(Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Democratic Republic of Congo (formerly Zaire), Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mayotte, Mozambique, Namibia, Niger, Nigeria, Reunion, Rwanda, Saint Helena, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania (including Zanzibar), Togo, Uganda, Zaire (see Democratic Republic of Congo), Zambia, Zimbabwe)

3.8.1  Disease Risks

Food and water-borne diseases highly endemic - intestinal helminth infections, the dysenteries and other diarrhoeal diseases including giardiasis, typhoid fevers and hepatitis A and E are widespread. Amoebiasis in southern countries. Cholera in many countries in the area. Dracunculiasis occurs in isolated foci.

Malaria: high transmission rate of P.falciparum in most areas except for the southern tip of the continent. There is no transmission above 3,000m altitude, nor in the islands of Reunion and the Seychelles, Lesotho and St. Helena; there is a little vivax malaria in Mauritius. Malaria in sub-Saharan Africa is highly resistant to chloroquine and the risk to travellers is great. See recommendations for individual countries below.

Other arthropod-borne diseases (see Chapter 7) are a major cause of morbidity in the area:

•   Yellow fever - outbreaks occur periodically in unvaccinated populations within the endemic zones (see map on inside back cover). See recommendations for individual countries below.

•   Lymphatic filariasis and onchocerciasis widespread.

•   Cutaneous and visceral leishmaniasis - particularly drier areas; visceral leishmaniasis is epidemic in eastern and southern Sudan.

•   Human trypanosomiasis (sleeping sickness) - small isolated foci in all countries except Djibouti, Eritrea, Gambia, Mauritania, Niger, Somalia, the island countries of the Atlantic and Indian Oceans, Lesotho, Saint Helena, South Africa and Swaziland. Transmission rate is high in north-western Uganda and very high in Angola, Democratic Republic of Congo and Southern Sudan and there is significant risk of infection in travellers visiting or working in rural areas.

•   Louse, flea and tick-borne typhus.

•   Plague - natural foci reported from Angola, Kenya, Madagascar, Malawi, Mozambique, Uganda, Tanzania, Zambia, Zaire and Zimbabwe and some areas of Southern Africa; not usually a risk for tourists.

•   Dengue and many other viral infections transmitted by mosquitoes, ticks, sandflies etc, some presenting as severe haemorrhagic fevers, throughout the region.

•   The virus reservoir for Lassa fever (the multimammate rat) exists in some rural areas of West Africa.

•   Ebola and Marburg haemorrhagic fevers are present, but reported only infrequently.

•   Relapsing fever

•   Rift Valley fever.

•   West Nile fever.

Diseases of close association:

•   Poliomyelitis in most countries except Cape Verde, Comoros, Mauritius, Reunion and the Seychelles. Southern Africa is an emerging poliomyelitis free zone.

•   Tuberculosis incidence considered high.

•   Meningococcal meningitis - epidemics occur throughout tropical Africa particularly in the savanna in the dry season, which varies from country to country and can be unpredictable.

•   Trachoma.

Sexually transmitted and blood-borne infections:

Hepatitis B and HIV infection of high prevalence.

Other hazards could include:

•   Tetanus common.

•   Schistosomiasis throughout the area except Cape Verde, Comoros, Djibouti, Reunion and the Seychelles, Lesotho, Saint Helena.

•   Rabies.

•   Snake bites.

•   Large animal attacks.

3.8.2  Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

FOR ALL COUNTRIES Check routine immunisations including tetanus. Immunisation against poliomyelitis, hepatitis A and typhoid. Yellow fever immunisation for many countries - risk to the traveller varies with itinerary but immunisation is always advised within the endemic zone (unless travel is exclusively to urban areas at high altitude) and may be mandatory - see individual entries below. Meningococcal A&C immunisation recommended for longer visits to certain countries (see entries below) especially if backpacking or living or working with local people, or if current outbreaks reported. The risk is greatest in the dry season, but these may vary within a country and from year to year. As a guide, dry season in West Africa is usually between November-May/June. In East Africa, seasons are variable. For those on longer visits consider immunisation against diphtheria and hepatitis B and check BCG status; for rural visits out of reach of medical attention, consider immunisation against rabies.

Malaria prophylaxis: see individual countries. Unless otherwise indicated, the recommended prophylaxis for Sub-Saharan Africa is mefloquine or doxycycline or atovaquone/proguanil (malarone). For those such as some children and pregnant women unable to take any of these: chloroquine plus proguanil, remembering that this regimen is likely to be less protective than the first-choice recommendations.

3.8.3  Country by country variations and malaria chemoprophylaxis:

Angola

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. P.falciparum resistant to chloroquine and sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Benin

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Botswana

Malaria risk, predominantly P.falciparum, from November to May/June in northern parts of the country: Boteti, Chobe, Ngamiland, Okavango and Tutume districts/subdistricts. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for the northern half of the country from November to June, chloroquine plus proguanil.

Burkino Faso

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Burundi

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Cameroon

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended for northern region in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. P.falciparum resistant to chloroquine and sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Cape Verde

Yellow fever vaccination certificate required from travellers over one year of age coming from countries having notified cases in the last six years; recommended for all travellers.

Malaria prophylaxis: none. Limited risk in Sao Tiago Island, no prophylaxis recommended but remember slight risk if fever occurs.

Central African Republic

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended for northern part in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Chad

Yellow fever vaccination certificate recommended for all travellers over one year of age (yellow fever is endemic South of 15ºN).

Meningococcal A&C vaccine recommended for southern part in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Comoros

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Congo

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Democratic Republic of Congo (formerly Zaire)

Yellow fever vaccination certificate required from travellers over one year of age.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Djibouti

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Equatorial Guinea

Yellow fever vaccination certificate required from travellers coming from infected areas and recommended for all travellers.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Eritrea

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk in all areas under 2,000m throughout the year. Asmara no risk. Predominantly P.falciparum.

Recommended prophylaxis: see 3.8.2 above

Ethiopia

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk, predominantly P.falciparum, in all areas under 2,000m throughout the year. Highly chloroquine resistant P.falciparum reported. No risk in Addis Ababa.

Recommended prophylaxis: see 3.8.2 above.

Gabon

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Gambia

Yellow fever vaccination certificate required from travellers over one year of age arriving from endemic or infected areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above). Not routinely recommended for tourist visits unless outbreak reported.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Ghana

Yellow fever vaccination certificate required from all travellers.

Meningococcal A&C vaccine recommended for northern area in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Guinea

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Guinea - Bissau

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and from the following countries:

•   Africa: Angola, Benin, Burkina Faso, Burundi, Cape Verde, Central African Republic, Chad, Congo, Democratic Republic of Congo, Djibouti, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Ivory Coast, Kenya, Liberia, Madagascar, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Tanzania, Togo, Uganda, Zambia

•   America: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Peru, Surinam, Venezuela

and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Ivory Coast

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended for northern areas in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Kenya

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers, except those who confine their visit to a few days in Nairobi city.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above). Not routinely recommended for tourist visits unless outbreak reported.

Malaria risk very high in most areas throughout the year. The only areas where there is normally little risk are the centre of Nairobi and the highlands (above 2,500m) of Central, Rift Valley, Eastern, Nyanza and Western provinces. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulfadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Lesotho

Yellow fever vaccination certificate required from travellers coming from infected areas.

No malaria risk.

Recommended prophylaxis: none.

Liberia

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above

Madagascar

Yellow fever vaccination certificate required from travellers coming from, or having been in transit in, areas considered to be infected.

Malaria risk in all areas throughout the year, especially in coastal areas. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above

Malawi

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above

Mali

Yellow fever vaccination certificate required from all travellers over one year of age (yellow fever is endemic south of 15ºN).

Meningococcal A&C vaccine recommended for southern areas in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Mauritania

Yellow fever vaccination certificate required from all travellers over one year of age, except those arriving from a non-infected area and staying in Mauritania less than two weeks.

Malaria risk, predominantly P.falciparum, throughout the year in all areas except Dakhlet-Nouadhibou and Tiris-Zemour, in the north. Risk in the north confined to the rainy season (Jul-Oct).

Recommended prophylaxis: in risk areas, chloroquine plus proguanil.

Mauritius

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, considered to be those listed as endemic zones.

Malaria risk, exclusively P.vivax, throughout the year in certain rural areas; not Rodrigues Island.

Recommended prophylaxis: for rural areas, chloroquine. For other areas, remember slight risk if fever occurs.

Mozambique

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Namibia

Yellow fever vaccination certificate required from travellers coming from, or transitting on unscheduled flights through, infected areas. Travellers on scheduled flights which have transitted through infected areas are exempt provided they remained at the scheduled airport or adjacent town. A certificate is not insisted on for children under one year, but such infants may be subject to surveillance. The countries, or parts of countries, included in the endemic zones in Africa and South America are regarded as infected.

Meningococcal A&C vaccine recommended for north of country in certain circumstances. Not routinely recommended for tourist visits unless outbreak reported (see recommendations for all countries (3.8.2) above).

Malaria risk, predominantly P.falciparum, in northern regions (approximately one third of the country) from November to June and along the Kavango and Kunene rivers (the northern border) throughout the year. Resistance to chloroquine reported.

Recommended prophylaxis: chloroquine plus proguanil for northern area November-June, year round in extreme north.

Niger

Yellow fever vaccination certificate required from all travellers over one year of age and recommended for travellers leaving Niger. (Yellow fever is endemic south of 15ºN).

Meningococcal A&C vaccine recommended for southern area in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Nigeria

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers

Meningococcal A&C vaccine recommended for visits to northern part of the country in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high throughout the year in the whole country. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Reunion

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

No malaria risk.

Recommended prophylaxis: none.

Rwanda

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Saint Helena

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Sao Tome and Principe

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk, predominantly P.falciparum, in all areas throughout the year. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Senegal

Yellow fever vaccination certificate required from travellers coming from endemic areas and recommended for all travellers.

Meningococcal A&C vaccine recommended for southern part of the country in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Seychelles

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas or who have passed through partly or wholly endemic areas within the preceding six days. The countries and areas in the endemic zones are considered as infected areas.

No malaria risk.

Recommended prophylaxis: none.

Sierra Leone

Yellow fever vaccination certificate required from travellers coming from infected areas, and recommended for all travellers.

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Somalia

Yellow fever vaccination certificate required from travellers coming from infected areas, and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

South Africa

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries or parts of countries included in the endemic zone in Africa and the Americas are regarded as infected.

Malaria risk, predominantly P.falciparum, throughout the year in low altitude areas of the northern and eastern Transvaal and eastern Natal as far south as the Tugela river (sixty miles north of Durban). At times of heavy rainfall this area may get larger and transmission rates may increase. Resistance to chloroquine reported.

Recommended prophylaxis: for risk areas (which are in the north eastern part of the country and include Kruger National Park), see 3.8.2 above.

Sudan

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries and areas included in the endemic zone are considered as infected. A certificate may be required from travellers leaving Sudan. Recommended for all travellers (yellow fever is endemic south of 12ºN).

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Highly chloroquine resistant P.falciparum reported.

Risk on the Red Sea coast is very limited, and that in the north and beside Lake Nasser is limited.

Recommended prophylaxis: see 3.8.2 above

Swaziland

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk, predominantly P.falciparum, throughout the year in all low veld areas (mainly Big Bend, Mhlume, Simunye and Tshaneni). These are in the eastern half of the country. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Tanzania (including Zanzibar)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, regarded as those listed as endemic zones, and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high throughout the year in all areas under 1,800m. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Togo

Yellow fever vaccination certificate required from all travellers over one year of age (yellow fever is endemic south of 15ºN).

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Uganda

Yellow fever vaccination certificate required from travellers over one year of age coming from endemic areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high throughout the year in the whole country including the main towns and cities. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Zaire - see Democratic Republic of Congo

Zambia

The western area is within the yellow fever belt; vaccination recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Zimbabwe

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended (May-October) in certain circumstances (see recommendations for all countries (3.8.2) above). Not routinely recommended for tourist visits unless outbreak reported.

Malaria risk, predominantly P.falciparum, from November to June in areas below 1,200m and throughout the year in the Zambezi valley. In Harare and Bulawayo the risk is negligible. Resistance to chloroquine reported.

Recommended prophylaxis: for the Zambezi valley, see 3.8.2 above. For other infected areas, chloroquine plus proguanil.