Fever in the returned traveller

Global travel has increased. With the ease of travelling, there has been a huge increase in the number of people going abroad. Also, more people are travelling for volunteer work and to more exotic destinations. 

The most common problem encountered during travelling is road traffic accidents. However up to 50% of travellers may develop a health problem during or after their trip; these are often related to the traveller’s underlying medical condition. Infections make up only a small proportion of the illness occurring amongst travellers. 

Fever after travel is a common scenario, and is often a clue to an infectious process which may have occurred during the travel. It may also be the only symptom of a serious or life threatening infection such as malaria. 

In regard to evaluating fever in the returned traveller, the initial focus would be to identify infections that are rapidly progressive, treatable or transmissible. 

Fever may develop during or after the travel period. Febrile illnesses may be accompanied by other clinical symptoms such as cough, breathlessness, diarrhoea and/or rashes. Depending on the travel destination and activities participated in (e.g. animal exposure, outdoor exposure, healthcare facility exposure), the exact cause of the fever may vary. 

Malaria is an important condition to exclude in persons presenting with fever during or after the trip, especially for travellers who have visited malaria endemic areas in recent months. In this group of travellers, they are advised to seek medical early, given that malaria can be rapidly progressive and potentially fatal if untreated. 

Infections can be acquired from different sources during travelling. To reduce infection risk, and therefore the incidence of fever occurring in the returned traveller, we recommend the following: 

The most common causes of fever in a returned traveller include upper respiratory traction infections, lower respiratory tract infections and gastroenteritis. However, unusual and emerging infections may be responsible for the fever instead. Also, potentially fatal conditions such as malaria should not be missed. 

The cause of the fever is dependent on the exposure involved. It is essential to verify where the traveller has visited and lived. Details of activities such as swimming in fresh water areas, insect bites, hiking during the travel may provide clues to the possible diagnoses. 

If pre-travel medical consultation was sought and vaccinations are up to date, infections with hepatitis A and typhoid are less likely. 

Evaluating fever in the returned traveller may sometimes be a clinical challenge for the physician. The fever could be due to unusual and emerging infections, and the amount of information available for the physician to make the diagnosis may be limited. The physician in charge needs to be knowledgeable with global information on outbreaks and offer a practical approach to emerging infections. 

There are a myriad of possible infectious causes of fever in the returned traveller. Much of the clue is in the travel history as well as the activities the traveller was engaged in. 

Investigations should be directed and guided by the clinical syndrome, travel history and physical examination findings. Blood tests, body fluid analysis or radiological investigations may be ordered to help confirm the diagnosis.