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KEY POINTS
■ An estimated 1% to 5% of travelers seek medical care on their return to the United States; among travelers to developing countries, this figure increases to 8%. The most common medical problems that travelers report are GI illnesses (10%), skin lesions and rashes (8%), respiratory tract infections (5%-13%, varies seasonally), and fever (3%).
■ The incidence of travel-related illnesses is increased by inadequate trip preparation, as less than half of travelers to high-risk areas seek pretravel medical care, including vaccinations and malaria chemoprophylaxis.
■ Malaria, dengue fever, typhoid fever, rickettsial infections, and chikungunya fever are all serious illnesses that manifest similarly (fever, malaise, and headache at onset) and can be easily mistaken for influenza or other infectious or inflammatory process.
When a patient presents in the emergency department (ED) with chills, do you think malaria? Could your urgent care patient with flulike symptoms actually have dengue fever? Does typhoid fever come to mind when your patient mentions chronic headaches and loss of appetite during an annual physical examination? As our patients travel to more and new places, our list of likely diagnoses needs to expand accordingly.
International travel has increased, with more than 30 million trips made each year for business, leisure, and to visit relatives and friends. Travelers are exposed to new pathogens, and many people bring home more than just souvenirs. The CDC estimates that 1% to 5% of travelers seek medical care for illness on their return to the United States; among travelers to developing countries, this figure increases to 8%.1,2
Overall, the most common medical problems that travelers report are GI illnesses (10%), skin lesions and rashes (8%), respiratory infections (5%-13%, varies seasonally), and fever (3%). However, different diseases are more prevalent in different areas. For example, skin lesions and rashes are more common among travelers to the Caribbean, Central America, and South America; diarrhea is a more common complaint among travelers to south central Asia; and fevers are common among travelers to Asia, Africa, and South America. This article discusses the most serious of these conditions, which are the fevers of malaria, typhoid, dengue, rickettsial infection, and chikungunya.1,2
In addition to making more trips, travelers are also journeying to different locations. Europe remains the most common destination among US travelers, but an increasing number of people visit developing countries.3 The 10 countries that the World Travel and Tourism Council expects to have the largest percentage increase in tourism by 2015 are Montenegro, China, India, Reunion, Croatia, Sudan, Vietnam, Laos, Czech Republic, and Guadeloupe. More than two-thirds of these countries have areas that are considered to be developing regions and pose greater associated health risks for travelers.4
The incidence of travel-related illnesses is increased by inadequate trip preparation, as fewer than half of travelers to high-risk areas seek pretravel medical care, including vaccinations and malaria chemoprophylaxis. This may be due in part to ignorance on the part of the traveler regarding local diseases and their transmission and prevention but may also occur in travelers who downplay the risks of illness when they return to areas with which they are familiar.5,6
The time frame for onset of symptoms plays an important role when evaluating a patient's history for a possible travel-related illness. Most travel-related illnesses occur within 12 weeks of the patient's return, but clinicians should have a high index of suspicion in patients who have traveled abroad within the past 6 months. A few diseases, such as chronic Chagas disease, leishmaniasis, brucellosis, and malaria, can even appear years after travel; however, these are exceptions.1,2
Other important aspects of the patient's history is the location to which he or she traveled, whether the patient stayed in more- or less-developed areas, and whether any pretravel immunizations or prophylactic medications were obtained. Also of import is whether the patient sustained any insect or animal bites, swam or waded in freshwater, had any sexual contacts, and ingested any raw meat, seafood, or unpasteurized dairy products.1,5
Laboratory and imaging tests for patients with suspected travel-related illnesses may include a CBC with differential; peripheral blood smear; liver function tests; urinalysis; chest radiography; cultures of blood, urine, and stool; and if indicated, serology tests and HIV tests.1 The World Health Organization (WHO) recommends medical examination of all travelers on their return if they have any chronic diseases such as cardiovascular disease (CVD), diabetes, or chronic respiratory tract diseases, or if they have spent more than 3 months in a developing country regardless of whether they have symptoms.6
Malaria, dengue fever, typhoid fever, rickettsial infections, and chikungunya fever are all serious illnesses that manifest similarly (fever, malaise, and headache at onset) and can be easily mistaken for influenza or other infectious or inflammatory process. These diseases are present on many continents, are easily contracted, and for many, vaccines or chemoprophylaxis are not available.