Of returning travelers who become ill, many have neither serious nor exotic illnesses.1 In a study evaluating 82,825 returning travelers seen in global travel clinics between 1996 and 2011, only 4.4% (3655) of the cases involved acute, tropical, potentially life-threatening causes of illness.2 The initial task is to separate the more common causes of symptoms, such as upper respiratory infections, diarrheal illnesses, reactions to stress, fatigue, or new medications, from more ominous causes of illness in travelers.
Key points for the initial ED care are as follows:
Isolate and use personal protective precautions early when evaluating patients with suspected travel-related infections.
Identify red flag symptoms such as hemorrhage and altered mental status and initiate isolation and treatment prior to diagnostic confirmation.
Consider malaria in the febrile patient returning from travel, even in the presence of prophylaxis, and initiate treatment promptly.
Report suspected reportable illnesses.
INITIAL EVALUATION OF THE RETURNING TRAVELER
Illness before and after travel is common3 (Table 162-1). Start by evaluating the travel destination. Diseases such as malaria are uncommon in the United States, but are leading causes of mortality overseas. Other parasitic agents, such as helminths and rickettsia, also occur with increased frequency and severity in the tropics (see Chapters 159 and 161, “Malaria” and “Zoonotic Infections”). Although both tuberculosis and human immunodeficiency virus are endemic to the United States, consider these in patients presenting from areas with a higher disease burden.
TABLE 162-1Risk of Infectious Exposure ||Download (.pdf) TABLE 162-1 Risk of Infectious Exposure
High risk (1 in 10 travelers): diarrhea, upper respiratory illness, and noninfectious illnesses such as injuries and exacerbation of preexisting chronic diseases
Moderate risk (1 in 200 travelers): dengue fever, chikungunya, enteroviral infection, gastroenteritis, giardiasis, hepatitis A, malaria, salmonellosis, sexually transmitted diseases, shigellosis
Low risk (1 in 1000 travelers): amebiasis, ascariasis, measles, mumps, enterobiasis, scabies, tuberculosis, typhoid, hepatitis B
Very low risk (1 in >1000 travelers): human immunodeficiency virus, anthrax, Chagas’ disease, hemorrhagic fevers, pertussis, plague, typhus, hookworm
Once imported disease in recent travelers is suspected, direct the history (Tables 162-2, 162-3 and 162-4). Immunosuppression, age <5 years, advanced age, pregnancy, and diabetes often render the patient less tolerant of tropical infections.
TABLE 162-2Typical Incubation Periods for Selected Tropical Infections ||Download (.pdf) TABLE 162-2 Typical Incubation Periods for Selected Tropical Infections
|Incubation Period ||Infections Likely |
|<10 d (short incubation) || |
Dengue fever and arboviral infections
Typhus (louse- and flea-borne)
|<21 d (intermediate incubation) || |
Viral hemorrhagic fevers
Enteric fevers (typhoid, paratyphoid)
|>21 d || |
Viral hepatitis (A, B, C, D, E)