Prospective, hospital based study of fever in children in the United Kingdom who had recently spent time in the tropics

Methods, subjects, and results

From August 1996 to July 1997 all children aged 16 years and under who were admitted with a fever (oral temperature >37.5°C) and had been in a tropical country within the previous four weeks were entered into the study; details of the few children who had a fever and had been in the tropics but were managed as outpatients were not recorded. Demographic, clinical, and laboratory features were recorded on a standard proforma.

In all, 31 children (18 boys) met the entry criteria; the median age was 4 years (range 5 months to 15 years). The regions visited were south Asia (19), sub-Saharan Africa (11), and the Caribbean (1). Twenty one children were normally resident in the United Kingdom, five in Africa, and five in south Asia; 23 were of south Asian ethnic origin, and eight were Afro-Caribbean. Of the 20 children normally resident in the United Kingdom who had visited a malarious region, only three had been fully compliant with an accepted regimen of antimalarial prophylaxis1; eight had taken no prophylaxis, and the other nine were poorly compliant, especially with proguanil.

The table shows the primary diagnoses at discharge from hospital. Fourteen children had non-specific, self limiting illnesses of presumed viral origin. Of the remaining 17 children, seven had potentially fatal infections requiring rapid diagnosis and antimicrobial treatment. All three cases of falciparum malaria were acquired in sub-Saharan Africa, and the single case of vivax malaria originated from India. Ten children had notifiable infectious diseases, and there were no deaths.

Comment

Although a large prospective study of fever in returning travellers has recently been published by researchers at the Hospital for Tropical Diseases in London,2 the patients in that study were highly selected and did not include children. To our knowledge this is the first prospective study of fever in children in the United Kingdom who have recently spent time in the tropics. Although the proportion of minor, self limiting illnesses would probably have been higher in children seen in general practice, we have documented a relatively high incidence of potentially fatal tropical infections in those referred to hospital. As the clinical features of malaria are frequently non-specific, and the diagnosis cannot be excluded by a single negative blood test, children at risk of this disease usually require hospital admission, with subsequent investigation by professionals with a detailed knowledge of the local prevalence of specific diseases.3

As in retrospective reviews of imported malaria,1 most of the cases in our study were among children of former immigrants who had visited their family's country of origin, with south Asia being the commonest destination (reflecting the large local south Asian community). The complete absence of white children in this study is remarkable, perhaps reflecting a reluctance in this section of the community to take children to exotic holiday locations. The poor understanding of the risks associated with travel in our study population is well illustrated by their underuse of antimalarial prophylaxis. Proguanil, which is available only as tablets, was particularly poorly tolerated, highlighting the need for a liquid suspension that is more palatable to children. With more than two children a month being admitted to our unit with potentially life threatening tropical infections, paediatricians in the United Kingdom clearly need a good working knowledge of these conditions, especially as access to specialists in tropical medicine is limited.