Febrile

The most common cause of fever in travellers returning to developed countries is:

• Never identified 10-30%
• Malaria
• Gastrointestinal infection — including typhoid and paratyphoid fever,
• Respiratory infection — especially influenza
• Dengue

Less Common:

• Viral haemorrhagic fever (apart from Dengue) — e.g. Ebola, Lassa

Afebrile

Traveller’s diarrhoea will occur in 20-50% of those who spend more than a week in a developing country and bacterial pathogens account for 80% of these cases. A 90% reduction in attack rate is seen with prophylactic use (not for greater than 1 week) of either fluoroquinolones, cotrimoxazole, or doxycycline, but is not routinely recommended for healthy travellers. For self-treatment, a single large dose of azithromycin or norfloxacin is often sufficient

• Bacterial
  • coli (ETEC)
  • Campylobacter
  • Salmonella
  • Shigella
  • Vibrio
• Parasitic
  • Giardia
  • Amoeba,
  • Toxoplasma
  • Trypanosomiasis (tsetse fly)
  • Leishmaniasis (sand fly)
  • Filariasis (mosquito)
  • Hookworm and Strongyloides
  • Schistosomiasis (snail)

History

Where have they been?

• Rural
• Adventure
• Visiting friends and relatives
• Expats and aid workers

Were there any unusual or at-risk exposures?

What prophylaxis was taken/used?

• Malaria chemoprophylaxis can be overwhelmed by high level exposure
• Typhoid vaccination is about 70% effective

Examination

What syndrome do they have?

• Fever without a focus
• Fever with rash/skin lesions
• Fever with diarrhoea
• Fever with respiratory symptoms
• Fever with neurological symptoms

Regardless of syndrome, consider malaria in all cases.

Investigation

• Thick and thin film — 2-3 blood samples over 24-48 hours — and RDT
• FBC
• EUC
• LFTs
• CRP
• Blood cultures
• Acute serology (hold pending convalescent sera @ 2-4 weeks) — e.g. amoebic serology
• Others according to clinical assessment
  • Stool
    • Microscopy: leukocytes, ova/cysts/parasites
    • Culture
  • Urine
    • Microscopy
    • Culture
  • Imaging

Management

Disposition

Do they need to be referred (to ED)?

Are they infectious and are they a public health risk?

WHO recommendations concerning the prevention of travellers’ diarrhoea

Travelers should

Avoid consumption of potentially contaminated food or drink.

Avoid contact with potentially contaminated recreational waters.

Know how to treat diarrhoea.

Carry oral rehydration salts and water-disinfecting agents.

Precautions for avoiding unsafe food and drink

Avoid cooked food that has been kept at room temperature for several hours.

Eat only food that has been cooked thoroughly and is still hot.

Avoid uncooked food, apart from fruit and vegetables that can be peeled or shelled, and avoid fruits with damaged skins.

Avoid dishes containing raw or undercooked eggs.

Avoid food bought from street vendors.

Avoid ice cream from unreliable sources, including street vendors.

In countries where poisonous biotoxins may be present in fish and shellfish, obtain advice locally.

Boil unpasteurised (raw) milk before consumption.

Boil drinking water if its safety is doubtful; if boiling is not possible, a certified, well-maintained filter and /or a disinfectant agent can be used.

Avoid ice unless it has been made from safe water.

Avoid brushing the teeth with unsafe water.

Bottled or packaged cold drinks are usually safe provided that they are sealed; hot beverages are usually safe.

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References

Cohen, J. “Parasites in travellers: a brief guide”. Medicine Today, July 2005, Volume 6, Number 7.

Hudson, B. “Fever in the returned traveller”. Medical Observer, September 3, 2010.

Leggat P, Goldsmid J. “Travellers’ diarrhoea: health advice for travellers”. Travel Medicine and Infectious Diseases (2004) 2, 17-22.

Pope J. “Traveller’s diarrhoea: Therapeutic Guidelines Update”. Medical Observer, October 27, 2006.