Chapter 4Select Destinations

Gary W. Brunette

DESTINATION OVERVIEW

South Africa has been called “a world in one country.” This refers, in part, to the diversity in the geography, which includes lush subtropical regions, old hardwood forests, sweeping Highveld vistas, and the deep desert of the Kalahari; the splendor of the animal species found throughout the country and protected in expansive games reserves; the diverse origins of the locals (African, European, Indian, and Asian); the cultural, artistic, and culinary variety; and access to the conveniences of a developed infrastructure amid the challenges of Africa.

South Africa has experienced a surge in tourism in the last 2 decades, with visitors from within the African continent as well as those from Europe and North America. Business travelers typically head to the commercial centers of Johannesburg, Cape Town, and Durban. Tourists may be attracted by the game reserves, the largest of which is Kruger National Park, located along the Mozambique border in the northeast. Kwa-Zulu Natal has a number of game parks (Hluhluwe-Umfolozi and Saint Lucia) set inland from Durban, and the Eastern Cape has parks (Addo Elephant Park and Shamwari) easily accessed from Port Elizabeth on the southern coast. Many smaller luxury reserves have emerged to cater to the high-end traveler. Visitors may be attracted to itineraries that include a trip from Cape Town along the south coast through the small scenic towns of Knysna and Plettenberg Bay; a tour of the old gold-mining towns in Mpumalanga, many of which are in near original condition; spectacular drives and fascinating tours of the old wineries along the wine routes in the Western Cape; or visits to the southernmost point of Africa at Cape Agulhas or Cape Point, where the Indian and Atlantic Oceans meet in a roar of foam. South Africa is also a common destination of humanitarian workers, missionaries, and students. A sizable number of South Africans live outside the country and would be considered VFRs (visiting friends and relatives) when returning to the country for a visit.

While there is a wide range of living standards in South Africa, most visitors experience standards comparable to those in developed countries. A smaller number of visitors may go to less developed areas, either the lower-income townships outside most towns and cities or to rural areas. Hikers, adventure-seekers, and missionaries will experience a wider range of living standards. Similarly, the quality and availability of health care are variable. Middle- and upper-income South Africans live in low-risk environments, have a standard of health comparable to that of North Americans, and have access to world-class medical facilities. Poorer South Africans live in areas with few amenities, are exposed to a wide range of diseases, and have limited access to adequate health care.

HEALTH ISSUES

Vaccine-Preventable Diseases

All travelers to South Africa should be up to date with their routine vaccinations. Infectious diseases such as measles and mumps are endemic in the region. In addition, travelers should obtain vaccinations for hepatitis A, hepatitis B, and typhoid.

HIV and Sexually Transmitted Diseases

South Africa has the largest number of people living with HIV of any other country in the world, and the prevalence is approximately 18% among people aged 15–49 years. The commercial sex industry is active, and the prevalence of HIV infection among prostitutes is as high as 33%. Other sexually transmitted diseases are also present at high rates in this population. Travelers should be made aware of these risks and advised to wear condoms if they participate in sexual activities with local residents.

Vectorborne Diseases

The risk for malaria transmission only exists in the northeast of the country in the Mpumalanga and Limpopo Provinces (including Kruger National Park) and in Kwa-Zulu Natal north of the Tugela River. Plasmodium falciparum is the predominant species and is universally resistant to chloroquine. Visitors to these areas should be on an appropriate chemoprophylaxis regimen and should be advised about mosquito precautions. Malaria in the northeastern game reserves is seasonal; the highest transmission occurs from October through May, and the period of highest risk is February to early May. The risk to visiting travelers is low. A study conducted in 1999 estimated a case rate of 4.5 cases per 10,000 visitors in April, a high-transmission month. The South African Department of Health recommends chemoprophylaxis for all travelers visiting from September through May and mosquito-avoidance measures for the rest of the year. CDC recommends chemoprophylaxis at all times of the year (see Chapter 3, Yellow Fever and Malaria Information, by Country).

Tick-bite fever caused by rickettsial species is common in South Africa and can result in severe and sometimes fatal complications. Hikers and campers in rural areas who are exposed to ticks are especially at risk. Measures should be taken to prevent tick bites (see Chapter 2, Protection against Mosquitoes, Ticks, and Other Insects and Arthropods). Doxycycline used for malaria prophylaxis will also protect against tick-bite fever. The use of antibiotics after a tick bite is not useful, because it prolongs the incubation period.

Waterborne Diseases

Schistosomiasis, a common parasite throughout Africa, may be present in any body of fresh water, such as lakes, streams, and dams. Travelers should avoid swimming in fresh, unchlorinated water. Those who swim in fresh water should have a serologic test 30 days after their return.

Animal Avoidance

While most travelers avoid wild animals in game reserves, it should be stressed that rabies is common in dogs and other animals throughout the country. Travelers may not be able to tell if an animal is infected and should avoid all contact with dogs and other animals. Any bite or scratch from an animal should be evaluated as soon as possible by a clinician. Rabies vaccine is available throughout South Africa, and human rabies immune globulin is available in major urban medical centers. Appropriate postexposure medical care for rabies exposures can be obtained in South Africa.

Safety and Security

South Africa has struggled with a rise in violent crime, which includes armed robberies, carjackings, home invasions, and rape. Most of these incidents occur in poor areas and, as such, most visitors will not be affected. However, awareness of personal safety and security should be stressed to all visitors.

Although South Africa has a modern road system, drivers should be alert for dangerous driving practices, stray animals, and poor roads in remote rural areas.

BIBLIOGRAPHY

1. Durrheim DN, Braack LE, Waner S, Gammon S. Risk of malaria in visitors to the Kruger National Park, South Africa. J Travel Med. 1998 Dec;5(4):173–7.
2. Kruger National Park. Malaria situation in Kruger National Park. Available from: http://www.krugersafari.com/malaria2.html.
3. South Africa Department of Health. Guidelines for the prevention of malaria in South Africa. 2009. Available from: http://www.doh.gov.za/docs/factsheets/guidelines/prevention_malaria09.pdf (PDF).