Fever - Returned traveller


These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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To guide staff with the assessment and management of fever in the returned traveller.


  • The most frequent causes of fever in paediatric returned travellers are common childhood infections which are also endemic in Australia. Most of these are non-specific respiratory viral illnesses, diarrhoeal diseases and other viral illnesses.
  • The most common specific diagnoses in returned travellers are malaria, dengue and salmonella (including typhoid, Salmonella typhi)
    Detailed assessment of exposures, symptoms and timing are invaluable in narrowing differential diagnoses
  • Any medical practitioner or nurse practitioner attending a patient whom he/she knows or suspects has a notifiable infectious disease or a related condition has a legal obligation to report the diagnosis to the Western Australian Department of Health
  • Use the available resources for up to date region-specific information:


Travel history checklist

Clinical syndrome
  • Timing, pattern and duration of symptoms.
  • Did you seek medical care while overseas? 
  • Did you take any medications, over the counter/supplements/herbs? Where were these medications acquired: Australia or overseas?
Geographic exposures
  • Countries travelled to, and transited through?
  • What regions or cities specifically were visited?
  • Include travel dates and duration of travel to establish possible incubation period.
Other exposures
  • What did you do while travelling? Any exposure to rural/forest/farm/water areas? 
  • Any animal exposure, especially scratches/bites/patting? 
  • What did you eat? Was water sterilised? Did anyone have gastroenteritis symptoms while travelling? Any undercooked meat or unpasteurised dairy?
  • Insect bites (mosquitos, sand flies, ticks etc.)
  • Any unwell contacts while you were travelling? (e.g. relatives with a cough)
Vaccination status and malaria prophylaxis 
  • Has the child had routine vaccinations per WA schedule? (Check the Australian Immunisation Registry [AIR] for confirmation). Note that some vaccine-preventable diseases e.g. measles, are more prevalent overseas.
  • Did the child have any extra vaccinations before travel? If so, what, and when? Note that some travel vaccines, e.g. typhoid, offer incomplete protection
  • Was any malaria prophylaxis taken? If so, which agent, when was it taken, assess adherence, and when it was ceased? What about other strategies? (bed nets, insect repellent)

Differential diagnosis

Infection  Incubation period    Clinical features 
Malaria  Variable  P. falciparum: 7 days - 12 weeks. Other malarial species: weeks to several years.  Fever, malaise, headache, nausea, vomiting, hepatosplenomegaly, anaemia. Refer to the Malaria - ED guideline.
Typhoid (Salmonella)  Variable  3 days - 3 months (usually 8-14 days)  Fever, headache, abdominal pain, altered bowel habit, rose spots rare in children.
Rickettsial infection  Variable 3-21 days (depending on type)  Fever, myalgia, primary inoculation lesion (eschar) ± generalised rash (petechial or macular papular). 
Dengue  Short  3-14 days (usually 5 days)  Fever + 2 of: myalgia, retro-orbital pain, arthralgia, headache, leucopenia, haemorrhagic manifestations 
Chikungunya  Short  1-12 days (usually 3-7 days)  Arthralgia, myalgia, headache, nausea, rash. 
Influenza  Short  1-5 days (usually 2 days)  Fever, URTI/LRTI, myalgia. 
Campylobacter Short  1-10 days (usually 3 days)  Fever, diarrhoea, vomiting abdominal pain, bloody stools.
Shigella  Short  12 hours - 7 days (usually 2 days)  Fever, diarrhoea, vomiting abdominal pain, bloody stools. 
Measles  Intermediate  7-18 days (usually 10 days)  Cough, coryza, conjunctivitis, rash. 
Viral haemorrhagic fever (Ebola)  Intermediate  2-21 days (usually 8 days) 

Fever, fatigue , headache , gastrointestinal signs, rash, petechiae, mucosal bleeding. 

Leptospirosis  Intermediate  2-26 days (usually 10 days) Headache, myalgia, vomiting, rash, abdominal pain, conjunctival suffusion. 
Hepatitis A Long  2-7 weeks (usually 30 days) Vomiting, abdominal pain, jaundice.
Rabies  Long  3-8 weeks (sometimes years)

Animal bite: tingling at the site, fever, myalgia, headache, neurological symptoms.

Note – bites are more likely to be infected with animal oral flora than Rabies. 

NB: Not a comprehensive list, other rare conditions are considered on a case-by-case basis


Children are unlikely to present as severely unwell, if indicated please refer to the management for the severely unwell patient (below).

First line investigations

  • Blood culture
  • Thick and thin blood film for malaria (purple top – EDTA tube) – this must be performed on 2-3 separate occasions, 12-24 hours apart, to be reliably negative
  • Rapid diagnostic test for malarial Ag (purple top – EDTA tube) (only positive in P. falciparum: call Haematology lab for urgent results available 24hr / day)
  • Full blood count, liver function tests, electrolytes, urea & creatinine
  • Serum to store
  • Urine microscopy, culture and sensitivity (MC&S)

If severely unwell:

As above PLUS:

  • Coagulation profile, glucose
  • Meningococcal and pneumococcal PCR (EDTA purple top tube)
  • Consider need for lumbar puncture.
  • Carbapenemase resistance screening (CRE) and extended-spectrum beta-lactamase (ESBL) screening: rectal swab or stool specimen


Further specific investigations to consider based on history and clinical presentation

  • If travel Hx includes arbovirus risk areas and a consistent incubation period:
    • Serology for dengue / arboviruses (+ dengue NS1 Ag in the 1st week of
      illness) (red/gold top)
    • Chest X-ray +/- nasopharyngeal aspirate for respiratory viruses.
    • Stool bacterial culture, faecal ova, cysts and parasites (O/C/P) and enteric viruses.

If travel to countries with endemic measles or measles outbreak:

  • Measles PCR on nasopharyngeal aspirate / urine in suspected cases (most frequently identified in unimmunised children)
If patient has a history of hospitalisation outside of WA within the last 12 months and is to be admitted
  • Multi-Resistant Organism (MRO) screening as per Multi-Resistant Organisms Identification and Management - Infection Prevention and Control Guideline (internal WA Health only).
    • 2 rectal swabs or 1 stool specimen (CRE, ESBL, vancomycin-resistant enterococci [VRE])
    • 1 nose and 1 throat swab for methicillin resistant Staphylococcus aureus (MRSA)
    • Swab of both axillae and groins (Candida auris) if admitted to hospital outside Australia.


If the patient requires admission, the primary admitting team will be General Paediatrics with consideration for obtaining an Infectious Diseases Consultation.

Severely unwell patient

  • Refer to the Serious Illness Assessment - ED Guideline.
  • Take initial investigations as above – prioritise blood culture and malaria rapid testing.



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Endorsed by: Co-Director Surgical Services  Date:  Aug 2021

 Review date:   Aug 2024

This document can be made available in alternative formats on request for a person with a disability.

  • Guideline Developed by: Anita Campbell (Infectious Diseases Fellow) July 2015 
  • External Review: PCH Infectious Diseases team and Sam Brophy-Williams, 2021
  • External Review: Zoy Goff (PCH Pharmacy Department), August 2015


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