General Approach to the Returned Traveler

General Approach to the Returned Traveler is a topic covered in the CDC Yellow Book.

To view the entire topic, please or .

Relief Central with Coronavirus COVID-19 Guidelnes is a free App with a companion website developed by the staff and friends of Unbound Medicine to assist relief workers, healthcare providers, first responders, and others called to serve in disaster relief situations around the world. Explore these free sample topics:

-- The first section of this topic is shown below --

The Posttravel Evaluation

As many as 43%–79% of travelers to low- and middle-income countries become ill with a travel-related health problem. Although most of these illnesses are mild, some travelers become sick enough to seek care from a health care provider. Most posttravel infections become apparent soon after returning from abroad, but incubation periods vary, and some syndromes can present months to years after initial infection. When evaluating a patient with a probable travel-related illness, the clinician should take a thorough medical and travel history, considering all the items summarized in Box 11-1. Salient points of the history, descriptions of common nonfebrile syndromes, and initial management steps are outlined below. The differential diagnosis and management for a traveler with fever (or febrile syndrome) is discussed in detail in this chapter in Posttravel Evaluation: Fever.

The Severity of Illness

As with any medical evaluation, the chief complaint and associated clinical factors are the first things to consider when approaching an ill returned traveler. Within this context, the severity of illness is not only important for patient triage but can help clinicians distinguish certain infections from one other. Is the traveler hemodynamically stable? Is the infection potentially life-threatening, such as malaria? Does the traveler have a severe respiratory syndrome or signs of hemorrhagic fever? Some suspected illnesses may also necessitate prompt involvement of public health authorities. See “Management” below for more details.

Box 11-1. Components of a complete travel history in an ill returned traveler

Chief complaint

Main symptoms

Associated symptoms

Date of illness onset

Location where symptoms started (while away, in transit, or after return)

Health care received for this problem (such as medications or hospitalizations) while abroad and after return

Trip details

Countries visited

Itinerary in country

Duration of travel

Date of return from travel

Reason for travel

Leisure

Visiting friends and relatives

Business

Research/education

Missionary/volunteer work

Providing medical care

Receiving medical care

Type of accommodations and sleeping arrangements

Hotel (with or without air conditioning)

Hostel

Safari accommodations (for example, lodge, luxury tent)

Camping

Someone’s home

Modes of transportation

Recreational activities

Safari

Hiking

Swimming

Ocean (scuba diving, marine life exposure)

Freshwater exposure (lake, river, stream)

Swimming pools and hot tubs

Rafting/boating

Sightseeing

Other adventuresome activities

Common exposures

Insect bites (for example, mosquito, tick, sand fly, tsetse fly)

Foods eaten

Raw produce

Undercooked meat

Unpasteurized dairy products

Seafood

Source of drinking water (for example, tap, bottled, purified, use of ice)

Other exposures

Sexual activity during travel (use of condoms, new partner)

Tattoos or piercings received while traveling

Animal or arthropod bites, stings, or scratches

Known outbreaks in the countries visited

Use of travel precautions

Effective insect repellent (DEET 25%–40% or other EPA-registered product)

Bed nets

Adherence to malaria prophylaxis

Past medical history

Chronic medical conditions

Diabetes

Heart disease

Autoimmune disease

Immunosuppressive conditions

Cancer

Recent illnesses or surgeries

Medications

Routine medications

Malaria prophylaxis

Antibiotics

Over-the-counter medications

Herbal, complementary, and alternative medicines

Pretravel and routine vaccinations received

Hepatitis A

Hepatitis B

Influenza

Japanese encephalitis

Meningococcal disease

Measles-mumps-rubella (MMR)

Polio

Rabies

Tetanus-diphtheria-acellular pertussis (Tdap)

Typhoid

Varicella

Yellow fever

Additional information

Smoking, alcohol, and illicit drug use

Recent domestic travel or prior international travel, especially within the prior 6 months

Family history

Travel Itinerary

The itinerary and activities in which the traveler participated are crucial to formulating a differential diagnosis, because potential exposures differ depending on the region of travel and behaviors. A febrile illness with nonspecific symptoms could be malaria, dengue, typhoid fever, or rickettsial disease, among others. Being able to exclude certain infections will avoid unnecessary testing. A 2013 study from the GeoSentinel Surveillance Network found that the frequency of certain diseases varied depending on the region of the world visited; among travelers with fevers, malaria was diagnosed most frequently among travelers returning from Africa, while dengue was diagnosed most frequently among travelers from Asia. The duration of travel is also important, since the risk of a travel-related illness increases with the length of the trip. A tropical medicine specialist can assist with the differential diagnosis and may be aware of outbreaks or the current prevalence of an infectious disease in an area. The 2014–2015 Ebola virus epidemic in West Africa highlighted the importance of epidemiologic factors and travel itineraries in managing patients and protecting staff and the community.

Timing of Illness in Relation to Travel

Because most common travel-related infections have short incubation periods, a majority of ill travelers will seek medical attention within 1 month of return from their destination. Travelers’ diarrhea, dengue, other arboviral infections, and influenza are examples of infections with shorter incubation periods (<2 weeks). Those with slightly longer incubation periods, up to 4–6 weeks, include malaria, typhoid fever, acute HIV, viral hepatitis, and leishmaniasis, among others. Occasionally, however, infections such as malaria, schistosomiasis, leishmaniasis, or tuberculosis can manifest months or even years later. In particular, malaria should be considered in the differential diagnosis of any traveler who traveled to a malaria-endemic area within a year of presentation. Therefore, a detailed history that extends beyond a few months before presentation can be helpful. The most common travel-related infections by incubation period are listed in Table 11-1.

Underlying Medical Illness

Comorbidities can affect the susceptibility to infection, as well as the clinical manifestations and severity of illness. An increasing number of immunosuppressed people (due to organ transplants, immune-modulating medications, HIV infection, or other primary or acquired immunodeficiencies) are international travelers (see Chapter 8, Immunocompromised Travelers). In addition, a number of factors associated with travel can increase the likelihood of exacerbations of chronic conditions during or following travel such as ischemic heart disease, inflammatory bowel disease, or chronic lung disease.

Vaccines Received and Prophylaxis Used

The history of vaccinations and malaria prophylaxis should be reviewed when evaluating an ill returned traveler. Fewer than half of US travelers to developing countries seek pretravel medical advice and may not have received vaccines or taken antimalarial drugs. Although adherence to malaria prophylaxis does not rule out the possibility of malaria, it reduces the risk and increases the likelihood of an alternative diagnosis. Fever and a rash in a traveler without measles vaccination would raise concern about measles. The most common vaccine-preventable diseases among returned travelers seeking care at a GeoSentinel clinic between 1997 and 2010 included typhoid fever, hepatitis A, hepatitis B, and influenza. More than half of these patients with vaccine-preventable diseases were hospitalized.

Individual Exposure History

Knowledge of the patient’s exposures during travel, including insect bites, contaminated food or water, or freshwater swimming, can also assist with the differential diagnosis. In addition to malarial parasites, mosquitoes transmit viruses (such as dengue, yellow fever, chikungunya, and Zika) and filarial parasites (such as Wuchereria bancrofti ). Depending on the clinical syndrome, a history of a tick bite could suggest a diagnosis of tickborne encephalitis, African tick-bite fever, or other rickettsial infections. Tsetse flies are large, and their bites are painful and often recalled by the patient. They can carry Trypanosoma brucei , the protozoan that causes African sleeping sickness. Freshwater swimming or other water contact can put the patient at risk for schistosomiasis, leptospirosis, and other diseases.

Types of accommodations and activities can also influence the risk for acquiring certain diseases while abroad. Travelers who visit friends and relatives are at higher risk of malaria, typhoid fever, and certain other diseases, often because they stay longer, travel to more remote destinations, have more contact with local water sources, and do not seek pretravel advice (see Chapter 9, Visiting Friends & Relatives: VFR Travel). Travelers backpacking and camping in rural areas will also have a higher risk of certain diseases than those staying in luxury, air-conditioned hotels.

Table 11-1. Common travel-related infections by incubation period

Disease

Usual Incubation Period (Range)

Distribution

Incubation <14 Days

Chikungunya

2–4 days (1–14 days)

Tropics, subtropics

Dengue

4–8 days (3–14 days)

Tropics, subtropics

Encephalitis, arboviral (Japanese encephalitis, tickborne encephalitis, West Nile virus, other)

3–14 days (1–20 days)

Specific agents vary by region

Enteric fever

7–18 days (3–60 days)

Especially in Indian subcontinent

Acute HIV infection

10–28 days (10 days to 6 weeks)

Worldwide

Influenza

1–3 days

Worldwide, can also be acquired while traveling

Legionellosis

5–6 days (2–10 days)

Widespread

Leptospirosis

7–12 days (2–26 days)

Widespread, most common in tropical areas

Malaria, Plasmodium falciparum

6–30 days (98% onset within 3 months of travel)

Tropics, subtropics

Malaria, Plasmodium vivax

8 days to 12 months (almost half have onset >30 days after completion of travel)

Widespread in tropics and subtropics

Spotted fever rickettsiosis

Few days to 2–3 weeks

Causative species vary by region

Zika virus infection

3–14 days

Widespread in Latin America, endemic through much of Africa, Southeast Asia, and Pacific Islands

Incubation 14 Days to 6 Weeks

Encephalitis, arboviral; enteric fever; acute HIV; leptospirosis; malaria

See above incubation periods for relevant diseases

See above distribution for relevant diseases

Amebic liver abscess

Weeks to months

Most common in resource-poor countries

Hepatitis A

28–30 days (15–50 days)

Most common in resource-poor countries

Hepatitis E

26–42 days (2–9 weeks)

Widespread

Acute schistosomiasis (Katayama syndrome)

4–8 weeks

Most common in sub-Saharan Africa

Incubation >6 Weeks

Amebic liver abscess, hepatitis E, malaria, acute schistosomiasis

See above incubation periods for relevant diseases

See above distribution for relevant diseases

Hepatitis B

90 days (60–150 days)

Widespread

Leishmaniasis, visceral

2–10 months (10 days to years)

Asia, Africa, Latin America, southern Europe, and the Middle East

Tuberculosis

Primary, weeks; reactivation, years

Global distribution, rates, and levels of resistance vary widely

-- To view the remaining sections of this topic, please or --

The Posttravel Evaluation

As many as 43%–79% of travelers to low- and middle-income countries become ill with a travel-related health problem. Although most of these illnesses are mild, some travelers become sick enough to seek care from a health care provider. Most posttravel infections become apparent soon after returning from abroad, but incubation periods vary, and some syndromes can present months to years after initial infection. When evaluating a patient with a probable travel-related illness, the clinician should take a thorough medical and travel history, considering all the items summarized in Box 11-1. Salient points of the history, descriptions of common nonfebrile syndromes, and initial management steps are outlined below. The differential diagnosis and management for a traveler with fever (or febrile syndrome) is discussed in detail in this chapter in Posttravel Evaluation: Fever.

The Severity of Illness

As with any medical evaluation, the chief complaint and associated clinical factors are the first things to consider when approaching an ill returned traveler. Within this context, the severity of illness is not only important for patient triage but can help clinicians distinguish certain infections from one other. Is the traveler hemodynamically stable? Is the infection potentially life-threatening, such as malaria? Does the traveler have a severe respiratory syndrome or signs of hemorrhagic fever? Some suspected illnesses may also necessitate prompt involvement of public health authorities. See “Management” below for more details.

Box 11-1. Components of a complete travel history in an ill returned traveler

Chief complaint

Main symptoms

Associated symptoms

Date of illness onset

Location where symptoms started (while away, in transit, or after return)

Health care received for this problem (such as medications or hospitalizations) while abroad and after return

Trip details

Countries visited

Itinerary in country

Duration of travel

Date of return from travel

Reason for travel

Leisure

Visiting friends and relatives

Business

Research/education

Missionary/volunteer work

Providing medical care

Receiving medical care

Type of accommodations and sleeping arrangements

Hotel (with or without air conditioning)

Hostel

Safari accommodations (for example, lodge, luxury tent)

Camping

Someone’s home

Modes of transportation

Recreational activities

Safari

Hiking

Swimming

Ocean (scuba diving, marine life exposure)

Freshwater exposure (lake, river, stream)

Swimming pools and hot tubs

Rafting/boating

Sightseeing

Other adventuresome activities

Common exposures

Insect bites (for example, mosquito, tick, sand fly, tsetse fly)

Foods eaten

Raw produce

Undercooked meat

Unpasteurized dairy products

Seafood

Source of drinking water (for example, tap, bottled, purified, use of ice)

Other exposures

Sexual activity during travel (use of condoms, new partner)

Tattoos or piercings received while traveling

Animal or arthropod bites, stings, or scratches

Known outbreaks in the countries visited

Use of travel precautions

Effective insect repellent (DEET 25%–40% or other EPA-registered product)

Bed nets

Adherence to malaria prophylaxis

Past medical history

Chronic medical conditions

Diabetes

Heart disease

Autoimmune disease

Immunosuppressive conditions

Cancer

Recent illnesses or surgeries

Medications

Routine medications

Malaria prophylaxis

Antibiotics

Over-the-counter medications

Herbal, complementary, and alternative medicines

Pretravel and routine vaccinations received

Hepatitis A

Hepatitis B

Influenza

Japanese encephalitis

Meningococcal disease

Measles-mumps-rubella (MMR)

Polio

Rabies

Tetanus-diphtheria-acellular pertussis (Tdap)

Typhoid

Varicella

Yellow fever

Additional information

Smoking, alcohol, and illicit drug use

Recent domestic travel or prior international travel, especially within the prior 6 months

Family history

Travel Itinerary

The itinerary and activities in which the traveler participated are crucial to formulating a differential diagnosis, because potential exposures differ depending on the region of travel and behaviors. A febrile illness with nonspecific symptoms could be malaria, dengue, typhoid fever, or rickettsial disease, among others. Being able to exclude certain infections will avoid unnecessary testing. A 2013 study from the GeoSentinel Surveillance Network found that the frequency of certain diseases varied depending on the region of the world visited; among travelers with fevers, malaria was diagnosed most frequently among travelers returning from Africa, while dengue was diagnosed most frequently among travelers from Asia. The duration of travel is also important, since the risk of a travel-related illness increases with the length of the trip. A tropical medicine specialist can assist with the differential diagnosis and may be aware of outbreaks or the current prevalence of an infectious disease in an area. The 2014–2015 Ebola virus epidemic in West Africa highlighted the importance of epidemiologic factors and travel itineraries in managing patients and protecting staff and the community.

Timing of Illness in Relation to Travel

Because most common travel-related infections have short incubation periods, a majority of ill travelers will seek medical attention within 1 month of return from their destination. Travelers’ diarrhea, dengue, other arboviral infections, and influenza are examples of infections with shorter incubation periods (<2 weeks). Those with slightly longer incubation periods, up to 4–6 weeks, include malaria, typhoid fever, acute HIV, viral hepatitis, and leishmaniasis, among others. Occasionally, however, infections such as malaria, schistosomiasis, leishmaniasis, or tuberculosis can manifest months or even years later. In particular, malaria should be considered in the differential diagnosis of any traveler who traveled to a malaria-endemic area within a year of presentation. Therefore, a detailed history that extends beyond a few months before presentation can be helpful. The most common travel-related infections by incubation period are listed in Table 11-1.

Underlying Medical Illness

Comorbidities can affect the susceptibility to infection, as well as the clinical manifestations and severity of illness. An increasing number of immunosuppressed people (due to organ transplants, immune-modulating medications, HIV infection, or other primary or acquired immunodeficiencies) are international travelers (see Chapter 8, Immunocompromised Travelers). In addition, a number of factors associated with travel can increase the likelihood of exacerbations of chronic conditions during or following travel such as ischemic heart disease, inflammatory bowel disease, or chronic lung disease.

Vaccines Received and Prophylaxis Used

The history of vaccinations and malaria prophylaxis should be reviewed when evaluating an ill returned traveler. Fewer than half of US travelers to developing countries seek pretravel medical advice and may not have received vaccines or taken antimalarial drugs. Although adherence to malaria prophylaxis does not rule out the possibility of malaria, it reduces the risk and increases the likelihood of an alternative diagnosis. Fever and a rash in a traveler without measles vaccination would raise concern about measles. The most common vaccine-preventable diseases among returned travelers seeking care at a GeoSentinel clinic between 1997 and 2010 included typhoid fever, hepatitis A, hepatitis B, and influenza. More than half of these patients with vaccine-preventable diseases were hospitalized.

Individual Exposure History

Knowledge of the patient’s exposures during travel, including insect bites, contaminated food or water, or freshwater swimming, can also assist with the differential diagnosis. In addition to malarial parasites, mosquitoes transmit viruses (such as dengue, yellow fever, chikungunya, and Zika) and filarial parasites (such as Wuchereria bancrofti ). Depending on the clinical syndrome, a history of a tick bite could suggest a diagnosis of tickborne encephalitis, African tick-bite fever, or other rickettsial infections. Tsetse flies are large, and their bites are painful and often recalled by the patient. They can carry Trypanosoma brucei , the protozoan that causes African sleeping sickness. Freshwater swimming or other water contact can put the patient at risk for schistosomiasis, leptospirosis, and other diseases.

Types of accommodations and activities can also influence the risk for acquiring certain diseases while abroad. Travelers who visit friends and relatives are at higher risk of malaria, typhoid fever, and certain other diseases, often because they stay longer, travel to more remote destinations, have more contact with local water sources, and do not seek pretravel advice (see Chapter 9, Visiting Friends & Relatives: VFR Travel). Travelers backpacking and camping in rural areas will also have a higher risk of certain diseases than those staying in luxury, air-conditioned hotels.

Table 11-1. Common travel-related infections by incubation period

Disease

Usual Incubation Period (Range)

Distribution

Incubation <14 Days

Chikungunya

2–4 days (1–14 days)

Tropics, subtropics

Dengue

4–8 days (3–14 days)

Tropics, subtropics

Encephalitis, arboviral (Japanese encephalitis, tickborne encephalitis, West Nile virus, other)

3–14 days (1–20 days)

Specific agents vary by region

Enteric fever

7–18 days (3–60 days)

Especially in Indian subcontinent

Acute HIV infection

10–28 days (10 days to 6 weeks)

Worldwide

Influenza

1–3 days

Worldwide, can also be acquired while traveling

Legionellosis

5–6 days (2–10 days)

Widespread

Leptospirosis

7–12 days (2–26 days)

Widespread, most common in tropical areas

Malaria, Plasmodium falciparum

6–30 days (98% onset within 3 months of travel)

Tropics, subtropics

Malaria, Plasmodium vivax

8 days to 12 months (almost half have onset >30 days after completion of travel)

Widespread in tropics and subtropics

Spotted fever rickettsiosis

Few days to 2–3 weeks

Causative species vary by region

Zika virus infection

3–14 days

Widespread in Latin America, endemic through much of Africa, Southeast Asia, and Pacific Islands

Incubation 14 Days to 6 Weeks

Encephalitis, arboviral; enteric fever; acute HIV; leptospirosis; malaria

See above incubation periods for relevant diseases

See above distribution for relevant diseases

Amebic liver abscess

Weeks to months

Most common in resource-poor countries

Hepatitis A

28–30 days (15–50 days)

Most common in resource-poor countries

Hepatitis E

26–42 days (2–9 weeks)

Widespread

Acute schistosomiasis (Katayama syndrome)

4–8 weeks

Most common in sub-Saharan Africa

Incubation >6 Weeks

Amebic liver abscess, hepatitis E, malaria, acute schistosomiasis

See above incubation periods for relevant diseases

See above distribution for relevant diseases

Hepatitis B

90 days (60–150 days)

Widespread

Leishmaniasis, visceral

2–10 months (10 days to years)

Asia, Africa, Latin America, southern Europe, and the Middle East

Tuberculosis

Primary, weeks; reactivation, years

Global distribution, rates, and levels of resistance vary widely

There's more to see -- the rest of this entry is available only to subscribers.