16.2 Fever in the Returning Traveller, Zoonoses, Notifiable Diseases & Infection Prevention
Key Takeaways
Malaria must be excluded in any febrile traveller returning from an endemic area, with blood films repeated to a total of three samples if the first is negative.
Severe falciparum malaria is treated with IV artesunate; uncomplicated falciparum malaria is treated with an artemisinin combination such as artemether-lumefantrine.
Erythema migrans after a tick bite is diagnosed clinically and treated with doxycycline for 21 days without testing (NICE NG95).
Doctors must notify suspected notifiable diseases to the UKHSA health protection team on clinical suspicion, without waiting for laboratory confirmation.
Alcohol hand gel does not kill C. difficile spores or reliably inactivate norovirus, so hands are washed with soap and water when caring for these patients.
Fever in the Returning Traveller, Zoonoses, Notifiable Diseases & Infection Prevention
Fever in the Returning Traveller
Take a detailed history: countries and dates of travel, activities (freshwater swimming, safaris, sexual contact, animal bites, unpasteurised food), malaria prophylaxis and adherence, vaccinations and the incubation period.
Malaria
- Malaria is the first diagnosis to exclude in anyone with fever who has visited an endemic area, particularly sub-Saharan Africa. Plasmodium falciparum usually presents within a month of return, but presentations up to a year later occur; P. vivax and P. ovale can relapse months later from liver hypnozoites.
- Investigations: thick and thin blood films with a rapid antigen test, repeated so that three samples (over about 48 hours) are negative before malaria is excluded; full blood count (thrombocytopenia), glucose, renal and liver function, lactate.
- Severe falciparum malaria: impaired consciousness or seizures, parasitaemia above 2%, hypoglycaemia, acidosis, AKI, pulmonary oedema or ARDS, severe anaemia, shock or bleeding. Treat with IV artesunate in a high-dependency setting.
- Uncomplicated falciparum malaria: an artemisinin combination therapy such as artemether-lumefantrine, usually as an inpatient.
- Non-falciparum malaria: an artemisinin combination or chloroquine, then primaquine (after checking G6PD status) to eradicate hypnozoites of P. vivax and P. ovale.
- Prevention ("ABCD"): Awareness of risk, Bite prevention (DEET repellent, nets, covering skin), Chemoprophylaxis (atovaquone-proguanil, doxycycline or mefloquine, depending on destination and patient), and prompt Diagnosis of fever.
Other Important Imported Infections
| Infection | Clues | Key Management |
|---|---|---|
| Dengue | Fever, severe headache, retro-orbital pain, myalgia, rash, thrombocytopenia; South and South East Asia, Latin America | Supportive fluids, avoid NSAIDs; watch for warning signs (abdominal pain, bleeding, plasma leak) |
| Enteric fever (typhoid, paratyphoid) | Gradual fever, headache, abdominal pain, constipation or diarrhoea, relative bradycardia, rose spots; South Asia | Blood cultures; ceftriaxone or azithromycin per sensitivities (resistance is common); notifiable |
| Viral haemorrhagic fever (for example Ebola, Lassa) | Travel to an affected area within 21 days with exposure risk | Isolate and follow the national VHF risk assessment before any samples are sent |
| Schistosomiasis | Freshwater swimming in Africa; itchy rash, fever (Katayama syndrome), later haematuria | Praziquantel |
| Rabies risk | Animal bite or scratch abroad | Wound cleaning and urgent post-exposure vaccine (with immunoglobulin if indicated) |
| Travellers' diarrhoea | Usually enterotoxigenic E. coli | Fluids; antibiotics only for severe or bloody diarrhoea |
Zoonoses in the UK
- Lyme disease (Borrelia burgdorferi, tick bites): erythema migrans (an expanding red rash at the bite site after 3–30 days) is diagnosed clinically and treated without testing: doxycycline for 21 days (NICE NG95). Without the rash, test with ELISA and, if needed, immunoblot. Later features include facial palsy, meningitis, carditis (heart block) and arthritis.
- Leptospirosis (Weil's disease): contact with water contaminated by rat urine (farmers, sewer workers, canoeists); fever, myalgia, conjunctival suffusion, then jaundice and AKI; treat with doxycycline or benzylpenicillin.
- Toxoplasmosis: cat faeces and undercooked meat; dangerous in pregnancy (congenital infection) and in advanced HIV (brain abscesses).
- Q fever (Coxiella burnetii): farm animals; pneumonia, hepatitis, culture-negative endocarditis.
- Brucellosis: unpasteurised dairy products abroad; undulant fever, arthritis.
- Psittacosis (Chlamydia psittaci): pet birds; atypical pneumonia.
Notifiable Diseases
Under the Health Protection (Notification) Regulations 2010, a registered medical practitioner must notify the proper officer of the local authority (in practice, the UKHSA health protection team) of suspected notifiable diseases. Do not wait for laboratory confirmation; urgent cases (for example meningococcal disease or measles) are reported by phone, ideally within 24 hours.
Examples include acute meningitis, meningococcal septicaemia, measles, mumps, rubella, scarlet fever, whooping cough, tuberculosis, food poisoning, infectious bloody diarrhoea, haemolytic uraemic syndrome, malaria, enteric fever, Legionnaires' disease, diphtheria, tetanus, acute infectious hepatitis, invasive group A streptococcal disease, COVID-19 and viral haemorrhagic fevers. HIV, chlamydia and gonorrhoea are not clinically notifiable (they are reported through separate confidential surveillance), so partner notification follows sexual health processes.
Infection Prevention & Control (IPC)
Standard Precautions (for every patient)
- Hand hygiene at the WHO "five moments": before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. Be bare below the elbows.
- Appropriate personal protective equipment, safe sharps disposal (never resheathe), safe handling of linen, waste and spillages, respiratory hygiene and environmental cleaning.
Transmission-Based Precautions
| Route | Examples | Precautions |
|---|---|---|
| Contact | C. difficile, norovirus, MRSA, multi-drug-resistant Gram-negative bacteria | Single room, gloves and apron; soap and water handwashing for C. difficile and norovirus (alcohol gel does not kill spores and is unreliable against norovirus); chlorine-based cleaning |
| Droplet | Influenza, pertussis, meningococcal disease (first 24 hours of antibiotics) | Single room or cohorting, fluid-resistant surgical mask within about 1–2 metres |
| Airborne | Pulmonary TB, measles, chickenpox, and aerosol-generating procedures in respiratory infections | FFP3 respirator (fit-tested), single room with negative pressure where available |
- Outbreaks such as norovirus: isolate or cohort patients, close affected bays to admissions, enhanced cleaning, and exclude affected staff until 48 hours after symptoms stop.
- MRSA: screening on admission according to local policy and decolonisation (nasal mupirocin with chlorhexidine body wash, usually for 5 days).
- Staff vaccination (influenza, hepatitis B, MMR, varicella, COVID-19) protects patients and staff.
Pyrexia of Unknown Origin (PUO)
Fever above 38.3°C on several occasions for more than 3 weeks, with no diagnosis despite initial investigation. The main causes are infection (tuberculosis, endocarditis, abscess, HIV-related infections), malignancy (especially lymphoma), and inflammatory conditions (adult-onset Still's disease, giant cell arteritis, vasculitis), plus drug fever. Assess with a full history (travel, animals, sexual history, drugs), repeated examination, blood cultures, HIV test, inflammatory markers and imaging (CT, PET-CT) before targeted biopsies. Avoid empirical antibiotics or steroids in a stable patient, as they can hide the diagnosis.
A 32-year-old woman returned from Ghana 10 days ago. She has fever, headache and vomiting and is now drowsy. Blood film shows Plasmodium falciparum with 6% parasitaemia. Glucose is 3.1 mmol/L. What is the most appropriate treatment?
Oral artemether-lumefantrine
IV artesunate
Oral atovaquone-proguanil
Oral chloroquine followed by primaquine
A 45-year-old man has an expanding, painless red rash with central clearing on his thigh, 10 days after walking in the New Forest, where he removed a tick. He is otherwise well. What is the most appropriate management?
Doxycycline for 21 days without testing
Reassure, as the rash will resolve
Lyme serology and treat only if positive
Refer to infectious diseases for a lumbar puncture
A ward has several patients with sudden vomiting and diarrhoea, and norovirus is suspected. Which infection control measure is most appropriate?
Use alcohol hand gel only between patients, as it is quicker than washing
Start oral metronidazole for all symptomatic patients and staff contacts
Close the bay, cohort patients and wash hands with soap and water
Let affected staff return to work as soon as their vomiting has stopped
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