Chapter 69: Fever in the Returned Traveler

DEFINITIONS AND EPIDEMIOLOGY

More than 60 million people travel to the tropics and the developing world every year and are exposed to diseases that are not commonly seen in the United States or other developed countries. Even though child travelers represent only a small fraction of this number, they constitute about a quarter of all travel-related hospital admissions.¹ Management of sick children after international travel is complicated; febrile illness caused by common, universally transmitted infections such as respiratory and gastrointestinal viruses is extremely common in this population, yet children are also vulnerable to tropical infections acquired during travel. Although pediatric data are lacking, the etiology of fever among returned travelers is generally equally distributed among the tropical diseases, commonly acquired infections (those found in both developed and developing countries) and illnesses of unknown etiology.² Thus, a complete evaluation requires elements that are seldom included in a general pediatric review: assessment of travel vaccinations and prophylaxis, specific destination and exposure history, and probable incubation period. The most common tropical diseases in the returning traveler are malaria, traveler’s diarrhea, dengue, rickettsiosis, and typhoid fever.

Resources available to assist in this evaluation are shown in Box 69-1. Although they may lack dedicated pediatric providers, physician-staffed travel medicine clinics are also a good source of support when evaluating illness in returned travelers.

CLINICAL PRESENTATION

EVALUATION OF FEVER AFTER TRAVEL

Pretravel Vaccination

Immunization records, and especially travel-specific immunization records that are often recorded on an International Certificate of Vaccination, may help guide the evaluation. Some immunizations are highly effective, and patients who have been vaccinated are at almost no risk for that specific disease. These infections include hepatitis A and B, as well as yellow fever. Other vaccines provide incomplete protection, such as the typhoid fever vaccinations (live and inactivated), which have only 50–80% efficacy against Salmonella enterica serotype. Typhi and offer no or limited protection against Salmonella enterica serotype Paratyphi, an increasingly common cause of typhoid fever.³ The polysaccharide, recombinant, and conjugate Neisseria meningitidis vaccines only prevent infection from some or all of serotypes A, C, Y, W-135 and B, depending on the type of vaccine given. Furthermore, given the continued circulation of vaccine-preventable diseases such as measles and polio in certain regions of the world, the status of these vaccinations should be determined.

Medication During Travel

For patients who attended a travel clinic prior to ...