251 (21.0) 37.380 0.000Cough medicine 347 (16.6) 34 (20.5) 100 (13.7) 213 (17.8) 7.459 0.024

Corticoid 236 (11.3) 21 (12.7) 77 (10.5) 137 (11.4) 0.728 0.695

ORS 160 (7.6) 28 (16.9) 54 (7.4) 78 (6.5) 22.254 0.000

ORS, oral rehydration solution; d.f., degrees of freedom.

Table 6 Presumptive diagnosis and prescribed treatment in patients presenting to primary health posts

Presumptive diagnosis (No.)

Frequency of prescriptions (%)

Antipyretic Vitamin Antibiotic IV fluids Anti-tussant Corticoid ORS (%)

Undiff. fever (1075) 97.1 86.6 58.6 18.2 11.0 4.2 4.7

Pharyngitis (501) 93.0 78.0 99.2 11.0 28.3 21.8 3.6Dengue fever (180) 97.8 86.7 51.1 30.0 3.3 1.1 31.1

Tonsillitis (147) 92.5 63.3 100.0 6.1 48.3 46.3 2.7

Typhoid fever (75) 92.0 70.7 93.3 13.3 10.7 2.7 2.7

Diarrhoea (58) 67.2 34.5 70.7 41.4 0.0 0 48.3Leptospirosis (11) 90.9 72.7 100.0 72.7 0.0 0 0.0

Hepatitis (10) 60.0 40.0 70.0 20.0 0.0 10.0 0.0

Others (39)* 76.9 69.2 74.4 2.6 5.1 23.1 2.6

ORS, oral rehydration solution; Undiff. fever, undifferentiated fever.* See Table 4.





seek help at public health posts. But even in that context it

is apparently a widespread habit to apply self-medication

at the first sign or symptom.

The signs and symptoms most frequently point at the

upper respiratory tract as the focus of infection, with

sore throat and pharyngitis being the most frequent

complaint and finding, respectively. Tonsillitis in children

and pharyngitis in adults are mainly diagnosed during

the dry season whereas in children dengue fever is

preferentially diagnosed in the wet season. The data do

not provide an explanation for the seasonal effect.

Seasonal difference in health seeking behaviour or the

healthcare workers’ perception of pre-test likelihoods

may play a role. Real seasonal differences in transmis-

sion of upper respiratory tract pathogens in the tropics

show a predilection for the rainy season albeit less

distinct as in the winter of colder climates (Shek & Lee

2003).

The healthcare workers’ unspecific diagnostic response is

not unique to this province. Many studies of the diagnostic

considerations at the primary healthcare level show similar

findings (Halfvarsson et al. 2000; Phillips-Howard et al.

2003; Sepehri et al. 2003). Of all the diagnostic leads, the

tourniquet test was interpreted by the health workers as the

most discriminating. The tourniquet test is an old test. It

aims to measure the hemorrhagic status of a patient, which

is often the result of thrombocytopenia, thrombopathy and

vasculopathy. In modern medicine this test is hardly used

anymore, mainly because other indicators are available

such as the platelet count and newer tests of haemostasis.

For dengue however, where vasculopathy and thrombo-

cytopenia may co-exist, the tourniquet test still has a place

in the diagnostic classification (World Health Organization

1997). The healthcare workers in Binh Thuan, similar to

many other dengue endemic regions, have been trained to

use the tourniquet test. However, they do not only use it

for assessment of severity of dengue, they apparently also

use it for separating dengue as a diagnosis from other

fevers and intuitively apply a lower cut-off point for the

number of petechiae per square inch. This interpretation of

the tourniquet test is unlikely to increase the diagnostic

accuracy.

Dimension 1

2.01.51.00.50.0–0.5–1.0–1.5–2.0–2.5

Dim

ensi

on 2

3.0

2.5

2.0

1.5

1.0

0.5

0.0

–0.5No ORS

ORS

No anti-tussant

AntitussantNo IV

Intravenous fluid (IV)

No vitamin

Vitamins

No corticoid

Corticoid

No antipyretic

Antipyretic

No antibiotic

Antibiotic Typhoid feverTonsillitis

Pharyngitis

Leptospirosis

Hepatitis

Diarrhoea

Dengue fever

UF

Figure 3 Correspondence between presumptive diagnosis and prescribed treatment. On two virtual scales of relative frequency, the

correspondence between the presumptive diagnosis (triangles) of febrile patients and the prescribed treatment (round dots) by primary

healthcare workers are shown. The association between presumptive diagnosis and treatment can be read from the plot as departures from

the origin (dimension 1 ¼ dimension 2 ¼ 0) in the same direction. Thus, for example, the preferred treatment for diarrhoea is with oralrehydration solution (ORS). No, no prescription.





The therapeutic response of the healthcare workers, i.e.

prescribing drugs for all and antibiotics for most patients,

is extreme but not unique (Sepehri et al. 2003; Yanagisawa

et al. 2004). Although the diagnosis ‘undifferentiated fever’

might exclude bacterial infections, this apparently was no

reason to withhold antibiotics. Especially the use of

corticosteroids seems an inadequate response to a short-

lived fever. However, it is common knowledge that the

patient’s subjective improvement after the use of cortico-

steroids is impressive, and that for a healthcare worker, not

restrained by much knowledge of evidence-based medicine,

it is a logical step to improve the patients well-being as

soon as possible.

This study indicates some potential points for

improvement in the management of undifferentiated

fever. First, febrile patients or parents of febrile patients

seek help shortly after onset of symptoms. The patient

delay may be even too short as most of the diseases are

self-limiting by nature. The low threshold for early

detection of malaria is probably one of the main reasons

for this short patient delay and high consumption of

healthcare. In order to reduce the workload of the public

primary healthcare service, a two-step policy, with

screening for malaria for all, but further consultation

only for severe cases, based on carefully defined criteria,

can be considered. However, the patients’ perceptions of

fever and disease and economic incentives should be

taken into consideration. For example, a high workload

can also mean a high income for a healthcare worker.

Second, the presumptive diagnosis of the healthcare

worker can be improved. The most rational approach

would be to upgrade the educational level of all

healthcare workers. As mentioned previously, such an

approach is currently being carried out by the Vietnam-

ese government. In addition, at every health post the

epidemiology of the locally prevalent infectious diseases

should also be known. These data are often available,

but not used as a way to increase the prior likelihood of

the presumptive diagnosis. This should be part of,

ongoing, postgraduate training. Another way of improv-

ing the diagnosis, by providing rapid confirmatory tests,

is a point for further study.

Last, improved, rational, pharmacotherapy may do

much benefit. The drawbacks of unguided drug use are

evident: high costs, potential side effects, selection of

resistant micro-organisms and so on. This requires extra-

education, including postgraduate training, of the

healthcare workers. It definitely also needs some re-

education of the population, to redress its hunger for

drugs.

In conclusion, management of uncomplicated fever at

the primary healthcare level in Vietnam can be improved

by better specification of the diagnosis, better knowledge

of local diseases and more rational pharmacotherapy.

These objectives can be achieved by better, postgraduate,

education.

Acknowledgements

The study was supported by the Dutch Foundation for the

Advancement of Tropical Research (WOTRO). We grate-

fully acknowledge the contributions of the healthcare

workers at 13 studied sites. We would like to thank Prof.

Truong Van Viet, MD, PhD, the director of Cho Ray

Hospital, HCMC and the authorities of Binh Thuan

province for their cooperation.

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Corresponding Author Peter J. De Vries, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center,

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[email protected]

Fievres aigues indifferenciees dans la province de Binh Thuan au Vietnam: diagnostic cliniques imprecises et pharmacotherapie irrationnelle

objectifs Decrire les caracteristiques des patients consultant des postes communautaires de soins de sante primaire pour des fievres aigues indiffe-

renciees autres que la malaria et explorer le diagnostic et les interventions therapeutiques des agents de la sante.

methodes Tous les patients presentant une fievre aigue indifferenciee dans 12 postes communautaires de sante et une clinique ont ete inclus dans

l’etude effectuee dans la station provinciale de malaria de Binh Thuan, une province endemique pour la dengue, dans le sud du Vietnam. Les formulaires

de records ont ete utilises pour saisir les caracteristiques de la maladie du patient, le traitement avant que le patient ne soit refere, les signes et les

symptomes, le diagnostic provisionnel et le traitement instaure, le resultat au moment ou le patient a ete refere et apres.

resultats 2096 patients ont ete inclus dans l’etude entre avril 2001 et mars 2002. Les delais medians pour atteindre le poste de sante etaient de 0,87

jour pour les moins de 5 ans, 1,15 jours pour ceux ages de 5 a 15 ans et de 1,41 jours pour les adultes (p < 0,001). 65% des patients ont recouru a

d’autres mesures avant de consulter le centre de sante. Parmi ceux-ci, 82% ont eu recours a l’automedication et 69% ont pris des antibiotiques. La prise

d’antibiotiques avant que le patient ne soit refere augmentait avec l’age (RR: 1,012 par annee d’age; IC95%: 1,004–1,019). Le diagnostic et l’inter-

vention des agents de sante etaient totalement non specifiques. Le test du tourniquet etait utilise de facon inappropriee comme test de discrimination et

pas uniquement pour la detection de la fievre hemorragique de dengue. Une therapie empirique aux antibiotiques etait instauree dans 77,2% des cas.

conclusion La prise en charge des fievres non compliquees et non malariques au niveau des services de sante primaire au Vietnam est non specifique,

dominee par la recherche de signes de dengue hemorragique et par un traitement empirique par antibiotiques. Cette attitude pourrait etre amelioree par

une meilleure education.

mots cles fievre, diagnostic clinique, traitement, Vietnam















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Fiebre aguda indiferenciada en la provincia de Binh Thuan, Vietnam: Diagnostico clınico impreciso y farmacoterapia irracional

objetivos Describir las caracterısticas de pacientes que consultan puestos comunitarios de atencion primaria por fiebre aguda indiferenciada (FAI), y

explorar el diagnostico y la respuesta terapeutica de los trabajadores sanitarios.

metodos Se incluyeron todos los pacientes con FAI en doce puestos comunitarios de salud y un hospital en la estacion provincial de malaria en Binh

Thuan, provincia de Vietnam del Sur endemica para dengue. Se utilizaron las historias clınicas para completar las caracterısticas de los pacientes y la

enfermedad, la medicacion previa, los signos y sıntomas, el diagnostico provisional y el tratamiento establecido, la derivacion y la resolucion final.

resultados Se incluyeron 2096 pacientes entre Abril 2001 y Marzo 2002. La media en el retraso de atencion en los centros de salud: 0.87 para

menores de cinco anos, 1.15 para ninos entre 5–15 anos y 1.41 para adultos (p < 0.001). El 65% de los pacientes tomo las mismas medidas antes de

consultar un centro de salud, de los cuales el 82% se automedico y el 69% tomo antibioticos. La automedicacion con antibioticos aumentaba con la

edad (RR 1.012 por ano por edad; 95% CI: 1.004–1.019). El diagnostico y la respuesta terapeutica de los trabajadores sanitarios fue muy inespecıfica.

La prueba del torniquete se utilizaba de forma inapropiada, no solo para detectar dengue hemorragico sino como un teste discriminatorio general. La

terapia antibiotica empırica se dio en un 77.2% de los casos.

conclusiones El manejo de la fiebre no complicada, no debida a malaria, en los centros de atencion primaria de Vietnam es inespecıfica y esta

dominada por la busqueda de signos de dengue hemorragico y por el tratamiento empırico con antibioticos. Tal vez esta situacion podrıa mejorarse

mediante campanas de educacion.

palabras clave fiebre, diagnostico clınico, tratamiento, Vietnam




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