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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- ALWAYS take a detailed travel history in any febrile or unwell patient: destination, dates, activities, vaccinations, prophylaxis, exposures (food, water, insects, animals, sexual)
- Malaria: the most important diagnosis to exclude in any febrile returning traveller from an endemic area — thick and thin blood films urgently
- Dengue: fever + headache + myalgia/arthralgia ("breakbone fever") + rash + thrombocytopenia. Transmitted by Aedes mosquito (daytime biting). No specific treatment — supportive. Avoid NSAIDs (bleeding risk)
- Typhoid (Salmonella typhi): gradual fever, relative bradycardia, rose spots, hepatosplenomegaly, constipation (not diarrhoea initially). Blood cultures, treat with ceftriaxone or azithromycin
- Pre-travel advice: destination-specific vaccinations (hepatitis A/B, typhoid, yellow fever, meningococcal, rabies), malaria prophylaxis, insect avoidance, food/water hygiene, travel insurance
Overview
Travel-related infections encompass a wide range of conditions acquired during international travel, particularly to tropical and subtropical regions. The returning traveller with fever is a common clinical scenario requiring systematic assessment. The most important initial consideration is excluding malaria — which is potentially fatal and treatable. Other important travel-related infections include dengue, typhoid, chikungunya, Zika, schistosomiasis, and viral haemorrhagic fevers (Ebola, Lassa). A thorough travel history including destination, timing, activities, vaccinations, prophylaxis adherence, and specific exposures is essential.
Epidemiology
Approximately 60-70 million people from the UK travel abroad each year. The most common travel-related infections seen in UK returning travellers are gastroenteritis, malaria, dengue, respiratory infections, and skin infections. Approximately 1,500-2,000 cases of malaria and 300-500 cases of typhoid are imported to the UK annually. VFR (visiting friends and relatives) travellers are at highest risk — they are less likely to seek pre-travel advice or take malaria prophylaxis.
Clinical Features
Symptoms
Fever — the most common presentation of the returning traveller. Always exclude malaria first
Dengue: high fever, severe headache (retro-orbital), myalgia/arthralgia ("breakbone fever"), maculopapular rash (day 3-5), thrombocytopenia
Typhoid: insidious onset fever (stepladder pattern), headache, abdominal pain, constipation initially (diarrhoea later), rose spots (faint pink macules on trunk)
Chikungunya: fever + severe polyarthralgia (incapacitating joint pain), rash
Schistosomiasis: Katayama fever (acute: fever, urticaria, eosinophilia) weeks after freshwater exposure in endemic area. Chronic: haematuria (S. haematobium), hepatosplenomegaly
Viral haemorrhagic fever: fever + bleeding + travel from endemic area (West Africa) within 21 days — ISOLATE and contact PHE/UKHSA immediately
Signs
Fever pattern may give clues (tertian/quartan — malaria; stepladder — typhoid; sudden onset — dengue)
Relative bradycardia (pulse-temperature dissociation) — typhoid
Hepatosplenomegaly (malaria, typhoid, schistosomiasis, visceral leishmaniasis)
Rash: maculopapular (dengue), rose spots (typhoid), eschar (rickettsial)
Jaundice (malaria, hepatitis, leptospirosis)
Investigations
First-line
Malaria thick and thin blood films (×3)URGENT — must be processed within 1-2 hours of collection. Send in ALL febrile returning travellers from malaria-endemic areas. Also RDT (rapid diagnostic test)
FBCEosinophilia: parasitic infection (schistosomiasis, helminths). Thrombocytopenia: dengue, malaria. Pancytopenia: leishmaniasis
Blood culturesTyphoid (Salmonella typhi), other bacteraemias
LFTs, U&Es, CRPBaseline assessment, hepatitis screen
Second-line
Dengue NS1 antigen + IgM/IgG serologyNS1 positive in first 5 days; serology becomes positive after day 5
Hepatitis A/B/C/E serologyIf jaundice or raised transaminases
Stool MC&S and ova/cysts/parasitesIf diarrhoea — Giardia, Entamoeba, Campylobacter, Salmonella, Shigella
Serology for schistosomiasisIf freshwater exposure in endemic area (Africa, South-East Asia). Also stool/urine microscopy for eggs
Specialist
PHE/UKHSA Imported Fever Service24/7 advice line for returning travellers with fever — specialist tropical disease input
Contact PHE IMMEDIATELY if VHF suspectedViral haemorrhagic fever (Ebola, Lassa): fever + travel to endemic area within 21 days + bleeding — STRICT isolation, contact PHE rare and imported pathogens team
1
Febrile returning traveller — systematic approach
- 1. Travel history: destination, dates, activities, prophylaxis, vaccinations, exposures
- 2. EXCLUDE MALARIA: thick and thin films urgently in ALL febrile travellers from endemic areas
- 3. Broad initial investigation: FBC, U&Es, LFTs, CRP, blood cultures, urinalysis, CXR
- 4. Consider: dengue, typhoid, hepatitis, rickettsial, chikungunya, Zika based on geography and symptoms
- 5. If VHF suspected (fever + bleeding + West African travel within 21 days): ISOLATE, PPE, contact PHE
2
Specific treatment
- Malaria: see malaria condition page — artemether-lumefantrine (uncomplicated), IV artesunate (severe)
- Typhoid: ceftriaxone 2g IV OD or azithromycin 500 mg OD for 7-14 days. Rising resistance to ciprofloxacin
- Dengue: supportive — IV fluids, paracetamol for fever. AVOID NSAIDs and aspirin (haemorrhagic risk). No specific antiviral
- Schistosomiasis: praziquantel (single dose) — treat ≥8 weeks after last exposure (drug acts on adult worms)
3
Pre-travel health advice
- Destination-specific vaccines: hepatitis A (most common vaccine-preventable travel infection), hepatitis B, typhoid, yellow fever (mandatory for some countries), meningococcal ACWY (sub-Saharan Africa "meningitis belt"), rabies (high-risk travel), Japanese encephalitis
- Malaria prophylaxis: atovaquone-proguanil, doxycycline, or mefloquine — dependent on destination
- General advice: food and water hygiene, insect avoidance (DEET, bed nets, long clothing at dusk/dawn), safe sex, travel insurance
- Seek medical attention if fever develops within 12 months of travel to malaria-endemic area — warn patients
Complications
- Severe malaria: Cerebral malaria, ARDS, AKI, severe anaemia — leading cause of travel-related death
- Dengue haemorrhagic fever / dengue shock syndrome: Plasma leak, haemorrhage, shock — risk increases with secondary infection with a different serotype
- Typhoid intestinal perforation: In untreated typhoid — surgical emergency
- Chronic schistosomiasis: Portal hypertension, bladder SCC (S. haematobium)
- VHF: Extremely high mortality (Ebola 50-90%) — public health emergency
UKMLA Exam Tips
- 1Fever + travel history = MALARIA until proven otherwise. Send urgent thick and thin films
- 2Dengue: thrombocytopenia is characteristic. AVOID NSAIDs (risk of haemorrhagic complications). No vaccine routinely available in UK
- 3Typhoid: stepladder fever + relative bradycardia + rose spots + constipation (not diarrhoea) = classic presentation
- 4Eosinophilia in a returning traveller = parasitic infection (schistosomiasis, helminth) until proven otherwise
- 5VHF (Ebola, Lassa): fever + bleeding + travel to West Africa within 21 days = ISOLATE and call PHE immediately — do NOT perform routine bloods until VHF excluded
- 6Katayama fever: acute schistosomiasis — fever, urticaria, eosinophilia weeks after freshwater swimming in Africa
- 7Hepatitis A: most common vaccine-preventable travel infection — faecal-oral transmission, self-limiting, no chronic state
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