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9: Infections in the Returned Traveller Infectious MJDiseasesA Practice Essentials InfectiousMJA Practice Diseases Essentials 9: Infections in the returned traveller David F M Looke and Jennifer M B Robson Remember to consider serious yet treatable diseases, such as malaria STUDIES SHOW that almost 50% of travellers returning to Europe and North America from the tropics experience Abstract health problems related to their travel, and that 8% consult ■ The usual presentation of a returned traveller is with The Medical Journal of Australia ISSN:1 0025-729X 19 August 2002 doctors either abroad or on return. Figures are not availa- a particular syndrome — fever, respiratory infection, ble for177 Australian 4 212-219 travellers but are probably similar. The ©The Medical Journal of Australia 2002 www.mja.com.au diarrhoea, eosinophilia, or skin or soft tissue infection — mostMJA common Practice diseasesEssentials —in Infectioustravellers Diseases to the tropics are or for screening for asymptomatic infection. travellers’ diarrhoea (35% incidence per month of travel), ■ Fever in a returned traveller requires prompt investigation followed by acute respiratory infections (1.4%), giardiasis to prevent deaths from malaria; diagnosis of malaria may (0.7%) and other infections (including hepatitis, amoebiasis require up to three blood films over 36–48 hours. and gonorrhoea).1 Australian travellers increasingly visit tropical and developing countries and may present with ■ Diarrhoea is the most common health problem in infections that are rare in Australia. travellers and is caused predominantly by bacteria; Pre-travel health assessment and planning can prevent or persistent diarrhoea is less likely to have an infectious ameliorate some of these problems (Box 1). Useful informa- cause, but its prognosis is usually good. tion about travel-related infections can be found at the ■ While most travel-related infections present within six websites of the World Health Organization (www.who.int/ months of return, some important chronic infections may ith), United States Centers for Disease Control and Preven- present months or years later (eg, strongyloidiasis, tion (www.cdc.gov/travel) and the Department of Public schistosomiasis). Health and Tropical Medicine at James Cook University, ■ Travellers who have been bitten by an animal require Townsville (www.jcu.edu.au/school/phtm/PHTM/ evaluation for rabies prophylaxis. putravel.htm). MJA 2002; 177: 212-219 Clinical presentations ■ time of symptom onset in relation to travel, which may Over 90% of infections related to short-term travel present help eliminate diseases with different incubation periods within six months of return. Diseases with long latent (eg, fever beginning over 10 days after departure from an periods or potential for lifetime persistence are rare after endemic area is unlikely to be dengue, which has a short short-term travel, but more common in those who have lived incubation period). Incubation periods of common travel- abroad or were born overseas. The usual presentation of a related infections are shown in Box 2. returned traveller is with a particular syndrome — fever, respiratory infection, diarrhoea, eosinophilia, or skin or soft Fever tissue infection — or for screening for asymptomatic infec- tion. Between 2% and 12% of travellers suffer from a febrile illness When assessing a returned traveller, it is important to while away or on return.1,3 Malaria is the most common obtain: diagnosis3-5 and is particularly frequent in travellers to West ■ a complete travel history, including dates and places Africa who have taken no prophylaxis (2%).1 Among people visited, and potential exposures to exotic diseases (eg, travel arriving in Australia, the incidence of malaria is highest in to rural areas, freshwater exposure, insect bites and sexual those who have been in Nigeria (1.3%), the Solomon Islands contacts); and (1.1%), Ghana (0.6%) and Papua New Guinea (0.4%).6 Other causes of fever are shown in Box 3. Younger travellers are more likely to have an exotic infection than the elderly, as their travel tends to be more adventurous. Older travellers are more likely to have a febrile complication of underlying Series Editors: M Lindsay Grayson, Steven L Wesselingh disease, such as endocarditis or pneumonia. Infection Management Services – Southern Queensland, Evaluation and initial management of fever in a returned Princess Alexandra Hospital, Woolloongabba, QLD. traveller is outlined in Box 4. It is important to exclude David F M Looke, FRACP, FRCPA, MMedSci (Clin Epidemiol), Infectious falciparum malaria, which is potentially fatal but treatable. Diseases Physician. Once this is excluded, patients require hospital admission Sullivan Nicolaides Pathology, Taringa, QLD. Jennifer M B Robson, FRACP, FRCPA, FACTM, Microbiologist. only if severely ill. Viral haemorrhagic fevers (eg, Lassa fever, Reprints will not be available from the authors. Correspondence: Dr J M B and Marburg and Ebola virus infections) usually present as Robson, Sullivan Nicolaides Pathology, 134 Whitmore Street, Taringa, QLD undifferentiated fever, but are rare in returned travellers. If 4068. [email protected] suspected (recent travel to an African country with endemic 212 MJA Vol 177 19 August 2002 MJA Practice Essentials Infectious Diseases 1: Pre-travel health assessment and planning 2: Incubation periods of travel-related infections2 This is recommended at least six weeks before departure and Short Intermediate Long should include: (<10 days) (10–21 days) (>21 days) Assessment of fitness to travel: pre-existing conditions (eg, diabetes, heart disease, pregnancy, immunocompromise); Influenza Malaria Malaria psychological state (eg, depression, seeking “way-out” of Dengue Viral haemorrhagic Hepatitis A, B, C, E problems, alcohol, drugs); need for specialised medications, with Yellow fever fevers Rabies doctor’s letter specifying this. Plague Typhoid fever Schistosomiasis Full travel history and risk assessment Scrub typhus Update of routine vaccinations: measles–mumps–rubella; Paratyphoid fever Leishmaniasis diphtheria; pertussis; tetanus; hepatitis B; poliomyelitis; influenza; Mediterranean Q fever Amoebic liver and pneumococcal vaccines. spotted fever Relapsing fever abscess Routine vaccinations for travel to developing countries: hepatitis A African tick-bite fever (Borrelia spp.) Tuberculosis and (if travelling for more than two weeks) typhoid. Rocky Mountain African Filariasis “Special circumstance” vaccinations: yellow fever; meningococcus; spotted fever trypanosomiasis Brucellosis rabies; and Japanese B encephalitis. Prophylactic drugs when indicated: antimalarials (mefloquine, doxycycline, chloroquine, proguanil or malarone); and antibiotics 3: Causes of fever in Canadian and Australian studies for travellers’ diarrhoea (if immunocompromised or other special circumstances). of returned travellers Advice on prevention: travellers’ diarrhoea; schistosomiasis and Percentage of fever cases fresh-water exposure in Africa; traffic-accident injuries; sexually transmitted diseases; sunburn and sunstroke; insect bites; scuba- Canada Australia diving accidents; deep venous thrombosis; and jet lag. Diagnosis (n=587)4 (n=232)5 Advice and drugs for medical or first-aid kit: including diarrhoea kit Undiagnosed 25 9 (loperamide, antibiotic [norfloxacin], thermometer and [for long- term traveller or trekker] tinidazole). Malaria 32 27 Advice on travel health insurance and assistance Respiratory infection* 11 18 Hepatitis 6 3 disease or a known outbreak), then public health authorities Diarrhoeal illness 5 14 7 must be notified to allow appropriate action. Pyelonephritis 4 1 Dengue 2 8 Malaria Enteric fever 2 3 Epstein–Barr virus infection 2 0.4 Malaria caused by Plasmodium falciparum generally presents Rickettsial infection 1 2 within six weeks of return from an endemic area, although Amoebiasis 1 1 onset may be delayed by prophylactic mefloquine.8 In contrast, malaria caused by Plasmodium vivax may present Tuberculosis 1 0.4 many months after exposure. No signs or symptoms are Acute HIV infection 0.3 0.4 specific to malaria, although fever is invariable. Occasion- Other infections 4 10 ally, malaria mimics acute gastroenteritis, acute abdomen, Other causes 4 3 pneumonia and meningoencephalitis. As prophylactic anti- * Including upper respiratory tract infection, bronchitis and pneumonia. malarials do not eliminate the possibility of malaria, appro- priate testing should always be done. Malaria is diagnosed by detecting the parasite in a blood chloroquine followed by primaquine to eradicate the hepatic film or circulating malarial antigen. Initial blood films may be stages of P. vivax and P. o v a l e . Patients receiving primaquine negative, and repeat films should be taken every six to 12 should have prior testing for glucose-6-phosphate dehydro- hours for 36–48 hours before malaria can be confidently genase deficiency, as the drug may cause severe haemolytic excluded. As untreated falciparum malaria can be fatal within anaemia if this is present. However, as chloroquine-resistant 24–48 hours of presentation, particularly in children, the P. vivax has now been reported throughout South-East diagnosis should be pursued urgently (case history, Box 5). Asia,10 specialist advice may be required, particularly for Patients with falciparum malaria require hospital admis- relapsing disease.9 sion until the disease is clearly under control. All should be treated as if they have chloroquine-resistant disease. Dengue Uncomplicated disease is treated with oral
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