Fever in the 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

• 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 via Notification of infectious diseases and related conditions. 
• Use the available resources for up to date region-specific information:
  • Disease distribution maps - WHO
  • Centre for Disease Control and Prevention

Assessment

Travel history checklist
Clinical syndrome	Timing, pattern and duration of symptoms. Medical care while overseas. Medications, over the counter/supplements/herbs. Were these medications acquired in 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 (mosquitoes, 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

Incubation Period
Short < 10 days	Intermediate 10-21 days	Long >21 days	Clinical features	Suggested investigations
Malaria (P. falciparum can have short-intermediate incubation periods. P. vivax and P. ovale have long incubation periods).			Fever, malaise, headache, nausea, vomiting, hepatosplenomegaly, anaemia. Refer to the Malaria - ED guideline	Urgent: Thick/Thin films (x3, 12-24h apart, EDTA); Malaria RDT (EDTA). +/- Malaria PCR (Reference lab). Monitor FBC, LFTs, UEC, Glucose.
Rickettsial infection			Fever, myalgia, primary inoculation lesion (eschar) ± generalised rash (petechial or macular papular).	Rickettsia serology (acute & convalescent) +/- PCR on eschar biopsy/blood (discuss with ID/Microbiologist).
Typhoid (Salmonella typhi or Salmonella paratyphi)			Fever, headache, abdominal pain, altered bowel habit. Rose spots rare in children.	Blood cultures (multiple sets); Stool M/C/S; +/- Urine culture; Monitor FBC
Campylobacter			Fever, diarrhoea, vomiting abdominal pain, bloody stools.	Stool M/C/S; +/- Faecal PCR panel.
Chikungunya			Arthralgia, myalgia, headache, nausea, rash.	Chikungunya IgM/IgG serology (from Day 5-7).
Dengue			Fever + 2 of - myalgia, retro-orbital pain, arthralgia, headache, leucopenia, haemorrhagic manifestations Warning signs: abdominal pain, persistent vomiting, oedema, mucosal bleed, hepatomegaly	Dengue serology- IgM, IgG, NS1 Ag (Day 1-7); rapid testing can be requested if urgent. Monitor FBC for thrombocytopenia, rising haematocrit
Influenza			Fever, URTI/LRTI, myalgia.	Respiratory virus PCR (NPA/throat swab).
Shigella			Fever, diarrhoea, vomiting abdominal pain, bloody stools.	Stool M/C/S; +/- Faecal PCR panel.
	Leptospirosis		Headache, myalgia, vomiting, rash, abdominal pain, conjunctival suffusion.	Leptospira serology (MAT - reference lab, acute & convalescent needed). Leptospira PCR (EDTA/urine. Monitor FBC, UEC, LFTs, CK.
	Measles		Cough, coryza, conjunctivitis, rash.	Measles PCR (NPA/throat swab, EDTA, urine); Measles IgM serology (from day 3 of rash). Notify Public Health.
	Viral Haemorrhagic Fever		Fever, fatigue, headache, gastrointestinal signs, rash, petechiae, mucosal bleeding.	Specific testing requires specialist consultation and high-level containment. High consequence - notify ID /Microbiology/ Public Health immediately.
		Hepatitis A	Vomiting, abdominal pain, jaundice.	LFTs; Hepatitis A IgM serology. This will be reflexed for PCR if serology is positive. Stool Hepatitis A PCR.
		Hepatitis E	Vomiting, abdominal pain, jaundice.	LFTs; Hepatitis E IgG serology.
		Rabies	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.	Primarily clinical diagnosis in symptomatic patient. Ante-mortem tests (PCR/FAT on saliva, CSF, skin biopsy) rarely useful/available in time. Post-exposure prophylaxis is key.
		Tuberculosis	Fever (low-grade, evening), night sweats, weight loss, fatigue. Pulmonary: prolonged cough (+/- haemoptysis). Extrapulmonary disease depends on site.	CXR; IGRA or TST; Sputum/Gastric aspirates (AFB smear/culture/PCR). Consider site-specific imaging/biopsy. Airborne precautions if pulmonary TB is suspected.

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

Infection Prevention and Control

Always consider infection prevention and control precautions when providing care for this patient group and their contacts. Please refer to the following for the precautions required.

• Transmissible Diseases Index
• Standard and Transmission Based Precautions
• Rash Management Guideline
• Exposure And Outbreak Management

Investigations

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 – particularly important for suspected typhoid fever.
• 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 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 history includes arbovirus risk areas and a consistent incubation period:
  • 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 (false negatives are more likely with patients who took some malaria prophylaxis, are early in the illness, and have not had malaria before).
  • 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)

Severely unwell patient

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

Treatment

• Malaria positive – refer to Malaria - ED guideline.
• See empiric antibiotics as per Sepsis and Bacteraemia - ChAMP Guideline (internal WA Health only)
• For further advice at any stage contact Infectious Diseases team. 

References

1. Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med 2002; 347:505-16

Bibliography

1. Looke DF, Robson JM. Infections in the returned traveller. MJA 2002; 177:212-219
2. Wilson ME, Weld LH, Boggild A, Keyston JS, Kain KC, Sonnenburg FV
3. 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
4. Phillips-Howard PA, Radalowicz A, Mitchell J, Bradley DJ. Risk of malaria in British residents returning from malarial areas. BMJ. 1990;300(6723):499
5. 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
6. 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
7. Traveller’s diarrhoea. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
8. Simmons CP, Farrar JJ, Nguyen VV, Wills BS. Dengue. N Engl J Med. 2012 Apr;366(15):1423-32
9. Kumar N, Lewis DJ. Fever and rash in a returning traveller. BMJ. 2012;344:e2400
10. WHO Dengue. Guidelines for diagnosis, treatment, prevention and control. New Edition, 2009 http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf
11. 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
12. Typhoid and paratyphoid fevers (Salmonella Typhi and Paratyphi A, B and C infection) In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; [Last updated: March 2025, Cited 8 May 2025] Available from: Antibiotic - Therapeutic Guidelines
13. Sepsis and Bacteraemia – Paediatric Empiric Guidelines PCH CHAMP guidelines. Last revised December 2024
14. Malaria In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; [Last updates March 2025, Cited: 8 May 2025]. Available from: Antibiotic - Therapeutic Guidelines

 

Endorsed by:	Co-Director Surgical Services	Date:	May 2025
		Review date:	May 2028

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