Following a trip abroad, up to 8% of travelers will present for medical attention1. Many of these complaints are mild, but some are life-threatening. A detailed travel history and history of the presenting illness are essential in identifying serious illnesses and preventing over-investigation of more common non-dangerous infectious complaints (i.e. URTI’s).
An easy mnemonic to help you remember key aspects of the travel history is TRAVEL:
T – Time of onset
The timing of fever can help identify the cause (and rule out other diagnoses)2. Most infections present within a month of return. Rarely, illness can occur months or years after travel-related exposure. Knowing the incubation periods of specific pathogens and possible fever patterns may provide clues to the organism involved.
R – Room and board
Important room and board-related factors include mosquito nets on beds, window screens, camping, source of drinking and bathing water, and the consumption of unpasteurized dairy products can help identify specific pathogens. Important living conditions include crowding, incarceration and sick contacts.
A – Activities
Inquire about the reason for travel and any associated activities. Important activities include freshwater and saltwater swimming, walking barefoot on soil and sand, camping, contact with wild animals and consumption of bushmeat (bats, monkeys, game). Ask about insect and animal bites, or any exposure to needles (e.g., tattoos). A thorough sexual history is also key, and one should be aware that sexual tourism is not uncommon.
V – Vaccination and Pre-trip Preparation
Ask about whether the patient consulted with a travel medicine clinic, received any vaccines, and took anti-malaria prophylaxis. Compliance with anti-malaria medications is variable, and exploring this can assist you in identifying possible pathogens. Be aware that depending on the region travelled and the medication chosen for prophylaxis infection can still occur, regardless of compliance. Also partial compliance with certain medications can make diagnosis more difficult if an infection occurs.
E – Exposure
Inquire about medical care oversees, injections, and transfusions. The type of medical care received abroad can give clues to possible exposures. Specifically explore any sexual relations abroad, exposure to bodily fluids and work done in a medical setting. It is not unusual for medical workers to convert from a negative to a positive Mantoux test after doing work in an endemic area.
L – Location
Identification of exact location of travel itinerary as potential exposures differ depending on region of travel. Ask about when the patient left home, when they arrived to their destination, where exactly did they travel and when and when did they arrive home again. Ask about traveling to urban and rural areas. Infection risk often differ in various areas of a country based on population density, altitude, general geography etc. Be sure to check travel advisories on reputable websites, like the WHO/CDC to assess each individual’s risk based on their specific travel itinerary.
This article was copyedited by Michael Bravo (@bravbro).
Reviewing with the Staff
Anali and Nour have created a simple and straightforward mnemonic to remind us all about key questions to ask of returning travellers. International travel is now so easy that it is critical for healthcare practitioners (HCPs) to be aware of diseases that are common in other countries. The spread of diseases like Ebola, Chikungunya, Zika, and SARS have all been facilitated by the increasingly accessible airways.
As an attending, I’d like to remind learners (or really, all HCPs reading this) about the importance of personal protective equipment (PPE). Many of our readers will not recall SARS. Suffice it to say that many HCPs became critically ill, and some even died, because we did not know how to prevent the transmission of the coronavirus. In Africa, the use of garbage bags and makeshift PPE was a contributing factor in containing the spread of Ebola.
When you are taking care of a returning traveller with a fever, consider donning PPE until you have a better sense of where the patient has been and what he or she has encountered.