Travel Tips for South Africa, Updated Intl. Guide – Travel Medicine, Inc.
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Capital: Pretoria

Time Zone: +2 hours. No daylight savings time in 2008.
Tel. Country Code: 27
USADirect Tel.: 0
Electrical Standards: Electrical current is 220/50 (volts/hz). United Kingdom Style Adaptor Plug. Grounding Adaptor Plugs C, H.


Sub-Saharan Africa has the highest incidence of insect-transmitted diseases, such as malaria, and all travelers need products to prevent mosquito and tick bites. I recommend all travelers use a combination of DEET or Picaridin repellent on their skin and Permethrin fabric insecticide on their clothing for greater than 99% protection against mosquito and tick bites.



World Health Organization
Travel Health Services
Country Insights
Travel Warnings
Consular Information
Foreign Commonweatlh Office


U.S. Embassy
877 Pretorius Street

The U.S. Consulate General in Johannesburg
Tel: [27] (11) 644-8000


HIV Test: Not required for tourists. Required for all mine workers, irrespective of their positions.

Required Vaccinations: A yellow fever vaccination certificate is required for travelers over 1 year of age coming from countries with risk of YF transmission in South America and Africa and also from Eritrea, Sao Tome and Principe, Somalia, and Tanzania. Note:This applies to airport layovers > 12 hours in such countries.

Travelers from Zambia no longer need a Yellow Fever Vaccination Certificate to enter South Africa. Zambia has now, in 2015, been declared by WHO as yellow fever-free.

Please note: If you were to fly from the US to South Africa by way of Brazil (where YF is endemic), stopping in Sao Paul, for example, you would need a valid YF Certificate.


Passport/Visa: A South Africa tourist visa is not required for citizens of United States for a stay up to 90 days. Further information can be obtained from the Embassy of South Africa in Washington, DC.

  • Also, check the current validity of your passport.
  • All travelers will need a passport valid for at least 90 days following your departure date from South Africa.
  • Second, make sure your passport has blank Visa pages.
  • Most destinations, including South Africa, require that you have adequate un-used pages in your passport, allowing for any necessary stamps upon arrival and departure. We recommend that you have at least two free pages in Visas section of your passport before any international travel.

Finally, confirm if transit visa is required for any connections.


Hepatitis A: Recommended for all travelers >1 year of age who have not been previously vaccinated.

Hepatitis B: Recommended for all non-immune travelers at potential risk for acquiring this infection. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; when receiving medical or dental injections, or unscreened blood transfusions; by direct contact between open skin lesions. Recommended for any traveler requesting protection against hepatitis B infection.

Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.

Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).

Rabies: Recommended for travelers spending time outdoors in rural areas where there is an increased the risk of animal bites. Children are considered at higher risk because they tend to play with animals and may not report bites. Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of a high-risk animal bite, but does not eliminate the need for treatment with the vaccine.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.

Typhoid: Recommended for all travelers with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers.

Yellow Fever: Yellow fever vaccination is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas (also Eritrea, Sao Tome and Principe, Somalia, and Tanzania) but is not recommended or required otherwise.


Medical facilities, usually private clinics, provide good care in urban areas and in the vicinity of game parks & beaches, but are limited elsewhere. Travelers should consult a doctor if entering a malaria risk area such as Kruger National Park, northern KwaZulu/Natal, and parts of Swaziland, Mozambique & northern Zimbabwe and they should take the necessary malaria prophylactic medication.
All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country – the equivalent drugs may not be available.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance.

• The South African National Travel Health Network (SaNTHNet) website lists clinics that can provides consultations for those headed to the game parks (or elsewhere) and who need additional travel vaccinations and/or medications. All Travel Doctor clinics stock a range of necessary products such as mosquito nets, DEET-based insect repellents and personalized medical kits, containing not only bandages and plasters, but a broad range of medications, including prescription-only medications, for the self treatment or prevention of the most commonly contracted travel-related diseases.

The SaNTHNet also provides comprrehensive information on various diseases endemic in South Africa, such s malaria and African tick-bite fever

Decompression chambers are located at Kleinmont Hospital in Capetown, St Augustine’s Hospital in Durban, Eugene Marais Hospital in Pretoria and Milpark Hospital in Johannesburg.


The Glynnwood Hospital
The Glynnwood is a modern 350-bed hospital situated approximately 10 kms from Johannesburg International Airport. It has thirty resident specialists covering all disciplines. The radiology department is equipped with an MRI and CT scanner. The Intensive care unit comprises 12 ICU beds and 8 high-care beds. 24-hour emergency services.

Netcare Olivedale Hospital
Full-service hospital with all specialties. The Olivedale Cardiothoracic unit was established in 1997. It has a Siemens Multistar Catheterization Laboratory (Cath Lab) and a dedicated cardiothoracic operating theater.

Arwyp Medical Centre
This 250-bed hospital and trauma center provides emergency services 24 hours a day. Located in the Kempton Park City Centre in Gauteng, South Africa, Arwyp Medical Centre Private Hospital is a short distance from O.R. Tambo International Airport.

Medi-Travel International
Milnerton Medi-Clinic
This is a medical facility serving both local and international visitors and travelers. The MTI center offers a casualty service for medical emergencies, a health care service and a registered travel clinic service. The center is staffed Mon-Friday 09H00 – 17H00 and Saturdays 09H00 – 13H00. There is a Registered Nurse on call after hours on weekends.

Entabeni Hospital
This 273-bed private hospital has emergency services available 24 hours a day.


Network of hospitals & clinics with more than 46 family and dental centres throughout South Africa.


Mediclinic Southern Africa operates a range of multi-disciplinary acute care private hospitals in South Africa and Namibia


AIDS/HIV: Southern Africa remains the epicentre of the global HIV epidemic: 32% of people with HIV globally live in this sub-region and 34% of AIDS deaths globally occur here. The only evidence of declining national adult HIV prevalence in southern Africa comes from Zimbabwe, where both HIV prevalence and incidence have fallen (UNAIDS).
In South Africa, heterosexual contact is now the predominate mode of transmission. In KwaZulu/Natal Province, 35% of the adult population is HIV-positive, the highest incidence in Africa. South Africa has an estimated five million people living with HIV—more than any other nation.
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions. The use of condoms reduces the risk of transmission of the virus.

A drug to prevent AIDS. In a major advance, the drug Truvada© is now available for pre-exposure prophylaxis) in adults and adolescents (≥35 kg) who are at risk for HIV. The drug is taken once daily. Its use should be combined with safe sex practices.

• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with the body fluids of another person or their blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.

Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.

African Tick Typhus: African tick typhus is focally distributed, including peri-urban areas near Johannesburg. Cases are often reported among travelers, usually after visiting game parks.
• Travelers, especially those engaging in outdoor activities in rural areas, such as campers and hikers, are advised to take measures to prevent tick bites during the peak transmission season. Tick-bite prevention measures include applying a DEET-containing repellent (such as Ultrathon) to exposed skin and permethrin spray or solution to clothing and gear (e.g., Sawyer Permethrin Aerosol or 10-Garmet Soak).

Air Pollution: Emissions from coal-fired power stations in the highveld east of Pretoria combine with stagnant air masses to produce dangerous levels of photochemical pollutants.

Animal Hazards: Animal hazards include snakes (cobras, mambas, adders, vipers) and spiders (black
and brown widow).

Arena Virus Disease: Arena virus disease has killed three people in 2008 in South Africa. The first victim was a safari tour guide working in Zambia, who on 12 September 2008 was evacuated in a critical condition to Johannesburg, South Africa. She was admitted to a clinic where she died on 14 September about 10 days after the onset of symptoms. The symptoms included a prodromal phase with fever, myalgia, vomiting, diarrhoea, followed by rash, liver dysfunction and convulsions. The paramedic who had cared for the index case during her evacuation to Johannesburg developed prodromal symptoms similar to the index case. He was hospitalised on 27 September. His condition deteriorated and he died on 2 October. An intensive care unit nurse who cared for the index case in Johannesburg developed similar flu-like symptoms and was hospitalised on 1 October. Her condition deteriorated on 4 October and she died on 5 October of acute respiratory distress syndrome. In both cases, the incubation period is estimated to have been about one week. On 13 October, the World Health Organization (WHO) posted a website update informing about a fourth case affecting a nurse who had been in contact with the paramedic.
• On 12 October 2008, the National Institute for Communicable Diseases (NICD) in South Africa provided preliminary evidence that the causative agent of the disease was a virus from the Arenaviridae family.
• Viruses of the Arenaviridae family are associated with rodent-transmitted disease in humans. Arenavirus infections are relatively common in humans in some areas of the world and can cause severe illnesses. The Arenaviridae are a family of viruses responsible for diseases such as hemorrhagic fevers.
• In nature, arenaviruses are found in animals such as rodents that are the natural reservoir for the viruses. The viruses are shed into the environment in the urine or droppings of infected rodents. Human infection is incidental, and occurs when a person comes into a contact with excretions or materials contaminated by an infected rodent.
• The professional activities of the index case could have favoured possible exposure to rodent excreta in a rural area. (The guide was known to have walked barefoot most of the time.)


Chikungunya Fever: This mosquito-transmitted viral illness is common in sub-Saharan Africa. Symptoms include fever, headache, fatigue, nausea, vomiting, muscle pain, rash, and joint pain. Acute Chikungunya fever typically lasts a few days to several weeks, but as with dengue, West Nile fever, and other arboviral fevers, some patients have prolonged fatigue lasting several weeks. No deaths related to chikungunya infection have been conclusively documented in the scientific literature.
• To prevent this disease, and other arboviral illnesses, you should take measures to prevent mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet at night.
• Other mosquito-borne diseases, such as dengue fever and malaria, can be confused with chikungunya fever. If you develop a fever while in India, it is important to consider the diagnosis of malaria.

Cholera: The most recent outbreak in 2008 is reported from Mpumalanga Province. Although cholera occurs in this country, the threat to tourists is low. Cholera is an uncommon disease in travelers from developed countries. Cholera vaccine is recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of more severe cholera is copious watery diarrhea.
• Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.
 A single 1-gm oral dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children.

Crimean-Congo Hemorrhagic Fever: Sporadic human cases are reported. This viral infection may occur following exposure to infected ticks, animals, or humans. Cases usually occur in the summer months but may occur at other times as well.
As of July 2008, five cases of CCHF have been reported including two deaths, one from Bloemfontein, Free State Province and the other from Paterson in the Eastern Cape province, Between five and 25 cases are reported in South Africa each year; most cases are reported in Karoo, the Western Free State, the Northern Cape and North West province, and are associated with farm or abattoir workers and hunters.
• CCHF is caused by a virus and is transmitted by tick bite or by exposure to blood or secretions from infected animals or humans. Anyone who has visited this country and is suffering from a fever, headache, chills, muscle aches, vomiting, red rash (which does not fade when pressed under glass), bleeding on the roof of the mouth, or any other unexplained symptoms should seek medical advice immediately. Risk is seasonal, associated with periods of high tick activity and increases in tick and rodent host populations.
• There is no vaccine to protect against CCHF.
• All travelers should exercise insect-bite prevention measures. Tick-bite prevention measures include applying a DEET-containing repellent (such as Ultrathon) to exposed skin and permethrin spray or solution (e.g., Sawyer permethrin aerosol or Miltary Soak) to clothing and gear.

Dengue Fever: Low risk. Dengue fever is widespread throughout the tropics and subtropics, with most infections occurring in SE Asia and the Pacific. Outbreaks are common and often occur in a seasonal pattern. Several or all of the dengue virus serotypes circulate within any one country The distribution of dengue continues to expand aided by global warming, urban expansion, population movement and increase in mosquito breeding habitats. For the first time in 2009, dengue transmission occurred locally in Europe after travellers returned home infected with dengue fever.

The cause is a virus spread by the Aedes aegypti species of mosquito which mainly bites during the day. After an incubation period of 4-10 days there is usually a sudden onset of fever, headache, muscle and joint pains. A rash may develop. Within a few days the illness usually resolves and serious complications are uncommon. In a few cases dengue can progress to a more serious form with shock, which can be fatal.

Treatment: There is no specific anti-viral treatment. Symptoms like headache and fever can be treated symptomatically. Hospital care is indicated in severe illness or if complications occur.

Recommendations for Travellers: Avoid mosquito bites and seek medical attention for feverish illness if you have been in an area where dengue is present. No vaccine is available against dengue virus.

Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Hepatitis A is transmitted through contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.

Hepatitis E may be endemic, but levels are unclear. Transmission of HEV occurs primarily through contaminated drinking water. In developing countries, prevention of HEV relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• Hepatitis B is hyperendemic. The overall hepatitis B (HBsAg) carrier rate in the general population is estimated as high as 15% in some groups. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic with a prevalence of 1.7% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C – an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.

Influenza: Influenza is transmitted from April through September in the Southern Hemisphere. The flu vaccine is recommended for all travelers over 6 months of age who have not had a flu shot in the past 12 months.

Insects: All travelers should take measures to prevent both daytime and nighttime insect bites. Insect-bite prevention measures include a DEET-containing repellent applied to exposed skin, insecticide (permethrin) spray applied to clothing and gear, and use of a permethrin-treated bednet at night while sleeping.

Malaria: There is a high risk of malaria in South Africa in the low altitude areas of Mpumalanga and Limpopo which border Mozambique and Zimbabwe. This includes Kruger National Park. The areas bordering these are low risk. There has been recent increased transmission in Limpopo province.
There is also a high risk of malaria in northeast KwaZulu-Natal as far south as Jozini and a low risk between Jozini and Richards Bay.
If you will be visiting a malaria risk area in South Africa, you will need to take one of the following antimalarial drugs: atovaquone/proguanil (Malarone), mefloquine (Lariam) or doxycycline.

The drug tafenoquine can be taken to prevent recurrent attacks of vivix malaria. Krintafel© (tafenoquine) is a single-dose medication for radical cure (prevention of relapse) of P. vivax malaria.

The malaria map identifies the risk area in the Kruger Park region. Take measures to prevent evening and nighttime mosquito bites.

 Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents (e.g., Ultrathon or Ben’s 30) are used in combination with permethrin-treated clothing .
NOTE: Picaridin repellents (20% formulation, such as Sawyer or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country.

Marine Hazards: Stingrays, jellyfish, and several species of poisonous fish are common in the country’s coastal waters and are potential hazards to swimmers.

Meningitis: Low risk. South Africa is south of the sub-Saharan meningitis belt. Long-term visitors who expect to have close contact with the indigenous population should consider vaccination.

Other Diseases/Hazards: Brucellosis (usually from the ingestion of unpasteurized dairy products)
• Leishmaniasis (low to negligible risk)
• Leptospirosis
• Trachoma (high incidence in northern Transvaal)
• Tuberculosis (highly endemic in Western Cape)

Plague: No human cases have been reported since the 1980’s. Known areas of risk include the northern and western borders with Lesotho and in Mount Zebra National Park north of Port Elizabeth. Prophylaxis against plague (doxycycline) is recommended only for persons who may be occupationally exposed to wild rodents (e.g., anthropologists, archaeologists, medical personnel).

Rabies: Rabies is endemic in South Africa and an outbreak was reported from Limpopo and KwaZulu-Natal in 2007, resulting in 42 fatalities. In 2008, there has been an outbreak of dog rabies in the Eastern Cape (Ukhahlamba District and Chris Hani District). No human cases have been reported so far from these two districts. Most cases of human rabies occur in KwaZulu/Natal Province and Eastern Transvaal, and are attributed to an increasing stray and wild dog population. Rabies is also found in cats, cattle, mongooses, jackals, and bat-eared foxes. Travelers at risk for infection are those traveling in rural parts of the country, especially in KwaZulu/Natal, the eastern Cape, and Mpumalanga provinces.
• All animal bites or scratches, especially from a dog, should be taken seriously, and immediate medical attention sought. Although rabies is rare among tourists• there is risk. No one should pet or pick up stray animals. All children should be warned to avoid contact with unknown animals.
Pre-exposure rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.
• Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Prompt medical evaluation and treatment of any animal bite is essential, regardless of vaccination status. Note: If adequate rabies treatment is not available locally, medical evacuation is advised to a facility that can provide treatment.

Rickettsial Diseases (African tick typhus, Q Fever, Scrub & Murine Typhus, Spotted Fevers) : Spotted fever group rickettsioses are the most common individual diagnoses for travelers to South Africa.
Rickettsia species are carried by many ticks, fleas, and lice, and cause diseases in humans such as typhus, rickettsialpox, African tick typhus (Boutonneuse fever), African tick bite fever, Rocky Mountain spotted fever, Australian Tick Typhus, Flinders Island Spotted Fever and Queensland tick typhus.

Diagnosis of rickettsial diseases in travelers returning from Africa

Important spotted fevers in South Africa include African tick typhus (also called Boutonneuse fever-caused by Rickettsia conorii) and African tick bite fever (caused by Rickettsia africae-a new species within the spotted fever group of rickettsiae). Sypmtoms include: fever, chills, maculopapular rash, headache, myalgia, arthralgias, and swollen lymph nodes. At the onset of the infection, a local lesion called tache noire appears at the site of the tick bite. The rash usually begins on the forearms and spreads over the rest of the body. The fever may persist into the second week, but death or complications are rare.

Rift Valley Fever: The epidemic of Rift Valley Fever continues. A confirmed case of Rift Valley fever (RVF) has been reported in a tourist who visited rural areas of the Eastern Cape and Western Cape in early April 2010. According to the Ministry of Health, 166 confirmed human cases, including 15 fatalities, have been reported in farm workers and veterinarians from the Free State, the Eastern Cape, the Northern Cape, the Western Cape, and the North West. Travelers visiting farms or game reserves in affected areas should take measures to prevent mosquito bites, avoid contact with animal tissues or blood, avoid unpasteurized milk, and should not eat raw or undercooked meat.

Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit diseases such as Rift Valley Fever (RVF) or malaria. Nearly 100% protection can be achieved when DEET repellents (such as Ultrathon or Ben’s 30) are used in combination with permethrin-treated clothing.
• You should consider the diagnosis of RVF (or malaria) if you develop an unexplained fever during or after being in this country.

Schistosomiasis: Risk is present primarily in the warmer months (October – April) in the northeast and the eastern coastal area, generally below 1,500 meters elevation. Foci of urinary schistosomiasis are distributed over large areas of the northeast (including Kruger National Park), KwaZulu/Natal Province, and along the coastal areas of Eastern Cape Province as far south as Humansdorp. Risk areas for intestinal schistosomiasis occur in the lowveld of Eastern and Northern Transvaal Provinces and sporadically in coastal areas of KwaZulu/Natal Province. There is also risk along the lower Orange River in Northern Cape Province bordering Namibia.
• Schistosomiasis is transmitted through exposure to contaminated water while wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection. All travelers should avoid swimming, wading, or bathing in freshwater lakes, ponds, streams, cisterns, aqueducts, or irrigated areas. There is no risk in chlorinated swimming pools or in seawater.

Sindbis Fever: Sporadic outbreaks occur, primarily in Central Cape Province, and eastern and southern Transvaal during warmer months. Travelers should take measures to prevent insect (mosquito) bites.

Travelers’ Diarrhea: Low to moderate risk in urban areas. Cities and townships have municipal water systems which supply water to hotels and homes. Tap water safety is variable. Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized dairy products. Do not eat raw or undercooked food, especially meat and fish. Peel all fruits.
• Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic (e.g., Cipro), or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.

Tuberculosis: Tuberculosis is highly endemic in South Africa with an annual occurrence >400 cases per 100,000 population. Co-infection with HIV is a significant factor in acquisition of TB and occurs in 58% of people who have this disease. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets.
• Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection.

• The unprecedented growth of the tuberculosis epidemic in Africa is attributable to several factors, the most important being the HIV epidemic. Although HIV is the leading cause of death in Africa, tuberculosis is the most common coexisting condition in people who die from AIDS. Post-mortem studies show that 30 to 40% of HIV-infected adults die from tuberculosis. Among HIV-infected children, tuberculosis accounts for up to one in five of all deaths.

• In 2006, extremely drug-resistant (XDR) tuberculosis appeared. In KwaZulu-Natal Province, half the XDR cases in patients with HIV infection were acquired in hospitals or clinics, and several occurred in health care workers. Mortality exceeded 95%. XDR-TB is defined as resistance to three or more second line antibiotics for TB. The condition remains treatable with other types of medications, but those are less effective, costlier and toxic. If the afflicted persons cannot be soon diagnosed and given proper treatment, they can die within a month.

Typhoid Fever: Typhoid vaccine is recommended by the CDC for all people traveling to or working in sub-Saharan Africa, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.

West Nile Fever: Sporadic outbreaks occur, primarily in Central Cape Province, and eastern and southern Transvaal during warmer months. Travelers should take measures to prevent daytime mosquito bites.