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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: Wed 29 May 2019 Source: Xinhua [edited] <http://www.xinhuanet.com/english/2019-05/29/c_138100250.htm>
A fresh positive polio case was detected in Afghanistan's eastern province of Kunar, bringing the number of confirmed cases of poliovirus to 8 since January this year [2019], a public health official said on Wednesday [29 May 2019]. "A new polio case has been reported from Watapur district of Kunar province which permanently paralyzed a 3-month-old boy," Wahidullah Mayar, spokesperson for the Ministry of Public Health, tweeted.
The latest case is the 1st case from the eastern Afghan region this year [2019], and the rest of 7 cases have been reported from southern provinces, he added. Poliovirus can be rapidly transferred, and the only way [to prevent the disease] is vaccination, according to the official.
The ongoing insurgency and conflicts have been hindering the efforts to stamp out the infectious disease in the mountainous country, as more than 1 million children from areas inaccessible to vaccination teams missed the latest vaccination drive.  [byline: Xuxin] ========================
[As this media report is based on a governmental announcement, I suspect this case will be in next week's global update, providing information on the date of onset of paralysis. It is noteworthy that this is the 1st case reported in Kunar province this year (2019). This represents the 8th case of WPV1-associated paralysis reported by Afghanistan with date of onset since 1 Jan 2019.
A map of Afghanistan showing provinces and districts can be found at <http://ontheworldmap.com/afghanistan/administrative-map-of-afghanistan-with-provinces-and-districts.jpg>.  Watapur district is located in the north central part of Kunar province. The southern and eastern districts of Kunar province border with Khyber Pakhtunkhwa and the tribal districts of Pakistan. The region is known for civil unrest. - ProMED Mod.MPP]
Date: Mon, 13 May 2019 18:12:22 +0200

Jalalabad, Afghanistan, May 13, 2019 (AFP) - At least three people were killed and another 20 wounded in a series of blasts in the eastern Afghan city of Jalalabad on Monday, an official said.   Nangarhar provincial spokesman Attaullah Khogyani said three blasts rocked the city centre, and had taken place near an armoured police vehicle.   "The nature of explosions is not clear, but it could be IEDs," Khogyani said, using the acronym for improvised explosive devices.   "So far we can confirm three people have been killed and 20 wounded."

No group immediately claimed responsibility for the attack, but the area around Jalalabad is home to fighters from both the Taliban and the Islamic State group's Afghan affiliate.   On March 6, at least 16 people were killed in a suicide attack on a construction company in Jalalabad, which is near the Pakistan border.   Violence in Afghanistan has continued apace even during the holy month of Ramadan, and despite government calls for a ceasefire.
Date: Sat, 11 May 2019 14:59:03 +0200

Ghazni, Afghanistan, May 11, 2019 (AFP) - A landmine explosion killed seven children and wounded two others in southern Afghanistan on Saturday, officials said, as war ordnance again claimed civilian lives.   The blast occurred in Ghazni province, south of the capital Kabul, when the children stepped on a landmine while playing near a main road, provincial spokesman Aref Noori told AFP.   "The mine was planted by the Taliban on a main road to inflict casualties on security forces," he said.   The Taliban did not immediately respond to a request for comment.   The insurgents often use roadside bombs and landmines to target Afghan security forces, but the lethal weapons also inflict casualties on civilians.   Amanullah Kamrani, a member of Ghazni provincial council, said the children were aged between seven and nine and at least four of them belonged to one family. 

Years of conflict have left Afghanistan strewn with landmines, unexploded mortars, rockets and homemade bombs -- and many are picked up by curious children.   Last month, seven children were killed and 10 more wounded in the eastern province of Laghman when a mortar shell exploded while they were playing with it.    According to the United Nations, 3,804 civilians -- including more than 900 children-- were killed in Afghanistan in 2018, with another 7,000 wounded. It was the deadliest year to date for civilians in Afghanistan's conflict.
Date: Tue, 16 Apr 2019 14:52:10 +0200

Kabul, April 16, 2019 (AFP) - Torrential rainstorms have lashed drought-stricken Afghanistan in recent days, bringing widespread flooding that has killed at least five people and washed away homes including in the capital Kabul, officials said Tuesday.   While some welcomed the wet weather after the punishing dry spell of recent years, residents complained about the lack of infrastructure and government assistance to help them clear up from the deluge.

Sixteen of Afghanistan's 34 provinces were hit in the past 24 hours, destroying or damaging hundreds of houses and sweeping away livestock, said Hashmat Bahaduri, a spokesman for Afghanistan's National Disaster Management Authority (ANDMA).   Hardest hit was Herat province in western Afghanistan, where at least five people were killed when their houses collapsed, Jilani Farhad, a spokesman for the local governor said.   Officials were also searching for 17 people whose minivan was swept away by flooding in the province's Obey district late Monday, Farhad added.    "There were women and children in the vehicle, we are searching but haven't found any sign of them yet," he said.

Extraordinary scenes played out in the capital, where the usually parched Kabul River swelled suddenly, bursting its banks in places and swamping surrounding streets and neighbourhoods with about one metre (three feet) of water in places.   Drug addicts who normally spend their time in the riverbed or hiding under bridges could be seen openly smoking opium at street level as water swirled around them.   By Tuesday, authorities were warning locals living along the river to be prepared to evacuate their homes as water levels surged.   Bahaduri said 113 houses had already been partially or completely destroyed in Kabul.

In the capital, a university student named Mujtaba bemoaned a lack of drainage canals, but others welcomed the rain.   "It is a bliss to have all this water and rain, we are thankful to God to have rain and get rid of the drought problems," Kabul resident Mansoor Majab told AFP.   Years of dry weather, combined with a booming population and wasteful consumption, have drained Kabul's water basin, forcing residents to drill ever-deeper wells.   This winter saw heavy snowfall across parts of Afghanistan, which had led to flash floods in the spring melt.   Over one hundred people had been killed as of March 28 due to flooding in Afghanistan so far this year, according to ANDMA.
Date: Mon 1 Apr 2019, 4:39 PM
Source: Xinhua Net [edited]

A 2-year-old child was reported to have been affected by poliovirus despite receiving anti-polio vaccination in Afghanistan's southern province of Uruzgan [Oruzgan], a local official said on [Mon 1 Apr 2019].

The case was found affecting a baby-boy in Charchino district of the restive province, where he received 5 times anti-polio immunization, Khan Agha Miakhil, director of provincial public health department, told Xinhua.

The ongoing insurgency and conflicts have been hindering the efforts to stamp the infectious disease out in the mountainous country, he said.

The latest confirmed polio cases have risen to 2 so far this year [2019] while 20 polio cases were registered in the country last year [2018], according to health officials.
=======================
[With the addition of this case, it will bring the number of confirmed cases of polio reported from Afghanistan this year (2019) to 3; 2 prior cases were reported from Kandahar province. The total number of cases reported by Afghanistan during 2018 was 21, including 2 cases from Uruzgan (Oruzgan) province.

The history of 5 doses of polio vaccine is an unfortunate occurrence, but well observed in many countries due to competing infections for receptor sites. One wonders if this child had received the recommended 1 dose of IPV as part of the vaccinations. Below are a collection of references that can give an overview of the observations and studies done to address the issue of observed OPV "vaccine failure" and possible causes.

Uruzgan province shares it's southern border with Kandahar province where the prior cases of polio were reported this year (2019) (see

The HealthMap/ProMED map of Afghanistan can be found at:

References discussing challenges in vaccine efficacy with OPV.
1. Nasir UN, Bandyopadhyay AS, Montagnani F, et al. Polio elimination in Nigeria: A review. Hum Vaccin Immunother. 2016 Mar 3;12(3):658-63. doi: 10.1080/http://promedmail.org/post/21645515.2015.1088617.
Full article available at:
2. Paul Y and Priya. Polio eradication in India: some observations. Vaccine. 2004 Oct 22;22(31-32):4144-8.
Abstract available at:
3. John TJ and Vashishtha VM. Eradicating poliomyelitis: India's journey from hyperendemic to polio-free status. Indian J Med Res. 2013 May;137(5):881-94.
Full article available at:
4. Taniuchi M, Platts-Mills JA, Begum S, et al. Impact of enterovirus and other enteric pathogens on oral polio and rotavirus vaccine performance in Bangladeshi infants. Vaccine. 2016 Jun 8;34(27):3068-3075. doi: 10.1016/j.vaccine.2016.04.080. Epub 2016 May 3.
Full article available at:
5. Saleem AF, Mach O, Quadri F, et al. Immunogenicity of poliovirus vaccines in chronically malnourished infants: a randomized controlled trial in Pakistan. Vaccine. 2015 Jun 4;33(24):2757-63. doi: 10.1016/j.vaccine.2015.04.055. Epub 2015 Apr 24.
Full article available at:
6. Patriarca PA. Poliomyelitis in selected African and Asian countries. Public Health Rev. 1993-1994;21(1-2):91-8.
Abstract available at:
7. John TJ. Experience with poliovaccines in the control of poliomyelitis in India. Public Health Rev. 1993-1994;21(1-2):83-90.
Abstract available at:
8. Balraj V, John TJ and Thomas M. Efficacy of oral poliovirus vaccine in rural communities of North Arcot District, India. Int J Epidemiol. 1990 Sep;19(3):711-4.
Abstract available at:
9. Sutter RW, Patriarca PA, Brogan S, et al. Outbreak of paralytic poliomyelitis in Oman: evidence for widespread transmission among fully vaccinated children. Lancet. 1991 Sep 21;338(8769):715-20.
Abstract available at:
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Comoros

Comoros US Consular Information Sheet
May 21, 2008
COUNTRY DESCRIPTION:
The Union of the Comoros is a developing nation located in the Indian Ocean off the east coast of Africa.
Comoros consists of three islands, Ngazidja (also known
s Grand Comore), Moheli, and Anjouan, that cover about 900 square miles.
A fourth island, Mayotte, is claimed by Comoros but remains a territory of France.
Ngazidja is home to the capital city, Moroni, and is the most developed of the three islands.
Facilities for tourism are limited and telecommunication links are unreliable.
French, Arabic, Swahili, and Comorian Creole are spoken.
Read the Department of State Background Notes on the Union of Comoros for additional information.
ENTRY/EXIT REQUIREMENTS:
A passport and onward/return ticket are required.
Visas are available from the Comoran Mission to the United Nations in New York; American citizens visiting Comoros can obtain a free, 24-hour transit visa upon entry.
The following day, visitors are required to go to the immigration office in Moroni to change their visa status.
A fee is charged, depending on length of stay.
Travelers should obtain the latest details from the Mission of the Union of Comoros, 420 East 50th Street, New York, NY 10022; telephone number (212) 972-8010, fax (212) 983-4712.

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:
Comoros has experienced frequent strikes and civil unrest, resulting in violent clashes between police and demonstrators.
The most recent unrest involved the de facto separation of Anjouan from the Union government.
In March 2008, Union forces re-took Anjouan and are preparing the island for elections.
The former leader of Anjouan, Mohamed Bacar, has applied for asylum with France and is being held on the French Island of Reunion while his asylum claims is adjudicated.
As the government completes the transition to constitutional federalism and as Bacar’s asylum claim is pending, periodic strikes and protests will likely continue to occur.
U.S. citizens should avoid political rallies and street demonstrations as even demonstrations intended to be peaceful can turn confrontational and possibly escalate into violence.
American citizens are therefore urged to avoid the areas of demonstrations if possible, and to exercise caution if within the vicinity of any demonstrations.
Conditions are subject to rapid change on each of the three islands of the Comoros due to weak political institutions and a lack of economic development.
In a rare, apparently religious-based attack, a clinic run by a foreign Christian organization was firebombed on the island of Grande Comore in August 2007.
Religious intolerance and religious-based violence remain very unusual in Comoros.

Although foreign residents and visitors have not been targeted, the potential for further outbreaks of civil disorder remains high, and Americans should exercise caution and good judgment, keep a low profile, and remain vigilant with regard to their personal security.
U.S. citizens are encouraged to register with the U.S. Embassy in Antananarivo, Madagascar, if visiting or residing in Comoros.
Embassy contact information is provided below.
For the latest security information, Americans traveling abroad should regularly monitor the Department’s web site, where the current Travel Warnings and Public Announcements, including 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:
U.S. travelers are advised to be vigilant against pick-pocketing and other forms of petty crime when visiting crowded market areas, parks, and at the beaches.
Violent crime is uncommon.
The most commonly reported crime is breaking into homes.
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, help you find appropriate medical care, to contact family members or friends and explain how funds could be transferred.
Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.
See our information on Victims of Crime.
MEDICAL FACILITIES AND HEALTH INFORMATION:
Medical facilities in Comoros are poorly equipped.
Travelers should bring their own supplies of prescription drugs and preventive medicines. Malaria is prevalent in Comoros.
Travelers to Comoros should take malaria prophylaxis.
The serious and sometimes fatal strain of malaria, P. falciparum, is resistant to the anti-malarial drug chloroquine.
Because travelers to Comoros are at high risk for contracting malaria, the Center for Disease Control and Prevention (CDC) advises that travelers should take one of the following antimalarial drugs: mefloquine (Lariam™), doxycycline, or atovaquone/proguanil (Malarone™).
The CDC has determined that a traveler who is on an appropriate antimalarial drug has a greatly reduced chance of contracting the disease.
In addition, other personal protective measures, such as the use of insect repellents, help to reduce malaria risk.
Travelers who become ill with a fever or flu-like illness while traveling in a malaria-risk area and up to one year after returning home should seek prompt medical attention and tell the physician their travel history and what antimalarials they have been taking.
For additional information on malaria, protection from insect bites, and anitmalarial drugs, please visit the CDC Travelers' Health web pages.
The East African Indian Ocean islands have seen a rise in the cases of chikungunya, a viral dengue-like ailment, and dengue itself.
As with malaria, chikungunya and dengue are transmitted by mosquitoes.
Every effort should be made to use repellants, proper clothing and barriers that discourage/prevent mosquito bites.
The CDC web site contains further information on chikungunya at http://www.cdc.gov/ncidod/dvbid/chikungunya/ and dengue at http://wwwn.cdc.gov/travel/yellowBookCh4-DengueFever.aspx.
There have been occurrences of measles in Comoros, with outbreaks of greater severity on the islands of Anjouan and Moheli.
Travelers are advised to ensure that their measles vaccinations are up to date.
Further, information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://wwwn.cdc.gov/travel/default.aspx.
For information about outbreaks of infectious diseases abroad consult the World Health Organization’s (WHO) web site at http://www.who.int/en.
Further health information for travelers is available at http://www.who.int/ith.
MEDICAL INSURANCE:
The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical evacuation.
Please see our information on medical insurance overseas.

TRAFFIC SAFETY AND ROAD CONDITIONS:
While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States.
The information below concerning Comoros is provided for general reference only, and may not be totally accurate in a particular location or circumstance.
In Comoros, one drives on the right side of the street.
Roads are ill-maintained, congested, very narrow and poorly lit at night.
Travelers should exercise extreme caution when driving after dark.
Most urban roads are paved, but many rural roads are not.
Many roads are full of potholes and dangerous curves.
Most roads have no posted speed limits, but road conditions limit speeds to below 30 miles an hour.
Drivers and front seat passengers are required to wear seat belts.
There are no laws regarding child safety seats.
There are no organizations in Comoros that provide emergency or roadside assistance.
Individuals involved in accidents rely on passersby for assistance.
Taxis or a rental car with driver are preferable to public transportation.
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 Comoros, the U.S. Federal Aviation Administration (FAA) has not assessed Comoros’ Civil Aviation Authority for compliance with International Civil Aviation Organization (ICAO) aviation safety standards. For more information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.
SPECIAL CIRCUMSTANCES: While religions other than Islam are permitted in Comoros, evangelization is illegal.
Violators of this law can be fined or imprisoned.
Few establishments accept credit cards in the Comoros and most prefer Comoran Francs or Euros to dollars.
Please see our Customs Information.
CRIMINAL PENALTIES: While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law.
Penalties for breaking the law can be more severe than in the United States for similar offenses.
Persons violating the laws of Comoros, even unknowingly, may be expelled, arrested, or imprisoned.
Penalties for possession, use or trafficking in illegal drugs in Comoros are strict, with convicted offenders receiving a mandatory minimum five-year jail sentence and heavy fines.
Engaging in sex with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States.
Please see our information on Criminal Penalties.
CHILDREN'S ISSUES:
For information see our Office of Children’s Issues web pages on intercountry adoption and international parental child abduction.
REGISTRATION / EMBASSY LOCATION:
The United States has no Embassy in Comoros.
Americans living or traveling in Comoros are encouraged to register with the U.S. Embassy in Antananarivo, Madagascar through the State Department's travel registration web site, and to obtain updated information on travel and security within Comoros.
Americans without Internet access may register in person at the U.S. Embassy in Antananarivo.
By registering, American citizens make it easier for the Embassy to contact them in case of emergency. The U.S. Embassy is located at 14-16 Rue Rainitovo, Antsahavola, Antananarivo.
The mailing address is B.P. 620, Antsahavola, Antananarivo, Madagascar; telephone [261] (20) 22-212-57; fax [261] (20) 22-345-39.
The Embassy web site is http://www.usmission.mg/.
*

*

*
This replaces the Country Specific Information dated October 26, 2007 to update the section on Safety and Security.

Travel News Headlines WORLD NEWS

Date: Sat 11 May 2019
Source: Revue Francophone des Laboratoires May 2019, no. 512, p. 18 [in French, transl., abridged, edited]

In February 2019, 63 cases of Rift Valley fever were diagnosed by PCR at the Mayotte hospital laboratory. The first 5 cases were detected in November 2018 by the hospital laboratory and confirmed by the Reunion Reference Center. The vector control center and the health emergency unit of the ARS OI [The Indian Ocean Health Agency] were able to analyze the epidemiology of 36 cases: 21 subjects had been in direct contact with animals and 5 others lived nearby; the last 5 declared no direct or indirect contact with animals. In addition, in 15 cases, patients had consumed raw or curdled milk. Finally, it is interesting to note that 21 patients resided in the communes of west-central Mayotte. With regard to the 63 confirmed cases, the average age of the patients was 38 years (range, 10 to 74 years), of which 16% were under 20 years, with a male/female sex ratio of 4. In addition, 29 patients lived in rural or semi-urban dwellings, 9 of whom lived in traditional huts. In terms of symptoms, 24 patients had headache, 19 arthralgia, 17 myalgia, 14 asthenia, 6 retro-orbital pain, and 6 nausea and vomiting. An entomological survey found several mosquito species, especially _Culex_, _Aedes_, _Anopheles_ and _Mansonia_.

At the same time, samples taken from farms in which abortions were reported identified 33 outbreaks of 1 to 6 animals, including 25 cattle and 8 small ruminants [the figures have increased since; see in comments].

Rift Valley fever, which has been present in Mayotte for a long time, had disappeared in the past decade, with 10 patients detected in 2008 following an epidemic in Kenya. Then there was a steady regression of verified seroprevalence on ruminants. But this seroprevalence rose to 3.6% in 2017 and then to 10.1% in 2018, indicating a new circulation of the virus. This is probably due to illegal and continuous importation of contaminated livestock.  [By: Dr. Patrice Bouree]
============================
[Mayotte's health authorities published on Sat 11 May 2019 the following update.

"Epidemiological situation as of May 10, 2019. In total, since the beginning of the epidemic (end of November 2018):
1. Animals.
Samples taken by veterinarians on sick animals or during abortions have identified 119 foci of sick animals (of which 95 are cattle and 24 small ruminants). Animal foci are mainly located in the center and northwest of the island. Additional outbreaks have appeared since the end of March [2019] in the communes of Dembeni, as well as on Petite Terre.
2. Humans.
The CHM laboratory reported 130 human cases of RVF [Rift Valley fever] at the monitoring and health emergencies platform of the ARS OI (CVAGS) of Mayotte.

The number of reported cases has remained stable since the beginning of April [2019] (on average, 4 to 5 reported cases per week). Since the beginning of the health alert, human cases have remained mainly in the center and northwest of the island." (<https://lejournaldemayotte.yt/2019/05/11/fievre-de-la-vallee-du-rift-a-mayotte-stabilite-du-nombre-de-nouveaux-cas/>).

Application of the following measures will contribute to the prevention of future RVF events in animals and humans in Mayotte:
1. Preventing illegal introduction of ruminants;
2. Preventive vaccination of cattle, sheep and goats (preferably, with an inactivated RVF vaccine; see http://promedmail.org/post/20190422.6434655). - ProMED Mod.AS]

[It would be of interest to know what role, if any, mosquito vectors are playing in transmission of RVF virus during the current outbreak. If _Aedes_ mosquitoes are involved, there is a risk of transovarial transmission of the virus that can persist for months in mosquito eggs with resumption of transmission when those eggs hatch and infected adult female mosquitoes emerge. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Region d'outre-mer de Mayotte, France:
Date: Mon, 25 Mar 2019 15:42:31 +0100
By Philippe ALFROY

Bambao, Comoros, March 25, 2019 (AFP) - The Bambao hospital, nestled in a tropical forest on Anjouan island in the Comoros, was meant to bring state-of-the-art medical care to the poor Indian Ocean nation.   Just two years later, the hospital is deep in debt and shunned by potential patients who find it too costly.   "A poisoned chalice", "a colossus with feet of clay", "a sinking ship" are among the cliches that chief paediatrician Ahmed Rakibou used to describe the facility funded and built under a Chinese aid scheme.   "If they had consulted us while building it, this could have been a jewel," the doctor said, regretting that "today it's all going straight to hell".   The hospital is some 30 kilometres (about 20 miles) east of Mutsamudu, the capital of Anjouan, the poorest of the three islands comprising the Union of the Comoros.

The aim was to make the hospital a flagship of Comoran healthcare, with 120 beds in a brand-new building, a team of 167 staff, many recruited locally, and modern equipment including a digital radio scanner.   China's ambassador to the Comoros, Xiao Ming, hailed a "new page in the annals of cooperation" at the opening ceremony, saying "public health has always had a priority place in Sino-Comoran cooperation".   But a project that cost four billion Comoran francs (8.1 million euros, $9.2 billion) today looks more like a ghost ship, with a handful of patients wandering its corridors in stifling heat. For lack of funds, about 100 staff jobs have not been filled.

- 'Not many patients' -
In the emergency ward, a doctor silently examines a child's injured arm. The lethargic mood is broken only by the arrival of an ambulance carrying the victim of a motorcycle accident.   "Our activity is very varied," nurse Ali Mosthadoi says cautiously before going further. "In fact, we don't have many patients."

Deputy director Sidi Chaanbane was more forthcoming. Since the hospital was opened by President Azali Assoumani in 2017, it has faced mounting difficulties, he said.   "At the start, the road from Mutsamudu was in a very bad state and patients had trouble getting here," the administrator said. "It's been repaired since, but our real problem is that we sorely lack equipment and staff."   In addition to staff salaries, the Comoran state provides just five million francs (10,000 euros) a month, but the hospital needs three times as much to pay its bills.   "We can't balance the budget," Chaanbane said.

Day-to-day management is a nightmare. The scanner broke down soon after it was first used. Repairs were not covered by the Chinese cooperation agreement, so the hospital took out a loan to get the machine working again.   The main problem is the cost of treatment, which is not free in the former French colony, independent since 1975.   Much of the funding comes from the French Development Agency (AFD) in its aid budget. France still rules over the fourth major island in the archipelago, Mayotte.   The three islands forming Comoros lack the standard of living on Mayotte and are far from able to make up the remaining health budget.

- 'Expensive' -
Rakibou said the hospital charges 125,000 Comoran francs for a Caesarean birth.   "What Comoran can pay that?" he asks. "No -- this hospital is not made for the population."   Kanissa Adbou, 27, brought her eight-year-old daughter who trod on a nail to the hospital. "The treatment is expensive. If I could afford it, I would go to Mayotte because there, hospital is free."   Those who believed that providing a modern hospital on Anjouan would dissuade Comorans from trying their luck on Mayotte have been disappointed, although the trip is illegal.   "People here prefer to pay 1,000 euros to go to Mayotte by kwassa kwassa (human traffickers' dugouts) than to come to us," a nurse said. "They trust only white doctors."

The failure to put the sophisticated equipment at Bambao to regular good use enrages Ahmed Abdallah, secretary general of the Hombo public hospital in Mutsamudu.   "The money spent there would have been enough to repair our buildings, replace our equipment and build roads so that sick people could come from nearby villages," he said.   "We don't have even a single ambulance, yet the government has I don't know how many four-wheel drives."   Health Minister Fatma Mbaraka declined to respond to requests for comment from AFP.   But Rakibou refuses to throw in the towel. He hopes that the winner of Sunday's presidential election and the international community will come up with increased funding. "It wouldn't take much to change our lives!" he said.
Date: Fri 15 Mar 2019
Source: Le Journal de Mayotte [in French, trans. ProMED B, edited]

The circulation of Rift Valley fever (RVF) continues in Mayotte. An animal disease of viral origin, Rift Valley fever mainly affects domestic ruminants (cattle, sheep, goats), causing abortions and high mortality in young animals. It can be transmitted from the infected animal to humans.

In total, since the beginning of the epidemic (end of November [2018]),
- samples taken by veterinarians from sick animals or during abortions led to the identification of 8 new outbreaks this week [week of Mon 11 Mar 2019], for a total of 60 cases in animals (including 49 cattle). Animal foci are located mainly in the centre and north west of the island;
- a total of 101 human cases of RVF have been reported to the platform/cell watch and health emergencies of the ARS OI (CVAGS) of Mayotte by the CHM laboratory. Of those who could be interviewed, almost 80% report having been in contact with animals;
- since the beginning of the health alert, human cases have been located mainly in the centre and north west of the island, with nearly 60% of cases in Chiconi and Tsingoni.

Since 25 Feb 2019, the weekly number of new human cases has been on the decrease.  [byline: Anne Perzo]
========================
[This Rift Valley fever (RVF) outbreak has been going on since November 2018. The number of human cases of RVF has increased from 82 to 101 in about 2 weeks. However, it is good to learn that the number of new human cases is decreasing. The above report implies that the human infections are the result of contact with infected animals or their products, with fewer from virus transmission by mosquito vectors. The cattle cases certainly are the result of mosquito transmission.

Because RVF virus can be transovarially transmitted in populations of aedes mosquito vectors, and those resulting eggs can persist for a long period of time in nature, cases can occur periodically when the virus-containing eggs hatch, and infected adult females emerge from them. There is a risk that RVF will reappear on the island after the current outbreak has ended.

Recent studies have shown that RVF virus may severely injure human foetuses if contracted by mothers during pregnancy. There is no indication of whether any of the 101 RVF virus-infected people were pregnant. Abortions in infected livestock are common. There is no vaccine available for human use, but there is for livestock. There is no mention of whether the livestock populations in the area have been vaccinated.

The clinical findings related to the above human cases are not mentioned. In an earlier comment, ProMED noted that: "The most common complication associated with RVF is inflammation of the retina. As a result, approximately 1-10% of affected patients may have some permanent vision loss. Approximately 1% of humans that become infected with RVF virus die of the disease." - ProMED

[ealthMap/ProMED-mail map of Region d'outre-mer de Mayotte, France:
Date: Fri 22 Feb 2019
Source: Le Journal de Mayotte [in French, trans. ProMED Corr. SB, edited]

Rift Valley fever (RVF) continues to circulate in Mayotte among the herds of ruminants, and the number of human cases is increasing.

The prefecture of Mayotte, in collaboration with the ARS Indian Ocean and the Directorate of Food, Agriculture and Forestry of Mayotte (DAAF) reminds the population of the importance of implementing recommendations and preventive actions to avoid being ill.

Epidemiological situation as of 22 Feb 2019:
- Samples taken by veterinarians from sick animals or during abortions have identified 33 animal FVR outbreaks.
- Since late November [2018], 63 human cases of RVF have been reported to the monitoring and health emergencies platform of the ARS OI (CVAGS) of Mayotte by the CHM laboratory.

Rift Valley fever (RVF) is a zoonosis (infectious disease that can be transmitted from animals to humans) of viral origin, which mainly affects domestic ruminants (cattle, sheep, goats), causing abortions and high mortality in young animals.

Transmission to humans can occur in different ways:
- By contact with blood, body fluids, or tissues of a sick animal (during slaughter, cutting of meat, calving, care, etc.). The most exposed people are therefore professionals such as breeders, slaughterhouse employees, and veterinarians.
- By mosquito bite, vectors of the disease near infected flocks, often in the rainy seasons.
- When eating unboiled milk or unpasteurized curd from an infected animal.

There is no [direct] person-to-person transmission of RVF [virus].

The disease in humans is usually manifested by an influenza-like illness that clears in a few days and includes symptoms such as high fever (39 deg C [102 deg F]), muscle and / or joint pain, intense headaches, and fatigue. However, in 5% of cases, more serious forms may occur: ocular meningitis / meningoencephalitis, haemorrhagic fever.

Recommendations for protection against the disease-causing virus:

For farmers and people in contact with animals:
- Wash hands with soap after contact with domestic ruminants (cattle, sheep, goats).
- Do not handle unprotected or diseased animals or abortion products without protection.
- Do not handle animal carcasses without protection.
- Wear gloves, goggles, and especially a mask for the slaughter of any animal. Infected animals may have no signs, although they can transmit the virus.

For food consumption:
Transmission by ruminants
- Boil the milk
- Do not consume curd unless it has been boiled and curdled with lactic fermentation.
- Wash hands after cutting meat.
- Do not eat uncooked meat.
- Do not consume the meat of a sick animal.

To protect yourself from mosquito bites:
- Eliminate breeding sites; empty all containers that may contain water.
- Use mosquito nets and repellents.

In case of appearance of symptoms, consult your doctor immediately.

Management measures:
By the Directorate of Food, Agriculture, and Forestry: The monitoring of Rift Valley fever involves the monitoring of abortions. Farmers are asked to report to veterinarians without delay any abortions occurring in their animals in order to take samples for the disease. The prevalence of RVF in the exchange zone with Mayotte being important, the risk of spread of the disease is not negligible in case of uncontrolled import of animals.

By the Indian Ocean Health Agency: Since the1st report, each ill person is interviewed by the ARS Indian Ocean to identify the risk factors for the disease.

A treatment of larval breeding and a mosquito control are done by the service of the Anti-vector Fight [unit] to the homes of the sick persons and around the houses. Information to health professionals was made to strengthen surveillance and identification of human cases.  [Byline: Anne]
======================
[This Rift Valley fever (RVF) outbreak has been going on since November 2018. The numbers of human cases of RVF have increased from 31 to 63 in about 2 weeks. The above report does not indicate whether the human infections are the result of virus transmission by mosquito vectors, but the cattle cases certainly are. Because RVF virus can be transovarially transmitted in populations of _Aedes_ mosquito vectors, and those resulting eggs can persist for a long period of time in nature, cases can occur periodically when the virus-containing eggs hatch and infected adult females emerge from them. Recent studies have shown that RVF virus may severely injure human fetuses if contracted by mothers during pregnancy. There is no indication of whether any of the 63 RVF virus-infected people were pregnant. Abortions in infected livestock are common. There is no vaccine available for human use, but there is for livestock. There is no mention of whether the livestock populations in the area have been vaccinated.

The clinical findings related to the above human cases are not mentioned, but the symptoms associated with RVF infections in general are listed. In an earlier comment, Mod.CP noted that, "The most common complication associated with RVF is inflammation of the retina. As a result, approximately 1-10% of affected patients may have some permanent vision loss. Approximately 1% of humans that become infected with RVF virus die of the disease." - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Region d'outre-mer de Mayotte, France:
Date: Fri 1 Feb 2019
Source: Outbreak News Today [edited]

In the Indian Ocean, between Madagascar and the coast of Mozambique, sits the archipelago of Mayotte, a Department of France.  Health officials have reported an increase in autochthonous Rift Valley fever (RVF) cases in the past 6 weeks. Since the 1st human case was detected on [Tue 11 Dec 2018], health officials have reported 19 human cases. Most of the cases were located in the western part of the island.  Samples made on ruminants present around human cases were analyzed at CIRAD in Reunion for the search for the RVF virus. The results identified several positive animals in different villages located in west and center of the island.

In addition, an IgM-positive cattle has been reported in Mamoudzou. This 2-year-old cattle belongs to a breeding herd of 8 cattle, including 4 adults and 4 2-month-old calves. Biological control and investigations are underway.  ECDC reports that the detection of autochthonous Rift Valley fever cases on Mayotte is not unexpected, but the occurrence of 19 cases within a short time period is of concern, as current weather conditions (rainy season from November to March) are favorable for the vectors.

Rift Valley fever (RVF) is an illness that is primarily spread by direct contact with blood, fluids, or tissues of infected animals such as cattle, buffalo, sheep, goats, and camels. Less commonly, it can also be spread through mosquito bites.  Most people with RVF do not feel sick or have only mild illness. Symptoms of RVF include fever, weakness, back pain, dizziness, and weight loss. However, a small percentage (8-10%) of people may have more serious illness, such as severe bleeding, swelling of the brain, or eye disease. Approximately 1% of people who get RVF die from the disease.  [Byline: Robert Herriman]
*************************************
Date: Sat 2 Feb 2019
Source: ECDC Communicable Diseases Threats Report Week 5, 27 Jan - 2
Feb 2019 [edited]

According to Institut de Veille Sanitaire (InVS), from 11 Dec 2018 - 28 Jan 2019, 19 Rift Valley fever cases were confirmed on Mayotte. All cases were locally acquired. Among these cases, 14 are male and 5 are female, with an age range of 27-64 years.

Most of the cases were located in the western part of the island. Further investigations identified several positive ruminants in the western and central parts of the island.

According to CIRAD, Rift Valley fever seroprevalence among ruminants has decreased from 2008 to 2017, but significantly increased in 2017 and 2018 (3.6%, CI 95% [2.3-5.6%]) and 2018 and 2019 (10.1% CI 95% [6.5-15.3%]). In addition, according to InVS, one case imported from Comoros was reported by authorities on Mayotte in 2011.

The detection of autochthonous Rift Valley fever cases on Mayotte is not unexpected, but the occurrence of 19 cases within a short time period is of concern, as current weather conditions (rainy season from November to March) are favourable for the vectors.

ECDC will continue monitoring this event through epidemic intelligence activities and report again if there is a relevant epidemiological update.

[Map] Distribution of RVF human cases and ruminants, Mayotte, 11 Dec 2018 to 28 Jan 2019

[Graph] Distribution of RVF confirmed human cases, Mayotte, 11 Dec 2018 to 28 Jan 2019

Year-Week / Number of cases
2018-50 / 1
2018-51 / 0
2018-52 / 2
2019-01 / 2
2019-02 / 0
2019-03 / 2
2019-04 / 8
2019-05 / 4
========================
[It is not surprising to have both human and cattle Rift Valley fever (RVF) cases occur simultaneously. The above report does not indicate if the human infections are the result of virus transmission by mosquito vectors, but the cattle cases certainly are. Because RVF virus can be transovarially transmitted in populations of _Aedes_ mosquito vectors, and those resulting eggs can persist for a long period of time in nature, cases can occur periodically when the virus-containing eggs hatch and infected adult females emerge from them. Recent studies have shown that RVF virus may severely injure human fetuses if contracted by mothers during pregnancy. There is no indication if any of the 19 RVF virus-infected people were pregnant. Abortions in infected livestock are common. There is no vaccine available for human use, but there is for livestock.

The clinical findings related to the above human cases are not mentioned. In an earlier comment, ProMED Mod.CP noted that, "The most common complication associated with RVF is inflammation of the retina. As a result, approximately 1-10% of affected patients may have some permanent vision loss. Approximately 1% of humans that become infected with RVF virus die of the disease. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Region d'outre-mer de Mayotte, France:
More ...

Finland

Finland - US Consular Information Sheet
January 13, 2009
COUNTRY DESCRIPTION:
Finland is a highly developed democracy with a modern economy.
It is a member of the European Union.
Tourist facilities are widely available.
Read
the Department of State Background Notes on Finland for additional information.
ENTRY REQUIREMENTS:
Finland is a party to the Schengen agreement.
As such, U.S. citizens may enter Finland for up to 90 days for tourist or business purposes without a visa.
The passport should be valid for at least three months beyond the period of stay.
For further details about travel into and within Schengen countries, please see our Schengen fact sheet.

Travelers can contact the Embassy of Finland at 3301 Massachusetts Avenue, N.W., Washington, DC 20008, tel: (202) 298-5800, or the Finnish Consulates General in Los Angeles or New York.
Additional information is available via the Internet at http://www.finland.org.
The U.S. Embassy in Helsinki is not able to assist private U.S. citizens in obtaining any necessary visas for neighboring countries, including Russia and other countries of the former Soviet Union.

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:
Finland remains largely free of terrorist incidents.
However, like other countries in the Schengen area, Finland’s open borders with its Western European neighbors allow the possibility of terrorist groups entering/exiting the country with anonymity.
Elements of organized crime groups operating in the former Soviet Union and Eastern Europe are present in Finland, but these do not represent a specific danger to U.S. citizen residents or tourists.
Americans are reminded to remain vigilant with regard to their personal security and to exercise caution.
For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov, where the current Travel Warnings and Travel Alerts, as well as the Worldwide Caution, can be found.
Up to date information on safety and security can also be obtained by calling 1-888-407-4747 toll-free in the United States and Canada, or for callers outside the United States 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 A Safe Trip Abroad.

CRIME:
Although the crime rate in Finland is low compared to the U.S. and most European countries, it has increased in recent years; however, Finland remains a relatively safe environment.
Americans visiting Finland are seldom victims of crime, but visitors should not be complacent regarding personal safety or the protection of valuables.
The same precautions employed in the U.S. should be followed in Finland.
Finnish police services are excellent. Travelers should be aware that some police officers speak little English.
Due to the low crime rate, Finland has one of the lowest numbers of police officers of any European nation.
Outside of key sites in major urban centers, they rarely project a visible presence; consequently, response times to crisis situations may be unpredictable.
All forms of public transportation are considered safe.
Street crimes, such as muggings and pick-pocketing, remain uncommon, but do occur.

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, to contact family members or friends and explain how funds could be transferred.
Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.

Finland has a program to provide financial compensation to victims who suffer serious criminal injuries.
According to existing regulations, the victim must report the incident to the police and file an application for compensation within 10 years of the date of the crime.
Finnish police routinely inform victims of serious crime of their right to seek compensation.
The relevant forms and further information can be obtained from http://www.treasuryfinland.fi.
The local equivalent to the “911” emergency line in Finland is 112.
Please see our additional information for 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 Finland’s laws, even unknowingly, may be expelled, arrested or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in Finland are strict and convicted offenders can expect jail sentences and heavy fines.
Engaging in illicit 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:
Commercial and financial transactions in Finland are increasingly automated and on-line.
Cash is almost always acceptable (the currency is the euro), but most major credit cards are widely recognized.
Automatic Teller Machines are very common and many U.S.-issued bankcards are compatible with them.

MEDICAL FACILITIES and Health information:
In Finland, medical facilities and their staff are generally excellent and are widely available for emergency services.
English is commonly spoken by Finnish medical personnel.
Helsinki is a frequent medical evacuation point for emergency cases from the countries of the former Soviet Union.
The public hospital system and many private hospitals honor foreign credit cards.
Most pharmacies (“apteekki” in Finnish) are open during normal shopping hours and major cities have at least one 24-hour service pharmacy.
If you are a tourist or temporary visitor to Finland and you require immediate emergency medical assistance, you may visit a local medical center or clinic, called “ensiapuasema” (first-aid station) in Finnish.
Usually these stations are located at hospitals and provide a full range of services.
The emergency telephone number, 112, can be used throughout Finland to contact emergency medical services.
For more detailed information on medicines and medical issues, please visit the website of the Finnish Embassy in Washington, DC at http://www.finland.org.
Travelers with special medical needs should consult with their personal physicians and take appropriate precautions, including bringing adequate supplies of necessary medication.
Medicines may be brought into the country as long as they are intended for the traveler’s personal use, however, there are special requirements concerning the quantity.
Medications categorized as narcotics may only be brought into the country to cover the traveler’s personal use for a maximum of 14 days and must be accompanied by a medical certificate stating why the traveler needs them.
For more detailed information, please contact the Finnish Embassy in Washington, DC at http://www.finland.org
In addition, stringent Finnish customs regulations prohibit travelers from receiving drugs from abroad after having arrived in the country.
Travelers may also find local physicians reluctant to prescribe equivalent quantities of dosages.

The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to or foreign residents of Finland.
Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://wwwn.cdc.gov/travel/default.aspx.
For information about outbreaks of infectious diseases abroad consult the World Health Organization’s (WHO) web site at http://www.who.int/en.
Further health information for travelers is available at http://www.who.int/ith.
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 Finland is provided for general reference only and may not be totally accurate in a particular location or circumstance.
Finnish roads are comparable to those in the U.S., though secondary roads may be less heavily traveled due to Finland’s sparse population outside the major urban areas.
These secondary routes often narrow to two lanes with a wider shoulder.
Slower vehicles are expected to move onto the shoulder to allow faster moving vehicles to pass.
Finland has an extensive network of highways throughout the country, as well as excellent public transportation services.
A valid U.S. driver’s license may be used while visiting Finland, but drivers must be at least 18 years of age.
Driving in Finland is on the right.
Traffic approaching from the right usually has priority, even if entering a primary roadway from a secondary one.
Road signs use standard international symbols and Finnish text.
Many urban streets have traffic lanes reserved for public transportation only.
Unless otherwise noted on traffic signs, the speed limit is 50 km/h in urban areas, 80 km/h on open roads, and 120 km/h on expressways during summer (reduced to 100 km/h during winter).
Vehicles must use headlights at all times.
Use of seatbelts is mandatory for drivers and all passengers.
Minor children must be seated in approved child or booster seats.

Public transport in Finland is of good quality and is the recommended method of travel.
Passenger trains, intercity buses, and air flights provide regular service over longer distances.
Public transportation in urban centers includes buses, subways, trams, suburban trains, and taxis.
Taxis are more expensive than in major U.S. cities.
Most local residents use public transport in Helsinki as parking can be hard to find and expensive.
The bus, train, and subway systems are relatively safe.
Travelers should be aware that drunk-driving laws are strict and acceptable blood alcohol levels are much lower in Finland than in the U.S.
Police strictly enforce all traffic laws and institute random roadside breath analyzer tests.
Drivers who register .05 or above alcohol content are subject to immediate arrest.
Drivers should be aware that regulations and traffic signs differ significantly from those in the U.S.
Visitors should be familiar with both prior to operating a vehicle in Finland.
Driving in Finland during the winter months can be hazardous.
Daylight hours are very short and one should be comfortable with driving in darkness.
Icy road conditions are common.
If driving in Finland, the vehicle must be winterized with studded snow tires and engine heaters are strongly recommended.
When driving at night, drivers must be alert to moose wandering onto major roadways.
There have been incidents of moose being struck by vehicles, causing severe damage to the vehicle and injury, sometimes fatal, to the occupants.
For real-time updates on road conditions throughout Finland, see the Finnish Road Administration’s travel and traffic information web site at http://www.finnra.fi
Please refer to our Road Safety page for more information.
Visit the website of the country’s national tourist office and national authority responsible for road safety at http://www.mek.fi
AVIATION SAFETY OVERSIGHT:
The U.S. Federal Aviation Administration (FAA) has assessed the Government of Finland’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Finland’s air carrier operations.
For more information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa
Please see our information on customs regulations.

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

REGISTRATION AND EMBASSY LOCATION:
Americans living or traveling in Finland are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration website, https://travelregistration.state.gov, so that they can obtain updated information on travel and security within Finland.
Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate.
By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.
The U.S. Embassy is located at Itainen Puistotie 14B.
The telephone number for the American Citizens Services unit is 358-9-616-25-701, 0830 to 1700 Monday to Friday (after hours, 358-9-616-25-0); the fax number is 358-9-616-25-800; e-mail:
HelsinkiACS@state.gov.
The address of the Embassy’s Internet home page is http://www.usembassy.fi
*

*

*
This replaces the Consular Information Sheet dated May 23, 2008 to update the sections on Information for Victims of Crime and Medical Facilities and Health Information.

Travel News Headlines WORLD NEWS

Date: Fri 14 Dec 2018
Source: UUTISET [edited]

An unvaccinated individual, who caught the contagious disease in Poland, attended a large church service in Tampere and infected at least 2 other people. Three adults have been diagnosed with measles in Tampere after attending a Catholic parish church event in late November along with more than 100 people, according to the Pirkanmaa Hospital District.

Two of the adults diagnosed have been vaccinated, so they are not contagious. The source of the outbreak is an unvaccinated person, who caught the measles in Poland. But according to the Pirkanmaa Hospital District, further cases may still arise.

In 1975 Finland began to administer a single dose of the measles vaccine to all one-year-olds and by 1982 Finland began administering the vaccine in 2 doses between the ages of 1 and 6. However some people born in the 1970s are among those who received only one jab. MMR is a triple-dose vaccine that provides protection against measles, mumps and rubella.

Measles spread at religious event
---------------------------------
The event in question was Tampere's Pyhan Ristin (Sacred Cross) Catholic Parish church mass on 25 Nov 2018. It was attended by more than 100 people, including children. Pirkanmaa Hospital District doctor Kirsi Valve, a specialist in infectious diseases, confirmed that the infected individual who caught the measles in Poland was at the church event. The cases came to light when 2 vaccinated individuals contracted high fevers and came down with skin rashes. The unvaccinated person, who infected the others, has had more severe symptoms than the vaccinated individuals.

"The individuals quickly got in touch with healthcare services owing to high fevers, and skin rashes that rapidly spread all over their bodies," says Valve. "It was confirmed that on 25 Nov 2018 the unvaccinated individual who caught the measles in Poland and brought it back to Finland was at the parish event and is the source of the outbreak."

As the source of the outbreak is known, healthcare officials are also looking into whether the person could have possibly exposed others.

Measles in the news
-------------------
Measles has been on the agenda this winter after an unvaccinated child in Ostrobothnia took ill with measles. Meanwhile, it also came to light that many adults in Finland may not have been vaccinated against measles during the early 1970s.

Measles is a rare disease. The previous outbreak was 2 summers ago when 4 vaccinated children caught measles in Italy and started showing symptoms after returning to Finland. The Pirkanmaa Hospital District recommends that anyone who attended the Catholic parish event in late November 2018 and exhibits symptoms that suggest measles or anyone who hasn't been vaccinated with the MMR vaccine contact their healthcare centre.

If those who attended the parish event are healthy, but have not been vaccinated, the Pirkanmaa Hospital District recommends that they contact their healthcare centre to be vaccinated. The measles vaccine is free and administered as part of the MMR shot, which also provides protection against rubella and the mumps.
Date: Fri 2 Nov 2018
Source: UUTISET [edited]

Around 1/3 of the ticks in Finland -- mostly found in the south -- carry at least one pathogen, and 2 percent of the persistent arachnids carry several disease-causing agents, researchers at Turku University said.

About 30 percent of common ticks and 24 percent of taiga tick populations have been found to carry one disease pathogen. Common ticks more commonly carry several disease-causing pathogens than taiga ticks, according to the researchers.

The most common pathogen found in the ticks was _Borrelia burgdorferi_, the bacterial species that causes Lyme disease in humans, an illness referred to locally as borreliosis. The pathogen was found in 17 percent of the ticks at the university's growing tick database bank.

Lyme disease cases are treated with aggressive antibiotics without necessarily determining which specific bacterium is responsible for the infection.

Thanks to a growing tick database at the University of Turku, researchers have new insights into the disease pathogens that the tiny, blood-sucking arachnids carry.

New research has revealed that ticks on the south coast carry the most pathogens, but the region is almost exclusively home to the most common ticks: _Ixodes ricinus_, or castor bean ticks).

Both castor bean ticks and taiga ticks [_Ixodes persulcatus_] are now commonly found in areas across central Finland, the researchers said. Even further north, the tick populations are quite similar to ones in central areas, but the taiga has become more common in the north.

About 3 years ago, researchers at the university asked members of the public to send in ticks they had found, and now the institution has received more than 20 000 ticks. The researchers say that they want to take advantage of the significant amount of information they can learn from the specimens.

Examination of those thousands of tiny arachnids have uncovered many types of disease-causing bacteria, and researchers have new insights into the arachnids themselves and the potential illnesses they carry.

The researchers said they hope to learn more about ticks, saying that their research has only begun, and that their study of the ticks will continue for several years. Ultimately, their goal is to find how tick-borne illnesses are transmitted, they said.
======================
[This is an interesting example of how a large group of people, many undoubtedly non-scientists, can contribute to an effort that requires many hours of collection effort. Although _Borrelia burgdorferi_ is endemic in Finland, finding it and possibly other bacterial pathogens in about 1/3 of the 20 000 ticks collected is of public health significance. _Ixodes ricinus_ is also the tick vector of European tick-borne encephalitis virus, but no mention is made of it in the above report. Perhaps it was not tested for. Images of both ticks can be found in the above report. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Date: Thu, 1 Nov 2018 16:46:12 +0100
From: topic@afp.com

Helsinki, Nov 1, 2018 (AFP) - Santa Claus has already begun his preparations in Lapland -- by protecting himself from winter viruses and making sure he hires enough elves.   On Thursday nurse Tiia Kahkonen administered an anti-influenza vaccine to Santa, at his village in the Arctic Circle town of Rovaniemi, northern Finland. 

The jab is likely to be a sensible precaution, as the flu season coincides with the busiest time of the year by far in Lapland.    In December last year 390,000 foreign visitors spent a night in Finnish Lapland, an increase of almost ten percent on the previous Christmas.    By far the largest group of Christmas holidaymakers were Brits, followed by Russian, French and German tourists, according to official statistics.

Meanwhile a recruitment agency in Finnish Lapland, inside the Arctic circle, has put out a call for Christmas elves to look after the hordes of tourists who come to visit Santa in his natural habitat during the winter months.   Prior experience is not essential as the advert, posted by the firm Lapland Staff, promises that training will be provided in "the required elfing and communication skills."   Successful applicants will also be given tips on how to deal with the cold in northern Finland where temeratures rarely rise above zero degrees Celsius, and can drop as low as minus 40.

Although handling Santa's reindeer is not listed among the job's duties, elves will need to herd groups of visitors on and off buses, as well as keep tourists entertained. "Looking after the fireplace and pouring hot juice" are also required, as is supervising the toboggan hill.   Tourism to Lapland has reached an all-time high in recent years, with visitors spending 3.5 million nights in Lapland across the whole year, up from 2.6 million a decade earlier, according to Statistics Finland.    Much of the recent growth has been driven by tourism from Asia.
Date: Sun, 17 Dec 2017 04:43:36 +0100
By Camille BAS-WOHLERT

Rovaniemi, Finland, Dec 17, 2017 (AFP) - In the run up to Christmas tourists from around the world flock to the Santa Claus Village, an amusement park in Finnish Lapland, where temperatures can hit nearly -15 degrees Celsius (5 Fahrenheit).    They buy soft toys and souvenirs from pricey gift shops while a bearded Santa receives hundreds of admirers a day throughout December before embarking on his world tour from the valleys of Finland to the skyscrapers of New York and beyond to deliver gifts.

Holding their winter beanie hats in their hands, visitors wait patiently in line for a brief encounter with "Joulupukki" -- the Finnish word for Santa Claus -- and a photo opportunity in exchange for hard currency.    "We've seen other Santas but that wasn't the real one. But we're told that is the real one," said Mary Gleadall, an eight-year-old tourist from Southampton in the UK, visiting the amusement park with her parents, brother and sister.    According to Christmas lore, Santa lives in a secret place in the middle of the snowy pines of the North Pole. But the question is where?     Since 2010, Rovaniemi, the capital of Finnish Lapland, has marketed itself as Santa's "official home".    Situated a few miles from the city, the Santa Claus Village is located in front of a huge gas station. 

Tourists rush to cross the Arctic Circle, marked by a white line, to meet Santa Claus in his wooden home with a pointed roof.    But entering his private cottage is out of the question as Mother Claus is reportedly protective of their privacy.    In a large room, the white-bearded old man sits in an armchair next to a chest full of letters.    Each year, he receives more than 300,000 visitors, a deluge he embraces with humility.    "I'm very happy. I'm not exhausted but, of course, I get tired once in a while" he says.    And how does Santa Claus regain his energy?    "I love to take nap every once and then. Fifteen minutes sleeping and then all is very good." he says.

- Exalted tourists -
Shizuka Kawahara and Saki Itoi, Japanese tourists in their thirties, flew for more than 24 hours to hug Santa for a few seconds in a precious moment immortalised with a photograph taken by an elf.    The price for one shot starts at 30 euros ($35). Photographing with one's own camera is forbidden as it would ruin the magic of the moment, says the staff of the house.     Four-year-old Harry Gleadall, Mary's brother, approaches Santa without fear.    He quickly states his list of what he wants for Christmas: Transformers and some more Transformers before he skeptically shakes Santa's hand.    "But what if it wasn't the real Santa Claus?" Harry asks with concern.    Eager to set the record straight -- and justify the long trip -- his mother quickly assures him that the chubby red-clothed man is indeed the real deal.    After a tour around the shop which sells hand-made "Lapland" emblems and tons of souvenirs, the family is back in the village square, surrounded by wooden homes, Christmas carols piped out of nearby speakers.

- Polar safari -
In this winter wonderland, tourists have the opportunity to go on a reindeer sleigh ride.    A snow "safari" of 400 metres costs 14 euros per child and 18 euros per adult, an exotic experience for many foreigners who seek to discover the arctic landscapes steeped in pink light.    The -13 degrees Celsius does not discourage the plucky visitors bundled up in their ski suits.    "Everything that have been told to me during childhood, it's come true," said Perpetua, a tourist from Dubai, describing the break from the year round desert climate as "heaven".   "We expected magic and this is what we found," added Max, an Italian tourist. "Everything seems to be magic, the lights, the place, everything here".   But Miriana, a 24-year-old Italian on a university exchange programme in southern Finland, was less convinced.   "The place is really nice. But I think nevertheless that it's a bit commercial," she said.
Date: Tue 18 Oct 2016
From: Tiina Nokireki <tiina.nokireki@evira.fi> [edited]

The Finnish Food Safety Authority (Evira) received a bat (Daubenton's bat, _Myotis daubentonii_) for laboratory analyses. The bat was found by a private person. The bat had neurological signs and then died.

Laboratory analyses conducted during the 13 and 14 Oct 2016, confirmed the presence of rabies by FAT. The virus was then identified as European Bat Lyssavirus type 2 (EBLV-2) by RT-PCR and partial sequencing of the gene for the nucleoprotein. Also cell culture is positive.

The bat originated from Inkoo in the province of Southern Finland and is part of the Uusimaa region. This is the 2nd case of EBLV-2 in a bat in Finland.
-----------------------------------------
Tiina Nokireki
Head of Section, DVM, Specialist in Veterinary Medicine, Infectious
Diseases
Finnish Food Safety Authority Evira
Research Department, Veterinary Virology
Mustialankatu 3,
FI-00790 Helsinki,
Finland
=========================
[Special thanks to Dr. Nokireki for this important contribution. Infections by European Bat Lyssavirus type 2 (EBLV-2) have been previously reported in Northern Europe, not only in bats, but also in humans. EBLV-1 appears to be more prevalent, accounting for the vast majority of all EBLV-infected bats. Reports of EBLV-2 correspond to Daubenton's bats (_Myotis daubentonii_), indicating that this bat species is the reservoir of this _Lyssavirus_ strain.

For a picture of a Daubenton's bat go to

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

Liberia

Liberia - US Consular Information Sheet
February 21, 2008
COUNTRY DESCRIPTION: Liberia is a country in West Africa that suffered from years of instability and conflict from 1990 - 2003, with attendant destruction of buildings, roads, and infras
ructure and public institutions.
A comprehensive peace accord ended the conflict in August 2003 and a United Nations peacekeeping force (UNMIL) was deployed to facilitate disarmament and demobilization, help arrange democratic elections and provide for security of the country.
In late 2005, Liberians went to the polls and elected Ellen Johnson Sirleaf as president.
The new government was inaugurated in January 2006, and has made tremendous progress towards restoring security and stability to the country.

Despite nearly four years of peace and a renewal of economic growth, Liberia is still one of the poorest countries in the world and many basic services (public power, water and sewage, land line phones) are either limited or unavailable.
Facilities for foreign visitors are adequate in the capital, Monrovia, but virtually non-existent in the rest of the country.
The official language of Liberia is English.
Read the Department of State Background Notes on Liberia for additional information.

ENTRY/EXIT REQUIREMENTS:
A passport and a visa are required for entry, as is evidence of a yellow fever vaccination and a physician's letter attesting to absence of communicable diseases.
Visa applicants may also be asked to provide evidence of health insurance.
Immigration officials no longer issue visas at the airport.
Persons arriving without a visa may be deported immediately, without leaving the airport.
Persons arriving from the United States must obtain a Liberian visa before traveling.
There is a US $25 airport tax on departing passengers, although this is usually collected as part of the ticket price.
For the latest information on entry requirements, visa fees and airport tax for Liberia, contact the Embassy of the Republic of Liberia, 5201 16th Street NW, Washington, DC 20011, tel. (202) 723-0437, web site www.embassyofliberia.org.
Overseas, inquiries should be made at the nearest Liberian embassy or consulate.

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 Department of State urges U.S. citizens to plan proposed travel to Liberia carefully and to exercise caution when traveling in Liberia.
Neither public transport nor taxis are available at the international airport, which is located 40 miles outside of Monrovia; therefore, before traveling to Liberia, Americans are urged to make arrangements for transportation from the international airport into the city center.
Americans traveling to Liberia are also urged to ensure that they have confirmed reservations at a reputable hotel, as rooms can be scarce and difficult to find without advance plans.

Americans who travel to or reside in Liberia should realize that Liberia's police force is in the process of being rebuilt.
There is a UN Mission in Liberia (UNMIL), but its mandate is to ensure political stability in Liberia.
Americans who travel around Liberia must realize that the role of UN Police (UNPOL) officers is to serve as advisors to the Liberia National Police. Accordingly, they do not have the authority to arrest or detain, and they are unarmed.
The Liberia National Police, for its part, has a limited presence in Monrovia, and even less of a presence outside of Monrovia.
In addition, police officers can be a source of problems for visitors as well as a source of aid or assistance.
Although problems with corruption have improved, travelers may be detained by police officers who solicit bribes.
Americans are encouraged to carry a photocopy of their passports with them at all times so that, if questioned by local officials, proof of identity and U.S. citizenship is readily available.
If detained or arrested, U.S. citizens should always ask to be allowed to contact the U.S. Embassy.

U.S. citizens in Liberia should be aware of their surroundings at all times and use caution when moving around, especially at night.
The U.S. Embassy recommends that American citizens observe a suggested curfew of 2:00 a.m. – 6:00 a.m.
Travel outside of Monrovia after dark is strongly discouraged as roads are in poor condition and thus dangerous to navigate at night.
U.S. citizens should avoid crowds, political rallies, and street demonstrations and maintain security awareness at all times.
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 Travel Alerts 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).

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

The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas.
For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State’s pamphlet A Safe Trip Abroad.
CRIME:
Crime in Liberia is rated high and is exacerbated by the high rate of unemployment.
Theft, assault, sexual crimes, and murder are problems, and they occur more frequently after dark.
Foreigners, including U.S. citizens, have been targets of street crime, robbery, and sexual assault.
Women have been attacked on deserted beaches.
Residential armed break-ins occur.
The police are ill equipped and largely incapable of providing effective protection or investigation.
Criminal activity is reported in both urban and rural areas.

Perpetrators of business fraud often target foreigners, including Americans.
Formerly associated with Nigeria, these fraud schemes are now prevalent throughout western Africa, including Liberia, and pose a danger of both financial loss and physical harm.
An increasing number of American citizens have been the targets of such scams.
The best way to avoid becoming a victim of fraud is common sense – if it looks too good to be true, it probably is.
Any unsolicited business proposal originating in Liberia should be carefully checked before committing any funds, providing any goods or services, or undertaking any travel.
There is also an increase in Liberian/American Internet relationships, where there are eventual requests for financial assistance under fraudulent pretenses.
For additional information, please see the Department of State's Bureau of Consular Affairs brochure International Financial Scams.

Petty corruption is rampant; poorly paid government officials are not immune from the temptation to collect fees for doing their job.
The result is that travelers may be asked for bribes and inconvenienced for not paying them.

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

See our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION:
Hospitals and medical facilities in Liberia are very poorly equipped and are incapable of providing many services.
Emergency services comparable to those in the U.S. or Europe are non-existent, and the blood supply is unreliable and unsafe for transfusion.
Americans with serious medical problems travel or are medically evacuated to the United States, Europe or South Africa.
Medicines are scarce, often beyond expiration dates, and generally unavailable in most areas.
As there is neither an effective garbage removal service nor a functioning sewer system, the level of sanitation throughout urban areas is very poor, which increases the potential for disease.
Upper respiratory infections and diarrhea are common, as well as the more serious diseases, typhoid and malaria.
All travelers to Liberia must be vaccinated against yellow fever and should carry a supply of all prescription medication, plus anti-malaria medication, adequate for their entire stay.
A typhoid vaccination is also recommended.

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

MEDICAL INSURANCE:
The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and whether it will cover emergency expenses such as a medical evacuation.
For travel to Liberia, obtaining separate medical evacuation insurance before arriving in Liberia is strongly recommended.
Please see our information on medical insurance overseas.
SWIMMING HAZARD:
Liberia has many excellent beaches along the Atlantic coastline that tourist and those who live in the country enjoy throughout the year, however American citizens should be aware of the threat of dangerous rip currents better known as rip tides.
These strong currents can occur anywhere on the coast given the right surf conditions.
The Liberia Weather Service does not provide information on where and when these tides form and there are no lifeguards posted on beaches.
American citizens who plan to swim in the Atlantic should read from various sources e about the dangers of rip currents and how to navigate if you find yourself in such a situation; or better still do not swim if you are unfamiliar with swimming in water where very strong rip currents occur.

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

Road travel in Liberia can be hazardous.
Potholes and poor road surfaces are common, making safe driving extremely challenging.
Cars, trucks, and taxis are often overloaded with people and goods and make frequent stops without signaling.
Drivers overtake on the right as well as the left.
Many vehicles operate with threadbare tires, and blowouts are frequent.
Public taxis are poorly maintained and usually overloaded.
Intersections must be approached with caution.
The absence of public streetlights makes pedestrians walking in the city streets and those walking on country roads difficult to see at night.
Drivers and pedestrians are cautioned that high-speed car convoys carrying government officials require all other vehicles to pull off the road until they have passed.

Travelers should expect delays at UNMIL security checkpoints, as well as time-consuming detours around the many bridges and roads damaged by war, neglect, or the heavy annual rains, which occur from May to November.
Travelers can expect strict enforcement of border controls by Liberian, Ivorian, Sierra Leonean, and Guinean authorities.
At times border crossings to neighboring countries are closed.

Please refer to our Road Safety page for more information.

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

SPECIAL CIRCUMSTANCES:
Lodging, fuel, transportation, and telephone services are unevenly available in Liberia, and are nonexistent or severely limited in rural areas.
Neither water nor electricity is commercially available in Liberia, including the capital of Monrovia.
Most hotels have utilities available, but not always on a 24-hour basis.
There is no working landline telephone system in Liberia.
Several cell phone companies provide service in Monrovia and some areas outside the capital.
US cellular phones do not always work in Liberia and it is advisable to rent or purchase a local cellular phone.
The postal system is slow and unreliable.
Commercial air courier service is available through UPS, Federal Express (FedEx), and other companies.

The U.S. dollar is readily accepted in Liberia, and there is no limit on the amount of foreign currency that can be transported into and out of the country, provided one follows the specific regulations on how such transfers must be done.
Sums in excess of US $10,000 must be reported at the port of entry and no more than US $7,500 in foreign currency banknotes can be moved out of the country at one time.
Larger sums must be transferred via bank drafts or other financial instruments; persons without a Liberian bank account are limited to two outgoing US $5,000 over-the-counter cash wire transfers per month.
Wire transfers are not widely used and are subject to substantial fees.
ATMs are unavailable and Traveler's checks and credit/debit cards are not accepted anywhere in Liberia.

Photographing military installations, air and seaports, and important government buildings is prohibited.
Visitors should not take photographs of sites or activities that might be considered sensitive, or police are liable to confiscate the camera.

Please see our information on Customs Information.

CRIMINAL PENALTIES:
While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law.
Penalties for breaking the law can be more severe than in the United States for similar offenses.
Persons violating Liberian law, even unknowingly, may be expelled, arrested, or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in Liberia are severe, and convicted offenders can expect long jail sentences and heavy fines.
The U.S. Embassy does not always receive timely notification of the arrest of U.S. citizens by Liberian authorities.
If arrested, U.S. citizens should ask to be allowed to contact the U.S. Embassy (see the Registration/Embassy Location section below).
Americans should carry a photocopy of their U.S. passport with them at all times.
The consular section of the U.S. Embassy cannot give legal assistance but can provide a list of Liberian attorneys if one is required.
Engaging in sexual conduct with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States.
Please see our information on Criminal Penalties.

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

REGISTRATION / EMBASSY LOCATION:
Americans living or traveling in Liberia are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration web site so that they can obtain updated information on travel and security within Liberia.
Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate.
By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.
The U.S. Embassy is located at 111 United Nations Drive, Mamba Point, Monrovia; telephone 231-77-054-826; fax 231-77-010-370; web site http://monrovia.usembassy.gov.
U.S. citizens who wish to write to the U.S. Embassy in Monrovia may address letters to the Consular Section, 8800 Monrovia Place, U.S. Department of State, Washington, D.C. 20521-8800, or send emails to ConsularMonrovia@state.gov.
*

*

*
This replaces the Consular Information Sheet on Liberia dated June 15, 2007 to include a caution on swimming at local beaches.

Travel News Headlines WORLD NEWS

Date: Mon 6 May 2019
Source: Front Page Africa [edited]

The emergence of a rare skin disease known in Liberia as "Be Serious" has sparked fear amongst residents of Charlie Town in Rivercess County. Residents, mainly parents, say children who are under 15 years of are seriously infected. They are afraid that the disease is contagious and is fast spreading rashes on the bodies of school-going-kids.

They are afraid that the situation will become an emergency, due to lack of adequate medication at the only clinic in the area. Joe Gbessigie, a resident of the town, says he's worried that instead of providing medicines, the clinic only gives patients prescriptions to buy drugs from private pharmacies.

Nathaniel Zoklah, the Township Commissioner, says some kids who are affected by the disease are in school, and he is concerned that the situation poses risk to other pupils. "At this time of the school year, keeping children who are affected with the disease may affect their education, so the kids are in schools with their friends but it is risky also," Commissioner Zoklah said. "They are interacting, eating together and this disease has the ability to spread through contact, so more children risk being affected."

The residents have not been able to state the actual cause of the disease, but some are assuming that it is waterborne. Some of the residents in Charlie Town and its surroundings said the hand pumps that are a major source of drinking water are all damaged, forcing residents to fetch water from creeks.  [Byline: Willie N. Tokpah]
===========================
[The disease referred to in this report and its accompanying photograph is most likely to be scabies.  Scabies is a skin infestation by the scabies mite - _Sarcoptes scabiei_. The infection is found worldwide and is transmitted under poor hygienic conditions. The mite is transmitted by physical contact and poor hygiene is a main risk factor. Outbreaks are seen in refugee camps and nursing homes.

An outbreak is handled by ensuring that the affected people and close contacts at risk have a frequent bath and change clothes daily. The traditional treatment is pyrethroid containing ointments which kill the mites, but ivermectin orally is easier to administer and thus more acceptable and ensures better compliance. Especially in an outbreak in a school the best way to stop the outbreak would be administration of ivermectin to all children. - ProMED Mod.EP]

[HealthMap/ProMED map available at:
Rivercess County, Liberia: <http://healthmap.org/promed/p/42309>]
Date: Tue 23 Oct 2018
Source: The Bush Chicken [edited]

The director for immunization at the Ministry of Health says there are currently 29 reported measles cases in Grand Gedeh, with 7 of those cases confirmed.

Director for immunization at the Health Ministry Adolphus T. Clarke said reports of the outbreak in Tchien district 1st emerged on [Wed 17 Oct 2018]. Speaking to The Bush Chicken in an exclusive interview, Clarke said out of the 29 cases reported, health officials in the area realized that 11 children under 5 years of age were affected by the disease. The other children were older than 5.

"The 29 cases identified were managed at the Martha Tubman Memorial Hospital in Zwedru, and the affected children fully recovered with no death reported."

With support from the Ministry of Health, Clarke said the county responded quickly with vaccinations. "The exercise has concluded, and health officials were able to reach a total of 1551 children not less than 5 years," he said. "So I can say that the county responded swiftly to the outbreak of the disease and recorded zero deaths."

However, things did not go smoothly. Due to the poor road conditions in the south-eastern region, Clarke said some health officials who left Monrovia with vaccinations for Grand Gedeh endured difficulties during the journey. "Others had to travel through neighbouring Ivory Coast to reach the country," he said.

The director indicated that, due to the challenge in attaining high vaccination coverage, health authorities in the country knew that, at some point in time, there would be sporadic outbreaks of the disease in the county.

Clarke said the current outbreak was not severe, because the ministry has dealt with sporadic outbreaks of measles in the past. He noted that health officials in Grand Gedeh have now been encouraged to carry out vaccination campaigns in affected and nearby communities as the dry season approaches.

"We have encouraged mothers to make use of the health facilities in the county and ensure that their children are vaccinated against all the diseases the ministry is preventing," Clarke said.  [Byline: Zeze Ballah]
Date: Thu 27 Sep 2018
Source: Front Page Africa [edited]

The National Public Health Institute of Liberia (NPHIL) in collaboration with the Ministry of Health (MoH) and partners is investigating a suspected case of yellow fever in Grand Kru County.

According to a release issued in Monrovia, the suspected case is a 2-year-old female from Farina Town, Barclayville Health District. There has been no death or new cases reported. The suspected case has been managed and is in good health.

A blood specimen has been collected and sent to the National Public Health Reference Laboratory (NPHRL) for confirmation. According to the release, health authorities in the county are conducting an active case search, risk assessment, and planning for a possible reactive vaccination exercise, pending the laboratory result.

Since January 2018, this is the 2nd reported suspected case from Grand Kru County. The 1st was a 29-year-old female from Dorbor District.

There have been no confirmed cases of yellow fever in the country since the 2009 nationwide preventive vaccination campaign. The release also noted that a total of 94 suspected cases of yellow fever have been recorded across the country since the beginning of 2018.

Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. The symptoms include fever, headache, jaundice, muscle pain, nausea, vomiting, and fatigue. Communities have been advised to report unexplained deaths for safe and dignified burials as measures to prevent infection. Community engagement and response activities have been intensified in the area.

Meanwhile, the public is advised to take the following public-health measures:
- Keep your environment clean
- Visit a health facility immediately when you feel the symptoms of yellow fever
- Continue sleeping under treated bed nets

Yellow fever is not transmitted through body touch or body fluids.
=====================
[Yellow fever (YF) cases have occurred sporadically in Liberia, although the last YF ProMED-mail post was in 2009. The 94 suspected YF cases this year (2018), including the most recent one above, is a cause for serious concern. It is important to have a timely laboratory diagnosis and well-developed contingency plans should YF be confirmed. YF can quickly spread if a significant proportion of the human population is unvaccinated and the vector mosquitoes are abundant. The above report does not indicate the number of unvaccinated individuals nor the status of the vector mosquito population. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Grand Kru County, Liberia: <http://healthmap.org/promed/p/32407>]
Date: Fri 6 Jul 2018, 5:00 PM
Source: WHO Weekly Bulletin on Outbreaks and Other Emergencies [edited]

Event Description
-----------------
Liberia has continued to experience sporadic cases of Lassa fever since the beginning of 2018. In week 25 (week ending 26 Jun 2018), 2 new confirmed Lassa fever cases were reported in Nimba County, the only county with active transmission currently. Nimba County has reported 5 confirmed Lassa fever cases since [12 May 2018]. In the latest event (the 2 confirmed cases in week 25), the 1st case-patient, a 59-year- old male from Gbehlay Geh district, fell ill on [4 Jun 2018] and was treated with antimalarials and antibiotics at a local clinic. On [20 Jun 2018], the case-patient presented to a public hospital with fever and other constitutional symptoms, and had bleeding from a venepuncture site.

On [21 Jun 2018], a blood specimen was collected and sent to the National Public Health Reference Laboratory (NPHRL). The test result released on [26 Jun 2018] was positive for Lassa fever virus infection. The 2nd case-patient, a 41-year-old female, is the wife of the first case-patient (described above). She developed illness on [17 Jun 2018] and was admitted to the same hospital on [20 June 2018] with fever and other constitutional symptoms. Being a known contact, a blood specimen was collected on [21 Jun 2018] and the test result released on [26 Jun 2018] was positive for Lassa fever. The 2 case-patients are admitted under barrier nursing and ribavirin treatment initiated. A total of 26 contacts, including 13 health workers, have been line listed and are being followed up.

Between [1 Jan 2018] and [27 Jun 2018], a total of 130 suspected Lassa fever cases, including 33 deaths, were reported. Of these, 20 cases were laboratory confirmed, 103 were discarded (after testing negative), and 7 cases were not tested due to inadequate specimens. Of the 20 confirmed cases, 14 have died, giving a case fatality rate of 70 percent. Females make up 60 percent (12) of the confirmed cases. The age range for the confirmed cases is 1 to 65 years old, with a median of 32.5 years. The confirmed cases are from 5 counties, namely (Nimba (9), Bong (4), Montserrado (3), Margibi (2), and Grand Bassa (2).

Public Health Actions
---------------------
- The Ministry of Health and the National Public Health Institute of Liberia (NPHIL) are coordinating response activities to the Lassa fever outbreak, with support from WHO, CDC and other partners. The national epidemic preparedness and response committee (NEPRC), under the leadership of NPHIL, have been meeting weekly to review the Lassa fever outbreak situation and provide technical support to sub-national level, with technical support from WHO, and US-CDC; 15 WHO field offices are providing technical and operational support to the response.
- Active surveillance, including case search, case investigation and contact tracing are ongoing in the affected districts. A specimen transport system using couriers is available at designated points across the country to transport specimens to the NPHRL for testing.
- The Ganta United Methodist Hospital has been designated as a treatment centre, and equipped with ribavirin and other medical supplies for case management. Orientation of healthcare workers on case management protocol is ongoing.
- Healthcare workers in the country are being trained on Lassa fever case management and infection prevention and control (IPC) measures by NPHIL and MOH, with support from WHO.
- Health workers' exposure risk assessment is planned to be conducted in the clinic or hospital where the confirmed cases sought care.
- Community engagement activities are ongoing in the affected communities, including home visits and providing information on environmental cleanliness.

Situation Interpretation
------------------------
Sporadic Lassa fever cases continue to occur in certain parts of Liberia where the disease is known to be endemic. Bong, Grand Bassa, Margibi, and Nimba are among the counties that report cases annually. In 2017, a total of 30 confirmed cases were reported from 7 counties. The reason for these sporadic cases is known: the constant interaction of rats (the vector for Lassa fever virus) and people in unsanitary conditions. The national authorities and partners need to prioritize measures mitigating this exposure risk factor by improving vector and environmental management components of the response. This goes along with effective social mobilization and community engagement strategies, targeting vector control and environmental management in the communities. There is also a need to enhance capacity at the subnational levels for early case detection, case investigation, appropriate case management and its associated IPC [infection prevention and control] measures aimed at averting infection among health workers.
========================
[The number of Lassa fever cases in Liberia continues to slowly increase. Between 1 Jan 2018 and 27 Jun 2018, 20 cases were laboratory confirmed, up from 18 cases on 1 Jun 2018. Apparently, all these Lassa fever virus infections were acquired by contact with infected rodents or their excretions. Lassa fever virus can be acquired from infected rodents or patients in the hospital but in the above report, there is no mention of Lassa fever virus nosocomial transmission. Transmission can occur in health facilities when personal protective equipment is not employed and barrier-nursing practices are not adequate to protect staff from blood and secretions of infected patients. The hospitals attending the patients mentioned above do have barrier measures in place.

As mentioned in previous posts, Lassa fever virus transmission to humans occur when people are in contact with the reservoir rodent host, the multimammate mouse (_Mastomys natalensis_ and _M. erythroleucus_) and the African wood mouse (_Hylomycus pamfi_) or their excreta, as was likely the situation in these cases. Rodent control has to be undertaken at the village level with individual households employing the preventive measures listed above. This requires an extensive and continuous public education effort.

Images of the _Mastomys natalensis_ mouse, the rodent reservoir of Lassa fever virus, can be seen at
_M. erythroleucus_ and _Hylomycus pamfi_ at:

[Maps of Liberia can be accessed at:
Date: Fri 15 Jun 2018
Source: WHO Regional Office for Africa, Health Information and Risk Assessment [edited]

Weekly bulletin on outbreaks and other emergencies week 24: [11-17 Jun 2018; data as of 15 Jun 2018]
----------------------------------------------------------------------
Liberia: 2930 cases, 14 deaths, 0.5 percent CFR

Event description
-----------------
Liberia has been experiencing recurrent measles outbreaks since the beginning of 2018. In week 23 (week ending 10 Jun 2018), a total of 61 new suspected measles cases (with no deaths) were reported from 13 out of the 15 counties in the country, compared to 72 new cases reported in week 22 [week ending 3 Jun 2018]. 23 blood specimens collected from the suspected cases have been shipped to the National Reference Laboratory, while 20 of the case-patients had epidemiological links to confirmed cases. During the reporting week, 14 out of 92 health districts (in 5 counties) attained measles epidemic threshold of 3 laboratory confirmed cases. The 5 counties are Grand Bassa, Margibi, Maryland, Montserrado, and Nimba.

Between week 1 and week 23 of 2018 [1 Jan-10 Jun 2018], a total of 3086 suspected measles cases were reported. Of these, 177 were laboratory confirmed, 1762 had epidemiological links to confirmed cases, 562 were clinically compatible, 156 were discarded (after testing negative), and test results for 429 cases were pending. Of the 2930 confirmed, epidemiologically linked, clinically compatible, and suspected cases, 14 have died, giving a case fatality rate of 0.5 percent in this group; 558 (19 percent) were vaccinated, 334 (11 percent) were not vaccinated and 2 038 (70 percent) had unknown vaccination status. About 39 percent of the affected people are 4 years of age and below, 25 percent are between 5 and 9 years and 36 percent are 10 years and above.

Public health actions
---------------------
The Ministry of Health Expanded Program on Immunization and the National Public Health Institute of Liberia (NPHIL) are coordinating response activities to the measles outbreak, with support from WHO, UNICEF, and other partners. The national epidemic preparedness and response committee (NEPRC), under the leadership of NPHIL and with technical support from WHO, UNICEF, US-CDC and other agencies, have been meeting weekly to review the measles outbreak situation and provide technical support to sub-national level. WHO has deployed the Polio STOP team in the 15 counties to support sub-national level response.

A nation-wide measles immunization campaign has been conducted across the country in 3 phases since 15 Feb 2018, targeting a total of 654 803 children aged 6-59 months. Preliminary data indicates that 97 percent (63 350) of the targeted populations were vaccinated across the country.

Active search for measles cases continues throughout the country and has been reinforced in districts and communities with sustained outbreaks. Epidemic threshold is monitored weekly across the country through routine data collection and analysis.

All measles cases are being provided with symptomatic management along with a high dose of vitamin A.

The National Public Health Reference Laboratory has been testing samples reported across the country, by serology (IgM detection), and routinely releasing test results.

Communities have been provided with education to seek early care for measles cases at the nearest health facility. Communities have also mobilized through town criers, radio messaging, and posters to ensure high coverage of the immunization campaign among targeted age group.

Situation interpretation
------------------------
Liberia has been experiencing recurrent measles outbreaks since the beginning of the year [2018]. The reason for these outbreaks is known: the accumulation of a large number of susceptible populations over the years due to suboptimal immunization coverage. It is concerning that measles incidence cases are occurring in spite of the 3 phases of mass immunization campaigns conducted since February 2018, with seemingly high administrative coverage. The national authorities and partners need to drastically and speedily reduce the number of susceptible individuals in the most affected age-groups, maintain the build-up of vulnerable individuals at very low levels by immunising a large proportion (over 95 percent) of each new birth cohort and implement additional vaccination activities to periodically protect susceptible individuals who have accumulated.

With the well-developed immunization programme, structures, and systems, such measles outbreaks should be predicted and adequate preparedness measures put in place. Additionally, each measles outbreak should be followed by thorough evaluation of the cause of the outbreak, the surveillance system for early outbreak detection, the preparedness measures preceding the outbreak and the management of the outbreak, and an overall review of immunization programme goals and operations.
==========================
[A map showing the geographical distribution of measles cases in Liberia, week 1-23, 2018 can be seen at the source URL above. - ProMED Sr.Tech.Ed.MJ]

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

Togo

Togo US Consular Information Sheet
September 10, 2008
COUNTRY DESCRIPTION:
Togo is a small West African country with a stagnant economy in a state of political uncertainty.
French is the official language, but Ewe and Mina are commonl
spoken as well.
Tourism facilities are limited, especially outside the capital city, Lomé.
Read the Department of State Background Notes on Togo for additional information.
ENTRY/EXIT REQUIREMENTS:
A passport and visa are required.
Travelers are encouraged to obtain visas prior to arrival due to recent difficulties with requesting them at the airport in Lomé or at some of the land borders.
Visas issued in Togo are limited to 7 days and can take an hour or more to be issued.
Travelers applying for visa extensions can also experience significant delays.
Vaccination against yellow fever is required before entry.
U.S. citizens should carry copies of their U.S. passports and vaccination records with them at all times while traveling in Togo so that, if questioned by local officials, they have proof of identity, U.S. citizenship, and required vaccinations readily available.

Travelers may obtain the latest information and details from the Embassy of the Republic of Togo, 2208 Massachusetts Avenue NW, Washington, DC
20008; telephone (202) 234-4212.
Overseas, inquiries should be made at the nearest Togolese embassy or consulate.

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.

SAFETY AND SECURITY:
U.S. citizens are urged to avoid political rallies, street demonstrations, and maintain security awareness at all times.
Togo has experienced periodic violence, strikes, and political tensions since 1990.
Following the death of President Eyadema in February 2005, political activists took to the streets and held demonstrations throughout the country that resulted in more than 500 deaths.
Land borders with Ghana and Benin are routinely shut down during elections. The October 2007 legislative elections were non-violent with only minor incidents reported during the single post-election demonstration. The next major elections are the presidential elections scheduled for 2010.

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

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

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

CRIME:
Over the past year, Togo has seen a marked increase in incidents of violent crime throughout the country, including several recent machete attacks in poorly lit areas of Lomé.
Rapid inflation and food shortages have contributed to increases in already critical crime levels in urban areas.
Particular areas for Americans to avoid within Lomé, especially during the hours of darkness, include the Grand Marché area, the beach road, and the Ghana-Togo border areas.
Travelers should avoid the beach even during daylight hours as purse-snatchings and muggings occur there regularly.
Pick pocketing and theft are common in Togo, especially along the beach and in the market areas of Lomé.
While incidents of residential burglary are less common against foreigners, carjacking is on the rise, and even western diplomats have been victims of carjacking. Theft while riding in taxis is also increasing, as thieves steal bags, wallets, and passports.
Taxicabs should not be shared with strangers.
Perpetrators of business fraud often target foreigners, including Americans.
Formerly associated with Nigeria, these fraud schemes are now prevalent throughout western Africa, including Togo, and pose a danger of both financial loss and physical harm.
An increasing number of Americans have been the targets of such scams, losing anywhere from several thousand to several hundred thousand dollars.
Typically, these scam operations begin with an unsolicited communication, usually by e-mail, from an unknown individual who describes a situation that promises quick financial gain, often by assisting in the transfer of a large sum of money or valuables out of the country.
The scenarios vary:
an American must pretend to be the next-of-kin to a recently deceased Togolese who left a fortune unclaimed in a Togolese bank, or a person claiming to be related to present or former political leaders needs assistance in transferring large sums of cash, or even a business deal that appears to be legitimate.
The requests are usually for the payment of advance fees, attorneys’ fees, or down payments on contracts.
The final payoff does not exist; the purpose of the scam is to get any money possible and to gain information about the American’s bank account.
The best way to avoid becoming a victim of advance-fee fraud is common sense – if it looks too good to be true, it probably is.
You should carefully check out any unsolicited business proposals originating in Togo before you commit any funds, provide any goods or services, or undertake any travel.
Please check the Embassy web site at http://togo.usembassy.gov/ for the most current information on fraud in Togo.
For additional information, please see the Department of State brochure on International Financial Scams.

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

The local equivalent to the “911” emergency line in Togo is: 117 or 171 for police, 172 for Gendarmerie, 242 for the Pharmacy on Duty, and 118 for Fire Services.

See our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION:
Medical facilities in Togo are limited and of very poor quality, with no adequate emergency medical care.
Availability of medications through local pharmacies is unreliable, and travelers should carry all necessary medications, properly labeled, with them.
Malaria, a serious and sometimes fatal disease, is prevalent in Togo.
For additional information on malaria, including protective measures, see the CDC travelers’ health web site at http://www.cdc.gov/malaria/.

For information on avian influenza (bird flu), please refer to the Department of State's Avian Influenza Fact Sheet.
According to the Togolese Ministry of Foreign Affairs and Ministry of Health, there are no HIV/AIDS entry restrictions for visitors to or foreign residents of Togo.

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

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

TRAFFIC SAFETY AND ROAD CONDITIONS:
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 Togo is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

While some major thoroughfares in urban parts of Togo are paved, many secondary streets are not, and become severely flooded every time it rains.
Driving conditions are hazardous throughout Togo due to the presence of pedestrians, large numbers of small motorcycles, disorderly drivers (moped, car and truck drivers), livestock on the roadways, and the poor condition of the roads, including deep potholes.
Overland travel off the main network of roads generally requires a four-wheel-drive vehicle.
Many drivers in Togo do not obey traffic laws and most traffic signals do not function properly.
Drivers should be prepared for other vehicles to run red lights or stops signs and drive in the wrong direction on one-way streets.
Nighttime travel on unfamiliar roads is dangerous.
Poorly marked checkpoints, often manned by armed, undisciplined soldiers, exist throughout the country, including in the capital.
Banditry, including demands for bribes at checkpoints, has been reported on major inter-city highways, including the Lomé-Cotonou coastal highway.
Travelers are advised to be aware of their surroundings and to drive defensively.
At official checkpoints, Togolese security officials prefer that you approach with your dome light on, and have your driver’s license, registration, and proof of insurance ready.
Americans should be aware of the staged-accident ploy when driving in Lomé.
In this scam, a motorbike will cut in front of you, cause a collision, and draw a crowd, which can turn hostile if you attempt to leave the scene of the so-called accident.
Such encounters appear designed to extort money from the vehicle driver.
Pedestrians also cause staged accidents.
Genuine accidents can also draw hostile crowds.
Travelers should drive with their car doors locked and windows closed, and have a cell phone in the vehicle.
If you are involved in this kind of accident and can drive away, you should leave the scene, drive to a safe location, and alert both the police and the U.S. Embassy.
Violent carjackings are periodically reported in Togo and tend to increase during the summer months and holiday season. Travelers are advised to exercise caution when using any form of local public transportation.
Never get into a taxi with unknown passengers and always agree on the fare before getting in.

Please refer to our Road Safety page for more information.
Visit the web site of the country’s tourist office at http://www.togo-tourisme.com/.

AVIATION SAFETY OVERSIGHT:
As there is no direct commercial air service to the United States by carriers registered in Togo, the U.S. Federal Aviation Administration (FAA) has not assessed Togo’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.

SPECIAL CIRCUMSTANCES:
Power outages, voltage fluctuations, and water shortages are common throughout the country.
Only certain U.S. credit cards are accepted in Togo.
Most major hotels and their restaurants accept American Express, MasterCard, and Visa, while smaller hotels and restaurants do not.
Travelers planning to use credit cards should know which cards are accepted before they commit to any transaction.
Travelers should keep all credit card receipts, as unauthorized card use and overcharging are common.
There are some Automatic Teller Machines that dispense local currency in major banks and they are generally considered safe.
Well-known money transfer firms, including Western Union, operate in Togo.
Photographing places affiliated with the government of Togo, including official government buildings, border crossings, checkpoints, police stations, military bases, utility buildings, airports, government vehicles, and government or military personnel, is strictly prohibited, and local authorities will confiscate film and cameras.
Government buildings are not always clearly identifiable, as they vary from being very well marked to being not marked at all.
Please see our Customs Information.

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

Please see our information on Criminal Penalties.

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

REGISTRATION / EMBASSY LOCATION:
Americans living or traveling in Togo are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration web site so that they can obtain updated information on travel and security within Togo.
Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate.
By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.
The U.S. Embassy is located on Boulevard Eyadema, Neighborhood Lomé II, Lomé; telephone (228) 261-5470, fax (228) 261-5499. The local mailing address is B.P. 852, Lomé.
The web site is http://togo.usembassy.gov/
* * *
This replaces the Country Specific Information for Togo dated March 3, 2008, to update the sections on Crime, Information for Victims of Crime, and Medical Facilities and Health Information.

Travel News Headlines WORLD NEWS

Date: Mon 7 Jan 2019
Source: Outbreak News Today [edited]

The Togo government confirmed last week [week of 1 Jan 2019] a Lassa fever case reported in Doufelgou district [Kara region] in the north of the country, according to a Agence de Presse Africaine report (computer translated).

This was a haemorrhagic fever case according to officials.

Lassa fever is a rare but potentially life-threatening viral haemorrhagic disease. The risk of infection is low but can occur if someone comes into contact with an infected person's blood or bodily fluids. Lassa fever cannot be spread through casual contact, including skin to skin contact, without exchange of bodily fluids. Those at highest-risk would be health care workers treating patients in facilities known to have Lassa fever and family members caring for infected patients.

Early diagnosis and supportive care are essential. One should consult a medical professional if he or she has been in direct contact with an infected person within the past 3 weeks and have symptoms of Lassa fever, which include: fever, chest, stomach or back pain, cough, vomiting, diarrhoea, or mucosal bleeding.
=========================
[Lassa fever virus is endemic in much of northwest Africa, including Benin, Togo, and Burkina Faso. There have been cases of Lassa fever in Togo as recently as 2017. In the 2017 report, health authorities in Togo implemented the following measures to respond to these Lassa fever cases, including:
- deployment of rapid response teams to the affected areas for epidemiological investigation;
- identification of contacts and follow-up;
- strengthening of infection prevention and control measures in health facilities and briefing of health workers;
- strengthening of cross border collaboration and information exchanges between Togo, Burkina, Mali, and Benin.

It seems odd that the case report above does not mention contact with rodent reservoirs of the virus or their excrement as a source of infection. Lassa fever virus is transmitted to humans from contact with food or household items contaminated with excreta of multimammate rats (_Mastomys_ spp), the reservoir host. Public education is an important measure to prevent infections in the home.

Images of the rodent reservoirs of Lassa fever virus can be seen as follows:
_Mastomys natalensis_:
_M. erythroleucus_ and _Hylomyscus pamfi_:

[Maps of Togo:
Date: Mon, 24 Sep 2018 21:11:35 +0200

Lome, Sept 24, 2018 (AFP) - A former lawmaker in Togo was on Monday on hunger strike to call for the release of opposition supporters who were arrested during anti-government demonstrations.   Nicodeme Ayao Habia, head of the Democrats party, began his protest six days ago in front of Ghana's embassy in the Togolese capital, Lome.   "I am on hunger strike to demand the release of all people who were arrested during protests by the opposition coalition who are still languishing in prison," he told AFP.   "I won't move from here as long as these people are in prison," he said, holding a small sign with photos of three of those detained.   "This morning, police tried to move me along but I refused as I am within my rights. They even tried to rough me up."

Habia held a two-day hunger strike previously this month in front of the US Embassy in Lome.   Some 44 people who were arrested during opposition protests against President Faure Gnassingbe and his government remain in prison, according to the coalition.   The oppositions wants the re-introduction of a two-term limit for presidents, applied retroactively, which would prevent Gnassingbe from standing for re-election in 2020.   The government has agreed to the two-term limit but not the retroactive element, which would allow the president to  stand at polls in 2020 and 2025.   He has already been in power since the death of his father, Gnassingbe Eyadema, in 2005. The army general seized power of the West African state in 1967.

As well as the release of opposition detainees, Habia said he also wanted the government to stick to the roadmap set out by leaders of the West African bloc ECOWAS.   "The regime must absolutely respect the recommendations contained in the ECOWAS roadmap," he added.   On Sunday, the government and opposition finally agreed common ground in the composition of the country's independent national electoral commission (CENI).   Lack of agreement about the make-up of the body had delayed an announcement of the date of local and parliamentary elections.    Local polls and a referendum on the proposed constitutional reforms will now take place on December 16, with parliamentary elections four days later.
Date: Wed, 31 Jan 2018 16:22:49 +0100

Lome, Jan 31, 2018 (AFP) - Togo's government was facing fresh turbulence on Wednesday as healthcare workers went on strike, joining thousands of demonstrators holding opposition protests on the streets.   The two-day nationwide strike was called by the National Union of Hospital Practitioners of Togo (SYNPHOT) who are demanding better equipment and more nursing staff.   "The strike is well-followed throughout the country. We will take stock tomorrow evening to know what to do in the coming days," SYNPHOT secretary-general Atchi Walla told AFP.

At Sylvanus Olympio university hospital, the country's largest health care centre, several departments were closed, according to an AFP journalist.   "We are here only for very urgent cases. The other patients will be rescheduled," said a worker at the entrance to the emergency surgery department.   There was a similar situation in the operating room and at reception, where only one person was working.   "This situation is tiring. I came to get treatment but nobody can help because they are on strike," said Albert Kudju, a retired civil servant.    "The authorities should meet the demands of the workers."

Primary and public school teachers are also on strike, demanding an increase in their wages, while students are protesting against a sharp rise in tuition fees.   The walk-outs come against a backdrop of widespread discontent with the government and opposition calls for the resignation of President Faure Gnassingbe.   Gnassingbe has been in power since 2005 and took over from his father, General Gnassingbe Eyadema, who himself ruled Togo for 38 years.   A coalition of 14 opposition parties has been organising almost weekly marches for the past five months.
Date: Wed, 20 Sep 2017 17:23:54 +0200

Lome, Sept 20, 2017 (AFP) - Thousands thronged the streets of Togo's seaside capital Wednesday after the ruling party asked supporters to march at the same time as planned opposition protests demanding the removal of President Faure Gnassingbe, the scion of Africa's oldest political dynasty.   The rival demonstrations in Lome came a day after the opposition boycotted a vote on constitutional reform which would have included a presidential term limit, arguing that it was a ploy to let Gnassingbe remain in power till 2030.

The opposition wanted the limit to apply retroactively so that Gnassingbe, who has been in power since 2005, could not run again in 2020. His father Gnassingbe Eyadema ruled from 1967 till his death in 2005.   The opposition marches began at around 11:00 am (1100 GMT) at three meeting points.   They came after giant rallies on September 6 and 7 seeking the president's ouster that drew more than 100,000 people on the streets -- a record in a country which has been widely criticised for stifling democracy.    The protesters held up posters declaring "Faure must go" and "Free my country, 50 years is enough".

Police and soldiers armed with heavy machine guns flanked the streets in pick-up trucks. Mobile  phone networks and 3G services appeared to have been severed.   "We are not jihadists, we are not rebels," said Abdallah, 42, a supporter of the Panafrican National Party (PNP). "We just want democracy, we are tired."   Communications Minister Guy Lorenzo condemned what he called a "coup d'etat" on the streets.   The government meanwhile asked the opposition to show "responsibility and restraint" and warned that "people of foreign nationalities were looking to participate in acts of violence"  during the marches.

- 'Explosive situation' -
More protests are planned on Thursday against what veteran opposition leader Jean-Pierre Fabre called "the monstrous machine that has been crushing Togo's people for more than 50 years".   He said there would be "no let-up" as long as Gnassingbe remains in power.   Comi Toulabor, head of research at the Institute of Political Studies in Bordeaux, called the counter-rallies by the ruling Union for the Republic (UNIR) party "a strategy to disrupt the opposition protest".   "It's very amateurish but it shows the party isn't ready to give way," he told AFP, calling the situation "explosive".

About one thousand UNIR supporters quietly gathered on the beach in Lome on Wednesday, some sitting in the shade of palm trees.   "It is a pleasure to be here," UNIR supporter Georgia, 34, told AFP. "We are peaceful."   One young protester said he received 5,000 CFA francs (7.50 euros, $9) to participate in the pro-government rally.   "You think we're here for politics?" asked Justin, 17, as his friends nodded approval.   The failure to pass the constitutional reform bill in parliament forced a referendum, which a member of the government said will be held in the coming months.   Gnassingbe has now won three elections, the results of which have been contested by the opposition.   Half of Togo's population lives below the poverty line, according to the United Nations, despite a GDP growth rate of five percent over the last three years.
Date: Thu 23 Feb 2017
Source: WHO Emergencies preparedness, response [edited]

Meningococcal Disease - Togo:
-----------------------------
Since [Sun 1 Jan 2017], 201 suspected cases of meningitis with 17 deaths were reported by 19 health districts. In week 2, the district of Akebou, which is part of the Plateau Region, issued an alert after 4 cases of meningitis were reported. In week 4, the epidemic threshold was reached with 9 cases and an attack rate of 12.4 per 100,000 inhabitants. From 2 January to 12 February 2017, 48 suspected meningitis cases with 3 deaths were reported (case fatality rate of 6.3 percent). Of these, 14 specimens were confirmed as _Neisseria meningitidis_ serogroup W by PCR.

The Plateau Region, together with the other 3 regions in the country benefited from the mass vaccination campaign with MenAfriVac in December 2014. [MenAfriVac is a protein conjugate vaccine developed for use in sub-Saharan Africa for children and adults between 9 months and 29 years of age against _Neisseria meningitidis_ group A (<https://en.wikipedia.org/wiki/MenAfriVac>).]

Togo is part of the African meningitis belt and documents cases and deaths due to meningitis every year. In 2016, the country recorded an epidemic in the northern part caused by _Neisseria meningitidis_ serogroup W. A total of 1975 cases and 127 deaths were reported in 2016.

In response to the outbreak, the following measures are being implemented:
 - 56,000 doses of meningitis vaccines have been requested from the International Coordinating Group (ICG) for the planned vaccination campaign.
 - WHO Field Mission was deployed in the field to strengthen outbreak management.
 - Strengthening of meningitis surveillance at the district level.
 - Training of clinicians at the district level on case management.
 - Conducting cross-border meetings with Ghana and Benin.

WHO risk assessment
------------------
The largest burden of meningococcal disease occurs in the African meningitis belt. Although the successful roll-out of MenA conjugate vaccine has resulted in the decreasing trend of meningitis A, other meningococcal serogroups are shown to have caused epidemics. This report of the _Neisseria meningitidis_ W outbreak in Togo calls for a close monitoring of the changing epidemiology of meningococcal disease. There is a need to ensure that global stocks of vaccines are available, laboratory and epidemiologic surveillance systems are strengthened and outbreak response strategies in the countries are on hand.

The epidemic response consists of prompt, appropriate case management involving reactive mass vaccination of populations, and strengthening of meningitis surveillance.
====================
[Although there are at least 13 _ Neisseria meningitidis_ serogroups, based on the antigenic specificity of their capsular polysaccharides, disease due to serogroups A, B, C, Y, and W are most common. There are vaccines that contain capsular polysaccharide (A, C, Y, W), either alone or conjugated to protein. Conjugate vaccines are preferable, because, unlike the polysaccharide vaccines, conjugate vaccines immunize infants, reduce the carriage of meningococci in the throat and thus its transmission, as well as confer a more sustained immune response, and, therefore, longer-term protection than the polysaccharide vaccines. Serogroup B vaccines are based upon meningococcal B outer membrane vesicle protein antigens, because group B polysaccharide is poorly immunogenic in humans and is a potential auto-antigen.

Immunity following use of a meningococcal vaccine is specific for the type of capsular polysaccharide the vaccine contains in regard to the A, C, Y, and W polysaccharide vaccines or the surface proteins in regard to serogroup B vaccine, with no cross-protection against infection due to other meningococcal groups.

Following the mass introduction into the population of a vaccine specific for one particular meningococcal serogroup, the incidence of disease due to that serogroup has been found to fall dramatically, e.g., serogroup C disease in the UK following the introduction of C vaccine and serogroup A in the African Meningitis Belt following A vaccine, only to be replaced by emergence of disease due to other meningococcal serogroups.

In view of replacement of meningococcal serogroup A with other serogroups, in the current case serogroup W, following mass vaccination of the population with serogroup A conjugate vaccine in Togo, reactive mass vaccination to control this outbreak would require use of a meningococcal vaccine containing serogroup W, e.g., the conjugate ACWY vaccine. However, the news article above fails to say what vaccine is being used.

ProMED-mail would appreciate more information in this regard from knowledgeable sources.

Togo is a country in West Africa on the Gulf of Guinea, between Ghana to the west, Benin to the east. The country is divided into 5 regions; from north to south, the regions are Savanes, Kara, Centrale, Plateaux and Maritime (<https://en.wikipedia.org/wiki/Togo>). - ProMED Mod.ML]

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World Travel News Headlines

31st May 2019

A volcano on the Indonesian island of Bali erupted Friday, spewing a plume of ash and smoke more than 2,000 metres (6,500 feet) into the sky. Mount Agung, about 70 kilometres from the tourist hub of Kuta, has been erupting periodically since it rumbled back to life in 2017, sometimes grounding flights and forcing residents to flee their homes.
Mount Agung is about 70 kilometres from the tourist hub of Kuta

The latest shortly before noon on Friday shot a cloud of volcanic ash high into the sky, but caused no disruption to flights, Indonesia's geological agency said.  Agung remained at the second highest danger warning level, and there is a four-kilometre no-go zone around the crater.

Last summer, dozens of flights were cancelled after Agung erupted, while tens of thousands of locals fled to evacuation centres after an eruption in 2017.

The last major eruption of Agung in 1963 killed around 1,600 people.

Indonesia is situated on the Pacific "Ring of Fire", a vast zone of geological instability where the collision of tectonic plates causes frequent quakes and major volcanic activity.

31st May 2019

Heatwaves across India have exacted heavy casualties this year, including dozens of deaths by sunstroke and other heat-related causes. The deaths have been mainly reported from states like Maharashtra (particularly Vidarbha), Andhra Pradesh (mainly Rayalseema) and Telangana, due to the temperature extremes in these regions. What's worrying is, a study suggests that the heatwave conditions are likely to increase from next year and continue till 2064 because of El Niño Modoki and depletion in soil moisture. Here's how the heatwave is taking a toll in the above states.

Maharashtra

Parts of Maharashtra have been reeling under high temperatures accompanied by severe heatwave condition during this summer. According to a report in The Times Of India, a 50-year old man in Beed succumbed to death because of heatstroke recently, taking the overall number to 8. Reports show a total of 456 cases of heat-related illnesses in Maharashtra this summer. Last year, the number of cases reported was 568. However, the death toll this year is more than last year's figure of 2 victims.

Regions like Nagpur and Akola show the most number of deaths and illnesses in the Vidarbha region. About 163 cases of heat-related illness were reported in Nagpur and 76 ailments were reported in Latur region. Recently, Chandrapur in Maharashtra (which lies 150km south of Nagpur) registered a day temperature of 48°C, the highest recorded in India this summer.

Andhra Pradesh

Parts of Andhra Pradesh have been experiencing temperatures of 45°C and more since the last few days. These conditions have persisted in the state after the heavy rains caused by Cyclone Fani.

Two women going on a two-wheeler and covered themselves with scarfs to protect themselves from the heat wave, in Vijayawada
(Mahesh G, TOI, BCCL, Vijayawada.)

Three people have died in Andhra Pradesh due to heat-related causes this year. Also, 433 people have been diagnosed with heatstroke. Earlier this month, electrical transformers had blown up in many parts of Krishna and Guntur districts, disrupting power supply for more than five hours and intensifying the effects of heatwave conditions and the severe temperatures.

In 2015, Andhra Pradesh experienced the most number of heat deaths in the country: 1,369 people died that year from heat-related illnesses.

Telangana

Seventeen people have succumbed in Telangana over the last 22 days. However, the number of unconfirmed deaths is expected to be higher. The region saw 541 heat-related deaths in 2015, and 27 in 2018. The farmers and those who work in the sun are usually the ones to be affected the most by high temperatures and heatwave conditions.

As heat blankets the country, make sure you stay protected. Follow official guidelines and do not step out in the Sun, especially in the afternoon hours, unless absolutely necessary.

(With inputs from The Times Of India.)

11th June 2019
https://afro.who.int/news/confirmation-case-ebola-virus-disease-uganda

Kampala, 11 June 2019 - The Ministry of Health and the World Health Organization (WHO) have confirmed a case of Ebola Virus Disease in Uganda. Although there have been numerous previous alerts, this is the first confirmed case in Uganda during the Ebola outbreak on-going in neighbouring Democratic Republic of the Congo.

The confirmed case is a 5-year-old child from the Democratic Republic of the Congo who travelled with his family on 9th June 2019. The child and his family entered the country through Bwera Border post and sought medical care at Kagando hospital where health workers identified Ebola as a possible cause of illness. The child was transferred to Bwera Ebola Treatment Unit for management. The confirmation was made today by the Uganda Virus Institute (UVRI). The child is under care and receiving supportive treatment at Bwera ETU, and contacts are being monitored.

The Ministry of Health and WHO have dispatched a Rapid Response Team to Kasese to identify other people who may be at risk, and ensure they are monitored and provided with care if they also become ill. Uganda has previous experience managing Ebola outbreaks. In preparation for a possible imported case during the current outbreak in DRC, Uganda has vaccinated nearly 4700 health workers in 165 health facilities (including in the facility where the child is being cared for); disease monitoring has been intensified; and health workers trained on recognizing symptoms of the disease. Ebola Treatment Units are in place.

In response to this case, the Ministry is intensifying community education, psychosocial support and will undertake vaccination for those who have come into contact with the patient and at-risk health workers who were not previously vaccinated.  

Ebola virus disease is a severe illness that is spread through contact with the body fluids of a person sick with the disease (fluids such as vomit, faeces or blood). First symptoms are similar to other diseases and thus require vigilant health and community workers, especially in areas where there is Ebola transmission, to help make diagnosis. Symptoms can be sudden and include:
  • Fever
  • Fatigue
  • Muscle pain
  • Headache
  • Sore throat
People who have been in contact with someone with the disease are offered vaccine and asked to monitor their health for 21 days to ensure they do not become ill as well.

The investigational vaccine being used in DRC and by health and frontline workers in Uganda has so far been effective in protecting people from developing the disease, and has helped those who do develop the disease to have a better chance of survival. The Ministry strongly urges those who are identified as contacts to take this protective measure.

Investigational therapeutics and advanced supportive care, along with patients seeking care early once they have symptoms, increase chances of survival.

The Ministry of Health has taken the following actions to contain spread of the disease in the country:
  • The District administration and local councils in the affected area have been directed to ensure that any person with Ebola signs and symptoms in the community is reported to the health workers immediately and provided with advice and testing.
  • The Ministry of Health is setting up units in the affected district and at referral hospitals to handle cases if they occur.
  • •Social mobilization activities are being intensified and education materials are being disseminated.

There are no confirmed cases in any other parts of the country.

The Ministry is working with international partners coordinated by the World Health Organization.

The Ministry of Health appeals to the general public and health workers to work together closely, to be vigilant and support each other in helping anyone with symptoms to receive care quickly. The Ministry will continue to update the general public on progress and new developments.
Date: Mon, 10 Jun 2019 14:24:43 +0200

Lima, June 10, 2019 (AFP) - Peru has declared a health emergency in five regions, including Lima, after the deaths of at least four people linked to Guillain-Barre syndrome, an autoimmune disorder that attacks the nervous system.   Health Minister Zulema Tomas said Sunday that in addition to the deaths there were currently 206 cases of the disease.   "We have an outbreak, there has been a brusque increase" since June 5, Tomas said on state-run TV Peru, adding that health authorities were taking steps to control and contain the disease.

While the syndrome is not contagious, a 90-day health emergency was declared because the current cases "have unusual and atypical characteristics that require rapid or immediate initial treatment," Peru's Institute of Neurological Sciences said.   The precise cause of the disorder is unknown, but most cases develop after a person has been sick with diarrhoea or a respiratory infection.

The Centers for Disease Control and Prevention in the US says its research suggests that the syndrome is "strongly associated" with the Zika virus, a mosquito-borne illness.   The regions affected by GBS include three on the country's northern coast -- Piura, Lambayeque, La Libertad -- tourist destinations known for their archaeological sites and beaches.   Also included was the central region of Junin and Lima, which has nine million inhabitants.   Two deaths were reported in Piura, one in La Libertad and another in Junin.
Date: Mon, 10 Jun 2019 16:39:03 +0200

Madrid, June 10, 2019 (AFP) - Three tourists have fallen from their hotel balconies in Spain's Balearic Islands in recent days, one of them dying on impact, police said Monday as the summer season in the party archipelago begins.   The incidents came as Britain's foreign office warned holidaymakers heading to Spain against "balcony falls" and asked them not to "take unnecessary risks... particularly if you're under the influence of drink or drugs."   On Friday in Magaluf, a party resort notorious for its booze-fuelled tourism, a 19-year-old British man fell to his death from the second floor of his hotel, Spain's Civil Guard police force said.

A spokesman said police were looking at two theories -- either "he threw himself off voluntarily, or he fell by accident."   He did not know whether the victim had consumed drugs or alcohol.   On Thursday, a 35-year-old German man fell from the second floor of his hotel too, this time in Palma de Majorca, and was seriously injured, police said.   A source close to the probe, who declined to be named, said the man had drunk, dozed off, woken up and subsequently fallen from the balcony, possibly disorientated.   And on Monday, an Australian man in his early thirties fell from the second floor of his hotel in Ibiza and was seriously hurt, police said, without giving further details.

Balcony falls happen every year in the Balearic Islands and other party resorts in Spain, most of them due to excessive drinking or drug-taking/   Some are accidental slips, while others happen when tourists miss while trying to jump into pools or onto another balcony -- a practice known as "balconing."   The British foreign office's online travel advice for Spain has an entire section warning against "balcony falls".   "There have been a number of very serious accidents (some fatal) as a result of falls from balconies," says the website.    "Many of these incidents have involved British nationals and have had a devastating impact on those involved and their loved ones."
Date: Mon, 10 Jun 2019 06:44:54 +0200

Sydney, June 10, 2019 (AFP) - Australian police said Monday they were scouring bushland for a Belgian teenage tourist missing in a popular surf town for more than a week.   Theo Hayez, an 18-year-old backpacker, was last seen on May 31 at a hotel in the coastal tourist town of Byron Bay -- some 750 kilometres (470 miles) north of Sydney -- New South Wales state police said.   "We have a large amount of resources searching... in bushland that is towards the east and northeast of the town," police Chief Inspector Matthew Kehoe said in a statement.   "We are advised that this disappearance is completely out of character for him."   Police said they were alerted to his disappearance on Thursday after he failed to return to a hostel he was staying in.   Hayez's passport and personal belongings were all left at the hostel, and police believe he had not made any financial transactions since his disappearance or used his mobile phone.
Date: Sat 8 Jun 2019
Source: New Jersey 101.5 [edited]

The potentially deadly Powassan tick-borne virus has been confirmed in 2 Sussex county residents, one of whom died last month [May 2019], state health officials confirmed [Sat 8 Jun 2019].

The Powassan virus is spread by the deer tick [_Ixodes scapularis_]. The illness is rarer than Lyme disease, which is also spread by the tick, but 10% of people who contract the [Powassan virus] illness die from it.

A Department of Health official on [Sat 8 Jun 2019] said that the department had not determined the cause of death for the patient who died last month [May 2019] but said that lab results this week [week of 3 Jun 2019] confirmed that he had the virus.

A 2nd victim continues to recover at home.

Symptoms of the virus include brain swelling, meningitis, fever, headache, vomiting, weakness, confusion, loss of coordination, trouble speaking, and memory loss. Symptoms can appear a week to a month after a tick bite, although some people show no symptoms and do not require treatment.

There is no vaccine or cure for the disease. Treatment includes hospitalization, support for breathing, and intravenous fluids.

Prevention involves the same precautions that should be taken to avoid Lyme disease: avoid wooded areas with tall grasses, use insect repellent while outdoors, and check for ticks after being outdoors.

Powassan [virus] -- first discovered in Powassan, Ontario, in 1958 -- has been confirmed in recent years in New Jersey, with one case each in 2013, 2014, and 2015, and 4 cases in 2017, the most recent year for which data is available. The cases were reported in Sussex, Warren, Morris, and Essex counties.

Between 2008 and 2017, there were 125 confirmed cases in the entire country and 9 deaths.

A person who said they were close to the man who died last month [May 2019] posted on Facebook that the man was bitten in the arm by a tick while gardening and fell ill about 2 weeks later. The Facebook post said that there was no bull's-eye mark around the bite -- a known tell-tale sign for Lyme infection. About a day before he was hospitalized, the man reported feeling like he was coming down with a cold and had a high fever.

State health department's tip sheet for preventing Powassan [virus infection]:
- avoid contact with ticks by avoiding wooded areas with high grass;
- when hiking, stay on the center of the trail;
- picnic in areas away from wooded and bushy areas;
- keep children on playground equipment and away from tall grass and shrubs;
- when outdoors, apply insect repellents;
- wear light-colored clothes so it is easy to see and remove ticks;
- wear long-sleeve shirts and pants;
- tuck long pants into socks so ticks cannot crawl under pants;
- do tick checks every couple hours while outdoors and before coming indoors;
- if you see a tick during tick checks, remove it right away;
- keep grass mowed short;
- keep children's toys, playground equipment, pools, and lawn furniture at least 15 feet [4.6 m] from wooded areas;
- create a woodchip or mulch border between your yard and wooded areas;
- keep areas under bird feeders and pet dishes clean, so they do not attract animals that may carry ticks;
- keep trash in closed containers or areas so it does not attract animals that may carry ticks.  [Byline: Sergio Bichao]
=======================
[Powassan virus is endemic in New Jersey, and cases occur there sporadically. The tick vector is the deer tick, _Ixodes scapularis_. Humans become infected with POWV during spillover transmission from the natural transmission cycles. In humans, POWV can be a causative agent of a severe neuroinvasive illness, with 50% of survivors displaying long-term neurological sequelae. Individuals living or visiting areas where the deer tick occurs, should follow the above recommendations to avoid tick bites. If a tick is found feeding, it should be removed with forceps or tweezers grasping the tick at skin level and then gentle, constant force applied. The tick should never be removed by grasping it with thumb and forefinger, as squeezing the tick may cause inoculation of contents containing the pathogenic agent into the feeding site.

POWV was recognized as a human pathogen in 1958, when a young boy died of severe encephalitis in Powassan, Ontario, Canada. In that case, POWV was isolated from the brain autopsy. There are 2 distinct genetic lineages now recognized: POWV (lineage I) and deer tick virus (lineage II). Since the index case in 1958, over 100 human cases of POWV have been reported, with an apparent rise in disease incidence in the past 16 years. This recent increase in cases may represent a true emergence of POWV in regions where the tick vector species are prevalent, or it could represent an increase in POWV surveillance and diagnosis. - ProMED Mod.TY]

[HealthMap/ProMED-mail map of New Jersey, United States:
New Jersey county map:
Date: 6 Jun 2019
Source: Washington Post [edited]

Dominican government officials released more-detailed autopsy results on Thursday [6 Jun 2019] for 3 American tourists who died at adjacent beach resorts owned by the same hotel company during the last week of May 2019.

All 3 victims experienced eerily similar symptoms and internal trauma before their deaths, according to a news release from Dominican authorities. Pathologists said autopsies showed the 3 had internal haemorrhaging, pulmonary oedema, and enlarged hearts.

Toxicology reports are pending [These are likely to be the most interesting. - ProMED Mod.TG].

A U.S. State Department official said authorities have not yet established a connection between the 30 May 2019 deaths of 49-year-old CAD, and 63-year-old NEH, both of Prince George's County, MD, and the death on 25 May 2019 of 41-year-old MSW of Pennsylvania.

The FBI is providing Dominican law enforcement with "technical assistance with the toxicology reports," the State Department official said.

MSW had just checked into the Luxury Bahia Principe Bouganville, in the town of San Pedro de Macoris, and was taking pictures from her room balcony when she started to feel ill.

Less than 2 hours later, she was dead, local authorities said.

The bodies of CAD and HEH were found inside their room at the Grand Bahia Principe La Romana after relatives grew concerned because they had not checked out of the resort.

The hotels are located next to each other on the island's southern coast, about 60 miles from the tourist-heavy Punta Cana area.

Dominican authorities initially did not run toxicology tests for MSW because there were no signs of violence, said Ramon Brito, a spokesman for the National Police's special tourism unit. After the Maryland couple was found, investigators ordered a set of tests to determine whether anything the 3 Americans consumed may have led to their deaths, Brito said.  [Byline: Arelis R. Hernandez]
Date: 31 May 2019
Source: 4 News [edited]

The Alachua County Health Department is warning residents that there are 12 confirmed cases of mumps, primarily from college students at the University of Florida.  "This is a little more than usual," says Steve Orlando, University of Florida spokesman.

Alachua County normally receives around 2 reported cases a year, and UF believes more students could be infected.  "So, it's curious because these are individuals who are vaccinated, and that's what we are seeing nationwide," says Paul Myers, Alachua County Health Department administrator.

Officials say it is still unclear why there has been an uptick with the virus. So far, the CDC shows 736 people have contracted mumps nationwide in 2019.

"The sharing of the utensils, sharing of the cups, sharing of the water bottles, you know it is a very common thing for students to share those things, and that's exactly the kind of thing that could lead to transmission," says Orlando.
Date: Sat 8 Jun 2019
Source: Business Standard [edited]

As many as 14 children have died due to acute encephalitis syndrome (AES) in the district, while over a dozen are admitted in hospitals with high fever and other symptoms of the infection.

Sunil Shahi, Superintendent of Shri Krishna Medical College and Hospital (SKMCH), told ANI, "We have received 38 patients so far; most of them have a deficiency of glucose in their blood. Of these, 2 have also tested JE [Japanese encephalitis] positive; the overall casualty till now is 14."

Dr Gopal Sahni, head of Critical Care Unit, said, "When heat and humidity rise, the body's sweat cannot evaporate. The humidity level is over 50 per cent in the last few days. We have about 15 such children admitted in the hospital currently, and 89 such cases come regularly."

Encephalitis is a viral infection, which causes mild flu-like symptoms such as a fever or a headache.
=======================
[Again, this year (2019), cases of AES and JE are appearing in north-western India. Of the 14 AES cases, 2 tested positive for JE. The aetiology of the remaining cases is not stated, but the majority are reported as hypoglycaemic. As noted previously, frequently, in reports of JE cases in India, acute encephalitis syndrome (AES) of undefined aetiology is often mentioned with JE cases that are a minority of those hospitalized.

The determination of the aetiology or aetiologies of AES has been confusing and elusive. Various etiological agents have been proposed in recent years as responsible for AES cases. AES has continued to be attributed to a variety of aetiologies, including Reye syndrome-like disease, possible enterovirus infection from polluted water, heatstroke, lychee fruit consumption, and scrub typhus (_Orientia tsutsugamushi_). Recently, scrub typhus has been implicated in many AES cases. A recent publication (reference below) states that dengue virus is one of the 3 most common agents identified in acute encephalitis syndrome (AES). Unfortunately, existing surveillance for AES does not include routine testing for dengue. Dengue accounts for 5% of AES cases in India, especially in the absence of laboratory evidence for other pathogens tested. Dengue should be added to the list of possible AES etiological agents.

Reference:
Vasanthapuram Ravi, Shafeeq Keeran Shahul Hameed, Anita Desai, Reeta Subramaniam Mani, Vijayalakshmi Reddy, et al.: Dengue virus is an under-recognised causative agent of acute encephalitis syndrome (AES): Results from a 4-year AES surveillance study of Japanese encephalitis in selected states of India. International Journal of Infectious Diseases. 2019. doi: <https://doi.org/10.1016/j.ijid.2019.01.008>.

Maps of India:

[HealthMap/ProMED map available at: