Differential Diagnosis of Illness in Travelers Arriving From Sierra Leone, Liberia, or Guinea: A Cross-sectional Study From the GeoSentinel Surveillance Network

Abstract

Background The largest-ever outbreak of Ebola virus disease (EVD), ongoing in West Africa since late 2013, has led to export of cases to Europe and North America. Clinicians encountering ill travelers arriving from countries with widespread Ebola virus transmission must be aware of alternate diagnoses associated with fever and other nonspecific symptoms. Objective To define the spectrum of illness observed in persons returning from areas of West Africa where EVD transmission has been widespread. Design Descriptive, using GeoSentinel records. Setting 57 travel or tropical medicine clinics in 25 countries. Patients 805 ill returned travelers and new immigrants from Sierra Leone, Liberia, or Guinea seen between September 2009 and August 2014. Measurements Frequencies of demographic and travel-related characteristics and illnesses reported. Results The most common specific diagnosis among 770 nonimmigrant travelers was malaria (n = 310 [40.3%]), with Plasmodium falciparum or severe malaria in 267 (86%) and non–P. falciparum malaria in 43 (14%). Acute diarrhea was the second most common diagnosis among nonimmigrant travelers (n = 95 [12.3%]). Such common diagnoses as upper respiratory tract infection, urinary tract infection, and influenza-like illness occurred in only 26, 9, and 7 returning travelers, respectively. Few instances of typhoid fever (n = 8), acute HIV infection (n = 5), and dengue (n = 2) were encountered. Limitation Surveillance data collected by specialist clinics may not be representative of all ill returned travelers. Conclusion Although EVD may currently drive clinical evaluation of ill travelers arriving from Sierra Leone, Liberia, and Guinea, clinicians must be aware of other more common, potentially fatal diseases. Malaria remains a common diagnosis among travelers seen at GeoSentinel sites. Prompt exclusion of malaria and other life-threatening conditions is critical to limiting morbidity and mortality. Primary Funding Source Centers for Disease Control and Prevention.

No evidence for major adverse events related to suspicion of Ebola in France, 2014–2015

“…We found that most patients with suspected EVD in France during the 2014e2015 outbreak were finally diagnosed with other infectious diseases, mostly malaria, and none had EVD. This is in line with studies from the GeoSentinel Surveillance Network [3], with malaria documented in 40% of ill travelers returning from Sierra Leone, Liberia and Guinea. We estimated that a diagnosis delay attributable to EVD suspicion occurred in 35% of patients, but remained limited in most, with no major clinical consequence.…”

“…The importance of these precautions has been outlined by reports of secondary transmission in Spain [1] and the United States [2], when they were not adequately implemented. However, most suspicion of EVD outside of the outbreak area turned out to be more common infectious diseases, including malaria [3], and concerns were raised that EVD suspicion could represent a loss of opportunity for early recognition and treatment of these potentially life-threatening conditions. In addition, the use of Ebola personal protective equipment has been shown to increase the risk of failure for common medical procedures [4] and has psychological consequences.…”

Development and Implementation of the Ebola Traveler Monitoring Program and Clinical Outcomes of Monitored Travelers during October – May 2015, Minnesota

“…Twice daily monitoring of fever and reporting to monitors was emphasized as a key screening tool for travelers. While not all cases of EVD have fever [17], this has been consistently used by military and non-military monitoring following travel to affected countries [12, 13]. In Minnesota, the regular contact between monitoring staff and traveler to discuss all symptoms and overall health status was the most important part of the monitoring, leading to reduced false alarms of possible EVD; this success, however, was resource-intensive.…”

Detecting Ebola with limited laboratory access in the Democratic Republic of Congo: evaluation of a clinical passive surveillance reporting system

“…Malaria, meningitis, typhoid fever, acute respiratory infection (ARI), yellow fever, measles and bloody diarrhoea are diseases included within IDSR weekly reports and considered differential diagnoses for EVD based on public health guidance and previous literature . Malaria, meningitis, typhoid fever, yellow fever and bloody diarrhoea share non‐specific symptoms of fever, abdominal pain, diarrhoea and vomiting.…”