See also

Immigrant health - acute presentations
Malaria
Gastroenteritis
Febrile child
COVID-19

Key points

1. Most infections are mild or self-limiting, however their non-specific presentations make them challenging to distinguish from serious infections such as malaria
2. Falciparum malaria is the most common serious infection and cause of death in returning travellers
3. Severe respiratory infections from novel viral infections (eg COVID-19, H5N1) highlight the needs for vigilance and the role of travelers as sentinels, carriers and spreaders
4. Drug-resistant infections or colonization may have been acquired, especially if hospitalised

Background

• Common diseases unrelated to travel are more likely than exotic ones acquired whilst overseas
• Returned travellers who have been visiting friends and relatives whilst overseas are more likely to have a serious cause for illness upon return

When assessing a febrile child recently returned from overseas travel it is important to consider non-infectious causes for fever (eg DVT/PE). There are three main possibilities in terms of infection:

• Common childhood infections contracted whilst away (Consider seasonal variations)
• Infection contracted whilst visiting an endemic region
• Infection contracted due to a regional outbreak

The keys to establishing a differential diagnosis and deciding on appropriate first line investigations are:

• Careful assessment (history and examination)
• Use of epidemiological surveillance tools (see Additional notes section below)
• Consideration of incubation times (see Incubation periods table below)

Always consider whether the presentation may indicate a disease of public health importance, where immediate infection control and containment measures are indicated. (See Australian national notifiable diseases and contact local health department for advice)

• Any child in whom measles is clinically suspected should be nursed in a negative pressure room with airborne precautions
• Any child with respiratory symptoms who may have a novel respiratory illness should be seen using appropriate precautions
• Haemorrhagic fevers (Ebola, Marburg, Lassa, Crimean-Congo) require strict isolation and strict barrier nursing

Assessment

History

• Travel location and type (country/regions, urban/rural, living conditions, altitude)
• Timing of travel (dates, seasons, duration)
• Exposure to risk factors
  • contact with animals, insect bites
  • drinking water and food sources
  • activities (including sexual contacts, illicit drug use, tattoos)
  • sick contacts
• Immunisation history (routine childhood and travel specific, noting Salmonella typhi vaccination only has ~70% efficacy)
• Prophylaxis
  • medication use and adherence
  • mosquito nets/insect repellent
• Symptom onset, duration and course
• Healthcare while away including any medications taken

Examination

• Fever (only clinical finding in majority)
• Tachypnoea
• Rash
• Altered consciousness*
• Haemorrhage*
• Hypotension*
  *Suggestive of cerebral malaria or hemorrhagic fever with shock

Management

Investigations

*Malaria should be considered in any child with undifferentiated fever up to two years after returning from an endemic region (See Malaria)
**Travellers’ diarrhoea: >3 diarrhoeal episodes in a 24-hour period after travel plus one of the following: cramping, abdominal pain, nausea, vomiting, fever

In a sick child, consider discussing with Infectious Diseases team for further advice about investigation and treatment

Treatment

Most children will not require empiric treatment and will be suitable for outpatient management with GP follow-up

In a sick child, empiric therapy for sepsis, malaria and/or typhoid may be warranted:

• Refer to individual CPGs or local antimicrobial guidelines for appropriate details
• Discuss with Infectious Diseases team when necessary

Consider consultation with local paediatric team when

• suspected sepsis
• malaria, typhoid
• unclear diagnosis with clinical concern

Consider transfer when 

• severe malaria
• sick child with persistent fever/symptoms despite basic empiric therapy and advice
• child requires care above the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Additional notes

US travel medicine guidelines and surveillance
WHO up to date surveillance and outbreaks
UK travel health resources of the National Travel Health Network and Centre (NaTHNaC)

Last updated April 2021