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

• 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:
  • Disease distribution maps - WHO
  • Centre for Disease Control and Prevention

Assessment

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

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
• 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)

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 In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
13. PCH CHAMP guidelines. Presumed Bacteraemia, Sepsis. Last revised 4th November 2013
14. Malaria In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar

 

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