Returned travellers commonly suffer from health problems related to travel, which can present as minor self-limited illnesses or potentially life threatening infections.
1 Non-specific viral illness, diarrhoeal diseases and respiratory illnesses are the most common clinical syndromes.
3,4 The most common specific diagnoses among returned travellers with fever are malaria, dengue and salmonella infections including typhoid. 3,4 Clinicians who are evaluating returned travellers who are ill must maintain a broad differential diagnosis that includes routine infections, as well as exotic infections and illness that may be non-infectious in nature.
2 Returned travellers from Bali will still need investigation for Malaria, even if they have not travelled to rural/remote or the Lombok area
Travel history checklist
Where did you travel?
Information regarding country specific risks can be found at:
When did you travel?
Vaccination status including routine vaccines and travel vaccines?
Vaccines such as typhoid, provide incomplete protection and travellers are still at risk.
2,6 Travellers unimmunised to standard vaccines, such as measles, are at increased risk of exposure abroad.
Malaria prevention strategies
Malaria prophylaxis is never 100 percent effective and the use of bed nets is the most effective strategy
Type of medication and dosing regimen
Adherence to medication and duration of therapy prior to and after leaving an endemic area
7 days-12 weeks Other malarial species: weeks to several years
3 days – 3 months (usually 8-14 days)
3-21 days (depending on type)
3-14 days (usually 5 days)
1-12 days (usually 3-7 days)
1-5 days (usually 2 days)
1-10 days (usually 3 days)
12 hours-7 days (usually 2 days)
7-18 days (usually 10 days)
Viral haemorrhagic fever (Ebola)
2-21 days (usually 8 days)
2-7 weeks (usually 30 days)
3-8 weeks (sometimes years) Management
Children are unlikely to present as severely unwell, if indicated please refer to the management for the
severely unwell patient.
Non Severely Unwell Patient
Always consider infection control precautions – refer to
Take a travel history
Perform a thorough examination including:
Rashes / skin lesions (dengue, typhoid, rickettsia, measles, leptospirosis)
Hepatomegaly (malaria, typhoid, dengue, viral hepatitis)
Splenomegaly (malaria, typhoid, mononucleosis)
Acute abdomen or GI haemorrhage (typhoid)
Cough, coryza, conjunctivitis (respiratory viruses, measles)
Jaundice (viral hepatitis, malaria)
Lymphadenopathy (rickettsia, toxoplasmosis, brucellosis, HIV, infectious mononucleosis)
Petechiae (meningococcal disease, viral haemorrhagic fever, rickettsia)
Neurologic findings: confusion, lethargy, meningism (malaria, meningitis)
Insect bites and eschars (malaria, dengue, rickettsia)
Investigations (to be performed on all returned travellers with a history of fever):
Thick and thin blood film for malaria (purple top) – this must be performed on 2-3 separate occasions, 12-24 hours apart, to be reliably negative
Rapid diagnostic test for malarial Ag (purple top) (only positive in P. falciparum: call Hematology lab for urgent results available 24hr/day)
Other tests to consider:
Serology for dengue/arboviruses (+/- the dengue NS1 Ag in the 1st week of illness) (red/gold top)
Measles PCR on PNA/urine/blood and IgM + IgG for Measles in suspected cases (most frequently identified in unimmunised cases)
CXR +/- NPA for respiratory viruses
Stool bacterial cultures and enteric viruses
Urine microscopy and culture
Depends on the patient’s clinical presentation and specific diagnosis.
If the patient is suitable for outpatient management, consult Infectious Diseases (in hours) prior to discharge. If urgent advice is required after hours contact Clinical microbiology on call.
If the patient requires admission, the primary admitting team will be General Paediatrics with consideration for obtaining an Infectious Diseases Consultation
Severely Unwell Patient
Altered conscious state
Refer to the
Serious Illness guideline Always consider infection control precautions – refer to Rash Management
FBC and thick and thin blood film for malaria (purple top)
Rapid diagnostic test for Malaria Ag (purple top) – label urgent and call Haematology Lab for result (available 24hrs/day)
Microscopy and culture of urine, CSF and stool (including rectal swab for ESBL)
LFT and EUC (green top)
Coagulation profile (blue top)
PCR (meningococcal, malaria) (purple top)
Serum tube (dengue and other serology) (red/gold top)
Malaria positive – refer to
Malaria guideline Otherwise treat with empirical antibiotics
First: IV Meropenem 40mg/kg (maximum 2 grams) 8 hourly
then IV Vancomycin 15mg/kg (maximum 750mg) 6 hourly
For Further advice contact the Infectious Diseases Fellow or Clinical Microbiologist (after hours)
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WHO Dengue. Guidelines for diagnosis, treatment, prevention and control. New Edition, 2009 http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf
Sanchez-vargas FM, Abu-el-haija MA, Gomez-duarte OG. Salmonella infections: An update on epidemiology, management, and prevention. Travel Medicine and Infectious Disease (2011) 9, 263-277.
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th November 2013 Malaria In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
Guideline Developed by: Anita Campbell (Infectious Diseases Fellow) July 2015
External Review: PMH Infectious Diseases Team August 2015 External Review: Zoy Goff (PMH Pharmacy Department) August 2015
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Author / Reviewer
Kids Health WA Guidelines Team
Dr Meredith Borland HoD, PMH Emergency Department
26 August, 2015
26 August, 2015