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Andorra

General
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This small country is situated between France and Spain. Because of its elevation and proximity to the Pyrenees the climate is generally pleasant throughout the year.
Climate
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During the summer months the temperatures can rise to 30c but there is usually a cooling breeze. Lightening storms can occur during the summer months associated with torrential rain.
Sun Exposure and Dehydration
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Those from Northern Europe can develop significant sun exposure and so remember to use a wide brimmed hat when necessary. The altitude can also lead to significant tiredness and dehydration so take sufficient initial rest and drink plenty of fluids.
Safety & Security
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The level of crime throughout the country directed at tourists is very low. Nevertheless take care of your personal belongings at all times and use hotel safety boxes where possible.
Local Customs
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There are strict laws regarding the use of illegal drugs. Make sure you have sufficient supplies of any medication you required for your trip and that it is clearly marked. The European E111 form is not accepted in Andorra and so it is essential that you have sufficient travel insurance for your trip.
Winter Sports
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Andorra is one of the regions where many travel to partake of their winter sport facilities. Generally this is well controlled and one of the safer regions. Nevertheless, make certain your travel insurance is adequate for the activities you are planning to undertake.
Vaccination
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The only standard vaccine to consider for Andorra would be tetanus in line with many other developed countries of the world.

Travel News Headlines WORLD NEWS

Date: Thu, 12 Jul 2018 15:24:06 +0200

Andorra la Vella, Andorra, July 12, 2018 (AFP) - The tax haven of Andorra has long been a favourite destination for smokers looking to stock up on cheap cigarettes, but the enclave said Thursday that it would soon stop advertising the fact.   The government said it had signed up to the World Health Organization's (WHO) anti-tobacco convention, which aims to encourage people to quit smoking and combat contraband sales.   "The goal is to contribute to public health and pursue the fight against trafficking," government spokesman Jordi Cinca said at a press conference.

The tiny principality of Andorra, perched in the Pyrenees on the border between France and Spain, attracts millions of shoppers each year to duty-free stores, where prices of alcohol, cigarettes, electronics and clothes can be up to 20 percent cheaper than elsewhere in the EU.   High taxes on tobacco imposed by many countries to help people kick smoking make Andorra's cigarettes a particularly good deal.   The average pack costs just three euros ($3.50) compared with eight euros in France, which has said it will gradually raise the price to 10 euros a pack by November 2020.

Tobacco sales bring in some 110 million euros a year for Andorra, whose economy is otherwise based almost entirely on tourism.   It is also an enticing destination for smugglers, with French and Spanish border agents regularly seizing cartons from people trying to sneak them out, either by car or by hiking down the mountain trails which criss-cross the Pyrenees.   No date has been set for the advertising ban, which will come into effect three months after the ratification of the WHO accord is voted by parliament.
Date: Fri, 16 Mar 2018 02:41:51 +0100

Andorra la Vella, Andorra, March 16, 2018 (AFP) - The tiny principality of Andorra is witnessing a once in a generation phenomenon -- a widespread strike.   Around a third of civil servants across the mountainous micro-state have walked out to protest proposed reforms to their sector in what has been described as Andorra's first large-scale strike since 1933.

With no negotiation breakthrough in sight, picket lines are expected to be manned again on Friday with customs officers, police, teachers and prison staff among those taking part.   The first major strike in 85 years was sparked by plans from the government of Antoni Marti to reform civil servant contracts.   He has assured officials "will not do an hour more" work under the reforms and that 49 million euros would be allocated for the next 25 years to supplement civil servant salaries.   But government workers are unconvinced with unions warning the reforms could risk their 35 hour working week and pay.

Customs officers involved in the strike interrupted traffic on the Andorran-Spanish border this week, according to unions, while some 80 percent of teachers have walked out of classes.   Strikers have occupied the government's main administrative building and held noisy protests outside parliament calling for Marti's resignation.    "We have started collecting signatures to demand the resignation of the head of government and now nobody will stop us," Gabriel Ubach, spokesman for the public service union, told reporters.
Date: Mon 27 Sep 2017
Source: Contagion Live [edited]

A recent Dispatch article published in the Centers for Disease Control and Prevention (CDC)'s Emerging Infectious Diseases journal, offers insight into a large norovirus outbreak that sprung up in Spain in 2016 that had been linked with bottled spring water. The Public Health Agency of Catalonia (ASPCAT) reported a staggering 4136 cases of gastroenteritis from 11-25 Apr 2016. Of the 4136 cases, 6 individuals required hospitalization. The CDC defines a "case-patient" as an "exposed person who had vomiting or diarrhoea (3 or more loose stools within 24 hours)," as well as 2 or more of the following symptoms: nausea, stomach pain, or fever.

ASPCAT investigators traced back the outbreak to contaminated bottled spring water in office water coolers. The water came from a source in Andorra, a small independent principality located between Spain and France. Norovirus is a "very contagious virus," according to the CDC, and it is common for individuals to become infected by eating contaminated food. Although it is possible to be infected by consuming contaminated drinking water, this mode of transmission is "rare in developed countries," according to the article.

The investigators collected water samples from a total of 4 19-L water coolers in 2 different offices located in Barcelona, "from which affected persons had drunk; samples 1 and 2 came from 2 water coolers in one office, while samples 3 and 4 came from 2 water coolers in another office. Using "positively charged glass wool and polyethylene glycol precipitation for virus concentration," the investigators tested the samples.

"We detected high RNA levels for norovirus genotype I and II, around 103 and 104 genome copies/L, in 2 of the 4 water cooler samples concentrated by glass wool filtration and polyethylene glycol precipitation," according to the article. The investigators noted that a drawback of using molecular methods is that they are not able to differentiate between particles that are infectious and those that are not. Therefore, they "predicted the infectivity of norovirus in the concentrated samples by treating the samples with the nucleic acid intercalating dye PMA propidium monoazide and Triton X surfactant before RT-qPCR," which allowed them to "distinguish between virions with intact and altered capsids."

In those 2 water samples, they found high genome copy values -- 49 and 327 genome copies/L for norovirus genotype I and 33 and 660 genomes copies/L for norovirus genotype II. This was not an unexpected finding, due to the large number of infected individuals associated with the outbreak. Through "PMA/Triton treatment before RT-qPCR assays," the investigators found that the proportion of infected virions accounted for 0.3% to 5.6% of the total number of physical particles in the water samples, "which was enough to cause gastrointestinal illness."

The investigators also analyzed faecal samples collected from infected individuals who worked at the office in which the 1st 2 water samples were collected. They detected the following genotypes in those faecal samples: GI.2 and GII.17. In the faecal samples collected from the other office, they isolated the following genotypes: GII.4/Sydney/2012, GI.2, GII.17, and GII.2.

"We hypothesize that the spring water was contaminated by all 4 strains (GI.2, GII.2, GII.4, and GII.17) but levels of viral contamination for each genotype were not homogeneous in all bottled coolers," the investigators wrote. "We may have detected only the GII.4 genotype in water samples 1 and 2 because of a higher concentration of this specific genotype or because of bias caused by the sampling, concentration, and molecular detection procedures."

The investigators admit one limitation to their study: the small number of water samples collected and analyzed. They attribute this to the fact that on 15 Apr 2016, 4 days after the onset of the outbreak, the company that produced the drinking water recalled over 6150 containers of water "of suspected quality" as a precautionary measure. The recall prevented the investigators from collecting more samples to assess, according to the article.

Although the exact cause of the contamination has not yet been identified, the investigators posit that "the high number of affected persons from 381 offices that received water coolers, and the many different genotypes found in some patients' faecal specimens" suggest that the spring aquifer had been contaminated by "sewage pollution," and the Andorra Ministry of Health and Welfare banned further use of the spring.

The investigators suggest that assessing commercially-produced mineral waters for different harmful pathogens, such as norovirus would be beneficial. They note, however, that creating, enhancing, and managing such "virus surveillance systems" would be costly. Thus, the investigators suggest taking a "balanced approach to keep both the cost and the time required for the analyses within feasibility limits."  [Byline: Kristi Rosa]
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[The interesting article published in the September 2017 issue of Emerging Infectious Diseases is:
Blanco A, Guix S, Fuster N, et al: Norovirus in bottled water associated with gastroenteritis outbreak, Spain, 2016. Emerg Infect Dis. 2017; 23(9): 1531-34; https://wwwnc.cdc.gov/eid/article/23/9/16-1489_article. - ProMED Mod.LL]

[Catalonia and Andorra can be located on the HealthMap/ProMED-mail map at http://healthmap.org/promed/p/1341. - ProMED Sr.Tech.Ed.MJ]
Date: Thu, 26 Dec 2013 22:25:05 +0100 (MET)

ANDORRA LA VELLA, Andorra, Dec 26, 2013 (AFP) - A Spanish skier and a French snowboarder have died in avalanches in different mountain ranges in Europe, officials said Thursday.

The 27-year-old skier, a woman from Barcelona, died Wednesday while going off-piste alone in the Soldeu resort in Andorra, in the Pyrenees mountains between France and Spain, a resort manager told AFP.   Although she was rescued within 10 minutes, after her glove was spotted on the surface, she was unable to be revived despite a helicopter dash to hospital.

In the Italian Alps, close to the border with France, a 24-year-old Frenchman who was snowboarding with three friends on a closed run died Thursday when an avalanche swept over him in the resort town of Les Arnauds.   Local officials said he succumbed to multiple injuries, asphyxia and hypothermia.

Avalanches are common in Europe's ski resorts at this time of year, when early snows are heavy with moisture, and several deaths occur each winter.   Last Sunday, a 35-year-old Frenchman died in an avalanche in the Alps near the Italian border while on a three-day trek with a friend.
Date: Fri 7 Feb 2003 From: Jaime R. Torres Source: EFE Salud, Thu 6 Feb 2003 (translated by Maria Jacobs) [edited] -------------------------------------------------- Close to 300 students in one school and 173 tourists staying in 7 hotels in the Principality of Andorra have been affected by outbreaks of gastroenteritis that, according to local authorities, are not related to each other. Monica Codina, Minister of Health, stated that the outbreak that has affected almost 300 children and 8 adults in the San Ermengol school was detected last Monday [3 Feb 2003] but that it may have started Wednesday or Thursday of the previous week. The epidemiological surveys of a group of pre-school and grammar school students that may also be affected have not been performed yet. Also pending are the results of the microbiological tests of the food and water served in the school dining room, but the minister has indicated that the probable cause of the outbreak is the fact that water pitchers were filled with hoses directly from the faucet. The Minister stated that this outbreak of gastroenteritis is not related to the one that affected 173 tourists, most of them young people on holiday, who where staying in 7 hotels of the Principality. The government is also investigating the cause of this outbreak and has indicated that an anomaly in the system that supplies water to the hotels was detected, requiring a process of chlorination, which has not been carried out due to the heavy snowfall of the past few days. * * * * * * * * * * [The suspicion that defective water supplies may be responsible for all of these independent outbreaks suggests that the etiologic agent may be an enterovirus, hepatitis A virus, or non-viral, rather than one of the noroviruses associated with sudden-onset viral gastroenteritis. Information on the outcome of diagnostic tests in progress would be welcomed. - ProMed Mod.CP]
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Gibraltar

United Kingdom and Gibraltar (England, Wales, Scotland, Northern Ireland) US Consular Information Sheet
June 03, 2008
COUNTRY DESCRIPTION:
The United Kingdom of Great Britain and Northern Ireland is a highly developed constitutional monarc
y comprised of Great Britain (England, Scotland and Wales) and Northern Ireland.
Read the Department of State Background Notes on the United Kingdom for additional information.
Gibraltar is a United Kingdom Overseas Territory bordering Spain and located at the southernmost tip of Europe at the entrance to the Mediterranean Sea.
It is one of thirteen former British colonies that have elected to continue their political links with London.
Tourist facilities are widely available.

ENTRY/EXIT REQUIREMENTS:
A visa is not required for tourist or business visits to the UK of less than six months in duration.
Visitors wishing to remain longer than one month in Gibraltar should regularize their stay with Gibraltar immigration authorities.
Those planning to visit the UK for any purpose other than tourism or business, or who intend to stay longer than six months, should consult the website of the British Embassy in the United States at http://britainusa.com for information about current visa requirements.
Those who are required to obtain a visa and fail to do so may be denied entry and returned to their port of origin.
The British government is currently considering reducing the visa-free period from six months to 90 days.
Travelers should be alert to any changes in legislation.
The U.S. Embassy cannot intervene in UK visa matters.
In addition to the British Embassy web site at http://britainusa.com, those seeking current UK visa information may also contact UK consular offices via their premium rate telephone service at 1-900-656-5000 (cost $3/minute) or 1-212-796-5773 ($12 flat fee).
Information about dual nationality or the prevention of international child abduction can be found on our web site.
For further information about customs regulations, please read our Customs Information sheet.
SAFETY AND SECURITY:
The United Kingdom is politically stable, with a modern infrastructure, but shares with the rest of the world an increased threat of terrorist incidents of international origin, as well as the potential, though significantly diminished in recent years, for isolated violence related to the political situation in Northern Ireland (a part of the United Kingdom).
On July 7, 2005, a major terrorist attack occurred in London, as Islamic extremists detonated explosives on three underground trains and a bus in Central London, resulting in over 50 deaths and hundreds of injuries.
Following the attacks, the public transportation system was temporarily disrupted, but quickly returned to normal.
A similar but unsuccessful attack against London’s public transport system took place on July 21, 2005.
UK authorities have identified and arrested people involved in these attacks.
Similarly, those involved in terrorist incidents in London and Glasgow during the summer of 2007 were identified and arrested.
Like the US, the UK shares its national threat levels with the general public to keep everyone informed and explain the context for the various increased security measures that may be encountered. UK threat levels are determined by the UK Home Office and are posted on its web site at http://www.homeoffice.gov.uk/security/current-threat-level/.
Information from the UK Security Service, commonly known as MI5, about the reasons for the increased threat level and actions the public can take is available on the MI5 web site at http://www.mi5.gov.uk/.
On August 10, 2006, the Government of the United Kingdom heightened security at all UK airports following a major counterterrorism operation in which individuals were arrested for plotting attacks against US-bound airlines.
As a result of this, increased restrictions concerning carry-on luggage were put in place and are strictly enforced.
American citizens are advised to check with the UK Department for Transport at http://www.dft.gov.uk/transportforyou/airtravel/airportsecurity/ regarding the latest security updates and carry-on luggage restrictions.
The British Home Secretary has urged UK citizens to be alert and vigilant by, for example, keeping an eye out for suspect packages or people acting suspiciously at subway (called the “Tube” or Underground) and train stations and airports and reporting anything suspicious to the appropriate authorities.
Americans are reminded to remain vigilant with regard to their personal security and to exercise caution.
For more information about UK public safety initiatives, consult the UK Civil Contingencies Secretariat web site at http://www.ukresilience.gov.uk.
The political situation in Northern Ireland has dramatically improved since the signing of the Good Friday Agreement in 1998, the announcement by the Irish Republican Army (IRA) on July 28, 2005, that it would end its armed campaign, and the agreement to set up a power-sharing government on May 8, 2007.
The potential remains, however, for sporadic incidents of street violence and/or sectarian confrontation. American citizens traveling to Northern Ireland should therefore remain alert to their surroundings and should be aware that if they choose to visit potential flashpoints or attend parades sporadic violence remains a possibility. Tensions may be heightened during the summer marching season (April to August), particularly during the month of July around the July 12th public holiday.

The phone number for police/fire/ambulance emergency services - the equivalent of "911" in the U.S. - is “999” in the United Kingdom and “112” in Gibraltar.
This number should also be used for warnings about possible bombs or other immediate threats.
The UK Anti-Terrorist Hotline, at 0800 789 321, is for tip-offs and confidential information about possible terrorist activity.
For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov, where the current Travel Warnings, Travel Alerts, as well as the Worldwide Caution can be found.
Recent communications from U.S. Embassy London to the local American citizen community, called Warden Messages, can be found on the U.S. Embassy's American Citizens' Services web site at http://london.usembassy.gov/cons_new/acs/index.html.
Up-to-date information on safety and security can also be obtained by calling 1-888-407-4747 toll free in the U.S., or for callers outside the U.S. and Canada, a regular toll-line at 1-202-501-4444.
These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).
The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas.
For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State’s pamphlet, A Safe Trip Abroad.
CRIME:
The United Kingdom and Gibraltar benefit from generally low crime rates and rates decreased slightly in 2007 in significant categories, including violent crime.
The crime situation in the UK is similar to the United States, with typical incidents including pick-pocketing; mugging; “snatch and grab” thefts of mobile phones, watches and jewelry; and theft of unattended bags, especially at airports and from cars parked at restaurants, hotels and resorts.
Pickpockets target tourists, especially at historic sites, restaurants, on buses, trains and the London Underground (the “Tube,” or subway).
Thieves often target unattended cars parked at tourist sites and roadside restaurants, looking for laptop computers and hand-held electronic equipment, especially global positioning satellite equipment.
Walking in isolated areas, including public parks, especially after dark, should also be avoided, as these provide advantageous venues for muggers and thieves.
At night or when there is little foot traffic, travelers should be especially careful using the underground pedestrian tunnels.
As a general rule, either walk the extra distance to use a surface crossing or wait until there are other adult pedestrians entering the tunnel.

In London, travelers should use only licensed “black taxi cabs,” or car services recommended by their hotel or tour operator.
Unlicensed taxis or private cars posing as taxis may offer low fares, but are often uninsured and may have unlicensed drivers.
In some instances, travelers have been robbed and raped while using these cars.
You can access 7,000 licensed “Black Cabs” using just one telephone number – 0871 871 8710. This taxi booking service combines all six of London’s radio taxi circuits, allowing you to telephone 24 hours a day if you need to “hail a cab.” Alternatively, to find a licensed minicab, text “HOME” to 60835 on your mobile phone to get the telephone number to two licensed minicab companies in the area. If you know in advance what time you will be leaving for home, you can pre-book your return journey.
The “Safe Travel at Night” partnership among the Metropolitan Police, Transport for London, and the Mayor of London maintains a website with additional information at http://www.cabwise.com/.
Travelers should not leave drinks unattended in bars and nightclubs.
There have been some instances of drinks being spiked with illegal substances, leading to incidents of robbery and rape.
Due to the circumstances described above, visitors should take steps to ensure the safety of their U.S. passports.
Visitors in England, Scotland, Wales, Northern Ireland, and Gibraltar are not expected to produce identity documents for police authorities and thus may secure their passports in hotel safes or residences.
Abundant ATMs that link to U.S. banking networks offer an optimal rate of exchange and they preclude the need to carry a passport to cash travelers’ checks.
Travelers should be aware that U.S. banks might charge a higher processing fee for withdrawals made overseas.
Common sense personal security measures utilized in the U.S. when using ATMs should also be followed in the UK.
ATM fraud in the UK is becoming more sophisticated, incorporating technologies to surreptitiously record customer ATM card and PIN information.
Travelers should avoid using ATMs that look in any way “temporary” in structure or location, or that are located in isolated areas.
Travelers should be aware that in busy public areas, thieves use distraction techniques, such as waiting until the PIN number has been entered and then pointing to money on the ground, or attempting to hand out a free newspaper.
When the ATM user is distracted, a colleague will quickly withdraw cash and leave.
If distracted in any way, travelers should press the cancel transaction button immediately and collect their card before speaking to the person who has distracted them.
If the person’s motives appear suspicious, travelers should not challenge them but remember the details and report the matter to Police as soon as possible.
In addition, travelers should not use the ATM if there is anything stuck to the machine or if it looks unusual in any way.
If the machine does not return the card, report the incident to the issuing bank immediately.

INFORMATION FOR VICTIMS OF CRIME:
The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the nearest U.S. Embassy or Consulate at the opening of the next business day.
The U.S. Embassy or Consulate only issues replacement passports during regular business hours.
If you are the victim of a crime while overseas, report it to local police.
The nearest U.S. Embassy or Consulate will also be able to assist by helping you to find appropriate medical care, contacting family members or friends, and explaining how funds could be transferred.
Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.

Visit the “Victim Support” web site, maintained by an independent UK charity to helps people cope with the effects of crime: http://www.victimsupport.org.uk/
See our information for Victims of Crime.
MEDICAL FACILITIES AND HEALTH INFORMATION:
While medical services are widely available, free care under the National Health System is allowed only to UK residents and certain EU nationals.
Tourists and short-term visitors will be charged for medical treatment in the UK.
Charges may be significantly higher than those assessed in the United States.
Hiking in higher elevations can be treacherous.
Several people die each year while hiking, particularly in Scotland, often due to sudden changes in weather.
Visitors, including experienced hikers, are encouraged to discuss intended routes with local residents familiar with the area, and to adhere closely to recommendations.
Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://wwwn.cdc.gov/travel/default.aspx.
For information about outbreaks of infectious diseases abroad consult the World Health Organization’s (WHO) web site at http://www.who.int/en.

MEDICAL INSURANCE:
The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation.
If your medical insurance policy does not provide overseas coverage, you may want to purchase a short-term policy for your trip.
The Department of State provides a list of travel insurance companies that can provide the additional insurance needed for the duration of one’s trip abroad in its online at medical insurance overseas.
Remember also that most medical care facilities and medical care providers in the UK do not accept insurance subscription as a primary source of payment.
Rather, the beneficiary is expected to pay for the service and then seek reimbursement from the insurance company.
This may require an upfront payment in the $10,000 to $20,000 range

Please see our information on medical insurance overseas.

TRAFFIC SAFETY AND ROAD CONDITIONS:
While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States.
The information below concerning the United Kingdom is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

UK penalties for driving under the influence of even minimal amounts of alcohol or drugs are stiff and often result in prison sentences.
In contrast to the United States and continental Europe, where traffic drives on the right side of the road, in the UK, it moves on the left.
The maximum speed limit on highways/motorways in the UK is 70MPH.
Motorways generally have a hard shoulder (breakdown lane) on the far left, defined by a solid white line.
It is illegal to stop or park on a hard shoulder unless it is an emergency.
In such cases, you should activate your hazard lights, get out of your vehicle and go onto an embankment for safety.
Emergency call boxes (orange telephone booths with “SOS” printed on them) may be found at half-mile intervals along the motorway.
White and blue poles placed every 100 yards along the motorway point in the direction of the nearest call box.
Emergency call boxes dial directly to a motorway center.
It is best to use these phones rather than a personal cell phone, because motorway center personnel will immediately know the location of a call received from an emergency call box.
Roadside towing services may cost approximately £125.
However, membership fees of automotive associations such as the RAC or AA (Automobile Association) often include free roadside towing service.
Visitors uncomfortable with, or intimidated by, the prospect of driving on the left-hand side of the road may wish to avail themselves of extensive bus, rail and air transport networks that are comparatively inexpensive.
Roads in the UK are generally excellent, but are narrow and often congested in urban areas.
If you plan to drive while in the UK, you may wish to obtain a copy of the Highway Code, available at http://www.highwaycode.gov.uk.
Travelers intending to rent cars in the UK should make sure that they are adequately insured.
U.S. auto insurance is not always valid outside the U.S., and travelers may wish to purchase supplemental insurance, which is generally available from most major rental agents.
The city of London imposes a congestion charge of £8 (eight pounds sterling, or approximately U.S. $16.00) on all cars entering much of central London Monday through Friday from 7:00 a.m. to 6:30 p.m.
Information on the congestion charge can be found at http://www.cclondon.com.
Public transport in the United Kingdom is excellent and extensive.
However, poor track conditions may have contributed to train derailments resulting in some fatalities.
Repairs are underway and the overall safety record is excellent.
Information on disruptions to London transportation services can be found at http://www.tfl.gov.uk and information about the status of National Rail Services can be found at http://www.nationalrail.co.uk.
Many U.S. pedestrians are injured, some fatally, every year in the United Kingdom, because they forget that oncoming traffic approaches from the opposite direction than in the United States.
Extra care and alertness should be taken when crossing streets; remember to look both ways before stepping into the street.
Driving in Gibraltar is on the right-hand side of the road, as in the U.S. and Continental Europe.
Persons traveling overland between Gibraltar and Spain may experience long delays in clearing Spanish border controls.
Please refer to our Road Safety Overseas page for more information.
For specific information concerning United Kingdom driving permits, vehicle inspection, road tax and mandatory insurance, refer to the United Kingdom’s Department of Environment and Transport web site at http://www.dft.gov.uk, the Driving Standards Agency web site at http://www.dsa.gov.uk or consult the U.S. Embassy in London’s web site at http://london.usembassy.gov/.

AVIATION SAFETY OVERSIGHT:
The U.S. Federal Aviation Administration (FAA) has assessed the Government of the United Kingdom’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of the UK’s air carrier operations.
For further information, travelers may visit the FAA's web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.

SPECIAL CIRCUMSTANCES:
The legal drinking age in the UK is generally lower than in the U.S. and social drinking in pubs is often seen as a routine aspect of life in Britain. Parents, organizers of school trips, and young travelers should be aware of the impact that this environment may have when combined with the sense of adventure that comes with being abroad.
Please see our Students Abroad web site as well Studying Abroad to help students plan a safe and enjoyable adventure.
The UK has strict gun-control laws, and importing firearms is extremely complicated. Travelers should consider leaving all firearms in the United States.
Restrictions exist on the type and number of weapons that may be possessed by an individual.
All handguns, i.e. pistols and revolvers, are prohibited with very few exceptions.
Licensing of firearms in the UK is controlled by the Police.
Applicants for a license must be prepared to show 'good reason' why they require each weapon.
Applicants must also provide a copy of their U.S. gun license, a letter of good conduct from their local U.S. police station and a letter detailing any previous training, hunting or shooting experience. Background checks will also be carried out.
Additional information on applying for a firearm certificate and/or shotgun certificate can be found on the Metropolitan Police Firearms Enquiry Teams web site at http://www.met.police.uk/firearms-enquiries/index.htm.
A number of Americans are lured to the UK each year in the belief that they have won a lottery or have inherited from the estate from a long-lost relative.
Americans may also be contacted by persons they have “met” over the Internet who now need funds urgently to pay for hospital treatment, hotel bills, taxes or airline security fees.
Invariably, the person contacted is the victim of fraud.
Any unsolicited invitations to travel to the UK to collect winnings or an inheritance should be viewed with skepticism.
Also, there are no licenses or fees required when transiting a UK airport, nor is emergency medical treatment withheld pending payment of fees.
Please see our information on International Financial Scams. Please read our Customs Information.

CRIMINAL PENALTIES:
While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law.
Penalties for breaking the law can be more severe than in the United States for similar offenses.
Persons violating British law, even unknowingly, may be expelled, arrested or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in the UK are severe, and convicted offenders can expect long jail sentences and heavy fines.
Engaging in sexual conduct with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States.
Please see our information on Criminal Penalties.
Many pocketknives and other blades, and mace or pepper spray canisters, although legal in the U.S., are illegal in the UK and will result in arrest and confiscation if detected.
A UK Metropolitan Police guide to items that are prohibited as offensive weapons is available at http://www.met.police.uk/youngpeople/guns.htm.
A UK Customs Guide, detailing what items visitors are prohibited from bringing into the UK, is available at http://customs.hmrc.gov.uk/channelsPortalWebApp/downloadFile?contentID=HMCE_CL_001734.
Air travelers to and from the United Kingdom should be aware that penalties against alcohol-related and other in-flight crimes (“air rage”) are stiff and are being enforced with prison sentences.
Please also see our information on customs regulations that pertain when returning to the US.

CHILDREN'S ISSUES:
For information on intercountry adoption and international parental child abduction, see the Office of Children’s Issues.

REGISTRATION / EMBASSY LOCATION:
Americans living or traveling in the United Kingdom are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration web site, and to obtain updated information on travel and security within the United Kingdom.
By registering, Americans make it easier for the Embassy or Consulate to contact them in case of emergency, and to relay updated information on travel and security within the United Kingdom.
The Embassy and Consulates regularly send security and other information via email to Americans who have registered.
As noted above, recent communications from U.S. Embassy London to the local American citizen community, called Warden Messages, can be found on the embassy’s web site.
Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate.
The Consular Section also disseminates a newsletter every month.
Those wishing to subscribe to the monthly consular newsletter in London should send a request by email to SCSLondon@state.gov.
The U.S. Embassy is located at 24 Grosvenor Square, London W1A 1AE; telephone: in country 020-7499-9000; from the U.S. 011-44-20-7499-9000 (24 hours); Consular Section fax: in country 020-7495-5012; from the U.S. 011-44-20-7495-5012, and on the Internet at http://london.usembassy.gov.
The U.S. Consulate General in Edinburgh, Scotland, is located at 3 Regent Terrace, Edinburgh EH7 5BW; Telephone: in country 0131-556-8315, from the U.S. 011-44-131-556-8315.
After hours: in country 01224-857097, from the U.S. 011-44-1224-857097.
Fax: in country 0131-557-6023; from the U.S. 011-44-131-557-6023.
Information on the Consulate General is included on the Embassy’s web site at http://london.usembassy.gov/scotland.
The U.S. Consulate General in Belfast, Northern Ireland, is located at Danesfort House, 228 Stranmillis Road, Belfast BT9 5GR; Telephone: in country 028-9038-6100; from the U.S. 011-44-28-9038-6100.
Fax:
in country 028-9068-1301; from the U.S. 011-44-28-9068-1301.
Information on the Consulate General is included on the Embassy’s web site at: http://london.usembassy.gov/nireland.
There is no U.S. consular representation in Gibraltar.
Passport questions should be directed to the U.S. Embassy in Madrid, located at Serrano 75, Madrid, Spain, tel (34)(91) 587-2200, and fax (34)(91) 587-2303.
The web site is http://madrid.usembassy.gov.
All other inquiries should be directed to the U.S. Embassy in London.
* * *
This replaces the Consular Information Sheet dated December 12, 2007, to update the sections on Entry Requirements, Safety and Security, Crime, Victims of Crime, Medical Facilities, Medical Insurance, Traffic Safety and Road Conditions, and Special Circumstances.

Travel News Headlines WORLD NEWS

Date: Thu 24 Aug 2017
Source: Gibraltar Chronicle [edited]
<http://chronicle.gi/2017/08/tiger-mosquito-found-in-gibraltar-but-no-cause-for-concern-officials-say/>

An aggressive species of mosquito known to transmit viral diseases has been detected in Gibraltar, but public health officials insist there is no cause for alarm. Public Health Gibraltar and the Environmental Agency confirmed that the mosquito of the species _Aedes albopictus_, also known as the tiger mosquito, has been found in Gibraltar.

Last June [2017] after 9 months of intensive surveillance, officials said no tiger mosquito had been found in Gibraltar. But this has now changed after the 1st tiger mosquito was found in the urban dome   stic environment within Gibraltar. "This finding alone does not however materially alter any health risks in Gibraltar and there is no immediate cause for public concern," the government said in a statement. Public Health Gibraltar was first alerted in January 2016 to the discovery of the mosquito in Malaga and Algeciras [in Andalusia, Spain]. Since then, together with the Environmental Agency, it began working with international experts to mount surveillance in Gibraltar.

World Health Organization experts visited Gibraltar and gave advice on setting traps and monitoring locations, but no tiger mosquito had been detected until now. The tiger mosquito is not native to Gibraltar and has not been previously found here. It is common in other countries where it transmits viral diseases like Zika, dengue, and chikungunya. It is a domestic species, breeds in water in urban areas -- water butts, blocked drains, rainwater gullies -- and is able to reach high abundance around residential areas.

It is also a day-time mosquito, that aggressively bites humans. "Health risks to the public only arise if the virus causing these diseases is also present, which is not the case in Gibraltar," the government said.  "The virus can, however, be imported by travellers returning from an overseas country and if this happens, there is a risk of spread, but only if the mosquito bites within a small window period of about a week after the fever starts."

Public Health Gibraltar has been raising awareness of travel risk amongst travellers through its publication A Factsheet for Travellers and recommends the following precautions:
- before travelling to affected areas, consult your doctor or seek advice from a travel clinic, especially if you have an immune disorder or severe chronic illness;
- if you are pregnant or are considering pregnancy, consider postponing non-essential travel;
- when staying in a mosquito-prone area, wear mosquito repellents and take mosquito bite prevention measures;
- if you have symptoms within 3 weeks of return from an affected country, contact your doctor;
- if you have been diagnosed with any of the diseases Zika, dengue, or chikungunya, take strict mosquito bite prevention measures for 10 days after the fever starts.
========================== 
[The appearance of _Aedes albopictus_ in Gibraltar is not surprising. A map of the distribution of this species as of April this year (2017) shows it present around the Mediterranean Basin and up to Gibraltar on the west (<https://ecdc.europa.eu/en/publications-data/aedes-albopictus-current-known-distribution-europe-april-2017>).

Now it has been found in Gibraltar. The concerns are real about transmission of dengue, chikungunya, and Zika viruses should populations of _Ae. albopictus_ become established. In 2015 there were a few locally acquired cases of dengue in the south of France. This also happened on a larger scale in Emilia Romagna, Italy, when a viraemic man introduced chikungunya virus into Italy and sparked an outbreak.

One hopes that mosquito surveillance will continue in Gibraltar, perhaps be intensified, and help guide vector control efforts. - ProMED Mod.TY]

[A HealthMap/ProMED-mail map can be accessed at: <http://healthmap.org/promed/p/517>.]
Date: Wed, 1 Jun 2011 01:46:48 +0200 (METDST)

GIBRALTAR, June 1, 2011 (AFP) - A fuel tank exploded and caught fire near a cruise ship in the British territory of Gibraltar Tuesday, injuring at least 15 people, most of them on the vessel, local officials and the ship's owners said. The blast was probably caused by a spark from welding operations, Chief Minister Peter Caruana told Radio Gibraltar. But police were not ruling out any possibility including that of an attack, he added. Flames several metres high could be seen coming out of the tank with dense black smoke billowing across the port as firefighters directed jets of water at the blaze from tugboats. The fire continued late into the night, with Radio Gibraltar reporting more explosions were heard. The tank was close to the giant cruise ship, Independence of the Seas, which had arrived in Gibraltar Tuesday morning. The ship made an emergency departure immediately after the blast Tuesday afternoon.

The Gibraltar government and the ship's owners, Royal Caribbean International, both said 12 people on the ship had been hurt. Gibraltar officials said one of the passengers had suffered a fractured arm. Two Spanish welders working on the tank were injured, including one who was in critical condition in a burns unit at a hospital in the southern Spanish city of Seville, Radio Gibraltar said. A police officer was also slightly injured in the rescue attempt, police said. "The lid of the tank was blown off by the blast," a police spokesman said. The statement from Royal Caribbean International said: "Immediately after the explosion, the ship retracted the gangway and moved a safe distance from the dock. "Twelve guests sustained minor injuries and have received medical treatment onboard." The boat was on a two-week cruise, having left the southern English port of Southampton on Saturday, the company added.

Air services to Gibraltar were suspended and offices in the port area evacuated. The police spokesman said the possibility of adjacent tanks overheating and exploding could not be ruled out. Caruana described it as a serious incident but said there was "no cause for concern". "Once it was established that there were welding operations going on, on top of the very tank at the time it exploded, (that) makes that a frontrunner for a likely explanation, but all possibilities are being kept open," he told Radio Gibraltar. "The police are obviously keeping their minds open to the possibility of maybe a security incident. It's looking unlikely but all possibilities are being looked into if only to be excluded."

"The plan is to allow it to carry on burning itself off," he said later Tuesday, but warned that the wind was due to change during the night, which could bring the smoke over land. Spanish tugs from a private company were helping the local fire services, he added. One witness said he was in his office nearby when he heard three loud explosions. "We started running out and saw one of the main tanks set alight. My concern was the poor people who were working there," he told Radio Gibraltar. The public was being advised to keep away from the area and keep windows closed due to the smoke. Gibraltar is a 6.5-square-kilometre (2.6-square-mile) British territory of around 30,000 people off the tip of southern Spain. Madrid ceded it to London in 1713 under the Treaty of Utrecht, but it has long fuelled tensions between the two countries.
Date: Tue, 10 Aug 2010 20:08:15 +0200 (METDST)

GIBRALTAR, Aug 10, 2010 (AFP) - Gibraltar on Tuesday condemned as "illegal" a proposal by the neighbouring Spanish town of La Linea to impose a tax on cars entering or leaving the tiny British territory by road.   The decision comes amid thorny relations between Madrid and London over the disputed British possession off the tip of southern Spain.

La Linea mayor Alejandro Sanchez on Monday announced the "congestion charge" of no more than five euros (6.5 dollars) on cars crossing into and out of Gibraltar, saying the measure will be imposed in October once it is passed by the town council.   He said lorries carrying debris and other materials used in Gibraltar to reclaim land from the sea will pay more, but the exact amount has not yet been determined.   Sanchez, a member of Spain's conservative opposition Popular Party, said the tax is needed partly to compensate the municipality for austerity measures imposed by the socialist government in Madrid.   La Linea residents would be exempt, but it was not clear if Gibraltarians would also have to pay.

The Gibraltar government reacted angrily and said it has contacted the Spanish authorities over the decision.   "The confused statements by the mayor of La Linea in respect of the proposed toll describe a litany of illegalities under EU Law and probably also under Spanish law," it said in a statement.   "The mayor of La Linea is clearly engaged in a political manoeuvre with his central government, which is unlikely to allow the proposal.

"The mayor's proposals are wholly unacceptable both legally and politically and in the unlikely event that these measures should be introduced, the (Gibraltar) government will take appropriate steps."   Spain ceded Gibraltar to Britain in 1713 under the Treaty of Utrecht but has retained first claim on the tiny peninsula should Britain renounce sovereignty.

"The Rock" has long fuelled tensions between Spain and Britain, with Madrid arguing the 6.5-square-kilometre (2.6-square-mile) territory that is home to roughly 30,000 people should be returned to Spanish sovereignty.   But its people overwhelmingly rejected an Anglo-Spanish proposal for co-sovereignty in a referendum in 2002.   In recent months British and Spanish naval and police boats have engaged in a series of cat and mouse games in the waters off Gibraltar, which lies at the strategic western entrance to the Mediterranean.
Date: Thu 23 Oct 2008
Source: Panorama.gi [edited]
---------------------------------
During the last 10 weeks, Gibraltar has experienced an outbreak of measles. "We have so far been notified of over 250 cases and notifications are still coming in at around 4-6 cases per day," said the Gibraltar Health Authority [GHA], who believe that the actual numbers are greater as many people with mild attacks have chosen not to report them. While the majority of infections in the outbreak have been mild, some have been severe and a few patients including babies have needed intensive care.  Measles is an unpleasant disease with fever, sore throat, streaming eyes, diarrhoea, and rash. Most people recover within a week or so, but complications like fits, bacterial infection, or pneumonia can develop. Long-term complications can also arise in very young children.

Says the GHA: It is important that all persons with symptoms suggestive of measles should report the illness to their doctor to enable complications to be detected at an early stage. In addition to medical advice, persons with the illness should follow general hygiene practices such as limiting contact with other people, carefully discarding soiled tissues, and washing their hands. Anyone who has had measles infection is immune for life and cannot get measles again. There is no basis for the rumour that some people have had measles twice. It is possible that infection with rubella (German measles, a different disease) may have caused the confusion. Vaccination with the MMR [measles, mumps, and rubella] vaccine is the only way to prevent measles infection.

[So far], the 250 cases have been in persons who are unvaccinated or partly vaccinated (one dose only). Not a single case has occurred in a person who has had a full course of MMR vaccine. MMR vaccine has been available free to children [from] Gibraltar's health service since 1989, although the boosters were only introduced in 2002. It is also a very safe and effective vaccine, with an impressive track record," they say. Gibraltar Health Authority adds that it is continuing to advise all parents of children who have not had the MMR vaccine to immunise their children. There had been some difficulties in obtaining vaccine recently due to an international shortage, but fresh supplies have now been received. The course consists of 2 injections, approximately 3 months apart. Please note that BOTH the doses are needed for adequate immunity. They add: If your child has received only one dose, either now or in the past, he or she could still be at risk. Arrangements have been made to offer additional  vaccination to all unimmunised children as follows: During October and November [2008], the Child Welfare Clinics (primary care centre) will be open on Mondays (2:00 pm to 4:00 pm), Wednesdays (9:00 am to 11:00 am) and Fridays (9:00 am to 11:00 am) for immunisations. Appointments are not necessary.
-------------------------------
[The Rock of Gibraltar is located at the entrance of the Mediterranean. Gibraltar is connected to Spain by a sandy isthmus, by a ferry to Morocco, and by flights to London. By virtue of its geographical position and political status Gibraltar is vulnerable to introduction of infectious disease from diverse sources. No information has been provided regarding the source of the measles virus responsible for this outbreak. In this respect it will be relevant to determine the genotype of the measles virus involved (see comment in ProMED-mail "Measles - Gibraltar 20080814.2529"). The outbreak has escalated from the 17 cases reported on 14 Aug 2008 to the current 250 cases. Despite the availability of free MMR vaccination it is clear that there is an appreciable number of unimmunised individuals in the community who remain susceptible to measles virus infection. It is encouraging that efforts are underway to expand vaccine coverage.


and the HealthMap/ProMED-mail interactive map at <http://healthmap.org/promed?g=2411586&amp;v=36.133,-5.35,7>. - ProMed Mod.CP]
Date: Wed, 16 Apr 2008 14:56:40 +0200 (METDST) GIBRALTAR, April 16, 2008 (AFP) - Animal rights groups have expressed outrage over a plan by Gibraltar's government to cull its famous Barbary Apes, which are posing a hazard as they roam the town in search of food. The government of the tiny British territory off Spain's southern coast plans to cull 25 of the simians, whose population has exploded to around 200. The mischievous primates climb over cars and pull out antennas, open rubbish bags and rifle through handbags left unattended in the popular tourist destination. Officially, the management of the apes is the responsibility of the Gibraltar Ornithological and Natural History Society (GONHS), on contract from the government. But the society said it has not approved the cull. "Our policy is that culling can be a population management solution but only in extreme cases when there is no other more suitable option," GONHS general secretary Dr. John Cortes said on Tuesday. "We would only ever recommend a cull after very careful assessment of the situation from a veterinary and a genetic point of view." However, Environment Minister Ernest Britto said a licence has been issued for the cull and two of the apes have already been given lethal injections. Helen Thirlway, the head of Britain's International Primate Protection League, said the government was failing to manage the apes "in a responsible manner." "There have been many advances and pilot studies in recent years on different methods of controlling free-roaming monkeys," she was quoted as saying in the local media Wednesday. "We are more than happy to work with the government of Gibraltar and with GONHS to help them develop more efficient, alternative solutions, but this needless slaughter has to stop." According to legend, if the apes disappear, Britain will lose control of Gibraltar. When wartime British prime minister Winston Churchill heard their population was low, British consuls in North Africa -- from where the apes originally came -- were tasked with sending new young simians to the Rock. At one time, the apes were looked after by the British army stationed in Gibraltar, which selected a place up the Rock where they were fed daily to keep them from loitering downtown. Spain ceded Gibraltar to Britain in 1713, but has retained a constitutional claim should Britain renounce sovereignty. The vast majority of the 30,000 people want to retain their links with Britain.
More ...

Australia

Travelling to Australia
===========================
Introduction
********************************************
Travelling to Australia for business or pleasure can be a most memorable experience and each year many Europeans travel this
route to experience something of life ‘down-under’. Staying healthy and well is essential if you want to enjoy your trip to its fullest extent. Australia is a huge continent and the climatic conditions vary considerably throughout. The main southern cities have a temperate climate similar to North West Europe, Perth enjoys a Mediterranean climate while Queensland and the Northern Territories have a sub-tropical weather pattern.
Preparation
********************************************
It is important that all travellers are in good general health before undertaking any long-haul trip. Patients who tire easily on light exercise or who have a significant underlying medical condition will need to take extra care. If you are concerned about this aspect of your proposed trip arrange for a meeting with a doctor at an early stage in your preparations.
Long Haul Flights
********************************************
On these long flights you will be travelling across many time zones. You will lose or gain hours depending on the direction of your flight. Your body will take time to adjust to the new time zone and so it is important to allow this to occur naturally. If you arrive during the daylight hours try to stay out in the sun for a period of time as this will help your body release a hormone which counteracts jet lag. (Watch you don’t get sun burnt!) Don’t plan to be too energetic during the first day or two after you arrive. Be sensible. If this is a business trip try not to make any major decisions over the first 24 hours. Even the relatively short flight from South East Asia down to Australia crosses time zones and again it will be important to allow your body to settle.
Stop-Overs in SE Asia
********************************************
Frequently travellers will stop-over in Singapore, Bali, Hong Kong or Bangkok on their way to or from Australia. During these short stops it is essential that travellers take all possible precautions to ensure that they rest and are careful about what they eat or drink as contaminated food or water is more common in some of these regions.

Mosquito protection in SE Asia
********************************************
Mosquito borne diseases are present depending on the location (Malaria, Dengue Fever, Japanese B Encephalitis etc) One of particular concern is Dengue Fever, which is a viral disease transmitted by the bite of an infected mosquito. These mosquitoes tend to bite during the day time. This is in contrast to the mosquitoes which transmit malaria which mainly bite at night. Many of the main tourist destinations throughout SE Asia are malaria free and so tablets to protect against the disease are not usually required. Those going off the usual routes will need to talk this through in depth before leaving.
Road Traffic Accidents
********************************************
Frequently, cars are purchased by tourists to Australia for the duration of their stay. Often the cost is low and the maintenance and safety of the vehicle may be somewhat questionable! Long monotonous driving associated with a lack of concentration can cause serious accidents. Car breakdown in the middle of ‘nowhere’ may lead to the risk of dehydration and potential animal attack (kangaroo, dingos, snakes etc). Make sure you always have sufficient food and water and some means of communication (fully charged mobile phone) before leaving to travel across the continent. Make sure other responsible friends or relations back home know of your intended route and inform them of any changes. Get contact numbers for essential services for your journey.

Health Concerns in Australia
********************************************
Many travellers feel that Australia is the same as at home in Europe and so little care with personal health needs be taken. This is not always the case as there are many local health variations throughout the country which should be considered.
Sun Exposure
********************************************
The northern European skin is usually unaccustomed to intensity of the sun exposure experienced in many parts of Australia. Unfortunately this regularly leads to sun burn among tourists but, more seriously, it also significantly increases the risk of potentially fatal skin cancers. Always use plenty of adequate sun block, cover exposed areas of your body where possible (especially by wearing a wide brimmed hat) and drink plenty of water. (You may also need to replace salt lost through increased perspiration ~ assuming no underlying blood pressure problem)
Northern Australia
********************************************
As mentioned previously, the northern parts of Australia are sub-tropical and mosquito borne diseases are more common. Malaria transmission does not occur and many of the diseases transmitted by mosquitoes or other insects cause mild discomfort. Unfortunately some are which are much more severe and can cause long term difficulties.
Ross River Fever
This viral disease is transmitted by mosquitoes and causes a severe arthritic type condition. The disease is often short lived but in some patients the disease may continue to cause arthritis for months and even years. There is no specific treatment and travellers need to be careful about avoiding bites.
Typhus
This disease occurs in isolated parts of Northern Australia through the bite of infected ticks. The disease can cause a skin rash, fever and general unwellness. Antibiotics can help to ease the symptoms but avoiding bites is essential at all times.
Dengue
This mosquito borne disease also occurs in parts of Northern Australia usually by day-biting mosquitoes. (See Dengue leaflet - TMB)
Other Risks
********************************************
The sea waters in parts of Australia are infested by sharks and jelly fish. Always take competent local advice before undertaking any sea activities. Drowning occurs regularly each year among tourists who disregard some of the basic rules of water safety. If in desert regions, take care with disturbing rocks in case you awaken a peaceful snake or scorpion.
Medical Care for Travellers
********************************************
If travellers have stopped in South East Asia and then become ill on arrival in Australia, they should make contact with a medical centre dealing with Tropical Medicine. Details of the centres in the major cities throughout Australia are available from the Tropical Medical Bureau.
Vaccinations for Stop-Overs
********************************************
Usually travellers will have vaccination cover for Typhoid, Poliomyelitis, Tetanus and Hepatitis A. Malaria prophylaxis may not be required depending on your actual itinerary. There is a higher risk of Hepatitis B in central Australia and so this may need to be considered if the risk of contact (mainly blood following accidents) is thought to be higher than usual. Rabies risk in Australia is almost non existent though obviously contact with all warm blooded animals should be avoided at all times.

Travel News Headlines WORLD NEWS

Date: Sun, 8 Dec 2019 05:56:06 +0100 (MET)

Sydney, Dec 8, 2019 (AFP) - Smoke haze from bushfires raging in Australia spread to the capital Sunday, as firefighters raced to contain more than 140 blazes ahead of a heatwave forecast early this week.   Australia is experiencing a horrific start to its fire season, which scientists say began earlier and is more extreme this year due to a prolonged drought and the effects of climate change.

Residents of Canberra in the country's southeast woke up to see the capital shrouded in haze Sunday, joining those in Sydney who have endured weeks of toxic air pollution caused by bushfire smoke.   Officials said favourable weather conditions had given them a chance to bring several blazes under control before the forecast return of strong winds and high temperatures Tuesday.   Among those is a "mega fire" burning across 250,000 hectares within an hour's drive of Sydney, Australia's largest city, where ash from the fires has occasionally fallen.

Firefighters are now bracing for Tuesday, when temperatures are expected to reach above 40 Celsius in parts of New South Wales state -- worst-hit by the bushfires -- and gusting westerly winds are likely to fan the flames.   "Today (fire) crews will be doing what they can to consolidate and strengthen containment lines, which in some areas will include backburning," NSW Rural Fire Service spokesman Greg Allan told AFP.   But the state's Bureau of Meteorology warned that the massive fires are "in some cases just too big to put out at the moment".   "They're pumping out vast amounts of smoke which is filling the air, turning the sky orange & even appearing like significant rain on our radars," the department tweeted.

Nearly 50 reinforcements from the United States and Canada have been flown in to support fatigued firefighters in recent days, with the international contingent tasked with providing logistical assistance.   In neighbouring Queensland, the focus was also on managing fatigue among frontline firefighters -- who in both states are almost all volunteers -- as weather there provided a brief reprieve from weeks of battling blazes.   "We're just looking to wind down and recover and prepare for the next round, whenever that may be," a Queensland Fire and Emergency Service spokesman told AFP.

Since the crisis began in September, six people have been killed, more than 700 homes destroyed and an estimated two million hectares (almost five million acres) scorched.   Though the human toll has been far lower than the deadliest fire season in 2009 -- when almost 200 people died -- the scale of this year's devastation has been widely described as unprecedented, as Australians grapple with the impacts of a changing climate.   Official data shows 2019 is on track to be one of the hottest and driest years on record in Australia.
Date: Fri, 6 Dec 2019 04:23:51 +0100 (MET)

Sydney, Dec 6, 2019 (AFP) - Three hundred animals have been evacuated from a wildlife park north of Sydney as massive bushfires encircled Australia's largest city and foreign firefighters arrived to relieve beleaguered local forces.   Walkabout Wildlife Park said it had shipped out lizards, dingoes, peacocks and marsupials, as firefighters battled more than 100 fires up and down the eastern seaboard.   "This fire has been doing some crazy things, so we have to be prepared," general manager Tassin Barnard told AFP.

Prolonged drought has left much of eastern Australia tinder dry and spot fires have raged every day for the past three months, leaving firefighters struggling to cope.   New South Wales rural fire chief Shane Fitzsimmons said Friday that some US and Canadian firefighters had arrived to help out, easing the strain on the exhausted largely volunteer Australian force.

The incident-management and aviation specialists will help ease "fatigue and crew rotations" he said.   "We are not only appreciative of their presence here today, but of their sacrifice," said Fitzsimmons -- who has become a fixture on Australian television screens for weeks, updating the public on blazes in towns, national parks and backwaters.    "They are volunteering to sacrifice time from loved ones, from families, to give up that special time of the year around Christmas and New Year to come down here and lend us a hand," he said.

More than 600 homes have been destroyed and six people have died since the crisis began in September. That is many fewer than Australia's deadliest recent fire season in 2009 when almost 200 people died, but 2019's toll belies the scale of devastation.    Millions of hectares have burned -- the size of some small countries -- across a region spanning hundreds of kilometres (miles).   Bushfires are common in Australia but scientists say this year's season has come earlier and with more intensity due to a prolonged drought and climatic conditions fuelled by global warming.

The fires have taken a toll in Sydney and other major cities, which have been blanketed in toxic smoke for weeks and occasionally sprinkled with snow-like embers.   Fitzsimmons said he could not "overstate the effect that this profound drought is having" as he warned of a long, painful summer ahead.   "There is an absolute lack of moisture in the soil, a lack of moisture in the vegetation... you are seeing fires started very easily and they are spreading extremely quickly, and they are burning ridiculously intensely."
Date: Tue, 3 Dec 2019 06:24:08 +0100 (MET)

Sydney, Dec 3, 2019 (AFP) - A man and woman have been rescued after surviving two weeks in Australia's arid outback on little more than vodka, groundwater and biscuits, but a third person is still missing, police said Tuesday.   The three friends set out to explore the country's vast sun-baked interior near Alice Springs on November 19 when their car became bogged down in a river bed.   After three days staying put and waiting for a rescue, the group feared supplies were dwindling and two of them decided to walk along a property fence line in the hope of finding help.   Police said Tuesday that a local rancher had found the man, 40-year-old Phu Tran, "slightly disorientated" but in a "good condition" a two-day walk from the vehicle.

His discovery came after Tamra McBeath-Riley, 52, was found on Sunday less than two kilometres from the same vehicle suffering from dehydration.   McBeath-Riley told public broadcaster ABC that the trio -- accompanied by their blue Staffordshire terrier Raya -- had survived by drinking pre-mixed vodka drinks and water from a hole dug for cattle, eating biscuits and sheltering in a hole dug under her car.   But the third person, 46-year-old Claire Hockridge, has not been seen since splitting from Phu two days ago.   "She was still fine when he left but we obviously are now focusing our search to identify where she is," police superintendent Pauline Vicary said.   Police were "hopeful that she's still in that condition," Vicary added, as her colleagues resumed an aerial search.   McBeath-Riley and Hockridge live in Alice Springs, while Phu was visiting from elsewhere in Australia.
Date: Tue, 26 Nov 2019 02:53:22 +0100 (MET)

Sydney, Nov 26, 2019 (AFP) - Australian police on Tuesday found a body they believed to be that of a British backpacker who ran from a campsite on the weekend, prompting an intensive search.   "Officers are yet to formally identify the body" police said in a statement. "However, it is believed to be Aslan King."

King was last seen at a camping ground in Princetown, on the popular and picturesque Great Ocean Road, at about 2 am on Saturday.   He had been camping with friends near the Twelve Apostles about three hours from Melbourne when he had a "medical episode" and hit his head, before suddenly running into bushland.

Fearing King -- who had been on holiday in Australia for two weeks -- had become disorientated and lost in the bush, police deployed a helicopter, horses, motorcycle riders, specialist rescue teams and volunteers to find him.   "The body was located about 10:15 am this morning in a creek just over a kilometre from the camping ground where Aslan was last seen," police said.   "Investigators will prepare a report for the coroner."
Date: Thu, 21 Nov 2019 01:25:15 +0100 (MET)

Sydney, Nov 21, 2019 (AFP) - The fire danger was elevated across wider swathes of southern Australia on Thursday, with residents warned to avoid at-risk areas as smoke from bushfires choked Sydney and other major cities.   Devastating fires along the country's east coast have claimed six lives and destroyed more than 500 homes since mid-October, with climate change and unseasonably hot, dry conditions fuelling the unprecedented blazes.   Now the fire danger has moved into states further south, with a so-called "Code Red" -- the highest possible fire risk in Victoria -- being declared in the state's northwest for the first time in a decade.   "What that means is that if we see fires in those areas they will be fast moving, they will be unpredictable, they will be uncontrollable," emergency management commissioner Andrew Crisp told reporters.

Country Fire Authority chief Steve Warrington told people living in rural areas to leave for the safety of cities.   "We are saying, 'do not be there, do not be there when a fire occurs, because you will not survive if you are there'," he said.   "There is a good chance if a fire occurs that your home will be destroyed."   The fire danger was also elevated to "severe" in the island state of Tasmania off mainland Australia's southeastern coast,  where a total fire ban was declared.   Two bushfires in the state's northeast did not pose an immediate threat to residents, the Tasmania Fire Service said.

For the second time in two days, smoke from bushfires blanketed Sydney, Australia's biggest city and home to more than five million people, sending air quality plummeting to hazardous levels.   More than 110 fires are still burning in worst-hit New South Wales and neighbouring Queensland, while in South Australia more than 40 fires broke out during catastrophic fire conditions Wednesday.    A South Australia Country Fire Service spokeswoman said all of those blazes had been brought under control or extinguished by Thursday, with the exception of a major fire on the Yorke Peninsula that had come perilously close to a small town.

Conditions were expected to ease in the coming days in South Australia, where the state capital Adelaide was also shrouded in bushfire smoke and residents were being told to stay indoors for health reasons.   Bushfire-prone Australia has experienced a horror start to its fire season, which scientists say is beginning earlier and becoming more extreme as climate change pushes temperatures higher and saps moisture from the environment after months of severe drought.   Growing calls to curb fossil fuels and drastically cut greenhouse gas emissions are being ignored by the country's conservative government, which is eager to protect its lucrative mining industry.   The country is bracing for challenging fire conditions to continue throughout the Southern Hemisphere summer.
More ...

Cape Verde

General
The Cape Verde islands are situated off the west coast of Africa (adjacent to Senegal) and are becoming a more popular destination for European travellers aiming to avoid the major busy tourist destinations of the world. There are nine inhabi
ed islands within the group and also some uninhabited volcanic ones. The capital is Praia (on Santiago) and Portugese is the official language. The major port is Mindelo on the island of Sao Vicente.

Travelling to Cape Verde
There is a recently opened international airport in Praia and a second international airport (Amilcar Cabral) located on Sal Island which is about 150 kms northeast of the capital. Generally the facilities for tourists are still quite limited though improving and most developed on Sal.
Arriving in Cape Verde
The climate is oceanic tropical with temperatures varying from 20oC to 30oC throughout the year. The light rainfall tends to occur in Aug to November. During this time humidity can be higher but this is not usually a significant factor.
Food & Water
In line with many hotter regions of the world the level of food and water hygiene varies greatly from area to area and depending on the establishment. Travellers are advised to eat freshly cooked hot food, to avoid cold meals (salads etc) and particularly to avoid any undercooked bivalve shellfish meals (clams, mussels, oysters etc). Fresh milk may be unpasteurised and should be avoided.
Travelling around the islands
As with many archipelago destinations there is a way of moving from island to island if you wish to explore. This can be by boat or plane in many but not all cases. However if travelling by plane be aware that the limited baggage handling capacity of the small planes may lead to some delay in eventually receiving your luggage. During the dry dusty season (December to April) flights may be cancelled due to poor visibility. The road traffic moves on the right and seatbelts are compulsory for all in the front seat. Motorcyclists must wear helmets and have their lights on at all times.

Accidents
The majority of accidents occur because of unlit narrow winding roads, aggressive driving and alcohol impairing the senses. There are a large number of festivals and around these times alcohol intake increases considerably with the resultant increase in danger for all road users.
Emergency numbers
The emergency numbers are 130 for medical assistance, 131 for fire assistance and 132 for the police. There is no organised roadside assistance and travellers are strongly advised to avoid hiring cars or motorbikes. Taxis and buses provide a reasonable service and are a much safer option.
Sun Exposure & Dehydration
Many travellers from Europe will enjoy the beautiful climate to excess and run the risk of severe sunburn and dehydration. This is particularly true for the first 24 to 48 hours after arrival (when the traveller may fall asleep under the glaring sun) and also for young children. Sensible covering, avoiding the midday sun and replacing lost fluids and salt are essential to maintain your health.
Swimming and Water Sports
Island life in the tropics tends to increase the amount of water exposure for many tourists. It is important to check out the facilities (both the professionalism of their personnel and the equipment) before undertaking any water sports. Talk to others who have already taken part or your holiday representative and listen to their experiences. This will help you make the right choices. Remember the tides and currents around the various islands can be very strong so always follow local advice and never swim alone. Watch children carefully.
Mosquitoes and Malaria
This island chain has only a few species of mosquitoes and the risk of malaria is thought to be negligible. WHO (2006) does not recommend prophylaxis for travellers but comments that there is a mild risk on Santiago mainly between August and November during the rainy season. Good repellents should be used by all travellers - especially at dusk and dawn.
Safety & Security
Unfortunately there is no idyllic destination throughout the world and petty crime occurs in Cape Verde as elsewhere. Take special care at festivals and in market places. Don't flaunt your personal wealth while out and about. Gangs of children have been involved in attacks against tourists so avoid any potential confrontation.
Contacts
U.S. Embassy: Rua Abilio m. Macedo 81, Praia Tel.: 238-61-56-16/17; Fax: 238-61-13-55; Web: usembassy.state.gov/praia
U.K. Embassy: Shell Cabo Verde, Sarl, Av Amilcar Cabral CP4, Sao Vincente
Tel.: 238-32-66-25/26/27; Fax: 238-32-66-29; E-mail: antonio.a.canuto@scv.sims.com
Vaccines
Travelling directly from Europe there are no essential vaccines for entering Cape Verde. It is a Yellow fever risk region but there have been no cases for many years. Other vaccines need to be considered against food and water borne diseases such as Hepatitis A & Typhoid.
Healthcare
This is a beautiful destination and direct flight will increase the numbers travelling. However all travellers to Cape Verde will need to be seen for a detailed medical consultation to ensure that they have appropriate advice and protection for their individual trip. Further information on health issues and all the latest world travel news reports are available at www.tmb.ie

Travel News Headlines WORLD NEWS

Date: Fri, 3 May 2019 12:24:17 +0200
By Anne-Sophie FAIVRE LE CADRE

Cha das Caldeiras, Cape Verde, May 3, 2019 (AFP) - Four years after the volcano erupted -- razing everything in its path in Cape Verde's Cha das Caldeiras valley -- the floor tiles of the small, rebuilt inn are warm to the touch.    "We constructed too quickly on lava that had not yet cooled down," says hotel owner Marisa Lopes, in her early 30s.   "For the first months, the floors in the rooms were so hot that you couldn't walk on them with bare feet."

Lopes is one of dozens of entrepreneurs locked in a perpetual tug of war with the Pico do Fogo volcano towering over Cha das Caldeiras, whose population numbers 500.    The name means Peak of Fire in Portuguese.   The volcano generates the bulk of the crater community's gross domestic product, attracting some 5,000 tourists every year who need hotel beds, food and tour guides -- about 30 make a living as guides in this remote part of West Africa.   But on the downside, the festering giant erupts once a generation -- six times in the last 200 years -- destroying everything in its path; crops, homes, roads.   On November 23, 2014, Lopes watched helplessly as the Pico -- almost 2,900 metres (9,500 feet) high -- erupted after a 19-year slumber.

Lava engulfed her brand new tourist hostel, eponymously named Casa Marisa.   Three months later, she built a new one, again in the flow zone of the crater.   "The volcano took a house from me, but it gave me another. Without it, there would be no tourism," she told AFP, undeterred.   Despite the constant danger and government efforts to dissuade them, the inhabitants of Cha das Caldeiras keep coming back.     After the last eruption, the military evacuated those in the path of the lava and the state provided food aid for six months afterwards.   But it was the people themselves who reconstructed roads and found the materials for rebuilding homes and hotels. Again.

- 'It's home' -
Cicilio Montrond, 42, was also there in 2014, looking on as a river of molten rock spewing from the Pico do Fogo burnt his fruit trees and buried everything he owned in a thick, grey coat.   The eruption killed no one, but left 1,500 people homeless.   After a few weeks in Sao Filipe, a nearby town to where the valley inhabitants were relocated, Montrond returned to Cha das Caldeiras with his wife.   Not a bird stirred in the air still polluted with ash, not a creature moved on the still warm lava ocean that now covered the valley floor.

For weeks, Montrond and his wife lived in a tent on the roof of their destroyed house with no water, no electricity and no food apart from a few canned goods.   "We lived in makeshift shelters, it was precarious, dangerous. But we were home."   For Montrond, it is unimaginable to live anywhere else than the fertile, lava-fed valley that, between outbursts, boasts an abundance of vines, fig trees and cassava.   "It is the volcano that allows us to live," said Montrond, tourist guide-turned-hotelkeeper and restaurateur.   The Pico's eruptions are rarely deadly in terms of human life.   But what about the next time?   "The volcano is my life," Montrond shrugged, as he gazed upon the house he built with his own hands.    "I was born here, I will die here."

- Rocks were falling -
The volcano gives. The volcano takes.   First it destroys the vines, then it provides fruitful soil for the planting of new ones. These produce wines -- some of it for the export market.   Far from fearing or despising the peak's constant threatening presence, the inhabitants appear to embrace it and have made it part of their identity.   They evoke past eruptions with a smile, sometimes even a touch of nostalgia.   Margarita Lopes Dos Santos, 99, has been forced out of her home by the three last eruptions of the Pico do Fogo.

The first was in June 1951, shortly after she gave birth to her first child.   "I remember the first time like it was yesterday," she said, through a beaming, toothless smile.   "It was a lot more violent. Rocks were falling from the sky. There were tornadoes of ash and of smoke," she recounted, while husking beans.   Outside her house, Lopes Dos Santos has planted flowers -- flashes of red begonias that provide the only colour in the grey and black landscape.   "The resilience of the people of Cha is extraordinary," said Jorge Nogueira, president of the municipal council of Sao Filipe, capital of the island of Fogo, Cape Verde.   "As soon as they could, they came back -- to poor living conditions, but no matter: the only thing that counted for them was to be home."
Date: Tue 3 Oct 2017
Source: Outbreak News Today [edited]

In a follow-up on the locally transmitted malaria increases reported on Cabo Verde [Cape Verde] this year [2017], 254 indigenous cases were reported through [24 Sep 2017].

Most cases (75 percent) have not sought treatment until 48-96 hours after illness onset. Despite this, case fatality rates have remained low (0.4 percent), with one death reported in an indigenous case to date. 7 severe malaria cases and 2 cases of malaria in pregnancy have been reported. There are also anecdotal reports of recrudescence.

To date, the disease has been localized to the city of Praia on Santiago Island without any further spread.

A handful of cases have also been detected on neighbouring islands (Sao Vicente, Sal, and Porto Novo); however, their infections were likely all acquired during travel to Praia or overseas, with no evidence of onward local transmission.

The malaria epidemic in Cabo Verde has begun to show early signs of improvement but the situation remains tenuous, with heavy rainfall continuing between August and October, health officials said.
===================
[The last news from ProMED from 4 Sep 2017 (archive no. http://promedmail.org/post/20170904.5293108) reported 116 cases of malaria in Praia. Thus, over the last month 136 new cases have been diagnosed. It is good news that the outbreak has not spread, showing that the control measures are working. Due to the present outbreak, the CDC is now recommending malaria chemoprophylaxis for travellers visiting the city of Praia on Santiago Island (<https://www.cdc.gov/malaria/new_info/2017/Cape_Verde_2017.html>). - ProMED Mod.EP]

[Maps of Cape Verde can be seen at
<http://healthmap.org/promed/p/6553>. - ProMED Sr.Tech.Ed.MJ]

08 Sep 2017


Following an increase in malaria cases, additional malaria prevention advice for some UK travellers to the capital city of Praia in Cape Verde is recommended.

Since June 2017, the Ministry of Heath for Cape Verde has reported an increase in locally acquired malaria cases in the capital city of Praia on the island of Santiago. As of 5 September 2017, a total of 164 locally acquired falciparum malaria cases have been reported in the local population [2][3]. Currently, there are no reports of malaria in tourists who have visited Cape Verde in 2017.  

Those travelling to Praia who are at increased risk of malaria e.g. long term travellers, or those at risk of severe complications from malaria: pregnant women, infants and young children, the elderly and travellers who do not have a functioning spleen, should consider taking anti-malarials and seek advice about which antimalarial is suitable for them from their travel health advisor.

Date: Sun 3 Sep 2017 08:58:00 WEST
Source: The Portugal News (TPN) Online [edited]
<http://theportugalnews.com/news/portugal-health-department-issues-malaria-warning-for-cape-verde-capital/43059

The Portuguese health department has advised pregnant women not to travel to the Cape Verde island of Santiago [where the capital, Praia, is located], and if travellers cannot put their journey off, they should take anti-malaria drugs.

The health department warning comes after the World Health Organisation (WHO) said in August [2017] that there was an outbreak of malaria in Praia, the archipelago's capital. Travellers are also advised that adults and children should use insect repellent throughout the day and reapply it as often as necessary. If travellers also use sun cream, they should apply the insect repellent on top of the sun cream, not under it, the warning said. So far, there have been 116 cases of malaria in Praia, numbers never before seen in the city, where the highest number was 95 cases in the whole of 2001.
============
[The Cape Verde authorities reported 45 cases of malaria up to 30 Jul 2017 (see archive no. http://promedmail.org/post/20170808.5236283).

The outbreak continues and it is important to introduce identification and spraying of breeding sites. Also using a single dose of primaquine after treatment, which kills gametocytes, to ensure that the cases cannot transmit the infection, as recommended by the WHO (http://www.who.int/malaria/publications/atoz/who_pq_policy_recommendation/en/). - ProMED Mod.EP

Maps of Cape Verde can be seen at
<http://www.nationsonline.org/maps/Cape-Verde-Map.jpg>
and <http://healthmap.org/promed/p/15>. - ProMED Sr.Tech.Ed.MJ]
Date: Tue 8 Aug 2017
Source: Outbreak News Today [edited]

During the past 5 years, an average of one locally acquired case annually of malaria has been reported in Cabo Verde, or Cape Verde. In 2017, between [30 Jun and 30 Jul 2017], 45 indigenous cases and one imported case were reported, all in the capital city of Praia, Santiago Island.

More than half the cases are reported in adult males. The causative agent has been confirmed as _Plasmodium falciparum_ using both microscopy and rapid diagnostic tests (RDTs).

Preliminary investigations have attributed the recent increase in local transmission to several factors, including suboptimal vector control strategies, possibly coupled with inappropriate use (incorrect dilution) of a new insecticide introduced into the country in November 2016; the unauthorized installation of a rice paddy field in the affected area; and an increase in mosquito breeding sites within construction zones of a shopping centre and houses. The local authorities are in the process of removing the paddy field as further investigations are ongoing.

Cape Verde is a low malaria transmission country, eligible for elimination of the disease. With limited underlying immunity, all people (irrespective of their age group) are at risk of infection and of developing severe disease.
======================
[In 2015, Cabo Verde reported 7 _P. falciparum_ infected cases <http://www.who.int/malaria/publications/country-profiles/profile_cpv_en.pdf>. Cabo Verde is close to the African continent, and visitors may be asymptomatic gametocyte carriers and can start a local transmission if the vector control is not optimal, as suggested here. - ProMED Mod.EP]

[A HealthMap/ProMED-mail map can be accessed at:
More ...

Nicaragua

Nicaragua - US Consular Information Sheet
December 22, 2008
COUNTRY DESCRIPTION:
Nicaragua’s fragile democracy remains under stress.
Following municipal elections in November 2008, in which opposition leaders have charged massive fr
ud took place, political tensions have increased significantly.
The economy remains among the poorest in the hemisphere.
Crime has increased significantly in recent months.

The national language is Spanish, although many residents of the Caribbean coastal areas also speak English and indigenous languages.
The climate is hot and humid, with the “summer” dry season running mid-November through mid-May and the “winter” rainy season running from mid-May through mid-November.
Terrain ranges from the hilly and volcanic to coastal beaches and tropical jungles.
Geological faults run throughout the country, along which active volcanoes are situated.
Earthquakes are common, but the last major earthquake, which destroyed the city of Managua, occurred in 1972.

Nicaragua lacks tourist infrastructure.
Except in the cities and major thoroughfares, most roads are unpaved.
Public transportation is unsafe and there are no sidewalks.
Most essential services are sporadic.
Most hospitals are substandard.
Hotels in Managua are adequate, but primarily are oriented to serve a business or government clientele.
Potential tourists may want to obtain information from the National Tourism Institute (INTUR), the governmental agency responsible for developing, regulating, and promoting tourism in Nicaragua at http://www.intur.gob.ni/.
Read the Department of State Background Notes on Nicaragua for additional information.

ENTRY/EXIT REQUIREMENTS:
A valid U.S. passport is required to enter Nicaragua.
Although there is a bilateral agreement that waives the six-month validity passport requirement, U.S. citizens are urged to ensure that their passports are valid for the length of their projected stay in the country before traveling.
U.S. citizens must have an onward or return ticket and evidence of sufficient funds to support themselves during their stay.
A visa is not required for U.S. citizens; however, a tourist card must be purchased for $5 upon arrival.
Tourist cards are typically issued for 30 to 90 days.

A valid entry stamp is required to exit Nicaragua.
Pay attention to the authorized stay that will be written into your entry stamp by the immigration inspector.
Visitors remaining more than the authorized time must obtain an extension from Nicaraguan Immigration at http://www.migracion.gob.ni/.
Failure to do so will prevent departure until a fine is paid.

There is also a $32 departure tax.
Many airlines include this tax in the price of the ticket.
If the tax is not included in the ticket, payment can be made at the airline counter upon departure.

Per Nicaraguan law, individuals should exit Nicaragua with the same passport with which they entered the country.
Dual national minors who entered Nicaragua on their Nicaraguan passports will be subject to departure requirements specific to Nicaraguan children under the age of 18, even though they may also be citizens of other countries.
More information on these requirements can be found on the U.S. Embassy web site at http://nicaragua.usembassy.gov/dual_nationality.html.

According to Nicaragua’s Laws for Foreigners, foreigners must be in possession of a valid identity document at all times while in Nicaragua and may be required to show it to Nicaraguan authorities upon request.
Acceptable identity documents are: (1) a permanent residency card, (2) temporary residency card, or (3) valid passport or travel document accompanied by an entry stamp.

In June 2006, Nicaragua entered a “Central America-4 (CA-4) Border Control Agreement” with Guatemala, Honduras, and El Salvador.
Under the terms of the agreement, citizens of the four countries may travel freely across land borders from one of the countries to any of the others without completing entry and exit formalities at Immigration checkpoints.
U.S. citizens and other eligible foreign nationals, who legally enter any of the four countries, may similarly travel among the four without obtaining additional visas or tourist entry permits for the other three countries.
Immigration officials at the first port of entry determine the length of stay, up to a maximum period of 90 days.
Foreign tourists who wish to remain in the four-country region beyond the period initially granted for their visit are required to request a one-time extension of stay from local Immigration authorities in the country where the traveler is physically present, or travel outside the CA-4 countries and reapply for admission to the region.
Foreigners “expelled” from any of the four countries are excluded from the entire “CA-4” region.
In isolated cases, the lack of clarity in the implementing details of the CA-4 Border Control Agreement has caused temporary inconvenience to some travelers and has resulted in others being fined more than one hundred dollars or detained in custody for 72 hours or longer.

For the most current information about visas to visit Nicaragua, visit the Embassy of Nicaragua web site at http://www.cancilleria.gob.ni.

Information about dual nationality or the prevention of international child abduction can be found on our website.
For further information about customs regulations, please read our Customs Information sheet.

SAFETY AND SECURITY:
Municipal elections took place across Nicaragua on November 9, 2008.
Violent demonstrations followed as opposition groups questioned the authenticity of the results.
Activities observed during protests included but were not limited to tear gas, rubber bullets, setting off fireworks, rock-throwing, tire burning, road blocks, bus and vehicle burning, and physical violence between law enforcement and protestors and between political rivals.
Political demonstrations and strikes continue to occur sporadically, are usually limited to urban areas, and occasionally become violent.
U.S. citizens are advised to monitor local media reports, to avoid crowds and blockades during such occurrences and to exercise caution when in the vicinity of any large gathering.

U.S. citizens are cautioned that strong currents and undertows off sections of Nicaragua's Pacific coast have resulted in a number of incidents of drowning.
Powerful waves have also resulted in broken bones, and injuries caused by sting rays are not uncommon in popular resort bathing areas.
Warning signs are not posted, and lifeguards and rescue equipment are not readily available.
U.S. citizens contemplating beach activities in Nicaragua's Pacific waters should exercise appropriate caution.

Hiking in volcanic or other remote areas can be dangerous and travelers should take appropriate precautions.
Hikers should have appropriate dress, footwear, and sufficient consumables for any trek undertaken.
Individuals who travel to remote tourist or other areas for hiking activities are encouraged to hire a local guide familiar with the terrain and area.
In particular, there have been instances of hikers perishing or losing their way on the volcanoes at Ometepe Island.
While they may look like easy climbs, the terrain is treacherous and heavily overgrown.

Although extensive de-mining operations have been conducted to clear rural areas of northern Nicaragua of landmines left from the civil war in the 1980s, visitors venturing off the main roads in these areas are cautioned that the possibility of encountering landmines still exists.
Domestic travel within Nicaragua by land and air, particularly to the Atlantic side can be dangerous.
Domestic airlines use small airstrips with minimal safety equipment and little boarding security.
For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov, where the current Travel Warnings and Travel Alerts, as well as the Worldwide Caution, can be found.
Up-to-date information on safety and security can also be obtained by calling 1-888-407-4747 toll-free in the U.S. and Canada, or for callers outside the U.S. and Canada, a regular toll line at 1-202-501-4444.
These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).

The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas.
For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State’s pamphlet A Safe Trip Abroad.

CRIME:
Violent crime in Managua is increasing and petty street crimes are very common.
Gang activity also is increasing, though not at levels found in neighboring Central American countries.
Pick-pocketing and occasional armed robberies occur on crowded buses, at bus stops and in open markets like the Oriental and Huembes Markets.
Gang violence, drive-by shootings, robbery, assault and stabbings are most frequently encountered in poorer neighborhoods, including the Ticabus area, a major arrival and departure point for tourist buses.
However, in recent months it spread to more upscale neighborhoods and near major hotels, including the Zona Hippos.
In 2008, a U.S. citizen was critically injured in a gang-motivated drive-by shooting that occurred in the San Judas area.
Another U.S. citizen was kidnapped and left for dead in the Villa Fontana area of Managua.

U.S. citizens are increasingly targeted shortly after arriving in the country by criminals posing as Nicaraguan police officers who pull their vehicles – including those operated by reputable hotels -- over for inspection.
In each case, the incidents happened after dark and involved gun-wielding assailants who robbed passengers of all valuables and drove them to remote locations where they were left to fend for themselves.
Some assailants employed threats of physical violence.
While the traditional scene of these attacks has been the Tipitapa-Masaya Highway, this activity has recently spread to the Managua-Leon Highway.
The U.S. Embassy warns U.S. citizens to exercise extreme caution when driving at night from Managua’s International Airport and to avoid traveling the Tipitapa-Masaya Highway at night.
U.S. citizens should exercise caution when approached by strangers offering assistance.
Several U.S. citizens traveling by bus from San Juan del Sur to Managua have reported being victimized by fellow women travelers who offered to assist them in locating and/or sharing a taxi upon arrival in Managua.
In all cases, upon entering the taxi, the U.S. citizens have been held at knife-point, robbed of their valuables, and driven around to ATM machines to withdraw funds from their accounts.

Violent criminal activities and petty crime are also increasing in the tourist destination of San Juan del Sur.
In 2008, a U.S. citizen family was violently assaulted and kidnapped by several armed men.
Other American citizens have been the victims of armed robberies by assailants wielding machetes, knives, and/or guns along the beaches in and around San Juan del Sur.
U.S. citizens should exercise particular caution when visiting the following beaches: Maderas, Marsella, Yankee, Coco, and Remanso.

Police coverage is extremely sparse outside major urban areas, particularly in Nicaragua’s Atlantic coast autonomous regions.
Lack of adequate police coverage has resulted in these areas being used by drug traffickers and other criminal elements.
Street crime and petty theft are a common problem in Puerto Cabezas, Bluefields, and the Corn Islands along the Atlantic coast.
For security reasons, the Embassy has limited travel by its staff to the North and South Atlantic Autonomous Regions (RAAN and RAAS), including the Corn Islands.
Given the area’s geographical isolation, the Embassy’s ability to provide emergency services to U.S. citizens who choose to travel in the Caribbean costal area is constrained.
Police presence on Little Corn Island is made up of volunteers with little to no formal training, and is minimal on Corn Island and other remote areas.
In late 2007, a U.S. citizen was assaulted and violently raped while on vacation in Little Corn Island.
U.S. citizens have previously been the victims of sexual assault on this island and other beaches in the country.
The Embassy recommends traveling in groups when in isolated areas.
Single travelers should exercise special caution while traveling in the Corn Islands and other remote areas of the country.
Throughout the country, U.S. travelers should utilize hotels and guest houses that have strong security elements in place, including but not limited to rooms equipped with safes for securing valuables and travel documents and adequate access control precautions.

Visitors should avoid walking and instead use officially registered taxicabs.
Radio-dispatched taxis are recommended and can be found at the International Airport and at the larger hotels.
Robbery, kidnapping, and assault on passengers in taxis in Managua are increasing in frequency and violence, with passengers subjected to beating, sexual assault, stabbings, and even murder.
Several U.S. citizens reported brutal attacks in taxis during 2008, particularly around the International Airport area.

Before taking a taxi, make sure that it has a red license plate and that the number is legible.
Select taxis carefully and note the driver's name and license number.
Instruct the driver not to pick up other passengers, agree on the fare before departing, and have small bills available for payment, as taxi drivers often do not make change.
Also, check that the taxi is properly labeled with the cooperativa (company) name and logo.
Purse and jewelry snatchings sometimes occur at stoplights.
While riding in a vehicle, windows should be closed, car doors locked, and valuables placed out of sight.

Do not resist a robbery attempt.
Many criminals have weapons, and most injuries and deaths have resulted when victims have resisted.
Do not hitchhike or go home with strangers, particularly from nightspots.
Travel in groups of two or more persons whenever possible.
Use the same common sense while traveling in Nicaragua that you would in any high-crime area of a major U.S. city.
Do not wear excessive jewelry in downtown or rural areas.
Do not carry large sums of money, ATM, or credit cards that are not needed, or other valuables.
INFORMATION FOR VICTIMS OF CRIME:
The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the nearest U.S. Embassy or Consulate.
If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the nearest U.S. Embassy or Consulate for assistance.
The Embassy/Consulate staff can, for example, assist you to find appropriate medical care, contact family members, or friends and explain how funds could be transferred.
Although the investigation and prosecution of the crime are solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.

See our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION:
Medical care is very limited, particularly outside Managua.
Basic medical services are available in Managua and in many of the smaller towns and villages.
However, treatment for many serious medical problems is either unavailable or available only in Managua.
Emergency ambulance services, as well as certain types of medical equipment, medications and treatments, are not available in Nicaragua.
Physicians and hospital personnel frequently do not speak English, and medical reports are written in Spanish.
Patients must have good understand and an ability to speak Spanish in order to navigate the local medical resources.

In an emergency, individuals are taken to the nearest hospital that will accept a patient.
This is usually a public hospital unless the individual or someone acting on their behalf indicates that they can pay for a private hospital.
Payment for medical services is typically done on a cash basis, although the few private hospitals will accept major credit cards for payment.
U.S. health insurance plans are not accepted in Nicaragua.

Dengue fever is endemic in Nicaragua.
Currently, no vaccine or specific medication is available to prevent or treat Dengue fever.
Malaria is endemic in the Atlantic coast region and anti-malarial medication should be taken before and after travel to this region.
Travelers are advised to take a prophylactic regimen best suited to their health profile.
No prophylaxis anti-malarial medication is required for Managua and the western, Pacific coast region.
For both Dengue fever and malaria, the best prevention is the use of DEET insect repellant, as well as the wearing of protective clothing and bed-nets to prevent mosquito bites.

Tap water is not considered safe in Nicaragua.
All persons should drink only bottled water.
Individuals traveling to Nicaragua should ensure that all their routine vaccinations are up to date.
Vaccination against Hepatitis A, Hepatitis B, rabies and typhoid is strongly recommended.
A yellow fever vaccination is not required to enter Nicaragua unless the traveler has recently visited a country where yellow fever is endemic.
Travelers taking prescription medications should bring an adequate supply with them when coming to Nicaragua.
Many newer combination medications are not available in local pharmacies.

The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to or foreign residents of Nicaragua.

Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://wwwn.cdc.gov/travel/default.aspx.
For information about outbreaks of infectious diseases abroad consult the World Health Organization’s (WHO) web site at http://www.who.int/en.
Further health information for travelers is available at http://www.who.int/ith/en
MEDICAL INSURANCE:
The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation.
Please see our information on medical insurance overseas.

TRAFFIC SAFETY AND ROAD CONDITIONS:
Driving in Nicaragua poses many difficulties and risks, including mandatory arrest for drivers involved in accidents that result in death or serious injury until police are able to determine who is at fault.

Driving is on the right side of the road in Nicaragua.
Motorists driving to Nicaragua should use the principal highways and official border crossings at Guasaule, El Espino, and Las Manos between Nicaragua and Honduras and Penas Blancas between Nicaragua and Costa Rica.
Although some of the principal highways connecting the major cities are in generally good condition, drivers should be aware that seasonal, torrential rains take a heavy toll on road beds.
With few exceptions, secondary roads are in poor repair, potholed, poorly lit, frequently narrow, and lack shoulders.
Road travel after dark is especially hazardous in all areas of the country.
Motorists are encouraged to prepare accordingly and may want to carry a cellular phone in case of an emergency.

Some of the major highways and roads are undergoing major repair, repaving, and upgrading.
Be on the lookout for detours and slow traffic on these roads.
In general, road signs are poor to non-existent.
Bicycles, oxcarts, dogs, horses, and vehicles without lights are at times encountered even on main thoroughfares in Nicaragua.
Motorcycles, often carrying passengers, dart in and out of traffic with little or no warning.
Many vehicles are in poor condition, travel very slowly, and break down without warning.
Drivers should be especially careful on curves and hills, as many drivers will pass on blind spots.
Speed limits vary depending on the type of road, but because the government lacks the resources, traffic rules are rarely enforced.
Due to the age and disrepair of many vehicles, many drivers will not signal their intentions using turn indicators.
Rather, it is common for a vehicle operator to stick his hand out the window to signal a turn.
If you do drive in Nicaragua, you need to exercise the utmost caution, drive defensively, and make sure you have insurance.

Nicaraguan law requires that a driver be taken into custody for driving under the influence or being involved in an accident that caused serious injury or death, even if the driver is insured and appears not to have been at fault.
The minimum detention period is 48 hours; however, detentions frequently last until a judicial decision is reached (often weeks or months), or until a waiver is signed by the injured party (usually as the result of a cash settlement).
Visitors to Nicaragua might want to consider hiring a professional driver during their stay.
Licensed drivers who are familiar with local roads can be hired through local car rental agencies.
In case of accident, only the driver will be taken into custody.

The Embassy has received an increasing number of complaints from U.S. citizens who have been stopped by transit police authorities demanding bribes in order to avoid paying fines.
Motorists in rental cars and those whose cars have foreign license plates are more likely to be stopped by transit police.
Transit police have seized driver licenses and car registration documents from motorists who refuse to or are unable to pay.
Subsequently, these drivers have reported difficulties in recovering the seized documents.
U.S. citizens are urged to ensure that their vehicles comply fully with Nicaraguan transit regulations, including being in possession of an emergency triangle and fire extinguisher, and that the vehicle is properly registered.
If transit police authorities demand an on-the-spot payment, drivers should ask for the officer's name and badge number, as well as a receipt, and inform the Embassy of when/where the event took place.
(Reports should be sent via email to ACS.Managua@state.gov.)
Rental car agencies should also be advised if their vehicles have been deemed negligent in meeting Nicaraguan transit regulations.

As noted in the “Crime” section above, several groups of U.S. citizens driving from Managua’s International Airport at night have been robbed and kidnapped by men dressed as Nicaraguan police officers.
While the majority of these crimes have occurred on the Tipitapa-Masaya Highway, recent reports indicate similar activity along the Managua-Leon Highway.
The U.S. Embassy warns U.S. citizens to exercise extreme caution when driving at night from Managua’s International Airport and to avoid traveling the Tipitapa-Masaya Highway at night.

Avoid taking public transportation buses.
They are overcrowded, unsafe, and often are used by pickpockets.
Because of the conditions discussed above, traffic accidents often result in serious injury or death.
This is most often true when heavy vehicles, such as buses or trucks, are involved.
Traditionally, vehicles involved in accidents in Nicaragua are not moved (even to clear traffic), until authorized by a police officer.
Drivers who violate this norm may be held legally liable for the accident.

Regulations governing transit are administered by the National Police.
For specific information concerning Nicaraguan driver’s permits, vehicle inspection, road tax, and mandatory insurance, you may wish to refer to the National Police web site at http://www.policia.gob.ni.
You may also contact the Embassy of Nicaragua or a Consulate for further information.
Please refer to our Road Safety page for more information.
Visit the website of the country’s national tourist office and national authority responsible for road safety at http://www.mti.gob.ni
AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of Nicaragua’s Civil Aviation Authority as not being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Nicaragua’s air carrier operations.
For more information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa
SPECIAL CIRCUMSTANCES:
Purchasing Property: U.S. citizens should be aware of the risks of purchasing real estate in Nicaragua and should exercise caution before committing to invest in property.
The U.S. Embassy has seen an increase in property disputes over the last several years.
The 1979-90 Sandinista government expropriated approximately 28,000 real properties, many of which are still involved in disputes or claims.
Land title remains unclear in many cases.
Although the government has resolved several thousand claims by U.S. citizens for compensation or return of properties, there remain hundreds of unresolved claims registered with the Embassy.
Potential investors should engage competent local legal representation and investigate their purchases thoroughly in order to reduce the possibility of property disputes.

The Nicaraguan judicial system offers little relief when the purchase of a property winds up in court.
The Embassy is aware of numerous cases in which buyers purchase property supported by what appear to be legal titles only to see themselves subsequently embroiled in legal battles when the titles are contested by an affected or otherwise interested third party.
Once a property dispute enters the judicial arena, the outcome may be subject to corruption, political pressure, and influence peddling.
Many coastal properties have been tied up in courts recently, leaving the ”buyer” unable to proceed with the intended development pending lengthy and uncertain litigation.
In other cases squatters have simply invaded the land while the police or judicial authorities are unable (or unwilling) to remove the trespassers.
Again, the Embassy advises that those interested in purchasing Nicaraguan property exercise extreme caution.
Please note that Nicaraguan law currently prohibits any individual from buying beach-front property (including islands) unless the original land title was registered before the 1917 Nicaraguan Agrarian Reform Law.
Coastal properties with titles pre-dating 1917 are not risk-free, however.
In 1987 the Nicaraguan Constitution established the property rights of indigenous communities over territory they have traditionally occupied.
The Embassy advises extreme caution when considering the purchase of coastal property in Nicaragua.

Currency and Credit Cards: U.S. dollars are widely accepted throughout the country, and major credit cards are also typically accepted in hotels, restaurants, stores, and other businesses in urban and tourist areas.
Visitors who need to change dollars are encouraged to do this at their hotel since this is typically the safest place.
ATM machines are available at banks in addition to some shopping centers and gas stations in urban and tourist areas.
However, individuals should exercise caution when using an automaticteller machine since they are typically in or near uncontrolled areas and criminal elements can easily see them withdrawing cash.
Traveler’s checks are accepted at a few major hotels and may also be exchanged for local currency at authorized exchange facilities ("casas de cambio").
Visitors will also find enterprising individuals - ”Cambistas” - waving wads of cash in the street.
Changing money in this fashion can be dangerous and is not recommended.

The U.S. Embassy has noted an increase in credit card fraud.
Although local police authorities have made several arrests in conjunction with credit card scam operations, the danger for abuse continues.
Illegal use can include “skimming” or making a copy of the magnetic strip on the credit card or simply copying the number for later use.
U.S. citizens who do continue to use credit cards in Nicaragua are advised to check statements frequently to monitor for abuse and/or to ask banks to email them when transactions exceed a certain number or size.

Disaster Preparedness: Nicaragua is prone to a wide variety of natural disasters, including earthquakes, hurricanes, and volcanic eruptions.
General information about natural disaster preparedness is available via the Internet from the U.S. Federal Emergency Management Agency (FEMA) at http://www.fema.gov
Boundary Disputes:
On the Atlantic side, nautical travelers should be aware that there is an ongoing boundary dispute with Colombia over the San Andres Island archipelago and the surrounding waters, specifically the area east of the 82nd and up to the 79th meridian.
Furthermore, the Government of Nicaragua has also begun to exercise sovereignty over territorial waters that were formerly controlled by Honduras but recently awarded to Nicaragua by the International Court of Justice.
Since October 2007, the Nicaraguan Navy has impounded about a dozen vessels, including two U.S.-owned vessels, for allegedly fishing without a Nicaraguan permit in theses zones.
Maritime boundary disputes also exist on the Pacific side.
In late-2007, the governments of Nicaragua, Honduras, and El Salvador reached an accord regarding shared fishing rights in the Gulf of Fonseca; however, questions remain regarding boundary demarcations in the Gulf of Fonseca.
Commercial fishing vessels should always ensure that they are properly licensed as problems have been reported in the areas off Cabo Gracias a Dios.
As a result of these disputes, in June 2008, the U.S. Coast Guard published a Special Warning on Nicaragua in the U.S. Notice to Mariners, which can be found at http://www.navcen.uscg.gov/Lnm/d1/lnm01242008.pdf (p. 6).

Travelers should also be aware that narcotics traffickers often use both the Caribbean and the Pacific coastal waters.
Customs Regulations: Before excavating archaeological materials, or agreeing to buy artifacts of historical value, all persons are strongly urged to consult with the National Patrimony Directorate of the Nicaraguan Institute of Culture.
Nicaraguan law and a bilateral accord limit the acquisition, importation into the United States and commercialization of said goods.
Severe criminal penalties may apply.
U.S. citizens planning to stay in Nicaragua for an extended period of time with the intention of bringing vehicles or household goods into the country should consult Nicaraguan customs officials prior to shipment.
Please see our Customs Information.

CRIMINAL PENALTIES:
While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law.
Penalties for breaking the law can be more severe than in the United States for similar offenses.
Persons violating Nicaraguan laws, even unknowingly, may be expelled, arrested, or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in Nicaragua are severe, and convicted offenders can expect long jail sentences and heavy fines.
Engaging in sexual conduct with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States.
Please see our information on Criminal Penalties.

CHILDREN'S ISSUES:
For information see our Office of Children’s Issues web pages on intercountry adoption and international parental child abduction.

REGISTRATION / EMBASSY LOCATION:
Americans residing or traveling in Nicaragua are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration website so that they can obtain updated information on travel and security within Nicaragua.
Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate.
By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.
The U.S. Embassy is located at Kilometer 5 1/2 (5.5) Carretera Sur, Managua; telephone (505) 252-7100 or 252-7888; after hours telephone (505) 252-7634; Consular Section fax (505) 252-7304; Email: consularmanagua@state.gov or ACS.Managua@state.gov; web page: http://nicaragua.usembassy.gov/
*

*

*
This replaces the Country Specific Information for Nicaragua dated June 3, 2008, to update sections on Country Description, Entry/Exit Requirements, Safety and Security, Crime, Medical Facilities and Health Information, Traffic Safety and Road Conditions, and Special Circumstances.

Travel News Headlines WORLD NEWS

Date: Thu, 25 Oct 2018 22:17:34 +0200

Montreal, Oct 25, 2018 (AFP) - Canadian tour operator Transat has cancelled all flights to Nicaragua this coming winter over the crisis that has left more than 320 dead in the Central American country, the company said Thursday.   This decision was made "because of the ongoing civil unrest and (the) weak demand that arises," Air Transat spokeswoman Debbie Cabana told AFP.   Air Transat would have offered three direct flights weekly form Toronto or Montreal to Managua from December 20 until the end of March.   "Customers who have reservations at the destination can change their booking or get a full refund," Cabana said.

Protests that began in April against a pension reform in Nicaragua grew into a movement demanding the departure of President Daniel Ortega and his wife, Vice President Rosario Murillo, who are accused of authoritarianism.    The protests have been severely repressed by police and paramilitaries, and the government proclaimed the situation normalized.   Canada continues to advise its nationals "to avoid any non-essential travel to Nicaragua."
Date: Fri, 7 Sep 2018 19:57:24 +0200

Managua, Sept 7, 2018 (AFP) - Many shops, banks and gas stations were closed Friday in a 24-hour strike in Nicaragua called by the opposition in protest at "political prisoners" and the rule of President Daniel Ortega's government.   In Mercado Oriental, one of the capital Managua's main trade districts, most of the 20,000 shops and businesses were shut, while few people were out on the streets.   "It's an excellent strike, this is how we are supporting those who were taken, who are being tortured, who have no business being in jail just for protesting," shopkeeper Geidy Areas, 38, told AFP.   The normally busy road south from Managua to Masaya, where many shops operate, appeared more desolate than normal.   Friday's strike, the first since July, was called by the opposition Civil Alliance for Justice and Democracy.   More than 300 Nicaraguans have been charged with crimes for taking part in protests, including 85 who are accused of terrorism.   The Alliance is demanding dialogue with Ortega's government after months of turmoil that left more than 300 people dead, according to rights groups.

In Managua, most banks, gas stations, shopping malls and book shops were closed but there were more buses and public transport vehicles running than during previous strikes in June and July.   In an important economic zone north of Managua, many hardware stores, shops and cafes remained open.   "People have to keep struggling because they've got bank debts and need to feed their children," food vendor Johana Blandon, who works in a busy free trade zone to the east of Managua, told AFP.   Government offices were operating as normal.   Nicaragua's descent into chaos was triggered on April 18 when relatively small protests against now-scrapped social security reforms were met with a government crackdown, backed by armed paramilitaries.

Catholic church-brokered peace talks broke down in June after Ortega rejected a key opposition demand to step down and bring forward presidential elections.   Last week, Ortega expelled the United Nations human rights mission after it published a report criticizing the "climate of fear" in the Central American country, one of the poorest in the region.   The UN denounced a wide range of serious violations, including disproportionate use of force by police, which in some cases resulted in extrajudicial killings, enforced disappearances, arbitrary detention and torture.   Ortega, a former guerrilla leader who has been in power for the last 11 years, denied the claims and described the UN as "an instrument of the policies of terror, lies and infamy."
Date: Thu, 6 Sep 2018 18:06:28 +0200

Managua, Sept 6, 2018 (AFP) - Nicaragua's opposition called a 24-hour strike on Thursday, due to start the next day, in protest against President Daniel Ortega and to demand the release of "political prisoners."   The strike is due to begin at midnight on Thursday, the Civil Alliance for Justice and Democracy, made up of students, businesses and civil service groups, said in a statement.

The opposition is demanding dialogue with Ortega's government after months of turmoil that left more than 300 people dead, according to rights groups.   It called on supporters to "join this national effort from your homes."   "Nicaragua needs an urgent and peaceful solution through dialogue," said the opposition.   "We need to live in security, without kidnappings, without political prisoners, without persecution and without the stigmatization of those who think differently."   Last week, Ortega expelled the United Nations human rights mission after it published a report criticizing the "climate of fear" in the Central American country, one of the poorest in the region.   The UN denounced a wide range of serious violations, including disproportionate use of force by police, which in some cases resulted in extrajudicial killings, enforced disappearances, arbitrary detention and torture.

Ortega, a former guerrilla leader who has been in power for the last 11 years, refuted the claims and described the UN as "an instrument of the policies of terror, lies and infamy."   In addition to the dead and 2,000 people injured in clashes between anti-government protesters and regime forces back by paramilitaries, more than 300 Nicaraguans have been charged with crimes for taking part in the protests, of which 85 are accused of terrorism.   Two Alliance leaders, Medardo Mairena and Edwin Carcache, are amongst those to have been charged.   The opposition says "dialogue is the only path" to overcome the current political crisis.

Nicaragua's descent into chaos was triggered on April 18 when relatively small protests against now-scrapped social security reforms were met with a government crackdown, backed by armed paramilitaries.   Catholic church-brokered peace talks broke down in June after Ortega rejected a key opposition demand to step down and bring forward presidential elections.   Opposition supporters claimed the last strike in mid-July was 90 percent respected, although government media said businesses had remained open in several trade zones.
Date: Fri, 27 Jul 2018 23:17:00 +0200

Managua, July 27, 2018 (AFP) - More than a dozen doctors, nurses and technical staff in a public hospital in Nicaragua have been sacked because they treated wounded anti-government protesters and were seen backing their cause, medical sources said Friday.

Those fired "without any legal justification" worked at the Oscar Danilo Rosales Hospital in the northwestern city of Leon, surgery and endoscopy department chief Javier Pastora told AFP.   The hospital is run by the health ministry.   The allegation bolstered reports that those perceived to back protest claims calling for the ouster of President Daniel Ortega were being persecuted by his government and sympathizers.

Nicaragua has seen more than three months of unrest as those protests were brutally countered by police and armed pro-government paramilitaries.   More than 300 people have been killed and thousands have fled to neighboring Costa Rica for safety, according to rights groups.   Pastora, who has worked in Nicaragua's public health system for 33 years, said the staff members were fired because they were deemed to support the protesters by treating them.   "They said we were people showing solidarity and support for the people's fight," he said.   Pastora said at least nine medical specialists were among those fired.

- Dismissed in surgery -
"I was in surgery when they came from human resources to tell me I could no longer stay because I was fired," said one of the dismissed medics, cancer surgeon Aaron Delgado.   A dismissed pediatrician, Edgar Zuniga, called the axings "arbitrary."   They were fired "for thinking differently, for saying Nicaragua needs democracy, freedom, that the repression and killings must stop and there has to be dialogue," he said.

The staff and residents in Leon held a protest in front of the hospital demanding the sackings be reversed.   Leon used to be a bastion of support for the Sandinista movement Ortega leads, but as the unrest took hold, there too paramilitaries and anti-riot police have stormed the city several times to crush protests.   Rights groups say more than 2,000 people have been hurt across the country since the clashes erupted mid-April.   Many of them sought medical attention for their wounds from volunteers outside the state health system, which was said to have received orders to turn them away.
Date: Wed, 11 Jul 2018 22:06:35 +0200

Washington, July 11, 2018 (AFP) - The known death toll from a four-month crackdown on anti-government protests in Nicaragua has risen to 264, the Inter-American Commission on Human Rights said Wednesday.

"As recorded by the IACHR since the start of the repression against social protests, to date, 264 people have lost their lives and more than 1,800 have been injured," the commission's chief Paulo Abrao told reporters.   He was speaking at a meeting of the Organization of American States -- of which the IACHR is part -- about the situation in the violence-wracked Central American country, where protesters are seeking the ouster of President Daniel Ortega.   The rights body had previously given a toll of 212 dead, although local estimates recently put the toll at about 250.

The influential Roman Catholic church has been mediating between Ortega's government and the opposition to end the unrest, but the process has become bogged down amid continuing violence.   In the latest outburst, at least 14 people died in a weekend raid by a pro-government mob near the opposition bastion of Masaya, in the country's southwest.   The opposition is planning to crank up the pressure on Ortega starting on Thursday with an anti-government protest and general strike.

A former leftist guerrilla, Ortega will next week commemorate the 1979 popular uprising that brought him to power with an annual July 19 march due to start in Masaya.   Once the hero of left-wing revolutionaries, Ortega is now widely viewed as an oppressor.   Having lost a presidential vote in 1990, he was re-elected in 2007 but opponents have accused him -- together with his wife Vice President Rosario Murillo -- of establishing a dictatorship characterized by nepotism and brutal repression.
More ...

Virgin Islands

British Virgin Islands US Consular Information Sheet
April 03, 2006
COUNTRY DESCRIPTION: The British Virgin Islands (BVI) are a British overseas territory, part of the British West Indies, lying about 60 miles east of Puerto Rico. There are abo
t 50 islands in the BVI, many of them uninhabited. Tortola is the main island; other islands include Virgin Gorda, Jost Van Dyke, and Anegada. Tourist facilities are widely available.
ENTRY/EXIT REQUIREMENTS: For tourist stays of up to six months, U.S. citizens need a valid U.S. passport or other proof of U.S. citizenship (original or certified birth certificate, Certificate of Naturalization or Certificate of Citizenship as well as photo identification), onward or return tickets, and sufficient funds for their stay. Upon initial entry, no more than 60 days will be granted. At the end of 60 days, visitors must report to the Immigration Department's main office in Road Town for an extension. Extensions of up to 90 days are issued at the discretion of the Immigration Officer subsequent to an interview. For further information on travel to the British Virgin Islands, travelers should contact the BVI Department of Immigration at 1-284-494-3471. Visit the Embassy of the British Government web site at for the most current visa information.
See Entry and Exit Requirements for more information pertaining to dual nationality and the international child abduction . Please refer to our Customs Information to learn more about customs regulations.

SAFETY AND SECURITY For the latest security information, Americans traveling abroad should regularly monitor the Department's Internet web site, where the current Travel Warnings and Public Announcements , including the Worldwide Caution Public Announcement , can be found.

Up-to-date information on safety and security can also be obtained by calling 1-888-407-4747 toll free in the U.S., or for callers outside the U.S. and Canada, a regular toll-line at 1-202-501-4444. These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).

The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas. For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State's pamphlet A Safe Trip Abroad .
CRIME: Thefts and armed robberies do occur in the BVI. Visitors should take common-sense precautions against petty crime. Avoid carrying large amounts of cash and use hotel safety deposit facilities to safeguard valuables and travel documents. Do not leave valuables unattended on the beach or in cars. Always lock up boats when going ashore.
INFORMATION FOR VICTIMS OF CRIME: The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the nearest U.S. Embassy or Consulate. If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the nearest U.S. Embassy or Consulate for assistance. The Embassy/Consulate staff can, for example, assist you to find appropriate medical care, contact family members or friends and explain how funds could be transferred. Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.
See our information on Victims of Crime .
MEDICAL FACILITIES AND HEALTH INFORMATION: Medical care in the British Virgin Islands consists of a small general hospital with an emergency room staffed 24-hrs/day by physicians, several clinics on Tortola, and one clinic in Virgin Gorda. Ambulances staffed with paramedics serve both islands. There are no medical facilities on the other islands. A volunteer organization, Virgin Islands Search and Rescue (VISAR), responds 24-hrs/day to medical emergencies at sea or on outer islands. VISAR transports casualties to the nearest point for transfer to ambulance. To reach VISAR, dial SOS (767) or call on Marine Channel 16.
There is no hyperbaric chamber in the BVI. Patients requiring treatment for decompression illness are transferred to St. John, U.S. Virgin Islands. Most sensitive medical cases are transferred to San Juan, Puerto Rico.
Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention's hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC's internet site at . For information about outbreaks of infectious diseases abroad consult the World Health Organization's (WHO) website at . Further health information for travelers is available at .
MEDICAL INSURANCE: The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation. Please see our information on medical insurance overseas
TRAFFIC SAFETY AND ROAD CONDITIONS: While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States. The information below concerning the British Virgin Islands is provided for general reference only, and may not be totally accurate in a particular location or circumstance.
Vehicles drive on the left (the British side) with most steering wheels on the left (the "American" side). Road signs are limited and seatbelts are required by law. Drivers often fail to yield the right-of-way to pedestrians, even at painted crosswalks. Speeding and reckless driving are fairly common in the BVI. Drivers can encounter nighttime drag racing on main thoroughfares and livestock on roads. Roads in Tortola's interior can be steep and extremely slippery when wet. Travelers planning to drive across the island should consider requesting four-wheel drive vehicles and should ensure that tires and brakes are in good operating condition on any rental vehicle. Please refer to our Road Safety page for more information, as well as the website of the BVI's national tourist office and national authority responsible for road safety at
.
AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of the British Virgin Islands as being in compliance with ICAO international aviation safety standards for oversight of BVI's air carrier operations. For more information, travelers may visit the FAA's Internet web site at .
CUSTOMS REGULATIONS: BVI customs authorities may enforce strict regulations concerning temporary importation into or export from the British Virgin Islands of items such as drugs and firearms. Visitors to BVI carrying firearms must declare them upon entry into any port in the territory. Firearms must be bonded and are held by the proper authorities until time of departure. Contact BVI Customs & Immigration at 1-284-494-3475, the Embassy of the United Kingdom in Washington, D.C. or one of the UK's consulates in the United States for specific information regarding customs requirements. Please see our information on Customs Information .
CRIMINAL PENALTIES: While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law. Penalties for breaking the law can be more severe than in the United States for similar offenses. Persons violating British Virgin Island laws, even unknowingly, may be expelled, arrested or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in the BVI are severe, and convicted offenders can expect long jail sentences and heavy fines. Engaging in sexual conduct with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States. Please see our information on Criminal Penalties .
DISASTER PREPAREDNESS: All Caribbean countries can be affected by hurricanes. The hurricane season normally runs from June to the end of November, but there have been hurricanes in December in recent years. General information about natural disaster preparedness is available via the Internet from the U.S. Federal Emergency Management Agency (FEMA).
CHILDREN'S ISSUES: For information on international adoption of children and international parental child abduction, see the Office of Children's Issues website.
REGISTRATION/EMBASSY AND CONSULATE LOCATIONS: Americans living or traveling in the British Virgin Islands are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration website , and to obtain updated information on travel and security within the BVI. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency. The nearest U.S. Embassy to the BVI is located in Bridgetown, Barbados. The Consular Section is located in the American Life Insurance Company (ALICO) Building, Cheapside, telephone 1-246-431-0225 or fax 1-246-431-0179, email ConsularBridge2@state.gov , or . The U.S. Consular Agent in Antigua, located at Jasmine court, St. John's, tel. 1-268-463-6531, is closer to the BVI and can also assist in some limited non-emergency cases, by previous appointment only.
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This replaces the British Virgin Islands Consular Information Sheet dated April 26, 2005 to update all sections.

Travel News Headlines WORLD NEWS

Date: Thu 19 Sep 2019
Source: Emerg Infect Dis [edited]

Citation:
Guendel I, Ekpo LL, Hinkle MK, Harrison CJ, Blaney DD, et al.: Melioidosis after Hurricanes Irma and Maria, St. Thomas/St. John District, US Virgin Islands, October 2017. Emerg Infect Dis. 2019; 25(10): 1952-1955. doi: 10.3201/eid2510.180959.

Melioidosis is caused by _Burkholderia pseudomallei_, a saprophytic, gram-negative bacillus endemic to tropical regions worldwide (1). Diagnosis is difficult because of wide-ranging clinical manifestations (2), and this bacterium is innately resistant to many antimicrobial drugs, making treatment options limited, complex, and lengthy (3). Infection occurs by percutaneous exposure, inhalation, or ingestion.

Melioidosis is rare in the USA, and cases are usually travel related (4,5). However, regional endemicity has been documented in Puerto Rico (6), and sporadic human cases have been reported in the Caribbean (5,7). In September 2017, the US Virgin Islands were affected by 2 category 5 hurricanes, Irma and Maria; widespread flooding continued for weeks. We describe the clinical manifestations, management, and outcome of post-hurricane melioidosis cases in 2 women in St. Thomas and St. John, US Virgin Islands.

The study
Despite major damage to the 2 hospitals in the territory during the 2 hurricanes, the Virgin Islands Department of Health (VIDOH) maintained surveillance at both emergency departments. Two isolates were recovered from each patient. Local specimen analysis for organism identification was performed by using the MicroScan WalkAway System (Siemens Healthcare Diagnostics, <https://www.siemens-healthineers.com>). All isolates were confirmed as _B. pseudomallei_ at the CDC. Whole-genome sequencing and single-nucleotide polymorphism analysis were performed (National Center for Biotechnology Information, <https://www.ncbi.nlm.nih.gov>. Genomes from a given patient were clonal to each other. However, representative genomes from both patients had differences (greater than 5600 single-nucleotide polymorphisms), indicating the presence of different strains in these infections. Genomic comparison with a reference panel indicated that the isolates were within the previously described Western Hemisphere clade and subclade associated with the Caribbean (8).

Patient 1 was an 80-year-old female resident of St. Thomas who had a history of cardiomyopathy and type II diabetes mellitus. She came to the emergency department (ED) at Schneider Regional Medical Center (St. Thomas, US Virgin Islands) because of shortness of breath (symptom onset 28 days after Hurricane Irma and 9 days after Hurricane Maria). Her symptoms were worsened orthopnea, increased abdominal girth, and edema, consistent with her symptoms at previous admissions. The patient was admitted for management of acute decompensated heart failure.

The patient had a temperature of 98.5 deg F [36.9 deg C]; diffuse pulmonary crackles; jugular venous distension; normal heart sounds; and bilateral, lower extremity pitting edema. Examination showed a focal area on the anterior left thigh that had a central, firm, warm, erythematous, tender, subcutaneous nodule about 2 cm [approximately 0.8 in] in diameter with a central fluctuant area and a small pinhole. Incision and drainage was performed, and a swab specimen of purulent drainage was sent for culture.

The patient was given intravenous clindamycin (600 mg every 8 h for 5 d) and was discharged while receiving oral clindamycin, but the treatment course was not completed. Cultured wound showed growth of _B. pseudomallei_ at 5 days. However, culture growth was not yet positive before patient discharge. The isolate was susceptible to trimethoprim/sulfamethoxazole (Table 1 [for Tables and Figure, see original URL - ProMED Mod.LL]).

Patient 1 returned to the ED 2 weeks later because of manifestations similar to those at the 1st visit. She was afebrile and admitted for diuresis. The left thigh lesion had progressed into a 2 cm [about 0.8 in], tender, shallow ulcer productive of purulent material surrounded by erythema and a focal area of induration (Figure). Laboratory data reflected a leukocyte count within reference ranges and mild renal insufficiency with estimated glomerular filtration rate of 40.47 mL/min (Table 2). A 2nd wound culture was collected, and the patient was given intravenous meropenem (1 g every 8 h). Culture was presumptively positive for _B. pseudomallei_ and _Serratia marcescens_ after 48 hours, confirmed after 8 days. Both isolates showed the same resistance pattern and were susceptible to meropenem and trimethoprim/sulfamethoxazole: the MIC for meropenem was <1 microgram/mL (Table 2). Meropenem was continued for 8 days, and ulcer improvement was observed. The patient was discharged while receiving oral trimethoprim/sulfamethoxazole (800 mg/160 mg 2x/d) to complete maintenance therapy. The patient completed a 3-month course of trimethoprim/sulfamethoxazole and achieved resolution.

Patient 2 was a 60-year-old female who had diabetes and was a resident of St. John. She was referred to the ED at Schneider Regional Medical Center by her primary care physician because of hyperglycemia, productive cough, and malaise for one week (symptom onset 46 days after Hurricane Irma and 33 days after Hurricane Maria). The patient was admitted to the intensive care unit because of community-acquired pneumonia.

The patient was lethargic and had a temperature of 101 deg F [38.3 deg C]; heart rate was 99 beats/min, respiratory rate 22 breaths/min, and blood pressure 142/81 mm Hg. Blood gas testing showed pO2 of 47.6 mm Hg with an oxygen saturation of 87.2% on 2-liter nasal cannula. A chest radiograph showed a left-sided mild infiltrate, and her leukocyte count was markedly increased (28 300 cells/mm3) (Table 2).

The patient was given intravenous ceftriaxone (1 g/d) and azithromycin (500 mg/d) after blood and sputum cultures were prepared. She required bilevel positive airway pressure but eventually required mechanical ventilation. The patient then became hypotensive and required norepinephrine to maintain a main arterial pressure greater than 65 mm Hg. Ceftriaxone was discontinued, and she was given intravenous piperacillin/tazobactam (3.375 g every 6 h). Trimethoprim/sulfamethoxazole- and ceftazidime-sensitive _B. pseudomallei_ were identified from sputum culture after 72 hours (Table 1). Methicillin-sensitive _Staphylococcus aureus_ and _Candida glabrata_ were also identified. One of 2 blood cultures was positive for gram-negative rods. Piperacillin/tazobactam was discontinued, and the patient was given meropenem (1 g every 8 h).

The patient remained critically ill and was transferred to a tertiary-care hospital in the continental USA. She died in a long-term care facility during October 2018 without showing signs of neurologic improvement.

Isolates from both patients showed susceptibility to routinely tested antimicrobial drugs (10,11). Isolates from patient 1 showed resistance to ceftazidime during preliminary analysis (Table 1). However, broth microdilution confirmatory testing performed at CDC indicated ceftazidime susceptibility, highlighting the need for additional antimicrobial resistance confirmation.

Both patients were interviewed to determine travel history and possible exposure sources. Patient 1 traveled occasionally to the southeastern USA; her last travel date was 3 months before her illness. This patient reported flooding and water damage to her home from the hurricanes but did not report contact with flood waters. Patient 2 reported no travel history before the hurricanes.

VIDOH has investigated and confirmed a subsequent case-patient with pulmonary melioidosis in St. Thomas during December 2018 (I. Guendel et al., unpub. data). This case-patient reported no recent travel and might have had occupational exposure as a professional gardener. This person had 2 risk factors (type II diabetes mellitus and heavy use of alcohol).

Conclusions
Given regional occurrence, detection of melioidosis in the US Virgin Islands is not surprising. Furthermore, emergence of melioidosis after extreme weather events has been well documented, and cases were likely acquired locally from storm-related exposure to flooded soil, surface water runoff, or generation of coarse aerosols (12,13). Although detection of _B. pseudomallei_ has yet to be confirmed in the environment, it might be endemic to the US Virgin Islands, as in Puerto Rico.

In January 2018, melioidosis was listed as a reportable disease in the US Virgin Islands. Future actions include disease education efforts for physicians and laboratory staff because misdiagnosis is common (14). Awareness campaigns highlighting preventive measures for the public are necessary because risk factors are prevalent in the local population (e.g., diabetes and other chronic disease) and might be exacerbated under disaster settings (e.g., respiratory effects and open wounds). VIDOH has implemented rapid diagnostic testing by using Active Melioidosis Detect (InBios International, <https://inbios.com>) on suspected specimens for prompt on-island case identification while routine ED diagnostic cultures are performed (5). All confirmatory testing is conducted at CDC.

References
-------
On Request
======================
[This infection is found primarily in southeast Asia and the Northern Territory of Australia. Despite this, cases of melioidosis have been acquired in other parts of the world including the Americas. Flooding from the increasing number of severe tropical storms related to climate change is increasing.

Melioidosis is a disease of the rainy season in its endemic areas. It mainly affects people who have direct contact with soil and water. Many have an underlying predisposing condition such as diabetes (most common risk factor), renal disease, cirrhosis, thalassemia, alcohol dependence, immunosuppressive therapy, chronic obstructive lung disease, cystic fibrosis, and excess kava consumption (kava is an herbal member of the pepper family that can be associated with chronic liver disease).

Melioidosis may present at any age but peaks in the 4th and 5th decades of life, affecting men more than women. In addition, although severe fulminating infection can and does occur in healthy individuals, severe disease and fatalities are much less common in those without risk factors.

The most commonly recognized presentation of melioidosis is pneumonia, associated with high fever, significant muscle aches, and chest pain, and -- although the cough can be nonproductive -- respiratory secretions can be purulent, significant in quantity, and associated with on-and-off bright red blood. The lung infection can be rapidly fatal -- with bacteremia and shock -- or somewhat more indolent.

Acute melioidosis septicaemia is the most severe complication of the infection. It presents as a typical sepsis syndrome with hypotension, high cardiac output, and low systemic vascular resistance. In many cases, a primary focus in the soft tissues or lung can be found. The syndrome, usually in patients with risk factor comorbidities, is characteristically associated with multiple abscesses involving the cutaneous tissues, lung, liver, and spleen, and a very high mortality rate of 80-95%. With prompt optimal therapy, the case fatality rate can be decreased to 40-50%.

The melioidosis bacillus is intrinsically insensitive to many antimicrobials, and in fact, bioterrorism strains may be engineered to be even more resistant. _Burkholderia pseudomallei_ is usually inhibited by tetracyclines, chloramphenicol, trimethoprim-sulfamethoxazole (SXT), antipseudomonal penicillins, carbapenems, ceftazidime, and amoxicillin/clavulanate or ampicillin/sulbactam. Ceftriaxone and cefotaxime have good in vitro activity but poor efficacy, and cefepime did not appear, as well, to be equivalent to ceftazidime in a mouse model. The unusual antimicrobial profile of resistance to colistin and polymyxin B and the aminoglycosides but sensitivity to amoxicillin/clavulanate is a useful tool to consider in treatment of infection with the organism.

The randomized and quasi-randomized trials comparing melioidosis treatment have been reviewed, and it was found that the formerly standard therapy of chloramphenicol, doxycycline, and SXT combination had a higher mortality rate than therapy with ceftazidime, imipenem/cilastatin, or amoxicillin/clavulanate (or ampicillin/sulbactam). The betalactam-betalactamase inhibitor therapy, however, seemed to have a higher failure rate.

Source: Tolaney P, Lutwick LI: Melioidosis. In: Lutwick LI, Lutwick SM (eds). Bioterror: the Weaponization of Infectious Diseases. Totowa NJ: Humana Press, 2008. pp 145-58. - ProMED Mod.LL]

[HealthMap/ProMED-mail map:
US Virgin Islands: <http://healthmap.org/promed/p/479>]
Date: Fri 31 Jan 2014
Source NBC News [edited]

The Explorer of the Seas outbreak was caused by norovirus, one of the worst outbreaks in 20 years, the Centers for Disease Control and Prevention (CDC) said. The Explorer of the Seas cruise ship returned to port after hundreds of passengers became ill. Federal health officials confirmed on Friday [31 Jan 2014] that norovirus was the culprit that sickened nearly 700 people on a cruise ship this week, and said it was one of the biggest norovirus outbreaks in 20 years. But the source of the outbreak on the Royal Caribbean ship Explorer of the Seas, which returned early to New Jersey on Wednesday [29 Jan 2014], may never be known, CDC said: "CDC has been investigating the outbreak since last Sunday [26 Jan 2014] but no particular source has been identified and it's quite possible a source won't be identified."

The report comes after passengers streamed off the Caribbean Princess on Friday morning [31 Jan 2014], the 2nd cruise cut short this week amid reports of illness on board. The ship, operated by Princess Cruises, returned to Houston [Texas] a day early with a confirmed outbreak of norovirus. "The ship was forced to return to Houston one day early because we were informed that dense fog was expected to close the port for much of the weekend," the company said in a statement. "The ship did not return early because of the increased incidence of norovirus on board, despite some media reports."

At least 178 people on board became ill during the cruise, according to the cruise line and CDC. Sick patients were quarantined to their rooms, and other passengers said they no longer had access to buffet tongs as crew members handed out hand sanitiser. CDC health officials met the Caribbean Princess at the Bayport Cruise Terminal in Pasadena, Texas. The vessel launched on a 7-day cruise to the western Caribbean on [25 Jan 2014] and had been scheduled to return on Saturday [1 Feb 2014]. Princess Cruises said the outbreak was over by the time the ship returned to Houston. "As a result of our actions, case numbers declined significantly and by the end of the cruise there were no passengers with active symptoms," the company said. "Over the course of the cruise 178 passengers (5.7 per cent) and 11 crew (1 per cent) reported ill to the Medical Center."

CDC officials also helped Royal Caribbean clean up the Explorer of the Seas, and said it had been approved to go back out again with a new batch of passengers Friday afternoon [31 Jan 2014]. Royal Caribbean officials say they cleaned the ship, which carried more than 3000 passengers, 3 times. It's the 3rd cruise ship outbreak to occur this year [2014]. A Norwegian Cruise Line ship, the Norwegian Star, reported that 130 passengers and 12 crew members became ill on 2-week cruise that launched [5 Jan 2014] from Miami.

About 20 million passengers take cruises in the US each year, fuelling a USD 37.8 billion annual industry, according to the American Association of Port Authorities. There were 9 vessel outbreaks in 2013 and 16 in 2012, according to the CDC. Norovirus is a common culprit in outbreaks on cruise ships, in nursing homes, and other confined places. It is a fast-moving gut bug typically spread by infected people or contaminated food or water. Norovirus is the most common cause of acute gastroenteritis in the US, resulting in about 21 million illnesses, between 56 000 and 71 000 hospitalizations and as many as 800 deaths, CDC says.

The virus lingers on surfaces and spreads very easily. Thorough hand washing with hot water and soap and meticulous environmental cleaning can help stop the spread. CDC says it's the season for norovirus. "Norovirus outbreaks wit high attack rates are common during this time of year," the agency said. "Most outbreaks occur between January and April."   [byline: Maggie Fox]
*****
Date: Wed 29 Jan 2014
Source: NBC News [edited]

Beleaguered passengers finally fled a Royal Caribbean cruise ship on Wednesday [29 Jan 2014] after a 10-day vacation cut short by a nasty gut bug that sickened nearly 700 people. One woman aboard the Explorer of the Seas yelled, "We made it!" as the ship docked in Bayonne [New Jersey], 2 days ahead of schedule. Other passengers stood on deck wrapped in blankets to watch the ship pull in. One person was removed from the Explorer of the Seas on a stretcher and taken away by ambulance. Others walked under their own power after the vessel arrived. Several passengers recounted a week full of tension and drama, but also professionalism and care from the cruise line crew.

Still, the ordeal on the 1020-foot ship -- whose relaxing voyage to the US Virgin Islands was thwarted by suspected norovirus -- may linger a little longer for people still showing signs of the fast-moving infection, health officials said. "We have passengers who are still exhibiting active disease," said Burnadette Burden, a spokeswoman for the Centers for Disease Control and Prevention. People who are still sick may be too ill to travel home -- and too contagious to use public transportation like trains and buses, health experts say. Royal Caribbean officials said Wednesday [29 Jan 2014] that they'd pay for hotels or make sure that ill passengers get additional medical care. "Should a guest feel sick enough that they want to go to the hospital, we will arrange for transportation," Royal Caribbean spokeswoman Cynthia Martinez said in an email. "We will work with the small number of guests that still feel ill to make them as comfortable as possible."

At least 630 of the ship's 3071 passengers and at least 54 of the 1166 crew members came down with diarrhea and vomiting -- classic signs of norovirus. Most of the cases occurred early in the cruise, which left New Jersey on [21 Jan 2014], and many passengers had already recovered. It's hard to say that the outbreak was the worst on record because of inconsistencies in record-keeping. But it's a bad one, Burden said. "It would be fair to say this is one of the largest numbers in the last 20 years or so," she said. One of the closest outbreaks to compare occurred in 2006, when a Carnival Cruise ship, the Carnival Liberty, was hit with an outbreak of norovirus that sickened 679 passengers and crew on a November trip to the US Virgin Islands.

CDC officials have not confirmed that norovirus is the culprit on the Explorer of the Seas, though it's a common cause of illness on cruise ships. Officials said testing was delayed by a treacherous winter snowstorm that closed the agency's Atlanta headquarters and results aren't expected until Friday [31 Jan 2014]. But if it is the germ, it's highly contagious for the one to 2 days when people are actively sick -- and for a few days afterward. The virus actually lingers in people's stool for 2 weeks or more, according to the CDC. That means that anyone who fell ill -- and those who were around them -- should pay extra attention to washing their hands and other kinds of cleanliness, said Dr Ruth Lynfield, outgoing head of the public health committee of the Infectious Diseases Society of America.

Cleanliness will be the key for the cruise line, too. Officials said they plan another scrub, a so-called "barrier sanitation" program to ensure that any remaining traces of illness are removed from the ship. Norovirus is a notoriously difficult bug to eradicate, health experts say. "It will be the 3rd aggressive sanitizing procedure the ship has undertaken since we became aware of the issue, and will additionally provide a window of more than 24 hours where there are no persons aboard the ship," officials said in a statement.   [byline: JoNel Aleccia]
******
Date: Fri 31 Jan 2014
Source: CDC, National Center for Environmental Health, Division of
Emergency and Environmental Health Services, Vessel Sanitation Program (VSP) [edited]

Cruise ship: Explorer of the Seas -- voyage dates: 21-31 Jan 2014
-----------------------------------------------------------------
- number of passengers who reported being ill during the voyage out of total number of passengers onboard: 634 of 3071 (20.6 per cent)
- number of crew who reported being ill during the voyage out of total number of crew onboard: 55 of 1166 (4.7 per cent)
- predominant symptoms: vomiting, diarrhea
- Causative agent: Norovirus

Actions: in response to the outbreak, Royal Caribbean Cruise Line and the crew aboard the ship took the following actions:
- increasing cleaning and disinfection procedures according to their outbreak prevention and response plan;
- making announcements to both notify onboard passengers of the outbreak and encourage case reporting;
- collecting stool specimens from ill passengers and crew for submission to the CDC lab;
- making multiple daily reports of gastrointestinal illness cases to the VSP [Vessel Sanitation Program];
- preparing additional crew members to join the ship mid-voyage to assist with case management and intensified sanitation procedures;
- consulting with CDC on plans for: passenger notification procedures and the planned delayed embarkation schedule in Bayonne, NJ on [31 Jan 2014], and disembarkation plans for active cases, terminal, and transport infection control procedures.

One CDC Vessel Sanitation Program epidemiologist, one contract epidemiologist, and one VSP environmental health officer boarded the ship in St Thomas, [US Virgin Islands] and are sailing on the ship as it travels back to port in New Jersey. This team is conducting an epidemiologic investigation, environmental health assessment, and evaluating the outbreak and response activities on board. One additional CDC Vessel Sanitation Program environmental health officer will board the ship upon arrival on [29 Jan 2014] to assist with the evaluation of the disinfection process. The team will continue the investigation and evaluation on the ship thru the boarding of new passengers for the next voyage. 5 clinical specimens were shipped to the CDC lab for testing on [26 Jan 2014].
**************************
Date: Fri 31 Jan 2014
Source: CDC, National Center for Environmental Health, Division of
Emergency and Environmental Health Services, Vessel Sanitation Program (VSP) [edited]

Cruise ship: Caribbean Princess -- voyage dates: 25 Jan-1 Feb 2014
------------------------------------------------------------------
- number of passengers who reported being ill during the voyage out of total number of passengers onboard: 181 of 3102 (5.8 per cent)
- number of crew who reported being ill during the voyage out of total number of crew onboard: 11 of 1148 (0.96 per cent)
- predominant symptoms: vomiting, diarrhea
- causative agent: Norovirus

Actions: in response to the outbreak, Princess Cruise Lines and the crew aboard the ship took the following actions:
- increasing cleaning and disinfection procedures according to their outbreak prevention and response plan;
- making announcements to both notify onboard passengers of the outbreak and encourage case reporting;
- collecting stool specimens from ill passengers and crew for submission to the CDC lab. Samples tested with the vessel's onboard rapid norovirus test were positive for norovirus. The specimens will be sent to the CDC lab for confirmatory analysis;
- making multiple daily reports of gastrointestinal illness cases to the VSP;
- consulting with CDC on plans for: passenger notification procedures and the planned delayed embarkation schedule in Houston, TX on [1 Feb 2014], and disembarkation plans for active cases, and terminal and transport infection control procedures.

Two CDC Vessel Sanitation Program environmental health officers will board the ship in Houston, TX on [31 Jan and 1 Feb 2014] to conduct an epidemiologic investigation, environmental health assessment, and evaluate the outbreak and response activities. Specimens are being collected and will be sent to the CDC lab for testing.
=====================
[ProMED-mail does not normally report outbreaks of norovirus-related gastroenteritis because of their ubiquity during the winter months. (Hence the alternate designation 'winter vomiting bug'). Norovirus infection is very contagious and can be contracted from an infected person, contaminated food or water, or by touching contaminated surfaces. The virus causes acute gastroenteritis with stomach pain, nausea, and diarrhea and vomiting. Anyone can be infected with norovirus and acquire norovirus illness repeatedly throughout life. Norovirus is the commonest cause of acute gastroenteritis in the United States. Each year, it causes 19-21 million cases and contributes to 56 000-71 000 hospitalizations and 570-800 deaths. Norovirus is also the commonest cause of foodborne disease outbreaks in the United States. There's no vaccine to prevent norovirus infection and no drug to treat it.

Norovirus illness is usually not serious. Most people get better in 1 to 3 days. But norovirus illness can be serious in young children, the elderly, and people with other health conditions. It can lead to severe dehydration, hospitalisation but rarely death. Most outbreaks of norovirus illness happen when infected people spread the virus to others. But, norovirus can also spread by consumption of contaminated food or water and by touching contaminated surfaces.

Health care facilities, including nursing homes and hospitals, are the most commonly reported places for norovirus outbreaks in the United States. Over half of all norovirus outbreaks reported in the United States occur in long-term care facilities. Outbreaks of norovirus illness appear to be occurring more frequently in cruise ships and similar environments. - ProMed Mod.CP]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/r/8vcv>.]
Date: Tue 13 Dec 2011
Source: Virgin Islands Daily News [edited]

The Centers for Disease Control and Prevention [CDC] has linked 5 past cases of Legionnaires' disease -- reported between March 2010 and August 2011 -- with stays at Marriott's Frenchman's Reef and Morning Star Beach Resort and Marriott's Frenchman's Cove [in Saint Thomas], prompting remediation work to the resorts' water systems. The VI [Virgin Islands] Health Department has been "working closely" with a team of CDC specialists to monitor the remediation efforts at the resorts, after an investigation into the 5 past cases, according to a statement the Health Department released Monday [12 Dec 2012].

The illness was found in stateside residents who had been guests at the resorts, said Health Department spokeswoman Eunice Bedminster. They required hospitalization but have since recovered, she said. There have been no reports of employees affected at either site, according to the Health Department statement.

The statement indicates that Frenchman's Reef and Morningstar Beach Resort has hired a consultant who led a cleaning project of the affected areas and treated the water system. Test results show no existence of _Legionella_ bacteria, although the Health Department statement said the test results have not yet been evaluated independently by the CDC.

The Health [Department] had asked the resorts to notify those who could potentially be affected by the bacteria: guests and employees, Bedminster said. The properties asked for an extension on a deadline that had been set, and it was granted, but the deadlines passed last week [week of 5 Dec 2011] without the notification to guests and employees going out, Bedminster said. She did not know if, after the deadline, the properties had made the requested notifications, she said.

The hotel provided The Daily News with a written statement that did not address guest notification: "Marriott takes hotel hygiene and cleanliness very seriously. As soon as we were notified of the possibility of the presence of _Legionella_ bacteria we immediately began to work with the USVI Department of Health (DOH) to address the situation. The Frenchman's Reef and Morning Star Beach Resorts hired a consultant who led a cleaning project of affected areas and the treatment of the water system. The latest test results taken after the implementation of these measures show no existence of _Legionella_ bacteria in the samples tested. We have complied with the recommendations provided by the DOH, and we have successfully addressed the issue at the resort. The DOH has allowed the hotel to remain fully open for business and welcome our guests."

The Daily News spoke with Marriott Frenchman's Reef and Morning Star Beach Resort General Manager Jose Gonzalez Espinosa by phone and asked for comment on the Health Department's assertion that the resort did not make the notifications it was supposed to make by the deadline. Gonzalez would not answer the questions unless they were in writing. The Daily News has a policy against submitting questions in writing because written Q and A stifles and slows follow-up and response. The resort underwent a major renovation during the summer, closing 3 May 2011 and reopening on 6 Oct 2011.

Legionnaires' disease is a pneumonia caused by the _Legionella_ bacteria, which live in warm water supplies, said Dr Lauri Hicks, a medical epidemiologist with the CDC. The bacteria that cause the disease do not pass from person to person. "It really requires exposure to water aerosol that contains _Legionella_," she said, Exposure may occur from showering or with time spent in a whirlpool or hot tub where the bacteria that lead to Legionnaires' disease are present, Hicks said.

Only a fraction of people -- typically those with certain risk factors, such as compromised immune systems -- exposed to the bacteria become ill, she said.

According to the Health Department statement, from 2000 through 2009, a total of 22 418 cases of legionellosis were reported to CDC from the 50 states and the District of Columbia. The CDC informed the Health Department in October [2011] of the 5 Legionnaires' disease cases among past guests at the resorts, and the Health Department asked for the agency's help in investigating. From 18 to 22 Oct 2011, CDC specialists conducted testing, and the properties were alerted about the possible _Legionella_ contamination, Bedminster said. On 3 Nov 2011, the Health Department notified each property of the CDC's conclusive findings and ordered them to immediately work on their water systems, including cleansing, superheating, chlorinating, and hiring a private consultant experienced in eliminating _Legionella_ from building water systems, according to the release. More than 6 weeks later, the Health Department notified the public with the statement it released Monday [12 Dec 2011].

Bedminster said that there had been no delay -- and that remediation work began immediately. "We have worked in good faith with both the resorts during what I have said was a monitoring process. We had some agreed-upon deadlines that had not been met, so we had to let the public know," she said.

Bedminster said that Health Department officials had discussed the possibility of enforcement actions with the Department of Labor and the Department of Planning and Natural Resources to get those deadlines met, but she did not know the outcome of the discussions. "Safeguarding the public's health, including that of employees and guests, from exposure and threats are of the utmost importance to the Department of Health," acting Health Commissioner Mercedes Dullum said in the prepared statement. "DOH will continue to monitor this situation with assistance from the CDC. People should not be discouraged from traveling to or within the US Virgin Islands."  [Byline: Joy Blackburn]
---------------------------------------------
Communicated by:
Denis Green
denis@gatesit.com.au
=======================
[The following has been extracted from the US CDC document Travel-Associated Legionnaires' Disease (<http://www.cdc.gov/legionella/faq.htm>):

"About 20-25 percent of all Legionnaires' disease reported to CDC is travel-associated. Legionnaires' disease is important to diagnose and to report because its identification implies the presence of an environmental source to which other susceptible individuals are likely to be exposed. Clusters of Legionnaires' disease associated with travel to hotels or aboard cruise ships are rarely detected by individual clinicians or health departments; travelers typically disperse from the source of infection before developing symptoms. Therefore, a travel history should be actively sought from patients with community-acquired pneumonia and _Legionella_ testing should be performed for those who have traveled in the 2 weeks before onset of symptoms.

"_Because of the multi-state nature of travel in the US, national-level surveillance is necessary to detect outbreaks of travel-associated Legionnaires' disease. CDC relies upon state and local health departments to conduct this surveillance. Surveillance through the National Notifiable Diseases Surveillance System (NNDSS) is still important for monitoring national trends; all cases should be reported through NNDSS."

"Because of the public health importance of timely reporting, inform CDC of travel-associated cases by emailing about the patient's movements in the 2-10 days before onset."

"Environmental sampling/testing should only be conducted after careful consideration of the epidemiologic evidence linking a case(s) to a particular location."

The following article is linked to the CDC document: Barbaree JM, et al: Protocol for Sampling Environmental Sites for Legionellae. Applied Environmental Microbiol 1987; 53(7): 1454-8 (<http://www.cdc.gov/legionella/files/sampling_protocol1987.pdf>): "Since legionellae not related to disease may be found in many of the sites sampled, an epidemiologic association with the probable source should be established before intervention methods, such as disinfection, are undertaken."

"Random sampling without an epidemiologic evaluation and comparing isolates from the environment and from patients could lead to false conclusions about sources of epidemic strains."

Potential environmental sampling sites for _Legionella_ spp that the CDC document suggests include: internal surfaces of faucets, aerators, and shower heads; and water from incoming water main, holding tanks and cisterns, water heater tanks, decorative fountains, irrigation equipment, fire sprinkler system (if recently used), whirlpools, and spas. Because _Legionella_ may be found in water supplies without linkage to any cases, the actual causative source should be demonstrated by matching the genotype of the environmental isolates with that of any clinical isolates to assure frequently costly corrective measures are carried out on the actual source (<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC86783/>; and <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730281/>).

The Virgin Islands are located in the Leeward Islands of the Lesser Antilles, which form the border between the Caribbean Sea and the Atlantic Ocean. Politically, the eastern islands form the British Virgin Islands and the western ones form the United States Virgin Islands. The US Virgin Islands consist of the main islands of Saint Croix, Saint John, and Saint Thomas (<http://en.wikipedia.org/wiki/United_States_Virgin_Islands >). They can be seen on the HealthMap/ProMED-mail interactive map at <http://healthmap.org/r/1xng>. - ProMed Mod.ML]
Date: Sat 18 Sep 2010
Source: Virgin Islands Daily News [edited]
<http://virginislandsdailynews.com/dengue-outbreak-confirmed-in-1.1018284>

After 19 cases of suspected dengue fever -- and at least one death -- reported in the St Thomas-St John District, the VI Health Department issued a statement Friday [17 Sep 2010] saying that the district is experiencing a dengue fever outbreak. According to the Health Department statement released [Fri 17 Sep 2010], 9 of the 19 suspected cases have been laboratory-confirmed as dengue fever in the St Thomas-St John District since June [2010]. On St Croix, there have been 4 suspected cases with no confirmed cases. There is no requirement in the territory that people with suspected dengue fever undergo testing to confirm whether or not they have the mosquito-borne virus, said Health Department epidemiologist Eugene Tull.

His experience with a 2005 outbreak on St Croix leads him to believe that the number of dengue cases this year [2010] is higher than reported, Tull said, adding that he is now receiving anecdotal information about more cases in the community. According to the release, the strain causing the current outbreak is [dengue virus] type 2, which was responsible for the 2005 outbreak on St Croix.
================
[An interactive HealthMap/ProMED-mail map showing the location of the Virgin Islands in the Caribbean can be accessed at
<http://healthmap.org/r/01tp>. - ProMed Mod.TY]
Date: Fri 27 Aug 2010
Source: Virgin Islands Daily News [edited]
<http://virginislandsdailynews.com/news/dengue-fever-possible-cause-of-death-of-st-john-woman-1.977556>

A St John woman who was transferred last week [week of 16 Aug 2010] to a Miami hospital with possible dengue fever symptoms died there 20 Aug [2010] from complications, her husband said. VI [Virgin Islands] Health Department epidemiologist Eugene Tull said earlier this week [week of 23 Aug 2010] that he had no information about a possible death from dengue fever.

Health Department spokeswoman Eunice Bedminster said Thursday [26 Aug 2010] that the department was not aware of any deaths from the territory's dengue fever cases but had been investigating since receiving inquiries from reporters Monday [23 Aug 2010].

Tull said earlier this week that so far this year [2010], there have been 8 confirmed, laboratory positive cases of dengue fever in the territory, 3 probable cases with lab results pending, and 15 suspected cases. All of those were in the St Thomas/St John District, except for 2 of the suspected cases, which were on St Croix, he said. [Byline: Joy Blackburn]
=====================
[The attribution of the woman's death to dengue virus infection is speculative. ProMED-mail awaits confirmation (or not) as further information becomes available. It is clear, however, that locally acquired dengue virus infections are occurring there.

Maps showing the location of the US Virgin Islands can be accessed at <http://www.worldatlas.com/webimage/countrys/carib.htm>. and the HealthMap/ProMED-mail interactive map at <http://healthmap.org/r/01tp> - ProMed Mod.TY]
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Greece

Background
Greece offers a great variety of attractions for the international traveller. A beautiful climate linked with great beaches, a vibrant nightlife and historical monuments to rival any other location throughout the world. All of this located
within western Europe and a short flight away from many of the cooler northern destinations - like Ireland. Travellers from these regions descent on Greece in very significant numbers each year and for the vast majority of them they will have a splendid and healthy time. However for some this may not be the case and serious illness and accidents are regularly reported. Following some commonsense rules would go a long way to avoiding disaster and ensuring that this trip is truly one to be remembered for all the right reasons.
Climate
Situated in southern Europe the country enjoys mild winters but very hot summers. There may be occasional cool breezes (meltemia) but these can serve only to fool the traveller into thinking that they are unlikely to burn. Rain is very uncommon during the height of summer (July and August) and all travellers should be advised to use very adequate sun-block lotion at all times.
Slip, Slop, Slap
Following the Australian mantra of Slip, Slop and Slap makes perfect sense. Slip on a shirt, slop on sunscreen and slap on a hat when out and about during the day and this should help protect against the intense suns rays. Nevertheless, despite all their best intentions, travellers get burnt. This is particularly a problem in the first few days after their arrival when they do not realise the intensity of the suns rays and how easily they can be exposed. Falling asleep beside the hotel's swimming pool or on the beach is a very common problem and must be avoided against. The tips of the ears, shoulders (especially along the bra-strap line, ankles and behind the knees are commonly exposed and forgotten areas.
After Sun care
To treat significant sunburn it is important to increase fluid intake but also to take extra salt on your food (unless medically contraindicated for some specific condition like high blood pressure etc). Soothing water soluble lotions (especially ones containing a mild anaesthetic and/or steroid cream) are probably best but certainly avoid any of the ones which paste the skin with a thick layer - which is almost impossible to remove without causing serious pain! The more severe sunburn cases may need medical care and even hospitalisation which really ruins a holiday.
Food & Water
As a European destination Greece has a good level of food and water hygiene. Unfortunately this can vary - especially as you move away from the main tourist destinations and also as the summer temperatures rise and food goes 'off' more quickly. Eating hot food, avoiding cold foods (side-salads, lettuce etc) and never eating undercooked bivalve shellfish (mussels, oysters, clams etc) makes perfect sense. Eating food or taking fruit juice drinks from street vendors is a risk just not worth taking.
Insect bites
There may be both mosquitoes and sandflys about so having good repellents (DEET based ones) is worthwhile. The biggest problem will be early in the morning and towards the end of the daylight hours. However sitting in the shade while having lunch may be nice and cool but it is also often a place where these insects tend to hover looking for their next meal. Just don't allow that meal to be the blood in your unguarded ankle!
Seeing the Monuments
As mentioned previously Greece is covered with ancient monuments and these attract many thousands of tourists each year. The ruins are often not the most hospitable places for sun-sensitive tourists so taking care against the suns rays is essential - especially while standing carefully listening to the tour guide explain some complicated piece of history while the back of your legs get roasted! The other issue, for those trekking through the ruins, is the distinct possibility of a nasty twisted ankle.
Laser Night shows
Many of the ancient sites have beautiful night shows which depict something of the past splendour and are definitely worth seeing. However it is wise to wear good shoes as stumbling across loose stones is a particular problem at night and also bring a small torch, if possible, to guide your way. Getting separated from your travelling companions, or not being able to find your return bus, can lead to some understandable panic so listen carefully to any instructions and look out for some land marks before you get too far away into the night time crowd.
Animal bites
Some tourists may forget that rabies is a problem in many countries throughout the world and, even though Greece is regarded as rabies-free', there is always a problem if someone should get bitten. The possibility that this animal could have been recently smuggled into the country cannot be out ruled and so many would advise full post exposure treatment should this contact occur. Children may be at particular risk due to their inquisitive nature.
Swimming
Sunburn and swimming go hand in hand but drowning can also occur all too frequently within this region. Strong currents, swimming after meals (or alcohol) and the ever popular romantic midnight swim are all serious risk factors. Also children running around the deep end of the pool may lose their footing and topple in without warning. Unfortunately a very small child sinks instantly with very little sign of the emergency to those close by. Parents need to keep aware of this risk at all times.
The summer working holiday
Many of our students head towards Greece for 2 to 3 months during the summer to work. The attractions are obvious but commonsense and sensible life-style choices are needed throughout their stay to lessen the risk of illness or them returning home with an infection they had not bargained for. Unfortunately many return home with life-long illnesses which have been contracted from a single unprotected sexual contact.
Vaccinations for Greece
As a general rule the usual travel vaccines are not recommended for most short-term travellers to this region. However for the student planning to spend a more prolonged period it would be sensible to consider cover against both Hepatitis A and Hepatitis B and also to check that their Tetanus cover is up-to-date.
Summary
This is still one of the most popular destinations for northern European travellers and, in the vast majority of cases, they will have a fantastic time with only good memories. Unfortunately some less prepared folks will end up with serious sunburn and other illnesses or diseases which perhaps are frequently associated with their own lack of care and protection rather than anything specific to this beautiful country.

Travel News Headlines WORLD NEWS

6th December, 2019
HSE Health Protection Surveillance Centre

On 27/11/2019, a possible case of diphtheria was reported to the Department of Epidemiological Surveillance and Intervention through the Mandatory Notification System in Greece. It concerned an 8 years old boy of Greek nationality, who was hospitalized in the ICU of General Children's Hospital  where he died.  This child had underlying conditions (severe pulmonary hypertension) and was admitted to ICU  on 22/11/2019 with clinical presentation of laryngitis (without the presence of characteristic pseudo membranes) and pneumonia, immediately intubated, covered with double antibiotic regimen and died due to deterioration of his clinical presentation on 26/11/2019.
 
According to the epidemiological data given , there is no travel history, group living, no connection to another case and the child does not belong to a specific population group. Regarding his immunization status, the child was vaccinated with at least 3 doses against diphtheria-tetanus-pertussis.
 
Laboratory investigation of bronchial exudate isolated Corynebacterium diphtheriae via VITEK. Further laboratory testing was performed by the Public Health England  reference Laboratory for Corynebacteria. On Thursday 5/12/2019, the National Public Health Organization was informed that multiplex PCR testing was positive for C. Diphtheriae and positive for the diphtheria toxin gene. The Elek test was also positive for toxin production. The results of the child's post-mortem exam are pending.

Contact tracing and management is ongoing and has identified most of the close contacts of the patient. The National Public Health Organization provided recommendations on obtaining nasopharyngeal cultures in close contacts to evaluate carriage as well as the necessary preventive measures to protect the child's close contacts as well as the medical staff involved in direct patient care (i.e. awareness for potential compatible with diphtheria symptoms and administration of antibiotic prophylaxis together with booster or complete vaccination series as appropriate) according to the WHO’s Diphtheria Surveillance Standards (September 2018). In addition we have initiated the procedure for the procurement of a limited stockpile of DAT.
Date: Wed, 27 Nov 2019 09:20:47 +0100 (MET)

Athens, Nov 27, 2019 (AFP) - A strong 6.1-magnitude undersea earthquake shook the Greek island of Crete on Wednesday and was felt in other parts of the country, officials said.   "It was a major earthquake, the whole island shook but fortunately so far no damage has been reported," Crete regional governor Stavros Arnaoutakis told state TV ERT.   The Athens observatory said the quake struck at 9:23 am (0723 GMT) and had a depth of over 70 kilometres (44 miles).

The tremor occurred a day after a 6.4-magnitude earthquake in Albania that has left more than 20 dead and hundreds injured.   Shortly after the Albania tremor, a 5.4-magnitude shock hit Bosnia, the European-Mediterranean Seismological Center reported on Tuesday.   Greece lies on major fault lines and is regularly hit by earthquakes but they rarely cause casualties.   In July 2017, a 6.7-magnitude earthquake killed two people on the island of Kos in the Aegean sea, causing significant damage.
Date: Wed, 2 Oct 2019 12:31:30 +0200 (METDST)

Athens, Oct 2, 2019 (AFP) - Greek workers staged a fresh 24-hour strike Wednesday against government plans to deregulate the labour market, paralysing road and rail transport, closing banks and shutting down news outlets.   Buses and trams stayed in their depots, the Athens metro was shut down and ferries serving islands on both sides of Greece stayed in port. The action also hit rail services, including to Athens airport.   Banks were closed Wednesday and Poesy, the journalists' union, said there would be no news bulletins over the 24-hour strike period.

The strike caused long traffic jams in Athens as the GSEE, the largest union representing private-sector workers, organised a rally in the city centre to protest the planned legislation.    It denounced "the suppression of collective conventions" and what it said was an assault on the unions.   This was the second strike in a week against the planned reforms of conservative Prime Minister Kyriakos Mitsotakis, which he argues will open the way to investment and encourage growth of more than two percent.   A strike last week hit transport, hospitals, schools and the courts.   The unions say the proposed reforms will undermine collective agreements and make it harder to organise strikes.

The proposed law would require a more-than 50 percent turn-out of the workforce in any strike vote for it to be valid.   Union leaders have also denounced a law passed in August which they say makes it easier to sack people in the private sector.   Adedy, the federation of public-sector unions, which organised last week's strike, called on its members to join Wednesday's action.   Mitsotakis came to power in July, replacing the left-wing government of Alexis Tsipras.
Date: Thu 12 Sep 2019, 7:54 PM
Source: Ekathimerini [edited]

The death toll from the West Nile virus since June this year has risen to 20, according to this week's report by the National Health Organization (EODY).

Up until [12 Sep 2019], authorities had diagnosed a total of 176 cases of the mosquito-borne virus. Of these, 109 developed illnesses affecting the central nervous system such as encephalitis or meningitis.

EODY is urging the public to spray insect repellent on bare skin and clothing, to install mosquito nets and screens, to remove stagnant water from basins, vases and gutters, to regularly mow lawns and to water plants in the morning.
=============================
[The first report mentions 20 fatal human cases as compared to the latest ECDC update that mentions 19 and the total case number is 176 versus 171 (ECDC report).

West Nile fever is a disease caused by West Nile Virus (WNV), which is a _Flavivirus_ related to the viruses that cause St. Louis encephalitis, Japanese encephalitis, and yellow fever. It causes disease in humans, horses, and several species of birds. Most infected individuals show few signs of illness, but some develop severe neurological illness which can be fatal. West Nile Virus has an extremely broad host range. It replicates in birds, reptiles, amphibians, mammals, mosquitoes and ticks <https://www.oie.int/doc/ged/D14013.PDF>.

The reservoir of the virus is in birds. Mosquitoes become infected when they bite an infected bird ingesting the virus in the blood. The mosquitoes act as carriers (vectors) spreading the virus from an infected bird to other birds and to other animals. Infection of other animals (e.g. horses, and also humans) is incidental to the cycle [as also evident in the ECDC update above] in birds since most mammals do not develop enough virus in the bloodstream to spread the disease.

Key to preventing the spread of West Nile fever is to control mosquito populations. Horses should be protected from exposure to mosquitoes. Likewise, people should avoid exposure to mosquitoes especially at dusk and dawn when they are most active, use insect screens and insect repellents, and limit places for mosquitoes to breed. - ProMED Mod.UBA]

[HealthMap/ProMED maps available at:
Date: Sun, 15 Sep 2019 15:38:29 +0200 (METDST)

Athens, Sept 15, 2019 (AFP) - More than 160 firefighters on Sunday battled to contain a large fire near Athens blazing for a second day amid gale force winds, officials said.   And in another emergency, authorities evacuated dozens of people from two villages and a hotel on the island of Zakynthos after a new fire broke out on Sunday.

The fire department said the blaze near Athens burned in the mountains above Loutraki, a coastal resort some 60 kilometres (35 miles) west of Athens.   "The fire is burning near the top of the mountain," Stefanos Kolokouris, the fire department's deputy chief of operations, told state TV ERT.   "We are trying to create a perimeter but the terrain is very difficult, with ravines," he said.   Four water bombers and six helicopters were participating in operations. Given a lack of roads in the area, two squads of firefighters had to be carried to the mountaintop by Super Puma helicopter, state agency ANA said.   Officials had already evacuated 50 people from a local monastery when the fire broke out on Saturday, but stressed that other inhabited areas were not in danger.

On Zakynthos, officials ordered the evacuation of the villages of Agalas and Keri in the south of the island. Some 120 tourists were also relocated to a safe area.   The Greek fire department on Sunday said it had been called to nearly 80 fires over the past 24 hours.   It has already faced more than 9,600 rural and urban fires this year.
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Pakistan

Pakistan - US Consular Information Sheet
October 02, 2008
COUNTRY DESCRIPTION:
Pakistan is a parliamentary federal republic in South Asia, with a population of nearly 170 million people. Following successful elections in February 2008, Pak
stan has a coalition government led by Prime Minister Yousef Gilani. Pakistan is a developing country, with some tourist facilities in major cities but limited in outlying areas. The infrastructure of areas of Kashmir and the Northwest Frontier Province was devastated as a result of the October 8, 2005 earthquake and is not yet recovered. Read the Department of State Background Notes on Pakistan for additional information.

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ENTRY/EXIT REQUIREMENTS: All U.S. citizens traveling to Pakistan for any purpose are required to have valid U.S. passports and Pakistani-issued visas. Further information on entry requirements can be obtained from the Embassy of Pakistan at 3517 International Court Avenue NW, Washington, DC 20008; telephone: 202-243-6500; e-mail: info@pakistan-embassy.org; web site: http://www.pakistan-embassy.org/.

Travelers may also contact one of the Consulates General of Pakistan in:
Boston: 20 Chestnut Street, Needham, MA 02492; telephone: (781) 455-8000; fax: (617) 266-6666; email: pakistan@tiac.net
Chicago: 333 North Michigan Ave., Suite 728, Chicago, IL, 60601; telephone: (312) 781-1831; fax: (312) 781-1839; email: parepchicago@yahoo.com
Houston: 11850 Jones Road, Houston, TX, 77070; telephone: (281) 890-2223; fax: (281) 890-1433; email: parephouston@sbcglobal.net
Los Angeles: 10850 Wilshire Blvd., Suite 1100, Los Angeles, CA 90024; telephone: (310) 441-5114; fax: (310) 441-9256; email: info@pakconsulatela.org
New York: 12 East 65th St., New York, NY 10021; telephone: (212) 879-5800; fax: (212) 517-6987; web site: www.pakistanconsulateny.org
If a traveler plans to stay longer than the time listed on the visa, he or she must extend the stay with the local passport office of the Ministry of Interior. Visit the Embassy of Pakistan web site at http://www.pakistan-embassy.org/ for the most current visa information.

Information about dual nationality or the prevention of international child abduction can be found on our web site. For further information about customs regulations, please read our Customs Information sheet.

SAFETY AND SECURITY:
A number of extremist groups within Pakistan continue to target American and other Western interests and high-level Pakistani government officials. Terrorists and their sympathizers have demonstrated willingness and capability to attack targets where Americans are known to congregate or visit. Terrorist actions may include, but are not limited to, suicide operations, bombing -- including vehicle-borne explosives and improvised explosive devices -- assassinations, carjacking, assault or kidnapping. U.S. Government personnel are not permitted to stay at or frequent major hotels in Islamabad, Karachi, Lahore and Peshawar.

Government personnel have also been advised to restrict the number and frequency of trips to public markets, and to avoid public restaurants in Islamabad, Karachi, and Peshawar.

In September 2008, over fifty people, including three Americans, were killed and hundreds were injured when a suicide bomber set off a truck filled with explosives outside a major international hotel in Islamabad. In August 2008 gunmen stopped and shot at the vehicle of an American diplomat in Peshawar. In March 2008, a restaurant frequented by westerners in Islamabad was bombed, killing one patron and seriously injuring several others, including four American diplomats. On March 2, 2006, an American diplomat, his locally employed driver, and three others were killed when a suicide bomber detonated a car packed with explosives in front of the U.S. Consulate General in Karachi. Fifty-two others were wounded in the attack.

Sectarian and extremist violence has resulted in fatal bomb attacks in Islamabad, Rawalpindi, Karachi, Peshawar, Quetta, Lahore, and other Pakistani cities since 2006. Since 2007, over 1,000 bombings have killed more than 1,000 people throughout Pakistan and injured many more. Rallies, demonstrations, and processions occur from time to time throughout Pakistan on very short notice and have often taken on an anti-American or anti-Western character. Because of the possibility of violence, Americans are urged to avoid all public places of worship and areas where Westerners are known to congregate.

During the Islamic (Shi’a) religious observance of Moharram, rivalries and hostilities often increase.

In 2007 and 2008, several American citizens throughout Pakistan were kidnapped for ransom or for personal reasons. Kidnappings for ransom are particularly common in some parts of Pakistan, such as the Northwest Frontier Province and Sindh Province.

It is best to avoid public transportation. For security reasons, U.S. Mission personnel are prohibited from using taxis or buses. (See the Traffic Safety and Road Conditions section below.)

Women are advised to dress conservatively, with arms and legs covered, and avoid walking around alone. It is unwise for anyone to travel on the streets late at night. Visitors to Pakistan should attempt to maintain a low profile, blend in, be aware of their surroundings, and seek security with their family or sponsoring organization.

Northern Areas – While we continue to discourage non-essential travel to Pakistan, we advise Americans wishing to trek in Gilgit, Hunza or Chitral to use only licensed guides and tourist agencies. While overall crime is low, there have been occasional assaults on foreign visitors.

Northwest Frontier Province - The Federally Administered Tribal Areas (FATA) along the Afghan border, and certain areas within the Northwest Frontier Province (NWFP), are designated as tribal areas and are not subject to normal government jurisdiction. The Government of Pakistan requires all citizens of countries other than Pakistan and Afghanistan to obtain permission from the Home and Tribal Affairs Department prior to visiting these locations. The permit may stipulate that an armed escort must accompany the visitor. Even in the settled areas of the NWFP there is occasional ethnic, sectarian, and political violence. There have been dozens of bombings in Peshawar of varying sophistication since September 2006. Members of the Taliban and Al-Qaida are known to be in the FATA, and may also be in the settled areas.

Kashmir - While direct military hostilities between India and Pakistan across the Line of Control (LOC) are infrequent, militant groups engaged in a long-running insurgency on the Indian side of the LOC are reported to have bases and supporters operating from the Pakistani side. Most of these groups are anti-American, and some have attacked Americans and other Westerners. The Government of Pakistan restricts access to many parts of this region and requires that visitors obtain a permit from the Ministry of Interior before traveling.

Punjab Province - Violence has increased in Punjab Province. Since September 2007, several suicide operations have taken place, including attacks in Rawalpindi and Lahore. As a precaution against these possible dangers, U.S. citizens are cautioned to avoid public transportation and crowded areas. The Wagah border crossing into India near Lahore remains open daily (from 9:30 a.m. to 3:30 p.m.) for travel to and from India if the passport holder has a valid visa for both countries. Visitors are advised to confirm the current status of the border crossing prior to commencing travel.

Sindh Province - In Karachi and Hyderabad, there has been recurring violence characterized by bombings, violent demonstrations and shootings. An October 2007 suicide attack on former Prime Minister Benazir Bhutto killed more than 130 and injured approximately 375 people in Karachi. In the aftermath of her December 2007 death, rioting in Karachi led to multiple deaths and injuries, as well as widespread property damage. In May 2008, clashing groups of lawyers burned buildings and vehicles in several areas of the city, resulting in at least 11 fatalities. Americans and other westerners continue to be a particular target of hostility and occasional anti-Western mob violence. The Consulate General in particular has been the target of several major terrorist attacks or plots in recent years, including the deadly March 2006 suicide attack described above. Non-essential travel to these cities is strongly discouraged. In rural Sindh Province, the security situation is hazardous, especially for those engaged in overland travel. The Government of Pakistan recommends that travelers limit their movements in Sindh Province.

Balochistan Province - The Province of Balochistan, which borders both Iran and Afghanistan, is notorious for narcotics and other forms of cross-border smuggling. Members of the Taliban and Al-Qaida are also believed to be present there. Tribal unrest sometimes turns violent. Because provincial police presence is limited, travelers wishing to visit the interior of Balochistan should consult with the province’s Home Secretary. Advance permission from provincial authorities is required for travel into many areas. Local authorities have detained travelers who lacked proper permission. Quetta, the provincial capital, has experienced an increase in bombings, occasional gun battles in the streets, and the imposition of curfews. Terrorist attacks against Pakistani government installations and infrastructure have been reported throughout 2005 and 2006.

For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov, where the current Travel Warnings, including the Travel Warning for Pakistan, Travel Alerts, as well as the Worldwide Caution, can be found.

Up-to-date information on safety and security can also be obtained by calling 1-888-407-4747 toll free in the U.S. and Canada, or for callers outside the U.S. and Canada, a regular toll-line at 1-202-501-4444. These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).

The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas. For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State’s pamphlet A Safe Trip Abroad.

CRIME: Crime is a serious concern for foreigners throughout Pakistan. Carjacking, armed robberies, house invasions, and other violent crimes occur in many major urban areas. Petty crime, especially theft of personal property, is common. American travelers to Pakistan are strongly advised to avoid traveling by taxi and other forms of public transportation, and have members of their host organizations or families meet them at the airport.

In many countries around the world, counterfeit and pirated goods are widely available. Transactions involving such products may be illegal under local law. In addition, bringing them back to the United States may result in forfeitures and/or fines. More information on this serious problem is available at http://www.cybercrime.gov/18usc2320.htm
INFORMATION FOR VICTIMS OF CRIME: The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the nearest U.S. Embassy or Consulate. If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the nearest U.S. Embassy or Consulate for assistance. The Embassy/Consulate staff can, for example, assist you to find appropriate medical care, contact family members or friends and explain how funds could be transferred. Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.

The local equivalent to the “911” emergency line in Pakistan is: 15
See our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION: Adequate basic non-emergency medical care is available in major Pakistani cities, but is limited in rural areas. Facilities in the cities vary in level and range of services, resources, and cleanliness, and Americans may find them below U.S. standards; facilities in rural areas are consistently below U.S. standards. Medical facilities require prepayment and do not accept credit cards.

Water is not potable anywhere in Pakistan and sanitation in many restaurants is inadequate. Stomach illnesses are common.

Effective emergency response to personal injury and illness is virtually non-existent in Pakistan. Ambulances are few and are not necessarily staffed by medical personnel. Any emergency case should be transported immediately to a recommended emergency receiving room. Many American-brand medications are not widely available, but generic brands from well-known pharmaceuticals usually are. The quality of the locally-produced medications is uneven.

The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to or foreign residents of Pakistan.
Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://wwwn.cdc.gov/travel/default.aspx. For information about outbreaks of infectious diseases abroad consult the World Health Organization’s (WHO) web site at http://www.who.int/en. Further health information for travelers is available at http://www.who.int/ith/en.

MEDICAL INSURANCE: The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation. As noted above, emergency medical care in Pakistan is very limited. Medical evacuations from Pakistan may cost in excess of $45,000 for uninsured travelers requiring emergency assistance. Please see our information on medical insurance overseas.

TRAFFIC SAFETY AND ROAD CONDITIONS: While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States. The information below concerning Pakistan is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

Traffic in Pakistan moves on the left, opposite of U.S. traffic. In addition to this source of potential confusion, travel by road in Pakistan has a variety of other risks. Roads are crowded, drivers are often aggressive and poorly trained, and many vehicles, particularly large trucks and buses, are badly maintained. Donkeys, cattle, horse carts, and even the occasional camel can pose roadside hazards in some areas. Roads, including most major highways, also suffer from poor maintenance and often have numerous potholes, sharp drop-offs and barriers that are not sign-posted. Drivers should exercise extreme caution when traveling at night by road, as many vehicles do not have proper illumination or dimmers nor are most roads properly illuminated or signed. Driving without experienced local drivers or guides is not recommended.

It is best to avoid public transportation. For security reasons, U.S. Mission personnel are prohibited from using taxis or buses. (See Safety and Security section above.)

Please refer to our Road Safety page for more information. Visit the website of Pakistan’s national tourist office at http://www.tourism.gov.pk/ and the national authority responsible for road safety at http://www.nha.gov.pk/.

AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of Pakistan’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Pakistan’s air carrier operations. For more information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.

SPECIAL CIRCUMSTANCES:
Pakistan is largely a cash economy. Personal checks are not commonly accepted. Most Pakistanis do not use checking accounts for routine transactions. Outside major cities, even credit cards and travelers’ checks are generally not accepted, and there have been numerous reports of credit card fraud. There are bank branches as well as registered moneychangers in all international airports. ATMs can also be found in major airports. English is widely spoken by professional-level airport staff.

Please see our Customs Information.

CRIMINAL PENALTIES: While in a foreign country, a U.S. citizen is subject to that country’s laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law. Penalties for breaking the law can be more severe than in the United States for similar offenses. Persons violating Pakistani laws, even unknowingly, may be expelled, arrested or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in Pakistan are severe, and convicted offenders can expect long jail sentences and heavy fines. Engaging in sexual conduct with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States.

Please see our information on Criminal Penalties.
CHILDREN'S ISSUES: For information see our Office of Children’s Issues web pages on intercountry adoption and international parental child abduction.

REGISTRATION / EMBASSY LOCATION:
Americans living or traveling in Pakistan are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration web site so that they can obtain updated information on travel and security within Pakistan. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.

The U.S. Embassy in Islamabad is located at Diplomatic Enclave, Ramna 5; telephone: (92-51) 208-0000; Consular Section telephone: (92-51) 208-2700; fax: (92-51) 282-2632; website: http://islamabad.usembassy.gov/
The U.S. Consulate General in Karachi, located at 8 Abdullah Haroon Road, closed its public operations indefinitely due to security concerns. U.S. citizens requiring emergency assistance should call the Consular Section in Karachi; telephone: (92-21) 520-4200; fax: (92-21) 568-0496; web site: http://karachi.usconsulate.gov/
The U.S. Consulate in Lahore is located on 50 Sharah-E-Abdul Hamid Bin Badees (Old Empress Road), near Shimla Hill Rotary; telephone: (92-42) 603-4000; fax: (92-42) 603-4200; web site: http://lahore.usconsulate.gov/; email: amconsul@brain.net.pk
The U.S. Consulate in Peshawar is located at 11 Hospital Road, Cantonment, Peshawar; telephone: (92-91) 526-8800; fax: (92-91) 528-4171; web site: http://peshawar.usconsulate.gov/
* * *
This replaces the Country Specific Information dated August 7, 2008 to update the section on Safety and Security.

Travel News Headlines WORLD NEWS

Date: Wed 4 Dec 2019
Source: Samaa News [edited]

The number of polio cases reported in Sindh this year [2019] has gone up to 14 as the Emergency Operation Centre [EOC] for Polio has confirmed a new case.

A 9-month-old boy from Larkana has contracted polio. According to EOC officials, the polio case surfaced in Larkana's UC Karani on [9 Nov 2019].

According to his parents, the child received 4 doses of the oral polio vaccine during a campaign and 3 doses during routine vaccination.

Officials say the poliovirus in the environment in Karachi and other parts of Sindh must be dealt with.
Date: Sat 23 Nov 2019
Source: Pakistan Today [edited]

The total number of polio cases across the country has touched 102, including 9 vaccine-derived cases, after 2 cases were reported in Upper and Lower Kohistan, Khyber Pakhtunkhwa [KP].

In spite of tall claims by the government and several anti-polio drives, there has been no let-up in the polio cases across the country, as only yesterday [Fri 22 Nov 2019] 5 cases were reported in Sindh and KP. These 2 provinces are among the worst-affected regions, witnessing a spike over the recent months.

Poliovirus was found in the sample of a girl child in Tehsil Pattan of Kohistan. Her samples were sent to the National Institute of Health in Islamabad on [27 Oct 2019]. Similarly, the same virus was found in a 5-year-old girl in Tehsil Dasu of Upper Kohistan.

5 cases in Sindh and KP
On Friday [22 Nov 2019], 3 cases were recorded in Sindh and 2 in Khyber Pakhtunkhwa. The 1st case was a 36-month-old female from Sakran in Shaheed Benazirabad, Sindh. She had received 3 doses of routine immunisation and 7 doses of supplementary immunisation.

The 2nd case was a 12-year-old male from Karachi's Keamari Town. He had received 3 doses of routine immunisation and 7 doses of supplementary immunisation. The 3rd case was a 3-month-old female from Lakki Marwat in Khyber Pakhtunkhwa. She had received no polio drops.

The 4th case was a 30-month-old female from Kotri in Jamshoro, Sindh. It is not clear whether she received any doses of the polio vaccine. The 5th case was a 10-month-male from Wazir in Bannu, Khyber Pakhtunkhwa. His immunisation record was incomplete.

According to an emergency operation centre (EOC) for polio: "Lakki Marwat and Bannu have become high-risk districts for polio cases in 2019, as 15 and 24 polio cases were reported in the districts, respectively. Polio cases from Lower and Upper Kohistan have been reported for the 1st time this year [2019]."

This week, the Gates Foundation pledged USD 1.08 billion and, along with other development partner organisations and governments, the meeting received total pledges worth USD 2.6 billion, including USD 160 million announced by Dr Mirza on behalf of Pakistan to eradicate polio in the world.

Polio remains endemic only in Pakistan and Afghanistan. The number of wild poliovirus cases stood at 77 in Pakistan and at 19 in Afghanistan as of [29 Oct 2019]. The corresponding figures during the same period last year [2018] were 6 for Pakistan and 19 for Afghanistan. However, the authorities show resolve, again vowing to enhance their efforts.

"We have conveyed to the international donors that we are developing consensus among all provinces to enhance our vaccination campaign with a new strategy. We need to give new confidence to the entire team, as we had controlled polio virus in the past, and we can do it again."
Date: Fri, 15 Nov 2019 13:19:27 +0100 (MET)

Karachi, Nov 15, 2019 (AFP) - Lightning strikes killed at least 18 people and injured several more during a deadly night in Pakistan's Thar desert, police said Friday, describing the deaths as "unprecedented".   Thunderstorms and a heavy downpour caused havoc in several villages, destroying dozens of homes, in an unusual rainfall event that a meteorologist says could be linked to climate change.

It was the lightning strikes in 18 different places which had the greatest impact.   "We have so far confirmation of 18 deaths in our district," Abdulah Ahmed, the police chief of the region -- which is located in southern Sindh province and stretches over 22,000 square kilometres (8,500 square miles)-- told AFP.   He said that officers in each village had verified that each death was caused by lightning strike.    In contrast, lightning kills an average of three people each year in the UK, according to the Royal Society for the Prevention of Accidents.

The Thar desert, straddling the Indian border and one of Pakistan's poorest areas, is dependent on monsoon rains.   But such a heavy rainfall in November is "unusual", while "lightning of that intensity is unprecedented," said Dr Syed Sarfraz, a senior meteorological officer in Karachi.   He said the causes were still being investigated but suggested hot air over the desert had met with a cold air mass entering from Iran, fuelling the storms. Climate change could also be playing a role, he added.    Dozens of tents and blankets were dispatched from Karachi in a relief effort for the families who lost their homes in the rain.
Date: Tue 12 Nov 2019
Source: Daily Times [edited]

[_Naegleria fowleri_] has claimed another life in Karachi on [Mon 11 Nov 2019]. This was the 16th death reported in the ongoing year [2019] because of the disease. According to details, a 28-year-old resident of New Karachi area was brought to a private clinic 4 days ago where he died of the disease during treatment.

According to the researchers, _Naegleria_ has a fatality rate of more than 98%. Infections can happen when contaminated water enters the body through the nose. It cannot be passed person-to-person.

The amoeba travels from the nasal membranes to the brain. Symptoms are initially very mild, including a headache, stiff neck, fever, and stomach pain. Death usually occurs 5 to 7 days after infection.

_N. fowleri_ is a microscopic amoeba, which is a single-celled living organism. It can cause a rare and devastating infection of the brain called primary amoebic meningoencephalitis (PAM). The amoeba is commonly found in warm freshwater such as lakes, rivers, ponds, and canals.

Once the amoeba enters the nose, it travels to the brain where it causes PAM (which destroys brain tissue) and is usually fatal. Infections usually occur when it is hot for prolonged periods of time, which results in higher water temperatures and lower water levels.
====================
[Even though the weather has cooled considerably in northern parts of the country, Sindh province, which includes Karachi, continues to experience hot and humid climate which is conducive to the proliferation of the Naegleria parasite.

A public awareness message from the Government of Sindh Health Department can be seen at

Optimum chlorination is the key measure to prevent _Naegleria fowleri_ infection. In the absence of chlorination of the supply water in the city, residents need to clean water tanks and chlorinate water in the tanks. - ProMED Mod.UBA]

[HealthMap/ProMED map available at:
Date: Fri, 15 Nov 2019 17:12:24 +0100 (MET)

Karachi, Nov 15, 2019 (AFP) - Pakistan has become the first country in the world to introduce a new typhoid vaccine, officials said Friday, as the country grapples with an ongoing outbreak of a drug-resistant strain of the potentially fatal disease.   The vaccine, approved by the World Health Organization (WHO), will be used during a two-week immunisation campaign in southern Sindh province.

Sindh is where most of Pakistan's 10,000 cases of typhoid have been documented since 2017.    "The two-week campaign beginning from today would target over 10 million children of nine months to 15 years of age," Azra Pechuho, the health minister in Sindh province, said in Karachi on Friday.   The new vaccines have been provided by Gavi, the Vaccine Alliance, to the Pakistani government free of cost.

After the two-week campaign, it will be introduced into routine immunisations in Sindh, and in other areas of Pakistan in the coming years.   Pakistan spends a meagre amount of its national resources on public health and a majority of its population remains vulnerable to contagious diseases such as typhoid.   In 2017, 63 percent of the typhoid cases documented and 70 percent of the fatalities were children, according to a joint press release from the Pakistani government, WHO and Gavi.
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Fiji

Fiji - US Consular Information Sheet
October 24, 2008
COUNTRY DESCRIPTION:
Fiji is a South Pacific island nation consisting of over 350 islands and islets, of which approximately 100 are inhabited. The capital is Suva. On December 5, 2006,
in the fourth coup since 1987, the Commander of Fiji’s military force deposed the lawfully elected government of Fiji. There is currently an unelected interim government in place established by the military. The coup has had a negative effect on Fiji’s economy. Tourist facilities are available. The Fiji Visitors Bureau, which has a wide range of information of interest to travelers, can be contacted via the Internet at http://www.bulafiji.com/. Read the Department of State Background Notes on Fiji for additional information.
ENTRY/EXIT REQUIREMENTS: A passport valid for at least three months beyond the intended date of departure from Fiji, proof of sufficient funds and an onward/return ticket are required for entry to Fiji. A visa is not required for tourist stays up to four months. Yachts wishing to call at the Lau group of islands need special permission granted at the first port of entry into Fiji. For further information on entry/exit requirements, travelers may contact the Embassy of the Republic of Fiji, 2233 Wisconsin Avenue NW, No. 240, Washington, DC 20007; telephone (202) 337-8320, or the Fiji Mission to the United Nations in New York. This is particularly important for travelers planning to enter Fiji by sailing vessel.

Information about dual nationality and the prevention of international child abduction can be found on our web site. For further information about customs regulations, please read our Customs Information.
SAFETY AND SECURITY:
While a state of emergency is no longer in effect, some basic rights remain uncertain. The independence of Fiji’s law enforcement and judicial systems appears compromised, putting into question protections ordinarily afforded by the rule of law. The Department of State continues to warn U.S. citizens to carefully consider the risks of travel to the Republic of Fiji at this time. While Fiji’s country situation appears calm on the surface, political, economic, and security uncertainties continue. It is possible that the security situation, especially in Suva, could deteriorate rapidly. American citizens in Fiji should remain vigilant, particularly in public places and near military activities in the greater Suva area, and should avoid demonstrations and large crowds. Even demonstrations intended to be peaceful could turn confrontational and escalate into violence unexpectedly.
For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affair’s web site at http://travel.state.gov, where the current Travel Warnings and Travel Alerts, including the Worldwide Caution, can be found.
Up-to-date information on security can also be obtained by calling 1-888-407-4747 toll-free in the U.S. and Canada or, for callers outside the U.S. and Canada, a regular toll line at 1-202-501-4444. These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).
The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas. For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State's pamphlet A Safe Trip Abroad.
CRIME: Urban areas experience a higher incidence of crime than do other areas. Travelers should protect their valuables and be aware that theft from hotel rooms and purse snatching or pick-pocketing are the most common crimes against tourists. Offenses against persons do occur, and visitors should remain attentive to their personal safety. Tourists should be cautious about sharing too much personal information about their country of origin or lodging. Americans not familiar with their environs should ask hotel staff about areas to avoid at night. Visitors are advised not to walk alone after dark and not to walk alone in isolated areas at any time. Due to crime directed against taxi drivers, travelers should not allow taxis to pick up other passengers while en route and should not enter a taxi that already carries other passengers.
INFORMATION FOR VICTIMS OF CRIME: The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the U.S. Embassy in Suva, Fiji at (679) 331-4466 (ask for American Citizen Services). If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the nearest U.S. embassy or consulate for assistance. The embassy/consulate staff can, for example, assist you to find appropriate medical care, contact family members or friends and explain how funds could be transferred. Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney, if needed.
The local equivalent to the “911” emergency line in Fiji is 911.

See our information on Victims of Crime.
MEDICAL FACILITIES AND HEALTH INFORMATION: Health-care facilities in Fiji are adequate for routine medical problems. Emergency response is extremely limited, and the few ambulances available are poorly equipped and staffed. Two major hospitals, the Lautoka Hospital in the western city of Lautoka, and the Colonial War Memorial Hospital in Suva, provide limited emergency and outpatient services. A private hospital in Suva provides Western-style medical care, and maintains the Fiji Recompression Chamber for the benefit of scuba divers. Other hospitals and clinics provide only a limited range of health services. Medical emergencies may be referred to Australia, New Zealand, or the United States. Serious medical problems requiring hospitalization and/or medical evacuation to the United States or elsewhere can cost thousands of dollars. Doctors and hospitals expect immediate cash payment for health services.
Fiji may impose HIV/AIDS travel restrictions on some visa applicants for work permits. Applicants must obtain a medical clearance, and the work permit committee will make the decision to grant the permit on a case-by-case basis. Before traveling, please inquire directly with the Embassy of the Republic of Fiji, 2233 Wisconsin Avenue NW, No. 240, Washington, DC 20007; telephone (202) 337-8320, or the Fiji Mission to the United Nations in New York.

Fiji is currently experiencing an increased number of Dengue fever cases, with almost 1,000 cases confirmed (but no deaths) since September 1, 2008. Dengue fever is a common disease caused by a virus that humans get by being bitten by infected mosquitoes (usually Aedes aegypti). For more information about Dengue fever, see the CDC website below.

Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention's hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747); or via the CDC's web site at http://wwwn.cdc.gov/travel/default.aspx. For information about outbreaks of infectious diseases abroad consult the World Health Organization's (WHO) web site at http://www.who.int/en. Further health information for travelers is available at http://www.who.int/ith/en
MEDICAL INSURANCE: The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical evacuation. Please see our information on medical insurance overseas.

TRAFFIC SAFETY AND ROAD CONDITIONS: While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States. The information below concerning Fiji is provided for general reference only, and it may not be totally accurate in a particular location or circumstance.
Traffic moves on the left in Fiji. While most roads in urban areas are paved, they are poorly maintained. Roads outside the city are usually not paved. In the city, driving after dark requires heightened attentiveness; outside the city, it is discouraged, except in emergency or exceptional circumstances. Stray animals, unwary pedestrians, and potholes make driving dangerous and particularly hazardous at night.
Please refer to our Road Safety page for more information. Visit the web site of Fiji’s national tourist office and national authority responsible for road safety at http://www.bulafiji.com
AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of Fiji’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Fiji's air carrier operations. For further information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa
SPECIAL CIRCUMSTANCES:
Water Sports: Many visitors to Fiji participate in water sports, including scuba diving, snorkeling, surfing, and operating jet-skis. The Embassy strongly recommends that anyone interested in scuba diving and snorkeling while in Fiji check the references, licenses, and equipment of tour operators before agreeing to or paying for a tour. Visitors should rent equipment only from reputable operators and should insist on sufficient training before using the equipment. Rental diving equipment may not always be properly maintained or inspected, and some local dive masters may fail to consider the skill levels of individual tourists when organizing dives. Deaths and serious mishaps have occurred in the past as a result of lack of attention to basic safety measures during diving and snorkeling trips. Surfing on Fiji’s numerous reef breaks can be highly dangerous. Safety precautions and emergency response capabilities may not be up to U.S. standards. Fiji has only one decompression chamber, which is located in Suva, far from most resorts.

Trekking: Terrain in the Fiji islands can be hazardous. Please consult with local guides and/or your place of lodging before undertaking a trek. Americans are also advised to hike with a companion and not to stray from marked or well-worn paths.
Customs: Fiji's customs authorities may enforce strict regulations concerning temporary importation into, or export from, Fiji of items such as alcohol or tobacco products. It is advisable to contact the Embassy of Fiji in Washington, DC at (202) 337-8320 for specific information regarding customs requirements. Importation of animals is strictly controlled. Pets may be imported only from designated, rabies-free locales. Those wishing to bring pets to Fiji should contact the Ministry of Agriculture in Suva as much as six months in advance for particulars.

Purchase of Real Estate: U.S. citizens should be aware of the risks inherent in purchasing real estate in Fiji, and should exercise caution before entering into any form of commitment to invest in property there. Investors must recognize the need to obtain authoritative information and to hire competent Fijian legal counsel when contemplating any real estate investment. Fijian law and practices regarding real estate differ substantially from those in the United States.
Notification of Arrest: U.S. citizens are encouraged to carry a copy of their U.S. passports with them at all times so, that if questioned by local officials, proof of identity and U.S. citizenship are readily available. According to Fijian law, a criminal detainee may be held for a maximum of 48 hours before being charged. Police authorities normally advise the U.S. Embassy of the detention or arrest of a U.S. citizen within 24 hours of the incident. Nevertheless, U.S. citizens who are detained are encouraged to request that a consular officer at the U.S. Embassy in Suva be notified.
Natural Disasters: Fiji is located in an area of high seismic activity. Although the probability of a major earthquake occurring during a particular trip is remote, earthquakes can and do occur. The cyclone season is November through April. The Fiji Meteorological Service maintains a Tropical Cyclone Warning Center (TCWC) in Nadi serving the Southwest Pacific Region. General information regarding disaster preparedness is available via the Bureau of Consular Affairs' web site, and from the U.S. Federal Emergency Management Agency (FEMA) home page at http://www.fema.gov/
CRIMINAL PENALTIES: While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law. Penalties for breaking the law can be more severe than those in the United States for similar offenses. Persons violating Fijian laws, even unknowingly, may be expelled, arrested or imprisoned. Penalties for possession of, use of, or trafficking in illegal drugs in Fiji are strict, and convicted offenders can expect jail sentences and heavy fines. Please see our information on Criminal Penalties.

CHILDREN'S ISSUES: For information see our Office of Children’s Issues web pages on international adoption and international parental child abduction.
REGISTRATION / EMBASSY LOCATION: Americans living or traveling in Fiji are encouraged to register with the U.S. Embassy in Suva through the State Department's travel registration web site, and to obtain updated information on travel and security within Fiji. Americans without Internet access may register directly with the nearest U.S. embassy or consulate. By registering, American citizens make it easier for the U.S. embassy or consulate to contact them in case of emergency. The U.S. Embassy is located at 31 Loftus Street in Fiji’s capital city of Suva. The telephone number is (679) 331-4466; the fax number is (679) 330-2267. Information may also be obtained by visiting the U.S. Embassy’s home page at http://suva.usembassy.gov/information_for_travelers.html
* * *
This replaces the Country Specific Information dated February 5, 2008, to update the sections on Information for Victims of Crime, and Medical Facilities and Health Information.

Travel News Headlines WORLD NEWS

Date: Sun, 1 Sep 2019 18:46:32 +0200 (METDST)

Sydney, Sept 1, 2019 (AFP) - A strong earthquake struck the Pacific Ocean between Fiji and Tonga early Monday, but there was no tsunami warning, the United States Geological Survey said.   The quake, at a depth of 616 kilometres (382 miles), struck 30 kilometres northeast of Ndoi island and about 400 kilometres from the Fijian capital Suva, USGS said.   "Some areas may have experienced moderate shaking," the US Pacific Tsunami Warning Center said, adding there was no tsunami threat.
21 Aug 2019

Fiji has recorded 1894 dengue cases in the 1st 4 months of this year [2019], which is predicted to go down as the dengue-preventing program goes forward, according to the Ministry of Health on Tuesday [20 Aug 2019]. Last year [2018], the island nation reported 9 deaths and 4000 cases of dengue fever.
HealthMap/ProMED-mail map of Fiji:
Date: Mon 10 Jun 2019
Source: Independent [edited]

A woman who died mysteriously in Fiji along with her partner sent a series of text messages to her mother in which she revealed her hands had gone "numb" and that she was going to the doctor.

MP and DP died 2 days apart after arriving for a "dream" holiday to the South Pacific nation on 22 May 2019 and becoming ill soon after.

Fiji's health ministry has been working with the US Centers for Disease Control and Prevention and the World Health Organisation to investigate what could have caused the seemingly healthy couple to become gravely ill.

Text messages sent to MP's mother in the United States and obtained by ABC News document how the pair's condition worsened.  "We are both going to doctor now," the 35-year-old texted her parents, who live in Nevada, soon after she and her husband arrived in Fiji.

We have been throwing up for 8 hours. DP has diarrhoea. My hands are numb. We will text when we can," she wrote.

Later that day, she texted her mother to update her on their condition. "We just got back from the clinic," she said. "They gave us fluids and anti-nausea drip. They gave us electrolyte packets and anti-nausea pills. We still don't feel 100 per cent. Going to rest in our room," she said.

MP's mother, responded: "Take care ... Drink a lot of fluid, bottled water. You need to rest."

MP died on 25 May 2019 and her 37-year-old husband passed away 2 days later. Fiji's health ministry said in a statement an investigation into the cause of death is ongoing.

"Influenza has been ruled out, and at this stage, we do not believe there is a risk to the public," the statement said.  [Byline: Abby Young-Powell]
=======================
[Vomiting for 8 hours, diarrhoea, dehydration numbness and scant details. There is no mention of an odd smell, as in the cases in the Dominican Republic (see archive http://promedmail.org/post/20190609.6511612). Nevertheless, I would want to rule out organophosphates (OP). I would like to know what they had to eat or drink and if something harmful was slipped to them or some contaminated seafood was consumed? The mnemonic used for the toxidrome or toxic syndrome in organophosphate (OP) toxicity or poisoning is SLUDGE, which stands for salivation, lacrimation, urination, defecation, gastric cramps, emesis (vomiting) symptoms. However, several other clinical signs and symptoms may be present.

I hope the investigation will help find where they were exposed to OP's or some other toxin if that is what this couple died of, or if not, the cause of death. - ProMED Mod.TG]

[HealthMap/ProMED-mail map of Fiji:
Date: Tue 29 Jan 2019
Source: FBC [edited]

Four people have died from leptospirosis in the Central Division [Fiji] so far this year [2019]. This has resulted in the Ministry of Health declaring an outbreak in the division.

There have been 69 cases of leptospirosis in the Central Division from 1 Jan [2019], with 18 people requiring admission to the CWM Hospital. A majority of the cases are between the age groups of 1-19 and 20-29.

Leptospirosis is a disease caused by bacteria that affect both humans and animals. Humans get leptospirosis through contact with the urine of infected animals. This often happens through contact with mud, water, or food contaminated with the urine of infected animals. The ministry says that people who work with animals, especially farmers, are at higher risk of getting this disease; however, the current outbreak in the Central Division is also affecting people who do non-animal related work. It says recent heavy rain and flooding are likely to have contributed to the increase in cases.

Symptoms of leptospirosis include high fever, chills, headache, muscle aches, nausea/vomiting, jaundice (yellow skin and/or eyes), red eyes, abdominal pain, diarrhoea, cough, shortness of breath and rash. Without treatment, the disease can lead to kidney damage, meningitis, liver failure, respiratory distress, and even death. Early treatment with antibiotics administered by a doctor is the key to preventing complications and deaths.  [Byline: Ritika Pratap]
=======================
[For a discussion of leptospirosis, please see the moderator's comments in ProMED-mail: Leptospirosis - Fiji: flood-related http://promedmail.org/post/20160421.4175079.

Fiji is an island nation in Melanesia in the South Pacific Ocean about 2000 km (1300 miles) northeast of New Zealand's North Island (<http://en.wikipedia.org/wiki/Fiji>). Fiji is divided into 4 major divisions: Central, Eastern, Northern, and Western.

For a map of Fiji's divisions, see

Fiji's wet season is from November to April, with the heaviest rains falling between December and mid-April

[HealthMap/ProMED map available at:
Date: Fri 7 Dec 2018
Source: The Fiji Times [edited]

A typhoid outbreak has been identified in the Naitasiri subdivision. This was confirmed by the Minister for Health, Dr. Ifereimi Waqainabete, who said there are 31 confirmed cases of typhoid and 14 suspected cases.

He said the Naitasiri medical team continued to make daily visits, implementing public health awareness and public health interventions in these villages. He added that families have been educated on safe food preparation, food handling and proper hygiene practices.

The minister strongly urged the general public to postpone nonessential travel to the outbreak-affected areas and take extra precaution during the holiday season.
======================
[Typhoid fever, so-called enteric fever caused by _Salmonella enterica_ serotype Typhi, has a totally different presentation from that of the more common kinds of salmonellosis. Epidemiologically, usually spread by contaminated food or water, typhoid is not a zoonosis like the more commonly seen types of salmonellosis. Clinically, vomiting and diarrhoea are typically absent; indeed, constipation is frequently reported. As it is a systemic illness, blood cultures are at least as likely to be positive as stool in enteric fever, particularly early in the course of the infection, and bone marrow cultures may be the most sensitive.

The symptoms of classical typhoid fever typically include fever, anorexia, lethargy, malaise, dull continuous headache, non-productive cough, vague abdominal pain, and constipation. Despite the (often high) fever, the pulse is often only slightly elevated. During the 2nd week of the illness, there is protracted fever and mental dullness, classically called coma vigil. Diarrhoea may develop but usually does not. Many patients develop hepatosplenomegaly (both liver and spleen enlarged). After the 1st week or so, many cases develop a maculopapular rash on the upper abdomen. These lesions ("rose spots") are about 2 cm (0.78 inch) in diameter and blanch on pressure. They persist for 2 to 4 days and may come and go. Mild and atypical infections are common.

The word typhoid (as in typhus-like) reflects the similarity of the louse-borne rickettsial disease epidemic typhus and that of typhoid fever; in fact, in some areas, typhoid fever is still referred to as abdominal typhus.

Naitasiri is one of the 14 provinces of Fiji and one of 8 located on Viti Levu, Fiji's largest island. - ProMED Mod.LL]

[HealthMap/ProMED-mail map:
More ...

World Travel News Headlines

6th December 2019
https://www.theguardian.com/world/2019/dec/06/flooding-hits-new-zealand-tourist-hubs-of-wanaka-and-queenstown

Heavy rain has led to rivers bursting their banks, forcing the closure of shops and restaurants

Streets in the South Island tourist towns of Wanaka and Queenstown were slowly going under water on Friday, after Lake Wanaka and Lake Wakatipu burst their banks earlier in the week, flooding businesses and sewerage systems.

Water and large debris closed the main street of Wanaka, a popular spot with Instagrammers thanks to its famous tree that appears to have grown out of the lake. On Friday businesses were sandbagging as heavy rain continued to fall.

Sewerage systems in the town were also at risk of contaminating the lake, with the Queenstown Lakes District council taking the precautionary measure of shutting down the sewer connection to a handful of premises.

Wanaka residents were told to be on “high alert” with heavy rain predicted all weekend.

The streets of the usually bustling tourist town were largely empty, and the popular cafes and restaurants on the lake shore were closed.

3rd December 2019
https://watchers.news/2019/12/03/at-least-25-dead-as-days-of-heavy-rain-hit-tamil-nadu-india/

At least 25 people were killed in various rain-related incidents in Tamil Nadu, India since November 29, 2019. 17 of the victims died after a wall collapsed following a continuous heavy downpour in Coimbatore on Monday morning, December 2.

Among the fatalities were 10 women. Around 1 305 huts and 465 tiled-roof houses were damaged, while 1,000 people were evacuated to government relief centers in Tuticorin, Cuddalore, and Tirunelveli districts as the north-east monsoon intensifies.

Schools remain closed on Monday including those in the districts of Chennai, Chengalpet, Kancheepuram, Tiruvallur, Cuddalore, and Tuticorin, as the areas received 90 mm (3 inches) rain in the past 36 hours.

A flood alert has been issued to residents near the banks of Bhavani River in this western district of Tamil Nadu as a dam built across it has burst in the wake of torrential rains in catchment areas, officials said on Monday.

6th December 2019
https://erccportal.jrc.ec.europa.eu/ECHO-Flash/ECHO-Flash-Item/oid/17835

  • Southern Angola has been affected by widespread floods, triggered by heavy rains on 2-4 December.
  • According to the Government of Angola, 60 people have been displaced in the city of Ondjiva (Cunene Province), while several houses are damaged, roads are flooded, and power outages have been reported across areas of Ondjiva.
  • In Kalepi Municipality (Huila Province, southern Angola), a lightning event killed five people, and injured one on 2 December.
  • Moderate to heavy rains will persist over central, southern and eastern Angola on 6-8 December.
6th December, 2019
HSE Health Protection Surveillance Centre

There is a case of human rabies in Latvia. The case has been clinically and laboratory confirmed (immunofluorescence and PCR). The case is 55 years old female from city Daugavpils, located 35 km from Belarus and Lithuania borders. Symptoms appeared on November, 22, she died on November, 28. 
 
Possible exposures: 
• In May, 2018 she was bitten in both legs (ankles) by puppy travelling in India;
• She worked as volunteer in animal shelter in Daugavpils, in April this year she was bitten/scratched there by a dog, and the dog is healthy now;
• She fed stray cats and dogs in the courtyard of the house in Daugavpils, as well as in a country house outside the city near the forest. Information about bites or other possible exposures is not known.

In none of these cases the person received PEP. Now 61 contacts receive post-exposure treatment (vaccination), mostly as precautions: staff of two hospitals and medical emergency service, and close contacts, including household. In Latvia the last cases of rabies in wild animals were registered in 2010, in 2012 was registered the last case in domestic animals. In 2014, Latvia received the status of a country free of rabies. Latvia continues to implement wild animal’s vaccination progamme. Neighbour countries Belarus and Russian Federation is not rabies free and animals can cross the border.
 
A test report has been received on the results of the rabies virus genotype identification and sequencing reaction (EURL-Rabies Protocol, (AFSSA) P. Meyer, 2009). The rabies virus genotype 1 was detected in the sample. According to the GenBank database, the virus sequence has 99.17% identity to the RV2924 isolate of rabies virus from Nepal. Information and evidence obtained during an epidemiological investigation demonstrated that the human rabies case had a dog bites during her travel in India (Naggar and Manali, state Himachal Pradesh – close to Nepal), in May 2018. No post exposure treatment was received.

No cases of illegally exported pets as the potential source of infection were identified in the relation to this rabies case. According to the literature in rare cases a long (more than one year) incubation period of rabies is observed. Taking into account the epidemiological data and the result of the rabies virus sequencing, the Center for Disease Prevention and Control of Latvia believes that this human rabies case is not epidemiologically linked to Latvia.
6th December, 2019
HSE Health Protection Surveillance Centre

On 27/11/2019, a possible case of diphtheria was reported to the Department of Epidemiological Surveillance and Intervention through the Mandatory Notification System in Greece. It concerned an 8 years old boy of Greek nationality, who was hospitalized in the ICU of General Children's Hospital  where he died.  This child had underlying conditions (severe pulmonary hypertension) and was admitted to ICU  on 22/11/2019 with clinical presentation of laryngitis (without the presence of characteristic pseudo membranes) and pneumonia, immediately intubated, covered with double antibiotic regimen and died due to deterioration of his clinical presentation on 26/11/2019.
 
According to the epidemiological data given , there is no travel history, group living, no connection to another case and the child does not belong to a specific population group. Regarding his immunization status, the child was vaccinated with at least 3 doses against diphtheria-tetanus-pertussis.
 
Laboratory investigation of bronchial exudate isolated Corynebacterium diphtheriae via VITEK. Further laboratory testing was performed by the Public Health England  reference Laboratory for Corynebacteria. On Thursday 5/12/2019, the National Public Health Organization was informed that multiplex PCR testing was positive for C. Diphtheriae and positive for the diphtheria toxin gene. The Elek test was also positive for toxin production. The results of the child's post-mortem exam are pending.

Contact tracing and management is ongoing and has identified most of the close contacts of the patient. The National Public Health Organization provided recommendations on obtaining nasopharyngeal cultures in close contacts to evaluate carriage as well as the necessary preventive measures to protect the child's close contacts as well as the medical staff involved in direct patient care (i.e. awareness for potential compatible with diphtheria symptoms and administration of antibiotic prophylaxis together with booster or complete vaccination series as appropriate) according to the WHO’s Diphtheria Surveillance Standards (September 2018). In addition we have initiated the procedure for the procurement of a limited stockpile of DAT.
Date: Mon, 9 Dec 2019 11:12:25 +0100 (MET)
By Clare BYRNE

Paris, Dec 9, 2019 (AFP) - France's transport chaos deepened Monday on the fifth day of a nationwide strike over pension reforms, ramping up tensions at the start of a crucial week in President Emmanuel Macron's battle with trade unions.   With only two of the Paris metro's 16 lines running as normal and suburban trains also heavily disrupted, many commuters slipped behind the wheel to try to get to work in torrential rain, causing major gridlock.

By 9 am, the tailbacks in the Paris area ran to 600 kilometres (370 miles), twice the normal level, the Sytadin monitoring website said.   Large queues formed at bus stops following an announcement that one out of two buses would be running but striking workers blocked seven out of 25 bus depots, leaving more travellers stranded.   With many having opted to work from home last week and only now returning to the workplace, this week will test public support for the strike.

A poll Sunday in the Journal du Dimanche newspaper showed 53 percent of the French supporting the strike or expressing sympathy for their demands, up six points in a week.   Unions have called a second day of mass protests for Tuesday, a day before the government unveils the full details of its plans for a single points-based pension scheme that does away with dozens of more advantageous plans enjoyed by train drivers, sailors, lawyers and other professions.

- 'A monstrosity' -
Critics argue that the shake-up will require people in both the public and private sector to work longer for a smaller retirement payout.   Teachers are expected to walk out again for the second time in a week Tuesday, leading to widespread school closures.

Firefighters, electricity workers and "yellow vest" anti-government demonstrators have also joined railway workers in the streets in recent days.   The government's pensions envoy Jean-Paul Delevoye, who drafted the reforms, and Health Minister Agnes Buzyn will meet with trade unions on Monday to try to negotiate an end to the deadlock.   But the unions have sounded an uncompromising note.   "I will not negotiate over the implementation of what I describe as a monstrosity which endangers tomorrow's pensioners," said Yves Veyrier, the head of the militant Force Ouvriere union.

The strike has squeezed retailers in the run-up to Christmas, raising the prospect of another bleak year-end after the unrest caused by the yellow vests in late 2018.   The first day of the stoppage already caused an average 30 percent drop in sales, according to the Alliance of Commerce, which represents 27,000 supermarkets and clothing and shoe stores with almost 200,000 workers.   A hotel association said reservations in the larger Paris region dropped by 30 to 40 percent on the first day of the strike.    Regional and international trains, including the Eurostar to London and Thalys to Brussels, have also been hobbled by the unrest, and several flights were cancelled on the first days of the strike.

- Fairer system for all? -
Over 800,000 people took to the streets when the strike was launched on December 5, many accusing Macron of trying to weaken France's generous social safety net.   The president, Prime Minister Edouard Philippe and senior cabinet ministers met late Sunday to discuss the changes, which they argue will ensure a fairer and more sustainable system for all.   "If we do not carry out a far-reaching, serious and progressive reform today, someone else will do a really brutal one tomorrow," Philippe told Le Journal du Dimanche.

The strike has drawn comparisons with late 1995 when three weeks of strikes forced the then centre-right government to withdraw its pension reforms.   Adrien Quatennens, a lawmaker from the far-left France Unbowed party, acknowledged on LCI radio that the strike was hard on businesses and commuters, but said: "It's better to endure a few weeks of hassle than... years of hardship" in retirement.
Date: Mon, 9 Dec 2019 10:20:33 +0100 (MET)
By Neil SANDS, with Holly Robertson in Sydney

Wellington, Dec 9, 2019 (AFP) - Five people were killed, 18 were injured and several more were left stranded after an island volcano popular with tourists erupted unexpectedly in New Zealand on Monday.   Police said some 50 people were visiting White Island when it exploded suddenly in the early afternoon -- hurling ash and rock high into the air.   Two dozen people made it off the island, five of whom have since died. The rest are being treated for injuries, including severe burns.

Nothing is yet known about a group -- now estimated to number in the double digits -- who are still trapped on the island.   "We're unsure of the exact numbers on there and we're unsure of their wellbeing," said deputy commissioner John Tims.   As night fell, he said volcanic activity made a rescue attempt too dangerous.   "The island is unstable, there's a danger of further eruptions, it is physically unsafe for us to return to the island"   "I've got to consider the safety of our people and emergency services staff."   The eruption occurred at 2:11pm (0111 GMT), thrusting a thick plume of white ash 3.6 kilometres (12,000 feet) into the sky.   Seconds before, live camera feeds showed a group of more than a half dozen people walking on the crater floor. Then the images went black.

A "considerable number" of those caught up in the disaster are believed to be Australian, according to officials in Canberra.   As many as 30 people are also believed to be cruise passengers on a day trip from the vessel Ovation of the Seas, Kevin O'Sullivan, chief executive officer of industry body the New Zealand Cruise Association told AFP.   The ship's operator Royal Caribbean -- who had billed the trip to White Island as "an unforgettable guided tour of New Zealand's most active volcano" -- said "a number of our guests were touring the island" but did not confirm that number.   The ship has a capacity of around 4,000 people and set sail from Sydney last week on a 12 day voyage.

- Scene of terror -
Tourist Michael Schade, made it off the island just in time and was able to capture footage of the devastation.   His videos showed groups of startled tourists clustered by the shoreline, waiting to be evacuated as the ground around them smouldered, the sky filled with white debris. An ash-caked helicopter lies damaged nearby.   As his ship hurtled away, the caldera became virtually invisible, shrouded by a thick bank of ash.   Volcanic Air said they had landed a helicopter on the island shortly before the eruption carrying four visitors and one pilot. All were now accounted for.   "It had landed on the island. What happened after that we don't know, but we know that all five made it back to Whakatane on one of the tourist boats," a company spokesman told AFP.

Guillaume Calmelet, the co-director of Skydive Tauranga, saw the eruption from above as he took a customer on a tandem skydive from a plane 12,000 feet above the Bay of Plenty.   "As soon as the parachute opened there was this huge cloud that was really different to whatever we've seen before," he told AFP. "I could see it coming out in freefall, so probably about 30 seconds for the whole cloud to form, if that. It was pretty quick."   The country's National Emergency Management Agency described the eruption as "moderate", although the plume of ash was clearly visible from the mainland and from satellites flying overhead.    "We have seen a steady decline in activity since the eruption. There remains significant uncertainty as to future changes but currently, there are no signs of escalation."

White Island -- - also known as Whakaari -- is about 50 kilometres (30 miles) offshore in the picturesque Bay of Plenty and is popular with adventurous tourists willing to don hard hats and gas masks.   It is New Zealand's most active volcano cone and about 70 percent of it is underwater, according to government-backed agency GeoNet.   Around 10,000 people visit the volcano every year. It has erupted frequently over the last half-century, most recently in 2016.

In August of that year the New Zealand Defence Force airlifted a 2.4-tonne shipping container onto the island to serve as an emergency shelter in case of an eruption.   "Sudden, unheralded eruptions from volcanoes such as White Island can be expected at any time," said University of Auckland volcanologist Shane Cronin.   "The hazards expected from such events are the violent ejection of hot blocks and ash, and formation of 'hurricane-like' currents of wet ash and coarse particles that radiate from the explosion vent."   "These can be deadly in terms of causing impact trauma, burns and respiratory problems. The eruptions are short-lived, but once one occurs, there are high chances for further, generally smaller ones as the system re-equilibrates."
Date: Mon, 9 Dec 2019 09:54:20 +0100 (MET)

Rome, Dec 9, 2019 (AFP) - A 4.5 magnitude earthquake hit the central Italian region of Mugello on Monday, sending panicked residents into the streets but causing minimal damage to buildings.   The quake, centred some 31 km (19 miles) northeast of Florence in Tuscany, hit at 4:37 am (0330 GMT), after a series of smaller quakes, according to the national institute for geophysics and vulcanology (INGV).

Residents fled their buildings in the rain,  congregating outside or in their cars to await authorities.    "The quake went on for awhile, especially the first one, things fell down at a supermarket but for the moment we haven't seen any damage to people or things," said Filippo Carla' Campa, mayor of the town of Vicchio.   A resident of Barberino del Mugello said his neighbours were panicking getting out of the building.    "Paintings fell off the walls, bookcases fell over," he told Rai 24.    In Barberino del Mugello, the 17th century church suffered a crack in one side, television images showed.

Schools were closed in the region and some trains through Florence were cancelled or delayed.    Italy is frequently struck by seismic activity, often devastating. Most recently, a series of strong quakes hit central Italy in late 2016 and early 2017, killing 300 people.   In 1919, the area was hit by an earthquake that killed 100 people.
Date: Mon, 9 Dec 2019 03:52:15 +0100 (MET)

Mount Hutt, New Zealand, Dec 9, 2019 (AFP) - Almost 1,000 tourists were stranded in New Zealand's South Island Monday after wild storms cut highways, washed away bridges and flooded the rugged landscape.   Meteorologists said up to 400 millimetres (16 inches) of rain was dumped on the South Island over 24 hours by a severe weather system that unleashed gale-force winds and 230,000 lightning strikes.   The main highway through the island was closed after the Rangitata river burst its banks. Townships near the popular Franz Josef glacier were isolated when landslips blocked road access.

With New Zealand entering its peak tourist season, some 970 travellers at Franz Josef were left facing the prospect of taking an expensive helicopter ride to get out or hunkering down until Friday, when the road is expected to be cleared.   "Between the community, the hotels and motels and our welfare centre we've managed to billet out most people overnight," Civil Defence spokesman Stephen Doran told TVNZ.   "We'd just ask people to stay put at the moment. We want to keep the work site clear so we can get supplies in there... and try to get the road into some sort of shape."

Another landslip on the island's west coast will take an estimated six weeks to clear.   The worst of the weather hit over the weekend and it is forecast to deteriorate again later in the week, leaving authorities scrambling during a brief respite to complete as much repair work as possible.
Date: Sun, 8 Dec 2019 17:30:45 +0100 (MET)

Kigali, Dec 8, 2019 (AFP) - Rwanda on Sunday started a voluntary Ebola vaccination programme at its border with the Democratic Republic of Congo in a bid to prevent the spread of the deadly virus from its neighbour.   All countries in high-risk areas, even if not hit by Ebola, had been advised by the WHO to use a new vaccine developed by US group Johnson & Johnson, the country's health minister, Diane Gashumba, told journalists.   The idea was "to protect those with high chances of getting in contact with people living in areas where Ebola has been reported to be active", she said.

The vaccine, Ad26-ZEBOV-GP, is an experimental drug produced by US pharmaceuticals giant, Johnson & Johnson. It was used for the first time in mid-November in Goma in DR Congo, on the other side of the border.    So far, there have no confirmed cases of Ebola in Rwanda.   The epicentre of the outbreak in DR Congo, which has killed more than 2,200 people since August 2018, is located 350 kilometres (217 miles) north of Goma, in the Beni-Butembo region.   That region sits on the DR Congo border with Uganda.   More than 250,000 people in DR Congo have already been vaccinated using another product, rVSV-ZEBOV, made by US drug company, Merck Shape and Dohme.

- Ebola in Goma -
People working in the health sector, at border crossings, police officers, and business executives who frequently travel between the two countries are being given priority in the vaccination campaign.   But all residents in the border districts can ask to be vaccinated if they wish.    The first volunteers expressed relief at the measure.    "We lived in a life of worry because of what was going on in DR Congo," Joel Ntwari Murihe, one of the first Rwandans to be vaccinated, told AFP.   "It caused a lot of border disruptions as we were restricted to buying or selling with DR Congo residents who live in Goma.    "The vaccine is an assurance to the safety for our lives and our children's lives."

The head of DR Congo's anti-Ebola efforts, Jean-Jacques Muyembe, and the WHO's representative in Rwanda, Kasonde Mwinga, were present at the campaign launch.    In August, Rwanda briefly closed its border with DR Congo and ordered its citizens not to visit the country when the first Ebola cases were recorded in Goma.   The city, which is the regional capital of the Congolese province of North Kivu, sits on the border with Rwanda.    The border has since been reopened, but strict medical checks are being enforced.