9

FEVERS

In this chapter, you will learn:

Page Number
1. What are fevers
9-1
2. Types of fevers
9-2 to 9-3
3. Malaria
9-5 to 9-7
4. Typhoid
9-8
5. Viral fever
9-9
6. Thermometer Reading
9-10 to 9-12

9-1

FEVERS
The human body has a normal hotness (temperature) of 98.4 degrees F
or 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 absolutely
crazy. Different parts and organs of the body may fail for a short while
until things become normal. If the temperature continues to be very high
or very low, permanent failure may set in and the person may die.
Low temperatures below normal may set in if our surroundings are very
cold. 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 are
much 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 become
high. A body temperature above 99 F is called fever. We as health workers will often be called upon
to help out, as people are very scared of fevers.

Fever is our friend

True, people are scared of fevers for they have seen their near and dear ones dying of fevers. Yet we need to
understand one thing. All fevers are not our enemies. Fevers are part of the defence mechanism of the body. The
body rises its temperature to stop the attacking germs from multiplying too fast. In fact, fevers warn us when our
body has been attacked by germs. Hence, Fevers are friends! What we should be fighting are germs that brings
fever, not the fever itself. Once the germs are killed, the fever shall go away. Fevers by themselves may get
worrisome only beyond 107 degreesF in adults and 104 degrees F in children.

9-2

KNOW THE FEVERS

Instead of taking fever - reducing medicines every time there is fever, it may be better to see its pattern
of rise and fall. Just by seeing some of the points below, we can get good hints as to the possible reason
of 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)

Cold, cough, Sinusitis
Dysentery
TB
AIDS
Cancers
Boils, appendicitis, etc
Viral hepatitis, any small infection

Malaria
Pneumonia
Abscess
Urinary Tract Infection
Viral Fevers including

3. Fevers with General complaints body ache, weakness

Viral fevers including Dengue
Malaria
Typhoid
Initial stages of cancers, AIDS

5. Fevers that are

nied by shivering:

Dengue
Typhoid
Severe infection
anywhere

4. Fevers with Organ

system specific complaints
Urinary Tract Infection
Appendicitis
Pneumonia
Abscess

accompa-

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 (even
without taking any fever-reducing medicine like Paracetamol)
before reappearing:

Malaria

Kala Azar found mainly

in Bihar in India, occasionally
seen in Meghalaya.

2. Fever disappears for a

few days and then reappears:
Infections spread by lice and ticks
(TYPHUS fever)
Rat bite fevers

3. Fever That Shows a

Step Ladder Pattern
- starts low and
then increases bit by bit.

Typhoid

The word Typhoid means like Typhus .

Typhus is a fever that was very common
earlier but is rare now. We can suspect
Typhus if a person with lice has some typhoid
like fever with some rash.
It is spread by lice on the body. Typhus can
be sucessfully treated by DOXYCYCLINE.

9-4

Some Common Fevers to know

1. MALARIA

2. TYPHOID
or ENTERIC
FEVER

3. VIRAL FEVER

9-5

1. MALARIA Fever
Malaria is a disease caused by a small germ called Plasmodium 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 PF
germ. The female Anopheles mosquito has to feed on human or animal blood every few days in
order to lay eggs. During such a time when it is feeding on a malaria patient, it takes the germs
along with the blood. These germs stay in the mosquitos mouth and stomach for seven to ten days
and give thousands of baby germs. After these seven to ten days, if the mosquito bites another
normal person, such a person receives the baby germs. In about ten days time, these new germs
that have entered the body multiply into thousands again and give rise to the first bout of shivering and fever.
As the fever rises, the germs try to hide inside the red blood cells and once again multiply. Within two days, they multiply
tenfold and come out of the red cells into the blood and yet again cause shivering and fever. No wonder that the malaria
fever 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 the
malaria germ under the microscope. There are other tests also available, but none as cheap and reliable.

9-6

Treatment for Malaria

Dangerous malaria

Replace fluids in body:As sweating and fever cause loss of

lots of fluid, it is important to drink plenty of watery substances like soups, milk, lime juice, etc. Water with some salt
and sugar is also excellent.

Although both PV and PF cause similar problems as given above, PF can get very dangerous and kill the patient. It can give rise to complications by blocking the blood supply to:

Keep fever down:

If the fever is very high, it may be a
good idea to bring the fever down by applying again and
again some cloth dipped in cool water to the forehead and
body. Paracetamol may also be taken to bring down the temperature.

- the brain: the patient may

get very severe headache
start talking irrelevantly
may get fits or convulsions
become unconscious or
get a new squint (both eyes
look in different directions)

Under 1
ye ar

1 to 4
years

5 to 8
ye ars

9 to 14
ye ars

Above
14 ye ars

1/4th
tablet

Half a
tablet

Half to 1
tablet

1 tablet

1 to 2
tablets

Malaria medicines:
Fever of any type may be malaria.
Before starting any treatment, try to confirm that it is malaria
by asking for blood test using a microscope. After a test has
been sent - even if the result is not available yet start the
malaria treatment according to the age as given later. If it is
not confirmed, the first days treatment is considered enough.
However, if one is sure that it is malaria DO REMEMBER
TO COMPLETE THE COURSE even if the fever has gone
after the first days dose.

- the kidneys: urine production may become

very less - at times none - and at times there
may be blood with the urine.
- the lungs: the person may have great difficulty in breathing and breathing rate may get
high.
- the heart: the pumping of the heart may decrease and the pulse gets difficult to find.
In all such cases it is better to get the patient
to a qualified doctor immediately.

Ways to prevent the spread of malaria

1. Early diagnosis and prompt treatment - we need to
make arrangements that every village knows the signals of
malaria and the problems that it may give. There must be
at least one person trained in every village who
knows how much of Chloroquine and other
drugs need to be given. She should have free or
cheap Chloroquine available with her and every
villager must know its availability with her. Early
treatment decreases the number of people with
malaria germs that may be bitten by mosquitoes and this reduces the spread of the disease.

2. Personal protection - each one of us

should know that covering our hands and
feet especially during dark hours will reduce the biting of mosquitoes and
hence malaria. A few leaves of Neem
eaten every day are known to decrease
the chances of malaria. A broth made
of Chiraita leaves taken every day during the rainy season is reputed to keep
malaria away.

3. Killing larvae - Larvae of mosquitoes grow

in stagnant or slow flowing water. Various fishes may eat
these and the most efficient of such species are available
with the malaria department. Also, any kind of oil or insecticide can be sprayed on the water surface to kill the
larvae in the ten days that it takes them to develop from
the egg stage to the adult stage.

4. Killing mosquitoes - mosquitoes

killed by spraying DDT on the walls helps
to prevent them from spreading malaria.
Walls of cattle sheds should not be
sprayed so that the mosquitoes can bite
the cattle and have no need to bite humans. This decreases malaria spread.

9-7

2. TYPHOID or ENTERIC FEVER

Typhoid fever is also called enteric fever because
it is due to an infection of the intestines. It has been
an old problem with us. Before we found good antibiotics to take care of typhoid, it used to kill
people in the third week of fever because the infection would puncture the intestine. Nowadays, almost all fevers attract a dose of antibiotics from
doctors and hence even typhoid gets treated before anyone can die of it. Rarely do people die of it
these days. Yet, it remains a common illness that
leads to a lot of misery and is badly treated.

What Causes Typhoid?

Typhoid is caused by bacteria that come to stay
in the intestine along with food that has been dirtied by flies, dirt and unwashed hands. Water
brought from rivers and canals or water from wells
and from hand pumps that are close to where
people shit is a known source of spreading typhoid. At times, people who pass typhoid germs
in their shit do not suffer from any illness and
may silently pass the germ to many others if
they are cooks or handle water and food.

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 the
temperature unless the patient is taking fever-reducing tablets. Headache is a common accompaniment and is specially a
good indicator if a child is complaining of it. There may be a rash in the second week but can usually be seen only in fair
skinned people.
These days, a bit of cough and cold are also seen
in typhoid. Typhoid is said to have a characteristic pattern, that of a stepladder. If the temperature 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.

9-8

3. VIRAL FEVER
Learn to Differentiate TYPHOID from VIRAL FEVER and also DENGUE
Viral fevers also have a continuous and a stepladder pattern. Headache is common like
in Typhoid. But severe body ache is more common in Viral fevers. Occasionally shivering and a bit of cough and cold may be seen in viral fevers.
More importantly though, is the fact that Viral Fevers only rarely last beyond 7 days. As
there are no germkiller medicines for Viral
fevers, it is suggested that unless one is sure,
we can wait until the eighth day of fever before we start any antibiotic. And if the fever
starts coming down within two days of starting the antibiotic, one can safely assume the
diagnosis to be that of Typhoid and the medicine MUST BE CONTINUED UNTIL 14
DAYS OF TREATMENT IS COMPLETED.

In Dengue (Den-gee) fever that is spread

by Aedes mosquitoes (which breed in
clean water especially in coolers / coconut shells) although other signs of Viral
fevers are also present, severe body ache
and pain in moving the eyes or in looking
at light are common. Fever may decrease
from its high state after 7-8 days for two
to three days and return, often with a rash.
Usually though, there is no fever after 7
to 10 days.

Other fevers usually have signs and symptoms of an infection being present at different
parts 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 READING
It is important at times to know the temperature of a
person. It can help us understand what disease it
is. By measuring and recording temperature, we
can see the pattern of rise and fall of temperature,
which can help in diagnosing.
The normal temperature of a person is
between 98and 99F (36.7C and 37.2C).
The body works best between these
temperatures. But when germs enter our
body, the body fights back by raising the
temperature to kill the germs. This is the
fever that we feel. The higher temperature
also helps in decreasing the rate of
multiplication of the germs.
You should understand that in many cases fever is
a way to protect our body from harm done by germs.
Only at times we should give medicines like
PARACETAMOL which reduce the fever. Unless the
temperature is above 104 F (102 F for children and
old people), we need not give PARACETAMOL. Knowing how to take the temperature of the body will also
tell you when to give medicines.

9-11

Thermometer
Temperature is measured by a THERMOMETER. Thermometers can be of different types. The simplest thermometer is a plastic strip that can be kept pressed on the forehead and one can directly read the temperature off
it. But the surrounding temperature can affect this reading it shows a lesser temperature if the room is cold and
a 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 96F 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 patients mouth and check the level of the mercury
column against the scale marked next to it. Note the reading in F or C. If the person has a temperature
more than 99F or 37.2C, she can be said to have fever.
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

9-12

Measuring Temperature of Children

For a small child who cannot be trusted to keep her mouth closed or someone who is not cooperative, the bulb of
the thermometer can be kept under the armpit for two minutes while the health worker holds the arm next to the
body. For a very small child, keep the thermometer on the thigh fold and keep the thigh folded on the abdomen
for two minutes. The body temperature is 1 to 2F more than the armpit or thigh temperature and the take care of
this while recording it.
In children, the best place to measure the temperature is the rectum, as the reading taken from the rectum is
considered to be the most reliable. The same thermometer that is used to measure the temperature in the mouth
can also be used for the rectum. Ask the person to take deep breaths and gently insert the thermometer into the
anus after applying a bit of Vaseline or oil, and press both the buttocks against each other for a minute. Take the
reading this is the most reliable temperature of the body! However, it may not be easy to convince people in our
areas to allow this.

Sites for Taking Thermometer Reading

Temperature without thermometer

Another way to measure the temperature is by measuring the persons pulse. The
heart rate and hence pulse - increases by 10 per minute for every 1F. If a patients
pulse counted for one minute is 100 per minute and her normal pulse at rest was 80
per minute, we can say that her temperature would be 98.6 plus (100 minus 80
divided by 10) or 98.6 plus 2 or 100.6F.
However this may not be very accurate unless we are sure of a persons pulse rate
before the illness. Some athletes may have a resting pulse as low as 40 or 50 per minute and a pulse rate of 100
per minute in such cases would falsely get calculated at 100.6F instead of 103.6F. Besides, blood loss or
anaemia since the time we last counted the pulse may also increase the pulse rate even without any fever.

9-13

Know the Answers

Fevers
1. 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?

9-14

My Notes