Background: The risk of malaria to visitors to South Africa's nature reserves is unknown. Current recommendations for travelers are based on malaria incidence rates in local communities. These rates may well overestimate travelers’malaria risk and lead to unnecessary use of antimalarial prophylaxis with associated drug-related adverse events. This study investigated the incidence of malaria in visitors to South Africa's Kruger National Park (KNP).

Methods: Postal questionnaires were sent to the cohort of visitors staying in the KNP during April 1996, 6 to 8 weeks after they returned to their homes. Nonrespondents received duplicate questionnaires 8 weeks later. Responses from 3267 groups, representing 11,107 visitors (56.8%) allowed determination of the malaria attack rate in this group of travelers and assessment of associations between malaria risk and a number of factors, including type of accommodation used during the visit; duration of stay; use of chemoprophylaxis; and use of personal protection measures. All travelers indicating that they had suffered an episode of malaria following their visit were telephonically contacted and their health providers traced to determine the basis of diagnosis and clinical outcome.

Results: One clinically suspected and four confirmed cases of Plasmodium falciparum malaria among the visitors suggest a low attack rate of 4.5 cases per 10,000 visitors during April, the highest risk month for malaria in South Africa. No association was found between malaria risk and accommodation type, duration of stay, use and type of chemoprophylaxis, and use and number of personal protection measures.

Conclusions: These findings confirm the importance of careful assessment of local malaria risk before individualized advice is provided to travelers.