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Afghanistan

Afghanistal US Consular Information Sheet March 03, 2009


COUNTRY DESCRIPTION:


Afghanistan has made significant progress since the Taliban were deposed in 2001, but still faces daunting challenges, including de

eating terrorists and insurgents, recovering from over three decades of civil strife, dealing with years of severe drought and rebuilding a shattered physical, economic and political infrastructure. Coalition and NATO forces under ISAF work in partnership with Afghan security forces to combat Taliban and al-Qa’ida elements who seek to terrorize the population and challenge the government. Violence in 2008 reached unprecedented levels, as both ISAF/Afghan forces and the Taliban initiated more battles than ever before. President Hamid Karzai was sworn in as President of the Islamic Republic of Afghanistan on December 7, 2004 and the Afghan Parliament was subsequently convened in late 2005. The government is working to develop a more effective police force, a more robust legal system, and sub-national institutions that work in partnership with traditional and local leaders to meet the needs of the population. The U.S. works closely with the international community to provide coordinated support for these efforts. An Afghanistan-hosted Peace Jirga with Pakistan resulted in a commitment to cooperate in combating terrorism, facilitate the return of Afghan refugees, and support regional economic activity. Read the Department of State Background Notes on Afghanistan for additional information.


ENTRY/EXIT REQUIREMENTS:


 A passport and valid visa are required to enter and exit Afghanistan. Afghan entry visas are not available at Kabul International Airport or any other ports of entry in Afghanistan. American citizens who arrive without a visa are subject to confiscation of their passport and face heavy fines and difficulties in retrieving their passport and obtaining a visa, as well as possible deportation from the country. Americans arriving in the country via military air usually have considerable difficulties if they choose to depart Afghanistan on commercial air, because their passports are not stamped to show that they entered the country legally. Those coming on military air should move quickly after arrival to legalize their status if there is any chance they will depart the country on anything other than military air. Visit the Embassy of Afghanistan web site at http://www.embassyofafghanistan.org for the most current visa information. The Consular office of the Embassy of Afghanistan is located at 2233 Wisconsin Avenue NW, Suite 216, Washington, DC 20007, phone number 202-298-9125. 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 latest Travel Warning for Afghanistan emphasizes that the security situation remains critical for American citizens. The Taliban and associated insurgent groups, al-Qaida network terrorist organizations, and narco-traffickers oppose the strengthening of a democratic government. These groups aim to weaken or bring down the Government of Afghanistan and to drive Westerners out of the country. They do not hesitate to use violence, including targeting civilians. Terrorist activities may include, but are not limited to bombings -- including improvised explosive devices and car bombs -- assassinations, carjackings, rocket attacks, assaults and kidnappings. There were over 120 suicide attacks in 2008. There is an ongoing threat to attack and kidnap U.S. citizens and Non-Governmental Organization (NGO) workers throughout the country. In 2008,, more than 30 NGO workers were killed (six foreigners) and at least 78 NGO staff members (seven foreigners) were abducted. Over 25 other foreign civilians, including journalists, were kidnapped. Kabul continues to experience suicide bombings against Afghan government personnel and installations, Afghan and coalition military assets, and international civilians. Riots -- sometimes violent -- have occurred in response to various political or other issues. Crime, including violent crime, remains a significant problem. Official Americans' use of the Kabul-Jalalabad, Kabul-Kandahar highways and other roads throughout the country is often restricted or completely curtailed because of security concerns. Insurgents continue to use roadside and car bombs to conduct attacks and abductions along major highways. Millions of unexploded land mines and other ordinance present a constant danger. The country faces a difficult period in the near term, and American citizens could be targeted or placed at risk by unpredictable local events. Americans should not come to Afghanistan unless they have made arrangements in advance to address security concerns. The absence of records for ownership of property, differing laws from various regimes and the chaos that comes from decades of civil strife have left property issues in great disorder. Afghan-Americans returning to Afghanistan to recover property, or Americans coming to the country to engage in business, have become involved in complicated real estate disputes and have faced threats of retaliatory action, including kidnapping for ransom and death. Large parts of Afghanistan are extremely isolated, with few roads, mostly in poor condition, irregular cell phone signals, and none of the basic physical infrastructure found in Kabul or the larger cities. Americans traveling in these areas who find themselves in trouble may not even have a way to communicate their difficulties to the outside world. For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site, where the current Travel Warnings and Travel Alerts, as well as the Worldwide Caution, can be found. Up-to-date information on safety and security can also be obtained by calling 1-888-407-4747 toll-free in the U.S. and Canada, or for callers outside the U.S. and Canada, a regular toll line at 1-202-501-4444. These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays). The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas. For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State’s pamphlet A Safe Trip Abroad.


CRIME:


 A large portion of the Afghan population is unemployed, and many among the unemployed have moved to urban areas. Basic services are rudimentary or non-existent. These factors may directly contribute to crime and lawlessness. Diplomats and international relief workers have reported incidents of robberies and household burglaries as well as kidnappings and assault. Any American citizen who enters Afghanistan should remain vigilant for possible banditry, including violent attacks.


INFORMATION FOR VICTIMS OF CRIME:


The loss or theft abroad of a U.S. passport should be reported immediately to the local police and to the U.S. Embassy in Kabul. If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the U.S. Embassy in Kabul for assistance. The Embassy staff can, for example, assist you to find appropriate medical care, contact family members or friends and explain how funds could be transferred. Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to provide a list of attorneys if needed. The local equivalent to the "911" emergency line in Afghanistan is: 119 Please see our information on Victims of Crime, including possible victim compensation programs in the United States.


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 Afghanistan’s laws, even unknowingly, may be expelled, arrested or imprisoned. During the last several years, there have been incidents involving the arrest and/or detention of U.S. citizens. Arrested Americans have faced periods of detention—sometimes in difficult conditions—while awaiting trial. Penalties for possession or use of, or trafficking in illegal drugs in Afghanistan are severe, and convicted offenders can expect long jail sentences and heavy fines. Another sensitive activity is proselytizing. Although the Afghan Constitution allows the free exercise of religion, proselytizing is often viewed as contrary to the beliefs of Islam and considered harmful to society. Proselytizing may lead to arrest and/or deportation. 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.


SPECIAL CIRCUMSTANCES:


Because of the poor infrastructure in Afghanistan, access to banking facilities is limited and unreliable. Afghanistan's economy operates on a "cash-only" basis for most transactions. Credit card transactions are not available. International bank transfers are limited. Some ATM machines exist at Standard Charter Bank and Afghan International Bank (AIB) in the Wazir Akbar Khan neighborhood of Kabul, but some travelers have complained of difficulties using them. International communications are difficult. Local telephone networks do not operate reliably. Most people rely on satellite or cellular telephone communications even to make local calls. Cellular phone service is available locally in Kabul and some other cities, but can be unreliable. Injured or distressed foreigners could face long delays before being able to communicate their needs to family or colleagues outside of Afghanistan. Internet access through local service providers is limited. In addition to being subject to all Afghan laws, U.S. citizens who are also citizens of Afghanistan may also be subject to other laws that impose special obligations on Afghan citizens. U.S. citizens who are also Afghan nationals do not require visas for entry into Afghanistan. The Embassy of Afghanistan issues a letter confirming your nationality for entry into Afghanistan. However, you may wish to obtain a visa as some Afghan-Americans have experienced difficulties at land border crossings because they do not have a visa in their passport. For additional information on dual nationality in general, see the Consular Affairs home page for our dual nationality flyer. U.S. citizens are encouraged to carry a copy of their U.S. passport with them at all times, so that, if questioned by local officials, proof of identity and U.S. citizenship is readily available. As stated in the Travel Warning, consular assistance for American citizens in Afghanistan is limited. Islam provides the foundation of Afghanistan's customs, laws and practices. Foreign visitors -- men and women -- are expected to remain sensitive to the Islamic culture and not dress in a revealing or provocative manner, including the wearing of sleeveless shirts and blouses, halter-tops and shorts. Women in particular, especially when traveling outside of Kabul, may want to ensure that their tops have long sleeves and cover their collarbone and waistband, and that their pants/skirts cover their ankles. Almost all women in Afghanistan cover their hair in public; American women visitors should carry scarves for this purpose. Afghan customs authorities may enforce strict regulations concerning temporary importation into or export from Afghanistan of items such as firearms, alcoholic beverages, religious materials, antiquities, medications, and printed materials. American travelers have faced fines and/or confiscation of items considered antiquities upon exiting Afghanistan. It is advisable to contact the Embassy of Afghanistan in Washington for specific information regarding customs requirements. Travelers en route to Afghanistan may transit countries that have restrictions on firearms, including antique or display models. If you plan to take firearms or ammunition to another country, you should contact officials at that country's embassy and those that you will be transiting to learn about their regulations and fully comply with those regulations before traveling. Please consult http://www.customs.gov for information on importing firearms into the United States. Please see our Customs Information sheet.


MEDICAL FACILITIES AND HEALTH INFORMATION:


Well-equipped medical facilities are few and far between throughout Afghanistan. European and American medicines are available in limited quantities and may be expensive or difficult to locate. There is a shortage of basic medical supplies. Basic medicines manufactured in Iran, Pakistan, and India are available, but their reliability can be questionable. Several western-style private clinics have opened in Kabul: the DK-German Medical Diagnostic Center (www.medical-kabul.com), Acomet Family Hospital (www.afghancomet.com), and CURE International Hospital (ph. 079-883-830) offer a variety of basic and routine-type care; Americans seeking treatment should request American or Western health practitioners. Afghan public hospitals should be avoided. Individuals without government licenses or even medical degrees often operate private clinics; there is no public agency that monitors their operations. Travelers will not be able to find Western-trained medical personnel in most parts of the country outside of Kabul, although there are some international aid groups temporarily providing basic medical assistance in various cities and villages. For any medical treatment, payment is required in advance. Commercial medical evacuation capability from Afghanistan is limited and could take days to arrange. Even medevac companies that claim to service the world may not agree to come to Afghanistan. Those with medevac insurance should confirm with the insurance provider that it will be able to provide medevac assistance to this country. There have been outbreaks of Avian Influenza in poultry in Afghanistan, to include the areas of Nangahar, Laghman, and Wardak provinces, and in the city of Kabul, however, there have been no reported cases of the H5N1 virus in humans. Updates on the Avian Influenza situation in Afghanistan are published on the Embassy’s web site at http://kabul.usembassy.gov/information_for_travelers.html. For additional information on Avian Influenza, please refer to the Department of State's Avian Influenza Fact Sheet available at http://travel.state.gov/travel/tips/health/health_1181.html Tuberculosis is an increasingly serious health concern in Afghanistan. For further information, please consult the CDC's Travel Notice on TB. http://wwwn.cdc.gov/travel/yellowBookCh4-TB.aspx| The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to or foreign residents of Afghanistan. However, if one has questions, please inquire directly with the Embassy of Afghanistan at http://www.embassyofafghanistan.org before you travel. 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. For information about outbreaks of infectious diseases abroad, consult the World Health Organization’s (WHO) web site. Further health information for travelers is available from the WHO.


MEDICAL INSURANCE:


The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation. Please see our information on medical insurance overseas. TRAFFIC


SAFETY AND ROAD CONDITIONS:


 While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States. The information below concerning Afghanistan is provided for general reference only, and may not be totally accurate in a particular location or circumstance. All drivers face the potential danger of encountering improvised-explosive devices and land mines that may have been planted on or near roadways. An estimated 5-7 million landmines and large quantities of unexploded ordinance exist throughout the countryside and alongside roads, posing a danger to travelers. Robbery and kidnappings are also prevalent on highways outside of Kabul. The transportation system in Afghanistan is marginal, although the international community is constructing modern highways and provincial roads. Vehicles are poorly maintained, often overloaded, and traffic laws are not enforced. Vehicular traffic is chaotic and must contend with numerous pedestrians, bicyclists and animals. Many urban streets have large potholes and are not well lit. Rural roads are not paved. 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 carriers registered in Afghanistan, the U.S. Federal Aviation Administration (FAA) has not assessed Afghanistan’s Civil Aviation Authority for compliance with International Civil Aviation Organization (ICAO) aviation safety standards. For more information, travelers may visit the FAA’s internet website at http://www.faa.gov/safety/programs_initiatives/oversight/iasa. U.S. Government personnel are not authorized to travel on Ariana Afghan Airlines or any other airline falling under the oversight of the Government of Afghanistan’s Civil Aviation Authority, owing to safety concerns; however, U.S. Government personnel are permitted to travel on international flights operated by airlines from countries whose civil aviation authorities meet international aviation safety standards for the oversight of their air carrier operations under the FAA’s International Aviation Safety Assessment (IASA) program.


CHILDREN'S ISSUES:


 For information see our Office of Children’s Issues web pages on intercountry adoption and international parental child abduction. R


EGISTRATION / EMBASSY LOCATION:


Americans living or traveling in Afghanistan are encouraged to register with the U.S. Embassy through the State Department’s travel registration web site and to obtain updated information on travel and security within Afghanistan. Americans without internet access may register directly with the U.S. Embassy. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency. The U.S. Embassy is located in Kabul on Great Massoud (Airport) Road, local phone number 0700-108-001 or 0700-108-002, and for emergencies after hours 0700-201-908. The web site is http://kabul.usembassy.gov/ * * * * * This replaces the Country Specific Information dated June 16, 2008 to update sections on Country Description, Entry/Exit Requirements, Safety and Security, Information for Victims of Crime, Criminal Penalties, Special Circumstances, and Medical Facilities and Health Information.

Travel News Headlines WORLD NEWS

Date: Thu, 7 Mar 2019 10:54:44 +0100
By Mushtaq MOJADDIDI

Kabul, March 7, 2019 (AFP) - At least two blasts struck a large ceremony Thursday attended by Afghanistan chief executive Abdullah Abdullah and other leading government officials, killing one person and injuring 17 others.   The Kabul attack represents a major security breach and marks a resumption of violence in the capital after weeks of calm amid ongoing peace talks between the US and Taliban in Doha.   "Stay calm, the area of the blast is far from us," said former lower house speaker Mohammad Younus Qanooni during a live broadcast of the event.   But moments after the announcement, another explosion and gunfire could be heard that sent people running.   A second unidentified voice then addressed the screaming crowd, saying: "I request my countrymen to stay calm. The mortar attack is far from the gathering."

The blasts happened during a ceremony marking the 24th anniversary of the death of Shiite Hazara leader Abdul Ali Mazari that was attended by many of the country's political elite, including Abdullah and former President Hamid Karzai.   "Terrorists were firing Mortars at Abdul Ali Mazari remembrance ceremony, from inside a compound," deputy interior minister Khoshal Sadat said in English on Twitter, adding that police had arrested one person linked to the attack.    "One martyred, 17 wounded -- 3 children and one woman among them," tweeted Wahidullah Mayar, spokesman for the health ministry.    Foreign Minister Salahuddin Rabbani -- who was at the scene -- later added that "terrorists launched rocket attacks on commemoration ceremony", and said he had escaped safely.   It remained unclear whether rockets or mortar fire were being used, with officials using both terms.

- 'Unforgivable attack' -
No group has claimed responsibility for the blasts.   "This was the most horrid and unforgivable attack on civilians by a merciless enemy," tweeted presidential candidate and former national security adviser Mohammad Haneef Atmar.   He added that eight of his security guards were injured in the attack.     The incident comes as US and Taliban negotiations continue to hold peace talks in Qatar aimed at ending the nearly 18-year conflict. 

The last major attack in Kabul occurred in January when the Taliban-claimed responsibility for a car bomb that struck the heavily fortified Green Village foreign compound.    Heavy snowfall across large swathes of Afghanistan has led to a reduction in violence this winter, but warmer weather in the country's south will likely spark an increase in bloodshed with the arrival of the spring fighting season.   Analysts have warned that the Taliban are likely to ramp up attacks in the coming months as they seek to maintain momentum on the battlefield and leverage at the negotiating table.

On Wednesday at least 16 people were killed in a suicide attack on a construction company in eastern Afghanistan's Jalalabad city.    The hours-long attack began early Wednesday when two suicide bombers detonated explosives at the gate of the compound, allowing three others to enter the area where they went on a killing spree.   No group has claimed responsibility for the attack, but both the Islamic State group and the Taliban are active near the city, in Nangarhar province.   Afghanistan has been enmeshed in nearly constant conflict since the Soviet invasion of 1979, which was followed by civil war, the Taliban regime, and the US invasion in late 2001.
Date: Sat, 2 Mar 2019 18:38:14 +0100

Kandahar, Afghanistan, March 2, 2019 (AFP) - At least 20 people were killed by flash floods in southern Afghanistan's Kandahar province, the UN said Saturday, as heavy rains swept away homes and vehicles and potentially damaged thousands of houses.   The United Nations Office for the Coordination of Humanitarian Affairs said widespread flooding indudated Kandahar city and surrounding districts in the province, with 97mm of rain falling in affected areas in the last 30 hours.   "At least 10 people, including children, are still missing," said the UN agency in a statement.

"It is anticipated that up to 2,000 homes may have been damaged", with severe damage to infrastructure also being reported.   Kandahar's deputy governor Abdul Hanan Moneeb said the flooding was the worst in at least seven years, with many nomadic herders camped in the area swept away by the floodwaters along with their livestock.   The official added that 400 families have been rescued by the Afghan army since the flooding began late Friday night.   Rescue operations, however, were largely delayed due to heavy rainfall, Raziq Shirzai, the provincial commander of the Afghan air force, told AFP.

Disasters such as avalanches and flash floods often hit mountainous areas and river valleys of Afghanistan as snow melts in the spring and summer. It is made worse by deforestation.   Heavy snowfall across large swathes of Afghanistan this winter has raised fears of severe flooding as spring approaches, following years of devastating drought in the country.   Nearly 50 people have been killed as of February 12 due to flooding in Afghanistan so far this year, according to the UN.
Date: Mon 18 Feb 2019 3:33:02 PM AFT
Source: MENAFN/Afghan Times, AT News report [edited]

One new polio case is just confirmed in southern Kandahar province, days after nationwide campaign against the crippling disease kicked off on [Mon 18 Feb 2019].  A 60-month-old boy from Ghorak district is infected by the poliovirus. This is the 2nd case reported in 2019, highlighting the ongoing risks of polio and the need for continued immunization, health officials said.  "From today [18 Feb 2019], polio vaccination teams will visit 5.8 million children under 5 years old in 195 high-risk districts of 21 provinces of West, Central, and Southeast regions of Afghanistan," said a statement issued by Ministry of Public Health (MoPH).

The Minister of Public Health Ferozuddin Feroz urged Afghan people to take the situation seriously and called on people to open doors to vaccinators in the upcoming campaign.  "We already have 2 cases reported from Kandahar this year [2019]. While there is polio anywhere in this country, all children are at risk. Polio will continue to fight for survival. Immunization is the only way to put an end to this virus. We urge the people of Kandahar and across the country to step up, open your doors and get your children vaccinated. We don't want to see any more children paralyzed by polio, and we need to work together to stop polio once and for all."

Polio is incurable and can paralyze children for life. The only way to prevent polio virus is to vaccinate all children with 2 drops of polio vaccine every time it is offered. Children are better protected with every additional dose of the vaccination. Repeated vaccination helps to build strong immunity of your child and the whole community.

The vaccination campaign will take place from [18-22 Feb 2019]. Parents should ensure their children are home and available to be vaccinated. All children under 5 should receive the polio vaccine, including children who are asleep, visiting other homes and new-borns, even if they have been immunized in the past. Children who miss the vaccination should visit their local health centre as soon as possible, where the vaccine is available free of charge. The polio vaccine is safe, even for sick and new-born children. It is very important these children get the vaccine, because they have lower immunity which makes them more susceptible to the virus. Polio vaccination has also been strongly endorsed by national and global Islamic scholars, the statement added.

Every country in the world except Pakistan, Nigeria, and Afghanistan has ended polio, highlighting the fact that the strategy and vaccines work Twenty-one Afghan children were infected by polio in 2018.
======================
[Sadly, transmission of the WPV continues in Pakistan and Afghanistan. Since the beginning of 2019 there have now been 6 cases confirmed, 4 in Pakistan and 2 in Afghanistan. The vaccination history of this child isn't included in this media report, but most likely the child was inadequately vaccinated at 60 months (5 years) of age. - ProMED Mod.MPP]

[HealthMap/ProMED map of Afghanistan:
Date: Tue 29 Jan 2019
Source: Afghanistan Times [edited]

Afghanistan's 1st polio case in 2019 was reported in Kandahar province, where a 22-month-old girl from Spin Boldak district was infected by the poliovirus.

According to a statement the Minister of Public Health, Dr Ferozuddin Feroz said, 'this case indicates that the poliovirus is still transmitting in Kandahar and the South region. This child's life is now changed forever. It is really sad that she will never walk properly again, therefore I call upon all of you, our Muslim parents, caregivers, community elders, and health workers to work together to protect our innocent children against this disease and eradicate polio in our country.'

He said that polio is a crippling and potentially fatal infectious disease. There is no cure and the polio vaccine is the only safe and effective way to protect children. All children should be vaccinated against polio during each campaign, until they reach the age of 5. House-to-house vaccination is the only effective way to achieve polio eradication because it means every child has access to vaccination. This strategy has been implemented in all countries and has proven efficacy. However, if parents live in areas where there is no house-to-house campaign available, they should take their children to the local health facility for free polio vaccine.

The polio vaccine is safe, even for sick and new-born children. It is very important these children get the vaccine, because they have low immunity which makes them more susceptible to the virus.

Polio vaccination has also been strongly endorsed by national and global Islamic scholars, he added.

Currently, Afghanistan, Pakistan, and Nigeria are the only 3 remaining polio-endemic countries in the world. There were 21 cases reported in Afghanistan in 2018. Of these, 15 cases were in the Southern region, while 6 cases were in the Eastern region. There is a polio vaccination campaign carried out in the Southern and Eastern regions of Afghanistan, parents should ensure their children are home and available to be vaccinated.
==========================
[The wording of the media report above suggests that the date of onset of paralysis of this case was in 2019, but it is possible onset was in late 2018. Clarification of the date of onset would be greatly appreciated.

Kandahar province is located in the Southwestern region of Afghanistan (see <https://www.researchgate.net/figure/Regions-of-Afghanistan_fig1_284510443> for a map of regions in Afghanistan and <http://www.afghana.com/GetLocal/Afghanistan/Provinces.htm> for a map of provinces in Afghanistan). It shares a border with Balochistan Pakistan.

In last week's global update, there was mention of 7 positive environmental samples in Afghanistan collected on 26 Dec 2018, that identified 3 of the 7 coming from Kandahar province, confirming that the WPV1 was actively circulating in the province (see Poliomyelitis update (08): global (Pakistan, Nigeria), WHO (Mozambique) http://promedmail.org/post/20190125.6277951). - ProMED Mod.MPP]

[HealthMap/ProMED-mail map of Afghanistan:
Date: Thu 24 Jan 2019
Source: Tolo News [edited]

At least 90 British military personnel have been diagnosed with confirmed cases of Q fever after serving in Helmand, Afghanistan. According to a UK military news outlet, Forces Network, a consultant in infectious diseases and tropical medicine told to the Central London Country Court on [Tue 22 Jan 2019], that 90 confirmed cases of Q fever had been recorded among British soldiers who had served in Helmand.

Lieutenant Colonel Mark Bailey's testimony was heard in the case of a private with 2nd Battalion, the Mercian Regiment, who said his life has been ruined after he contracted the disease while in Helmand in 2011/2012. During his tour, his lawyers said [the private] was in contact with goats and sheep and "was often required to take cover and jump through ditches and crawl along the ground -- coming into contact with animal products and excrement." The soldier was medically discharged from the Army in 2014 because of his Q fever and chronic fatigue symptoms.

Humans can catch Q fever by breathing in dust from the secretions of infected farm animals such as sheep, cattle, and goats.

Bailey, who specializes in infectious diseases and tropical medicine, and a national expert in Q fever said he has 90 military and 10 civilian cases in his care after they were referred to him. He confirmed the 90 had served in Helmand and said the number of military cases "built up from 2008", Forces Network reported. Bailey told the court: "We have seen no new cases since 2014 from Afghanistan. Occasionally we get other military cases from other locations. Cyprus most recently."

Bailey said he had seen "one British soldier who very, very nearly died" as a result of Q fever and subsequent complications, but there have been no UK deaths in his group.
====================
[Q fever is due to _Coxiella burnetii_, an obligate intracellular rickettsia-like bacterial pathogen. It is highly resistant to drying and heat, which enables the bacteria to survive for long periods in the environment. Its survival is attributed to a small cell variant of the organism that is part of its biphasic developmental cycle. Q fever is a zoonosis. Domestic ungulates such as sheep, cattle, and goats serve as the reservoir of infection for humans. The organism is shed in urine, feces, milk, and especially birthing products; intermittent high-level shedding occurs at the time of parturition, with millions of bacteria being released per gram of placenta.

Humans usually become infected by inhaling aerosolized organisms. Acute symptoms of a flu-like illness usually develop within 2-3 weeks of exposure, although as many as half of humans infected with _C. burnetii_ do not show symptoms (<http://www.cdc.gov/qfever/symptoms/index.html>). Although most persons with acute Q fever infection recover, others may experience serious illness with complications that may include pneumonia, granulomatous hepatitis, endocarditis (especially in patients with previous cardiac valvulopathy), myocarditis, and central nervous system involvement. Pregnant women who are infected may be at risk for pre-term delivery or miscarriage.

The solider likely suffers from Q fever-associated chronic fatigue. The following related to post-Q fever fatigue syndrome is extracted from Melgar TA, Bauler TJ, Lutwick LI. Q fever in man: A one health paradigm disease. In, The Principles and Practice of Q Fever, Simoes JCC, Anastacio SF, da Silva GJ (eds), Nova Science Publishers, 2017, pp 1-24:

"Up to 20% of patients with acute Q fever report chronic fatigue more than a year later. Most of these cases meet the CDC criteria for chronic fatigue syndrome. Other symptoms include night sweats, nausea, headache, myalgia, enlarged lymph nodes, arthralgia, insomnia, depression, decreased concentration and short term memory impairment. The pathogenesis is not clear although there is evidence that genetic factors may play a role and _C. burnetii_ antigens and DNA can be found in patients' macrophages for up to 12 years and in one case 70 years after acute infection (1,2). Treatment is focused on chronic fatigue including exercise therapy and cognitive behavior therapy. There are no current recommendations for antimicrobial therapy for Q fever-associated chronic fatigue although case reports and one study demonstrated improvement with antimicrobials (3). A large placebo controlled randomized trial in the Netherlands (4,5) reported some non-sustained improvement was found with cognitive-behavioral therapy but not with long term doxycycline.

References
----------
1. Marmion BP, Sukocheva O, Storm PA, et al. Q fever: persistence of antigenic non-viable cell residues of _Coxiella burnetii_ in the host - implications for post Q fever infection fatigue syndrome and other chronic sequelae. QJM 2009; 102(10): 673-84; abstract available at <https://www.ncbi.nlm.nih.gov/pubmed/19556396>.
2. Sukocheva OA, Marmion BP, Storm PA, et al. Long-term persistence after acute Q fever of non-infectious _Coxiella burnetii_ cell components, including antigens. QJM 2010; 103(11): 847-63; abstract available at <https://www.ncbi.nlm.nih.gov/pubmed/20639288>.
3. Arashima Y, Kato K, Komiya T, et al. Improvement of chronic nonspecific symptoms by long-term minocycline treatment in Japanese patients with _Coxiella burnetii_ infection considered to have post-Q fever fatigue syndrome. Intern Med 2004; 43(1): 49-54; <https://www.jstage.jst.go.jp/article/internalmedicine/43/1/43_1_49/_article>.
4. Keijmel SP, Delsing CE, Bleigenberg G, et al. Effectiveness of long-term doxycycline treatment and cognitive-behavioral therapy on fatigue severity in patients with Q fever fatigue syndrome (Qure study): a randomized controlled trial. Clin Infect Did 2017; 64(8): 998-1005; <https://academic.oup.com/cid/article/64/8/998/3056564>.
5. Raijmakers RPH, Keijmel SP, Breukers EMC, et al. Long-term effect of cognitive behavioural therapy and doxycycline treatment for patients with Q fever fatigue syndrome: one-year follow-up of the Qure study. J Psychosom Res 2019; 116: 62-7; <https://www.sciencedirect.com/science/article/pii/S0022399918308183>.

Helmand is one of the 34 provinces of Afghanistan, in the south of the country. It can be seen on a map at

[HealthMap/ProMED-mail map of Afghanistan:
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Bolivia

Bolivia US Consular Information Sheet
July 19, 2006

COUNTRY DESCRIPTION: Bolivia is a constitutional democracy and one of the least-developed countries in South America. Tourist facilities are generally adequate, but vary greatly in qualit
. The capital is La Paz, accessible by Bolivia's international airport in El Alto. Read the Department of State Background Notes on Bolivia for additional information.

ENTRY/EXIT REQUIREMENTS: A U.S. passport valid for at least six months from the date of proposed entry into Bolivia is required to enter and depart Bolivia. U.S. citizen tourists do not need a visa for a stay of one month or less (that period can be extended up to 90 days upon application to the Bolivian immigration authorities). Visitors for other purposes must obtain a visa in advance. U.S. citizens whose passports are lost or stolen in Bolivia must obtain a replacement passport and present it, together with a police report of the loss or theft, to a Bolivian government immigration office in order to obtain permission to depart. For more information on replacement passport procedures, please consult the U.S. Embassy's Web site at . An exit tax is charged when departing Bolivia by air. Travelers with Bolivian citizenship or residency pay an additional fee upon departure. While the Bolivian Government does not require travelers to purchase round-trip air tickets in order to enter the country, some airlines have required travelers to purchase round-trip tickets prior to boarding aircraft bound for Bolivia. Some tourists arriving by land report that immigration officials did not place entry stamps in their passports, causing problems at checkpoints and upon departure. See our Foreign Entry Requirements brochure for more information on Bolivia and other countries. Visit the Embassy of Bolivia web site at for the most current visa information (please note that the web site is primarily in Spanish).

Bolivian consulates are located in Houston, Los Angeles, Miami, Oklahoma City, New York, San Francisco, and Seattle. For information on in-country visa procedures and requirements, please consult the Bolivian Immigration Service at (please note that the web site is in Spanish), fax/telephone (591-2) 211-0960, street address Avenida Camacho entre Loayza y Bueno, La Paz, Bolivia. See Entry and Exit Requirements for more information pertaining to dual nationality and the international child abduction . Please refer to our Customs Information to learn more about customs regulations.

ADDITIONAL REQUIREMENTS FOR MINORS: In an effort to prevent international child abduction, the Bolivian Government has initiated procedures at entry/exit points. Minors (under 18) who are citizens or residents of Bolivia and who are traveling alone, with one parent or with a third party, must present a copy of their birth certificate and written authorization from the absent parent(s) or legal guardian, specifically granting permission to travel alone, with one parent or with a third party. When a parent is deceased, a notarized copy of the death certificate is required in lieu of the written authorization. If documents are prepared in the United States, the authorization and the birth certificate must be translated into Spanish, notarized, and authenticated by the Bolivian Embassy or a Bolivian consulate within the United States. If documents are prepared in Bolivia, only notarization by a Bolivian notary is required. Using these documents, a t ravel permit may be obtained from the Juzgado del Menor. This requirement does not apply to children who enter the country with a U.S. passport as tourists, unless they hold dual U.S./Bolivian citizenship or have been in Bolivia for more than 90 consecutive days.

SAFETY AND SECURITY: The countrywide emergency number for the police, including highway patrol, is 110. The corresponding number for the fire department is 119. The National Tourism Police has an office in La Paz, with plans to expand to Cochabamba and Santa Cruz, providing free assistance to tourists 24 hours a day. These services include English-speaking officials who may assist tourists in filing police reports of lost/stolen documents or other valuables. The La Paz office is located at Plaza del Stadium, Edificio Olympia, planta baja, Miraflores, telephone number 222-0516.

Protests, strikes, and other civic actions can occur at any time and disrupt transportation on a local and national level. This is particularly true before, during and after elections or other changes in government. While protest actions generally begin peacefully, they have the potential to become violent. The police have used tear gas to break up protests. In addition to rallies and street demonstrations, protesters sometimes block roads; they sometimes react with force when travelers attempt to pass through or go around roadblocks and occasionally have used the threat of explosives to press their point.

U.S. citizens should avoid roadblocks and demonstrations. Demonstrations protesting government or private company policies occur frequently, even in otherwise peaceful times. Roadblocks and demonstrations in June 2005 led to the closure of the El Alto airport in La Paz, resulting in cancellation and diversion of flights and other inconveniences to travelers. U.S. citizens planning travel to or from Bolivia should take into consideration the possibility of disruptions to air service in and out of La Paz and other airports. Americans should monitor Bolivian media reports for updates. The Embassy strongly recommends that U.S. citizens avoid areas where roadblocks or public demonstrations are occurring or planned. Political rallies should similarly be avoided in light of press reports of violence at some rallies in various parts of Bolivia.

U.S. citizens who find themselves in a roadblock should not attempt to "run" a roadblock, as this may aggravate the situation and lead to physical harm. Taking alternative, safe routes, or returning to where the travel started may be the safest courses of action under these circumstances. U.S. citizens embarking on road trips should monitor news reports and may contact the American Citizen Services Unit of the U.S. Embassy in La Paz at (591)(2)(216-8297 or the U.S. consular agencies in Cochabamba at (591)(4)425-6714 and/or Santa Cruz at (591) (3) 351-3477 for updates. Given that roadblocks may occur without warning and have stranded travelers for several days, travelers should take extra food and water. The U.S. Embassy also advises its employees to maintain at least one week's supply of drinking water and canned food in case roadblocks affect supplies, as occurred in June 2005. For more information on emergency preparedness, please consult the Federal Emergency Management Authority (FEMA) Web site at . That Web site includes a Spanish language version.

Americans living or traveling in Bolivia are encouraged to register and update their contact information at the U.S. Embassy in La Paz and/or the U.S. consular agencies in Cochabamba and Santa Cruz, Bolivia. Registration may be done online and in advance of travel. Information on registering may be found at the Department of State's Consular Affairs website .

In February and October 2003, approximately one hundred people died during violent demonstrations and protests in downtown La Paz and the nearby city of El Alto. These demonstrations also affected Cochabamba and other towns and villages in the Altiplano. While the protests and demonstrations subsided, many of the underlying social, political, and economic causes remain, and in March 2005, several intercity roads, including Bolivia's major east-west highway, were closed by blockades for several weeks.

Since 2000 the resort town of Sorata, located seventy miles north of La Paz, has been cut off by blockades on three occasions, ranging from one week to one month. Visitors contemplating travel to Sorata should contact the Consular Section in La Paz prior to travel.

In the Chapare region between Santa Cruz and Cochabamba and the Yungas region northeast of La Paz violence and civil unrest, primarily associated with anti-narcotics activities, periodically create a risk for travelers to those regions.

Confrontations between area residents and government authorities over coca eradication have resulted in the use of tear gas and stronger force by government authorities to quell disturbances. Pro-coca groups have expressed anti-U.S. sentiments and may attempt to target U.S. Government or private interests. U.S. citizen visitors to the Chapare or Yungas regions are encouraged to check with the Consular Section of the U.S. Embassy prior to travel. Violence has also erupted recently between squatters unlawfully invading private land and security forces attempting to remove them.

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

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

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

CRIME: The U.S. Department of State currently classifies Bolivia as a medium to high crime threat country. Street crime, such as pick pocketing and theft from parked vehicles, occurs with some frequency in Bolivia. Theft of cars and car parts, particularly late-model four-wheel-drive vehicles, is common. Hijacking of vehicles has occurred, and travelers should take appropriate precautions to avoid being victimized. In November 2003, an American citizen was murdered during an attempted carjacking in Santa Cruz.

Bolivian police state that there are currently eight organized criminal groups operating in the La Paz area. The techniques employed by these groups vary, but there are a few major patterns that can be identified.

There have been reports of "false police" -- persons using police uniforms, identification, and even buildings modified to resemble police stations -- intercepting and robbing foreign tourists. Under Bolivian law, police need a warrant from the "fiscal" or prosecutor to detain a suspect. Any searches or seizures must occur at a bona fide police station in the presence of the fiscal. The warrant requirement also applies to suspected drug trafficking cases, although such searches and seizures may occur without a fiscal present. If detained, U.S. citizens should request to see the warrant and demand immediate contact with the nearest U.S. Consular Office (in La Paz, Cochabamba or Santa Cruz).

According to press reports, criminals using the "false police" method focus on foreigners in areas frequented by tourists including bus terminals and tourist markets such as Sagarnaga Street in La Paz. The perpetrators will identify a potential victim and have an accomplice typically driving a white taxi offer taxi services to the potential victim. They focus on European/American tourists who are not wearing a traditional "trekker" backpack and are traveling without a large number of bags. A few blocks after the potential victim boards the taxi another accomplice, pretending to be a recently arrived tourist, boards the taxi with the potential victim. With all the accomplices then in place, the "false police" stop the taxi, "search" the passengers, and rob the victim. As part of this scam, the false police may take the victim to a "false police" station.

A similar variation also introduces a "tourist" to the victims. This introduction can take place on a bus, taxi, train, or just walking down the street. The "tourist" will befriend the victims and might seek assistance in some manner. After a period of time, the "police" intercept the victims and the "tourist." At this point, the "police" discover some sort of contraband (usually drugs) on the "tourist." The entire group is then taken to the "police station." At this point, the "police" seize the documents, credit cards, and ATM cards of the victims. The perpetrators obtain pin numbers, sometimes by threat of violence, and the scam is complete.

Another technique again introduces a "tourist" to the victims. This "tourist" can be any race or gender and will probably be able to speak the language of the victims. This meeting can happen anywhere and the goal of the "tourist" is to build the trust of the victims. Once a certain level of trust is obtained, the "tourist" suggests a particular mode of transportation to a location (usually a taxi). The "taxi" picks up the victims and the "tourist" and delivers the group to a safe house in the area. At this point the victims are informed that they are now kidnapped and are forced to give up their credit cards and ATM cards with pin numbers.

Bolivian police sources state that two Austrian citizens fell victim to this scam and had their bank accounts emptied through use of their ATM card. The perpetrators then suffocated the victims and buried them in clandestine graves, where police found their bodies on April 3, 2006. During that timeframe, a Spanish citizen also purportedly fell prey to this scam, and his body was found nearby.

In most instances, the victims are released, but the murder of the victims is still a possibility. The techniques and the perpetrators are convincing. Authentic uniforms, badges, and props help persuade the victims that the situation is real and valid. All tourists visiting Bolivia should exercise extreme caution. Visitors should be suspicious of all "coincidences" that can happen on a trip. If the tourist has doubts about a situation, the tourist should immediately remove him/herself from the scene.

Thefts of bags, wallets, and backpacks are a problem throughout Bolivia, but especially in the tourist areas of downtown La Paz and the Altiplano. Most thefts involve two or three people who spot a potential victim and wait until the bag or backpack is placed on the ground, often at a restaurant, bus terminal, Internet café, etc. In other cases, the thief places a disagreeable substance on the clothes or backpack of the intended victim, and then offers to assist the victim with the removal of the substance. While the person is distracted, the thief or an accomplice grabs the bag or backpack and flees. In such a situation, the visitor should decline assistance, secure the bag/backpack, and walk briskly from the area. To steal wallets and bags, thieves may spray water on the victim's neck, and while the person is distracted, an accomplice takes the wallet or bag. At times the thief poses as a policeman, and requests that the person accompany him to the police station, using a nearby taxi. The visitor should indicate a desire to contact the U.S. Embassy and not enter the taxi. Under no circumstances should you surrender ATM or credit cards, or release a PIN number. While most thefts do not involve violence, in some instances the victim has been physically harmed and forcibly searched for hidden valuables. Visitors should avoid being alone on the streets, especially at night and in isolated areas.

Five years ago female tourists reported being drugged and raped by a tourist guide in the city of Rurrenabaque in the Beni region. Visitors should be careful when choosing a tour operator and should not accept any type of medication or drugs from unreliable sources. The Embassy has received reports of sexual assaults against female hikers in the Yungas Valley, near the town of Coroico. Visitors to Coroico are advised to avoid hiking alone or in small groups.

INFORMATION FOR VICTIMS OF CRIME: The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the nearest U.S. Embassy or Consulate. If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the nearest U.S. Embassy or Consulate for assistance. The Embassy/Consulate staff can, for example, assist you to find appropriate medical care, contact family members or friends, and explain how funds may be transferred. Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.

See our information on Victims of Crime .
MEDICAL FACILITIES AND HEALTH INFORMATION: Medical care in large cities is adequate for most purposes but of varying quality. Ambulance services are limited-to-non-existent. Medical facilities are generally not adequate to handle serious medical conditions. Pharmacies are located throughout Bolivia, and prescription and over the counter medications are widely available. Western Bolivia, dominated by the Andes and high plains (Altiplano), is largely insect-free. However, altitude sickness (see below) is a major problem. Eastern Bolivia is tropical, and visitors to that area are subject to related illnesses. In March 2005, several cases of yellow fever were reported in the Chapare region. News media periodically report outbreaks of rabies, particularly in the larger cities.

Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention's hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC's Internet site at . For information about outbreaks of infectious diseases abroad consult the World Health Organization's (WHO) website at . Further health information for travelers is available at .

MEDICAL INSURANCE: The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation. Most medical evacuation flights cannot land at the airport serving La Paz due to the altitude; instead flights may need to use the international airport in Santa Cruz, Bolivia. Please see our information on medical insurance overseas .

HIGH-ALTITUDE HEALTH RISKS: Official U.S. Government travelers to La Paz are provided with the following information: The altitude of La Paz ranges from 10,600 feet to over 13,000 feet (3,400 to 4,000 meters) above sea level. Much of Western Bolivia is at the same altitude or higher, including Lake Titicaca, the Salar de Uyuni, and the cities of Oruro and Potosi. The altitude alone poses a serious risk of illness, hospitalization, and even death, if you have a medical condition that affects blood circulation or breathing.

Prior to departing the U.S. for high-altitude locations (over 10,000 feet above sea level), travelers should discuss the trip with their personal physician and request information on specific recommendations concerning medication and lifestyle tips at high altitudes. Coca-leaf tea is a popular beverage and folk remedy for altitude sickness in Bolivia. Possession of this tea, which is sold in bags in most Bolivian grocery stores, is illegal in the United States.

The State Department's Office of Medical Services does not allow official U.S. Government travelers to visit La Paz if they have any of the following:

Sickle cell anemia or sickle cell trait: 30 percent of persons with sickle cell trait are likely to have a crisis at elevations of more than 8,000 feet.
Heart disease: A man 45 years or older, or a woman 55 years or older, who has two of the following risk factors (hypertension, angina, diabetes, cigarette smoking, or elevated cholesterol) should have a stress EKG and a cardiological evaluation before the trip.
Lung disease: Anyone with asthma and on maximum dosage of medication for daily maintenance, or anyone who has been hospitalized for asthma within the last year should not come to La Paz and surrounding areas.
Given potential complications from altitude sickness, pregnant women should consult their doctor before travel to La Paz and other high-altitude areas of Bolivia.
All people, even healthy and fit persons, will feel symptoms of hypoxia (lack of oxygen) upon arrival at high altitude. Most people will have increased respiration and increased heart rate. Many people will have headaches, difficulty sleeping, lack of appetite, minor gastric and intestinal upsets, and mood changes. Many travelers limit physical activity for the first 36 to 48 hours after arrival and avoid alcohol and smoking for at least one week after arrival.

For additional information, travelers should visit the World Health Organization's website at as well as the CDC's travel warning on high altitude sickness at .

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 Bolivia is provided for general reference only, and may not be totally accurate in a particular location or circumstance. U.S. citizens planning on driving in Bolivia, despite the hazards described below, should obtain an international driver's license through their local automobile club before coming to Bolivia.

Road conditions in Bolivia are hazardous. Although La Paz, Santa Cruz, and Cochabamba are connected by improved highways, the vast majority of roads in Bolivia are unpaved. Few highways have shoulders, fencing or barriers, and highway markings are minimal. Yielding for pedestrians in the cities is not the norm. For trips outside the major cities, especially in mountainous areas, a four-wheel-drive vehicle is highly recommended. Travel during the rainy season (November through March) is difficult, as most routes are potholed, and some roads and bridges are washed out. Added dangers are the absence of formal training for most drivers, poor maintenance and overloaded vehicles, lack of lights on some vehicles at night, and intoxicated or overly tired drivers, including commercial bus and truck drivers.

The majority of intercity travel in Bolivia is by bus, with varying levels of safety and service. In recent years there have been major bus crashes on the highway between La Paz and Oruro, and on the Yungas road. The old Yungas road is considered one of the most dangerous routes in the world. Taxis, vans, and buses dominate intracity transportation. From a crime perspective, public transportation is relatively safe and violent assaults are rare. However, petty theft of unattended backpacks and other personal items does occur. For reasons of safety, visitors are advised to use radio taxis whenever possible.

Drivers of vehicles involved in traffic accidents are expected to remain at the scene until the arrival of local police authorities. Any attempt to leave the scene is in violation of Bolivian law. The Embassy believes any attempt to flee the scene of an accident would place the driver and passengers at greater risk of harm than remaining at the scene until the arrival of local police. Please refer to our Road Safety page for more information.

AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of Bolivia as being in compliance with ICAO international aviation safety standards for oversight of Bolivia's air carrier operations. For more information, travelers may visit the FAA's Internet web site at www.faa.gov/avr/iasa/index.cfm . There are limited flights within Bolivia and to neighboring countries. Flight delays and cancellations are common. In February and March 2006, strikes at national carrier Lloyd Aereo Boliviano led to the cancellation of both national and international flights with resultant delays and other inconveniences for travelers.

SPECIAL CIRCUMSTANCES: In the run-up to the July 2006 Constituent Assembly elections, President Morales accused the United States military of infiltrating Bolivia with operatives disguised as "students and tourists." As an apparent result of these comments, some U.S. citizens have reported harassment by Bolivian officials and been subjected to unwanted media attention. In one case, a local Bolivian newspaper wrongly identified an American citizen as an operative for the Central Intelligence Agency. Americans planning on traveling to Bolivia should be aware of the political atmosphere and the possibility of unwanted attention from pro-governmental groups and other Bolivian officials.

For information on in-country visa procedures and requirements, please consult the Bolivian Immigration Service at (please note that the Web site is in Spanish), fax/telephone (591-2) 211-0960, street address Avenida Camacho entre Loayza y Bueno, La Paz, Bolivia. In emergency cases, the Immigration Service may permit temporary residency applicants to retrieve their passports from those applications. However, under current regulations in such cases the applicant would need to commence the application anew, including paying the corresponding fees. Any U.S. documents, such as birth, marriage, divorce or death certificates, to be presented in Bolivia must first be authenticated in the U.S. at the nearest Bolivian Embassy or consulate. For information on those procedures, please consult the Department of State Office of Authentications web site, www.state.gov/m/a/auth , and the nearest Bolivian Embassy or consulate.

Please see our information on customs regulations .
MARRIAGE: Please see our information on marriage in Bolivia , available on the Embassy's Web site at
MOUNTAIN TREKKING AND CLIMBING SAFETY: U.S. citizens are advised to exercise extreme care when trekking or climbing in Bolivia. Since June 2002, four American citizens have died in falls while mountain climbing in Bolivia. Three of the deaths occurred on Illimani, a 6,402-meter peak located southeast of La Paz. Many popular trekking routes in the Bolivian Andes cross passes as high as 16,000 feet. Trekkers must have adequate clothing and equipment, not always available locally, and should be experienced mountain travelers. It is not prudent to trek alone. Solo trekking is the most significant factor contributing to injuries and robberies. The safest option is to join an organized group and/or use a reputable firm to provide an experienced guide and porter who can communicate in both Spanish and English. If you develop any of the following symptoms while climbing at altitude - severe headache, weakness, vomiting, shortness of breath at rest, cough, chest tightness, unsteadiness - descend to a lower altitude immediately. Trekkers and climbers are strongly encouraged to purchase adequate insurance to cover expenses in case of injury or death.

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 Bolivian laws, even unknowingly, may be expelled, arrested, or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in Bolivia 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 .

It often takes years to reach a decision in Bolivian legal cases, whether involving property disputes, civil, or criminal matters. Depending on the circumstances of the case, the court can order a defendant held in jail for the duration of the case. Prison conditions are primitive, and prisoners are expected to pay for food and lodging. For further information, please see the Annual Human Rights Report for Bolivia at . Lists of local Bolivian attorneys and their specialties are available from the Consular Section of the U.S. Embassy in La Paz and the Consular Agencies in Santa Cruz and Cochabamba, and may also be found on our Web site at .

CHILDREN'S ISSUES: For information on international adoption of children and international parental child abduction, see the Office of Children's Issues website . Pending U.S. implementation of the Hague Convention on International Adoptions, under Bolivian law U.S. citizens who are not resident in Bolivia are not permitted to adopt Bolivian children./p>

REGISTRATION / EMBASSY LOCATION: Americans living or traveling in Bolivia are encouraged to register with the nearest U.S. Embassy or Consular Agency through the State Department's travel registration website, and to obtain updated information on travel and security within Bolivia. Americans without Internet access may register directly with the nearest U.S. Embassy or Consular Agencies in Cochabamba and Santa Cruz. By registering, American citizens make it easier for the Embassy or Consular Agency to contact them in case of emergency.

The U.S. Embassy is located at 2780 Avenida Arce in La Paz, between calles Cordero and Campos; telephone (591-2) 216-8297 during business hours 8:30 a.m.-5:30 p.m., or (591-2) 216-8000 for after-hours emergencies; fax (591-2) 216-8808; Internet . The U.S. Embassy in La Paz is open for American Citizen Services Monday through Thursday from 1:30PM to 5:00PM and Fridays from 08:30 to12:30 and from 2:00PM to 4:00PM, except U.S. and Bolivian holidays. Questions should be directed to the email address USCit.Services.Bolivia@gmail.com or consularlapaz@state.gov .

There are two consular agencies in Bolivia, which provide limited services to American citizens, but are not authorized to issue passports. Anyone requesting service at one of the consular agencies should call ahead to verify that the service requested would be available on the day you expect to visit the agency.

Santa Cruz: The Consular Agency in Santa Cruz is located at 146 Avenida Roque Aguilera (Tercer Anillo); telephone (591-3) 351-3477, 351-3479, or 351-3480; fax (591-3) 351-3478. The U.S. Consular Agency in Santa Cruz is open to the public Mondays from 09:00 to 12:30 and from 2:00PM to 5:00PM and on Tuesday through Friday from 09:00 to 12:30, except U.S. and Bolivian holidays.

Cochabamba: The Consular Agency in Cochabamba is located at Avenida Oquendo 654, Torres Sofer, room 601; telephone (591-4) 411-6313; fax (591-4) 425 -6714. The U.S. Consular Agency in Cochabamba is open Monday through Friday from 9:00 a.m. - 12:00 noon, excluding U.S. and Bolivian holidays.
* * *
This replaces the Consular Information Sheet dated April 4, 2006 to update Entry/Exit Requirements, Safety and Security, Crime, Marriage, Special Circumstances and web links.

Travel News Headlines WORLD NEWS

Date: Mon, 4 Feb 2019 21:12:01 +0100

La Paz, Feb 4, 2019 (AFP) - Two landslides in Bolivia left 14 people dead and seven missing, national police chief Romulo Delgado said on Monday.   Torrential rain caused the landslides on Saturday and Sunday on the road linking the capital La Paz to the northern town of Caranavi, the gateway to the Amazon rainforest.   President Evo Morales said on his Twitter account that helicopters were being used to transport 34 people who were injured to ocal hospitals.   He also posted pictures of himself at the scene alongside rescue teams.

Morales advised people to stay clear of the area and said humanitarian flights would be organized for emergency cases.   Saturday's landslide left 13 people dead, Delgado told the Panamericana private radio station, with Sunday's killing one person.   Pupils were due to return from their holidays on Monday but the local education authority in Caranavi postponed the start of the new school year by a week.   Bolivia's rainy season generally lasts from November to March with January and February often the wettest months.
Date: Wed, 2 Jan 2019 22:17:29 +0100

La Paz, Jan 2, 2019 (AFP) - Public sector doctors in Bolivia announced a 48-hour strike on Wednesday in response to a government move to make healthcare free for all.   "Our goal is to register 5.8 million people in Bolivia," said Adolfo Zarate, the program's spokesman, in a statement sent to AFP.   Doctors working in public hospitals responded by announcing they would down tools on Thursday and Friday.   According to the health ministry, some 5.8 million of Bolivia's 11 million population do not have health insurance but will be given access to free services once the registration period is completed in the next three months.

Diseases and illnesses covered by the universal healthcare system will include Parkinson's, child cancer, diabetes, pneumonia, flu and dental problems.   The health ministry said the program will have a budget of around 1.6 million bolivianos (about $230 million) but Erwin Viruez, president of Bolivia's professional medical college, said that won't be enough.   "We're going to need one billion dollars, at least, but this won't be enough to guarantee universal health care," he said.   "We don't have any supplies, there aren't enough beds."   President Evo Morales has called on striking doctors to engage in dialogue.
Date: Sat 1 Dec 2018
Source: Pagina Siete [In Spanish, trans., edited]

The Departmental Health Service (SEDES) of La Paz reported yesterday [30 Nov 2018] that this year [2018], to date, 1101 positive cases of leishmaniasis have been reported. "We have 1101 cases reported and confirmed with a laboratory in the department of La Paz," said Gunder Gutierrez, head of the SEDES vector-borne diseases program. He recommended that people take preventive measures if they visit endemic areas, such as using repellents, wearing long-sleeved clothing and avoiding staying out in the open after sunset.

Gutierrez indicated that in the La Paz municipality of Ixiamas, where the Madidi National Park is located, this year [2018] 42 cases were reported, and this sector registered 2. He indicated that there would not be an epidemic in that sector, but if the vector issue is in that place.

According to the authority, to access the medication, patients have to meet a series of requirements, such as the clinical record, epidemiology and personal documents, among others. The Dermatology unit of the Hospital de Clinicas de La Paz reported on Thursday [29 Nov 2018] the outbreak of cases of leishmaniasis in the Madidi, a tourist site that is located in the northeast of the department of La Paz.

The specialists explain that the vector now adapts to the urban areas of the Yungas of La Paz. "We have cases of leishmaniasis in Arcopongo, Palos Blancos, Caranavi, La Asunta, Chulumani and others; in fact, from the Yungas of La Paz, but what is striking is that Madidi patients have begun to arrive," the chief of the Dermatology unit of the Hospital de Clinicas de La Paz, Sandra Encinas, said.

Encinas explained that the Hospital de Clinicas is the only place where the treatment for leishmaniasis is performed. "Before we had few patients, but now we register at least 15 a month," he said.
======================
[Leishmaniasis in Bolivia has been reviewed (Alvar J, Velez ID, Bern C, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS ONE 2012;7(5):e35671 <https://doi.org/10.1371/journal.pone.0035671>).

Bolivia has the highest incidence of cutaneous leishmaniasis (CL) in Latin America, with 33 cases per 100 000 population reported in 2006. In the department La Paz, the forest of the Yungas area is highly endemic for CL. Most CL cases are caused by _Leishmania braziliensis_, and 10% to 20% of all CL cases progress to mucosal leishmaniasis, more than anywhere else in the Americas, with the municipality of Palos Blancos in the Yungas region the most affected. In addition, 12% of dogs are seropositive in areas highly endemic for CL. - ProMED Mod.EP]

[HealthMap/ProMED-mail map:
Date: Sun 14 Oct 2018
Source: El Periodico [in Spanish, trans., edited]

The Tarija Departmental Health Services (SEDES) reported the latest case of [a] hantavirus [infection] in Bermejo city, making a total of 9 confirmed cases so far in the 2018 term. Hantavirus [causes] an acute viral disease that is transmitted to humans via rats from their saliva, faeces and urine.

The responsible departmental head of the Chagas Program of SEDES, Eduardo Rueda, stated that to date in [2018], there are 28 suspected cases of hantavirus [infection] in Tarija, of which 9 were confirmed. "To date so far this year [2018] we have 28 suspected cases of which corresponding tests were done and of which 9 were confirmed, and those are being treated by specialists," he said.

According to the information from SEDES, the Bemejo municipality registered 5 cases, followed by Yacuiba with 2 cases, Carapari with one and Padcaya with one. In addition, "according the epidemiological report, the last case was registered in Bermejo and those responsible for the program presented the suspected or confirmed cases, carrying out the prevention and control tasks for this disease," he added.

For the past 2 decades, the Bermejo and Padcaya municipalities have not stopped reporting this disease. For this reason, Tarija is one of the departments that received 100 kg [220 lb] of rodenticides (rat poison) from the Ministry of Health, and other amounts have been distributed in La Paz, Santa Cruz, Beni and Cochabamba [departments]. "The goal is to eliminate the rodents and prevent diseases such as bubonic plague, hantaviruses, hemorrhagic fever and leptospirosis," he mentioned.

The person responsible for the National Program for Diseases Transmitted by Rodents and Influenza of the Ministry of Health, Yandira Alcon, stated that a [risk] forecast was made on 21 Feb [2018] with the provision of rodenticides at a cost of 135,000 bolivianos [USD 19,500] to control rodent population densities. "From February [2018] until now, the chemical was given to 5 departmental health services that they [in turn] later gave to the endemic municipalities," he pointed out.

The [health] professionals recommended to families that they take preventive measures such as eliminating vegetation around their houses, disinfecting the environment, not living with farm animals and notifying health personnel of the presence of rodents.

Hantavirus [infections cause] an acute, serious viral disease transmitted through the saliva, feces and urine of the [infected] rodents.  [Byline: Saul Cardozo]
=======================
[Cases of hantavirus infection have occurred in Tarija department in recent years, including the current one [2018]. The previously reported cases in 2015 of hantavirus pulmonary syndrome (HPS) that occurred in Tarija department were confirmed. The above advice to the public in the endemic municipalities is prudent. Control and significant reduction of rodent populations, especially in rural areas, is difficult, and unless the recommended measures are applied continuously, likely to be of short-term effect. As noted in previous comments, earlier cases of HPS have been reported from tropical lowland areas of Bolivia. The specific hantaviruses involved in these or previous cases in 2013 and 2014 in Bolivia are not given.

In the lowland Amazon Basin of Bolivia, the possible hantavirus and its rodent hosts that might be involved in these HPS cases, include the following:
- Laguna Negra virus (_Calomys laucha_, _Calomys callosus_ and
_Oligoryzomys microtis_)
- Rio Mamore (_C. callosus_ and _C. laucha_)
- Rio Mearim (_Holochilus sciureus_)
- Bermejo (_Oligoryzomys chacoensis_)
- Neembucu (_O. chacoensis_)
- Oran (_Oligoryzomys longicaudatus_ ).

Clearly, there are a variety of hantaviruses in Bolivia that can cause HPS involving several rodent hosts and found in many different ecological settings.

Dr. Jan Clement earlier pointed out the need to be able to differentiate Seoul hantavirus, with its wide distribution around the world, from hantaviruses found in the Americas. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Date: Thu 11 Oct 2018, 1:07 AM
Source: Pagina 7 [in Spanish, trans., ProMED Mod.TY, edited]
<https://www.paginasiete.bo/sociedad/2018/10/11/confirman-casos-positivos-de-hantavirus-en-la-asunta-196557.html>

Local physicians in the La Asunta municipality confirmed yesterday [Wed 10 Oct 2018] 9 positive hantavirus infections and declared a health emergency in the communities of this population, located in the Yungas in the La Paz department. "A total of 9 hantavirus [infection] positive cases have been confirmed as well as one death," Carlos Tintaya, the La Asunta municipal hospital physician, said to Page 7. He indicated that 17 members of the Fuerza de Tarea Conjunta (FTC) [military joint taskforce] were evacuated this past weekend, "9 were positive according to laboratory tests. With one death, there are 10 cases," he emphasized.

Of the 9 hantavirus [infected] soldiers, according to Tintaya, one is in intensive care and the other 8 are recovering in a hospital in Santa Cruz. According to the physician, a team of professionals were sent to 2 camps in the Puerto Aroma and Inchura sector to examine the soldiers. "We took samples from 3 of them because they had pain in the abdomen, muscles and joints, and send them yesterday [Tue 9 Oct 2018] to Santa Cruz," he said. The physician added that the 3 samples were sent as a preventive measure.

He stated that during the inspection of the camps of those affected, they did not find remnants of rodent feces or urine; "We have not found anything that caught our attention," he stated. He added that a brigade from SEDES [Servicio Departamental de Salud; Health Services Department] will arrive to both localities in order to take further samples. The La Paz SEDES stated via an information release that today [Thu 11 Oct 2018] they will release a report about the hantavirus cases in La Asunta. Hantavirus [infection can result in] a disease that humans contract when they breathe in places contaminated by urine, excrement and saliva of [infected] rodents.
================================
[Hantavirus infections have occurred previously in various parts of Bolivia, including in tropical areas of La Paz department. Occurrence of hantavirus infections in soldiers in military camps in Bolivia is not surprising. As noted in the previous comments, earlier cases of hantavirus pulmonary syndrome have been reported from tropical, lowland areas of Bolivia.

The specific hantaviruses involved in these or previous cases for the last several years in Bolivia are not reported. In the lowland Amazon Basin of Bolivia, the possible hantavirus, its rodent hosts that might be involved in these hantavirus pulmonary syndrome (HPS) cases, with their images, include:

- Rio Mamoré virus (small eared pygmy rice rat _Oligoryzomys microtis_ <https://www.uwsp.edu/biology/VertebrateCollection/Pages/Vertebrates/Mammals%20of%20Paraguay/Oligoryzomys%20microtis/Oligoryzomys%20microtis.aspx>);
- Laguna Negra virus (small vesper mouse _Calomys laucha_ <http://www.faunaparaguay.com/calomyslaucha.html>  and large vesper mouse _C. callosus_; <http://www.faunaparaguay.com/Calomys%20callosus%20www.pybio.org%201.jpg>);
- Bermejo virus (Chaco rice rat _Oligoryzomys chacoensis_ <http://www.faunaparaguay.com/oligorizomyschacoensis.html>);
- Oran virus (long-tailed pygmy rice rat _O. longicaudatus_ <http://calphotos.berkeley.edu/imgs/512x768/0000_0000/0711/1203.jpeg>).

Dr. Jan Clement earlier pointed out the need to be able to differentiate Seoul hantavirus, with its wide distribution around the world, from hantaviruses found in the Americas. - Mod.TY HealthMap/ProMED map available at: La Paz, La Paz, Bolivia: <http://healthmap.org/promed/p/10123>]
More ...

World Travel News Headlines

Date: Fri, 15 Mar 2019 19:08:37 +0100
By Joaquim Nhamirre

Maputo, March 15, 2019 (AFP) - Tropical cyclone Idai battered Mozambican coastal city Beira Friday, leaving half a million people virtually cut off after power lines crashed, airport shut and roads were swamped by flooding that killed 66 people nationwide.   "There is no communication with Beira. Houses and trees were destroyed and pylons downed," an official at the National Institute of Disaster Management (NIDM) told AFP.   Authorities had to close Beira international airport after the air traffic control tower, the navigation systems and the runways were damaged by the storm.   "Unfortunately there is extreme havoc," said the official.   "Some runway lights were damaged, the navigation system is damaged, the control tower antennas and the control tower itself are all damaged.    "The runway is full of obstacles and parked aircrafts are damaged."

Late on Wednesday, the national carrier LAM cancelled all flights to Beira and Quelimane, which is also on the coast, as well as to Chomoio, which is inland.    Power utility Electricidade de Mocambique said in a statement that the provinces of Manica, Sofala and parts of Inhambane have been without power since Thursday.   Officials did not report any confirmed deaths, but local Beira station STV reported a child had died in Manica province west of the city, apparently the victim of a falling roof.   "There was no tsunami-type storm but Beira and Chinde (400 kilometres, 250 miles northeast of Beira on the coast) were badly hit," added the NIDM official.

Another official, Pedro Armando Alberto Virgula, in Chinde, said a hospital, police station and seven schools there lost their roofs and four houses were destroyed.   Virgula added that efforts were under way to assess the damage caused after Idai made landfall late on Thursday.   Local officials said that this week's heavy rains claimed 66 lives, injured 111 people and displaced 17,000 people.   The World Food Programme (WFP) said it would move 20 tonnes of emergency food aid to the affected areas.   The UN Office for the Coordination of Humanitarian Affairs (OCHA) had warned that the storm could pack winds of up to 190 kilometres per hour (118 miles per hour).

- 'Devastation' -
At least 126 people were killed by the downpour that has struck parts of Mozambique, Malawi and South Africa over the past week, officials said.   Heavy rains in neighbouring Malawi have affected almost a million people and claimed 56 lives, according to the latest government toll.   Authorities there have opened emergency relief camps where malaria and shortages of supplies have led to dire conditions, according to AFP correspondents.

Malawian President Peter Mutharika this week declared a natural disaster.   Mozambique's weather service has warned that heavy rain will continue to batter Beira and surrounding areas until Sunday.   The UN warned of damage to crops, "including about 168,000 hectares (415,000 acres) of crops already impacted by flooding in early March, which will undermine food security and nutrition".   Mozambique and Malawi, two of the poorest countries in the world, are prone to deadly flooding during the rainy season and chronic drought during the dry season.   In neighbouring Zimbabwe, weather services have warned that violent thunderstorms, lightning and strong winds will be experienced in the eastern regions of the country.
Date: Fri, 15 Mar 2019 19:00:39 +0100

Niamey, March 15, 2019 (AFP) - Health authorities in Niger said Friday they had found a fake version of a meningitis vaccine after the country had launched a campaign to innoculate millions of children against the disease.   In a statement, the health ministry asked doctors to be vigilant over a "counterfeit" version of a vaccine called Mencevax ACWY.   The fake drug is marked as having been manufactured in December 2016, with an end-date for use by November 2021, it said.   Niger launched a week-long campaign on March 5 to vaccinate six million children against meningitis, which killed nearly 200 people two years ago.   The country lies in the so-called "meningitis belt" stretching from Senegal in the west to Ethiopia in the east, where outbreaks of the disease are a regular occurrence. 

The vaccination programme is against meningitis A, one of the six groups of meningitis bacteria that can cause epidemics.   The ministry's spokesman told AFP the bogus drug had been discovered during a "routine inspection" of a privately-owned pharmacy in the capital Niamey.   An investigation is underway to try to ascertain how many of the fake vaccines have been used, the spokesman said.   Health workers administering meningitis jabs are being asked to take special care about their supply source, and the public are being urged to scrutinise vaccines clearly, even if they buy them in "licensed" pharmacies.   Fake drugs -- medications that are outright counterfeits or whose active ingredients have been diluted -- are a major problem in West Africa.

In the 2017 outbreak, and in an epidemic in 2015 in which nearly 500 people died, Niger sounded the alarm over purported vials of vaccine that just contained water.   Meningitis is transmitted between people through coughs and sneezes, close contact and cramped living conditions.   The illness causes acute inflammation of the outer layers of the brain and spinal cord, with the most common symptoms being fever, headache and neck stiffness.
Date: Fri, 15 Mar 2019 02:55:29 +0100
By Khaliun Bayartsogt

Bornuur, Mongolia, March 15, 2019 (AFP) - In the world's coldest capital, many burn coal and plastic just to survive temperatures as low as minus 40 degrees -- but warmth comes at a price: deadly pollution makes Ulaanbataar's air too toxic for children to breathe, leaving parents little choice but to evacuate them to the countryside.   This exodus is a stark warning of the future for urban areas in much of Asia, where scenes of citizens in anti-pollution masks against a backdrop of brown skies are becoming routine, rather than apocalyptic.   Ulaanbaatar is one of the most polluted cities on the planet, alongside New Delhi, Dhaka, Kabul, and Beijing. It regularly exceeds World Health Organisation recommendations for air quality even as experts warn of disastrous consequences, particularly for children, including stunted development, chronic illness, and in some cases death.

Erdene-Bat Naranchimeg watched helplessly as her daughter Amina battled illness virtually from birth, her immune system handicapped by the smog-choked air in Mongolia's capital.   "We would constantly be in and out of the hospital," Naranchimeg told AFP, adding that Amina contracted pneumonia twice at the age of two, requiring several rounds of antibiotics.   This is not a unique case in a city where winter temperatures plunge towards uninhabitable, particularly in the districts that rural workers moved to in search of a better life.   Here row upon row of the traditional tents -- known as gers -- are warmed by coal, or any other flammable material available. The resulting thick black smoke shoots out in plumes, blanketing surrounding areas in a film of smog that makes visibility so poor it can be hard to see even a few metres ahead.   Hospitals are packed and young children are vulnerable, common colds can quickly escalate into life-threatening illness.

- Birth defects -
The situation was so bad that doctors told Naranchimeg the only solution was to send her little girl to the clean air of the countryside.   Now aged five, Amina is thriving. She lives with her grandparents in Bornuur Sum, a village 135 kilometres away from the capital.   "She hasn't been sick since she started living here," said Naranchimeg, who makes the three-hour round trip to see Amina every week.   "It was very difficult in the first few months," she said. "We used to cry when we talked on the phone."   But like many parents in Ulaanbaatar, she felt the move was the only way to protect her child.

The levels of PM2.5 -- tiny and harmful particles -- in Ulaanbaatar reached 3,320 in January, 133 times what the World Health Organisation (WHO) considers safe.   The effects are terrible for adults but children are even more at risk, in part because they breathe faster, taking in more air and pollutants.   As they are smaller, children are also closer to the ground, where some pollutants concentrate, and their still-developing lungs, brains, and other key organs are more vulnerable to damage.   Effects to prolonged exposure range from persistent infections and asthma to slowed lung and brain development.   The risks apply in utero, too, because gases and fine particles can enter a mother's bloodstream and placenta, causing miscarriage, birth defects and low birth weights, which can also affect a child for the rest of their lives.   Researchers are now investigating whether pollution, like exposure to tobacco smoke, has health effects that could even be passed down to the next generation.

- 'Terribly afraid' -
Buyan-Ulzii Badamkhand and her husband need to stay in capital for work, but they have decided to send their two-year-old son Temuulen more than 1,000 kilometres away.   The 35-year-old mother-of-three struggled with the decision, even moving from one ger district to another in the hope her son's health would improve.   But successive bouts of illness, including bronchitis that lasted a whole year, finally convinced her to send Temuulen to his grandparents.   Hours after he arrived, she called her mother-in-law to discuss her son's medicines.   "But my mother-in-law asked me 'does he still need medicine? He isn't coughing anymore," she said.   "I tell myself that it doesn't matter that I miss him and who raises him, as long as he is healthy, I am content."   Respiratory problems are the most obvious effect of air pollution, but research suggests dirty air can also put children at greater risk for diabetes and cardiovascular disease later in life.   And the WHO links it to leukaemia and behavioural disorders.   When air pollution peaks in winter, Ulaanbaatar's playgrounds empty and those who are able to are increasingly travelling abroad to wait out the smog.

In desperation, Luvsangombo Chinchuluun, a civil society activist, borrowed money to take her granddaughter to Thailand for all of January.   "We can't let her play outside (in Ulaanbaatar) because of the air pollution, so we decided to leave," she said.   The persistent smog has caused tensions in the city, with those living in wealthier areas blaming the ger residents for the pollution and even calling for the tent districts to be cleared.   But the ger residents say coal is all they can afford.   "People come to the capital because they need sustainable income," said Dorjdagva Adiyasuren, a 54-year-old mother of six.   "It's not their fault," she added.    In a bid to tackle the problem, the local government banned domestic migration in 2017, and a ban on burning coal comes into force from May.   But it is unclear whether the moves will be enough to make a difference.   For Naranchimeg, the problems are serious enough to make her consider whether she wants more children.    She explained: "Now, I am terribly afraid of to give birth again. It is risky to carry a child and what will happen to the child after it is born in this amount of pollution?"
Date: Thu, 14 Mar 2019 18:17:56 +0100

Reykjavik, March 14, 2019 (AFP) - Iceland has blocked the millions of tourists who descend upon the volcanic island each year from visiting a canyon that has been overrun since it was featured in a Justin Bieber music video.   An influx of tourists and a humid winter have disrupted the Fjadrargljufur canyon's fragile ecosystem, so the Environment Agency of Iceland has closed the site to the public until June 1.   "During periods of thaw, the path is completely muddy and is practically unusable for hikers," agency advisor Daniel Freyr Jonsson told AFP on Thursday.   "Because the mud is so thick, visitors step over the fences and walk parallel to the path, which rapidly damages the plant life," he added.

Fjadrargljufur is a gorge about 100 meters (yards) deep and two kilometres (1.25 miles) long, with steep green walls and a winding riverbed. The canyon was created by progressive erosion from water melting from glaciers 9,000 years ago.   The canyon was little known to foreigners until the end of 2015, when Canadian singer Justin Bieber featured the site in his song "I'll Show You".   "Visits to the site have risen by 50 to 80 percent per year since 2016," said Daniel Freyr Jonsson, estimating that around 300,000 people visited the canyon in 2018.   A growing number of tourist sites in Iceland have been closed in a bid to
preserve them.

The popular Reykjadalur valley and its hot springs were temporarily closed in April 2018 and a hiking trail overlooking the Skogafoss waterfall is currently shut.   "The infrastructure is not set up to accomodate so many visitors," said Daniel Freyr Jonsson.    "Tourism in winter and spring, the most sensitive periods for wildlife in Iceland, (was previously) almost unheard of in Iceland."   Since 2010 and the eruption of the Eyjafjallajokull volcano -- which generated a lot of publicity for the island -- the number of visitors has grown by 25 percent per year on average.   Last year, a record 2.3 million people visited Iceland.
Date: Thu, 14 Mar 2019 16:50:58 +0100

Geneva, March 14, 2019 (AFP) - The deadly Ebola outbreak raging in eastern Democratic Republic of Congo should be over within six months, the head of the World Health Organization said Thursday.   Seven months since the outbreak erupted in DRC's violence-torn North Kivu province, WHO Director-General Tedros Adhanom Ghebreyesus told reporters there were clear signs the spread of the virus was "contracting".   "Our target is now to finish it in the next six months," he told reporters in Geneva, warning though that increased unrest in the affected area could reverse the progress being made.   "It's always good to plan beyond the horizon to prepare for any eventualities," he said, while voicing optimism that massive efforts to rein in the outbreak are working.

The ongoing Ebola outbreak, the 10th in DRC's history, emerged in North Kivu in August 2018 and then spread to neighbouring Ituri province.    It has claimed 584 lives out of nearly 1,000 believed to have been infected, WHO said.   Security in eastern DRC, a region rampant with rebel fighters, has dramatically complicated the response, with numerous attacks on Ebola treatment centres.   The Doctors Without Borders (MSF) medical charity has also sounded the alarm over increasingly "toxic" relations with local communities, whose resistance to Ebola response efforts have also fuelled the spread.   MSF pointed out that 40 percent of deaths from the extremely contagious virus are occurring in communities rather than in Ebola treatment centres.

- 'Contracting' -
"The Ebola response is failing to bring the epidemic under control," MSF chief Joanne Lieu told reporters in Geneva last week.   But Tedros denied Thursday that this was the case.   "That's not true," he said. "You cannot say it's failing when the outbreak is contracting. It's contracting."   He stressed that over the past seven months, the virus had been contained to North Kivu and Ituri.

"It hasn't spread to other parts of the country and it hasn't spread to neighbouring countries," he said, adding that transmission had been halted in a number of places, including in Beni and Mangina.   "So the cases are now shrinking in certain geographic areas," he said.   Tedros also stressed that the number of new cases had been cut in half since January, with an average of 25 new cases reported each week now compared to 50 at the beginning of the year.   He acknowledged though that violence, unrest and community resistance remained a challenge in Butembo especially, which along with Katwa is where the spread of the virus is now concentrated.   "I don't want to undermine the risk, because it may again (resurge) if the security situation continues to deteriorate," he said, acknowledging that there is still a chance Ebola could spread to other parts of DRC and neighbouring countries.
Date: Thu, 14 Mar 2019 03:42:36 +0100

Kuala Lumpur, March 14, 2019 (AFP) - Over 100 schools in Malaysia have been closed after the dumping of toxic waste into a river caused hundreds of people to fall ill, including many children, authorities said.   A lorry is believed to have dumped the waste in southern Johor state last week, sending hazardous fumes across a wide area and causing those affected to display symptoms of poisoning such as nausea and vomiting.

Over 500 people, many of them school pupils, have received medical treatment after inhaling the fumes, with over 160 admitted to hospital, according to official news agency Bernama.    It was unclear what type of poisonous gas had been emitted near the industrial town of Pasir Gudang.   Education Minister Maszlee Malik initially ordered the closure of 43 schools in the area Wednesday, but later announced that figure had more than doubled.

"The ministry of education has decided to close all 111 schools in the Pasir Gudang area immediately," he said in a statement.    "The education ministry is requesting that all parties take precautions."   Three men were arrested earlier this week over the toxic waste dumping. One is expected to be charged in court soon and could face up to five years in jail if found guilty of breaking environmental protection laws.
Date: Tue 12 Mar 2019
Source: Carmelo Portal [in Spanish, trans. Mod. TY, edited]

The departmental health director, Dr Jorge Mota, confirmed for Carmelo Portal the death in our city of a young 17 year old girl from [a] hantavirus [infection]. "In Colonia department, there are on average 3 cases per year. The evolution of the disease is in thirds. One-third of the [infected] people do not have notable symptoms; another third have serious symptoms, especially respiratory symptoms and ones in all the systems, but with adequate treatment, [the infected people] survive, sometimes with sequelae. There is another third that die. It is those few with the virus that die with an evolution so drastic, such as is the case of this girl, sadly," Dr Mota stated.

The department health director said that hantaviruses are not contagious person-to-person. "It is transmitted from an intermediate animal, the field mouse. Only 3% of these mice have [a] hantavirus. To become infected, one must be in contact with an [infected] mouse's secretions that have dried, are mixed with dust, and are in a closed space, away from sunlight and ventilation. A spa, a shed, or a wood pile [are examples of such a space]. The person had to have been moving around there and inhaled the dust," he explained.

Dr Mota spoke about the epidemiological surveillance that is carried out. "We tracked places where the person was, even those that could be identified 2 months before contracting the virus; sometimes we found the place, but sometimes not." As a preventive measure, Mota stated that in these cases, ventilate these closed spaces for at least half an hour. Wet down floors and shelves with water [with 10% bleach]. Use masks [and gloves].
==========================
[The report above does not mention the circumstances under which the infection might have been acquired nor which hantavirus was responsible for this or earlier cases in Uruguay. Hantaviruses that cause hantavirus pulmonary syndrome (with rodent hosts found in Uruguay) include Laguna Negra virus (_Calomys laucha_), Maciel virus (_Necromys benefactus_), Central Plata virus, Lechiguanas virus (_Oligoryzomys flavescens_, complex of rodents), and Anajatuba virus and Juquitiba virus (_Ologoryzomys fornesi_).

The rodent reservoir hosts shed the virus in its saliva, urine, and faeces, contaminating the environment in which they live and breed.

A HealthMap/ProMED-mail map showing the location of Uruguay in South America can be accessed at
<http://healthmap.org/promed/p/28995>.

A map of Colonia department in southern Uruguay is available at
<https://en.wikipedia.org/wiki/Colonia_del_Sacramento>
and <http://healthmap.org/promed/p/27367>. - ProMED Mod.TY]
Date: Wed 13 Mar 2019
Source: Outbreak News Today [abridged, edited]

The number of measles deaths has topped 1100 in Madagascar. In an update on the measles epidemic in Madagascar, UN health officials report 6607 cases of measles, including 41 deaths, in the week ending 24 Feb [2019]. Cases are reported in children aged 1 to 14 years. Of 114 districts in all 22 regions, 104 are in the epidemic phase, officials report.
=======================
[The number of cases and deaths from measles in Madagascar is horrifying, even more so since the disease is vaccine-preventable. There is no information on how the health sector in the country is responding, but clearly the clinics are overburdened during this devastating outbreak. - ProMED Mod.LK]

[HealthMap/ProMED-mail map of Madagascar:
Date: Mon 11 Mar 2019
Source: Focus Taiwan [abridged, edited]

A Taipei resident in her 20s has been confirmed to be infected with measles and is suspected of having had contact with 247 people during the incubation period, according to the Centers for Disease Control (CDC). The woman, who works at a restaurant in the ATT 4 Fun shopping centre in Taipei's Xinyi District might have been infected through coming into contact with foreign tourists in her workplace, said CDC deputy director-general Lo Yi-chun in a statement issued on Mon [11 Mar 2019].

To date, 247 people considered to have had contact with the patient, including her family, colleagues and health care personnel, have been traced. The contact tracing will continue until 27 Mar [2019]. The CDC alerted people who used the same bus and had been to the same places the patient visited to beware of possible exposure to the measles virus. It asked those who might have had contact with the woman to conduct self-health management for 18 days.

The reported new case has brought the total number of confirmed measles cases in Taiwan to 29 since the beginning of this year [2019], 16 contracted at home and 13 from abroad. Among the 16 indigenous cases, 8 have been linked to imported cases, the CDC said.

Lo reminded the public that measles is highly contagious and now is the peak transmission season. Outbreaks in some Asian countries have been growing, including the Philippines, Vietnam, Thailand, China, India and Indonesia, he said. As of 24 Feb [2019], the number of measles cases in Japan has risen to 258, the highest in the same period since 2009, Lo added.  [byline: Chang Ming-hsuan and Evelyn Kao]
===========================
[HealthMap/ProMED-mail map of Taiwan:
Date: Thu 14 March 2019
Source: South China Morning Post [abridged, edited]

Health authorities seek passengers on Cathay Pacific Hong Kong-Tokyo flight [1 Mar 2019] after a man [said to be a Cathay Pacific flight attendant] contracted measles, a contagious disease. The man tested positive for the immunoglobulin M antibody that confirms a measles infection. He was admitted to St Paul's Hospital in Causeway Bay after he returned to Hong Kong. He was later declared to be in a stable condition and discharged.

This is the 11th case of measles confirmed in city this year [2019] with at least 7 infections imported. Authorities seek passengers on the Cathay Pacific flight who might have had contact with the 23 year old man.  [byline: Danny Mok]
==================
[HealthMap/ProMED-mail map of Hong Kong: