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Diseases potentially acquired by travel to North Africa

Diseases potentially acquired by travel to North Africa
Literature review current through: Jan 2024.
This topic last updated: Jan 26, 2023.

INTRODUCTION — North Africa refers to the region of the African continent north of the Sahara Desert. For the purposes of this discussion, the countries within this region are Algeria, the Canary Islands (Spain), Egypt, Libya, Morocco, and Tunisia. This region is characterized by fertile coastal areas and a desert hinterland.

ARTHROPOD-BORNE DISEASES

Malaria — There is no malaria transmission in North Africa. Previously there were small foci of transmission in Algeria and Egypt, but there is no malaria risk for travelers to this region [1]. (See "Prevention of malaria infection in travelers".)

Yellow fever — There is no risk for yellow fever in North Africa. However, Algeria, Egypt, Libya, and Tunisia require travelers to have a yellow fever vaccination certificate if they are coming from specified areas in South America or sub-Saharan Africa. (See "Yellow fever: Epidemiology, clinical manifestations, and diagnosis".)

Leishmaniasis — Both cutaneous and visceral leishmaniasis occur in the Mediterranean littoral areas of Algeria, Egypt, Libya, Morocco, and Tunisia. Sand flies of the genus Phlebotomus are the vectors. The main reservoirs are dogs, foxes, and humans. In this region, Leishmania infantum is the principal cause of visceral leishmaniasis, and Leishmania tropica is the principal cause of cutaneous leishmaniasis. (See "Cutaneous leishmaniasis: Epidemiology and control" and "Visceral leishmaniasis: Epidemiology and control".)

Rickettsioses — Several rickettsial diseases are endemic in North Africa, including epidemic typhus (caused by Rickettsia prowazekii) [2,3], murine typhus (caused by Rickettsia typhi) [4], and Mediterranean spotted fever (caused by Rickettsia conorii) [5]. Murine typhus has also been reported from the Canary Islands [6].

Epidemic typhus is transmitted by the body louse, and human conditions that favor the proliferation of lice occur during cold weather (eg, Algerian highlands) and during war or natural disasters (eg, among refugees). (See "Epidemic typhus".)

Murine typhus is transmitted to humans by rat or cat fleas and occurs most commonly in urban settings. (See "Murine typhus" and "Murine typhus", section on 'Diagnosis'.)

Mediterranean spotted fever is transmitted to humans by hard ticks. (See "Other spotted fever group rickettsial infections", section on 'R. conorii (Mediterranean spotted fever)'.)

Other arboviral infections — There is very limited risk of arboviral infections in North Africa. Localized outbreaks of Rift Valley fever have occurred in the Nile River valley of Egypt. An outbreak of dengue fever has been reported from Red Sea Governorate, Egypt from 2015 [7].

FOODBORNE AND WATERBORNE DISEASES

Travelers' diarrhea — North Africa is a high-risk area for the development of travelers' diarrhea, with enterotoxigenic Escherichia coli being the most common pathogen identified [8]. Diarrhea occurs in 10 to 50 percent of travelers to this region [8]. (See "Travelers' diarrhea: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

Typhoid — Typhoid fever is endemic throughout most of North Africa with regional incidence rates of 10 to 100 cases per 100,000 persons per year [9]. (See "Enteric (typhoid and paratyphoid) fever: Epidemiology, clinical manifestations, and diagnosis" and "Immunizations for travel", section on 'Typhoid vaccine'.)

Hepatitis A and hepatitis E — Hepatitis A and hepatitis E viruses are endemic throughout North Africa and have been associated with outbreaks [10-12]. (See "Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis" and "Hepatitis E virus infection" and "Immunizations for travel", section on 'Hepatitis A vaccine'.)

Schistosomiasis — Schistosomiasis due to Schistosoma haematobium and Schistosoma mansoni is widespread in North Africa; S. haematobium infection predominates in the western areas of this region. For travelers, the Nile River valley in Egypt is an area of particular risk. Transmission occurs through exposure to fresh water (lakes and slow-moving rivers) in endemic regions. (See "Schistosomiasis: Epidemiology and clinical manifestations".)

Echinococcosis — Echinococcosis is hyperendemic in Algeria, Morocco, Libya, and Tunisia and is endemic in Egypt [13]. (See "Epidemiology and control of echinococcosis".)

OTHER INFECTIONS

HIV infection — There are relatively low rates of human immunodeficiency virus (HIV) infection in North Africa. The main mode of transmission in this region is unprotected sexual contact; injection drug use is becoming an increasingly important factor. (See "Global epidemiology of HIV infection".)

Hepatitis B and hepatitis C — Hepatitis B virus is highly endemic throughout North Africa. (See "Hepatitis B virus: Clinical manifestations and natural history".)

The prevalence of hepatitis C is also high in many regions. (See "Clinical manifestations and natural history of chronic hepatitis C virus infection" and "Clinical manifestations, diagnosis, and treatment of acute hepatitis C virus infection in adults".)

Plague — Occasional cases of plague are reported from North Africa. (See "Epidemiology, microbiology and pathogenesis of plague (Yersinia pestis infection)".)

Rabies — Rabies is endemic throughout Africa and has been reported with increasing frequency [14,15]. The domestic dog plays a key role in maintenance and transmission of rabies. Postexposure treatment is recommended following all potential exposures, and prophylaxis should be considered by travelers spending significant periods of time in North Africa. (See "Rabies immune globulin and vaccine" and "Indications for post-exposure rabies prophylaxis" and "Immunizations for travel", section on 'Rabies vaccine'.)

Tuberculosis — Tuberculosis is relatively common in many parts of North Africa, although short-term travelers from countries of low endemicity are generally not considered at increased risk of infection.

OTHER HAZARDS

Snake bites — Venomous snakes are present throughout North Africa. The most important species include the saw-scaled or carpet viper (Echis spp), puff adder (Bitis arietans), and spitting cobra (Naja nigricollis, N. mossambica, and others). (See "Snakebites worldwide: Management".)

Heat-associated illness — Heat-associated illnesses, including heat stroke and heat exhaustion, are risks for travelers to many areas within North Africa.

High-altitude disease — The main high-altitude destinations for travelers in North Africa are the Atlas Mountains of Morocco and the volcanoes of the Canary Islands. (See "High-altitude illness: Physiology, risk factors, and general prevention".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Travel medicine".)

SUMMARY

North Africa is comprised of Algeria, the Canary Islands (Spain), Egypt, Libya, Morocco, and Tunisia. (See 'Introduction' above.)

There is no malaria risk for travelers to North Africa. (See 'Malaria' above.)

Other arthropod-borne diseases include leishmaniasis and rickettsioses. (See 'Arthropod-borne diseases' above.)

Foodborne and waterborne diseases include travelers' diarrhea, typhoid, hepatitis A, hepatitis E, schistosomiasis, and echinococcus. (See 'Foodborne and waterborne diseases' above.)

Other infections include HIV infection, hepatitis B, hepatitis C, plague, rabies, and tuberculosis. (See 'Other infections' above.)

  1. Centers for Disease Control and Prevention. Malaria Information and Prophylaxis, by Country. https://www.cdc.gov/malaria/travelers/country_table/a.html (Accessed on January 21, 2021).
  2. Mokrani K, Fournier PE, Dalichaouche M, et al. Reemerging threat of epidemic typhus in Algeria. J Clin Microbiol 2004; 42:3898.
  3. Niang M, Brouqui P, Raoult D. Epidemic typhus imported from Algeria. Emerg Infect Dis 1999; 5:716.
  4. Letaïef AO, Kaabia N, Chakroun M, et al. Clinical and laboratory features of murine typhus in central Tunisia: a report of seven cases. Int J Infect Dis 2005; 9:331.
  5. Letaïef A, Souissi J, Trabelsi H, et al. Evaluation of clinical diagnosis scores for Boutonneuse fever. Ann N Y Acad Sci 2003; 990:327.
  6. Hernández Cabrera M, Angel-Moreno A, Santana E, et al. Murine typhus with renal involvement in Canary Islands, Spain. Emerg Infect Dis 2004; 10:740.
  7. Abozeid S, Elsayed AK, Schaffner F, Samy AM. Re-emergence of Aedes aegypti in Egypt. Lancet Infect Dis 2018; 18:142.
  8. Steffen R. Epidemiology of traveler's diarrhea. Clin Infect Dis 2005; 41 Suppl 8:S536.
  9. Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ 2004; 82:346.
  10. Frank C, Walter J, Muehlen M, et al. Large outbreak of hepatitis A in tourists staying at a hotel in Hurghada, Egypt, 2004--orange juice implicated. Euro Surveill 2005; 10:E050609.2.
  11. Stoszek SK, Engle RE, Abdel-Hamid M, et al. Hepatitis E antibody seroconversion without disease in highly endemic rural Egyptian communities. Trans R Soc Trop Med Hyg 2006; 100:89.
  12. Benjelloun S, Bahbouhi B, Bouchrit N, et al. Seroepidemiological study of an acute hepatitis E outbreak in Morocco. Res Virol 1997; 148:279.
  13. Sadjjadi SM. Present situation of echinococcosis in the Middle East and Arabic North Africa. Parasitol Int 2006; 55 Suppl:S197.
  14. Cleaveland S. Royal Society of Tropical Medicine and Hygiene meeting at Manson House, London, 20 March 1997. Epidemiology and control of rabies. The growing problem of rabies in Africa. Trans R Soc Trop Med Hyg 1998; 92:131.
  15. Gautret P, Ribadeau-Dumas F, Parola P, et al. Risk for rabies importation from North Africa. Emerg Infect Dis 2011; 17:2187.
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