Fever - Returned traveller

Disclaimer

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. 

Read the full PCH Emergency Department disclaimer.

Aim

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

Background

  • Returned travellers commonly suffer from health problems related to travel, which can present as minor self-limited illnesses or potentially life threatening infections
  • Non-specific viral illness, diarrhoeal diseases and respiratory illnesses are the most common clinical syndromes. The most common specific diagnoses among returned travellers with fever are malaria, dengue and salmonella infections including typhoid
  • Clinicians who are evaluating returned travellers who are ill must maintain a broad differential diagnosis that includes routine infections, as well as exotic infections and illness that may be non-infectious in nature
  • Returned travellers from Bali will still need investigation for Malaria, even if they have not travelled to rural / remote or the Lombok area.

Assessment

Travel history checklist

What countries were travelled to?  Information regarding country specific risks can be found at:
When was the travel conducted?  Include travel dates and duration of travel to establish possible incubation period 
What is the vaccination status including routine vaccines and travel vaccines 
  • Vaccines such as typhoid, provide incomplete protection and travellers are still at risk. 
  • Travellers unimmunised to standard vaccines such as measles are at an increased risk of exposure abroad.
Malaria prevention strategies 
  • Malaria prophylaxis is never 100% effective and the use of bed nets is the most effective strategy
  • Type of medication and dosing regimen
  • Adherence to medication and duration of therapy prior to and after leaving and endemic area.

Differential diagnosis

Infection  Incubation period   
Malaria  Variable  P. falciparum: 7 days - 12 weeks. Other malarial species: weeks to several years. 
Typhoid (Salmonella)  Variable  3 days - 3 months (usually 8-14 days) 
Rickettsial infection  Variable 3-21 days (depending on type) 
Dengue  Short  3-14 days (usually 5 days) 
Chikungunya  Short  1-12 days (usually 3-7 days) 
Influenza  Short  1-5 days (usually 2 days) 
Campylobacter Short  1-10 days (usually 3 days) 
Shigella  Short  12 hours - 7 days (usually 2 days) 
Measles  Intermediate  7-18 days (usually 10 days) 
Viral haemorrhagic fever (Ebola)  Intermediate  2-21 days (usually 8 days) 
Hepatitis A Long  2-7 weeks (usually 30 days)
Rabies  Long  3-8 weeks (sometimes years)

Management

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

Non severely unwell patient

  • Always consider infection control precautions - refer Rash Management
  • Take a travel history.

Perform a thorough examination including:

  • Rashes/skin lesions (dengue, thyroid, rickettsia, measles, leptospirosis)
  • Hepatomegaly (malaria, typhoid, dengue, viral hepatitis)
  • Splenomegaly (malaria, typhoid, mononucleosis)
  • Acute abdomen or GI haemorrhage (typhoid)
  • Cough, coryza, conjunctivitis (respiratory viruses, measles)
  • Jaundice (viral hepatitis, malaria)
  • Lymphadenopathy (rickettsia, toxoplasmosis, brucellosis, HIV, infectious mononucleosis)
  • Petechiae (meningococcal disease, viral haemorrhagic fever, rickettsia)
  • Neurologic findings: confusion, lethargy, meningism (malaria, meningitis)
  • Insect bites and eschars (malaria, dengue, rickettsia).

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)
  • FBC
  • LFT, EUC.

Other tests to consider

  • Serology for dengue / arboviruses (+/- the dengue NS1 Ag in the 1st week of illness) (red/gold top)
  • Measles PCR on PNA / urine / blood and IgM + IgG for Measles in suspected cases (most frequently identified in unimmunised cases) 
  • CXR +/- NPA for respiratory viruses
  • Stool bacterial cultures, O/C/P and enteric viruses
  • Urine microscopy and culture.

Management

 

  • Depends on the patient’s clinical presentation and specific diagnosis.
  • If the patient is suitable for outpatient management, consult Infectious Diseases team prior to discharge.
  • If urgent advice is required about testing, contact Clinical Microbiologist on call.
  • If the patient requires admission, the primary admitting team will be General Paediatrics with consideration for obtaining an Infectious Diseases Consultation.

Severely unwell patient

  • Haemodynamic compromise
  • Altered conscious state
  • Seizures
  • Bleeding
  • Refer to the Serious illness guideline
  • Always consider infection control precautions – refer to Rash Management.

Initial investigations

  • Blood cultures
  • FBC and thick and thin blood film for malaria (purple top) 
  • Rapid diagnostic test for Malaria Ag (purple top) – label urgent and call Haematology Lab for result (available 24 hrs/day)
  • Microscopy and culture of urine, CSF and stool (including rectal swab for ESBL)
  • LFT and EUC (green top)
  • Coagulation profile (blue top)
  • PCR (meningococcal, malaria) (purple top)
  • Serum tube (dengue and other serology) (red/gold top).

Treatment

 

For further advice contact Infectious Diseases team.

Bibliography

  1. Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med 2002; 347:505-16
  2. Looke DF, Robson JM. Infections in the returned traveller. MJA 2002; 177:212-219
  3. Wilson ME, Weld LH, Boggild A, Keyston JS, Kain KC, Sonnenburg FV
  4. West NS, Riordan FA. Fever in returned travellers: a prospective review of hospital admissions for a two and a half year period. Arch Dis Child 2003 88:432-434
  5. Phillips-Howard PA, Radalowicz A, Mitchell J, Bradley DJ. Risk of malaria in British residents returning from malarial areas. BMJ. 1990;300(6723):499
  6. Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO et al. The practice of travel medicine: Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1499-1539
  7. Dorsey G, Gandhi M, Oyugi JH, Rosenthal PJ. Difficulties in the prevention, diagnosis, and treatment of imported malaria. Arch Intern Med. 2000;160(16):2505
  8. Traveller’s diarrhoea. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
  9. Simmons CP, Farrar JJ, Nguyen VV, Wills BS. Dengue. N Engl J Med. 2012 Apr;366(15):1423-32
  10. Kumar N, Lewis DJ. Fever and rash in a returning traveller. BMJ. 2012;344:e2400
  11. WHO Dengue. Guidelines for diagnosis, treatment, prevention and control. New Edition, 2009 http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf
  12. Sanchez-vargas FM, Abu-el-haija MA, Gomez-duarte OG. Salmonella infections: An update on epidemiology, management, and prevention. Travel Medicine and Infectious Disease (2011) 9, 263-277
  13. Typhoid In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
  14. PCH CHAMP guidelines. Presumed Bacteraemia, Sepsis. Last revised 4th November 2013
  15. Malaria In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar

Endorsed by:  Director, Clinical Services  Date:  Jun 2017


 Review date:   Mar 2021


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 August 2015 
  • External Review: Zoy Goff (PCH Pharmacy Department) August 2015

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