Fever in the recently returned traveller

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

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
Date and duration of travel
Accommodation
Exposures: contact with animals, insect bites, drinking water and food sources (raw meat / unpasteurized milk)
Activities
Sick contacts: typhoid, TB, varicella, influenza, chronic cough
Pre-travel prophylaxis and compliance, immunisation history NB Salmonella vaccination has 70% efficacy
Symptom complex, onset and duration of symptoms
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

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

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines