Emergency Care Institute – Clinical tools

Returned traveller

Published: June 2015. Minor revision: July 2025. Next review: 2030. Printed on 6 Jun 2026.

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Travellers can present to EDs with health issues or a high suspicion of infectious diseases, regardless of where they are returning from. Early identification of travel history and activities is crucial, as it helps guide differential diagnosis, investigations, and infection control measures.

For current public health alerts, patient fact sheets and contact details for local public health units, see NSW Health's infectious diseases page.

Infection control

Clinical suspicion of certain travel-related infections should prompt the initiation of additional infection control precautions. For example, airborne and droplet precautions may need to be added to standard contact precautions. Refer to the Clinical Excellence Commission's Infection Prevention and Control (IPAC) and Healthcare Associated Infections (HAI) Program.

Escalation

High consequence infectious diseases are rare but deadly infections that require a broad system response. Refer to NSW Health guidance for high consequence infectious diseases.

Some infectious diseases in returned travellers are notifiable diseases. Refer to NSW Health's disease notification page.

History

Complete travel history:

Possible infections for given destinations

The U.S. Centres for Disease Control and Prevention: Travelers’ Health Yellow Book has a comprehensive list.

Individual exposures

  • Types of accommodation: hotel, budget
  • Source of drinking water
  • Ingestion of raw meat, seafood, fresh fruit and/or vegetables or unpasteurised dairy products
  • Insect precautions taken, such as repellent, bed nets
  • Insect or arthropod bites, such as spiders, lice, centipedes, flies
  • Animal contact, bites or scratches
  • Freshwater exposure, such as swimming, rafting
  • Body fluid exposure, such as tattoos, sexual activity
  • Medical care while overseas, such as surgery, injections, transfusions.

History of presenting symptoms

  • Timing of onset of symptoms in relation to travel.

Incubation periods of possible infections

Refer to the NSW Health control guideline for detailed information on each infectious disease.

Examination

Key examination findings which may indicate specific causes include:

  • jaundice
  • hepatosplenomegaly
  • rashes, e.g. rose spots (typhoid), macular-maculopapular (dengue), blotchy rash spreading from the head to the rest of the body (measles)
  • purpura and/or petechiae (meningococcal)
  • regional lymphadenopathy
  • insect bites.

Findings that should prompt urgent attention include:

  • haemorrhage
  • purpuric rash
  • neurologic impairment
  • acute respiratory distress.

Investigations

Choice of investigations depends on region of travel, the patient’s symptoms and signs and individual risk factors. The following are a reasonable starting point for most returned travellers seen in EDs:

  • FBC, LFT
  • Thick and thin films, taken on two separate occasions
  • Blood cultures
  • Serology for HIV, syphilis, hepatitis A, B, C or E
  • Consider risk of certain conditions based on area of travel and clinical concern (measles, malaria, dengue fever, chikungunya, rickettsia, strongyloides, Zika, Japanese encephalitis)
  • Consideration for influenza, RSV, COVID-19
  • CXR if clinically appropriate
  • Urine microscopy, culture and sensitivity (if suspect urinary tract infection)
  • Stool cultures with or without ova, cysts and parasite.

Returned traveller with fever

The initial focus in evaluating a febrile returned traveller should be on identifying infections that are rapidly progressive, treatable or transmissible. Presence of associated signs, symptoms, or laboratory findings can help direct attention to specific infections.

See UpToDate: Evaluation of fever in the returning traveller (NSW Health login required)

Malaria is the most common diagnosis amongst Australian travellers suffering from a febrile illness.

A history of taking anti-malarial prophylaxis does not exclude the possibility of malaria.

Treatment

Patients with Plasmodium falciparum malaria require hospital admission as the disease can progress rapidly.

Urgent treatment is essential if the patient has any of the following features suggesting severe disease:

  • altered consciousness with or without seizures
  • metabolic acidosis
  • severe anaemia
  • circulatory collapse
  • respiratory distress (acute respiratory distress syndrome)
  • renal or hepatic failure.

Treatment of severe malaria

IV artesunate and if artesunate not available, use IV quinine. See Therapeutic Guidelines: Malaria.

Side effects of quinine include:

  • prolonged QTc interval (will require cardiac monitoring during loading dose)
  • hypoglycaemia.

Endemic throughout the tropics and subtropics. Dengue is a leading cause of febrile illness among travellers returning from the Pacific, the Caribbean, Central and South America, Pacific Islands and Southeast Asia. Spread via the Aedes aegypti mosquito, which, unlike other mosquitoes, bites during the day.

Primary or first infection is usually benign (and may go unnoticed), whereas subsequent infections cause an immune response which can result in more severe illness. Severe, albeit rare, manifestations include dengue shock syndrome or haemorrhagic fever.

Characterisitics

Characterised by short incubation period followed by abrupt onset of:

  • high fever
  • backache, myalgia, arthralgia or bone pain
  • frontal and retro-orbital headache
  • malaise, anorexia, vomiting

Findings

Examination findings include:

  • Flushed appearance progressing to generalised maculopapular or rubelliform rash
  • Haemorrhagic signs: petechiae, purpura or positive tourniquet test

Characteristic investigation findings:

  • FBC: thrombocytopenia, leukopenia, elevated haematocrit
  • LFTs: hypoalbuminaemia, elevated aspartate transaminase: alanine transaminase
  • Non-structural protein 1 and PCR - positive early infection
  • Serology (IgG and IgM) are tests of choice after five days of illness

Treatment

Treatment is largely supportive with analgesia and fluid and electrolyte replacement. Patients should be encouraged to take fluids orally (approx. 2.5L/24h), with paracetamol as required for pain or fever. Opiates may be required for severe pain. Non-steroidal anti-inflammatory drugs increase bleeding risk and should be avoided.

Some patients can progress to a critical phase of infection characterised by plasma leakage, bleeding, shock and organ impairment. This critical phase can be heralded by specific warning signs:

  • abdominal pain or tenderness
  • persistent vomiting
  • accumulation of fluid (e.g. ascites, pleural effusion, pericardial effusion)
  • mucosal bleeding
  • altered mental status
  • lethargy or restlessness
  • liver enlargement >2cm
  • increase in haematocrit with rapid decrease in platelet count.

To guide management, the Centers for Disease Control and Prevention classifies patients with dengue into three groups based on disease severity, as outlined in the Dengue Clinical Management Pocket Guide.

  • Group A – Outpatient management
    • No warning signs
  • Group B – Inpatient management
    • Developing warning signs
    • Risk-factors (diabetes, obesity, pregnancy, renal failure)
    • Coagulopathy
    • Shortness of breath
    • Not tolerating oral fluids
    • Poor social support
    • Increasing haematocrit or rapidly declining platelets
  • Group C – Inpatient management (emergency treatment with access to intensive care and blood products)
    • Severe plasma leakage with shock and/or fluid accumulation causing respiratory distress
    • Severe bleeding
    • Severe organ impairment

  • Systemic infection with the bacterium Salmonella enterica (serotype typhi and paratyphi)
  • Infection through ingestion of contaminated food or water
  • Typhoid vaccination confers about 70% protection, so does not rule out the diagnosis. The vaccine does not protect against paratyphoid fever.
  • Characterised by fever, malaise, poorly localised abdominal discomfort, myalgia, hepatosplenomegaly and blanching erythematous maculopapular rash.

Treatment

Refer to Therapeutic Guidelines: Salmonella typhi and paratyphi A, B and C bacteraemia (NSW Health login required) for age-appropriate treatment.

Cerebrospinal fluid analysis should be performed in all neonates and children younger than three months to exclude neurological disease.

Returned traveller with respiratory infection

Respiratory complaints are frequent among returned travellers and are typically associated with common respiratory viruses.

Influenza is one of the most common vaccine-preventable diseases associated with international travel.

Severe respiratory symptoms associated with fever in a returned traveller are likely to be caused by common infectious diseases, such as influenza, COVID-19, bacterial pneumonia and malaria. They could also suggest more unusual entities, such as Legionnaires’ disease.

Other non-infectious causes, such as pulmonary emboli, should also be considered. Delayed onset and chronic cough after travel could be tuberculosis.

Returned traveller with diarrhoea

Most cases of travellers’ diarrhoea are the result of bacterial infection and are short-lived and self-limited. Mean duration of symptoms is four days.

When symptoms persist for 14 days or more, bacterial causes are less likely. Parasites as a group are the pathogens most likely to be isolated from patients with persistent diarrhoea. Their probability relative to bacterial infections increases with increasing duration of symptoms.

An approach to the investigation and management of returned travellers with persistent diarrhoea is available via UpToDate: Travelers' diarrhea: Treatment and prevention (NSW Health login required)

In some cases, persistence of gastrointestinal symptoms relates to chronic underlying gastrointestinal disease, such as coeliac disease or inflammatory bowel disease. Therefore, a more comprehensive search for underlying causes of chronic diarrhoea could be considered.

Management

Most illnesses in returned travellers can be managed on an outpatient basis, but some patients may need to be hospitalised.

Patients with systemic febrile illnesses and other severe presentations, such as those with respiratory distress, mental status change and haemodynamic instability, will require inpatient care. Ensure the correct infection prevention and control measures are used as per the Clinical Excellence Commission guidelines.

Inpatient management is especially important for patients who may not reliably follow up or when there is high likelihood of rapid clinical deterioration.

Consultation with an infectious diseases specialist team is recommended for management of patients with severe travel-related infections, where there is diagnostic uncertainty, or when management is complicated.

Resources

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/tools/returned-traveller

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