Challenges of Establishing the Correct Diagnosis of Outbreaks of Acute Febrile Illnesses in Africa: The Case of a Likely Brucella Outbreak among Nomadic Pastoralists, Northeast Kenya, March–July 2005

Mary D. Ari Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Argata Guracha Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Moustafa Abdel Fadeel Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Charles Njuguna Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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M. Kariuki Njenga Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Rosalia Kalani Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Hassan Abdi Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Osman Warfu Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Victor Omballa Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Christopher Tetteh Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Robert F. Breiman Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Guillermo Pimentel Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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Daniel R. Feikin Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology and Laboratory Training Program, Kenya; United States Naval Medical Research Unit-3, Cairo, Egypt; Disease Detection and Surveillance Response Unit, Kenya Ministry of Public Health and Sanitation, Kenya; International Emerging Infections Program – Kenya, Centers for Disease Control and Prevention; Garissa District Ministry of Health, Kenya

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DOI:
https://doi.org/10.4269/ajtmh.2011.11-0030
Volume/Issue:
Volume 85: Issue 5
Page(s):
909–912
Restricted access
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An outbreak of acute febrile illness was reported among Somali pastoralists in remote, arid Northeast Kenya, where drinking raw milk is common. Blood specimens from 12 patients, collected mostly in the late convalescent phase, were tested for viral, bacterial, and parasitic pathogens. All were negative for viral and typhoid serology. Nine patients had Brucella antibodies present by at least one of the tests, four of whom had evidence suggestive of acute infection by the reference serologic microscopic agglutination test. Three patients were positive for leptospiral antibody by immunoglobulin M enzyme-linked immunosorbent assay, and two were positive for malaria. Although sensitive and specific point-of-care testing methods will improve diagnosis of acute febrile illness in developing countries, challenges of interpretation still remain when the outbreaks are remote, specimens collected too late, and positive results for multiple diseases are obtained. Better diagnostics and tools that can decipher overlapping signs and symptoms in such settings are needed.

Author Notes

*Address correspondence to Mary D. Ari, Office of the Associate Director for Science, Office of the Director, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS D50, Atlanta, GA 30333. E-mail: mari@cdc.gov

Financial support: This outbreak investigation was supported by core funding of the Kenya Ministry of Health, the International Emerging Infections Program, CDC, and the U.S. Naval Medical Research Unit-3, Egypt.

Authors' addresses: Mary D. Ari, Office of the Associate Director for Science, Office of the Director, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: mari@cdc.gov. Argata Guracha, WHO Garissa Field Office, Garissa, Kenya, E-mail: gurachaa@ke.afro.who.int. Moustafa Abdel Fadeel, U.S. Naval Medical Research Unit-3 (NAMRU-3), Cairo, Egypt, E-mail: Moustafa.Abdelfadeel.eg@med.navy.mil. Charles Njuguna and Rosalia Kalani, Kenya Ministry of Health, Nairobi, Kenya, E-mails: njugunack@yahoo.co.uk and rosaliakalani@yahoo.co.uk. M. Kariuki Njenga, Victor Omballa, and Robert F. Breiman, KEMRI/CDC, Nairobi, Kenya, E-mails: knjenga@ke.cdc.gov, VOmballa@ke.cdc.gov, and rbreiman@ke.cdc.gov. Hassan Abdi and Osman Warfu, Garissa Ministry of Health, Garissa, Kenya, E-mails: dsoeast@yahoo.com and owarfa@yahoo.com. Guillermo Pimentel, U.S. Naval Medical Research Center, Silver Spring, MD, E-mail: Guillermo.Pimentel@med.navy.mil. Daniel R. Feikin, KEMRI/CDC, Kisumu, Kenya, E-mail: Dfeikin@cdc.gov. Christopher Tetteh, Faculty of Public Health, College of Physicians and Surgeons, P.O. Box MB 429, Ministries–Accra, Ghana, E-mail: Ctettehc@msn.com.

Copyright:
©The American Society of Tropical Medicine and Hygiene 2011
Received:
14 Jan 2011
|
Accepted:
25 Apr 2011
|
Published Online:
01 Nov 2011
Cover The American Journal of Tropical Medicine and Hygiene
The American Journal of Tropical Medicine and Hygiene
Print ISSN:
0002-9637
Online ISSN:
1476-1645
  • 1.

    Sergon K, Njuguna C, Kalani R, Ofula V, Onyango C, Konongoi LS, Bedno S, Burke H, Dumilla AM, Konde J, Njenga MK, Sang R, Breiman RF, 2008. Seroprevalence of Chikungunya virus (CHIKV) infection on Lamu Island, Kenya, October 2004. Am J Trop Med Hyg 78: 333–337.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Dahouk SA, Tomaso H, Nockler K, Neubauer H, Frangoulidis D, 2003. Laboratory-based diagnosis of brucellosis: a review of literature. Part II: Serological tests for brucellosis. Clin Lab 49: 577–589.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Fadeel MA, Wasfy MO, Pimentel G, Klena JD, Mahoney FJ, Hajjeh RA, 2006. Rapid enzyme-linked immunosorbent assay for the diagnosis of human brucellosis in surveillance and clinical settings in Egypt. Saudi Med J 27: 975–981.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Brown SL, Klein GC, McKinney FT, Jones WL, 1981. Safranin O-stained antigen microagglutination test for detection of Brucella antibodies. J Clin Microbiol 13: 398–400.

  • 5.

    Yagupsky P, 1999. Detection of Brucellae in blood cultures. J Clin Microbiol 37: 3437–3442.

  • 6.

    Gad El-Rab MO, Kambal AM, 1998. Evaluation of a Brucella enzyme immunoassay test (ELISA) in comparison with bacteriological culture and agglutination. Infect 36: 197–201.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Araj GF, 1999. Human brucellosis: a classical infectious disease with persistent diagnostic challenges. Clin Lab Sci 12: 207–212.

  • 8.

    Bajani MD, Ashford DA, Bragg SL, Woods CW, Aye T, Spiegel RA, Plikaytis BD, Perkins BA, Phelan M, Levett PN, Weyant RS, 2003. Evaluation of four commercially available rapid serologic tests for diagnosis of leptospirosis. J Clin Microbiol 41: 803–809.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Almuneef M, Memish ZA, 2002. Persistence of Brucella antibodies after successful treatment of acute brucellosis in an area of endemicity. J Clin Microbiol 40: 2313.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Cumberland PC, Everard CO, Wheeler JG, Levett PN, 2001. Persistence of anti-leptospiral IgM, IgG and agglutinating antibodies in patients presenting with acute febrile illness in Barbados 1979–1989. Eur J Epidemiol 17: 601–608.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Wright FJ, Cooke ER, D'Souza J, 1953. Observations on brucellosis in Kenya. Trans R Soc Trop Med Hyg 47: 117–129.

  • 12.

    Jumba MM, Mirza NB, Mwaura FB, 1996. Agglutinins for Brucellae antigens in blood sera of an urban and rural population in Kenya. East Afr Med J 73: 204–206.

  • 13.

    Paul J, Gilks C, Batchelor B, Ojoo J, Amire M, Selkon JB, 1995. Serological responses to brucellosis in HIV-seropositive patients. Trans R Soc Trop Med Hyg 89: 228–230.

  • 14.

    Schelling E, Diguimbaye C, Daoud S, Nicolet J, Boerlin P, Tanner M, Zinsstag J, 2003. Brucellosis and Q-fever seroprevalences of nomadic pastoralists and their livestock in Chad. Prev Vet Med 61: 279–293.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Centers for Disease Control and Prevention, 1997. Case definitions for infectious conditions under public health surveillance. MMWR Morb Mortal Wkly Rep 46: 8–9.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Araj GF, Kaufmann AF, 1989. Determination by enzyme-linked immunosorbent assay of immunoglobulin G (IgG), IgM, and IgA to Brucella melitensis major outer membrane proteins and whole-cell heat-killed antigens in sera of patients with brucellosis. J Clin Microbiol 27: 1909–1912.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Centers for Disease Control and Prevention, 2005. Public health consequences of a false-positive laboratory test result for Brucella–Florida, Georgia and Michigan. MMWR Morb Mortal Wkly Rep 56: 603–605.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Memish ZA, Almuneef M, Mah MW, Qassem LA, Osoba AO, 2002. Comparison of the Brucella standard agglutination test with the ELISA IgG and IgM in patients with Brucella bacteremia. Diagn Microbiol Infect Dis 44: 129–132.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Reddin JL, Anderson RK, Jenness R, Spink WW, 1965. Significance of 7S and macroglobulin Brucella agglutinins in human brucellosis. N Engl J Med 272: 1263–1268.

  • 20.

    Morata PM, Queipo-Ortuño L, Reguera JM, Miralles F, Lopez-Gonzalez JJ, Colmenero JD, 2001. Diagnostic yield of a PCR-assay in focal complications of brucellosis. J Clin Microbiol 39: 3743–3746.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Queipo-Ortuno MI, Tena F, Colmenero JD, Morata P, 2008. Comparison of seven commercial DNA extraction kits for the recovery of Brucella DNA from spiked human serum samples using real-time PCR. Eur J Clin Microbiol Infect Dis 27: 109–114.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Queipo-Ortuno MI, Colmenero JD, Bravo MJ, Garcia-ordonez MA, Morata P, 2008. Usefulness of a quantitative real-time PCR assay using serum samples to discriminate between inactive, serologically positive and active human brucellosis. Clin Microbiol Infect 14: 1128–1134.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Baddour MM, Alkhalifa DH, 2008. Evaluation of three polymerase chain reaction techniques for the detection of Brucella DNA in peripheral human blood. Can J Microbiol 54: 352–357.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Navarro-Martinez A, Navarro E, Castano MJ, Solera J, 2008. Rapid diagnosis of human brucellosis by quantitative real time PCR: a case report of Brucella spondylitis. J Clin Microbiol 46: 385–387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    de Geus A, Wolff JW, Timmer VE, 1977. Clinical leptospirosis in Kenya (I): a clinical study in Kwale District, coast province. East Afr Med J 54: 115–124.

  • 26.

    de Geus A, Wolff JW, Timmer VE, 1977. Clinical leptospirosis in Kenya (II): a field study in Nyanza province. East Afr Med J 54: 125–132.

  • 27.

    Forrester AT, Kranendonk O, Turner LH, Wolff JW, Bohlander HJ, 1969. Serological evidence of human leptospirosis in Kenya. East Afr Med J 46: 497–506.

  • 28.

    Silva MV, Camargo ED, Batista L, Vaz AJ, Brandão AP, Nakamura PM, Negrão JM, 1995. Behavior of specific IgM, IgG and IgA class antibodies in human leptospirosis during the acute phase of the disease and during convalescence. J Trop Med Hyg 98: 268–272.

    • PubMed
    • Search Google Scholar
    • Export Citation
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