Fever from the tropics

Editor—Klein and Millman describe 31 children with fever who had recently visited the tropics and presented to their department.1 Many of these children, including the 11 who had visited sub-Saharan Africa, would be likely to fall into the moderate risk category as defined by guidelines published in a document by the Advisory Committee on Dangerous Pathogens.2 This category includes febrile patients who have been in an endemic area during the 21 days before onset of illness. It would be interesting to know if the possibility of viral haemorrhagic fever was considered in any of these children, and if the guidelines were followed. There are serious implications for the clinical management of patients falling into the moderate risk category. These people can be admitted only to isolation facilities, which have stringent specifications and are not available in most district hospitals. Urgent laboratory investigations are severely limited. If, for example, viral haemorrhagic fever cannot be excluded with certainty only a thin blood film for malaria may be examined outside a high security laboratory for infectious diseases. Only two of these are listed in the guidelines for investigations of these patients—in Coppetts Wood Hospital, London, and Newcastle General Hospital, Newcastle upon Tyne. With the addition of Congo Crimean haemorrhagic fever to the list of viral haemorrhagic fevers of concern to the United Kingdom, the areas where the disease is potentially endemic have been substantially increased. They now cover countries such as Greece and Turkey, which are popular destinations for British residents. Insufficient information is given in the document on the distribution of viral haemorrhagic fever and which parts of endemic areas pose a considerable risk for travellers.2 Importation of viral haemorrhagic fever into the United Kingdom is extremely rare, whereas other life threatening infections are more common.1,3 More specific guidance should be available on areas where diseases are endemic—for example, in the form of a regularly updated website or a telephone hotline. This way, most of the visitors to areas currently identified in the document who present with a fever in the United Kingdom could possibly be excluded. Otherwise patients may unnecessarily be transferred over long distances and put at risk by investigation being restricted. If guidelines are impracticable and unrealistic they may be ignored. The true risk of viral haemorrhagic fever in returning travellers is extremely small. Risk assessment as detailed in the guidelines can be improved, and made more accessible to the general practitioners and hospital doctors who see these patients.