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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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Iraq

Iraq US Consular Information Sheet
2nd October 2008
COUNTRY DESCRIPTION:
In 2005, Iraqi citizens adopted a new constitution and participated in legislative elections to create a permanent, democratic government, and in May 2006, a new Gove
nment of Iraq (GOI), led by Prime Minister Nouri al-Maliki, was sworn in. Although the GOI has made political, economic and security progress, Iraq still faces many challenges, including overcoming three decades of war and government mismanagement that stunted Iraq's economy, sectarian and ethnic tensions that have slowed progress toward national reconciliation, and ongoing (even if abating) insurgent, sectarian, criminal, and terrorist violence. Conditions in Iraq are extremely dangerous. While Iraqi Security Forces now take the lead in providing security in most provinces, Multinational Force-Iraq (MNF-I) continues to assist the Iraqi government in providing security in many areas of the country. The workweek in Iraq is Sunday through Thursday. Visit the Department of State Background Notes on Iraq for the most current visa information.
ENTRY/EXIT REQUIREMENTS: Passports valid for at least six months and visas are required for most private American citizens. An Iraqi visa may be obtained through the Iraqi Embassy in Washington, D.C. Travelers should not rely on obtaining a visa upon arrival at an airport or port of entry in Iraq. Visitors to Iraq who plan to stay for more than 10 days must obtain a no-fee residency stamp. In Baghdad, the stamps are available for all visitors at the main Residency Office near the National Theater. Contractors in the International Zone may also obtain exit stamps at the Karadah Mariam Police Station (available Sunday and Wednesday, 10:00-14:00.). There is a 10,000 Iraqi dinar (USD 8) penalty for visitors who do not obtain the required residency stamp. In order to obtain a residency stamp, applicants must produce valid credentials or proof of employment, two passport-sized photos, and HIV test results. An American citizen who plans to stay longer than two months must apply at the Residency Office for an extension. Americans traveling to Iraq for the purpose of employment should check with their employers and with the Iraqi Embassy in Washington, D.C. for any special entry or exit requirements related to employment. American citizens whose passports reflect travel to Israel may be refused entry into Iraq or may be refused an Iraqi visa, although to date there are no reported cases of this occurring.
U.S. citizens who remain longer than 10 days must obtain an exit stamp at the main Residency Office before departing the country. In Baghdad, they are available for all visitors at the main Residency Office near the National Theater. Contractors in the International Zone may also obtain exit stamps at the Karadah Mariam Police Station (available Sunday and Wednesday, 10:00-14:00). Exit stamp fees vary from USD 20 to USD 200, depending on the length of stay, entry visa and other factors. Those staying fewer than 10 days do not need to get an exit stamp before passing through Iraqi immigration at the airport. Visitors who arrive via military aircraft but depart on commercial airlines must pay a USD 80 departure fee at the airport.
Note: For information on entry requirements for other countries, please go to the Entry/Exit Requirements section in the Country Specific Information Sheet for the country you are interested in at http://travel.state.gov/travel/cis_pa_tw/cis/cis_1765.html. You may also contact the U.S. embassy or consulate of that country for further information.
Visit the Iraqi Embassy web site at http://www.iraqiembassy.us for the most current visa information. The Embassy is located at 1801 P Street NW, Washington, DC 20036; phone number is 202-742-1600; the fax is 202-333-1129.
Information about dual nationality or the prevention of international child abduction can be found on our web site. For further information about customs regulations, please read our Customs Information sheet.
SAFETY AND SECURITY:
The risk of terrorism directed against U.S. citizens in Iraq remains extremely high. The Department of State continues to strongly warn U.S. citizens against travel to Iraq, which remains very dangerous.

Remnants of the former Baath regime, transnational terrorists, criminal elements and numerous insurgent groups remain active throughout Iraq. Multinational Force-Iraq (MNF-I) and Iraqi Security Forces (ISF)-led military operations continue, and attacks persist against MNF-I and the ISF throughout the country. Turkish government forces have carried out operations against elements of the Kongra-Gel (KGK, formerly Kurdistan Worker’s Party, or Partiya Karkeren Kurdistan (PKK)) terrorist group that are located along Iraq’s northern border. Despite recent improvements in the security environment, Iraq remains dangerous, volatile and unpredictable. Attacks against military and civilian targets throughout Iraq continue, including in the International (or “Green”) Zone. Targets include hotels, restaurants, police stations, checkpoints, foreign diplomatic missions, and international organizations and other locations with expatriate personnel. Such attacks can occur at any time. Kidnappings still occur; the most recent kidnapping of an American citizen occurred in July 2008. Improvised Explosive Devices (IEDs), Explosively Formed Penetrators (EFPs), and mines often are placed on roads, concealed in plastic bags, boxes, soda cans, dead animals, and in other ways to blend with the road. Grenades and explosives have been thrown into vehicles from overpasses and placed on vehicles at intersections, particularly in crowded areas. Rockets and mortars have been fired at hotels, and vehicle-borne IEDs have been used against targets throughout the country. Occasionally, U.S. Government personnel are prohibited from traveling to certain areas depending on prevailing security conditions. In addition to terrorist and criminal attacks, sectarian violence occurs often. Detailed security information is available on the Embassy's web site at http://iraq.usembassy.gov and at http://www.centcom.mil.
For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov where the current Travel Warnings, including the Travel Warning for Iraq, and Travel Alerts, as well as the Worldwide Caution, can be found. Travelers are also referred to the U.S. Embassy Baghdad’s Warden Notices which are available on the Embassy web site at http://iraq.usembassy.gov.
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 and Tips for Traveling Abroad.
CRIME: The U.S. Embassy and MNF-I are working with Iraqi authorities to establish law enforcement and civil structures throughout the country. U.S. and British military personnel are providing police protection as well, as the security situation permits. Petty theft is common in Iraq, including thefts of money, jewelry, or valuable items left in hotel rooms and pick-pocketing in busy places such as markets. Carjacking by armed thieves is very common, even during daylight hours, and particularly on the highways from Jordan and Kuwait to Baghdad. Foreigners, primarily dual American-Iraqi citizens, and Iraqi citizens are targets of kidnapping. The kidnappers often demand money but have also carried out kidnappings for political/religious reasons.
INFORMATION FOR VICTIMS OF CRIME: The loss or theft abroad of a U.S. passport should be reported immediately to 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. While U.S. Consular Services in Iraq are limited due to security conditions, the Embassy/Consulate staff can, for example, assist you to 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.There is no 911-equivalent emergency telephone number in Iraq.
MEDICAL FACILITIES AND HEALTH INFORMATION: Basic modern medical care and medicines are not widely available in Iraq. The recent conflict in Iraq has left some medical facilities non-operational and medical stocks and supplies severely depleted. The facilities in operation do not meet U.S. standards, and the majority lack medicines, equipment and supplies. Because the Baghdad International Airport has limited operations for security reasons, it is unlikely that a private medical evacuation can be arranged.
Iraq does not allow visitors with HIV/AIDS to enter the country. At this time there is no waiver available for this ineligibility. However, please inquire directly with the Embassy of Iraq at http://www.iraqiembassy.org before you travel for any changes.

Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://www.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.
AVIAN INFLUENZA: The WHO and Iraqi authorities have confirmed human cases of the H5NI strain of avian influenza, commonly known as the "bird flu." Travelers to Iraq and other countries affected by the virus are cautioned to avoid poultry farms, contact with animals in live food markets, and any surfaces that appear to be contaminated with feces from poultry or other animals. In addition, the CDC and WHO recommend eating only fully cooked poultry and eggs. For the most current information and links on avian influenza, see the State Department's Avian Influenza Fact Sheet.
MEDICAL INSURANCE: The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation as well as whether medical evacuation would be possible from Iraq. 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 Iraq is provided for general reference only, and may not be totally accurate in a particular location or circumstance.
All vehicular travel in Iraq is extremely dangerous. There have been numerous attacks on civilian vehicles, as well as military convoys. Attacks occur throughout the day, but travel at night is exceptionally dangerous and should be avoided. There have been attacks on civilian vehicles as well as military convoys on Highways 1, 5, 10 and 15, even during daylight hours. Travelers are strongly urged to travel in convoys with at least four vehicles in daylight hours only. Travel in or through Ramadi and Fallujah, in and between al-Hillah, al-Basrah, Kirkuk, and Baghdad and between the International Zone and Baghdad International Airport, and from Baghdad to Mosul is particularly dangerous. Occasionally, U.S. Government personnel are prohibited from traveling to select areas depending on prevailing security conditions. There continues to be heavy use of Improvised Explosive Devices (IEDs) and/or mines on roads, particularly in plastic bags, soda cans, and dead animals. Grenades and explosives have been thrown into vehicles from overpasses, particularly in crowded areas. Travel should be undertaken only when absolutely necessary and with the appropriate security.
Buses run irregularly and frequently change routes. Poorly maintained city transit vehicles are often involved in accidents. Long distance buses are available, but are often in poor condition and drive at unsafe speeds. Jaywalking is common. Drivers usually do not yield to pedestrians at crosswalks and ignore traffic lights (if available), traffic rules and regulations. Roads are congested. Driving at night is extremely dangerous. Some cars do not use lights at night and urban street lights may not be functioning. Some motorists drive at excessive speeds, tailgate and force other drivers to yield the right of way. Please refer to our Road Safety page for more information.
AVIATION SAFETY OVERSIGHT: As there is no direct commercial air service to the United States by air carriers registered in Iraq, the U.S. Federal Aviation Administration (FAA) has not assessed Iraq's Civil Aviation Authority for compliance with International Civil Aviation Organization (ICAO) aviation safety standards. For more information, travelers may visit the FAA web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.
There is credible information that terrorists are targeting civil aviation. Military aircraft arriving and departing from Baghdad International Airport (ORBI) have been subjected to small arms and missile fire. Travelers choosing to utilize civilian aircraft to enter or depart Iraq should be aware that, although there have been no recent attacks on civilian aircraft, the potential threat still exists. Official U.S. Government (USG) personnel are strongly encouraged to use U.S. military or other USG aircraft when entering or departing Iraq. All personnel serving in Iraq under Chief of Mission (COM) authority are prohibited from entering or departing ORBI on commercial airlines unless they receive COM approval, which is granted on a case-by-case basis for emergency purposes only. Other personnel not under COM authority must be guided by their own agencies. Personnel under COM authority assigned to the Erbil and Sulaymaniyah areas are permitted to use commercial flights in and out of Erbil on a case-by-case basis.

SPECIAL CIRCUMSTANCES:
As of September 21, 2006, Iraqi law prohibits adult Iraqis and foreigners from holding and transporting more than U.S. $10,000 in cash out of Iraq. In addition, it permits adult Iraqi and resident foreigners to hold and transport no more than 200,000 Iraqi dinars to cover travel expenses. Iraqi law also prohibits taking more than 100 grams of gold out of the country. Iraqi customs personnel are taking action to enforce these laws and may pose related questions to travelers during immigration and customs exit procedures. (Civil customs personnel also will verify passport annotations related to any items such as foreign currency, gold jewelry, or merchandise that were declared by passengers upon entry into Iraq on Form-8.)
All U.S. citizens are reminded that it is their duty to respect Iraqi laws, including legal restrictions on the transfer of currency outside of Iraq. If you are detained at the airport or at any other point of exit regarding your attempt to transfer currency out of Iraq, you should contact – or ask that Iraqi authorities immediately contact -- the American Embassy.

Transporting large amounts of currency is not advisable. Almost all of the international companies working in Iraq have the capability to make payments to their employees and at least four Iraqi banks are also able to convert cash into an international wire transfer directed to a bank account outside Iraq. Branches of the Credit Bank of Iraq on Al-Sa’adoon St., Baghdad (creditbkiq@yahoo.com), Dar Es Salaam Bank (info@desiraq.com), Iraqi Middle East Investment Bank (coinvst@iraqimdlestbank.com) and Al-Warqaa Investment Bank (warkabank@hotmail.com) all have this capability. Please be aware that large wire transfers may require Central Bank of Iraq approval because of measures in place to combat money laundering. Such approvals can be obtained by the sending bank, if information on the origin of the funds and the reason for its transfer are provided. Additional information on banking in Iraq is available at the Central Bank of Iraq web site http://www.cbi.iq/.
Customs and MNF-I officers have the broad authority to search persons or vehicles at Iraq ports of entry. Officers may confiscate any goods that may pose a threat to the peace, security, health, environment, or good order of Iraq or any antiquities or cultural items suspected of being illegally exported. Goods that are not declared may be confiscated by an officer. Persons may also be ordered to return such goods, at their expense, to the jurisdiction from which they came. Please see our Customs Information.
The banking and financial infrastructure has been disrupted and is in the process of rebuilding. Hotels usually require payment in foreign currency. Automatic Teller Machines (ATMs) are extremely limited but the Trade Bank of Iraq (TBI) provides ATM services in dinars and U.S. dollars at the TBI head office in central Baghdad and two other locations (See http://www.tbiraq.com.)
Telecommunications are very poor. There is limited international phone service in Iraq at this time. Local calls are often limited to a neighborhood network. There are no public telephones in the cities; however, calls may be made from hotels, restaurants or shops. Limited cellular telephone service and Internet service are available in Iraq.
Due to security conditions, the Consular Section of the U.S. Embassy is able to provide only limited emergency services to U.S. citizens. Because police and civil structures are in the process of being rebuilt, emergency service and support will be limited.
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 Iraqi laws, even unknowingly, may be expelled, arrested or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in Iraq 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: The U.S. and international media have occasionally reported on the difficult situation faced by Iraq's children, and it is completely understandable that some American citizens want to respond to such stories by offering to open their homes and adopt these children in need. However Iraqi law does not permit full adoptions as they are generally understood in the United States. It is not possible to adopt Iraqi children at this time. For more information on this issue, please refer to our flyer Intercountry Adoptions – Iraq.
Iraq is not party to the Hague Convention on the Civil Aspects of International Child Abduction, nor are there any international or bilateral treaties in force between Iraq and the United States dealing with international parental child abduction. The security situation in Iraq limits consular access to children. For more information see our Office of Children’s Issues web pages on intercountry adoption and international parental child abduction.
REGISTRATION / EMBASSY LOCATION:
The Travel Warning on Iraq urges U.S. citizens to defer travel to Iraq. However, Americans living or traveling in Iraq despite that Warning are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration web site so that they can obtain updated information on travel and security within Iraq. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency. U.S. citizens may also contact the consular section of the U.S. Embassy in Baghdad, Iraq located in the International Zone via e-mail at baghdadacs@state.gov, via landline at 1-240-553-0581, extension 2413 (this number rings in Baghdad) or the U.S. Embassy's web site at http://iraq.usembassy.gov. The after-hours number in case of extreme emergency is GSM 1-914-822-1370 or Iraqna 07901-732-134.
* * * * * *
This replaces the Country Specific Information for Iraq dated January 22, 2008, to update sections on Country Description, Entry/Exit Requirements, Safety and Security, Crime, Information for Victims of Crime, Medical Facilities and Health Information, Aviation Safety Oversight, and Registration/Embassy Location.

Travel News Headlines WORLD NEWS

Date: Thu 5 Jul 2018
Source: IraqiNews.com [edited]

Mosul, Iraq's former Islamic State (IS) capital, is witnessing a growing rate of scabies infections in its western region, medical workers reported as the city struggles to overcome destruction resulting from the war against the extremist group. Moamen Shahwani, a doctor at the health department in Mosul, was quoted by the Iraqi website Sky Press in a press statement that western Mosul has recorded 150 scabies cases, warning that parasites causing the disease are spreading in the city.

He attributed the spread of the disease to several factors, most importantly the return of displaced families to the regions, which are still scarred by the war against Daesh (IS) and the resulting waste matter. "Garbage, debris and remains of corpses are almost at every corner; moreover, there is a shortage in water, electricity and other essential services," Shahwani said.

The doctor noted that, besides registered cases, there are other unregistered ones, with infected persons seeking treatment at outpatient clinics or resorting to herbal medicines. "The disease is highly dangerous and rapidly progressing, and it is difficult to contain it in a short period [in] an environment that lacks the simplest services," he added.

Mosul was IS's capital and base of operations in Iraq. It was from its Grand Nuri Mosque that IS founder, Abu Bakr al-Baghdadi, proclaimed the group's rule. Iraqi forces recaptured the city last July [2017] after an operation that lasted for more than 8 months. Most of the city's infrastructure was demolished due to battles, and authorities continue to extract dead bodies from under the debris.  [Byline: Mohamed Mostafa]
====================
[Scabies is found worldwide and is an indicator of poor hygienic conditions, including lack of personal hygiene and clean clothes, crowded sleeping conditions and inadequate water resources. Thus, it is not surprising that scabies is found in Mosul under the present circumstances. More importantly, scabies can be an indicator of infections transmitted by human lice, like _Borrelia recurrentis_, _Rickettsia prowazekii_ and _Bartonella quintana_. Thus, those treating persons with severe febrile illness in Mosul should consider these infections. - ProMED Mod.EP]

[HealthMap/ProMED-mail map:
Date: Tue 26 Jun 2018
Source: Rudaw [edited]
<http://www.rudaw.net/english/middleeast/iraq/26062018>

After 3 reported deaths caused by viral haemorrhagic fever in Iraq's Euphrates Valley, a rights group has called on the government to undertake measures to prevent the disease from spreading, while officials say: "The situation doesn't call for worry." "The Iraqi High Commission for Human Rights warns of spreading the viral haemorrhagic fever, which causes human deaths and has great dangers to public health and the economy of Iraq," read a statement from IHCHR on Tuesday [26 Jun 2018].

The virus is spread by mosquitoes, ticks, rodents, and bats into livestock and humans, or when humans butcher already-infected livestock. "We call on the Ministry of Health and Diwaniyah Health Department to fumigate animal sheds in the province and carry out rapid preventive measures to prevent the spreading of the disease to Iraq's provinces," added the rights group.

They call for butchers only to work at licensed locations and for the police and relevant administrations to issue instructions. Additionally, posters should be displayed, and seminars should be offered as part of an educational campaign. "After 2 people lost their lives due to the hemorrhagic fever in the Diwanyah province, our ministry has swiftly undertaken the necessary measures to prevent the disease and provide necessary medications," Sayf Badir, a spokesperson for the ministry, said in a statement.

A source from the Diwanyah Hospital told Baghdad Today of another death on Monday [25 Jun 2018], increasing the number to 3. The Provincial Council of Diwanyah held a meeting in the presence of the governor and the head of the province's police to discuss the issue. Dr. Sabah Mahdi, the director of the National Center for Containing and Preventing Diseases, said on Monday [25 Jun 2018] that the 1st recorded case of the disease in Iraq was in 1979. He revealed that there are continuous efforts by the veterinaries to spray pesticides on cattle fields.

"To prevent this disease, we advise all ranchers, laboratory employees, and veterinary employees to wear personal protection gear while dealing with animals," added Mahdi. "The preventive measures are continuous, and by following up on all the cases, the situation doesn't call for worry." The World Health Organization defines viral haemorrhagic fever as "a general term for a severe illness, sometimes associated with bleeding, that may be caused by a number of viruses." Symptoms are sudden and include fever, muscle ache, dizziness, neck pain, backache, headache, and sore eyes, among other symptoms. The mortality rate is 30 percent. There is no vaccine available for humans or animals. There have been no reported cases outside of Diwanyah.
======================
[If the virus is believed to be spread by mosquitoes, ticks, rodents, and bats into livestock and humans, the identity of the virus has not been determined. However, if it is transmitted to humans when they butcher livestock, that raises the possibility that the etiological agent is Congo-Crimean haemorrhagic fever (CCHF) virus.

Cases in Iraq would not be surprising because cases have occurred this year (2018) across the region, including Iran and Afghanistan, and was suspected in 2 fatal and 4 suspected cases in Iraq in 2010. Crimean-Congo hemorrhagic fever (CCHF) is caused by infection with a tick-borne Nairovirus in the family Bunyaviridae. It is a viral zoonosis (animal to human) caused by infection with a tick-borne virus.

The hosts of the CCHF virus are mostly wild and domestic animals, including cattle, sheep and goats. Human transmission may occur when human beings come into contact with infected ticks (through tick bites) or direct contact with blood or tissues of an infected animal. CCHF can be transmitted from one infected human to another by contact with infectious blood or body fluids. In humans, until the etiological agent is identified, effective prevention will be difficult. ProMED-mail would appreciate receiving the name of the virus involved and the laboratory tests used to identify it. - ProMED Mod.TY]

[HealthMap/ProMED-mail map: Qadisiyyah Governorate, Iraq:
<http://healthmap.org/promed/p/25538>]
Date: Mon 9 Oct 2017
Source: MedPage Today [edited]

US service members deployed to Iraq showed signs of having been infected with latent visceral leishmaniasis during their service, researchers said.

In one study, latent visceral leishmaniasis was identified in asymptomatic Operation Iraqi Freedom soldiers (10.2 percent of 88), potentially putting them at risk of activation of the disease if they are immunosuppressed, according to Edgie-Mark Co of the William Beaumont Army Medical Center in El Paso, Texas <https://academic.oup.com/ofid/article/4/suppl_1/S122/4295608/A-Stealth-Parasite-Prevalence-and-Characteristics>.

In another study, 20 veterans with asymptomatic latent visceral leishmaniasis had no active disease, although it was not clear how likely the condition was to resurface and cause serious health problems, reported Nate Copeland of the Clinical Trials Center at Walter Reed Army Institute in Bethesda, Maryland, and colleagues <https://academic.oup.com/ofid/article/4/suppl_1/S122/4295606/Clinical-Evaluation-of-Latent-Visceral>.

Both studies were presented at the annual ID Week meeting, sponsored jointly by the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), the Society for Healthcare Epidemiology of America (SHEA), and the HIV Medicine Association (HIVMA).

Leishmaniasis is spread by sand flies and is common in the Middle East. The zoonotic parasitic disease can cause chronic fever, weight loss, spleen problems, and pancytopenia. Bacterial infections, malnutrition, and severe bleeding can also occur. Researchers are concerned because visceral leishmaniasis, unlike the more common cutaneous form, can cause serious health problems.

"Visceral leishmaniasis can be severe, and even life-threatening if not recognized and treated appropriately," Copeland told MedPage Today.

He said that more than 20 cases of active visceral leishmaniasis were reported among US service members in the Iraq region from 2000-2013, along with hundreds of cutaneous cases.

The study by Copeland [et al.] checked 88 soldiers from the El Paso area who'd served in areas with endemic visceral leishmaniasis from 2002-2011 (86 percent male, median age 39). Via various tests, they found that 10.2 percent showed signs of asymptomatic visceral leishmaniasis.

"If you have a healthy immune system, it shouldn't be an issue. That's what your immune system does, it suppresses the disease," Co told MedPage Today. "But once you have conditions that weaken the system, that's when the disease reactivates." HIV, treatment with immunosuppressant drugs, and the use of steroids could put these soldiers at risk of emergence of active disease, he said.

"Reactivation has been reported in the literature among immunocompromised patients such as solid organ transplants patients and rheumatologic patients with immunosuppressive treatment," said Kanokporn Mongkolrattanothai of Children's Hospital of Los Angeles, who has treated leishmaniasis patients.

Mongkolrattanothai, who was not involved with the studies, told MedPage Today that the new studies are "useful" in light of the life-threatening nature of visceral leishmaniasis.

In the study of 20 soldiers with active visceral leishmaniasis (all male, median age 38.5), "the majority tested positive with a test showing a good cell-mediated immune response, which is essential for control of the _leishmania_ parasites," Copeland said. "These service members were all counseled on the clinical syndrome of visceral leishmaniasis as well as potential risk factors for activation based on what is known at this time."

These patients will be able to visit for re-checks every 1 or 2 years, Copeland said, "but if they remain asymptomatic they likely do not need further care in light of being a healthy and immune-competent group."

Tests revealed that another 2 service members showed signs of genetic material from leishmania parasites in their blood. "While they are also without symptoms, we are following them very closely, every 3-6 months, and monitoring their levels of parasite," Copeland said. "We have also been doing some evaluation as to whether these individuals have any evidence of an immunodeficiency allowing them to have parasites circulating in their blood stream."

"Neither service member is being treated at this point, " he said, "because there are definite known risks to treatment, but no clearly defined benefit to treating people without symptoms. [But] if they were to develop symptoms, there would be a very low threshold to treat them."

The next steps are to understand the risk to service members of latent visceral leishmaniasis infection and gain insight into risk factors for activation, he said.

"In tuberculosis, we have a very similar disease, conceptually," he said. "You have a parasite that most often causes no problems in healthy people exposed, but a certain subset go on to active disease early on after exposure, and others reactivate months to years later, often as a result of some risk factor."

"While we are not sure if the later reactivation is the case in leishmaniasis, we are concerned it may be," Copeland added. "In tuberculosis, there is clear evidence that if you treat those with latent infection, especially those with risk factors for reactivation, you can decrease the risk of future active disease. So that begs the question, would the same be true in leishmaniasis? In other words, can we treat these asymptomatic people now and prevent them from ever getting disease?"  [Byline: Randy Dotinga]
========================
[We know very little about latent Leishmaniasis in healthy subjects. There is no doubt that the exposure to leishmaniasis in the US armed forces in Iraq was extensive (see ProMED reports below from 2001 to 2004).

The tests described here respond with an Interferon-gamma response to stimulation with Leishmania antigens. The test may be false positive or negative and we have no data showing that even if the tests correctly identify people who have been exposed to Leishmania, they will eventually become ill with clinical visceral leishmaniasis.

The authors draw a comparison with tuberculosis. We know a lot more about latent tuberculosis but even here treating latent tuberculosis based on a positive quantiferon test in healthy, asymptomatic individuals is controversial. These people, if treated, are exposed to side effects and the benefit is not well quantified. It is a good rule in clinical medicine, that we treat patients and not laboratory results. Thus a sensible scenario would be to do follow up in Leishmania test positive, asymptomatic individuals.

For subjects with a confirmed (repeated) positive PCR for Leishmania in their blood or other samples like a bone marrow, the infection is no longer asymptomatic and should be treated accordingly, probably with liposomal amphotericin B. - ProMED Mod EP]

[A HealthMap/ProMED-mail map can be accessed at:
Date: Sun 24 Sep 2017
Source: Alghad Press [in Arabic, trans. Mod.NS, edited]

The Parliamentary Health and Environment Committee revealed on [Sun 24 Sep 2017] the spread of plague and called for a national campaign against rodents that are causing the disease.

The deputy head of the Parliamentary Health and Environment Committee, Fares Al-Barefkani, told Alghad Press that "new cases of plague have been identified, and the causes of the disease are known and are related to the poor municipal, disease control, sewage, and landfill services, in addition to widespread residential slums."

Al-Barefkani indicated that "there are a lot of residential slums that have emerged and are not under the control of Baghdad municipality and lack health services." He called for "a serious national campaign to combat rodents in the residential neighbourhoods that cause plague and provide medicines that help to eliminate the disease" and stressed that "there is a need to support Baghdad municipality and the health and the environment directorates to educate people on how to combat plague."

Al-Barefkani added that "the Parliamentary Health and Environment Committee does not have accurate data on the number of cases because we are in the process of follow-up in all the governorates."

On Tuesday [12 Sep 2017], the Ministry of Health denied some social media and other media reports about the occurrence of plague cases.
===================
[ProMED would again appreciate more information regarding whether plague cases have occurred in Iraq as it had been previously denied. If plague is present there, a program to eradicate rodents alone will not be effective in preventing human cases as the infected flea vector will seek other blood sources, such as humans.

This publication regarding the history of _Yersinia pestis_ in Iran also reviews the history of plague in other countries in the Middle East including Iraq:

Hashemi Shahraki A, Carniel E, Mostafavi E: Plague in Iran: its history and current status. Epidemiol Health. 2016 Jul 24; 38: e2016033; available at

"Throughout its history, Iraq has experienced multiple epidemics of plague. In 716 and 717 CE, a large outbreak known as al-Ashraf (the Notables) was recorded in Iraq and Syria. In an epidemic of bubonic plague in 1772 and 1773, many victims died in cities such as Basra (with 250 000 deaths) and Mosul. In 1801 CE, a large plague epidemic occurred in Mosul and Baghdad. A plague epidemic occurred again in Baghdad in 1908. From 1923 to 1924, approximately 90 cases of pneumonic plague were reported in Baghdad, and some plague outbreaks were reported in Basra." - ProMED Mod.LL]

[A HealthMap/ProMED-mail map can be accessed at:
Date: Tue 12 Sep 2017
Source: Alghad Press [in Arabic, trans. ProMED Mod.NS, edited]

The Ministry of Health denied on [Tue 12 Sep 2017] what has been circulated in some social media sites and other media sources about the occurrence of plague cases. The spokesman for the Ministry of Health, Saif Al-Bader, said in a statement that "after communicating with the relevant authorities and departments, it has been found that no deaths due to plague have occurred." He indicated that "this disease was eliminated from Iraq a long time ago and the health departments, whether in Baghdad or the other governorates, have not registered any cases in the whole country."

"The Ministry of Health is carrying out intensive campaigns to combat vectors of diseases, under the supervision and follow-up of the Communicable Diseases Control Center," Al-Bader added.

The director of the Communicable Diseases Control Center, Sabah Abdul-A'ayma, said that "the center continues to supervise all the teams from the different units of the center that are involved in the ongoing campaigns to fight disease carriers, especially in the areas that were mentioned in the rumors such as Al-Rusafa, Al-Saadoun, and Al-Batawin."

Abdul-A'ayma added that "the last campaign was carried out today [Tue 12 Sep 2017] as a team from the Communicable Diseases Control Center conducted an intensive rodent control campaign in the area of Al-Batawin, through the distribution of toxic baits and carrying out fumigation of rodent burrows in the region."

Abdul-A'ayma stressed that "these measures taken by the Communicable Diseases Control Center are aimed to reduce the spread of rodents, which are hard to control due to rapid reproduction as well as the presence of a poor environment from the accumulation of wastes and sewage that contributes to the spread of rodents."

Al-Bader pointed out that "the ministry calls on people not to believe these rumors that are aimed at spreading panic in society." He called on the media to adhere to the scientific standards and accuracy in the dissemination of any information affecting the health of the country, without reference to specialists particularly under the circumstances of the country's fight against terrorism.
========================
[ProMED would appreciate more information regarding whether plague cases have occurred in Iraq. If plague is present there, a program to eradicate rodents alone will not be effective in preventing human cases as the infected flea vector will seek other blood sources such as humans.

This publication regarding the history of _Y. pestis_ in Iran also reviews the history of plague in other countries in the Middle East including Iraq:

Hashemi Shahraki A, Carniel E, Mostafavi E: Plague in Iran: its history and current status. Epidemiol Health. 2016 Jul 24; 38: e2016033; available at <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037359/>

"Throughout its history, Iraq has experienced multiple epidemics of plague. In 716 and 717 CE, a large outbreak known as al-Ashraf (the Notables) was recorded in Iraq and Syria. In an epidemic of bubonic plague in 1772 and 1773, many victims died in cities such as Basra (with 250 000 deaths) and Mosul. In 1801 CE, a large plague epidemic occurred in Mosul and Baghdad. A plague epidemic occurred again in Baghdad in 1908. From 1923 to 1924, approximately 90 cases of pneumonic plague were reported in Baghdad, and some plague outbreaks were reported in Basra." - ProMED Mod.LL]

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

World Travel News Headlines

Date: Tue, 23 Apr 2019 13:01:09 +0200
By Ron LOPEZ

Porac, Philippines, April 23, 2019 (AFP) - Philippine rescuers raced Tuesday to reach some two dozen people still feared buried under a building near Manila that collapsed a day earlier in a deadly earthquake, as a powerful second tremor hit the nation.   The US Geological Survey put the second quake -- on the central island of Samar -- at 6.4 magnitude, stronger than the one that wrought significant damage Monday near the capital in the north.

The latest quake sent terrified locals fleeing into the streets, with images on social media showing cracked roads, crumbling church walls and shattered glass.   "No one started crying, but of course some panicked because it was really strong," said Rey Estrobo, a supervisor at a hotel in Borongan town, near the epicentre.   At the same time, the toll in Monday's quake rose to 16, with most of the fatalities in the worst-hit northern province of Pampanga, national disaster officials said.   More than 100 others were injured by falling rubble on Monday, including in Manila, according to police.

However, initial reports indicated relatively minor destruction in Samar given the strength of Tuesday's quake, which could be down to differences in ground composition.   "The damage is more pronounced if the houses and buildings are built on a foundation of soft soil," seismologist Myla Advincula told AFP, referring to Pampanga's soft sediment. "It enhances the shaking effect."

Scores of rescuers in the northern town of Porac spent Tuesday using cranes and jackhammers to peel back the pancaked concrete structure of a four-storey market building where the Red Cross said 24 people were unaccounted for.   "Every minute, every second is critical in this rescue," Cris Palcis, a volunteer rescue dog handler, told AFP. "Time is short for the people under the rubble so we have to be quick."

Pampanga Governor Lilia Pineda told journalists that rescuers could still hear at least one person trapped beneath the rubble, but the digging was proceeding delicately to avoid accidentally crushing the survivor.   Rogelio Pacelo was shopping with his wife and child when the market building collapsed around them, but they incredibly made it out almost without a scratch.   "I thought this only happens in movies. I thought that was the end of the world, it's our end," he told journalists. "I looked for a way out."   The quake also damaged several centuries-old churches which were crowded with worshippers in recent days as the majority-Catholic Philippines marked the Easter holiday.

- 'Ring of Fire' -
Father Roland Moraleja, who is based in Porac, said the 18th-century belfry of the Saint Catherine of Alexandria church collapsed in the quake.   "It was the only part left from the old church," he told AFP. "The historical value is now gone, but we are hopeful that it will rise again."   High-rise buildings in the capital swayed after the tremor struck Monday evening, leaving some with large cracks in their walls.

Thousands of travellers were stranded after aviation authorities shut down the secondary Clark Airport, which is located on the site of the former US military installation that lies about an hour's drive north of the capital.   It was still closed on Tuesday as officials assessed the heavy damage to the terminal building and some cracking on the air traffic control tower.

The quake was centred on the town of Castillejos, about 100 kilometres (62 miles) northwest of Manila, local geologists said.   Seismologists put Monday's tremor at 6.3 initially, but subsequently downgraded it to a 6.1 magnitude.   The Philippines is in the Pacific "Ring of Fire", an arc of intense seismic activity that stretches from quake-prone Japan through Southeast Asia and across the Pacific basin.
Date: Tue, 23 Apr 2019 10:08:27 +0200

Johannesburg, April 23, 2019 (AFP) - At least five people died early Tuesday in South Africa's coastal city of Durban after torrential rains triggered mudslides that crushed homes, emergency services said.   Among those killed were a six-month-old baby, a child of about 10 and two adults.   "Torrential rains damaged peoples houses (and) there were mudslides," Garrith Jamieson, spokesman for Rescue Care, told AFP.

"I can confirm five (deaths) but there are many more casualties," he said, adding there were unconfirmed reports of "multiple" deaths in other parts of the KwaZulu-Natal province.   Victims were either crushed to death by the mudslides or drowned in flood waters.   It was not immediately clear how many people were missing, but search and rescue operations continued on Tuesday.

Downpours have caused flooding in the southern and eastern parts of the country.   The military has been dispatched to help in rescue and evacuation efforts in some of the affected areas.   The South African Weather Services warned that more heavy rain was expected until Wednesday which could lead to more flooding and pose a threat to low-lying bridges and roads.
Date: Tue, 23 Apr 2019 06:03:52 +0200

Colombo, April 23, 2019 (AFP) - The toll from a string of deadly suicide bomb attacks in Sri Lanka has risen to 310, with several people dying of their injuries overnight, a police spokesman said Tuesday.   Around 500 people were wounded in the blasts, Ruwan Gunasekera said in a statement.   He added that 40 people were now under arrest in connection with the attacks, which Sri Lanka's government has blamed on a previously little-known local Islamist group, National Thowheeth Jama'ath.
Date: Mon, 22 Apr 2019 06:22:23 +0200

Melbourne, April 22, 2019 (AFP) - A father and son lifesaving team drowned while trying to save a tourist swept out to sea near one of Australia's most famous sights off the south coast, officials said Monday.   Ross Powell, 71, and his son Andrew, 32, died on Sunday after their lifesaving boat overturned in the surf during the rescue of a 30-year-old man near the Twelve Apostles, a set of 12 limestone stacks off the Victoria state coast.

The tourist, whose nationality or name has not been released, had been wading at the mouth of a river when he got into trouble.   He was winched from the water alongside a third lifesaver from the boat, who was seriously injured, by a rescue helicopter and taken to hospital, Victoria Police said. The bodies of the Campbells were found in the water shortly after.   The tragedy has rocked the small tourist town of Port Campbell where the two men came from, with Prime Minister Scott Morrison leading the tributes.   "Surf lifesavers are selfless & brave. We thank them all for their service & extend our deepest sympathies to Ross & Andrew's family & friends," Morrison tweeted Monday.

Surf Lifesaving Victoria president Paul James hailed the pair as heroes, and said the conditions had been rough and "not the place to be swimming".   "It's just terrible, it's heart-breaking," he told reporters in an emotional press conference of the death of the dairy farmers and experienced volunteer lifesavers.   "I understand the boat was operating in a two-metre (6.5 feet) swell, so a very high swell, and we know that it is very treacherous down there... These brave people, these heroes, have gone out to try and help."   Amber Griffiths, the partner of Andrew Campbell and who local media reported was pregnant with their second child, wrote about her heartbreak on Facebook.   "Today we lost two of the most beautiful people to ever exist -- always putting others first," she wrote.   "The love of my life, light of my life, father of my baby girl. My heart is broken. I miss you Andrew Powell."

Australia's beaches are among the island continent's biggest tourist drawcards, but can have strong rips and tides. Swimmers are advised to keep between areas bounded by flags and patrolled by lifesavers.   The area where the tourist was rescued is near high cliffs and said to have wild and treacherous seas.   The Twelve Apostles are giant rock stacks of varying heights in the Southern Ocean which began forming 20 million years ago when erosion gradually began whittling away the limestone cliffs of Port Campbell.
Date: Mon, 22 Apr 2019 01:55:28 +0200

Montreal, April 21, 2019 (AFP) - Flooding in eastern Canada forced the evacuation of more than 1,500 people while over 600 troops have been deployed in response, authorities said Sunday.   Warming weather over the Easter weekend has brought spring floods due to heavy rains and snowmelt from Ontario to southern Quebec and New Brunswick.

Authorities, who initially feared a repeat of catastrophic 2017 floods in Quebec, the worst in half a century, appeared more confident about the situation on Sunday.   "We are optimistic about the coming days," civil security spokesman Eric Houde told AFP.   "There will be significant floods but overall not at the level of 2017, except in certain areas like Lake St Pierre," a widening of the St Lawrence River in Quebec, he added.   "The big difference from 2017 is the level of preparation of municipalities and citizens."

Over the past several days, towns have mobilized volunteers and distributed hundreds of thousands of sandbags to erect barriers or protect houses in threatened areas.   The areas most affected were around Ottawa, and Beauce, a region south of Quebec City where nearly 800 people were evacuated. More than 1,200 homes had been affected by the flooding in Quebec by late Sunday.

The provincial governments of Quebec and New Brunswick asked for reinforcements from the military.    About 200 soldiers had deployed in Quebec by late Saturday, and 400 others near Ottawa, in Laval north of Montreal and in Trois-Rivieres between Montreal and Quebec City.   About 120 additional soldiers stood at the ready to be mobilized in New Brunswick.   On Saturday, the flooding claimed its first victim in the municipality of Pontiac, west of Ottawa: a man in his seventies who did not see that a bridge had been washed away, and plunged his car into the stream below.
Date: Mon, 22 Apr 2019 01:08:11 +0200

Montreal, April 21, 2019 (AFP) - The bodies of three world-renowned professional mountaineers -- two Austrians and an American -- were found Sunday after they went missing during an avalanche on a western Canadian summit, the national parks agency said.   American Jess Roskelley, 36, and Hansjorg Auer, 35, and David Lama, 28, of Austria went missing late Tuesday at Banff National Park. 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.

They were part of a team of experienced athletes sponsored by American outdoor equipment firm The North Face.   "Parks Canada extends our sincere condolences to their families, friends and loved ones," the agency said in a statement.   "We would also like to acknowledge the impact that this has had on the tight-knit, local and international climbing communities. Our thoughts are with families, friends and all those who have been affected by this tragic incident."

Roskelley was the son of John Roskelley, who was also considered one of the best mountaineers of his own generation.   Father and son had climbed Mount Everest together in 2003. At the time, the younger Roskelley was only 20 years old, and became the youngest mountaineer to climb the planet's highest mountain above sea level.   Auer and Lama, from Tyrol in Austria, were also considered among the best mountaineers of the times.
Date: Sun, 21 Apr 2019 23:36:53 +0200

Kano, Nigeria, April 21, 2019 (AFP) - Two people including a British aid worker have been shot dead and four tourists abducted in an attack by armed gunmen on a holiday resort in north-western Nigeria, police said on Sunday.   Police and aid agency Mercy Corps named the dead woman as Faye Mooney.   "Faye was a dedicated and passionate communications and learning specialist", Chief executive Neal Keny-Guyer said in a statement posted on social media, adding that colleagues were "utterly heartbroken".   Mooney had "worked with Mercy Corps for almost two years, devoting her time to making a difference in Nigeria", Keny-Guyer added.

Gunmen stormed the Kajuru Castle resort, 60 kilometres (40 miles) southeast of Kaduna City at 11.40 pm (2240 GMT) on Friday, Kaduna state police spokesman Yakubu Sabo told reporters.   The Briton "was gunned down from the hill by the kidnappers who tried to gain entrance into the castle but failed", Sabo said.   "They took away about five other locals but one person escaped," he said.   A Nigerian man believed by local residents in Kajuru to be Mooney's partner was also killed in the attack on the resort where a group of 13 tourists had arrived from Lagos, southwest Nigeria the police spokesman said.   In Kaduna and the wider northwest region, kidnapping for ransom has become an increasingly rampant, particularly on the road to the capital, Abuja, where armed attacks have thrived.

Kidnapping in Nigeria's oil-rich south, has long been a security challenge, where wealthy locals and expatriate workers are often abducted.   Yet the problem has escalated in northern areas too, like Kaduna where criminal gangs made up of former cattle rustlers have been pushed into kidnapping after military crackdowns on cattle theft.   Kajuru is also flash point in the deadly conflict over increasingly limited land resources in Africa's most populous country, between herders and farmers, predominantly across central and northern Nigeria.    The conflict has increasingly taken on ethnic and religious dimensions in the region, with the Fulani Muslim herders in conflict with Christian Adara farmers in Kajuru.

Tourists are rarely affected by the herder-farmer violence and Kajuru Castle resort has attracted many foreign and local visitors.   Yet police have struggled to thwart kidnappers in the region. The latest attack comes in a resort in northern Nigeria, particularly popular amongst foreign and well-to-do local tourists.   In January four western tourists -- two Americans and two Canadians -- were also abducted in Kaduna by gunmen in an ambush in which two of their police escorts were killed.   Earlier in April, recently re-elected President Muhammadu Buhari, ordered his most senior security chiefs to curb kidnapping in the region.
Date: Sun, 21 Apr 2019 09:55:31 +0200

Lilongwe, Malawi, April 21, 2019 (AFP) - Three people died after a landslide hit a village in the Rumphi district in northern Malawi, with at least five still missing Sunday and many others injured and hospitalised.   Rumphi police spokesperson Tupeliwe Kabwilo told AFP that incessant rains in the area led to the landslide early Saturday which washed away an entire village nestled between Mphompha Hills and Lake Malawi.   Among the dead are two boys aged 12 and 15 and a 35-year-old woman, according to police.   The missing persons, who are feared dead, include a one-year-old boy, two other boys aged six and 10 as well as two women aged 35 and 46.

A Rumphi district council official who was at the scene of the disaster told AFP that the affected area was inaccessible by road and it would be impossible to mount a rescue operation.   "Huge boulders rolled from the mountain and these are the ones that cause the biggest damage and if the missing victims are buried under these rocks, then we will need an excavator to move them." said council official Wakisa Mtete.    "But there is no access by road to the area so this is an impossible task. The boulders are so big that moving them by hand is not possible," Mtete said.    He added that it was also possible for some of the missing bodies to have been washed into the lake, in which case the bodies would resurface within the next two days.

Disaster management officer Alufeyo Mhango told AFP that government ministries were preparing to step in to transport heavy duty excavation equipment over the lake as soon as the weather cleared.   "We have been informed by government ministries that we should get ready to transport the equipment. But this will depend on whether we get a large boat for that and on whether the hailstorm stops because there could be a recurrence of the landslide," he said.   According to Mhango, Police officers, soldiers and emergency personnel are on site attending to the disaster.
Date: Sat, 20 Apr 2019 15:21:54 +0200

Butembo, DR Congo, April 20, 2019 (AFP) - The DR Congo army fought off an attack on a hospital by a rebel group, killing one militiaman, police said Saturday, in the latest assault on medical staff trying to rein in an Ebola outbreak in the east of the country.   Armed rebels from the Mai-Mai militia attacked Katwa hospital near the city of Butembo at around 3.40 am (0140 GMT), officers told AFP.   "We have resisted and repelled the attack even though these 'Mai-Mai' had a PKM machine gun," said Butembo police chief Colonel Paul Ngoma.   He said one rebel was killed and four captured.   The attack came a day after a WHO doctor, Richard Valery Mouzoko Kiboung, was shot dead in an assault by armed militiamen on Butembo University Hospital, according to the World Health Organization.   The WHO said the epidemiologist had been deployed to help combat Ebola in the region.

The attacks are the latest in a string of assaults on teams grappling with a near nine-month-old Ebola outbreak that has claimed almost 850 lives.   UN Secretary General Antonio Guterres on Friday condemned the Butembo University Hospital attack and called on Congolese authorities to bring the perpetrators to justice.   DR Congo declared its tenth outbreak of Ebola last August, in north-eastern North Kivu province, before the virus spread into the neighbouring Ituri region.   Local organisations have said the number of Ebola deaths is rising.    An updated toll by the health ministry, issued on Wednesday, said there had been 843 deaths since August.

WHO data from April 9 put the number of confirmed or probable cases at 1,186, of which 751 had been fatal.   The outbreak is the second deadliest on record, after the epidemic that struck West Africa in 2014-16, which killed more than 11,300 people.    Efforts to roll back the highly contagious haemorrhagic fever in DRC have been hampered by fighting but also by resistance within communities to preventative measures, care facilities and safe burials.    On March 9, an attack on a treatment centre at Butembo left a policeman dead and a health worker wounded. It was the third attack on that centre.   On February 24, a treatment centre in Katwa was set ablaze.
Date: Fri, 19 Apr 2019 16:36:32 +0200

Khokha, Yemen, April 19, 2019 (AFP) - Oxfam has warned that war-torn Yemen risks a "massive resurgence" of cholera, with around 195,000 suspected cases of the disease recorded so far this year.   "Fears that the world's worst cholera outbreak could be set for a massive resurgence are growing," the relief organisation said Thursday.   It said aid agencies were struggling to reach suspected cases.

In a statement, Oxfam pointed to "fighting and restraints on access, including checkpoints and permit requirements imposed by the warring parties", and warned the coming rainy season was likely to accelerate the spread of the disease.   The water-borne bacterial infection has claimed more than 3,000 lives in Yemen since the outbreak began in 2016, according to Oxfam.

At a medical centre for the displaced in the government-held western town of Khokha, Qassem Suleiman had brought his son Alaa for tests after a serious case of diarrhoea.   Doctor Wadah al-Tiri told AFP that several patients had been transferred to Aden while others had been treated at the Khokha centre.   He said a tent was to be set up for suspected cases.

The doctor said Yemen badly needed international aid to combat the epidemic.   The UN's humanitarian coordination office OCHA said last month that children under the age of five make up nearly a third of this year's cases.   The spike, which comes two years after Yemen suffered its worst cholera outbreak, was concentrated in six governorates including in the Red Sea port of Hodeida and Sanaa province, both combat zones, it said.

Yemen's conflict, which pits Iran-linked rebels against a regional pro-government alliance led by Saudi Arabia, has left some 10,000 people dead since 2015 and pushed millions to the brink of famine.   Aid groups say the actual death toll could be five times as high.    The war has created the perfect environment for cholera to thrive, as civilians across the country lack access to clean water and health care.