9 FEVERS In this chapter, you will learn: Page Number1. What are fevers 9-12. Types of fevers 9-2 to 9-33. Malaria 9-5 to 9-74. Typhoid 9-85. Viral fever 9-96. Thermometer Reading 9-10 to 9-12
9-1 FEVERSThe human body has a normal hotness (temperature) of 98.4 degrees For 37 degrees C. At this temperature, the body systems work the best.The body does not work so well if the temperature is hotter or colder.And if the temperature gets very hot (above 107 degrees, or very cold(below 90 degrees) the working of the body may become absolutelycrazy. Different parts and organs of the body may fail for a short whileuntil things become normal. If the temperature continues to be very highor very low, permanent failure may set in and the person may die.Low temperatures below normal may set in if our surroundings are verycold. Anyone without adequate clothing and food may die if exposed to such cold climate for too long.But children who have been born much before nine months in the mothers’ wombs and those who aremuch below normal weight can die of cold if exposed to low surrounding temperatures for a few hours.Such children need to be well wrapped up during cold.What we usually find amongst our people are illnesses in which the body temperature has becomehigh. A body temperature above 99° F is called fever. We as health workers will often be called uponto help out, as people are very scared of fevers.Fever is our friendTrue, people are scared of fevers for they have seen their near and dear ones dying of fevers. Yet we need tounderstand one thing. All fevers are not our enemies. Fevers are part of the defence mechanism of the body. Thebody rises its temperature to stop the attacking germs from multiplying too fast. In fact, fevers warn us when ourbody has been attacked by germs. Hence, Fevers are friends! What we should be fighting are germs that bringsfever, not the fever itself. Once the germs are killed, the fever shall go away. Fevers by themselves may getworrisome only beyond 107 degreesF in adults and 104 degrees F in children.
9-2KNOW THE FEVERSInstead of taking fever - reducing medicines every time there is fever, it may be better to see its patternof rise and fall. Just by seeing some of the points below, we can get good hints as to the possible reasonof the fever: whether the fever is low or high whether there are also complaints specific to a body organ system whether there is a rise & fall pattern of temperature 1. Low grade Fever 2. High fever (Not very high temperature) • Malaria • Cold, cough, Sinusitis • Pneumonia • Dysentery • Abscess • TB • Urinary Tract Infection • AIDS • Viral Fevers including • Cancers Dengue • Boils, appendicitis, etc • Typhoid • Viral hepatitis, any small infec- • Severe infection tion anywhere 3. Fevers with General com- 4. Fevers with Organ plaints – body ache, weakness system specific com- • Viral fevers including Dengue plaints • Malaria • Urinary Tract Infection • Typhoid • Appendicitis • Initial stages of cancers, AIDS • Pneumonia • Abscess 5. Fevers that are accompa- nied by shivering: • Malaria • Urinary Tract Infection • Pneumonia • Abscess • Infections spread by lice and ticks etc.
9-3 Fevers that show a pattern:1. Fever come and goes :It disappears completely (evenwithout taking any fever-reduc-ing medicine like Paracetamol)before reappearing:• Malaria• Kala Azar – found mainlyin Bihar in India, occasionallyseen in Meghalaya. The word “Typhoid” means “like Typhus” .2. Fever disappears for a Typhus is a fever that was very commonfew days and then reappears: earlier but is rare now. We can suspect• Infections spread by lice and ticks Typhus if a person with lice has some typhoid(TYPHUS fever) like fever with some rash.• Rat bite fevers It is spread by lice on the body. Typhus can be sucessfully treated by DOXYCYCLINE.3. Fever That Shows aStep Ladder Pattern- starts low andthen increases bit by bit.• Typhoid
9-4 Some Common Fevers to know1. MALARIA 2. TYPHOID or ENTERIC FEVER 3. VIRAL FEVER
9-5 1. MALARIA Fever Malaria is a disease caused by a small germ called Plas- modium that can be tested by checking our blood under a microscope. Usually of two types, Plasmodium falciparum and Plasmodium vivax are also commonly - and more easily — referred to as PF and PV. Malaria is commonly known to cause high fever that comes after half an hour of severe shivering and chills. After the fever that lasts one to two hours or so, the fever comes down on its own with lots of sweating. The fever may be accompanied by headache and vomiting. Any health worker can easily treat such malaria.How mosquitoes spread malaria?Mosquitoes spread malaria germs by carrying them from a patient whose blood has the PV or PFgerm. The female Anopheles mosquito has to feed on human or animal blood every few days inorder to lay eggs. During such a time when it is feeding on a malaria patient, it takes the germsalong with the blood. These germs stay in the mosquito’s mouth and stomach for seven to ten daysand give thousands of baby germs. After these seven to ten days, if the mosquito bites anothernormal person, such a person receives the baby germs. In about ten days time, these new germsthat have entered the body multiply into thousands again and give rise to the first bout of shiver-ing and fever.As the fever rises, the germs try to hide inside the red blood cells and once again multiply. Within two days, they multiplytenfold and come out of the red cells into the blood and yet again cause shivering and fever. No wonder that the malariafever comes every two days!To check if one has malaria, a trained person can test a small drop of blood pricked out from the finger and look for themalaria germ under the microscope. There are other tests also available, but none as cheap and reliable.
9-6Treatment for Malaria Dangerous malariaReplace fluids in body:As sweating and fever cause loss of Although both PV and PF cause similar prob-lots of fluid, it is important to drink plenty of watery sub- lems as given above, PF can get very danger-stances like soups, milk, lime juice, etc. Water with some salt ous and kill the patient. It can give rise to com-and sugar is also excellent. plications by blocking the blood supply to:Keep fever down: If the fever is very high, it may be a - the brain: the patient maygood idea to bring the fever down by applying again and •get very severe headacheagain some cloth dipped in cool water to the forehead and •start talking irrelevantlybody. Paracetamol may also be taken to bring down the tem- •may get fits or convulsionsperature. •become unconscious or •get a new squint (both eyes look in different directions)Under 1 1 to 4 5 to 8 9 to 14 Above ye ar years ye ars ye ars 14 ye ars - the kidneys: urine production may become 1/4th Half a Half to 1 1 to 2 very less - at times none - and at times there 1 tablet tablet tablet tablet tablets may be blood with the urine. - the lungs: the person may have great diffi-Malaria medicines: Fever of any type may be malaria. culty in breathing and breathing rate may getBefore starting any treatment, try to confirm that it is malaria high.by asking for blood test using a microscope. After a test hasbeen sent - even if the result is not available yet — start the - the heart: the pumping of the heart may de-malaria treatment according to the age as given later. If it is crease and the pulse gets difficult to find.not confirmed, the first day’s treatment is considered enough.However, if one is sure that it is malaria DO REMEMBER In all such cases it is better to get the patientTO COMPLETE THE COURSE even if the fever has gone to a qualified doctor immediately.after the first day’s dose. Ways to prevent the spread of malaria1. Early diagnosis and prompt treatment - we need to 2. Personal protection - each one of usmake arrangements that every village knows the signals of should know that covering our hands andmalaria and the problems that it may give. There must be feet especially during dark hours will re-at least one person trained in every village who duce the biting of mosquitoes andknows how much of Chloroquine and other hence malaria. A few leaves of Neemdrugs need to be given. She should have free or eaten every day are known to decreasecheap Chloroquine available with her and every the chances of malaria. A broth madevillager must know its availability with her. Early of Chiraita leaves taken every day dur-treatment decreases the number of people with ing the rainy season is reputed to keepmalaria germs that may be bitten by mosqui- malaria away.toes and this reduces the spread of the disease.3. Killing larvae - Larvae of mosquitoes grow 4. Killing mosquitoes - mosquitoesin stagnant or slow flowing water. Various fishes may eat killed by spraying DDT on the walls helpsthese and the most efficient of such species are available to prevent them from spreading malaria.with the malaria department. Also, any kind of oil or in- Walls of cattle sheds should not besecticide can be sprayed on the water surface to kill the sprayed so that the mosquitoes can bitelarvae in the ten days that it takes them to develop from the cattle and have no need to bite hu-the egg stage to the adult stage. mans. This decreases malaria spread.
9-72. TYPHOID or ENTERIC FEVERTyphoid fever is also called enteric fever because What Causes Typhoid?it is due to an infection of the intestines. It has been Typhoid is caused by bacteria that come to stayan old problem with us. Before we found good an- in the intestine along with food that has been ‘dirt-tibiotics to take care of typhoid, it used to kill ied’ by flies, dirt and unwashed hands. Waterpeople in the third week of fever because the infec- brought from rivers and canals or water from wellstion would puncture the intestine. Nowadays, al- and from hand pumps that are close to wheremost all fevers attract a dose of antibiotics from people shit is a known source of spreading ty- phoid. At times, people who pass typhoid germsdoctors and hence even typhoid gets treated be- in their shit do not suffer from any illness andfore anyone can die of it. Rarely do people die of it may ‘silently’ pass the germ to many others ifthese days. Yet, it remains a common illness that they are cooks or handle water and food.leads to a lot of misery and is badly treated.What is the typhoid fever like?The typhoid fever usually starts as a low-grade fever that is continuous. There are not much ups and downs in thetemperature unless the patient is taking fever-reducing tablets. Headache is a common accompaniment and is specially agood indicator if a child is complaining of it. There may be a rash in the second week but can usually be seen only in fairskinned people. These days, a bit of cough and cold are also seen in typhoid. Typhoid is said to have a character- istic pattern, that of a stepladder. If the tem- perature of a person is taken at regular intervals in typhoid, the temperature does not fluctuate much and instead it is seen to rise bit by bit until in the second week, when it becomes quite high. Although adults with typhoid fever are usually constipated, children often have diarrhoea and vomiting in the first few days. In the second week though, diarrhoea and pain on pressing the right side of the abdomen are common. A blood test can help to indicate Typhoid in a person. The fever either gets better on its own in the third week or else the patient can really get very worse by then. Bleeding from the intestine and puncture of the intestine is what can kill the patient in the third week. Treatment of Typhoid Fever • Typhoid must be suspected especially if there is any fever that has been continuously increasing since more than a week and has no other signals of any other organ being involved. • An antibiotic needs to be given and that too for 14 days and no less. This is because typhoid is known to come back and in such a case, the chances of intestinal perforation and death are higher. • Give AMOXYCILLIN or CIPOFLOXACIN in highest doses three times a day. Once the fever has come down, the dose may be reduced and continued until 14 days are completed. If the person cannot afford it or if Amoxycillin is not accessible, COTRIMOXAZOLE may be given, but it may take more time to bring the fever down.
9-83. VIRAL FEVERLearn to Differentiate TYPHOID from VIRAL FEVER and also DENGUEViral fevers also have a continuous and a stepladder pattern. Headache is common likein Typhoid. But severe body ache is more common in Viral fevers. Occasionally shiver-ing and a bit of cough and cold may be seen in viral fevers.More importantly though, is the fact that Vi- In Dengue (Den-gee) fever that is spreadral Fevers only rarely last beyond 7 days. As by Aedes mosquitoes (which breed inthere are no germkiller medicines for Viral clean water especially in coolers / coco-fevers, it is suggested that unless one is sure, nut shells) although other signs of Viralwe can wait until the eighth day of fever be- fevers are also present, severe body achefore we start any antibiotic. And if the fever and pain in moving the eyes or in lookingstarts coming down within two days of start- at light are common. Fever may decreaseing the antibiotic, one can safely assume the from its high state after 7-8 days for twodiagnosis to be that of Typhoid and the medi- to three days and return, often with a rash.cine MUST BE CONTINUED UNTIL 14 Usually though, there is no fever after 7DAYS OF TREATMENT IS COMPLETED. to 10 days. Other fevers usually have signs and symptoms of an infection being present at differentparts of the body. For example, in pneumonia there are signs of the lungs and the air tubes being infected. If an abscess, a big boil can be asked for. Pain in the abdomen, and pain while passing urine or with loose motions can also hint at the underlying cause of fever. These kinds of fevers are dealt with in other sections of the manual.
9-10 THERMOMETER READINGIt is important at times to know the temperature of aperson. It can help us understand what disease itis. By measuring and recording temperature, wecan see the pattern of rise and fall of temperature,which can help in diagnosing.The normal temperature of a person isbetween 98°and 99°F (36.7°C and 37.2° C).The body works best between thesetemperatures. But when germs enter ourbody, the body fights back by raising thetemperature to kill the germs. This is thefever that we feel. The higher temperaturealso helps in decreasing the rate ofmultiplication of the germs.You should understand that in many cases fever isa way to protect our body from harm done by germs.Only at times we should give medicines likePARACETAMOL which reduce the fever. Unless thetemperature is above 104° F (102° F for children andold people), we need not give PARACETAMOL. Know-ing how to take the temperature of the body will alsotell you when to give medicines.
9-11ThermometerTemperature is measured by a THERMOMETER. Thermometers can be of different types. The simplest ther-mometer is a plastic strip that can be kept pressed on the forehead and one can directly read the temperature offit. But the surrounding temperature can affect this reading – it shows a lesser temperature if the room is cold anda higher reading if the person is sitting in the sun.The commonest thermometer is made of glass and has a bulb with mercury. To measure the temperature with this: 1. Clean the thermometer with normal water and shake it (take care not to hit the glass to a wall or table nearby while doing this). 2. Check the level of mercury column – the silver coloured shiny column visible against a white wall or ceiling) and ensure that it is lower than 96°F mark. 3. Now ask the patient to open her mouth and lift the tongue to touch the palate. Place the bulb of the thermometer under the tongue and ask the person to close the mouth, taking care not to close the teeth or else the bulb may break inside. 4. Although the guidelines of thermometers asks only for a time of half a minute, one should keep the thermometer in the mouth for at least one and a half minutes. 5. After this period, take out the thermometer from the patient’s mouth and check the level of the mercury column against the scale marked next to it. Note the reading in ° or ° If the person has a temperature F C. more than 99° or 37.2° she can be said to have fever. F C, 6. After recording the temperature carefully, one should clean the thermometer by rinsing it in water or wiping it clean with cotton dipped in antiseptic. Preferably, shake down the mercury column to normal before replacing the thermometer in its case. Convert Fahrenheit (F) to Centigrade (C), subtract 32 and then multiply by 5/9, i.e., F-32 X 5/ 9=C. For the reverse, multiply by 9/5 and add 32, i.e., C X 9/5 + 32 = F
9-12Measuring Temperature of ChildrenFor a small child who cannot be trusted to keep her mouth closed or someone who is not cooperative, the bulb ofthe thermometer can be kept under the armpit for two minutes while the health worker holds the arm next to thebody. For a very small child, keep the thermometer on the thigh fold and keep the thigh folded on the abdomenfor two minutes. The body temperature is 1 to 2° more than the armpit or thigh temperature and the take care of Fthis while recording it.In children, the best place to measure the temperature is the rectum, as the reading taken from the rectum isconsidered to be the most reliable. The same thermometer that is used to measure the temperature in the mouthcan also be used for the rectum. Ask the person to take deep breaths and gently insert the thermometer into theanus after applying a bit of Vaseline or oil, and press both the buttocks against each other for a minute. Take thereading – this is the most reliable temperature of the body! However, it may not be easy to convince people in ourareas to allow this. Sites for Taking Thermometer ReadingTemperature without thermometerAnother way to measure the temperature is by measuring the person’s pulse. Theheart rate – and hence pulse - increases by 10 per minute for every 1° If a patient’s F.pulse counted for one minute is 100 per minute and her normal pulse at rest was 80per minute, we can say that her temperature would be 98.6 plus (100 minus 80divided by 10) or 98.6 plus 2 or 100.6° F.However this may not be very accurate unless we are sure of a person’s pulse ratebefore the illness. Some athletes may have a resting pulse as low as 40 or 50 per minute and a pulse rate of 100per minute in such cases would falsely get calculated at 100.6° instead of 103.6° Besides, blood loss or F F.anaemia since the time we last counted the pulse may also increase the pulse rate even without any fever.
9-13 Know the Answers Fevers1. Mark whether “Right” or “Wrong” a. Fevers harm the body and should be brought down with medicines immediately. b. All fevers should be treated with germkillers. c. Typhoid fevers should be treated with germkillers for at least 14 days. d. Malaria fever can quickly result in death unless treated. e. It is difficult to make a difference between Typhoid and Urine Infection.2. Please answer the follwing questions: a. How can you make out Typhoid fever from Malaria? b. Can we give Chloroquine to pregnant women? c. How can you make out the difference between typhoid and viral fevers? d. What are the methods that we can use to lower temperature?