Travel-associated Febrile Illness

HISTORY TAKING

The first step is to characterize the fever, e.g., its onset, pattern and duration and any prodromes.

Some of the classical febrile patterns are:

• High-grade fever – Dengue, Malaria.

• Step ladder pattern – Enteric fever.

• Biphasic pattern – Dengue, Leptospirosis.

• Periodicity – Malaria, Borreliosis.

Knowledge of the incubation period is also vital for assessing probable etiology, for example:

When it is less than 10 days it could be dengue, chikungunya, plague while if within 10–14 days we have to consider malaria, enteric fever, leptospirosis, toxoplasmosis.

History of fever onset after 2 weeks, even at times more than 6 weeks of travel, may be found in:

• Typhoid or paratyphoid fever.

• Malaria (Plasmodium ovale, P. vivax).

• Cytomegalovirus, Epstein-Barr virus, HIV (acute).

• Tuberculosis, melioidosis, brucellosis.

• Acute hepatitis B, hepatitis C, hepatitis E.

The list of diseases is extensive and mindboggling which makes it very difficult for the treating physician to pinpoint the diagnosis. In that case we need a meticulous enquiry into other aspects like;

• A personal medical history:

  • – Comorbidity.

  • – Occupational history.

  • – Drug history.

  • – Underlying immune suppression.

  • – Whether the patient has been visiting friends and relatives (VFR).

  • – Childhood vaccinations up to date or not.

  • – Status of vaccination/prophylaxis for specific destination risk.

• Details about the travel:

  • – Country visited as well as traveled through and its endemicity, e.g., malaria, dengue.

  • – Local geography (mountains/lakes/beaches/urban or rural)–where the patient resided.

  • – Accommodation (family/hostel/hotel/camping).

  • – Information about ongoing outbreaks.

• What was the patient doing while abroad?

  • – Work or vacation.

  • – History of sexual contact.

  • – Was there any hospital treatment or admission.

  • – Any history of insect bites.

The elucidation of symptoms associated with fever is of prime importance because it helps in following the syndromic approach to fever.

Various infections have predilection in producing particular organ involvement – the syndromes commonly encountered in the tropics are:

• Acute encephalitic syndrome.

• Fever with rash.

• Fever with hepatosplenomegaly.

• Fever with lymphadenopathy.

• Fever with bleeding.

• Fever with abdominal pain.

• Fever with hepatorenal syndrome.

• Fever with arthralgia/arthritis.

• Fever with acute kidney injury.

• Fever with acute respiratory distress syndrome (ARDS).

• Fever with multiorgan failure.

MANAGEMENT

The management issues primarily focus on patient stabilization and treatment of the cause along with supportive therapy. Infection control considerations by isolation are needed if there is a chance of spread.

However, it is clear to all, that awareness and prevention is the key to effective handling of travel associated illness.

A visit to the local physician is to be highlighted as a necessary step around 4–6 weeks before a planned vacation or tour. The physician needs to take detailed information about the following:

• Destination, personal details, date of trip, itinerary and purpose of visit.

• Personal medical history, including pregnancy, medication, and allergies (e.g., to eggs, vaccines, antibiotics) are not to be missed.

• Advice regarding good quality insect repellents, appropriate clothing is to be given if visit is in remote seaside or forest destinations.

• The traveler needs to be up to date with regular vaccinations and specific vaccines depending on destination (varies from country to country) should be recommended.

• In special situations for foreigners visiting from nonendemic zones, chemoprophylaxis for malaria, leptospirosis, scrub typhus, travelers’ diarrhea may be required if they are to stay for a long duration (>1 month) in remote places.

CONCLUSION

There are many challenges in diagnosing undifferentiated fever after travel, and dates of travel and exposures are key to establishing a timeline for the onset of symptoms and signs.

However, hurdles for diagnosis are posed by atypical or overlapping features, and cross-reactivity in serological investigations.

Therapy is also difficult as there are no drugs for many of the viral infections, coupled with a lack of proper guidelines or algorithm for therapy. Drug resistance in infections like malaria, enteric fever and other bacterial sepsis is another monster to wrestle with.

Thus, there is no doubt that we have to take all precautions before and during travel. Specialized travel clinics that are a regular feature in many countries, need to be set up here, to provide information, counseling and prophylaxis against common infections for the safety and wellbeing of all travelers.

SUGGESTED READING

1. Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006;354(2):119–130. DOI: 10.1056/NEJMoa051331.

2. Gubler DJ. The global emergence/resurgence of arboviral diseases as public health problems. Arch Med Res 2002;33(4):330–342. DOI: 10.1016/S0188-4409(02)00378-8.

3. Ooi EE, Gubler DJ. Dengue in Southeast Asia: Epidemiological characteristics and strategic challenges in disease prevention. Cad Saude Publica 2009;25(Suppl 1):S115–S124. DOI: 10.1590/S0102-311X2009001300011.

4. Steffen R, Rickenbach M, Wilhelm U, et al. Health problems after travel to developing countries. J Infect Dis 1987;156(1):84–91. DOI: 10.1093/infdis/156.1.84.