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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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Puerto Rico

No Profile is available at present

Travel News Headlines WORLD NEWS

Date: Mon, 12 Feb 2018 05:54:19 +0100

San Juan, Feb 12, 2018 (AFP) - Most of San Juan and a strip of northern Puerto Rico municipalities were plunged into darkness Sunday night after an explosion at a power station, five months after two hurricanes destroyed the island's electricity network.

The state electric power authority (AEE) said the blast was caused by a broken-down switch in Rio Piedras, resulting in a blackout in central San Juan and Palo Seco in the north.   "We have personnel working to restore the system as soon as possible," the AEE said.   San Juan's mayor, Carmen Yulin Cruz, said on Twitter that emergency services and local officials attended the scene in the neighbourhood of Monacillos, but no injuries were reported.

Meanwhile, the Puerto Rican capital's airport said it was maintaining its schedule using emergency generators.   The blackout comes as nearly 500,000 of AEE's 1.6 million customers remain without power since Hurricanes Irma and Maria struck the US territory in September 2017.   AEE engineer Jorge Bracero warned on Twitter that the outage was "serious," and advised those affected that power would not be restored until Monday.
Date: Wed, 13 Dec 2017 03:08:12 +0100
By Leila MACOR

Fajardo, Puerto Rico, Dec 13, 2017 (AFP) - Until Hurricane Maria hit Puerto Rico, Jose Figueroa did brisk business renting kayaks to tourists itching to see a lagoon that lights up by night thanks to millions of microorganisms.   Today, things are so dire he's considering selling water to motorists stopped at red lights.   "Now we are trying to survive," the 46-year-old tour guide said.

It used to be that visitors had to reserve a month in advance to get one of his kayaks and paddle around in the dark on the enchanting, bioluminescent body of water called Laguna Grande.   But tourists are scarce these days as the Caribbean island tries to recover from the ravages of the storm back in September.   "We do not know if we will have any work tonight," Figueroa said. "Last week, we worked only one day."    He and another employee of a company called Glass Bottom PR are cleaning kayaks on the seaside promenade of Fajardo, a tourist town in eastern Puerto Rico whose main attraction is the so-called Bio Bay.

The year started off well for Puerto Rico, with the global success of the song "Despacito" by local musicians Luis Fonsi and Daddy Yankee.   The catchy tune helped promote the US commonwealth island of 3.4 million people, which is saddled with huge debts and declared bankruptcy in May.    But the hurricane turned what should be an island bustling with tourists into one with deserted beaches, shuttered restaurants and hotels full of mainland US officials working on the rebuilding of the island.   "What few tourists we have are the federal officials themselves," said Figueroa.

- Locals only -
The grim outlook spreads up and down the seaside promenade of Fajardo, where many restaurants are closed because there is no electricity.   On this particular day around noon, the only restaurant open is one called Racar Seafood. It has its own emergency generator.   "We get by on local tourists," said its 61-year-old owner, Justino Cruz.   "Our clients are local -- those who have no electricity, no generator, cold food or no food."

Puerto Rico's once-devastated power grid is now back up to 70 percent capacity, but this is mainly concentrated in the capital San Juan.   So while inland towns that depend on tourism are struggling mightily, things are getting better in San Juan as cruise ships are once again docking.   On November 30, the first cruise ship since the storm arrived with thousands of vacationers on board. They were received with great fanfare -- quite literally, with trumpet blaring and cymbals crashing.

- Pitching in to help -
The World Travel & Tourism Council, based in London, says tourism accounted for about eight percent of Puerto Rico's GDP in 2016, or $8.1 billion.   Hurricane Maria's damage has been uneven. Although some tour guides now have no work and many eateries are shut down, hotels that have their own generators are doing just fine.   Thanks to the thousands of US government officials and reconstruction crew members that came in after the storm, the hotels that are open -- about 80 percent of the total -- are pretty much full.

These people are starting to leave the island this month but hotels may receive tourists around Christmas, at least in San Juan, where power has for the most part been restored.   The hurricane "undoubtedly cost billions in lost revenue," said Jose Izquierdo, executive director of the Puerto Rico Tourism Company.    But Izquierdo nevertheless says he is "optimistic" and suggests an alternative: put tourists to work as volunteers in the gargantuan reconstruction effort that the island needs.   "We want to look for travellers who want to travel with a purpose, who might have the commitment to help rebuild," said Izquierdo.

The program, called "Meaningful Travel" and launched in mid-November, organizes trips on which residents, Puerto Ricans living abroad and tourists are invited to help the island get back on its feet.   "The plan aims to create empathy with this tourist destination," said Izquierdo.    "We want to be like New Orleans after Katrina, where 10 years after the hurricane, tourism is the driving force of its economy. We want to build that narrative of recovery," he added.   "There are different ways in which the world wants to help Puerto Rico. The best way is to visit us."
Date: Thu, 9 Nov 2017 12:39:04 +0100
By Marcos PÉREZ RAMÍREZ

San Juan, Nov 9, 2017 (AFP) - Andrea Olivero, 11, consults her classmate Ada about an exercise during their daily English class at San Juan's Sotero Figueroa Elementary School. The task: list the positive and negative aspects of Hurricane Maria's passing almost two months ago.

The girls only have to look around. There is no electricity and they "roast" in the heat, Andrea says. At the back of the room, computers and televisions collect dust.   "We would like to move past the topic of the hurricane a bit. It is already getting repetitive," Andrea told AFP.   She is one of more than 300,000 pupils in the public education system, although only half of schools are functioning. Barely 42 per cent of Puerto Ricans have electricity seven weeks after Maria struck, killing at least 51 in the American territory.

The lack of power has prompted disorienting timetable changes on the tropical island, to avoid both the hottest hours of the day and the use of dining facilities.   "The children are very anxious. We manage to make progress in lessons and they change the hours again. Everything is messed up and we fall behind," English teacher Joan Rodriguez explained.   "We can't use the computers to illustrate classes," she said. "They are reading the novel "Charlotte's Web," and we wanted to do exercises comparing it to the film version. But we cannot use the television.

- Suspicions -
From October 23, some directors reopened their schools in the western region of Mayaguez and San Juan.   But last Thursday, the Department of Education ordered their closure, insisting they must be evaluated by engineering and architectural firms, then certified by the US Army Corps of Engineers.   One of those schools was Vila Mayo, also in San Juan. The community presumed it would open, as it had been used as a shelter, its electrical infrastructure had been inspected and it had not suffered structural damage.

But Luis Orengo, the education department's director in San Juan, told protesters outside the school it was closed as inspectors' findings had not reached the central government.   "This is unacceptable! The school is ready to give classes but they don't want to open it. Our children cannot lose a year," fumed Enid Guzman, who protested with her 11-year-old son, Reanny De la Cruz.   There are suspicions the stalled reopening of schools is, in part, related to the prior closure of 240 schools over the past year during Puerto Rico's long-running financial crisis.   The fiscal difficulties have seen the island's population drop over the past decade by 14 percent, leading in turn to a fall in school enrolment.

Before the storms, 300 schools were at risk of closure -- and for the president of Puerto Rico's federation of teachers, Mercedes Martinez, the government's aim is clear.   "Secretary (Julia) Keleher seems to have an orchestrated plan to close schools," she said, referring to the education secretary. "Why do you have to wait 30 days to get a certification so a school can open?"   Keleher has announced she expects most schools to be open by the middle of November.
Date: Tue 24 Oct 2017
Source: KFOR Oklahoma News4 [edited]

Puerto Rico has reported at least 76 cases of suspected and confirmed leptospirosis, including a handful of deaths, in the month after Hurricane Maria, said Dr. Carmen Deseda, the state epidemiologist for Puerto Rico.

Two deaths involved leptospirosis confirmed through laboratory testing, and "several other" deaths are pending test results, Deseda said. The 76 cases, up from 74 last week, also include one patient with confirmed leptospirosis who is currently hospitalized.

The island typically sees between 63 and 95 cases per year, she said. Health officials had expected that there would be a jump after the hurricane. "It's neither an epidemic nor a confirmed outbreak," Public Affairs Secretary Ramon Rosario Cortes said at a news conference Sunday [22 Oct 2017]. "But obviously, we are making all the announcements as though it were a health emergency."

Leptospirosis may be treated with antibiotics, but many people recover on their own. "The majority of leptospirosis cases is a mild, subclinical disease with no complications," Deseda said. "But one out of 10 people who have leptospirosis develop severe illness." In the 1st stage of leptospirosis, symptoms vary widely from fever and headache to red eyes and rashes. Some people may have no symptoms at all. But a small number will develop dire complications: meningitis, kidney and liver damage, bleeding in the lungs and even death.

Doctors are required to report any potential leptospirosis cases to health authorities, Deseda said. Those cases must then be tested to confirm the bacteria, since the symptoms can be difficult to tell apart from other illnesses. After that, health officials may look for patterns or clusters and determine whether there is an outbreak.

The lab tests on the suspected cases have been sent to the US Centers for Disease Control and Prevention, Deseda said. The turnaround time is about 5-6 days.

Doctors on the island have expressed concerns about burgeoning health crises amid hospitals that are overwhelmed, undersupplied and sometimes burning hot. Influenza is another concern on the horizon, Deseda said. Drinking water is also hard to come by on many parts of the island.

Dr. Raul Hernandez, an internist in San Juan, told CNN that people were drinking water from whatever sources they could find, such as rivers and creeks. If that water contains urine from a [leptospirosis-infected rat], those people will be at risk, he said.

Deseda said people should be discouraged from walking barefoot, drinking or swimming in potentially leptospirosis-contaminated waters.

"These diseases are everywhere, and there's a way to prevent them," she said.
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[Leptospirosis is a zoonotic, spirochetal infection that occurs worldwide and is transmitted to humans by exposure to soil or fresh water contaminated with the urine of wild and domestic animals (including dogs, cattle, swine, and especially rodents) that are chronically infected with pathogenic _Leptospira_. _Leptospira_ may survive in contaminated fresh water or moist soil for weeks to months. Outbreaks of leptospirosis frequently follow heavy rainfall, flooding with fresh water, and increasing rodent numbers.

Parts of Puerto Rico saw more than 30 inches of rain and consequent flooding with recent Hurricane Maria. A map showing the estimated rainfall across Puerto Rico with this hurricane is available at <https://twitter.com/NWSSanJuan/status/910983698597777409/photo/1?ref_src=twsrc%5Etfw&ref_url>.

With continued absence of potable water, inadequate sanitation, and flooding in the streets for a large proportion of the population in Puerto Rico, food- and water-borne diseases, like leptospirosis, will be a major problem. - ProMED Mod.ML]

[A HealthMap/ProMED-mail map can be accessed at:
Date: Thu, 19 Oct 2017 16:37:27 +0200
By Ricardo ARDUENGO, con Nelson DEL CASTILLO en San Juan y Leila MACOR en Miami

Utuado, Puerto Rico, Oct 19, 2017 (AFP) - It's been a month since Hurricane Maria ripped through Puerto Rico and Samuel de Jesus still can't drive out of his isolated, blacked-out town.   In fact, much of the US territory in the Caribbean is still a crippled mess four weeks after that fierce Category Four storm.

The bridge connecting Rio Abajo to the rest of the island was swept away when Maria slammed the island on September 20. For two weeks Rio Abajo, located in a mountainous region in central-western Puerto Rico, was cut off and forgotten, without power or phone service.   "We didn't know what to do. We were literally going crazy," said de Jesus, 35.   "Those were difficult, desperate days. We could not find a way out, and the hurricane caused extensive damage," he told AFP.

During the two long weeks following Maria, the 27 families living in Rio Abajo saw their supplies quickly deplete.   De Jesus, who has diabetes, needed to keep his insulin refrigerated. The storm blew away the island's already decrepit power grid, so people resorted to emergency generators.   "But I was running out of gasoline to run the generator," he said.   A helicopter now makes regular deliveries of food, water and medicine because with the bridge washed out, there is no other way in or out of town.

People can't wade across the river because it is contaminated with human waste after a pipe broke when the bridge went.   Some brave souls use a precarious ladder rigged to get across the water, but for most people it is too dangerous.   We need a bridge "to take out our vehicles and leave in case of emergency, or if there is a landslide," he said.   Where the bridge once stood, residents set up a system of ropes, pulleys and buckets to move supplies over the river, which has been contaminated with sewer water since the hurricane.   Over the remains of the bridge locals hung the single-star, red, white and blue flag of Puerto Rico and a sign that reads "the campsite of the forgotten."

- Desperate need for electricity -
Puerto Rico Governor Ricardo Rossello visited the surrounding municipality of Utuado on Wednesday to deliver supplies, but he did not stop in Rio Abajo.   "Utuado is certainly one of the most severely affected municipalities in all of Puerto Rico," Rossello said.   "Our commitment is to give it support and aid during the whole road to recovery."   Eighty-one percent of Puerto Rico remains blacked out one month after Maria struck. Clean water for drinking, cooking and bathing is scarce, too.

Puerto Ricans' main obstacle to getting back to some semblance of normality is the slowness of the Puerto Rico Electric Power Authority in getting the power grid back up and running.   The lack of power has paralyzed a key industry -- pharmaceutical production -- and most businesses including restaurants are closed or operating at great cost through the use of diesel powered generators.

This nightmare comes about a year after the US government established an external fiscal control board for the island after it declared bankruptcy because of 73 billion dollars in debt.   Economist Joaquin Villamil told AFP that damage from Hurricane Maria is estimated at 20 billion dollars -- four times that of Hurricane Georges in 1998, when measured in 2016 dollars.

Villamil said reconstruction money provided by the Federal Emergency Management Agency and from insurance companies will have a positive impact on the island's economy in the second half of fiscal 2018 and in fiscal 2019, but this boost will just be temporary.   "From an economic point of view there is not much net gain," said Villamil, who works for a consulting firm called Estudios Tecnicos.   He said the economy has been shrinking since 2006 and Maria will delay any prospect of recovery.   It will take at least until 2026 to get back to the GDP level of 2006, he added.

Making things worse, people are leaving the island for the mainland US. Forecasts are that the population now at 3.4 million will go down to 3.1 million or even less by 2026, said Villamil.   The government of Florida estimates that since October 3 -- the day a state of emergency to deal with an influx of Puerto Ricans was declared -- more than 36,000 people from the island have poured in.
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Benin

Benin - US Consular Information Sheet
April 28, 2008

COUNTRY DESCRIPTION:
Benin is a developing country in West Africa. Its political capital is Porto Novo. However, its administrative capital, Cotonou, is Benin's largest city and the
site of most government, commercial, and tourist activity. Read the Department of State Background Notes on Benin for additional information.

ENTRY/EXIT REQUIREMENTS: A passport and visa are required. Visas are not routinely available at the airport. Visitors to Benin should also carry the WHO Yellow Card (“Carte Jaune”) indicating that they have been vaccinated for yellow fever. Contact the Embassy of Benin for the most current visa information. The Embassy is located at: 2124 Kalorama Road NW, Washington, DC 20008; tel: 202-232-6656.

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:
U.S. citizens should avoid crowds, political rallies, and street demonstrations and maintain security awareness at all times.
U.S. citizens should not walk on the beach alone at any time of day. It is also highly recommended not to carry a passport or valuables when walking in any part of the city. Travelers should carry a notarized photocopy of the photo page of their passport (see Crime section). They should not walk around the city after dark, and should take particular care to avoid the beach and isolated areas near the beach after dark.
The ocean currents along the coast are extremely strong and treacherous with rough surf and a strong undertow, and several people drown each year.

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: Street robbery is a significant problem in Cotonou. Robbery and mugging occur along the Boulevard de France (the beach road by the Marina and Novotel Hotels) and on the beaches near hotels frequented by international visitors. Most of the reported incidents involve the use of force, often by armed persons, with occasional minor injury to the victim. Travelers should avoid isolated and poorly lit areas and should not walk around the city or the beaches between dusk and dawn. Even in daylight hours, foreigners on the beach near Cotonou are frequent victims of robberies. When visiting the beach, travelers should not bring valuables and should carry only a photocopy of their passport. If you are a victim of crime, you should contact the U.S. Embassy immediately. There has been a continued increase in the number of robberies and carjacking incidents after dark, both within metropolitan Cotonou and on highways and rural roads outside of major metropolitan areas. Motorists are urged to be wary of the risk of carjacking. Keep the windows of your vehicle rolled up and the doors locked. Stay alert for signs of suspicious behavior by other motorists or pedestrians that may lead to carjacking, such as attempts to stop a moving vehicle for no obvious reason. Travelers should avoid driving outside the city of Cotonou after dark and should exercise extreme caution when driving in Cotonou after dark (see Traffic Safety and Road Conditions below). Overland travel to Nigeria is dangerous near the Benin/Nigeria border due to unofficial checkpoints and highway banditry.
Travelers should avoid the use of credit cards and automated teller machines (ATMs) in Benin due to a high rate of fraud. Perpetrators of business and other kinds of fraud often target foreigners, including Americans. While such fraud schemes in the past have been largely associated with Nigeria, they are now prevalent throughout West Africa, including Benin, and are more frequently perpetrated by Beninese criminals. Business scams are not always easy to recognize, and any unsolicited business proposal should be carefully scrutinized. There are, nevertheless, some indicators that are warnings of a probable scam. Look out for:

Any offer of a substantial percentage of a very large sum of money to be transferred into your account, in return for your "discretion" or "confidentiality";

Any deal that seems too good to be true;
Requests for signed and stamped, blank letterhead or invoices, or for bank account or credit card information;
Requests for urgent air shipment, accompanied by an instrument of payment whose genuineness cannot immediately be established;
Solicitations claiming the soliciting party has personal ties to high government officials;
Requests for payment, in advance, of transfer taxes or incorporation fees;
Statements that your name was provided to the soliciting party either by someone you do not know or by "a reliable contact";
Promises of advance payment for services to the Beninese government; and
Any offer of a charitable donation.
These scams, which may appear to be legitimate business deals requiring advance payments on contracts, pose a danger of both financial loss and physical harm. Recently more American citizens have been targeted. The perpetrators of such scams sometimes pose as attorneys. One common ploy is to request fees for “registration” with fictitious government offices or regulatory authorities. The best way to avoid becoming a victim of advance-fee fraud is common sense – if it looks too good to be true, it probably is. Travelers should carefully check out any unsolicited business proposal originating in Benin before committing any funds, providing any goods or services, or undertaking any travel. For additional information, please see the Department of State’s Bureau of Consular Affairs brochure, International Financial Scams.

Scams may also involve persons posing as singles on Internet dating sites or as online acquaintances who then get into trouble and require money to be "rescued." If you are asked to send money by someone you meet online please contact the U.S. Embassy before doing so.

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 facilities in Benin are limited and not all medicines are available. Travelers should bring their own supplies of prescription drugs and preventive medicines. Not all medicines and prescription drugs available in Benin are USFDA-approved. Malaria is a serious risk to travelers to Benin. For information on malaria, its prevention, protection from insect bites, and anti-malarial drugs, please visit the CDC Travelers' Health web site at http://www.cdc.gov/malaria/.

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 website 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: 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 Benin is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

With the exception of the road linking Cotonou in the south to Malanville on the border with Niger in the north, and from Parakou in central Benin to Natitingou in the northwestern part of the country, roads in Benin are generally in poor condition and are often impassable during the rainy season. Benin's unpaved roads vary widely in quality; deep sand and potholes are common. During the rainy season from mid-June to mid-September, dirt roads often become impassable. Four-wheel drive vehicles with full spare tires and emergency equipment are recommended.
Most of the main streets in Cotonou are paved, but side streets are often dirt with deep potholes. Traffic moves on the right, as in the United States. Cotonou has no public transportation system; many Beninese people rely on bicycles, mopeds, motorbikes, and zemidjans (moped taxis). All official Americans are required to wear safety helmets when on a motorcycle and are strongly discouraged from using zemidjans. Travelers using zemidjans, particularly at night, are much more vulnerable to being mugged, assaulted or robbed. Buses and bush taxis offer service in the interior.
Gasoline smuggled from Nigeria is widely available in glass bottles and jugs at informal roadside stands throughout Cotonou and much of the country. This gasoline is of unreliable quality, often containing water or other contaminants that can damage or disable your vehicle. Drivers should purchase fuel only from official service stations. There are periodic gas shortages, which can be particularly acute in the north of the country where there are few service stations.
U.S. citizens traveling by road should exercise extreme caution. Poorly maintained and overloaded transport and cargo vehicles frequently break down and cause accidents. Drivers often place branches or leaves in the road to indicate a broken down vehicle is in the roadway. Undisciplined drivers move unpredictably through traffic. Construction work is often poorly indicated. Speed bumps, commonly used on paved roads in and near villages, are seldom indicated. Drivers must be on guard against people and livestock wandering into or across the roads. Nighttime driving is particularly hazardous as vehicles frequently lack headlights and/or taillights, and brake lights are often burned out.
With few exceptions, Cotonou and other cities lack any street lighting, and lighting on roads between population centers is non-existent. The U.S. Embassy in Cotonou prohibits non-essential travel outside of metropolitan areas after dusk by official Americans and strongly urges all U.S. citizens to avoid night driving as well. There have been numerous carjackings and robberies on roads in Benin after dark, several of which resulted in murder when the driver refused to comply with the assailants' demands. The National Police periodically conduct vehicle checks at provisional roadblocks in an effort to improve road safety and reduce the increasing number of carjackings. When stopped at such a roadblock, you must have all of the vehicle's documentation available to present to the authorities.
Please refer to our Road Safety page for more information. Visit the website of the country’s national tourist office at http://www.benintourisme.com.

AVIATION SAFETY OVERSIGHT: As there is no direct commercial air service to the United States by carriers registered in Benin, the U.S. Federal Aviation Administration (FAA) has not assessed Benin’s Civil Aviation Authority for compliance with International Civil Aviation Organization (ICAO) aviation safety standards. For more information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.

SPECIAL CIRCUMSTANCES:
U.S. citizens are advised to keep a notarized photocopy of the photo page of their passport with them at all times when traveling in Benin.
The Embassy has had a few reports of officials requesting a "gift" to facilitate official administrative matters (e.g., customs entry). Such requests should be politely but firmly declined.
It is prohibited to photograph government buildings and other official sites, such as military installations, without the formal consent of the Government of Benin. In general, it is always best to be courteous and ask permission before taking pictures of people. Beninese citizens may react angrily if photographed without their prior approval.
Obtaining customs clearance at the port of Cotonou for donated items shipped to Benin from the United States may be a lengthy process. In addition, to obtain a waiver of customs duties on donated items, the donating organization must secure prior written approval from the Government of Benin. Please contact the U.S. Embassy in Cotonou for more detailed information.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 Benin laws, even unknowingly, may be expelled, arrested or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in Benin 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 Benin are encouraged to register with the U.S. Embassy through the State Department’s travel registration web site so that they can obtain updated information on travel and security within Benin. Americans withoutInternet access may register directly with the U.S. Embassy. 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 Rue Caporal Anani Bernard in Cotonou. The Embassy's mailing address is B.P. 2012, Cotonou, Benin. The 24-hour telephone numbers are (229) 21-30-06-50, 21-30-05-13, and 21-30-17-92. The Embassy’s general fax number is (229) 21-30-06-70; the Consular Section’s fax number is (229) 21-30-66-82; http://cotonou.usembassy.gov/.
* * *
This replaces the Country Specific Information for Benin dated August 17th, 2007 to update sections on Safety and Security and Traffic Safety and Road Conditions.

Travel News Headlines WORLD NEWS

Date: Fri, 10 May 2019 19:38:30 +0200
By Hazel WARD and Daphne BENOIT

Paris, May 10, 2019 (AFP) - French special forces have freed two French hostages, an American and a South Korean in northern Burkina Faso in an overnight raid in which two soldiers died, authorities announced Friday.   The operation was launched to free two French tourists who had disappeared while on holiday in the remote Pendjari National Park in neighbouring Benin on May 1.

But during the raid, the French troops were surprised to discover two women also in captivity, with top officials saying they had been held for 28 days.    The French tourists were identified as Patrick Picque, 51, and Laurent Lassimouillas, 46, but the women's identities were not immediately clear.     "No one was aware of (the women's) presence," French Defence Minister Florence Parly told reporters, while French armed forces chief Francois Lecointre said.   "We know little about these other two hostages," Parly told reporters, saying that even Seoul and Washington did not appear to be aware the pair were in increasingly unstable Burkina Faso.    The raid was approved by French President Emmanuel Macron in what was seen as the last opportunity to stop the hostages being transferred to lawless territory in Mali to the north.

Parly said it was "too early to say" who had snatched the two French nationals from Benin, which has long been an island of stability in a region where Islamist militants are increasingly active.   "The message to terrorists and criminal gangs is clear: those who attack France and its nationals know that we will not spare any effort to track them down, find them and neutralise them," she said.   Four of the six kidnappers were killed in the raid.    French forces, helped by intelligence provided by the United States, had been tracking the kidnappers for several days as they travelled across the semi-desert terrain of eastern Burkina Faso from Benin to Mali.   They seized the opportunity to prevent "the transfer of the hostages to another terrorist organisation in Mali," Lecointre said, referring to the Macina Liberation Front (FLM).   The FLM is a jihadist group formed in 2015 and headed by a radical Malian preacher, Amadou Koufa. It is aligned with Al-Qaeda in the region.

- US intelligence support -
In a statement, Macron congratulated the special forces on the operation, in which he also expressed sorrow over the death of the two soldiers "who gave their lives to save those of our citizens".   And Parly thanked authorities in Benin and Burkina Faso for their help with the "complex operation", as well as the United States which provided intelligence and support.

The operation was also made possible by the presence of France's Operation Barkhane, which counts some 4,500 troops deployed in Mali, Burkina Faso, Niger and Chad to help local forces battle jihadist groups.   American special forces and drones are also known to operate in the violence-wracked Sahel region, which France fears could become further destabilised as jihadist groups are pushed out of north Africa, Iraq and Syria.   Burkina Faso has suffered from increasingly frequent and deadly attacks attributed to a number of jihadist groups, including the Ansarul Islam group, the Group to Support Islam and Muslims (GSIM) and Islamic State in the Greater Sahara.

- Relief and sadness -
The French tourists -- Patrick Picque who works in a Paris jewellery shop, and Laurent Lassimouillas a piano teacher, -- went missing with their guide on the last leg of their holiday in usually peaceful Benin.   The Pendjari wildlife reserve, which is famed for its elephants and lions, lies close to the porous border with Burkina Faso.   The badly disfigured body of their guide was found shortly after they disappeared, as well as their abandoned four-wheel Toyota truck.   The two freed men will be flown back to France on Saturday, alongside the South Korean woman, where they will be met on arrival by Macron and other top French officials.   Washington thanked the French forces for freeing the American hostage, with France saying she would likely be "repatriated independently" from the other three. 

The two dead French soldiers were named as Cedric de Pierrepont and Alain Bertoncello, decorated naval special forces members born in 1986 and 1991 respectively.   They were part of the prestigious Hubert commando unit of the French naval special forces which was deployed to the Sahel at the end of March.   A total of 24 French soldiers have died in the region since 2013 when France intervened to drive back jihadist groups who had taken control of northern Mali. The last death was on April 2.
Date: Tue 15 Jan 2019
Source: Punch [edited]

The Kwara state government has confirmed 2 cases of Lassa fever infecting a husband and wife in the state.

Speaking with newsmen on Tuesday [15 Jan 2019] at a news briefing, the Kwara commissioner for health, Alhaji Usman Rifun-Kolo, said the outbreak of Lassa fever was identified in a farm settlement in Taberu, Baruten local government area.

He explained that the 2 cases of the disease affected a husband and wife, natives of Benin republic, which shares a border with the state. He added that the husband and wife are farming in Baruten. "These cases of Lassa fever originated from Benin republic, whose citizen have interrelations with people in the Baruten area," he said.

According to him, the husband and wife were diagnosed in a health facility, and the state government had already deployed a disease-surveillance team to identify those who have been in contact with the patients.

Rifun-Kolo further explained that the surveillance team identified 4 people with a history of fever in the area. He said that the 4 cases raised suspicion of Lassa fever, which prompted them to take samples from the individuals for further investigation. He noted that the 4 individuals have commenced treatment in Taberu, Baruten LGA.
=====================
[The above report states that the couple was infected in Benin, although the timeline when that may have occurred is not given. The report also mentions 4 individuals in the Kwara state who had a history of Lassa fever, implying that the virus is present in that state in Nigeria as well. In December [2018], there were Lassa fever cases in Benin that were imported from Nigeria as well as infections that were locally acquired in Benin, so the Lassa fever cases cross the border in both directions. The source of the infecting virus for any of these cases is not mentioned. - ProMED Mod.TY

[HealthMap/ProMED-mail maps:
Kwara state, Nigeria: <http://healthmap.org/promed/p/19690>]
Date: Wed 26 Dec 2018
Source: Quotidein Le Matinal [in French, trans. ProMED Corr.SB, edited]

Minister of health Benjamin Hounkpatin confirmed on Wednesday [26 Dec 2018] 4 new cases of Lassa haemorrhagic fever in Benin, including one in Cotonou. This occurred in the period from 15-26 Dec 2018.

In the case of Cotonou, a 28-year-old (has been infected). His case was detected on 24 Dec [2018], but his illness commenced the previous week. He had a fever, a cough, a cold, and fatigue. Due to the persistence of the cough and cold, and with the appearance of traces of blood in nasal discharge on 24 Dec 2018, the alert was given.

The patient was placed in isolation on [Tue 25 Dec 2018], and on the morning of Wed 26 Dec 2018, his result from the laboratory came back positive [for Lassa fever]. Subsequently, the patient was isolated and put on treatment.

According to the details provided by Hounkpatin, there is no indication of travel [by the patient] to an epidemic locality of Lassa fever. According to the patient's statements, there is no known contact with rodents.

Taking advantage of this opportunity, the minister reassured the public that public health measures are underway. He also reminded people of the behaviours that will help avoid becoming infected. This involves washing hands regularly with soap and water; avoiding contact with stool, sperm, urine, saliva, vomit, and contaminated objects from a person suspected to be ill or dead from Lassa; and protecting food and keeping it in a safe place, out of reach of rodents.

It should be recalled that 7 cases have been recorded since the beginning of the epidemic to date, including 5 positive cases.
=======================
[One case is located in Cotonou on the Benin coast and apparently was locally acquired, perhaps from contact with the rodent host or its excrement. The location of the other 3 cases is not mentioned, but a 13 Dec 2018 report indicated that there were 3 cases in the municipality of Parakou in Borgou Department, in the northern part of Benin. Perhaps these 3 cases, which came from the village Taberou (in Nigeria), located 5 km [3.1 mi] from Tandou in the commune of Tchaourou, are the ones mentioned in this report.

The previous Lassa fever cases in Benin this year [2018] occurred in January and also involved case importation from Nigeria. A previous WHO report stated that Lassa fever is endemic in bordering Nigeria, and, given the frequent population movements between Nigeria and Benin, the occurrence of additional cases is not unexpected. Strengthening of cross-border collaboration and information exchange between the 2 countries is, therefore, needed. - ProMED Mod.TY]

[Images of the rodent reservoirs of Lassa fever virus can be seen as follows:
For _Mastomys natalensis_, see
For _M. erythroleucus_ and _Hylomycus pamfi_, see

HealthMap/ProMED-mail maps:
Date: Fri, 29 Jun 2018 13:37:32 +0200

Cotonou, June 29, 2018 (AFP) - Benin's Constitutional Court has banned the right to strike by workers in the country's defence, security, justice and health sectors, sparking concern among union officials and legal observers.   The ruling, issued late on Thursday, came after months of wrangling between the government and the court, which had previously said the measure was unconstitutional.

"Civil servants, public security forces and equivalents should fulfil their duties in all circumstances and not exercise their right to strike," the court said in its new ruling.   "There should be no disruption to the duties of public sector defence, security, justice and health workers."   The decision was taken "in the public interest" and for "the protection of citizens", it said.

Speaking on Friday, one senior union leader, who asked to remain anonymous, described the ruling as shocking and a "hammer blow".   And Benin legal affairs expert Albert Medagbe told AFP the decision was a "worrying sudden legal U-turn".   Earlier this month, a close ally of President Patrice Talon, Joseph Djogbenou, was elected to lead the Constitutional Court during a vote held behind closed doors.   Djogbenou is Talon's former personal lawyer and was previously  Benin's attorney general.

Until his arrival, the court had strained relations with Talon, and had criticised the government for misunderstanding and failing to respect the constitution.   The small West African nation was last year hit by a wave of public sector strikes, which brought the education, health and justice system to a near halt.   The industrial action was sparked by Talon's attempts to introduce free-market reforms.
Date: Wed, 21 Feb 2018 17:31:52 +0100

Cotonou, Feb 21, 2018 (AFP) - Nine people appeared in a Benin court Wednesday on charges of selling fake drugs at the start of a landmark trial in a regional campaign against illicit medicines.   The suspects, who include executives from major pharmaceutical companies operating in the West African nation, were remanded in custody until March 6 on technical grounds.   They are accused of "the sale of falsified medicines, (and) display, possession with a view to selling, commercialisation or sale of falsified medical substances."   A tenth defendant, the head of the Directorate for Pharmacies, Medications and Diagnostic Evaluation (DPMED) under the control of the ministry of health, was not in court on the trial's opening day.   He is accused of failing to prevent the offences.

Benin launched the crackdown last year after mounting alarm about the scale of the trafficking of expired and counterfeit drugs in West Africa.   Fake medicines are drugs that are bogus or below regulatory standards but often are outwardly indistinguishable from the genuine product.   Taking them may do nothing to tackle an illness or -- in the case of antibiotics -- worsen the problem of microbial resistance.   According to an investigation by the Paris-based International Institute of Research Against Counterfeit Medicines (IRACM), West African markets are awash with fake drugs made in China and India.

In 2015, the American Society of Tropical Medicine and Hygiene estimated that 122,000 children under five died due to taking poor-quality antimalarial drugs in sub-Saharan Africa.   A 15-nation regional body, the Economic Community of West African States (ECOWAS), last April announced an investigation into the fake drugs business.   A lawyer for the civilian plaintiffs told AFP that the trial in Benin was adjourned until March 6 at their request "in order to incorporate another case, of illegal pharmaceutical practice".
More ...

Bulgaria

Bulgaria US Consular Information Sheet
September 20, 2007
COUNTRY DESCRIPTION: Bulgaria is a quickly developing European nation undergoing significant economic changes.
Tourist facilities are widely available, although conditions vary and
ome facilities may not be up to Western standards.
Goods and services taken for granted in other European countries may not be available in many areas of Bulgaria.
Read the Department of State Background Notes on Bulgaria for additional information.
ENTRY/EXIT REQUIREMENTS:
A United States passport is required for U.S. citizens who are not also Bulgarian nationals.
As of September 1, 2006, U.S. citizens who enter the country without a Bulgarian visa are authorized to stay for a total of 90 days within a six-month period.
This law is strictly enforced.
An application to extend one’s stay beyond the original 90 days can be filed for urgent or humanitarian reasons, but must be submitted to regional police authorities no later than five days prior to the end of the original 90-day period.
Travelers who have been in the country for 90 days, and then leave, will not be able to reenter Bulgaria before the six-month period expires.
Travelers using official or diplomatic passports must secure visas prior to arrival.
Upon entering the country, Bulgarian immigration authorities request that all foreigners declare the purpose of their visit and provide their intended address.
U.S. citizens intending to live or work in Bulgaria for more than 90 days within six months (or more than six months within a year) must obtain a “D” visa prior to arrival.
The practice of switching from tourist status to long-term status when already in Bulgaria is no longer allowed.
Those wanting to do so must leave Bulgaria and apply for a “D” visa at a Bulgarian embassy or consulate.
This procedure takes from two to four weeks.
American citizens who marry Bulgarian nationals and want to switch to long-term status must also leave the country, present their marriage license at a Bulgarian embassy or consulate in a neighboring country, and apply for a “D” visa.

The Bulgarian authorities do not consider presentation of a copy of the passport sufficient for identification purposes.
Visitors should carry their original passports with them at all times.
For further information concerning entry requirements, travelers should contact the Embassy of the Republic of Bulgaria at 1621 22nd St. N.W., Washington, D.C. 20008; http://www.bulgaria-embassy.org; tel. (202) 387-7969 (main switchboard (202) 387-0174), or the Bulgarian Consulate in New York City at 121 East 62nd Street, New York, NY 10021; http://www.consulbulgaria-ny.org; tel. (212) 935-4646.
See our Foreign Entry Requirements brochure for more information on Bulgaria and other countries.
Visit the Embassy of Bulgaria web site at http://www.bulgaria-embassy.org for the most current visa information.
Traveling with Bulgarian minors: Bulgarian authorities are particularly strict in matters involving the travel of Bulgarian children.
Adults, other than a child’s parents, departing Bulgaria with a Bulgarian national (including dual or multi-national Bulgarian) child, must present to authorities a certified/legalized declaration signed by the child’s parents authorizing custody for travel purposes.
This holds true even if the adult is otherwise related to the child.
If the declaration is signed in Bulgaria, certification by a Bulgarian notary public is required.
If signed in the U.S., the declaration must be certified by a notary public and the court in the jurisdiction where the notary is licensed.
The declaration must then be legalized with an apostille issued by the individual state's Department of State or the Governor’s office.
Please note Bulgarian authorities do not require such documentation for minors who are not Bulgarian.
Find more information about dual nationality and the prevention of international child abduction on our web site. For further information about customs regulations, please read our Customs Information.

SAFETY AND SECURITY:
Bulgaria’s accession to the European Union has enhanced the overall security environment for tourist and business travelers.
However, the country still suffers from many of the ills of a former Eastern Bloc country in transition.
Organized crime groups and criminals who specialize in petty crimes and credit card fraud are highly prevalent in Bulgaria’s largely cash economy.
Petty criminals such as pick-pockets and purse snatchers operate in crowded public areas and on public transportation.
Also, technology exists in Bulgaria to clone credit cards and trap ATM cards for later retrieval.
Suspected organized crime members often travel in convoys of late-model SUVs and luxury sedans, accompanied by armed men, and frequent expensive restaurants, hotels, and nightclubs.
For the latest security information, Americans traveling abroad should regularly monitor the Department’s Internet web site at http://travel.state.gov, where the current Worldwide Caution Public Announcement, Travel Warnings and Public Announcements 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:
Petty street crime, much of which is directed against persons who appear to have money or to be foreign, continues to be a problem.
Pocket picking and purse snatching are frequent occurrences, especially in crowded markets and on shopping streets.
Con artists operate on public transportation and in bus and train stations.
Credit cards and ATMs should be used with caution.
Be wary of people who approach you at an ATM and offer assistance.
Do not give your PIN number to anyone under any circumstances. (See the Special Circumstances section below.) Travelers should be suspicious of "instant friends" and should also require persons claiming to be government officials to show identification.
There have been incidents in which tourists have been drugged or assaulted and robbed after accepting offers of coffee or alcoholic beverages from "friendly” individuals met by “chance” at hotels, the airport, or at bus or train stations.
Travelers should be wary of unfamiliar individuals who encourage them to drink or eat products, as these may be tainted with strong tranquilizers (such as valium) that can lead rapidly to unconsciousness.
Reporting a crime immediately to the police has helped recover money and valuables on more than one occasion and is recommended.
To avoid becoming a victim of more serious crimes, one should use the same personal safety precautions that they would use in large urban areas of the United States.

Travelers should pay special attention to the drink prices at high-end bars and nightclubs.
There have been instances of travelers being charged exorbitant prices, especially for champagne and hard alcohol.
Bills have been as high as several thousand dollars for drinks, and in some establishments the management may use force to assure payment.

On occasion, taxi drivers overcharge unwary travelers, particularly at Sofia Airport and the Central Train Station.
We recommend travelers use taxis with meters and clearly marked rates displayed on a sticker on the passenger side of the windshield.
Travelers should be aware that there is no official commission that sets taxi cab rates.
Taxi drivers are within their full rights to charge passengers any price they want, provided that it corresponds with the price shown on the windshield sticker.
At the airport, there is a clearly marked booth within the arrivals terminal, which arranges for metered taxis at a fair rate.
Finding reputable taxis at the Central Train Station is more difficult.
It is recommended to inquire about the fare first, to avoid excessive payment if a metered taxi cannot be found.
Always ensure that you have and account for all luggage, packages and hand-carried items before you pay and release a taxi.
The likelihood of retrieving articles left behind in a taxi is remote.
Because pilferage of checked baggage may occur at Sofia Airport, travelers should not include items of value in checked luggage.
Automobile theft is a concern, with four-wheel-drive vehicles and late model European sedans the most popular targets.
Very few vehicles are recovered.
Thieves smash vehicle windows to steal valuables left in sight.
Break-ins at residential apartments occur as frequently as in major cities everywhere.
Persons who plan to reside in Bulgaria on a long-term basis should take measures to protect their dwellings.
Long-term residents should consider installation of window grilles, steel doors with well-functioning locks, and an alarm system that alerts an armed response team.

Travelers should also be cautious about making credit card charges over the Internet to unfamiliar websites.
As recent experience has shown, offers for merchandise and services may be scam artists posing as legitimate businesses.
A recent example involves Internet credit card payments to alleged tour operators via Bulgaria-based web sites.
In several cases, the corresponding businesses did not actually exist.
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:
While Bulgarian physicians are trained to a very high standard, most hospitals and clinics, especially in village areas, are generally not equipped and maintained to meet U.S. or Western European standards.
Basic medical supplies and over-the-counter and prescription medications are widely available, but highly specialized treatment may not be obtainable.
Pediatric facilities are in need of funding and lack equipment.
Serious medical problems requiring hospitalization and/or medical evacuation to the United States may cost thousands of dollars.
Doctors and hospitals often expect immediate cash payment for health services.
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 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.
All foreign citizens traveling to Bulgaria should be prepared to present valid evidence of health insurance to the Bulgarian border authorities in order to be admitted into the country.
The insurance should be valid for the duration of the traveler’s stay in Bulgaria.
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 Bulgaria is provided for general reference only, and may not be totally accurate in a particular location or circumstance.
The Bulgarian road system is largely underdeveloped.
There are few sections of limited-access divided highway.
Some roads are in poor repair and full of potholes.
Rockslides and landslides may be encountered on roads in mountainous areas.
Livestock and animal-drawn carts present road hazards throughout the country, especially during the agricultural season.
Travel conditions deteriorate during the winter as roads become icy and potholes proliferate.
The U.S. Embassy in Sofia advises against driving at night because road conditions are more dangerous in the dark.
Some roads lack pavement markings and lights, and motorists often drive with dim or missing headlights.
Driving in Bulgaria is extremely dangerous.
Aggressive driving habits, the lack of safe infrastructure, and a mixture of late model and old model cars on the country’s highways contribute to a high fatality rate for road accidents.
Heavy traffic conditions have led to a significant increase in “road-rage” accidents.
Motorists should avoid confrontations with aggressive drivers in Bulgaria.
In particular, drivers of late-model sedans (BMW, Mercedes, Audi) are known to speed and drive dangerously.
Motorists should exercise caution and avoid altercations with the drivers of such vehicles, which may be driven by armed organized crime figures.
In some cities traffic lights late at night blink yellow in all directions, leaving rights-of-way unclear and contributing to frequent accidents.
Heavy truck traffic along the two-lane routes from the Greek border at Kulata to Sofia and from the Turkish border at Kapitan Andre to Plovdiv creates numerous hazards.
Motorists should expect long delays at border crossings.
A U.S. state driver's license is valid in Bulgaria only when used in conjunction with an International Driving Permit.
For information on how to obtain a permit, please see our road safety information.
If pulled over by a police officer, motorists should remember that, under Bulgarian law, police officers may not collect fines on the spot; they may only issue a ticket with the fine to be paid at the motorist’s local regional tax office.
Buses, trams, and trolleys are inexpensive, but they are often crowded and of widely varying quality.
Passengers on the busiest lines have reported pick pocketing, purse slashing, and pinching. The use of seat belts is mandatory in Bulgaria for all passengers, except pregnant women.
Children under 10 years of age may ride in the front seat only if seated in a child car seat.
In practice, these rules are often not followed.
Speed limits are 50 km/h in the cities/towns, 90 km/h out of town, and 130 km/h on the highways.
For motorcycles, speed limits are 50 km/h in the cities/towns, 80 km/h out of town, and 100 km/h on the highways.
Motorcyclists must drive with helmets and with lights on at all times.
At crossings that are not regulated, the driver who is on the right has the right-of-way, but this rule, too, is frequently ignored.
Drivers may be charged with driving under the influence of alcohol with a blood level as low as 0.05 percent.
Right turns on red lights are not permitted unless specifically authorized.
The penalties for drivers involved in an accident resulting in injury or death range from a 25 U.S. Dollar fine up to imprisonment for life.
A new law requires the use of headlights day and night from November 1st through March 31st.
The most generally encountered local traffic custom is a driver flashing high beams, which usually means that a traffic police post is ahead.
In case of emergency, drivers should contact the police at telephone number 166 and/or Roadside Assistance at telephone number 146.
For an ambulance, please call 150.
The fire department can be reached at 160.
For specific information concerning Bulgarian driving permits, vehicle inspection, road tax, and mandatory insurance, please contact the Bulgarian Embassy via the Internet at http://www.bulgaria-embassy.org.
Please refer to our Road Safety page for more information.
Visit the web site of the country’s national tourist office at http://www.bulgariatravel.org/eng/index.php and the web site of the Bulgarian national authority responsible for road safety at http://www.kat.mvr.bg.
[Note: the latter web site is available in the Bulgarian language only.]
AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of Bulgaria’s Civil Aviation Authority as not being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for the oversight of Bulgaria’s air carrier operations.
For more information, travelers may visit the FAA’s Internet web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.

SPECIAL CIRCUMSTANCES:
Bulgaria is still largely a cash economy.
Due to the potential for fraud and other criminal activity, credit cards should be used sparingly and with extreme caution.
There have been reports of false ATM fronts on bona fide machines that capture cards and PINs for later criminal use, including unauthorized charges or withdrawals.
In connection with such scams, travelers should be extremely wary of friendly bystanders near ATMs who offer assistance.
Any time a card is not returned the traveler should immediately report the card as lost/stolen to the card-issuing company.

Visitors may exchange cash at banks or Exchange Bureaus, but they should know that Exchange Bureaus sometimes post misleading rate quotations that confuse travelers.
People on the street who offer high rates of exchange are usually con artists intent on swindling the unwary traveler.
Damaged or very worn U.S dollar bank notes are often not accepted at banks or Exchange Bureaus.
Major branches of the following Bulgarian banks will cash travelers' cheques on the spot for Leva, the Bulgarian currency, or another desired currency:
Bulbank, Bulgarian Postbank, Biochim, First Investment Bank, and United Bulgarian Bank (UBB).
UBB also serves as a Western Union agent and provides direct transfer of money to travelers in need.
There are also many Western Union branches in major towns and cities.
Most shops, hotels, and restaurants, with the exception of the major hotels, do not accept travelers' cheques or credit cards.
Only some local banks can cash U.S. Treasury checks and the payee may need to wait up to a month to receive funds.
Corruption remains an important concern of the Government.
The Commission for Coordinating of the Activity for Combating Corruption manages the efforts of each government agency’s internal inspectorate in fighting public corruption and engages in public awareness campaigns.
Complaints of public corruption can be made to it at the Ministry of Justice, 2A Knyaz Dondukov Blvd., 1055 Sofia, Bulgaria, email: acc@government.bg, 359-2-980-9213, 359-2-923-7595, 359-2-940-3630 or to the Ministry of Finance hotline: 0800180018.
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 Bulgaria’s laws, even unknowingly, may be expelled, arrested or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in Bulgaria 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 Bulgaria are encouraged to register with the U.S. Embassy through the State Department’s travel registration web site, and to obtain updated information on travel and security within Bulgaria.
Americans without Internet access may use a public computer at the U.S. Embassy to register.
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 16, Kozyak St., Sofia1407; tel.: (+359 2) 937-5100; fax (+359 2) 937-5209; web site: http://sofia.usembassy.gov/.
Questions regarding consular services may be directed via email to: niv_sofia@state.gov (for non-immigrant visa matters); iv_sofia@state.gov (for immigrant visa matters) and acs_sofia@state.gov (for American Citizen Services matters).
*

*

*
This replaces the Consular Information Sheet dated March 28, 2007, to update the sections on Entry and Exit
Requirements, Safety and Security, Crime, Traffic Safety and Road Conditions, Children’s Issues, and Registration/Embassy.

Travel News Headlines WORLD NEWS

Date: 30 Aug 2018
Source: Euro Surveillance [summarized, edited]

In June 2018, Crimean-Congo haemorrhagic fever (CCHF) was diagnosed in a Greek construction worker who returned home after becoming ill with fever and haemorrhagic symptoms in south-western Bulgaria. Here, we describe the case along with the epidemiological investigation and phylogenetic analysis.

On 30 May 2018, a Greek male in his late 40s returned to Greece after spending 23 days in a forested area in Blagoevgrad province, south-western Bulgaria, where he was working in bridge construction. Three days earlier (27 May 2018, day 1), while in Bulgaria, he developed fever, severe headache, myalgia (mainly in the lower extremities), malaise and loss of appetite; on 28 May 2018 he visited a local hospital and received symptomatic treatment as an outpatient. As his condition deteriorated (onset of photophobia and abdominal pain) he returned to his permanent residence in northern Greece. On 31 May 2018 (day 5), the patient was admitted to a local hospital.

He was transferred to the university hospital in Alexandroupolis the next day because he presented severe thrombocytopenia and leukopenia; elevated levels of liver enzymes, creatine phosphokinase (CPK) and lactate dehydrogenase (LDH); and prolonged activated partial thromboplastin time (aPTT) (Table). On day 6, his headache was resolved, but his fever (38.2 C [101 F]), malaise and myalgia were ongoing. The main laboratory findings were thrombocytopenia, prolonged aPTT (82 s) and increased level of aminotransferases. His laboratory parameters indicated rhabdomyolysis (CPK 1739 U/L) and slightly elevated urea and creatinine levels (Table). A bone marrow biopsy showed haemophagocytosis. ...

Based on the patient's clinical presentation, and as he was bitten by a tick in an area of Bulgaria where CCHF cases have been reported previously, CCHF was highly suspected. Typically, the incubation period of CCHF after a tick bite is short (1-3 days), but the exact date of the bite was unknown in this case. The treating physician contacted the National Reference Centre for Arboviruses and Haemorrhagic Fever Viruses in Thessaloniki, and the suspected case was immediately notified to the Hellenic Center for Disease Control and Prevention (HCDCP). ...

The HCDCP investigated the case immediately after the diagnosis of CCHF (through telephone interviews with a close family member and with the patient, after recovery, to confirm the dates) and his contacts while he was ill (household members, co-workers, roommates in Bulgaria and relatives who visited him in the hospitals). Close contacts were tested for CCHF and monitored for 14 days for any symptom development. The risk for further transmission was also assessed. The HCDCP promptly informed the Bulgarian health authorities about the case; they also informed the patient's Greek co-workers in Bulgaria about prevention and proper management of tick bites (informative material in Greek was sent to them) advising them to seek medical care in case they develop symptoms.

No other cases were reported among the patient's co-workers in Bulgaria, up to the end of July 2018. The regional and local public health authorities were also informed about the case, and they performed further contact investigation in Greece. No secondary cases were detected. The HCDCP raised awareness for CCHF among health professionals working in local health centres and hospitals in northern Greece, especially in areas with populations travelling to Bulgaria for occupational reasons.

The patient and his laboratory samples, apparel, waste and cleaning procedures were managed in accordance with the national guidelines for viral haemorrhagic fevers (available in Greek from HCDCP website: <http://www.keelpno.gr/>). In particular, upon the suspicion of CCHF (day 8), the patient was immediately isolated, and strict barrier precautions were utilised (waterproof gowns, gloves, FFP3 respiratory masks, goggles), and personal protective equipment was used by healthcare workers (HCWs) and visitors; however, visitors were discouraged from entering the isolation room. The HCDCP sent guidelines for contact tracing and active surveillance of symptoms in HCWs possibly exposed to CCHFV. Patients who were hospitalised in the same room with the patient before the suspicion of CCHF (2 patients in the 1st hospital (days 5-6), and 3 patients in the 2nd hospital (days 6-8)), were also monitored for symptoms for 14 days after their last contact with the patient. No secondary cases were observed. ...

Discussion
---------
CCHF was 1st recognised in Bulgaria in 1952; since then, several cases have been reported. Genetic characterisation of the Bulgarian strains showed that they cluster into the clade Europe 1. Our patient was infected in an area that was considered at low risk for CCHF outbreaks up to 2008, when a cluster of cases was observed in the region. Although the seroprevalence in the human population in Blagoevgrad province is low (1 percent), a seroprevalence of 41.9 percent in livestock was reported recently. Since CCHFV is transmitted mainly by bites of infected Ixodid ticks, persons living in rural areas are at increased risk for acquiring the infection. This was the reason that information about preventive measures was sent to our patient's Greek co-workers in Bulgaria, and all related public health authorities were informed about the case.

Regarding Greece, no other imported cases have been reported so far, and the only autochthonous CCHF case was observed in 2008. A review of travel-associated CCHF cases published during 1960-2016 reported 21 cases; 2 imported cases have been reported within Europe: Bulgaria to Germany in 2001 and Bulgaria to the United Kingdom in 2014.

Due to the high pathogenicity of CCHFV, the absence of a specific drug treatment or vaccine, and the risk of person-to-person transmission, rapid diagnosis is crucial to ensure that appropriate infection control measures (e.g. isolation of patient and barrier precautions) can be implemented in a timely manner. A detailed medical history of the patient, including travel history and possible risk factors, is important for the timely diagnosis of the disease. In our case, information regarding the tick bite was not provided immediately, and this, in combination with the non-specific initial symptoms, meant that CCHF was 1st suspected on day 8 of illness. Despite this delay, the patient fully recovered, and no secondary cases of CCHF have been reported. Since the northern part of Greece is close to CCHF-endemic countries, HCWs in this region should be made aware of CCHF, including the provision of training to better help them address questions from patients about travel history (to identify potential risk of exposure). Physicians should include CCHF in the differential diagnosis for patients with haemorrhagic syndromes, especially if patients report a tick bite, outdoor activities, or occupation in rural areas and recent travel to an endemic area.
=======================
[The above report provides an excellent example of CCHF transmission in a case with no history of conventional professional contact with infected cattle, such as cattle rearing or butchering. History of travel to a location that has reported human cases, presence of the vector, and the clinical picture should raise suspicions in health care providers, with appropriate diagnostic tests conducted as soon as possible. - ProMED Mod.UBA]

[HealthMap/ProMED maps available at:
Date: Thu, 8 Mar 2018 12:10:48 +0100
By Diana SIMEONOVA

Bansko, Bulgaria, March 8, 2018 (AFP) - "Unlimited Ski and Fun!" promises a pamphlet touting the Bansko ski resort, a magnet for bargain-hunting holidaymakers in southwest Bulgaria.   But nature lovers are demanding limits to the growth of the bustling resort carved into the majestic pine forests of Pirin National Park, a UNESCO World Heritage site since 1983.

The clearance of more than 160 hectares (400 acres) of centuries-old forest to build the ski zone already prompted UNESCO in 2010 to remove the area from the World Heritage designation, labelling it a "buffer zone".   Now a much larger area could come under threat after a government decision in December opened 48 percent of the park's 40,000 hectares for construction, sparking weekly protests attended by thousands across the country.

Protestors accuse the government of favouring business interests in a country ranked by watchdog Transparency International as the EU's most graft-prone, with one huge banner at a recent rally in the capital Sofia reading: "Corruption! Save Pirin".   But the resort is the area's biggest employer and locals have responded with their own demonstrations in favour of expansion.   At issue in particular is a plan to build a second ski lift to ease persistent queues at the sole six-person lift, which currently takes 2,200 skiers per hour up to the 75 kilometres (46 miles) of runs.

- 'Horrific' queue -
British holidaymaker Carolyn Bennett, 30, is among the skiers who come in droves to Bansko from Britain, Russia and Bulgaria's Balkan neighbours, attracted by the cheap food and lift passes as well as budget flights.   But even on a supposedly quiet day, she was among scores of people at the foot of the ski lift, where queues form from early morning and waits can last up to three hours.

"Another gondola is going to have a huge impact environmentally but I imagine coming here in peak season, that queue would probably be horrific," she shrugged in the crammed gondola cabin.    "With a daily lift pass costing 28 euros ($34), Bansko is the cheapest resort of its capacity in Europe, and even if our queues have become notorious, people keep pouring in," Bansko's marketing chief Ivan Obreykov told AFP.   Daily lift passes at ski resorts in France and Austria typically cost twice as much.

Bansko hosts some 35,000 to 40,000 visitors per month during the winter season. On a busy day, up to 7,000 people could hit the ski lift at the same time in the mornings.   Booming construction in the once quiet town of 9,500 inhabitants has seen its two-storey houses and cobbled streets surrounded by hotels and luxury apartments with space for 18,000 guests.   While ugly concrete skeletons of a number of hotel projects abandoned after the 2008 financial crisis mar the landscape, pressure is mounting to expand both the town and the ski zone.

- Trojan horse claim -
Obreykov praised the government's green light for the second ski lift, adding that its construction was the resort's "first and most pressing task".   But those opposed to the plan say it is a Trojan horse to cover up previous unauthorised building and encourage even more expansion.   "If they wanted to do just a second gondola, they would not have opened almost half of the territory of Pirin National Park for construction," WWF's Konstantin Ivanov said at a rally in Sofia.   "We don't buy their promises that nothing more will be built there," he added.   WWF claims the ski zone has already grown to cover 60 percent more territory than initially agreed and points to as yet unapproved plans for huge expansion of the resort.    Obreykov denied the charge, adding that new ski runs could be built only within the current area of the ski zone.

A recent study for the WWF concluded that the resort has already inflicted "irreparable damage" on the reserve, calling for UNESCO to inscribe Pirin on its List of World Heritage in Danger if new construction begins.    A report by the International Union for Conservation of Nature (IUCN) in November also said the conservation outlook for Pirin National Park -- home to bears, chamois and wolves -- was of "significant concern" and just one step away from the final "critical" stage.   IUCN also underlined the "threats of disturbance and fragmentation of the site associated with the exclusion of the skiing areas as incompatible with its World Heritage status."

- 'Deepening mistrust' -
For economist Petar Ganev, of the Sofia-based Institute for Market Economics, the row is an example of "deepening mistrust in Bulgaria's institutions".   On the one hand, Ganev said Bansko is "a positive example of a very poor place which grew into a prosperous resort" and that building a second ski lift could be justified for that reason.   But, he added, suspicions that development is not being regulated fairly will "continue to bring people out on the streets".   "The problem is not the second gondola but the corruption in the country," Ganev said.
Date: Fri 1 Dec 2017 15:26
Source: Focus News Agency [edited]

The hepatitis A outbreak in the Kosharnik, an all-Roma neighbourhood of Montana, is spreading, the number of people infected has reached 15, Dr. Mariya Kamenova, Deputy Director of Montana Regional Health Inspectorate (RHI) told FOCUS Radio . Another 8 cases were registered for the period from [Fri 27 Oct 2017] until the end of November 2017, adding up to the 7 cases registered by [Thu 26 Oct 2017]. Those 1st 7 cases were children under 14, while the newly infected are 4 children under 4 years of age, 2 children aged 5 to 9, and 2 children aged 15 to 19.

A 51-year-old male from the neighborhood is also probably hepatitis A infected, but his tests are pending. The Montana municipality has taken measures and the streets in Kosharnik and the yards of the infected families have been disinfected every month. The RHI has said that they will continue to monitor the situation.
=====================
[The location of Montana in Bulgaria is north and west of Plovdiv where HAV is being reported in the Roma community there. Montana's location can be seen on a map at <https://en.wikipedia.org/wiki/Montana,_Bulgaria>. Since most ca es of
HAV in children are unrecognized, being either asymptomatic or anicteric (without jaundice), the total number of cases are likely to be much higher. - ProMED Mod.LL]

[A HealthMap/ProMED-mail map can be accessed at:
Date: Thu 23 Nov 2017 10:13
Source: Sofia News Agency [edited]

There is a boom of infected patients with hepatitis A in Rakovski. There are sick children in several schools and kindergartens. The 1st diseases have been since the beginning of September 2017. Everyone has gone through the infectious clinic in Plovdiv, say the city's health
inspection.

"This is an infection that is transmitted by faecal-oral route and the problem is that the incubation period of the disease is quite long -- up to 45 days, a person is infectious before he becomes yellow," health inspectors warn.

In the Roma neighbourhood of Rakovski, almost every house has a hepatitis A sufferer. Residents of the neighbourhood admit they do not know how to protect themselves. There are a total of 35 reported cases of infected children at Hristo Smirnenski School in Rakovski. Parents of students are worried and threaten to stop their children from school if no action is taken.
****************************
Date: Fri 24 Nov 2017 15:30
Source: Focus News Agency [edited]

>From the beginning of July 2017 to the end of October 2017, there have been 2 outbreaks of type A viral hepatitis with a total of 144 cases in the municipality of Rakovski, said minister of health Kiril Ananiev during [Fri's 24 Nov 2017] parliamentary control session, FOCUS News Agency reports.

"The 1st outbreak started on [Sun 23 Jul 2017] and included a total of 50 cases from the villages of Belozem, Shishmantsi and Chalakovi. The infection was transmitted from the village of Milevo, where in April 2017, 16 cases were reported. The 2nd outbreak was reported on [Wed 16 Aug 2017], and up to now there have been 62 cases in the town of Rakovski. In addition, in the village of Katunutza, Sadovo municipality, from [Fri 18 Aug 2017] to date, a total of 32 cases have been reported. Out of a total of 144 cases from Rakovski and Sadovo, 105 or 72.9 per cent are children under 15 with mild symptoms.

Since the beginning of 2017, 568 cases of viral hepatitis A have been reported in the region of Plovdiv. The infection was caused by inadequate sanitation and poor personal hygiene, not by unsafe water or food," the minister said.
==================
[The source in this outbreaks is unclear but appears related to general defects in poor sanitary conditions. Hepatitis A infection in children is primarily asymptomatic or anicteric (without jaundice). With a spate of children recognized with the acute infection, it is certainly likely that many more cases will have occurred. - ProMed Mod.LL]

[A HealthMap/ProMED-mail map can be accessed at:
Date: Thu, 7 Sep 2017 16:05:20 +0200

Sofia, Sept 7, 2017 (AFP) - Other European holiday spots may be getting fed up with tourists, but not Bulgaria, where the government is sending thank-you postcards to some of the record numbers of visitors to the country this year.   The "Thank you for choosing Bulgaria!" cards, showing the Thracian tomb in Kazanlak or the Rila Monastery, will be sent to 400,000 tourists chosen randomly from the five million who visited as of July 31.

Tourism Minister Nikolina Angelkova said on her ministry's website that the cards would be personally signed by her as a sign of her "gratitude". The addresses were obtained from hotels.   Bulgaria is a cheap winter and summer holiday hotspot bordering Greece and the Black Sea, and tourism accounts for 13 percent of its economic output.   The country, the European Union's poorest member, posted a 7.2 percent rise in visitors through July 31.
More ...

World Travel News Headlines

Date: Wed, 22 May 2019 16:52:39 +0200
By Nazeer al-Khatib with Hashem Osseiran in Beirut

Maaret al-Numan, Syria, May 22, 2019 (AFP) - Syrian government air strikes killed 18 civilians, including a dozen people at a busy market, as fierce fighting raged for the jihadist-held northwest, a war monitor said on Wednesday.   Regime forces battled to repel a jihadist counteroffensive around the town of Kafr Nabuda that has left 70 combatants dead in 24 hours, the Syrian Observatory for Human Rights said.   The Hayat Tahrir al-Sham alliance, led by Syria's former Al-Qaeda affiliate, controls a large part of Idlib province as well as adjacent slivers of Aleppo, Hama and Latakia provinces.   The jihadist-dominated region is nominally protected by a buffer zone deal, but the government and its ally Russia have escalated their bombardment in recent weeks, seizing several towns on its southern flank.   At least 12 people were killed and another 18 wounded when regime warplanes hit the jihadist-held Idlib province town of Maarat al-Numan around midnight (2100 GMT) on Tuesday, the Observatory said.

The market was crowded with people out and about after breaking the daytime fast observed by Muslims during the holy month of Ramadan.   The bombardment blew in the facades of surrounding buildings, and ripped through the flimsy frames and canvas of stalls in the market square, an AFP photographer reported.    The bodies of market-goers were torn apart.   "Residents are still scared," stallholder Khaled Ahmad told AFP.   Three more civilians were killed on Wednesday by air strikes in the nearby town of Saraqib, the Observatory said.    Two others were killed in strikes on the town of Maaret Hermeh, it added.    Another civilian was killed in air raids on the town of Jisr al-Shughur, the monitor said.   The Britain-based Observatory relies on a network of sources inside Syria and says it determines whose planes carried out strikes according to type, location, flight patterns and munitions.

- 'Worst fears'-
The strikes came as heavy clashes raged in neighbouring Hama province after the jihadists launched a counterattack on Tuesday.   Fresh fighting on Wednesday took the death toll to 70 -- 36 regime forces and militia and 34 jihadists, the Observatory said.   It said the jihadists had recaptured most of Kafr Nabuda from government forces, who had taken control of the town on May 8.   State news agency SANA on Wednesday however said the army repelled a jihadist attack in the area, killing dozens of insurgents.

Russia and rebel ally Turkey inked the buffer zone deal in September to avert a government offensive on the region and protect its three million residents.   But President Bashar al-Assad's government upped its bombardment of the region after HTS took control in January.   Russia too has stepped up its air strikes in recent weeks.   The Observatory says nearly 200 civilians have been killed in the flare-up since April 30.   The United Nations said Wednesday that Idlib's civilian population once again faced the threat of an all-out offensive.   "A full military incursion threatens to trigger a humanitarian catastrophe for over 3 million civilians caught in the crossfire, as well as overwhelm our ability to respond," said David Swanson, a spokesman for the UN humanitarian office.   Swanson said more than 200,000 people have been displaced by the upsurge of violence since April 28.   A total of 20 health facilities have been hit by the escalation -- 19 of which remain out of service, Swanson said.   Collectively they served at least 200,000 people, he added.

- 'Break the status quo' -
The September deal was never fully implemented as jihadists refused to withdraw from a planned buffer zone around the Idlib region.   But it ushered in a relative drop in violence until earlier this year, with Turkish troops deploying to observation points around the region.   The Syrian government has accused Turkey of failing to secure implementation of the truce deal by the jihadists.   But Turkish Defence Minister Hulusi Akar accused the Syrian regime late Tuesday of threatening the ceasefire deal.   "The regime is doing all that it can to break the status quo including using barrel bombs, land and air offensives," Akar told reporters.   "Turkish armed forces will not take a step back from wherever they may be", he however added.   Earlier, the US State Department said it was assessing indications that the government had used chemical weapons on Sunday during its offensive in Idlib.   HTS accused government forces of launching a chlorine gas attack on its fighters in the northern mountains of Latakia.   But the Observatory said Wednesday it had "no proof at all of the attack".
Date: Wed, 22 May 2019 02:06:35 +0200
By Amelie BARON

Port-au-Prince, May 22, 2019 (AFP) - With no oxygen in intensive care or gloves in the emergency room, residents at Haiti's largest hospital have gone on strike to protest the filthy environment and demand six months of back pay.   "We have almost nothing when we talk about emergency services," said Emmanuel Desrosiers, 24, one of the doctors-in-training at the State University of Haiti Hospital (HUEH) that began the work stoppage Monday.    "When a patient arrives, when we should immediately take charge, we start by listing the things they or their family need to go buy."   The HUEH, known as the "general hospital," is where the most disadvantaged families in this impoverished Caribbean country crowd. Buying the medical supplies themselves is a financial headache, but private clinics are far too expensive.   In crumbling buildings in the center of Port-au-Prince, male and female patients are crowded together in tiny rooms, while trash cans overflow.   "We feel ridiculous when we give hygienic advice to patients," one resident said of the situation.

The residents' selflessness as they work in an unsanitary environment is compounded by the fact that they have not been paid since the start of their residency, nearly six months ago.   After five years of medical studies, the state is required to pay them 9,000 Haitian gourdes (HTG) per month -- only about $100, due to the devaluation of the national currency.   Nothing is being done about the hospital's disrepair, with those in charge waiting for a new building to be completed, according to resident Yveline Michel.   The new HUEH will have two floors and more than 530 beds once it's finished -- but it's unclear when that will be.   The project began after the January 2010 earthquake, which destroyed more than half the hospital. The United States, France and Haiti invested $83 million in a new hospital, which should have been completed by 2016.   Instead, there is little visible activity on the construction site, which can be seen through the windows of the current building.

Due to the heat, the windows are always open, letting in noise and dust from the street. There are only a few fans in the hospital rooms, which do little to combat the humidity or the flies.   "At any moment we could lose patients, but the state isn't doing anything to save their lives," said Michel, 25.   "We're striking for the population, since it should make these demands."   But some locals question the residents' position because the strike prevents the already struggling hospital from functioning.   Since the strike began, the poorest families in the area no longer know where to go for medical emergencies, as the residents are in charge of admitting patients.   "Due to the lack of resources and the unsanitary environment, there are always people dying in the hospital, so it's not the strike causing that," said Michel in response.
Date: Tue 21 May 2019
Source: Le Dauphin [in French, trans., edited]

Lovers of sushi, maki, sashimi, and other raw fish, beware of your stomach! 7 cases of fish tapeworm, better known as tapeworm [ProMED presumes it is Diphyllobothrium latum], have been reported in 2 years by the Rennes hospital in Ille-et-Vilaine [Brittany].

An exceptional number of cases was counted between July 2016 and September 2018, especially since no case had been detected for at least 20 years.

The infection is acquired by "eating raw or marinated fish which contains larvae of this parasite. The larvae will undergo several moults and develop in our digestive tract," explained Professor Florence Robert-Gangneux to our colleagues in France Bleu Armorique.

The parasite can measure up to 20 meters [66 ft] long and live 10 years in the body. The fish tapeworm can cause digestive disorders, deficiencies, although some patients do not notice.

The only solution to eliminate these parasites of the fish is freezing. This is what a 2004 European regulation imposes on restaurant owners serving raw fish. Freezing should be from -20 deg C [-4 deg F] during 24 hours or -35 deg C [-31 deg F] during 15 hours. And to get rid of the worm once ingested, it is necessary to undergo an unpleasant antiparasitic treatment, often on several occasions.
=====================
[We presume it is the fish tapeworm _Diphyllobothrium latum_, which is a tapeworm found in freshwater fish (<https://www.cdc.gov/parasites/diphyllobothrium/index.html>). In saltwater fish the most common parasite is _Anisakis_, but this is not a tapeworm. - ProMED Mod.EP]

[HealthMap/ProMED-mail map of France:
Date: Mon 20 May 2019
Source: El Pais [in Spanish, trans. Mod.TY, edited]

Tarija Departmental Health Services (SEDES) reported a new case of hantavirus [infection] in Padcaya municipality. The number of patients with this illness is within what is expected, because this season is when more people acquire the disease. Epidemiological surveillance is continuing in Arce province. The person who acquired this illness is male and is under medical care until his recuperation.

The head of the Epidemiological Unit of SEDES, Claudia Montenegro, stated that the patient is hospitalized in the San Juan de Dios Regional Hospital in Tarija awaiting his recuperation. The physician said that in Bermejo and Padcaya municipalities, the harvest of citrus fruit and sugar cane for production of sugar has begun, so there is a trend for the cases of this illness to increase. This is due to the large number of families that move to the countryside where the rodent (long tail) is present that transmits this disease [virus].

"In contrast to previous seasons, this year [2019], there were positives for this disease in Gran Chaco province, including fatalities," Montenegro commented. "Epidemiological surveillance there is being implemented, as well as in areas such as Padcaya and Bermejo."

The official explained that in these localities, the rodent that transmits the disease [virus] to families is present, and with agricultural activities, [people] move into places where this animal lives, and so new cases of patients with hantavirus [infections] are registered every year.

In order to prevent this illness, it is recommended that rodent control campaigns be done to reduce their populations, openings in houses be sealed, and that residents reduce the possibility for rodents to make nests within a radius of 30 meters [100 ft] around the house, and eliminate items that could attract these animals near the house (food, grain, garbage). Workers should employ protective measures during agricultural tasks and cleaning work.

Initial symptoms include fatigue, fever and muscle pain, especially in the thighs, hips and back. Also, patients may present with headache, dizziness, chills, nausea, vomiting, diarrhea and abdominal pain. [These symptoms may progress rapidly to respiratory difficulty requiring mechanical ventilation (hantavirus cardio pulmonary syndrome). Death can occur. - ProMED Mod.TY]
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[The hantavirus involved in the above cases is not mentioned. Cases of hantavirus infections in Tarija department are not new. Tarija department is endemic for hantaviruses, and cases occur there sporadically. Last year (2018), there were 11 cases. The previouslyreported 2015 cases of hantavirus pulmonary syndrome (HPS) that occurred in Tarija department were confirmed. As noted in the previous comments, earlier cases of hantavirus pulmonary syndrome have been reported from tropical, lowland areas of Bolivia, including 7 cases in Tarija during 2014. The specific hantaviruses involved in these or previous cases in Bolivia were not given.

In the lowland Amazon Basin of Bolivia, the rodent hosts of the hantavirus that might be involved in these hantavirus pulmonary syndrome (HPS) cases, with their images, include the following: - Laguna Negra virus (_Calomys laucha_ <http://www.faunaparaguay.com/images/Calomys%20laucha%20enciso%2031aug2011.jpg> and _C. callosus_ <https://eee.uci.edu/clients/bjbecker/PlaguesandPeople/Calomyscallosusb.jpg>); - Bermejo (Chaco rice rat _Oligoryzomys chacoensis_ <http://www.faunaparaguay.com/oligorizomyschacoensis.html>); and - Oran (_O. longicaudatus_ <http://calphotos.berkeley.edu/imgs/512x768/0000_0000/0711/1203.jpeg>).

Since previous cases in Tarija department have occurred in Bermejo, perhaps Bermejo hantavirus was involved.

Dr. Jan Clement commented that there is a need to be able to differentiate Seoul (SEOV) as a causative agent, but that is hampered by the fact that most current commercial ELISA or WB formats do not contain (anymore) a SEOV antigen, so that a preliminary presumption of a hantavirus infection can even be missed in non-research laboratories (ibidem, and: Reynes J-M, Carli D, Bour J-B, Boudjeltia S, Dewilde A, Gerbier G, et al. Seoul virus infection in humans, France, 2014-2016. Emerg Infect Dis. 2017;23:973-7;  <https://wwwnc.cdc.gov/eid/article/23/6/16-0927_article>.

SEOV is widely distributed around the world in the brown rat and is likely found in Tarija department. - ProMED Mod.TY]

[HealthMap/ProMED map available at:
Tarija, Tarija, Bolivia: <http://healthmap.org/promed/p/12643>]
Date: Tue 21 May 2019
Source: ZBC (Zimbabwe Broadcasting Corporation) [edited]

The Zambezi Parks & Wildlife Management Authority (Zimparks) says it has managed to contain the anthrax outbreak in the Zambezi Valley which claimed 6 elephants, 3 buffalo, a lion and an impala. Zimparks, which has been working together with other stakeholders following the outbreak of anthrax in Zambezi Valley, confirmed that the infectious disease has now been brought under control.

Zimparks Public Relations Manager, Mr. Tinashe Farawo said the authority is pleased to have contained the disease, adding that measures are being put in place to strengthen surveillance mechanisms. "We can confirm that we have managed to contain the anthrax diseases in the Zambezi Valley thanks to efforts by our officers and support from private stakeholders," said Mr. Tinashe Farawo.

The disease killed a number of hippos in Binga last year [2018]. Anthrax is usually transmitted by feed and water contaminated with spores, which can lie dormant in the soil for many years. The primary sign of anthrax in grazing animals is sudden death, often with bloody discharges.
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[So far so good, but I must point out that nature is illiterate and does not read the announcements of senior bureaucrats. She does what she does. Hopefully Mr. Farawo is correct but we should wait a couple of weeks at full alert.

Maps of Zimbabwe can be seen at

For a description of Hwange national park, go to
<https://en.wikipedia.org/wiki/Hwange_National_Park>.

Hwange is in the western part of the country bordering Botswana and Zambia
(<https://en.wikipedia.org/wiki/Hwange>). - ProMED Mod.MHJ]

[HealthMap/ProMED map available at:
Matabeleland North Province, Zimbabwe:
Date: Mon 20 May 2019, 2:49 PM
Source: KDKA [edited]

Pennsylvania's Secretary of Health, Dr. Rachel Levine has announced that the state has declared a hepatitis A outbreak with 171 cases in 36 counties. According to the map provided by the Department of Health, Allegheny and Philadelphia counties are hit the hardest with anywhere between 31-50 cases.

The counties hit hardest by this outbreak are Philadelphia and Allegheny, but we have seen an increase of cases throughout much of the state," Dr. Levine said. "We are taking this action now to be proactive in our response to treating Pennsylvanians suffering from this illnesses and prevent it from spreading. The best way to prevent hepatitis A is through vaccination."
=======================
[Pennsylvania is the latest (now almost half of the states in the USA) to declare a hepatitis A outbreak. As the numbers of cases continue to rise in a number of states, and news of smaller (so far) outbreaks occur in others, the question at the end of ProMED post http://promedmail.org/post/20190104.6241686 by a Kentucky official, "This is a disease of developing countries.

One has to ask: Why are we seeing it in the USA?" is more and more relevant. We are seeing these outbreaks because of the inability to deal with marginalized populations among their midst. The dramatic cutbacks in public health infrastructure in some of these states clearly feed the fire of these outbreaks. They must be addressed by bolstering public health resources and education and directly addressing the needs of these marginalized populations. - ProMED Mod.LL]

[HealthMap/ProMED map available at:
Pennsylvania, United States: <http://healthmap.org/promed/p/240>]
Date: Thu 16 May 2019
Source: AllAfrica, The Guardian report edited

A serving medical doctor has been infected with Lassa fever while 2 persons were confirmed dead in Kebbi state. Another medical doctor disclosed this yesterday [15 May 2019] when The Guardian visited the Federal Medical Centre (FMC), Birnin Kebbi. He said that 2 children died last week [week of 6 May 2019] as a result of the Lassa fever while a medical doctor, who was doing his primary assignment treating the patients, was also infected.

"You see, the management of the FMC has opened a special unit called isolated unit for the Lassa fever patients. We still have some patients inside. Also, a medical doctor, who was managing some patients last month [April 2019], has also been infected and he is presently on admission," he said.

Meanwhile, the state's Commissioner for Health, Alhaji Umar Kambaza, who confirmed the incident, said they were aware of the cases in the state but the government is working towards them.  [Byline: Michael Egbejule, Ahmadu Baba Idris]
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[The dates of occurrence of these cases is not given. Presumably, they were hospitalized after 12 May 2019 when the Nigeria CDC update was issued. It is indeed unfortunate that an attending physician became infected in the hospital. Nosocomial infections are not unusual when personal protective equipment and barrier nursing measures are not employed. - ProMED Mod.TY]
Date: Sun 19 May 2019
Source: Vax Before Travel [abridged, edited]

The eastern African country of Ethiopia has been reporting measles outbreaks for many years, however, in 2019, new information indicates children are the ones most vulnerable for this infectious disease.

According to reporting by the European Commission, approximately 54% of the 4000 measles cases in Ethiopia reported during 2019 affected children under 5 years of age.

Moreover, over 60% of the children had never received their 1st measles vaccine dose.

This new data estimates that by the end of 2019, about 3.5 million children will be susceptible to the measles virus, mainly because of the failure to achieve the 'herd-immunity' necessary to interrupt transmission.

Moreover, these Ethiopian children are not the only under-vaccinated population.

An estimated 169 million children missed out on the 1st dose of the measles vaccine between 2010 and 2017, or 21.1 million children a year on average, said UNICEF on 25 Apr 2019.

And, the measles virus is one of the leading causes of death among children, particularly in developing countries. An estimated 100,000 measles deaths occurred globally in 2017.

Ethiopia announced it would aggressively confront this under-vaccination issue by integrating the measles vaccine 2nd dose (MCV2) vaccination into the routine immunization program in the 2nd year of life.

The Ethiopian Ministry of Health said about 3 348 363 children will receive measles vaccine 2nd doses.

Dr Chatora Rufaro, World Health Organization (WHO) Ethiopia representative said in a press release, "The introduction of the 2nd dose of measles vaccination in Ethiopia will significantly contribute to a reduction of measles morbidity and mortality as well as the overall child mortality by preventing measles outbreaks."

To notify visitors about Ethiopia's ongoing measles risks, the CDC issued an initial Level 1 Travel Alert in 2015. Since then, the CDC advises all visitors to Ethiopia to ensure they are immunized against the measles virus.  [Byline: Don Ward Hackett]
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[HealthMap/ProMED-mail map of Ethiopia:
Date: Mon 20 May 2019 08:47 IST
Source: The Hindu [abridged, edited]

The current global resurgence in measles is having its resonance in Kerala too, which has been witnessing a serious surge in the disease since January [2019].

Across the globe, huge local outbreaks have been caused by travel as well as the increase in unvaccinated populations.

In Kerala, however, the majority of the cases are reported from Thiruvananthapuram, which has good vaccination coverage and amongst people who are well-nourished and have received at least one dose of vaccine in their lifetime.

Kerala reports around 600 plus cases of measles every year. This year [2019], as many cases have been reported in the first 4 months itself, with over 50% cases in the 19-40 year age group. There are also cases in the less than 9 months age group, but fewer cases than before in the 1-5 years group.

Immunisation
------------
"When universal routine immunisation in childhood improves and the virus is still in circulation, the disease will naturally move to the older age group who may be unimmunised or whose vaccine-derived immunity has begun to wane. At a time when the state is moving towards measles elimination, adult measles is a major concern," a senior health official said.

Historically, measles has been a childhood disease. The epidemiological shift to older population presents new public health challenges because of the increased severity of the disease, especially in vulnerable populations like pregnant women and immunocompromised patients (HIV, organ transplant recipients on immunosuppressants, cancer patients), who cannot be vaccinated with the live attenuated measles vaccine.

"Earlier, nearly 90% of measles cases could be managed on out-patient basis. This year [2019], most cases are in the 19-35 age group and over 60% of the cases had to be admitted as in-patients, with a good percentage requiring ICU management," said R Aravind, head of infectious diseases at Thiruvananthapuram Medical College.

The changing epidemiology of measles has not just brought forth the several unknowns but also raised important questions on whether adult immunisation should be a policy, on vaccine potency and the adequacy of vaccine immune response.

Though measles vaccine is highly immunogenic, as part of the national measles elimination strategy, a mandatory 2nd dose at 15-18 months was introduced in 2010, so that there is better immune protection. It is fairly certain that those currently in the 18-40 years age group have not had the protection of the 2nd dose and may be one reason for the increase in cases in this age group.

The 1st vaccination age for measles has been fixed at 9 months because till then, the maternal antibodies transferred in utero are supposed to afford protection to the child. If vaccinated earlier, the maternal antibodies might interfere with the immune response to vaccine.

Susceptible
-----------
However, at Rajiv Gandhi Centre for Biotechnology, the director, M Radhakrishna Pillai and team, who are currently studying the efficacy of measles vaccination in South India, have reported that children under the recommended vaccination age of 9 months are highly susceptible to measles.

SAT Hospital too has recently reported the death of an infant younger than 9 months due to measles.

"If the young mothers of the day do not have sufficient antibody protection, how do we protect infants younger than 9 months against measles? Given measles' age shift to older age group, should we move the vaccination age to 12 months for better vaccine response?

"Is a 3rd dose of MMR (mumps-measles-rubella) necessary? And should we recommend that all adults be given a dose of MMR as the virus is still in circulation? These questions need to be looked at from a research perspective by the State/National Technical Advisory Group on Immunisation," a public health expert said.  [Byline: C Maya]
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[HealthMap/ProMED-mail map of Kerala State, India:
Date: Fri 17 May 2019
Source: The Government of Hong Kong Special Administrative Region, press release [abridged, edited]

The Centre for Health Protection (CHP) of the Department of Health (DH) said today (17 May 20-19) that no additional case of measles infection had been recorded as at 4pm today and announced that the outbreak of measles infection at Hong Kong International Airport earlier has concluded.

A spokesman for the CHP said, "A total of 73 cases of measles infection were recorded so far this year [2019], among them 29 cases were associated with the outbreak among airport workers.

Regarding measles control measures implemented at the airport, a total of 23 persons had received measles vaccination at the airport vaccination station as at 6pm today [17 May 2019], bringing the cumulative number of vaccinations given to 8501 since 22 Mar 2019. The airport vaccination station will cease operation from [18 May 2019].

As for the blood test service, the DH earlier provided the measles serology test service to airport staff. A cumulative total of 777 blood samples have been collected. For the pilot service to provide measles serology testing for Filipino foreign domestic helpers working in Hong Kong, a total of 146 blood samples have been collected to date. Participants are notified individually of the serology results.
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[HealthMap/ProMED-mail map of Hong Kong: