Illness in the returned traveller


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network


  • See also:

    Febrile Child under 3 Yr
    Fever and Petechiae/Purpura 
    Immigrant health 
    Meningitis   

    Background

    Returned travellers commonly have health related problems upon their return. Fever in the returned traveller may be a symptom of a minor self-limiting illness or mark the onset of a life threatening disease. Remember disease unrelated to travel can occur after exotic travel.

    Illness in the returned traveller includes:

    Assessment

    The assessment of the returned traveller depends on a good history and careful examination:

    History

    What infections are possible given the destination? (see: Center for Disease Control and Prevention)

    What is the incubation period of the possible infections? ( see table below)

    Specific history that should be elicited: 

    • Travel - urban versus rural travel, destination, altitude
    • Occupation/Hobbies - activities 
    • Contact with animals/ Bites
    • Drugs - prescription, complementary and illicit
    • Sexual contacts
    • Routine childhood and travel immunisations/Prophylaxis
    • Food

    Examination

    A full examination is required.

    Key examination findings which may indicate specific causes include:

    • Jaundice
    • Hepatosplenomegaly
    • Cough, coryza, conjunctivitis +/- rash (measles)
    • Rashes, eg Rose spots (typhoid), macular-maculopapular (dengue and rickettsia)
    • Purpura/petechiae (meningococcal)
    • Regional lymphadenopathy
    • Insect bites/ Insects (eg ticks)

    Management

    Investigations:

    • FBE (Anaemia and thrombocytopenia more likely with malaria)
    • Rapimal™ (rapid diagnostic test(RDT) for malaria- NB this test is only useful in the diagnosis of falciparum malaria; poor sensitivity for the other plasmodia)
    • Thick and thin films, taken on 2 separate occasions
    • Measles PCR - nasopharyngeal (flocked) swab (prodromal period before rash appears to day 6 of symptoms) Note: blood (day 1 to 3) and urine (day 4 to 6) are alternative specimens for PCR.
    • Measles serology - Measles IgM and IgG appear 1 to 3 days after rash.
    • LFT (if suspecting hepatitis, malaria)
    • Blood cultures (routine in all febrile returned travellers)
    • CXR
    • Urine M+C (if suspect UTI)
    • Stool cultures +/- OCP (eg to diagnose bacillary dysentery, Giardia, viral gastroenteritis etc)

    Consider storing serum in the case of suspected Dengue or other arbovirus infections.

    Notes

    • Any patient in whom measles is clinically suspected should be nursed in a negative pressure room with airborne precautions.
    • Any patient who has been to a malarious region and who gives a history of fever should be tested for malaria.
    • An initial negative blood smear for malaria does not exclude the diagnosis.
    • Returned travellers who have been visitors to family and relatives overseas are more likely to have a serious cause for illness upon return; e.g. malaria and typhoid fever.
    • Remember non-infectious causes for fever; thrombophlebitis etc
    • Consider referral to Infectious Diseases Fellow (pager 5787) and/or the Travel Clinic (9345 6180): See:  RCH Travel Clinic
    • Many illnesses in returned travellers are notifiable diseases - see http://ideas.health.vic.gov.au/notifying.asp 
    Infection  Incubation period
    Malaria P.falciparum 7 days (minimum) to 12 weeks (usual maximum) 
      Other Plasm.species. Weeks to several years
    Measles 7 - 18 days
    Dengue  3 - 14 days
    Hepatitis A  14 - 50 days
    Hepatitis B  45 - 180 days
    Typhoid  3 days - 3 mths
    Campylobacter   1 - 10 days
    Shigella  12 hrs - 4 days
    Viral hemorrhagic fevers  2 - 21 days
    Influenza  2 - 5 days