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Fever in the recently returned traveller

  • See also

    Immigrant health - acute presentations
    Malaria
    Gastroenteritis
    Febrile child
    COVID-19

    Key points

    1. Most infections are mild or self-limiting, however their non-specific presentations make them challenging to distinguish from serious infections such as malaria
    2. Falciparum malaria is the most common serious infection and cause of death in returning travellers
    3. Severe respiratory infections from novel viral infections (eg COVID-19, H5N1) highlight the needs for vigilance and the role of travelers as sentinels, carriers and spreaders
    4. Drug-resistant infections or colonization may have been acquired, especially if hospitalised

    Background

    • Common diseases unrelated to travel are more likely than exotic ones acquired whilst overseas
    • Returned travellers who have been visiting friends and relatives whilst overseas are more likely to have a serious cause for illness upon return

    When assessing a febrile child recently returned from overseas travel it is important to consider non-infectious causes for fever (eg DVT/PE). There are three main possibilities in terms of infection:

    • Common childhood infections contracted whilst away (Consider seasonal variations)
    • Infection contracted whilst visiting an endemic region
    • Infection contracted due to a regional outbreak

    The keys to establishing a differential diagnosis and deciding on appropriate first line investigations are:

    • Careful assessment (history and examination)
    • Use of epidemiological surveillance tools (see Additional notes section below)
    • Consideration of incubation times (see Incubation periods table below)

    Always consider whether the presentation may indicate a disease of public health importance, where immediate infection control and containment measures are indicated. (See Australian national notifiable diseases and contact local health department for advice)

    • Any child in whom measles is clinically suspected should be nursed in a negative pressure room with airborne precautions
    • Any child with respiratory symptoms who may have a novel respiratory illness should be seen using appropriate precautions
    • Haemorrhagic fevers (Ebola, Marburg, Lassa, Crimean-Congo) require strict isolation and strict barrier nursing

    Assessment

    History

    • Travel location and type (country/regions, urban/rural, living conditions, altitude)
    • Timing of travel (dates, seasons, duration)
    • Exposure to risk factors
      • contact with animals, insect bites
      • drinking water and food sources
      • activities (including sexual contacts, illicit drug use, tattoos)
      • sick contacts
    • Immunisation history (routine childhood and travel specific, noting Salmonella typhi vaccination only has ~70% efficacy)
    • Prophylaxis
      • medication use and adherence
      • mosquito nets/insect repellent
    • Symptom onset, duration and course
    • Healthcare while away including any medications taken

    Incubation periods

    Short
    <10 days

    Intermediate
    10-21 days

    Long
    >21 days

     Malaria (P. falciparum)

    Malaria (P. falciparum)

    Malaria (P. vivax, P. ovale)

    Typhoid (S. typhi or S. paratyphi) (usually 8-14 days)

    Typhoid

    Typhoid

    Rickettsial infection

    Rickettsial infection

    Hepatitis

    Arboviral infections, eg Dengue, Yellow fever

    Measles

    Rabies

    Viral haemorrhage fever

    Viral haemorrhage fever

    Amoebic liver abscess

    Influenza

    Q fever

    Tuberculosis

    Campylobacter

     

    Filariasis

    Shigella

     

    HIV

    Chikungunya

     

     

    Examination

    • Fever (only clinical finding in majority)
    • Tachypnoea
    • Rash
    • Altered consciousness*
    • Haemorrhage*
    • Hypotension*
      *Suggestive of cerebral malaria or hemorrhagic fever with shock
    Clinical Features Specific to Infection

    Clinical Features

    Infection or disease implicated

    Rashes/skin lesions

    Dengue, typhoid, rickettsial infections, measles, leptospirosis, syphilis, gonorrhoea, brucellosis, chikungunya

    Eschar

    Rickettsial infections, borrelia, Crimean-Congo haemorrhagic fever

    Hepatomegaly

    Malaria, typhoid, dengue, viral hepatitis, amoebiasis, leptospirosis

    Splenomegaly

    Malaria, typhoid, mononucleosis, trypanosomiasis, brucellosis, dengue, kala-azar

    Acute abdomen or GI haemorrhage

    Typhoid

    Cough, coryza, conjunctivitis

    Respiratory viruses, measles

    Jaundice

    Viral hepatitis, measles

    Lymphadenopathy

    Rickettsia, toxoplasmosis, brucellosis, HIV, mononucleosis, visceral leishmaniasis

    Petechiae

    Meningococcal disease, viral haemorrhagic fever, rickettsia

    Haemorrhage

    Dengue, meningococcaemia, Lassa fever, Marburg or Ebola, Crimean-Congo virus, Yellow fever, Rocky Mountain Spotted Fever

    Altered conscious state, lethargy,
    Meningism

    Cerebral malaria, meningitis, African trypanosomiasis

    Fever persisting >2 weeks

    Malaria, enteric fever, EBV, CMV, toxoplasmosis, acute HIV, acute schistosomiasis, brucellosis, TB, Q fever

    Fever with onset >6 weeks after travel

    Plasmodium vivax or P ovale, acute hepatitis (B, C or E), TB, amoebic liver abscess

    Management

    Investigations

    Investigation Based on Clinical Syndrome

    Clinical syndrome

    Most important infections to consider

    Investigations

    Fever alone

    Malaria*
    Typhoid
    Dengue
    Hepatitis A

    FBE thick and thin film*
    Blood culture
    LFT if jaundiced
    BGL
    Serum to store
    (Specific tests should be discussed with Infectious Diseases team)

    Other tests to consider depending on most likely pathogens:

    • measles serology +/- throat or nose swabs for PCR
    • urine microscopy and culture
    • CSF microscopy and culture in severely unwell patients with meningism, encephalopathy or seizures (after consideration of need for further neuroimaging first)

    Fever + diarrhoea

    Malaria*
    Typhoid
    Dengue
    Hepatitis
    Travellers’ diarrhoea**
    Cholera
    Dysentery (bloody diarrhoea)

    As for fever alone plus
    Stool MCS + OCP (latter, particularly if prolonged >10 days)

    Fever + respiratory

    Malaria*
    Pneumonia
    Influenza
    Tuberculosis (TB)

     

    As for fever alone plus
    CXR
    Swab for respiratory viruses, including influenza and COVID
    If Tuberculosis considered, discuss investigations with Infectious Diseases team

    *Malaria should be considered in any child with undifferentiated fever up to two years after returning from an endemic region (See Malaria)
    **Travellers’ diarrhoea: >3 diarrhoeal episodes in a 24-hour period after travel plus one of the following: cramping, abdominal pain, nausea, vomiting, fever


    In a sick child, consider discussing with Infectious Diseases team for further advice about investigation and treatment

    Treatment

    Most children will not require empiric treatment and will be suitable for outpatient management with GP follow-up

    In a sick child, empiric therapy for sepsis, malaria and/or typhoid may be warranted:

    • Refer to individual CPGs or local antimicrobial guidelines for appropriate details
    • Discuss with Infectious Diseases team when necessary

    Consider consultation with local paediatric team when

    • suspected sepsis
    • malaria, typhoid
    • unclear diagnosis with clinical concern

    Consider transfer when 

    • severe malaria
    • sick child with persistent fever/symptoms despite basic empiric therapy and advice
    • child requires care above the level of comfort of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Additional notes

    US travel medicine guidelines and surveillance
    WHO up to date surveillance and outbreaks
    UK travel health resources of the National Travel Health Network and Centre (NaTHNaC)

    Last updated April 2021

  • Reference List

    1. Canadian Paediatric Society. Fever in the returning child traveller: Highlights for health care providers. https://www.cps.ca/en/documents/position/fever-in-the-returning-child-traveller (viewed 6 March 2020).
    2. Emergency Care Institute. Returned Traveller – Fever. https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/infectious-diseases/returned-traveller/returned-traveller-fever (viewed April 2020).
    3. Fink, D et al. Fever in the returning traveller. British Medical Journal (BMJ). 2018. 360, j5773 https://www.bmj.com/content/360/bmj.j5773 (viewed March 2020).
    4. Leggat, PA. Assessment of febrile illness in the returned traveller. Australian Family Physician. 2007. Vol 36 (5), pp. 328-333
    5. Perth Children’s Hospital 2017. Fever – Returned traveller. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Fever-Returned-traveller (viewed April 2020).
    6. Thwaites, GE et al. Approach to Fever in the Returning Traveler. The New England Journal of Medicine. 2017. Vol 376 (6), pp 548-560
    7. Wilson, ME. Post travel Evaluation - Fever. Centre for Disease Control and Prevention http://wwwnc.cdc.gov/travel/yellowbook/2020/posttravel-evaluation/fever (viewed March 2020).