Beyond misdiagnosis: how malaria-centered fever management threatens Chikungunya detection and patient safety in East Africa

¹Faculty of Health Sciences and Tropical Medicine, Somali National University, Mogadishu, Somalia, ²Benaadir Research, Consultancy and Evaluation Center, Mogadishu, Somalia, ³Center for Health Research and Innovation, Somali National University, Mogadishu, Somalia

^&Corresponding author
Abdisamad Abdihakim Aadam, Faculty of Health Sciences and Tropical Medicine, Somali National University, Mogadishu, Somalia

To the editors of the Pan African Medical Journal    

Arboviral diseases are an expanding cause of febrile illness in East Africa, yet fever management remains heavily structured around malaria. Chikungunya virus (CHIKV) has circulated in East Africa for decades, caused major regional outbreaks, and remains endemic in Kenyan primary care settings, where it accounted for 12.7% of febrile presentations in one coastal cohort [1,2]. At the same time, malaria continues to dominate diagnostic thinking in endemic areas, even when a large share of febrile cases is non-malarial, creating a predictable blind spot for CHIKV and other arboviruses [3,4].

Why is CHIKV repeatedly overlooked? First, Chikungunya and malaria share early clinical features, so syndromic diagnosis performs poorly in settings with limited laboratory confirmation [5,6]. Second, access to RT-PCR and serological testing remains sparse in peripheral facilities; Kenyan field surveillance showed that arboviral etiologies of non-malaria febrile illness are often unknown in counties with limited diagnostic capacity, and molecular detection required mobile laboratory deployment rather than routine care infrastructure [7]. Third, clinician preparedness is inadequate. In northeast Ethiopia, only 23.4% of healthcare workers demonstrated good knowledge of Chikungunya, and the same study identified major gaps in diagnostic practices for Chikungunya and other non-malarial febrile illnesses [3].

The consequences are clinical as well as epidemiological. Among malaria-suspected febrile patients in Ethiopia, acute CHIKV IgM seroprevalence reached 47.8%, while malaria prevalence was only 10.6%, suggesting that malaria-first case management can substantially misclassify the true cause of fever [5]. Such errors expose patients to inappropriate antimalarial treatment, delay recognition of Chikungunya, and risk persistent morbidity, especially given that Chikungunya-associated arthralgia and myalgia can last for years and impair quality of life and productivity [1,6]. Co-infection further complicates care: a meta-analysis found real-time RT-PCR-confirmed malaria-CHIKV co-infection in 4% of febrile patients overall and in 4% of Kenyan datasets, reinforcing that a positive malaria test does not reliably exclude concurrent Chikungunya [6].

The larger and less recognized problem is what these missed diagnoses do to surveillance. Underdiagnosis and underreporting produce an incomplete picture of CHIKV burden in Africa, especially where clinically similar arboviruses co-circulate [4]. This is already visible in Kenya, where malaria, dengue, and CHIKV overlap spatially in children, and where Chikungunya seropositivity reached 9.8% across multiple sites, yet routine fever algorithms do not consistently incorporate arboviral testing [8]. Existing literature has primarily framed Chikungunya misdiagnosis as a clinical challenge. Far less attention has been given to its systemic consequences for epidemic intelligence, surveillance sensitivity, and health security in malaria-endemic settings. These diagnostic failures may delay outbreak detection, distort disease burden estimates, and limit effective public health responses. Reframing Chikungunya misdiagnosis as both a patient safety issue and a surveillance systems challenge is therefore essential for strengthening epidemic preparedness in East Africa.

The response should be practical. National fever management algorithms in East Africa should incorporate arboviral testing triggers for patients with malaria-negative fever or prominent polyarthralgia. Governments and partners should expand decentralized RT-PCR and serological capacity, including mobile and multiplex platforms, strengthen laboratory networks, and improve clinician training on non-malarial febrile illness differentiation [3,9]. Surveillance systems should link clinical, laboratory, entomological, and cross-border data under a One Health framework so that missed cases no longer accumulate silently until outbreaks become obvious [1,4]. Failure to detect Chikungunya should no longer be viewed as an isolated diagnostic error but as a measurable weakness in epidemic preparedness. Recognizing Chikungunya misdiagnosis as both a patient safety and health security priority is essential for building resilient surveillance systems capable of responding to the growing threat of arboviral diseases in East Africa.

Competing interests    

The authors declare no competing interests.

Author contributions     

Abdisamad Abdihakim Aadam and Maida Ali Daahiye conceptualized and designed the study. Abdishakur Ahmed Mahad and Abdimalik Dahir Ali conducted the literature review. Abdisamad Abdihakim Aadam drafted the initial manuscript. Ilyas Abdullahi Khalif critically revised the manuscript for important intellectual content. All authors reviewed and approved the final version of the manuscript, and agreed to be accountable for all aspects of the work.

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