www.fevertravel.ch: an online study prototype to evaluate the safety and feasibility of computerized guidelines for fever in returning travellers and migrants

Aetiology of fever in returning travellers and migrants: a systematic review and meta-analysis

BACKGROUND

Numerous publications focus on fever in returning travellers, but there is no known systematic review considering all diseases, or all tropical diseases causing fever. Such a review is necessary in order to develop appropriate practice guidelines.

OBJECTIVES

Primary objectives of this review were (i) to determine the aetiology of fever in travellers/migrants returning from (sub) tropical countries as well as the proportion of patients with specific diagnoses, and (ii) to assess the predictors for specific tropical diseases.

METHOD

Embase, MEDLINE and Cochrane Library were searched with terms combining fever and travel/migrants. All studies focusing on causes of fever in returning travellers and/or clinical and laboratory predictors of tropical diseases were included. Meta-analyses were performed on frequencies of etiological diagnoses.

RESULTS

10 064 studies were identified; 541 underwent full-text review; 30 met criteria for data extraction. Tropical infections accounted for 33% of fever diagnoses, with malaria causing 22%, dengue 5% and enteric fever 2%. Non-tropical infections accounted for 36% of febrile cases, with acute gastroenteritis causing 14% and respiratory tract infections 13%. Positive likelihood ratios demonstrated that splenomegaly, thrombocytopenia and hyperbilirubinemia were respectively 5-14, 3-11 and 5-7 times more likely in malaria than non-malaria patients. High variability of results between studies reflects heterogeneity in study design, regions visited, participants' characteristics, setting, laboratory investigations performed and diseases included.

CONCLUSION

Malaria accounted for one-fifth of febrile cases, highlighting the importance of rapid malaria testing in febrile returning travellers, followed by other rapid tests for common tropical diseases. High variability between studies highlights the need to harmonize study designs and to promote multi-centre studies investigating predictors of diseases, including of lower incidence, which may help to develop evidence-based guidelines. The use of clinical decision support algorithms by health workers which incorporate clinical predictors, could help standardize studies as well as improve quality of recommendations.

Feasibility and clinical outcomes when using practice guidelines for evaluation of fever in returning travelers and migrants: a validation study

BACKGROUND

Practice guidelines for examining febrile patients presenting upon returning from the tropics were developed to assist primary care physicians in decision making. Because of the low level of evidence available in this field, there was a need to validate them and assess their feasibility in the context they have been designed for.

OBJECTIVES

The objectives of the study were to (1) evaluate physicians' adherence to recommendations; (2) investigate reasons for non-adherence; and (3) ensure good clinical outcome of patients, the ultimate goal being to improve the quality of the guidelines, in particular to tailor them for the needs of the target audience and population.

METHODS

Physicians consulting the guidelines on the Internet (www.fevertravel.ch) were invited to participate in the study. Navigation through the decision chart was automatically recorded, including diagnostic tests performed, initial and final diagnoses, and clinical outcomes. The reasons for non-adherence were investigated and qualitative feedback was collected.

RESULTS

A total of 539 physician/patient pairs were included in this study. Full adherence to guidelines was observed in 29% of the cases. Figure-specific adherence rate was 54.8%. The main reasons for non-adherence were as follows: no repetition of malaria tests (111/352) and no presumptive antibiotic treatment for febrile diarrhea (64/153) or abdominal pain without leukocytosis (46/101). Overall, 20% of diversions from guidelines were considered reasonable because there was an alternative presumptive diagnosis or the symptoms were mild, which means that the corrected adherence rate per case was 40.6% and corrected adherence per figure was 61.7%. No death was recorded and all complications could be attributed to the underlying illness rather than to adherence to guidelines.

CONCLUSIONS

These guidelines proved to be feasible, useful, and leading to good clinical outcomes. Almost one third of physicians strictly adhered to the guidelines. Other physicians used the guidelines not to forget specific diagnoses but finally diverged from the proposed attitudes. These diversions should be scrutinized for further refinement of the guidelines to better fit to physician and patient needs.

Prospective multicenter evaluation of the expert system "KABISA TRAVEL" in diagnosing febrile illnesses occurring after a stay in the tropics

BACKGROUND

KABISA TRAVEL is a clinical decision support system developed by the Institute of Tropical Medicine of Antwerp, Belgium, for the diagnosis of febrile illnesses after a stay in the tropics. This study aimed to compare the diagnostic accuracy of KABISA TRAVEL with that of expert travel physicians.

METHODS

From December 2007 to April 2009, travelers with fever after a stay in the tropics were included in a multicenter trial conducted in travel referral centers in the Netherlands, Italy, Spain, and Belgium. Physicians were asked (1) to rank their first assessment diagnoses, (2) to enter in KABISA TRAVEL clinical and laboratory data available within 36 hours, and (3) to interact with the tutor until its final diagnostic ranking. Both physicians and KABISA TRAVEL rankings were then compared with the final diagnosis confirmed by reference methods. The clinical utility was also surveyed.

RESULTS

A total of 205 cases with confirmed diagnosis were evaluated (male/female ratio: 1.85; mean age: 35 y). Most patients were western travelers or expatriates (60%) and were returning from sub-Saharan Africa (58%). Travel physicians and KABISA TRAVEL ranked the correct diagnosis in the first place for 70 and 72% of the cases, respectively, and within the top five both for 88% of them. Travel physicians reported having been suggested useful further investigations in 16% of the cases, and having been helped for obtaining the diagnosis in 24%. This was reported more frequently when they had initially missed the diagnosis (suggestion: 48% in missed vs 12% in found diagnoses, p < 0.001; helpful: 48% in missed vs 21% in found diagnoses, p = 0.005).

CONCLUSIONS

KABISA TRAVEL performed as well as expert travel physicians in diagnosing febrile illnesses occurring after a tropical stay. Clinicians perceived the system as more helpful when they had not immediately considered the correct diagnosis.

Evaluation of the GIDEON Expert Computer Program for the Diagnosis of Imported Febrile Illnesses

Objective. The authors evaluate the performance of the expert system Global Infectious Diseases and Epidemiology Network (GIDEON) in diagnosing febrile illnesses occurring after a stay in the tropics. Methods. One investigator (E.B.) entered into the program the collected characteristics of 161 febrile travelers randomly extracted from a database of 1842 cases prospectively included during a study on imported fever. Accuracy was considered acceptable if the correct diagnosis appeared in the top 5 GIDEON ranking list. Interuser agreement was assessed by J.V.d.E. and J.M., who also entered the data of the first 50 sample cases with an established diagnosis. Results. The sample was epidemiologically and clinically representative of the whole cohort. An infectious etiology had been established in 129 cases; diagnosis was unknown in 31 cases and non-infectious in 1 case. GIDEON generated a median of 29 diagnoses per case, including 23 with a probability lower than 1%. Accuracy was acceptable in 64% of the 129 fevers with infectious etiology. It tended to decrease when more than 3 findings were entered per case. Eleven (8%) severe conditions were rejected by GIDEON because non-disease-related characteristics had been introduced. In other cases, the posttest probability was inadequately affected by the insufficient weight of absent relevant findings. Interuser agreement was good for acceptable accuracy and final ranking (kappa=0.83 and 0.72, respectively). Conclusion. The performance of GIDEON in diagnosing imported fever is relatively good and reproducible but is impaired by some conceptual weaknesses. Its use might be hazardous for inexperienced physicians.