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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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Brazil

General

 Brazil is the largest country in South America and extends from the Atlantic Ocean to the Caribbean to the depths of the Amazon basin. The climate varies throughout the country but generally it experiences a humid

tropical climate.

Safety & Security

The level of crime in many of the main urban centres is certainly rising and tourists need to be aware of the risks involved in travelling particularly in the evening hours. It is wise to use an official taxi for any journeys after dark. It is sensible not to flaunt any personal wealth and to use the hotel safety boxes for any valuables and your travel documents. The amount of crime against tourists tends to be greater in areas surrounding hotels, discotheques, bars, nightclubs and other similar establishments that cater to visitors, especially at dusk and during the evening hours. There are frequent reports of theft on city buses and such transportation should be avoided. A number of the main cities have established specialised tourist police units to patrol areas frequented by tourists. Rio de Janeiro, Sao Paulo and Brasilia all continue to experience a high incidence of crime.

Road Safety

Throughout this huge country the state of the roads varies greatly. In many regions the roads are dirt tracks and assistance would be hard to obtain for those travelling off from the main tourists routes. Bag snatching from traffic lights occurs in the main cities. If considering hiring a car make certain that your travel insurance is sufficient.

Jet Lag

After your flight you will experience a degree of jet lag. Travelling from Europe this will be less than when you travel home but nevertheless it will still cause your body to complain for 24 to 48 hours. Try to have a more relaxing time for the first few days (and also after returning home if possible!). Be careful not to fall asleep by the pool and then awaken with sunburn which could ruin your time abroad.

Medical Facilities

In any country of this size the level of medical care will vary greatly. This is particular true out side the main tourist resorts. English speaking doctors should be available but the level of hospital care can be worrisome. Make certain you carry sufficient supplies of any medication you may require for your entire holiday. Essential drugs (asthma, diabetes, epilepsy etc) should be divided for security.

Sun Exposure and Dehydration

The hot humid tropical climate often leads to quite significant problems for the Irish traveller. Make sure you cover your head when out in the sunlight and drink plenty of fluids to replenish that lost through perspiration. Replace the salt you loose by eating crisps etc orby putting salt on your meal (providing there is no contraindication).

Visiting the Iguassu Falls

These huge waterfalls border Argentina, Brazil and Paraguay. There is only minimal risk of malaria and so malaria prophylaxis is not generally recommended. Also, Yellow fever is not transmitted in this area but mosquitoes can abound. Sensible insect bite precautions should be followed at all times.

Food & Water

Many tourists who visit Brazil stay in the main resorts along the southern coast. The food and water preparation in the hotels is normally excellent but eating food from street vendors is generally unwise. Shell fish (bivalve oysters, mussels, clams etc) are unwise even in a five star hotel. Check the water from the cold water tap in your room. If you can’t easily smell chlorine (swimming pool style) don’t use it even for brushing your teeth. If travelling around the country (Caribbean coast or into the Amazon regions) take significantly more care.

Rabies 

This viral disease occurs throughout Brazil and it is usually transmitted through the bite from an infected warm-blooded animal (eg dogs, cats & monkeys). Any contact should be avoided but if it occurs treat it very seriously and seek competent medical attention immediately after you wash out the area and apply an antiseptic.

Malaria

The risk of malaria is significant all year throughout the Amazon regions. There is insignificant risk for those staying along the coast up as far as Fortaleza and for those remaining in this region prophylaxis is not usually recommended. The risk in the region of Brasilia is also thought to be minimal though this is an area which has unusually experience an outbreak of Yellow Fever recently, and so the situation will require review.

Mosquito Borne Diseases  Apart from malaria the other two main diseases transmitted by mosquitoes which cause problems in Brazil are Dengue Fever (mainly along Caribbean Coast but has been reported much further south) and Yellow Fever (mainly in the Amazon Basin but thought to be spreading to other regions). Avoidance techniques are important at all times throughout the day. Swimming **************************************** Most of the main tourist swimming pools will be well maintained and the smell of chlorine will be evident. If sea swimming is on your agenda make sure you go where there are plenty of others and never swim alone. Look for warning signs and pay attention to local advice. Be very careful of local currents which can be dangerous. Vaccinations **************************************** The Brazilian Embassy is advising all travellers to Brazil to have vaccination cover against Yellow Fever. Also for your personal protection it is wise to consider some further vaccines. Generally we would recommend the following vaccination cover; * Yellow Fever (mosquito borne) * Tetanus (childhood booster) * Typhoid (food & water borne) * Hepatitis A (food & water borne) For those travelling more extensively or staying in the country for longer periods we would usually suggest that further vaccines are considered including Hepatitis B, Meningitis and Rabies. Summary **************************************** Many travellers to Brazil will remain perfectly healthy and well providing they follow some sensible precautions. Further information is available from either of our centres regarding any recent disease outbreaks.

Travel News Headlines WORLD NEWS

Date: Wed, 10 Apr 2019 18:49:48 +0200

Rio de Janeiro, April 10, 2019 (AFP) - Residents of a hillside Rio de Janeiro favela risk finding hungry caimans at their front door after the city was hit hard by heavy flooding caused by torrential rain.   The cold-blooded creatures -- smaller relatives of alligators -- belong to
a resident of the Rolas favela in western Rio, and escaped on Tuesday when a wall holding them in burst when struck by a flash flood.

An animal control team has been mobilized to re-capture the reptiles, the Rio environmental services office told AFP.   How many were on the loose? Officials did not say.   The team faces a risky task: not only must they be wary of the aggressive animals, but they must navigate streets knee-deep in water or slick with mud, dodging uprooted trees and loose power lines like the one that electrocuted a man to death near where the caimans escaped from.   They also face more mundane dangers, such as being shot, knifed, mugged or kidnapped in the high-crime favela.

As of Wednesday the team had been unable to enter the favela "due to the strong presence of drug traffickers," city officials said.   "I saw the wall collapse and two people have already seen caimans at their front door," a local resident wrote on social media.   The unusually heavy rain, which began late Monday and continued into Tuesday, has killed at least 10 people, officials said.   The rain triggered flash flooding that turned some streets into raging rivers, uprooting trees and sweeping away vehicles.   Heavy runoff from neighbouring hills gushed through some apartment buildings and shops, leaving behind mud and debris.
Date: Sat 6 Apr 2019
Source: Globo.com [in Portuguese, machine trans. edited]

In the Northern Region of Rio Grande do Sul, the death of cattle has worried producers. At least 50 animals have died this year [2019] on 15 properties with signs of rabies. [This appears to be a large outbreak and needs some serious support from the local and state governments. - ProMED Mod.TG]

In the town of Soledade, Adriano Borges Knopf lost 4 animals in less than 15 days. "We started to suspect it was not a normal thing. We noticed the animals lost their legs [weakness in legs] and did not get up any more," said the farmer.

A sample [from the animal necropsy, and the laboratory] report found Adrian's cattle had herbivore rabies, a disease caused by a virus transmitted by bats. [Cattle are herbivores, and consequently in some areas it is called herbivore rabies, but this virus could equally affect people, or dogs or horses. - ProMED Mod.TG]

Four other cattle belonging to the producer Luiz Carlos dos Santos also died because of the problem. "It's their milk we live on. We were even planning to improve this year [2019]," he lamented about the losses in production.

The challenge now is to control the transmission of the disease affecting these cattle. Most of the animals that died were attended by the veterinarian Bolivar Camargo, who is part of a cooperative in the region. "There are people who had 10 lactating cows and ended up losing 7, so their profitability ends, right?" he pointed out.

Last week, a bat was found near one of the affected properties. Technicians from the State Department of Agriculture are doing a survey to try to identify the source of these infections.  In addition to injury, producers are also concerned about the transmission of rabies to humans. The disease, however, is not transmitted by the consumption of milk or meat.  "They [the people] should be vaccinated if they have a very high risk, if they have suffered a bite from an animal, or had very intimate contact with an animal showing clinical signs of rabies," explained veterinarian Isadora Correa.

She added: "[The vaccine] is not available to the entire population, nor would it be the case, because the risk of transmission of herbivore rabies from a bovine to a human being is fairly low."
======================
[Most likely, the bats responsible for transmitting the rabies virus are vampire bats. While these bats can and do move around, deforestation seems to upset them, causing them to move to areas where there previously has not been a problem.

Vampire bats are distributed in tropical areas of the western hemisphere from Argentina to Mexico and have been responsible for transmitting rabies virus, most frequently to cattle and equine animals, and, infrequently, to humans [by bite]. Of the 3 vampire bat species, _Desmodus rotundus_ is by far the most common rabies virus transmitter.

There are 2 options for rabies control in these situations:
vaccination of animals upon which the vampire bats feed, or reduction of the vampire bat populations, or perhaps a 3rd option would be a combination of the 2 approaches. Eliminating vampire bat hosts is the fastest and most effective approach when vampire bat-transmitted rabies appears in an area. In areas where repeated vampire bat-transmitted rabies occurs, control of these bats has been employed in some countries. Controlling vampire bats by eliminating their roosts is extremely difficult because these roosts can be hard to find. Effective vampire bat control has been accomplished by capturing bats in mist nets when they come to feed on livestock and applying anticoagulant jelly (warfarin and similar products), which they and their roost-mates ingest on grooming.

As animals can be vaccinated, it would prudent to do so immediately, as there is approximately 2 weeks from vaccination of the cattle until they are capable of mounting an immune response. In addition to vaccination, the suggestion of netting the bats and using anticoagulant jelly is perhaps equally as important. So, employing additional methods instead of only one method, would be the most prudent approach to a more rapid control of this disease from these bats.

The loss of these animals to these families is huge, and this is a large outbreak needing immediate containment. Perhaps the government could send out some vaccine and additional people to help vaccinate animals and to net and coat the bats with anticoagulant jelly. Coating the bats means handling the bats, minimally, and gloves should be worn. Likewise, any bite or scratch should receive immediate medical attention and post exposure prophylaxis rabies vaccine for the individual(s) affected.

References
----------
1. Brass DA. Rabies in bats: natural history and public health implications. Ridgefield CN: Livia Press, 1994. 335 pp.
2. Greenhall AM: Feeding behavior. In: AM Greenhall and U Schmidt, editors. Natural history of vampire bats. Boca Raton, FL: CRC Press, 1988. 111:31. - Mod.TG

HealthMap/ProMED map available at:
Rio Grande do Sul, Brazil: <http://healthmap.org/promed/p/3419>]
Friday 5th April 2019
http://www.hpsc.ie/a-z/vectorborne/yellowfever

Brazil is currently in the seasonal period for yellow fever, which occurs between December and May. The expansion of the historical area of YF transmission to areas previously considered risk-free led to two prior waves of transmission one during the 2016-2017 seasonal period, with 778 human cases, including 262 deaths, and another during the 2017-2018 seasonal period, with 1,376 human cases, including 483 deaths.  Human cases reported so far during the current 2018-2019 period, (July 2018 to March 2019) in in São Paolo State, as well as the confirmation of a human case and epizootics due to yellow fever in the states  of Paraná, and Santa Catarina mark the beginning of what could be a third wave and a progression of the outbreak towards the Southeast and South regions of the country.

From December 2018 through March 2019, 75 confirmed human cases, including 17 deaths, have been reported in the states of São Paulo (62 cases), Paraná (12 cases), and Santa Catarina (1 case). Among these confirmed cases, 88% are male, the median age is 43 years, and 71% are rural workers. Between 1 July 2018 and 18 March 2019, 33 confirmed epizootics were reported, in five federal entities: São Paulo (20), Rio de Janeiro (8), Minas Gerais (1), Mato Grosso (2), and Parana (2). In the last 4 weeks epizootics have been confirmed in São Paulo and Parana states.

Given the gradual geographical expansion of the epizootic wave that Brazil has faced during the last two seasonal periods, the country has had to adjust its immunization policies for yellow fever. The number of areas with recommended vaccination has increased from 3,526 municipalities in 2010 to 4,469 municipalities in 2018.

In line with the World Health Organization guidelines, Brazil has adopted a single dose vaccination scheme for yellow fever since April 2017. The use of fractional doses to respond to outbreaks and the risk of urbanization of yellow fever, especially in large cities, was also adopted. This strategy was implemented in 77 municipalities with the greatest risk for yellow fever in the states of São Paulo (54 municipalities), Rio de Janeiro (15 municipalities), and Bahía (8 municipalities). As of epidemiological week (EW) 39 of 2018 (23-29 September), preliminary results of the mass vaccination campaign against yellow fever indicate that 13.2 million people were vaccinated. With respect to the accumulated doses and doses administered during the campaign, a total of 13.3 million people in São Paulo, 6.5 million people in Rio de Janeiro, and 1.85 million in Bahía states were vaccinated, which represent vaccination coverage of 53.62%, 55.60% and 55.03%, respectively.

WHO risk assessment

Further transmission is expected in the coming months based on seasonal patterns. Recent human cases of YF during the current seasonal cycle have been reported in São Paulo, Paraná, and Santa Catarina states in Southeast Brazil.

The preliminary results of the vaccination coverages in municipalities from Paraná, Rio Grande do Sul, São Paulo, and Santa Catarina states suggests a high proportion of persons remaining at-risk and the necessity to intensify risk communications among high-risk groups.

The geographical distribution of human cases and epizootics from the current and previous two seasonal cycles suggests southward movement of the virus, which presents further risk to the states of Paraná, Rio Grande do Sul, and Santa Catarina. Furthermore, these areas have ecosystems favourable for yellow fever transmission and borders with other countries such as Argentina, Paraguay, and Uruguay.

During the previous season cycle, human yellow fever cases were reported among travellers, though to date, most imported cases have been reported in countries where the vector are absent (or absent during winter). These reports illustrate the importance of maintaining high levels of awareness, especially for international travellers from areas with favourable ecosystems for yellow fever transmission.

To date, yellow fever transmission by Aedes aegypti has not been documented. More recently, an investigation conducted by the Evandro Chagas Institute reported by the Brazil Ministry of Health revealed the detection of yellow fever virus in Aedes albopictusmosquitoes captured in rural areas of 2 municipalities in Minas Gerais (Ituêta and Alvarenga) in 2017. The significance of this finding requires further investigation. The last documented outbreak of urban yellow fever in Brazil was recorded in 1942. The sylvatic yellow fever virus is transmitted to monkeys by forest dwelling mosquitoes such as Haemagogus and Sabethes spp. Humans who are exposed to these mosquitoes can become infected if they are not vaccinated. In entomological studies conducted during the 2016-2017 outbreak in some of the affected states, isolated Haemagogus mosquitoes were found to be positive for yellow fever, indicating predominantly sylvatic transmission.

WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information. Currently, based on available information, WHO assesses the overall risk as High at the national level, Moderate at the regional level, and Low at the global level.

WHO advice

On 25 January 2019, PAHO/WHO alerted Member States about the beginning of the seasonal period for yellow fever and therefore, the highest risk of transmission to unvaccinated humans. Thus, PAHO/WHO advises Member States with areas at-risk for yellow fever to continue efforts to immunize the at-risk populations and to take the necessary actions to keep travelers informed and vaccinated prior to traveling to areas where yellow fever vaccination is recommended.

WHO recommends vaccination of international travelers above 9 months of age going to Brazil. The updated areas at-risk for yellow fever transmission and the related recommendations for vaccination of international travelers were updated by WHO on 3 May 2018; the map of revised areas at risk and yellow fever vaccination recommendations is available on the WHO ITH website:http://www.who.int/ith/en/

Yellow fever can easily be prevented through immunization, provided that vaccination is administered at least 10 days before travel. A single dose of yellow fever vaccine is sufficient to confer sustained immunity and life-long protection against yellow fever disease: a booster dose of the vaccine is not needed and cannot be required of international travelers as a condition of entry. The vaccine has been used for many decades and is safe and affordable.

Resources

·         Information on the YF situation in Brazil and other countries in the Americas is published regularly on the PAHO/WHO website. Available at: www.paho.org/epialerts
·         Information on the yellow fever situation in Brazil is available on the Brazil Ministry of Health website. Available athttp://bit.ly/2Eqlccu
·         Information on the yellow fever situation in Sao Paulo State. Available at: https://bit.ly/2qZVisQ
·         Information on the yellow fever situation in Paraná State. Available at: https://bit.ly/2QKDSc7
·         Information on the yellow fever situation in Santa Catarina State. Available at: http://www.dive.sc.gov.br/

 
Further Information:

The WHO Risk Assessment is as follows:
Serious Public Health impact: Yes

Yellow fever (YF) is an acute viral disease transmitted by mosquitoes infected with the yellow fever virus with a high case-fatality rate among patients presenting with the toxic phase of the disease.  In 2018 Brazil launched mass YF vaccination campaigns and preliminary results of the campaigns indicate 64.2% of vaccination coverage in São Paulo, 55.6% in Rio de Janeiro and 51.7%, in Bahia states [1]. Suboptimal vaccine coverage implies that herd immunity is not reached and that a high proportion of persons remain at-risk.

Unusual or unexpected: Yes

Human cases of yellow fever during the current seasonal cycle have been reported in the states of São Paulo, Paraná and Santa Catarina in Southeast Brazil, with probable sites of infection in municipalities which had no confirmed epizootics or human cases due to yellow fever in the previous 2 seasonal cycles. In the state of Paraná there had been no reported human cases since 2015 and in the state of Santa Catarina none since 1966.

International disease spread: Yes
The geographical distribution of human cases and epizootics from the current and previous two seasonal cycles suggest southward movement of the virus where there are ecosystems favorable for yellow fever transmission and an area bordering other countries (Argentina, Paraguay, and Uruguay). However, so far, no YF human cases have been reported outside Brazil, in link with the current outbreak.
Interference with international travel or trade: No 
WHO does not recommend any restrictions on travel and/or trade for Brazil based on available information on this event.
Actions requested: For information only, please circulate to all relevant staff
 
Additional documents included: None
 
Further sources of information:
·         PAHO/WHO yellow fever fact sheet: http://www.who.int/mediacentre/factsheets/fs100/en/   
·         WHO yellow fever Health Topics: http://www.who.int/topics/yellow_fever/en/   
·         WHO list of countries with vaccination requirements and recommendations for international travelers:http://www.who.int/ith/ith-country-list.pdf
·         WHO yellow fever risk mapping and recommended vaccination for travelers: http://www.who.int/ith/yellow-fever-risk-mapping/state_request/en/
·         WHO International Travel and Health website: http://www.who.int/ith/en/WHO strategy for yellow fever epidemic preparedness and response: http://www.who.int/topics/yellow_fever/en/
Date: Sun 30 Mar 2019
Source: Tribuna do Norte [in Portuguese trans. ProMED Mod.TY, edited]

Infectious disease physicians in the state health network of the Rio Grande do Sul Federal University UFRN) did not confirm that the disease, having symptoms similar to chikungunya [virus infection], observed this past week in 140 residents of 2 neighborhoods of Tirol and Petropolis in Natal [state] is in fact chikungunya. Blood tests done on Sat 23 Mar 2019 on samples from 6 individuals detected the presence of that virus, but the specialist physicians do not discard other hypotheses. Occurrence of this number of cases in less than one month is considered an outbreak.

Investigations were done on 73 cases in order to identify whether there is a mutation of that virus or a new virus in circulation in Natal. "The fact of a confirmation of chikungunya [virus infection] in some of the cases does not close the case [outbreak]," stated Kleber Luz, an infectious disease physician at the Federal University of Rio Grande do Norte.

In a meeting of infectious disease physicians convened for studies in order to identify the virus [responsible for the cases], 4 hypotheses were presented:
- 1st that this could be an arbovirus called "Ross River" that is present in Australia,
- 2nd an arbovirus call Barmah Forest, also in Australia,
- 3rd Mayaro virus present in other states of Brazil since 2016,
- Last, it could be a modification [mutant] of chikungunya [virus] caused by the circulation of another virus [another type of chikungunya virus? - ProMED Mod.TY]
All are transmitted by the _Aedes aegypti_ mosquito [not correct. See comment below. - ProMED Mod.TY].

The profile of the ill individuals:
The majority are women with a median age of 58 years. No children were identified with the disease. The majority are residents and workers in the Tirol neighborhood, a locality in which the numbers of _Aedes aegypti_ mosquitoes increased according to the municipal surveillance team. The most frequent symptoms are pain in the joints, fever and rash.

It is the unusual nature of the symptoms that impede the diagnosis as chikungunya [virus infection], Zika [virus infection] or dengue. For example: the majority of the patients examined present with arthralgia, sores in the mouth and fever, which are common in chikungunya cases, but also have a rash which is common in Zika cases, but with strong itching; a symptom that the new patients have is itching, but not to the point of troubling them as in Zika [virus infections].

The symptoms of the new cases are less intense than the known diseases and appear more rapidly. Most of the patients feel pain in the soles of their feet on the 1st day [of illness]; when this pain happens in known chikungunya cases, generally it appears during the 2nd week.

"A patient told me, 'Doctor, when I decelerate (step on the clutch) of the car, it hurts a lot.' This pain of the soles of the feet only appears at the end of [chikungunya] disease," said Kleber.

This difference does not mean that this could be a new virus. During the meeting, the infectious disease physician Andre Prudente called attention to the "spectrum" of symptoms that arboviruses produce. "The big problems with arbovirus diseases is that the spectrum of symptoms is very wide. Some patients have intense pain, and others do not. And this can be with the same disease [virus]," he explained.

"Some symptoms seem to be a milder chikungunya," a caveat offered by infectious disease physician Kleber Luz. He accredits this to the hypothesis of a modified virus but will not discard the others [hypotheses] until the end of the investigation. "That is to say, laboratory tests, and until then, we will continue to work with all the hypotheses. I believe that it is chikungunya, but not only that."

The specialists discussed the progress of the studies.

Hypotheses raised up to now:
- A modified chikungunya or other virus is circulating or present in the people.
This hypothesis takes into consideration that the chikungunya virus could have had a modification from another [chikungunya] virus in circulation. This could explain why patients had chikungunya [virus] present in their blood but with symptoms different from the disease.

Ross River arbovirus, for its similarity of symptoms
Transmitted by _Aedes aegypti_, Ross River [virus] causes joint pains,rash, but unlike the symptoms identified in Natal, the rash appears just 10 days after illness. [In Australia, the recognized vectors for Ross River virus are _Aedes vigilax_, _Ae. camptorhynchus_, and _Culex. annulirostris_. _Aedes aegypti_ is not considered a significant vector. - ProMED Mod.TY]

Barmah Forest arbovirus is also present in Australia
Barmah Forest virus also causes similar symptoms, mainly a red rash. They are similar to those of Ross River [virus infections] but the symptoms last longer. Another similarity is that Barmah [Forest virus] is found in possums. According to some of the physicians present in the meeting, there are species of possums in Dunas Park near Tirol, a place most related to the cases. [The recognized vectors of Barmah Forest virus in Australia are: _Ochlerotatus vigilax_, _Culex annulirostris_, _Aedes (Oc.) camptorhynchus_, _Ae. normanensis_, and _Coquillettidia spp._. _Aedes notoscriptus_ is considered an additional potential vector (see ProMED-mail archive Barmah Forest virus - Australia: (TS) http://promedmail.org/post/20190309.6359062). _Aedes aegypti_ is not considered a significant vector of this virus. - ProMED Mod.TY]

Mayaro arbovirus, present in Brazil but never identified in Ro Grande do Norte Cases of Mayaro, an arbovirus similar to those in Natal, are related to Goiania. The symptoms are similar and [the virus occurs] near cities with forests [as is the case with Goiania and wetlands; in Natal Dunas Park) which is a common factor.

[Mayaro virus was 1st isolated by Charles Anderson and his colleagues during the 1950s from humans with febrile illnesses in Trinidad. Mayaro virus has since been identified in the Amazon and other tropical regions (Trinidad, Suriname, French Guyana, Brazil, Peru, Bolivia, and Venezuela) and more recently in Haiti. In South America, it has been shown mostly to be transmitted by _Haemogogus_ mosquitoes. However, the urban mosquito _Aedes aegypti_ has now been also shown to be an experimental vector of the virus and was recovered from this mosquito captured in Mato Grosso state.

[There follows a summary of the observations, discussion and points covered in the above text. - ProMED Mod.TY]
======================
[Occurrence of Ross River or Barma Forest viruses in Natal state, Brazil, is very unlikely. Mayaro virus is a much more likely possibility. The laboratory tests that were done identified chikungunya virus (CHIKV), but apparently, differences in the clinical picture caused the infectious-disease physicians to doubt that diagnosis or instead postulate a variant of that virus that causes milder disease. The type of test that was done that detected the virus (or RNA?) in the blood of affected patients is not specified. There is no mention of whether mosquitoes, especially _Aedes aegypti_, were collected in the area where the cases occurred and were tested for the presence of viruses. Until further laboratory tests are completed, the only laboratory-based evidence points to CHIKV infections. ProMED would appreciate receiving additional information as it becomes available. - ProMED Mod.TY]

[Regarding unidentified febrile disease in Rio Grande do Norte, 23 of 34 samples examined suggested CHIKV infection (there is no information about if the tests performed were serological and/or biomolecular tests). On 25 Mar [2019], it was informed by local public health authorities that there is the circulation of all DENV serotypes, ZIKAV, and CHIKV. The director of the Natal Health Surveillance Department said, "I do not consider that [the disease] is any mystery. We have 6 types of arboviruses circulating in the [Tirol] municipality: dengue types 1, 2, 3, and 4; Zika virus; and chikungunya [virus]." ([in Portuguese]).

Despite the lack of more qualified clinical, epidemiological, and laboratorial clues, it should be considered that the current circulating arboviruses are the most probable agent of this apparent cluster. - ProMED Mod.RNA]

[HealthMap/ProMED-mail map:
Date: Thu 21 Mar 2019 17:55 BRT
Source: Bem Parana [in Portuguese trans. ProMED Mod. TY, edited]

The weekly epidemiological bulletin released on [Thu 21 Mar 2019] by the State Department of Health reports that the number of cases of yellow fever rose in Parana. Last week [week of 11 Mar 2019] there were 8 confirmed cases and now there are 12 in the updated bulletin, corresponding to the period from 1 Jul 2018 to 20 Mar 2019.

According to the Secretary of State for Health, Beto Preto, the 22 regional health centers of Parana are involved with the intensification of vaccination. "We reaffirm the guidance that being immunized is the only way to protect against the disease. Everyone aged 9 months to 59 years should receive the vaccine," he said.

He adds that the Health Department is actively pursuing people who have not yet been immunized and live in areas of difficult access, as well as reinforcing guidelines on the importance of vaccination at community events. He also promoted the training of teams for vaccination at the Hospital do Trabalhador, in Curitiba, and in the 3rd Health Regional of Ponta Grossa.

The 12 confirmed cases of the disease are in Antonina, Morretes, Adrianopolis, Campina Grande do Sul, Curitiba, Piraquara, and Sao Jose dos Pinhais. Of the patients, (92%) are males, with a mean age of 36 years; 3 of them are rural workers. There is one confirmed yellow fever death in Parana in the 1st week of March [6 Mar 2019], with residence and probable place of infection in the municipality of Morretes.

The municipalities with the highest incidence of notifications are Paranagua (55), Curitiba (33), and Sao Jose dos Pinhais (30). The Capital reported 8 more notifications than the bulletin of the previous week and Sao Jose dos Pinhais 7 new cases. In total, there are 224 notifications and 61 cases under investigation, in addition to the 12 confirmations.

Monkeys: the State Department of Health also intensifies disease surveillance and death of monkeys, and reaffirms that they do not transmit the virus. On the contrary, they provide an alert for the circulation of the virus, since in the regions where these infected animals appear, the transmitting mosquito is present.

This week's newsletter [week of 18 Mar 2019] shows 4 confirmed epizootics [monkey cases] and 12 under investigation and 2 new areas recorded occurrences: Paranagua and Sao Jose dos Pinhais. The municipalities of Antonina and Morretes had already reported the disease in monkeys.

Vaccine: in the period from 1 Jan to 19 Mar 2019, around 445,000 doses of the yellow fever vaccine were applied throughout Parana in the population aged 9 months to 59 years.
=====================
[Parana state is within the endemic area for yellow fever virus. The occurrence of monkey cases of yellow fever suggest that the human cases reported above were acquired from spill over of the sylvan (forest) transmission cycle and not from urban human-_Aedes aegypti_-human transmission cycle. Vaccination is urgent to prevent the urban cycle from being initiated and to protect the lives of humans living in or visiting areas where the sylvan cases are occurring. - ProMED Mod.TY]

[Maps of Brazil:
More ...

World Travel News Headlines

Date: Fri, 19 Apr 2019 04:57:44 +0200
By Fran BLANDY

Udier, South Sudan, April 19, 2019 (AFP) - By the time he was brought into the remote clinic in northeastern South Sudan, two-year-old Nyachoat was already convulsing from the malaria attacking his brain.   After being given medication he lies fast asleep, naked and feverish, attached to a drip, his anxious mother sitting on the bed next to him.   Nyachoat could be saved, but others are not so lucky.   In South Sudan mind-bending horrors abound of war, ethnic violence, rape, hunger and displacement.

But for civilians living in the shadow of conflict, the greatest danger is often being cut off from health services, whether due to violence or lack of development in the vast, remote areas that make up much of the country.   According to the International Committee of the Red Cross (ICRC), which supports the tiny clinic where Nyachoat is recovering in Udier village, 70 percent of all illness deaths are due to easily treatable malaria, acute watery diarrhoea and respiratory infections.   In case of more serious illness there is "no place" to go, said Nyachoat's 22-year-old mother Buk Gader.

A study by the London School of Hygiene and Tropical Medicine (LSHTM) last year showed almost 400,000 people had died as a result of South Sudan's nearly six-year war.   Half of these were due to violent deaths, and half because of the increased risk of disease and reduced access to healthcare as a result of the conflict.   ICRC health field officer Irene Oyenya said the Upper Nile region was particularly affected.   "There were (aid) organisations which were supplying primary healthcare, but then during the war, most of the organisations got evacuated" and pulled out of the country, she said.

- Blocked by swamps -
Udier is a village with a dirt airstrip whose sun-baked sand, which when not used by twice weekly ICRC flights bringing medicine and supplies, serves as a football pitch for youths. It is also a pedestrian highway for those who come from far flung huts and cattle camps to market.   In the tiny market, there is little fresh food available. Villagers can buy red onions or sit for a strong Sudanese coffee, infused with ginger, while in the dry season nomadic Falata herdswomen in flowing dresses sell milk from their cattle.   A brick building next to the airstrip, its roof long blown off in a storm, is the village school, but for several days in a row no teacher shows up.   In the surrounding villages, women are hard at work mudding their huts and re-thatching the roof in anticipation of the rains to come within weeks.

When they do come, swelling the swampy marshlands and rivers for miles around, roads will become impassable.    It becomes "difficult for young children to swim or women or men to carry patients to reach here," said Oyenya.   Marginalised for decades prior to independence from Sudan in 2011, and engulfed in war since 2013, South Sudan has seen little development. The healthcare sector is one of many propped up by international aid organisations.   However, the country is also the most dangerous for humanitarian workers with around 100 killed over the past five years, according to United Nations figures. Dozens of organisations have been forced to pull out of areas they served due to the conflict.

The Upper Nile region, where Udier is situated near the borders of Sudan and Ethiopia, was wracked by conflict in 2017 as government forces waged a major offensive to seize the opposition-held town of Pagak.   The ICRC was forced to evacuate patients and staff from its hospital and health centre in the village of Maiwut which was looted, leaving "not even a needle on the ground", according ICRC's Oyenya.   Many relocated to Udier, which was spared from fighting.   A year later in 2018, angry protesters looted around 10 humanitarian agency compounds in the town of Maban, 72 kilometres (44 miles) north of Udier.   ICRC's head of delegation in South Sudan, James Reynolds, said a peace deal signed in September 2018 "has improved security, mobility, and access for humanitarian workers".   But fresh fighting in the southern Equatorias region "has made access to certain areas very difficult."

- Women bear the burden -
In opposition-held Udier, the clinic supported by the ICRC provides crucial healthcare support to the region, where like throughout South Sudan, maternal and child mortality is sky-high.   Every day a small group of patients sits outside under a fragrant Neem tree, waiting to be helped, some from nearby while others have walked for a day or two.   Oyenya says a major challenge is that women, who do all the heavy work and take care of up to 10 children, may delay bringing them to the centre in time. That can be deadly.

Sometimes the children come alone: a nine-year-old girl in a purple polka dot dress confidently tells Oyenya she is suffering from bloody diarrhoea and, she thinks, malaria. Her parents are nowhere in sight.   For anything more serious, such as pregnancy complications, blood transfusions and operations, the nearest hospital is in government-held Maban, a five-hour drive away or a three-day walk.   The other option is a three-day walk to Gambella in Ethiopia.   "They may reach there alive, or they may not reach there alive," said Oyenya.
Date: Fri, 19 Apr 2019 03:13:16 +0200
By Andrea PALASCIANO

Naftalan, Azerbaijan, April 19, 2019 (AFP) - Immersed up to her neck in a dark viscous liquid, Sulfiya smiles in delight, confident that the fetid substance will cure her painful condition.   Sulfiya, a Russian woman in her 60s, has travelled to Azerbaijan's north-western city of Naftalan in the hope that crude oil baths at a local sanatorium will end her years of suffering from polyarthritis, a disease affecting the joints.   "This is so pleasant," she enthuses, despite the reek of engine oil.

Her naked dip in oil heated to just above body temperature lasts 10 minutes, after which an attendant scrapes the brown oil off her skin and sends her into a shower.   The native of Russia's Tatarstan region said she and her friends "have long dreamed of coming" for treatment in Naftalan.   The petroleum spa resort in the oil-rich Caucasus country is a draw for visitors despite its proximity to Nagorny Karabakh, a region disputed between Azerbaijan and Armenia in a long-running armed conflict.

After 10 days of bathing in crude oil Sulfiya says she now feels "much better" and has even reduced her medication for the polyarthritis that she has had for 12 years.   "It is a gift from God," agrees 48-year-old Rufat, an Azerbaijani journalist and opposition party member who is undergoing treatment in the sanatorium called Sehirli, or "magic" in Azerbaijani.   Azerbaijan's vast oil deposits were discovered in the mid-19th century, making what was at the time part of the Russian Empire one of the first places in the world to start commercial oil production.

Oil exports to markets all over the world are the largest sector of Azerbaijan's economy, but the crude that comes from subsoil reservoirs in Naftalan is not suitable for commercial use.   Instead the local oil is used to treat muscular, skin and bone conditions as well as gynaecological and neurological problems.   According to a legend, which spa staff readily tell clients, the healing properties of Naftalan's "miraculous oil" were discovered by accident when a camel left to die near a pool of oil was cured.

The small town of Naftalan some 300 kilometres (185 miles) from the capital Baku became a popular health resort for Soviet citizens in the 1920s.   "In the past, when there weren't any hotels or sanatoriums, people would come to Naftalan and stay with locals," said one of the doctors at the Sehirli sanatorium, Fabil Azizov, sitting in her office under a portrait of strongman President Ilham Aliyev.   "But as time passed, sanatoriums were built and treatment methods developed."

- Controversial benefits -
Some specialists warn the method has dangerous side effects.   "Despite the stories of past cures, the use of crude oil for medicinal purposes has been condemned by Western doctors as potentially carcinogenic," former journalist Maryam Omidi wrote in a 2017 book published in Britain about Soviet-era sanatoriums.

In fact, the oil at Naftalan is almost 50 percent naphthalene, a carcinogenic substance found in cigarette smoke and mothballs that in large amounts can damage or destroy red blood cells.   But doctors and patients at Naftalan brush aside any misgivings and the sanatorium even has a small museum displaying crutches that once belonged to patients who have recovered from their illnesses.

- 'We heard gunshots' -
During its heyday in the 1980s, Naftalan would host more than 70,000 visitors a year.    But in 1988, a bloody war began with neighbouring Armenia for the control of Azerbaijan's separatist Nagorny Karabakh region, which unilaterally proclaimed independence from Baku in 1991.

The conflict claimed the lives of some 30,000 people from both sides and forced hundreds of thousands to flee their homes.   A 1994 ceasefire agreement ended hostilities, but the arch foes have yet to reach a definitive peace deal and there are frequent skirmishes along the volatile frontline.   During the war, the sanatoriums in Naftalan -- a few kilometres from the frontline -- were converted into hospitals for wounded soldiers and temporary accommodation for refugees.

Over the last two decades, the Azerbaijani authorities have worked hard to re-establish Naftalan's reputation as a health resort.    They resettled refugees in other regions, demolished decrepit Soviet-era sanatoriums and built brand-new tourist facilities.   Modern Naftalan is a blend of kitsch-looking high-end spas where a week's treatment costs some 1,000 euros, and modest sanatoriums where a week's treatment costs around 100 euros.   The simmering Karabakh conflict may be out of sight, but guests can still feel uncomfortably close to the military action.   During one of the deadliest recent bouts of fighting in April 2016, "we heard gunshots," said a member of staff at Naftalan's luxurious Garabag spa, adding quickly that "everyone stayed on."
Date: Fri, 19 Apr 2019 02:59:34 +0200

Montreal, April 19, 2019 (AFP) - Three world-renowned professional mountaineers -- two Austrians and an American -- were missing and presumed dead after an avalanche on a western Canadian summit, the country's national parks agency said Thursday.   American Jess Roskelley, 36, and Austrians Hansjorg Auer, 35, and David Lama, 28, went missing Tuesday evening in Banff National Park, according to media reports. Authorities launched an aerial search the next day.

The three men were attempting to climb the east face of Howse Pass, an isolated and highly difficult route, according to Parks Canada.   They were part of a team of experienced athletes sponsored by American outdoor equipment firm The North Face, the company confirmed to AFP.   Rescuers found signs of several avalanches and debris consistent with climbing equipment, Parks Canada said, leading them to presume that the climbers were dead.

Poor weather conditions have increased avalanche risks in the mountainous area on the border between Alberta and British Columbia, with the search halted for safety reasons.   It is unlikely the three men survived, John Roskelley, father of missing Jess Roskelley, told local media in the US state of Washington.   "This route they were trying to do was first done in 2000. It's just one of those routes where you have to have the right conditions or it turns into a nightmare. This is one of those trips where it turned into a nightmare," he told the Spokesman-Review.   Himself considered one of the best American mountaineers of his generation, John Roskelley climbed Mount Everest with his son in 2003, making then 20-year-old Jess Rosskelley the youngest person to have conquered the summit.
Date: Thu, 18 Apr 2019 17:35:41 +0200

London, April 18, 2019 (AFP) - Climate change activists on Thursday brought parts of the British capital to a standstill in a fourth consecutive day of demonstrations that have so far led to more than 400 arrests.   Hundreds of protesters continued to rally at several spots in central London, where they have blocked a bridge and major road junctions this week as part of a Europe-wide civil disobedience campaign over the issue.   The Metropolitan Police said, as of 0830 GMT on Thursday, that 428 people had been arrested since the protests began on Monday, with reports of further detentions during the day.   Meanwhile, a judge denied bail to three people who appeared in court charged with obstructing the transport system at financial hub Canary Wharf on Wednesday.

District judge Julia Newton ordered the trio, who allegedly glued themselves to a train, be held in custody until their next court appearance on May 16.   Under pressure in the media to crackdown on the distruptive demonstrations, interior minister Sajid Javid warned "unlawful behaviour will not be tolerated" after meeting Met Commissioner Cressida Dick.   "No one should be allowed to break the law without consequence," he said in a statement, adding he expected police "to take a firm stance".   Protesters have been snaring traffic and setting up impromptu encampments at Waterloo Bridge, Parliament Square and at Oxford Circus in London's busy West End entertainment and shopping district.   They laid trees in pots along the bridge's length and also set up camps in Hyde Park in preparation for further demonstrations.

More than 1,000 officers were being deployed to the streets of the capital each day this week, according to the interior ministry.   The police have ordered the protesters to confine themselves to a zone within Marble Arch, a space at the junction of the park, Oxford Street and luxury hotel-lined Park Lane.   The protests are being spearheaded by the "Extinction Rebellion" activist group, which was established last year in Britain by academics and has become one of the world's fastest-growing environmental movements.   It has vowed to maintain the protests for weeks in a bid to force state action over climate change, with Heathrow Airport -- Europe's busiest flight hub -- the latest site to be targeted on Friday.

The group wants the British government to declare a climate and ecological emergency, reduce greenhouse gas emissions to zero by 2025, halt biodiversity loss and be led by new "citizens' assemblies on climate and ecological justice".   Its protesters say they are practising non-violent civil disobedience and aim to get arrested to raise awareness of their cause.    The majority arrested this week were detained for breaching public order laws and obstructing a highway.   However, police seized three men and two women outside the UK offices of energy giant Royal Dutch Shell on suspicion of criminal damage after they allegedly daubed graffiti and smashed a window there.
Date: Thu, 18 Apr 2019 07:40:27 +0200

Taipei, April 18, 2019 (AFP) - A 6.0-magnitude earthquake jolted Taiwan on Thursday, the US Geological Survey said, shaking buildings and disrupting traffic.   In the capital Taipei, highrises swayed violently while some panicked school children fled their classrooms in eastern Yilan county, according to reports.      Local media said the quake had been felt all over the island and a highway connecting Yilan and Hualien was shut down due to falling rocks.    The quake struck at 13:01 pm (0501 GMT) at a depth of 19 kilometres (11.8 miles) in eastern Hualien county. There were no immediate reports of casualties.

The island's central weather bureau put its magnitude at 6.1.   The Japan Meteorological Agency warned people living near the coast could notice some effects on sea levels, but said there would be no tsunami.   "Due to this earthquake, Japan's coastal areas may observe slight changes on the oceanic surface, but there is no concern about damage," the agency said.   Hualien was hit by a 6.4 magnitude earthquake last year that killed 17 people.    Taiwan lies near the junction of two tectonic plates and is regularly hit by earthquakes.    The island's worst tremor in recent decades was a 7.6 magnitude quake in September 1999 that killed around 2,400 people.
Date: Thu, 18 Apr 2019 03:07:58 +0200

Canico, Portugal, April 18, 2019 (AFP) - Twenty-nine German tourists were killed when their bus spun off the road and tumbled down a slope before crashing into a house on the Portuguese island of Madeira.   Drone footage of the aftermath of the accident showed the badly mangled wreckage of the bus resting precariously on its side against a building on a hillside, the vehicle's roof partially crushed and front window smashed.

Rescue workers attended to injured passengers among the undergrowth where the bus came to rest, some of them bearing bloodied head bandages and bloodstained clothes, others appearing to be more seriously hurt.   Local authorities said most of the dead were in their 40s and 50s.   They were among the more than one million tourists who visit the Atlantic islands off the coast of Morocco each year, attracted by its subtropical climate and rugged volcanic terrain.   "Horrible news comes to us from Madeira," a German government spokesman tweeted after the crash.   "Our deep sorrow goes to all those who lost their lives in the bus accident, our thoughts are with the injured," he added.

German holidaymakers were the second largest group after British tourists to visit the islands -- known as the Pearl of the Atlantic and the Floating Garden in the Atlantic -- in 2017, according to Madeira's tourism office.    The islands are home to just 270,000 inhabitants.    Filipe Sousa, mayor of Santa Cruz where the accident happened, said 17 women and 11 men were killed in the crash, with another 21 injured.    A doctor told reporters another woman died of her injuries in hospital.   "I express the sorrow and solidarity of all the Portuguese people in this tragic moment, and especially for the families of the victims who I have been told were all German," President Marcelo Rebelo de Sousa told Portuguese television.   He said he would travel to Madeira overnight.

- 'Profound sadness' -
Portuguese Prime Minister Antonio Costa added on Twitter that he had contacted German Chancellor Angela Merkel to convey his condolences   "It is with profound sadness that I heard of the accident on Madeira," he wrote on the government's Twitter page.   "I took the occasion to convey my sadness to Chancellor Angela Merkel at this difficult time," he added.  The regional protection service in Madeira confirmed 28 deaths in the accident that happened at 6:30 pm (1730 GMT) Wednesday, while hospital authorities said another woman later died of her injuries.

The bus had been carrying around 50 passengers.   Regional government Vice President Pedro Calado said it was "premature" to speculate on the cause of the crash, adding that the vehicle was five years old and that "everything had apparently been going well".   Judicial authorities had opened an investigation into the circumstances of the accident, the Madeira public prosecutor's office told the Lusa news agency.   Medical teams were being sent from Lisbon to help local staff carry out post-mortems on the dead.
Tanzania - National. 11 Apr 2019

Tanzania on Thursday [11 Apr 2019] confirmed an outbreak of dengue fever, saying the business capital, Dar es Salaam, has reported 252 cases and Tanga has 55 diagnosed cases.
- La Reunion. 10 Apr 2019

From 800 confirmed cases the previous week, the dengue epidemic increased to 904 cases in the week.
<https://la1ere.francetvinfo.fr/reunion/dengue-barre-900-cas-confirmes-semaine-est-depassee-698934.html> [in French, trans. ProMED Corr.SB]

- La Reunion. 12 Apr 2019. Dengue La Reunion (French overseas territory): dengue cases near 5000 in Q1 2019. New transmission zones have been identified in Saint-Andre, Saint-Denis, Sainte-Marie, and Sainte-Suzanne. In addition, the number of hospitalizations is increasing with 25-30 recorded weekly.

- La Reunion. 27 Mar 2019. The circulation of the dengue virus continues at a sustained level, say the prefecture and the ARS. From 11-17 Mar 2019, 682 cases of dengue fever were confirmed. Since the beginning of the year [2019], 153 emergency room visits have been recorded and 80 patients have been hospitalized. In addition, 5 deaths have been reported since the beginning of 2019, of which 2 have been considered, after investigation, as directly related to dengue fever. The most active households are located at: the Saint-Louis River, Saint Louis, Saint Pierre, the Etang-Sale Cabris Ravine.
- Cook Islands. 12 Apr 2019

As of Wednesday [10 Apr 2019], the Ministry for Health has 18 confirmed and 12 probable dengue fever cases. This is a total of 30 cases compared to 24 previously identified.
- Taihiti (French Polynesia). 13 Apr 2019

DEN-2 confirmation of several autochthonous cases