Fever in the returning traveller

Infectious diseases
NHS Lothian

Fever in returning traveller: risk assessment

This guideline should be used for the secondary care assessment of patients returning from travel outside Western Europe who have presented with fever >38 degrees or a history of feverishness.

 

1. Initial focused travel history

Ask the patient:

  • Where did you go? 
  • What did you do there?
  • When did you become unwell?

It is essential to know the countries (and locations within these) visited/transited and the exact dates of travel.

2. High Consequence Infectious Diseases (HCID) risk assessment

  1. Has the patient developed a fever and respiratory illness within 14 days of travel or transit in the Middle East? If yes: perform MERS risk assessment.
  2. Has the patient had a history of fever within 21 days of travel to a Viral Haemorrhagic Fever (VHF) endemic area? If yes: perform VHF risk assessment.
  3. Has the patient developed a fever and compatible clinical syndrome within 21 days of travel to an area at risk of Mpox clade 1b? If yes: perform Mpox risk assessment.

 

A complete list of HCIDs are listed on the UKHSA guidance page, along with this country-specific risk list 

All patients who meet the criteria for a potential HCID should be discussed with the ID physician on-call immediately (see step 6 below). The patient should be isolated and further contact avoided until after this discussion. Do not perform observations, tests or examinations until after discussion with ID.

3. Isolation and PPE assessment

Isolate patients presenting with fever after travel in a side room until a full assessment has taken place.

Consider using Personal Protective Equipment as follows:

Respiratory symptoms

Droplet precautions

Diarrhoea or rash

Contact precautions

Clinical syndrome suggestive of measles

 Airborne precautions - gloves, fluid resistant gown, FFP3 mask (must be fit tested), visor

Suspected HCID

 Enhanced precautions - Follow HCID guidelines as above, dependent on suspected pathogen

Patient admitted to healthcare facility whilst abroad

 CPE precautions - gloves, long sleeved apron. Send CPE and MRSA screens.

Always use Standard Infection Prevention Control (SIPC) measures. Further details on isolation and PPE can be found here:

 

4. Initial actions

  1. Undertake full history including a travel history as outlined below. Undertake examination as guided by the clinical presentation
  2. Assess geographic risk factors and disease epidemiology using these resources:
    1. https://www.fitfortravel.nhs.uk/home (malarial risk maps)
    2. https://promedmail.org (information on new and emerging pathogens)
    3. https://www.travax.nhs.uk (requires sign up via NHS email)
  3. Send initial investigations as outlined below, plus any additional investigations guided by the clinical presentation
  4. Consider specific causes of imported fever relating to the presenting syndrome, as outlined below

Non-travel related diagnoses are common in these patients, and should be managed as per usual practice.

5. Malaria risk assessment

Malaria should be excluded in all patients with fever who have returned from an endemic area. Almost all individuals with falciparum infection present within six months of exposure, however the presentation of non-falciparum malaria may be delayed for years. Tests should be sent as soon as it is established that there is no VHF risk. Malaria is a medical emergency and testing should occur urgently, including out-of-hours.

Malaria risk countries

Review the following list of country specific risks, in particular the malarial risk maps:

Malaria testing Malaria treatment guidelines
  • If malaria is confirmed, review the malaria treatment guidelines which include details on how and where malarial treatment is stocked within NHS Lothian
  • Parasite count must be performed urgently, even out-of-hours, as this guides treatment choice
  • Note: Malaria is not treated empirically without confirmatory investigations
  • All confirmed cases of malaria should be discussed with the ID physician on-call urgently (see step 6 below)

6. How & when to contact the ID team

Please contact the Infectious Diseases team as soon as possible if these criteria are met:
  • Suspected HCID (see step 2)
  • Confirmed malaria
  • Severely unwell travellers returning with a fever

 

There is no need to call out-of-hours if the patient is clinically well and there is no risk of HCID, please defer referral until usual working hours (0900-1900)

How to contact infectious diseases:

How to take a travel history

  • Travel destinations:
    • Detailed history of travel including dates of arrival and departure, and countries of transit.
    • Detailed information on the locations visited within each country (useful for assessing specific risks)
  • Environments:
    • Rural versus urban, humidity/temperature, season, altitude, type of accommodation.
  • Activities:
    • Swimming in fresh or salt water, safari, caving, hiking, hunting, etc.
  • Diet:
    • Consumption of street food, meat, bottled water.
  • Animal/insect exposure:
    • Any close contact or bites from animals, insects, or ticks.
  • Sexual history:
    • was barrier contraception used, details of sexual partners whilst travelling
  • Malaria prophylaxis and pre-travel health:
    • Use of chemoprophylaxis, mosquito nets, and insect repellent
    • pre-travel/childhood immunisation history
  • Health while traveling:
    • Details of any illness episodes while traveling and any healthcare settings
      accessed, admission to hospital or intensive care, cosmetic/aesthetic procedures undertaken
      outside the UK (including dental procedures and tattoos), use of antimicrobials.
  • Unwell contacts:
    • Contact with unwell individuals in the community or in hospital.
  • Funeral attended: 
    • Details of any funerals attended (relevant to HCID assessment)

 

Suggested initial investigations

Investigation Sample type How to order on TRAK
Full blood count EDTA blood (red cap tube) "Full blood count..."
U&Es, LFTs, CRP Clotted gel blood (brown cap)

"Urea, Creat, Electrolytes", "LFTs", "C-reactive Protein"
Blood borne virus screen:
HIV Ag/Ab, HBcAb, HCV IgG		 Clotted gel blood (brown cap) "HIV Ag/Ab Antibody screen", "Hepatitis B core IgG ab", "Hepatitis C Antibody"
Peripheral blood cultures Paired blood culture bottles "Blood culture Ix - ADULT ONLY" - print 2 labels
If in a malarial risk zone:
Malaria screen x3		 EDTA blood (red cap tube)

"Malarial parasites (inc FBC and film)"

- this investigation including a Rapid Diagnostic Test (RDT), thick and thin films. 
If respiratory tract symptoms: 
Viral throat swab + sputum for culture/PCR if productive cough		 Viral transport media (red cap)

"Resp virus screen + SARS-CoV2 (symptomatic patient only)"

"C&S - respiratory (routine bacteriology)"

"Respiratory Sputum PCR (Inc atypicals) ADULTS only"
If urinary symptoms:
Urinalysis (<65 years) + urine culture		 Sterile specimen container (white cap) "C&S - urine (microbiology)"
If diarrhoea:
Faeces C&S x3 and faeces for viral PCR		 Stool pot (blue cap)

RIE/WGH: "Faeces - Micro ADULT WGH/RIE only", for SJH: "Faeces- Micro SJH". Please state request for ova, cysts and parasites (OCP), symptoms, and travel history and suspected pathogen in the 'clinical details' field.

Faeces PCR: "Combined noro & rotavirus"
If sexual contacts:
First void urine (male) or high vaginal swab for chlamydia/gonorrhoea +/- rectal swab +/- mouth swab. 
Syphilis serology

Abbott Orange Cap Tube

+

Clotted gel blood (brown cap)

"Chlamydia Gonorrhoea dual NAAT" - change specimen type.

+

"Anti-treponema IgG antibody"
Serum sample for storage (can be sent later for geographical screen at reference laboratory) Clotted gel blood (brown cap) "Serum specimen stored"

Details of all available investigations in NHS Lothian available here: Test Directory | Edinburgh and Lothians Laboratory Medicine (edinburghlabmed.co.uk)

Causes of imported fever by presenting syndrome

Fever with jaundice with or without hepato / splenomegaly 
  • Consider life-threatening infections such as severe malaria, leptospirosis, and VHF. 
  • Viral hepatitis (A, B, C, E, CMV, and EBV). 
  • Acute cholangitis due to bacterial infection or liver flukes (fasciola). 
Fever with respiratory symptoms 
  • Most commonly will be caused by respiratory viruses such as influenza, COVID-19 and seasonal viruses.
  • Perform CXR looking for consolidation. If present and bacterial pneumonia suspected treat as community acquired pneumonia.
  • Consider highly transmissible infection such as:
    • Measles, particularly if there is a rash and conjunctivitis
    • Tuberculosis, particularly if epidemiological risk factors or more prolonged symptoms.
  • MERS should be considered if returned from or transited through the Middle East within the last 14 days.
  • If eosinophilia is present, consider helminth infections (e.g., filariasis, strongyloidiasis).
Fever with abdominal pain/ tenderness 
  • Common causes (urinary tract infection, appendicitis, cholecystitis).
  • Typhoid (enteric fever) or liver abscess (pyogenic, or amoebic).
Fever with diarrhoea 
  • Most cases of travel-related diarrhoea are self-limiting and do not require antimicrobial treatment. 
  • Common causes include:
    • Bacterial: Toxin producing E.coli, Shigella, Campylobacter, Non-typhoidal Salmonella
    • Parasitic: Giardiasis, Amoebiasis
    • Viral: Norovirus and Rotavirus  
  • If bloody diarrhoea is present, assess for signs of Haemolytic Uraemic Syndrome (e.g. acute kidney injury, haematuria, purpuric rash, jaundice). Consider non-infective causes (e.g. inflammatory bowel diseases). 
Fever with skin manifestations 
  • If exanthem is present, consider measles. 
  • If petechial or purpuric rash and neurological symptoms are present, consider meningococcal infection.
  • Consider the possibility of arboviral infection (e.g. Dengue, Zika, Chikungunya) – assess geographical risk factors. 
  • If eosinophilia and rash are present, consider testing for Strongyloides (non-urgent discussion with ID on-call). 
  • If eschar is present, consider scrub typhus or rickettsial infection. 
  • For vesicular/pustular rashes consider chickenpox (if non-immune) and mpox, if relevant exposure.
  • Acute HIV infection can present with rash and a glandular fever type illness.

Useful links

 

Editorial Information

Last reviewed: 05/08/2024

Next review date: 05/08/2025

Author(s): Dr Husni Zainal, Dr Osuri Wijesooriya, Dr Sarah Clifford, Dr Callum Mutch.

Version: 1.0

Reviewer name(s): Dr Sarah Clifford.