Fever in the recently returned traveller

  • See also

    Immigrant Health: acute presentations guideline

    Immigrant Health: malarial screening guideline

    Febrile Child under 3 years guideline

    Fever and Petechiae - Purpura guideline

    Gastroenteritis guideline

    Background to condition

    When assessing a febrile child who recently returned from foreign travel there are three possibilities:

    1.      Common childhood infection contracted while away. Consider seasonal variations i.e. different RSV / Influenza season

    2.      Infection contracted during visit to an endemic region i.e. malaria, typhoid, dengue

    3.      Infection contracted due to regional outbreak i.e. Measles 

    The key components in establishing a differential diagnosis and deciding on appropriate first line investigations are:

    • Careful assessment based on the guidelines below
    • Use of epidemiological surveillance tools
    • Consideration of incubation times (see Table 1 Additional Information)

    Assessment 

    All children with fever who recently returned from foreign travel should be assessed for common infections of childhood as per standard practice. 

    Features on history 

    1. Travel location - refer to the below websites for information on local infectious diseases
      wwwnc.cdc.gov/travel : travel medicine guidelines and surveillance
      www.who.int/ith/en : up to date surveillance and outbreaks 
    2.  Date and duration of travel
    3.  Accommodation
    4.  Exposures: contact with animals, insect bites, drinking water and food sources (raw meat / unpasteurized milk)
    5.  Activities   
    6.  Sick contacts: typhoid, TB, varicella, influenza, chronic cough
    7. Pre-travel prophylaxis and compliance, immunisation history NB Salmonella vaccination has 70% efficacy     
    8. Symptom complex, onset and duration of symptoms
    9. Healthcare while away including any medications taken 

    Investigations

    Clinical Syndrome

    Most Important Infections to consider

    Investigations

    Fever alone

    Malaria#

    Typhoid

    Dengue

    Hepatitis

    FBE

    Malaria ICT

    Malaria thick and thin films

    Blood culture

    (Malaria films and blood culture should be repeated when febrile)

    Serum to store

    ± LFTs if jaundiced

    Fever + Diarrhoea

    Malaria

    Typhoid

    Dengue

    Hepatitis

    Traveller's Diarrhoea*

    Cholera

    Dysentery (bloody diarrhoea)

    As for Fever alone + 

    Stool m,c,s + o,c,p (ova, cysts and parasites)

    Fever + Respiratory

    Malaria

    Pneumonia

    Influenza

    Tuberculosis

    As for Fever alone + 

    CXR

    Viral swabs/NPA for respiratory viruses

    If TB considered possible discuss investigations with Infectious Diseases unit

    # Malaria should be considered in any child with undifferentiated fever up to two years after returning from an endemic region

    * Travelers Diarrhea: >3 diarrhoeal episodes in a 24 hour period after travel + one of cramping, abdominal pain, nausea, vomiting, fever. 

    Acute management

    See also

    Malaria guideline

    Gastroenteritis guideline

    Pneumonia guideline 

    Main points:

    1. Undifferentiated fever requires exclusion of Malaria and Typhoid. Empiric therapy may be warranted and should be discussed with an Infectious Diseases Specialist.
    2. Consider the need for isolation and/or notification especially with undiagnosed respiratory syndromes, haemorrhagic syndromes and diarrheal syndromes. (http://ideas.health.vic.gov.au/notifying.)
    3. Traveller's Diarrhoea
      1. Hydration
      2. If moderate to severe symptoms consider antibiotics 

    When to consider transfer to tertiary centre

    Consider transfer after consultation with the infectious diseases service in cases of:

    ·         Severe Malaria

    ·         Undiagnosed illness in a returned traveller with persistent fever/symptoms despite basic empiric therapy and advice

    For ICU level transfer ring the NETS/PETS hotline: (03) 9345 7007

    Information Specific to RCH - Including whom to consult for inpatients.

    Patients should be admitted under a General Medical unit.

    The Infectious Diseases fellow can be contacted on pager 5787 for further advice or the Infectious Diseases consutant on-call through switchboard after hours.

    Information Specific to Monash Medical Centre

    Contact

    The Infectious Diseases fellow can be contacted on pager 100 for further advice or on PID SMS out of hours. 

     
    Additional notes: 

    Table 1: Clinical syndromes, incubation periods and epidemiological features of infections commonly causing illness in the Recently Returned Traveller. 

    Fever alone

    Common infections

    Possible additional clinical features

    Incubation

    Region

    Malaria

    (P falciparum)

    Neurological, GI, Respiratory

    6 days - 2 years

    Widespread in tropics and subtropics

    Malaria

    (P vivax)

    Neurological, GI, Respiratory

    8 days - 2 years

     

    Widespread in tropics and subtropics

    Typhoid

    (S Typhi /  S Paratyphi)

    Constipation, abdominal pain. Diarrhoea a late sign. Rose spots rare in childhood

    3-60days

    Indian Subcontinent

    Hepatitis A

    Vomiting, abdominal pain, jaundice

     

    15-50 days

    Worldwide / poor sanitation

    Hepatitis E

    Vomiting, abdominal pain, jaundice

    2-9 weeks

    Widespread

    Dengue

    Fever + 2 of myalgia, retro-orbital pain, arthralgia, headache, leucopoenia, haemorrhagic manifestations

    3-14 days

     

    Tropics / Subtropics particularly:

    Latin America

    South East Asia

    Chikungunya

    Arthralgia, myalgia, headache, nausea, rash

    1-14 days

    Tropics / Subtropics particularly:

    India

    Indian Ocean

    Central America

    Leptospirosis

    Headache, rigors, myalgia, vomiting, jaundice, abdominal pain, rash

    2-26days

    Most tropical areas (Ecuador / Amazon)

    Rickettsiae

    Arthralgia, rash, tick eschar.

    Few days - 2/3 weeks

    Species vary by region NB outdoor activity / insect bites

    Fever + Diarrhoea

    Malaria

    (P falciparum)

    Neurological, GI, Respiratory

    6 days - 2 years

    Widespread in tropics and subtropics

    Malaria

    (P vivax)

    Neurological, GI, Respiratory

    8 days - 2 years

     

    Widespread in tropics and subtropics

    Typhoid

    (S Typhi /  S Paratyphi)

    Constipation, abdominal pain. Diarrhoea a late sign. Rose spots rare in childhood.

    3-60 days

    Indian Subcontinent

    Hepatitis A

    Vomiting, abdominal pain, jaundice

    15-50 days

    Worldwide / poor sanitation

    Hepatitis E

    Vomiting, abdominal pain, jaundice

    2-9 weeks

    Widespread

    Campylobacter

    Travellers diarrhea

    Dysentery

    1-10 days

    Indian subcontinent / South east Asia

    ETEC

    Travellers diarrhea

    Dysentery

    Hours - 4 days

    Africa / Latin America

    Shigella

    Travellers diarrhea

    Dysentery

    12 hours - 4 days

    Widespread

    Cholera

    Mild - Severe watery diarrhoea

    2 hours - 5 days

    Widespread

    Amoebiasis

    Travellers diarrhea

    Dysentery

    Hours - 4 days

    Widespread

    Giardia

    Travellers diarrhea

    Prolonged diarrhea, abdominal pain, bloating

    Hours - weeks

    Widespread

    Fever + Respiratory

    Malaria

    (P falciparum)

    Neurological, GI, Respiratory

    6 days - 2 years

    Widespread in tropics and subtropics

    Malaria

    (P vivax)

    Neurological, GI, Respiratory

    8 days - 2 years

     

    Widespread in tropics and subtropics

    Pneumonia

    Anorexia, lethargy, vomiting, respiratory distress

     

    Worldwide

    Influenza

    URTI / LRTI, myalgia

    1-3 days

    Worldwide

    Tuberculosis

    Lethargy, weight loss, sweats, cough

    Primary: weeks

    Reactivation: years

    Worldwide