ObjectiveTo identify the etiology and risk factors of undifferentiated fever in a cluster of patients in Western Province, Solomon Islands, May 2014.MethodsAn outbreak investigation with a case control study was conducted. A case was defined as an inpatient in one hospital in Western Province, Solomon Islands with high fever (> 38.5 °C) and a negative malaria microscopy test admitted between 1 and 31 May 2014. Asymptomatic controls matched with the cases residentially were recruited in a ratio of 1:2. Serum samples from the subjects were tested for rickettsial infections using indirect micro-immunofluorescence assay.ResultsNine cases met the outbreak case definition. All cases were male. An eschar was noted in five cases (55%), and one developed pneumonitis. We did not identify any environmental factors associated with illness. Serum samples of all five follow-up cases (100%) had strong-positive IgG responses to scrub typhus. Nine out of ten controls were negative for ST antibodies. Four controls had low levels of antibodies against spotted fever group rickettsia, and only one had a low-level response to typhus group rickettsia.DiscussionThis outbreak represents the first laboratory-confirmed outbreak of scrub typhus in the Western Province of Solomon Islands. The results suggest that rickettsial infections are more common than currently recognized as a cause of an acute febrile illness. A revised clinical case definition for rickettsial infections and treatment guidelines were developed and shared with provincial health staff for better surveillance and response to future outbreaks of a similar kind.

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In their sensitive account of suffering in end-of-life decisionmaking, 1 Professor Isaacs and Ms Preisz are right to assert that children do not exist in isolation, but rather that the positive value in their lives is derived from the web of relations they exist within. Despite this network of relations being a fundamental source of value for the individual, the individual remains the fundamental unit to which rights may accrue. In their prudent reluctance to overrule parents in life and death decisions about children's suffering, the authors give undue weight to the parents' own suffering arising from their children's ongoing illness and survival.Consider John and Jane, two children with the same illness. After careful consideration, a small majority of physicians argue for ongoing treatment and therefore survival for both John and Jane, but the burdens of ongoing treatment and survival are considered significantly more onerous by John's parents than Jane's parents. Per the authors' reasoning, where the parent's perceptions of the burdens of treatment and survival are taken into account as one of a number of variables in the burdens versus benefits calculus, it is conceivable that the decision to ultimately terminate John's ongoing treatment may turn on the burdensomeness to his parents of his treatment and survival. If we assume that John and Jane have an otherwise equal claim to continued existence, then it would seem a perverse outcome that John's claim is overruled by his having, through no fault of his own, parents for whom the burdens of his own ongoing illness and survival are more onerous.Furthermore, just as the burdens of intensive care may be ameliorated by for example analgesia, sedation, and other nonpharmacological means of mitigating suffering, so may the burdens of the child's ongoing illness and survival on their family be ameliorated. The particular family unit in which we imagine a child might benefit from love and affection is itself historically contingent. Children may thrive in other arrangements, for example, living with extended family or kinship networks, or in foster-care or adoption arrangements. We can also imagine a society where the almost superhuman expectations placed on parents of children with profound neuro-disability are recognised for what they are, and new models of care, appropriately resourced, are directed towards these families to ease the burdens of care, and tip the balance of this tragic calculus in favour of survival.

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