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Brazil

General

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

tropical climate.

Safety & Security

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

Road Safety

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

Jet Lag

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

Medical Facilities

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

Sun Exposure and Dehydration

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

Visiting the Iguassu Falls

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

Food & Water

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

Rabies 

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

Malaria

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

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

Travel News Headlines WORLD NEWS

Date: Fri 8 Feb 2019
Source: Health Secretariat of Health of Piaui [in Portuguese, trans. ProMED Mod.TY, edited]

The State Health Secretariat of Piaui (SESAPI) confirmed this Friday [8 Feb 2019] the occurrence of another human case of neurological disease in the state caused by West Nile virus. (WNV). The case is a young man resident of the rural zone of Picos, who suffered from acute flaccid muscle paralysis in 2017. The patient was admitted to the University Hospital of the UFPI in Piaui, where the standard protocol for the diagnosis of neuroinvasive diseases issued by SESAPI was applied; he received treatment and recovered completely. The tests were conducted at the time, but the Ministry of Health released the results only in early 2019, indicating the presence of neutralizing antibodies against the virus in the patient's blood.

The 1st and, until then, only case of West Nile fever in Piaui had occurred in August 2014, corresponding to a cowboy from the city of Aroeiras do Itaim, Piaui. In fact, it was the 1st case of the disease in the country. At the time, tests on birds and equines of the region indicated that these animals also had contact with the virus. To date, examinations of 32 other suspected human cases in the state have resulted as "undetermined." In April 2018, WNV was detected in the brain of sick and dead horses with neurological symptoms in the state of Espirito Santo, but without confirmation of human cases in that state.

West Nile fever can be transmitted to humans through the bite of mosquitoes infected with the virus acquired from infected (wild) migrating birds. There is no transmission through interhuman contact or through contact with horses. Most infected individuals have no symptoms, and cases of neurological impairment are exceptional. Preventive measures are similar to those against dengue, Zika, and chikungunya [viruses]. Since 2014, the state of Piaui has intensively monitored cases of neurological disease and tests all suspected cases reported for the disease, both in the public and private hospital network.
=======================
[West Nile virus (WNV) was 1st reported in South America in equine animals in Colombia in 2004 and in 2006 in horses in Argentina, 5 and 7 years, respectively, after it was introduced into the Americas in New York in 1999. As mentioned above, the 1st reported case of neurological WN in Piaui state was in 2014. The virus has been detected in other parts of Brazil. Interestingly, WN virus antibodies have been shown to be present in horses from 4 ranches of southern Pantanal, Mato Grosso do Sul state (see archives below). In a more extensive follow-up study, WNV-seropositive equines were detected in 10 ranches.

A comparative analysis of the genome of the WNV circulating in Piaui state, or other localities in Brazil, to compare with North American or Caribbean isolates would be very interesting and epidemiologically valuable. Health authorities in the state are to be congratulated for their surveillance and tests of human patients with neurological disease.

The health officials of SESAPI are thanked for sending in this report to ProMED-mail. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Date: Tue 29 Jan 2019
Source: Precision Vaccinations [edited]

Level 2 travel alert issued by CDC for Brazil regarding the yellow fever virus [YFV]
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During 2019, the Brazilian state of Sao Paulo has reported 12 new cases of yellow fever virus, including 6 deaths, said the Pan American Health Organization (PAHO).  Historically, yellow fever virus transmission is at its highest between December and May each year, the PAHO said on 25 Jan 2019.  This is important news since over 6 million people visited Brazil during 2018, says the World Tourism Organization.  And, protection from the yellow fever is important since about 15% of people who get this virus develop serious illness, that can sometimes be fatal, says the US Centers for Disease Control and Prevention (CDC).

As of 2018, the preliminary results of the mass vaccination campaign against yellow fever indicate that 13.3 million people in Sao Paulo, 6.5 million in Rio de Janeiro, and 1.85 million in the Bahia states were vaccinated.  "Human cases reported during the current 2018-2019 seasonal period in Sao Paulo State, as well as the confirmation of epizootics in the state of Parana, mark the beginning of what could be a 3rd cycle and a progression of the outbreak towards the Southeast and South regions of Brazil," the PAHO said.

The previous yellow fever waves of transmission were during the 2016-2017 seasonal period, with 778 human cases, including 262 deaths, and another during the 2017-2018 seasonal period, with 1376 human cases, including 483 deaths.  In the United States, the CDC's Advisory Committee on Immunization Practices (ACIP) published a recommendation in 2015 that one dose of yellow fever vaccine provides long-lasting protection and is adequate for most travellers.  The CDC says the clinician's decision whether or not to vaccinate any traveller must take into account the traveler's risk of being infected with YFV, country entry requirements, and individual risk factors for serious adverse events after yellow fever vaccination.

Revaccination against yellow fever was previously required by certain countries at 10-year intervals to comply with the International Health Regulations.  As of July 2016, a completed International Certificate of Vaccination is valid for the lifetime of the vaccinee. Moreover, countries cannot require proof of revaccination against yellow fever as a condition of entry, even if the last vaccination was more than 10 years prior, says the CDC. With the caveats described above, international travelers should refer to the online version of this CDC book [<https://wwwnc.cdc.gov/travel/page/yellowbook-home>] and the CDC Travelers' Health website [<https://wwwnc.cdc.gov/travel>] for any reported updates to country entry requirements since the publication of this edition.

As of July 2018, the CDC published updated maps [<https://www.cdc.gov/yellowfever/maps/index.html>] indicating which countries require yellow fever vaccination.

In response to Brazil's YFV outbreak, the CDC issued a Level 2 Travel Alert [<https://wwwnc.cdc.gov/travel/notices/alert/yellow-fever-brazil>] during May 2018 recommending visitors to Brazil protect themselves from yellow fever by getting the vaccination at least 10 days before arrival.

Yellow fever is a disease caused by a virus that is spread through mosquito bites. To prevent getting sick from the yellow fever virus, the CDC says to use insect repellent, wear long-sleeved shirts and long pants, and get vaccinated.

International travelers can find convenient locations to schedule a vaccination appointment by visiting Vax-Before-Travel

In the USA, the Stamaril vaccine is approved and has a clinical efficacy profile similar to the YF-VAX vaccine and is available at select locations.

The CDC Vaccine Price List provides private sector vaccine prices for general information. And, vaccine discounts can be found on this webpage.

Vaccines, like any medicine, can have side effects. You are encouraged to report negative side effects of vaccines to the CDC [<https://vaers.hhs.gov>].  [Byline: Don Ward Hackett]
=====================
[Although no information is provided about the specific localities where YF was acquired in Sao Paulo state, their proximity to cases that occurred during the previous YF outbreak in the state, or the conditions under which the 12 new cases became infected, this news is of concern. The situation for Brazil is of concern, as the yellow fever (YF) transmission season for the current year (2019) is just beginning. The percent vaccination coverages for the affected municipalities in Sao Paulo state are not mentioned. Statewide, the 6.5 million individuals already vaccinated represent just 53.6% coverage of the population, far short of the 80% or more necessary to provide good YF coverage. One hopes that the Sao Paulo health authorities are responding aggressively to the occurrence of these cases and mounting intensified surveillance for infected people and monkeys, coupled with an aggressive vaccination campaign to provide coverage to people in the areas of risk who have not been vaccinated. - ProMED Mod.TY]

[Maps of Brazil:

HealthMap/ProMED-mail maps:
Date: Tue 29 Jan 2019
Source: Governo do Estado do Parana/Agencia de Noticias do Parana [in Portuguese, trans. ProMED Mod.TY, edited]

A 21-year-old man who had never been vaccinated is the 1st confirmed case of yellow fever in Parana. This case was identified on Sat 26 Jan 2019, when a task force of the State Secretariat of Health went to the Litoral in order to organize, together with the Antonina municipality, strategies to deal with the disease. The young man is hospitalized in the Litoral Regional Hospital and is doing well, with a mild form of the disease.

With the formation of the Center of Emergency Health Operations (COES) by the state Secretariat, a team went again to the Litoral this Tue 29 Jan 2019, and created a Paranagua First Regional Health COES in order to monitor the disease.

The COES also prepared a document with the so-called clinical management flow in order to orient the health professionals with the identification and treatment of yellow fever, since the last case of the disease occurred in 2015, when the disease was contracted outside the state.

Various measures and strategies to deal with the disease are now in progress by the State Secretariat for Health, especially directed at the 7 municipalities of the 1st region and municipalities of the 2nd region, due to their proximity to Sao Paulo state where several cases now have been confirmed [see the report below].

A reinforcement team sent by the State Secretariat is visiting each of the cities of these 2 regions in order to identify the difficulties and actively search in communities more isolated to urge the population to take the vaccination. From Thu 31 Jan 2019 until 5 Feb 2019, a person by person search will be carried out in the entire area where the virus is suspected to circulate.

The alert is also extended to strategic groups in the areas of risk, such as truck drivers who descend to the Port of Paranagua, public security officials, and workers of companies that circulate in the Atlantic Forest. Up to now, no more dead monkeys have been found.
 
Alert: The symptoms are fever with sudden onset in people who have never been vaccinated against yellow fever or with vaccination of less than 10 days and who have been in forested areas where circulation of the virus has been documented during the 15 previous days.
These conditions must be associated with another 2 or more signs such as headache, nausea, vomiting, joint pains, abdominal pain, lumbar pain, icterus, or haemorrhage.

The Health Secretariat orients [everyone] that all information about dead monkeys and the occurrence of suspected cases, be immediately notified to the Center for Strategic Information for Health Surveillance (CIEVS), that is on continuous duty. The telephone numbers are (41) 99117-3500 and (41) 99917-0444.
=====================
[Although the response to this single case may seems like an overreaction, it is not. Presumably, this case is due to spillover from the sylvan (forest) transmission cycle to the young man. The valid concerns are that a single case indicates that active yellow fever (YF) virus transmission is occurring in the area and that there is the risk that a sylvan case could spark an urban outbreak should a viremic individual be in a setting where _Aedes aegypti_ vector mosquitoes are abundant and the people not vaccinated. - ProMED Mod.TY]
Date: Fri 25 Jan 2019
Source: PAHO/WHO Epidemiological update: yellow fever [edited]

Between January 2017 and December 2018, 6 countries and territories in the Region of the Americas reported confirmed cases of yellow fever: Bolivia, Brazil, Colombia, Ecuador, French Guiana, and Peru. The number of cases reported during this period in the Region of the Americas exceeded the number reported in several decades.

In 2019, Brazil and Peru reported confirmed cases that occurred between December 2018 and January 2019. The following is a summary of the epidemiological situation in both of these countries.

In Brazil, it is currently the period which has historically been recognized as having the highest transmission (seasonal period), which occurs between December and May. The expansion of the historical area of yellow fever transmission to areas previously considered risk-free led to 2 waves of transmission (Figure 1), one during the 2016-2017 seasonal period, with 778 human cases, including 262 deaths, and another during the 2017-2018 seasonal period, with 1376 human cases, including 483 deaths.

In the current seasonal period (2018-2019), 12 confirmed human cases, including 6 deaths, have been reported in the municipalities of Eldorado (9 cases), Jacupiranga (1 case), Iporanga (1 case), and Cananeia (1 case), all of which are located in the southern part of Sao Paulo State. Among these confirmed cases, 83 percent (10/12) are male, the median age is 45 years, and 83 percent (10/12) are rural workers. Additionally, the Parana Secretariat of Health reported that the tests performed on dead monkeys in Antonina, on the Parana coast, were positive for yellow fever.

Human cases reported during the current 2018-2019 seasonal period in 4 municipalities in Sao Paulo State, as well as the confirmation of epizootics in the state of Parana, mark the beginning of what could be a 3rd cycle and a progression of the outbreak towards the Southeast and South regions of the country (Figure 2).

Figure 1 [graph]. Distribution of confirmed human yellow fever cases by epidemiological week (EW). Brazil, 2016-2019.

Figure 2 [map]. Distribution of epizootics and confirmed human cases. Brazil, 2016 to EW 2 of 2019.

Given the gradual geographical expansion of the epizootic wave that Brazil has faced during the last 2 seasonal periods, the country has had to adapt its immunization policies for yellow fever. The number of areas with recommended vaccination has increased from 3526 municipalities in 2010 to 4469 municipalities in 2018, and to the entire country starting in 2019. In line with the World Health Organization guidelines, Brazil has adopted a single dose vaccination scheme for yellow fever since April 2017. The use of fractional doses to respond to outbreaks and the risk of urbanization of yellow fever, especially in large cities, was also adopted. This strategy was implemented in 77 municipalities with the greatest risk for yellow fever in the states of Sao Paulo (54 municipalities), Rio de Janeiro (15 municipalities), and Bahia (8 municipalities).

As of epidemiological week (EW) 39 of 2018, preliminary results of the mass vaccination campaign against yellow fever indicate that 13.3 million people in Sao Paulo, 6.5 million in Rio de Janeiro, and 1.85 million in Bahia states were vaccinated, which represent vaccination coverage of 53.6 percent, 55.6 percent and 55.0 percent, respectively.

In Peru, between EW 1 and EW 52 of 2018, there were 20 cases of yellow fever reported, including 6 deaths; of the total cases, 10 were laboratory-confirmed, and 10 remain under investigation. This figure is higher than that reported during the same period in 2017 when 6 cases of yellow fever were reported. Of the total confirmed cases, 11 are male and 9 are female.

In 2018, the confirmed cases were from the departments with forests: Loreto, San Martin, Ucayali, and Madre de Dios.

The occurrence of the 1st confirmed human cases of yellow fever in Brazil marks the beginning of the seasonal period (December to May) and, therefore, the highest risk of transmission to unvaccinated humans. Thus, the Pan American Health Organization/World Health Organization (PAHO/WHO) reiterates its recommendation that Member States with areas at-risk for yellow fever continue efforts to immunize the at-risk populations and to take the necessary actions to keep travelers informed and vaccinated prior to traveling to areas where yellow fever vaccination is recommended.

Recommendations for international travellers regarding yellow fever vaccination are available at: <https://bit.ly/2B8LT1T>.

The guidelines pertaining to laboratory diagnosis and vaccinations are the same as those published in the 7 Dec 2018 PAHO/WHO Epidemiological Update 2.
========================
[The situation for Brazil is of concern, since the yellow fever (YF) transmission season for the current year (2019) is just beginning. The percent vaccination coverages for the affected municipalities in Sao Paulo state are not mentioned. State-wide, the 6.5 million individuals already vaccinated represent just 53.6 percent coverage of the population, far short of the 80 or more percent or more necessary to provide good YF coverage. One hopes that the nation-wide vaccination campaign planned for this year (2019) will focus on the areas where the YF cases have occurred. Since 10 of the 12 cases occurred in rural residents, they represent spill-over of the sylvan (forest) transmission cycle, as was the case in the previous 2 YF outbreaks in Brazil. The circumstances under which the other 2 non-rural infected individuals acquired their infections are not mentioned but perhaps occurred during visits to more rural, forested areas. These sylvan YF cases are of concern because of the risk of introduction of the virus into urban and suburban settings where _Aedes aegypti_ vector mosquitoes are abundant and could initiate a rapidly-spreading urban outbreak.

Although the Peruvian cases occurred last year (2018), YF virus is endemic in forests of the Amazon Basin areas, and there is an ongoing risk of cases if individuals resident or visiting in these area are not vaccinated.

A map of Brazil can be accessed at <http://healthmap.org/promed/p/6>.
A map showing the location of Peru in South America can be accessed at
or <http://healthmap.org/promed/p/10>. - ProMED Mod.TY]
Date: Thu 17 Jan 2019
Source: Space-time clusters of dengue, chikungunya, and Zika cases in the city of Rio de Janeiro. [BioRxIv, edited]

ref: Picinini Freitas L, Goncalves Cruz O, Lowe R, Sa Carvalho M. Space-time clusters of dengue, chikungunya, and Zika cases in the city of Rio de Janeiro. BioRxIv. 2019; (preprint). doi:
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Abstract. Brazil is a dengue-endemic country where all 4 dengue virus serotypes circulate and cause seasonal epidemics. Recently, chikungunya and Zika viruses were also introduced. In Rio de Janeiro city, the 3 diseases co-circulated for the 1st time in 2015-2016, resulting in what is known as the "triple epidemic." In this study, we identify space-time clusters of dengue, chikungunya, and Zika to understand the dynamics and interaction between these simultaneously circulating arboviruses in a densely populated and heterogeneous city. We conducted a spatio-temporal analysis of weekly notified cases of the 3 diseases in Rio de Janeiro city (July 2015-January 2017), georeferenced by 160 neighbourhoods, using Kulldorff's scan statistic with discrete Poisson probability models.

There were 26,549, 13,662, and 35,905 notified cases of dengue, chikungunya, and Zika, respectively. The 17 dengue clusters and 15 Zika clusters were spread all over the city, while the 14 chikungunya clusters were more concentrated in the north and downtown areas. Zika clusters persisted over a longer period of time. The multivariate scan statistic -- used to analyse the 3 diseases simultaneously -- detected 17 clusters, 9 of which included all 3 diseases.

This is the 1st study exploring space-time clustering of dengue, chikungunya, and Zika in an intra-urban area. In general, the clusters did not coincide in time and space. This is probably the result of the competition between viruses for host resources and of vector-control attitudes promoted by previous arbovirus outbreaks. The main affected area -- the north region -- is characterised by a combination of high population density and low human-development index, highlighting the importance of targeting interventions in this area. Spatio-temporal scan statistics have the potential to direct interventions to high-risk locations in a timely manner and should be considered as part of the municipal surveillance routine as a tool to optimize prevention strategies.
====================
[This approach depends on accurate surveillance, diagnosis, and reporting of clinical cases of infections by the 6 viruses (4 dengue and one each chikungunya and Zika viruses). One wonders if reporting of clinical cases is the same across the various economic groups across the city. Could it be that marginal populations, which might have higher incidences of infection, also have underreporting because residents seek medical attention less frequently or medical facilities are less readily available than in neighbourhoods of higher economic status? Defining high-risk neighbourhoods will be a useful tool for focusing medical attention, public education, and vector control efforts. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Rio de Janeiro, Brazil: <http://healthmap.org/promed/p/63696>]
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World Travel News Headlines

Date: Thu, 21 Feb 2019 07:52:47 +0100
By Amelie BARON

Port-au-Prince, Feb 21, 2019 (AFP) - With flaming barricades and widespread looting, 10 days of street violence in Haiti have all but buried a tourism industry that managed to resurrect itself after a devastating earthquake in 2010.   Ugly, violent footage beamed around the world has again sent the message that this impoverished Caribbean country is politically unstable and no place to go on vacation.

The final straw was the helicopter evacuation last week of 100-odd Canadian tourists trapped as angry protesters demanded the resignation of the president, whom they accuse of corruption.   "We have been through 12 days of hell. We managed the crisis but today we are suffering from the aftershocks," said Tourism Minister Marie-Christine Stephenson.

- Blacklist -
Beside the direct effects of the demonstrations, the United States delivered another crushing blow on February 14 when it urged its citizens not to travel to Haiti, which thus joined a no-go list with war-torn countries like Syria, Yemen and Afghanistan.

The minister said the US travel alert for Haiti was too harsh, calling the riots something that flared up unexpectedly and are now over.   "OK, they lasted 12 days but I am not sure that other Caribbean countries, which have had riots of their own, have been punished as severely and quickly as we have," said Stephenson.   Overnight, the decision by the US State Department hit the tourism industry hard. Travel web sites simply stopped offering flights to Haiti's two international airports.   Hotels are reporting cancellation of reservations and many empty rooms.

Officials in the industry have yet to tally up the damage but say that for the second time in less than a year, they will have to lay off workers.   In July of last year, three days of riots over a government attempt to raise fuel prices ruined the summer vacation season for Haiti's tourism industry.   It is not just hotels that will suffer again, said Beatrice Nadal-Mevs, president of the Haitian Tourism Association.   "This is going to affect everyday people because these are direct jobs that are going to be lost and supply chains will be threatened: farming, fishing, crafts, transport," Nadal-Mevs said.

- Mardi Gras cancelled -
With the opposition planning more demonstrations to seek the resignation of President Jovenel Moise, the sector got yet more bad news with word that Carnival celebrations have been called off in the Haitian capital, Port-au-Prince.   City Hall said it could not guarantee revelers' safety.   The festivities, which this year were planned for March 3-5, usually draw many Haitians living abroad and fleeing the winter cold in Canada and the eastern US.

Another major Carnival celebration is scheduled to take place in the city of Gonaives, but the government has not said if it will go ahead.   As grim as things are, some foreign tourists have gone ahead with visits to Haiti.   On Wednesday, a group of Australians under police escort visited a square featuring statues of heros of Haiti's independence from France. Days ago, demonstrators at the same plaza were throwing rocks at police, who responded with volleys of tear gas grenades.

A woman named Carole, who did not want to give her last name, said, "I trust the company we're traveling with. They not only want to take us but they want to bring us back."   Kevin McCue, another of the people in the group of 20, said he was glad that their tour operator had not opted for Plan B, which would have meant skipping Haiti and spending the whole week in the neighboring Dominican Republic.   "Tourism is alive and well here. People should come. The more they come, the better they spread some money among people who need it and the better for Haiti," said McCue.
Date: Thu, 21 Feb 2019 07:20:54 +0100
By Shafiqul ALAM

Dhaka, Feb 21, 2019 (AFP) - At least 70 people were killed when fire tore through crumbling apartment blocks in a historic part of Dhaka, setting off a chain of explosions and a wall of flames down nearby streets, officials said Thursday.    It started in one building where chemicals for deodorants and other household uses were illegally stored and spread at lightning speed to four nearby buildings, the fire service said.    People became trapped by the flames at a nearby bridal party and a restaurant. TV images showed the gates to one building were chained up so residents were unable to escape.

Traffic jams in the clogged narrow streets held up the rescue operation.   Bangladesh fire chief Ali Ahmed said at least 70 people were killed but that the toll would likely rise.    "The number of bodies may increase. The search is still going on," he told AFP.   Doctors said at least 10 of the scores of injured were in critical condition.   Firefighters who took almost 12 hours to bring the fire under control, went through the blackened floors of the building, littered with spray cans, looking for bodies.

The fire started at about 10.40pm (1640 GMT) on Wednesday at Chawkbazar in the old Mughal part of the capital.   Ahmed said it may have been started by a gas cylinder and quickly spread through the building where chemicals were stored in rooms alongside the apartments.   Chemicals used for household products were also stored in the nearby buildings. They exploded as the fire spread, witnesses said.     "There was a traffic jam when the fire broke out. It spread so quickly that people could not escape," the fire chief said.   Another fire official told reporters the blaze was under control but was not extinguished despite the efforts of more than 200 firefighters.   "It will take time. This is not like any other fire," he said, adding that the inferno had been made more devastating by the "highly combustible" chemicals.   Fire trucks had struggled in the narrow streets to reach the scene and there was also a lack of water for the battle, officials said.   The main gate of one five storey building was chained up, trapping residents inside, according to images shown on Bangladesh television.

- 'Flames were everywhere' -
Members of a bridal party in a nearby community centre were also caught in the fire and many were injured. Others were caught in small restaurants.   Dhaka deputy police commissioner Ibrahim Khan said at least two cars and 10 cycle rickshaws were burned in the fire.   "The victims included passersby, some people who were eating food at a restaurants and some members of the bridal party," he told AFP.   "I saw the charred body of a woman who was holding her daughter in her lap as their rickshaw was caught in the fire," said one witness.

Haji Abdul Kader, whose shop was destroyed, said he only survived the blaze as as he had left to go to a pharmacy.   "When I was at the pharmacy, I heard a big bang. I turned back and saw the whole street, which was jam packed with cars and rickshaws, in flames. Flames were everywhere," he told AFP.   "I got burned and rushed to hospital," he said.

Doctors at Dhaka Medical College Hospital said at least 55 people were injured, including 10 in a critical condition.   Hundreds of people rushed to the hospital looking for missing relatives.  However, most of the bodies of the dead were charred beyond recognition.    Sohag Hossain, one of the injured, told the Daily Star that he and two friends were working at a plastic factory in one of the buildings at the time of the fire.    They heard an explosion and could not escape the flames.

A similar blaze in 2010 in an old Dhaka building, which was also used as a chemical warehouse, killed more than 120 people in one of the worst fire disasters in the city of 20 million people.      Dhaka authorities launched a crackdown on chemical warehouses in residential areas following the blaze, but efforts to rein in the practice have waned.   Many buildings in Bangladesh lack adequate fire safety measures and the enforcement of fire regulations in factories and apartment buildings is lax.  
Date: Wed 20 Feb 2019, 2:13 PM CET
Source: El Pais in English [edited]
<https://elpais.com/elpais/2019/02/20/inenglish/1550655774_604104.html>

An investigation has been opened to determine the cause of death of a 46-year-old woman, who became ill after eating at a one-star Michelin restaurant called RiFF in Valencia. A total of 23 other patrons, including the victim's husband and 12-year-old son, also fell sick after the meal but their symptoms were mild and they have reportedly all recovered. The case was confirmed by regional health chief Ana Barcela, who expressed her condolences to the family and said that an investigation was already underway. "We've conducted a primary inspection of the establishment and everything appears to be normal," she said. "Analytical tests will now be carried out on the food products."

Barcela explained that the regional public health department will be in charge of the investigation and for determining the causes behind the woman's death. According to sources from the regional health department, the food poisoning outbreak was reported on [Sun 17 Feb 2019], after the 3 family members fell ill. They began to show symptoms of food poisoning - vomiting and diarrhoea - on [Sat 16 Feb 2019]. According to Europa Press, the father and son recovered but the woman's symptoms were more severe, and she died in her home early on the following morning. The investigation into the death revealed that a total of 9 patrons had experienced illness, mainly vomiting, after eating at the same restaurant.

Subsequently, it emerged that a further 14 people had also suffered light symptoms. "17 people have been interviewed, of whom 14 stated that they had some kind of mild symptoms," explained regional health chief Ana Barceló today, [Wed 20 Feb 2019]. "The samples that have been collected over the last few days have been sent to the National Toxicology Institute to be analyzed." Public health officials inspected the restaurant on [Mon 18 Feb 2019], but did not find any problems that could have contributed to the food poisoning. Investigators also collected samples of ingredients and raw food products that were part of the menu, and are currently analyzing them.

Barcela added that at this point she could not confirm whether the sickness had been caused by morel mushrooms that were on the restaurant's menu. "We will have to wait for the autopsy to be carried out on the woman before we can determine whether it was the ingestion of a food that directly caused her death, or whether it prompted a state that led to this fatal outcome, or if she had an existing condition," she explained on [Wed 20 Feb 2019].

Forensic teams are working to determine whether she could have been poisoned by something she ate, or whether she may have choked on her own vomit. In a statement, the owner of RiFF, Bernd H. Knaller, announced that the restaurant will remain closed until the cause of the food poisoning outbreak is determined and "activities can resume with full assurances for the staff and the patrons." The owner said he has been cooperating with the regional health department on the investigation and pointed out that the inspection "showed that the restaurant complies with all sanitary regulations." He added: "Regardless of what caused the situation, I want to convey my deep regret for what happened, and I hope all of the facts will be clarified shortly." [Byline: Cristina Vazquez]
Date: Mon 18 Feb 2019
Source: The News International [edited]

An elderly man died due to complications of the Crimean-Congo haemorrhagic fever (CCHF), commonly known as Congo virus, at the Jinnah Postgraduate Medical Centre (JPMC) on early [Sun 17 Feb 2019] morning, becoming the 2nd victim of the deadly tick-borne disease in the city [Karachi] in 2019.

"MUY, an elderly person of 75 years of age, died due to CCHF complications at JPMC on early [Sun 17 Feb 2019] morning," said JPMC Executive Director Dr. Seemin Jamali while taking to The News. She added that the deceased had earlier been taken to a private hospital from where he was shifted to Jinnah hospital.

It is the 2nd death in the city caused by the CCHF within a week as earlier on [Tue 12 Feb 2019] morning, a 35-year old woman from Orangi Town had died of Congo virus at an isolated ward of the JPMC.

CCHF is a tick-borne viral disease, which is caused when a person comes in contact with an animal infected with the Congo virus due to the presence of the parasite on its skin. Mostly butchers, sheep and animal herders and those who are associated with cattle farming become victims of the CCHF, which has a 40 to 50% mortality rate.

Dr. Jamali said both the woman from Orangi Town and the latest CCHF victim, who lived in the Landhi area of the city, were brought to the JPMC from Liaquat National Hospital where they had tested positive for the lethal disease.

She said the 2nd victim had a history of dealing with cattle and was in a serious condition when brought to the JPMC. He was suffering from high grade fever as well as internal and external bleeding, low platelets count and other comorbidities.

"We had moved both the patients to an isolation ward where they were given antiviral drugs, mega units [blood/platelets?] and other symptomatic treatment, but they could not survive due to the complications of the lethal ailment. All precautionary measures had also been adopted to prevent other patients and the medical staff from contracting the viral infection," she said.

"There were many people who contracted this disease in Karachi during their interaction with cattle, but they survived due to their strong immunity and the medical care they received at hospitals, including the JPMC. People should take precautionary measures while dealing with cattle and livestock," Dr. Jamali said. She added that in case the symptoms of red spots on the body, high-grade fever and blood oozing from mouth and nose are found in any patient, they should be rushed to a major hospital.

According to Dr. Kamran Rizvi, district officer (preventive) of Karachi Metropolitan Corporation, around 16 people died at various hospitals in Karachi last year [2018] due to CCHF, a majority of whom were residents of different areas of Balochistan, including Quetta, as people from the province are now regularly brought to Karachi for treatment.

He said a total of 41 Congo virus patients were brought to different hospitals in Karachi last year [2018], of whom 16, mostly males, could not survive while the others were successfully cured.
=====================
[The CCHF virus is now endemic in both rural and urban parts of the country, and he best safeguard on the human side is to inform the public regarding the risks and provide education on the use of appropriate practices and protection measures.

Persons working in close contact with animals are at risk for CCHF due to presence of ticks that can transmit the virus through bites or crushing during removal through skin cuts, etc. The animals do not show clinical disease during viraemia and the virus can be transferred in butchering, handling of meat and hides, etc.  The veterinary aspect of the problem requires establishment of animal screening with measures for tick control. Collaborative work by health and veterinary sectors with support of entomologists for setting up CCHF surveillance can help plan prevention and control programs - ProMED Mod.UBA]
[HealthMap/ProMED map available at:
Date: Tue 19 Feb 2019, 1:32 PM
Source: KCRG-TV9 [edited]

TV9 has learned the Johnson County Public Health Department and the Iowa Department of Public Health are investigating reports of food poisoning following an event in Swisher, Iowa.

The illnesses have been linked to the Swisher Men's Club's Game Feast Dinner this past weekend [16-17 Feb 2019]. The group's Facebook page says the fundraiser has been going on for 15 years and features dishes that include meat from animals that are often hunted. The health departments are looking for anyone who may have attended the meal to try to track down the source of the illnesses. It's asking attendees to email <diana.vonstein@idph.iowa.gov> with their contact information.

Johnson County Public Health Director Dave Koch tells TV9 part of their investigative efforts have included taking part in a conference call with officials from the Iowa Department of Public Health on [Tue 19 Feb 2019]. Koch says part of the investigation will also include testing samples of the food that was served along with conducting tests on any individuals who think they may have contracted an illness.

It is unclear how many people may be claiming to be sick however the club posted the following message to their Facebook page which reads in part: "The Swisher Men's Club is aware of a number of illnesses as a result of our Game Feast Dinner. We are actively working with the county and state health departments to determine the cause of these illnesses."

TV9 has reached out to the Swisher Men's Club for comment. President Mike Brown, Jr. referred back to the statement provided on Facebook. Brown declined TV9's offer for an on-camera interview, but did say they are relaying all necessary information to the Iowa Department of Public Health.  [Byline: Josh Scheinblum & Aaron Scheinblum]
Date: January 2019
Source: Nigeria CDC: Nigeria monkeypox monthly situation report

Nigeria monkeypox -- monthly situation report
---------------------------------------------
Key indicators / Numbers
New suspected cases reported / 6
New confirmed cases / 3
Total deaths / 0
Healthcare worker infection / 0

Epidemiological summary
- Nigeria continues to report sporadic cases of monkeypox after the index case reported in September 2017.
- In the reporting month (January 2019), 6 new suspected monkeypox cases were reported in 4 states (Bayelsa - 2; Rivers - 1; Bauchi - 1; Lagos - 1; Borno - 1; Delta - 1) out of which 3 confirmed cases were recorded in 2 states (Rivers - 1, Bayelsa - 2). - No death recorded.
- All reported cases (suspected and confirmed) are males.
- The confirmed cases are all between 32-39 years of age.
- The South-South region of the country has the highest burden of monkeypox.
- Since the beginning of the outbreak in September 2017, 311 suspected cases and 7 deaths have been reported in 26 states. Of this, 132 were confirmed in 17 states (Rivers, Bayelsa, Cross River, Imo, Akwa Ibom, Lagos, Delta, Edo, FCT [Federal Capital Territory], Abia, Oyo, Enugu, Ekiti, Nasarawa, Benue, Plateau, Anambra)
- Results of animal surveillance carried out in 2 states are awaited.

[Available at the source URL above]:
Figure 1 [graph]: weekly trend of Nigeria monkeypox cases as at 31 Jan 2019
Figure 2 [graph]: line graph of Nigeria monkeypox cases weeks 31-52, 2017; 1-52, 2018 and 1-2, 2019
Figure 2 [map]: map of Nigeria showing distribution of monkeypox cases by LGA [local government area], September 2017-January 2019
=======================
[The number of monkeypox cases in Nigeria continues to increase slowly but steadily, with 6 new suspected and 3 new confirmed cases in January 2019. Interestingly, all cases are male individuals. Monkeypox virus transmission continued over a broad geographic area in Nigeria last year (2018). The report above provides the most recent update of the monkeypox situation in Nigeria. This outbreak has been unusual. Rather than sporadic or rare cases, there have been over 100 cases scattered over a large geographic area since 2017 and again this year (2019). The reasons for this relatively sudden appearance are not clear. Perhaps there has been an epizootic of monkeypox virus infections among its rodent hosts, with spill-over to people. As mentioned earlier, prevention will require a proactive public education effort to convince local people to take measures to prevent contact with the infected rodents and their excreta to avoid transmission, a difficult task involving so many local people over such a large geographic area.

Interested readers can see the graphs of cases by week and a map showing the location of cases by state.

Non-human primates are not monkeypox virus reservoirs. The main reservoirs of monkeypox virus are suspected to be rodents, including rope squirrels (_Funisciurus_ spp, an arboreal rodent) and terrestrial rodents (genera _Cricetomys_ and _Graphiurus_). - ProMED Mod.TY]

[Maps of Nigeria:
Date: Wed 20 Feb 2019
Source: Daily Times [edited]

The Sindh Health Department, on Tue 19 Feb 2019, admitted its failure to formulate an action plan to prevent the spread of the extensively drug-resistant (XDR) strain of typhoid fever in the province. The provincial minister for health, Dr Azra Fazal Pechuho, sighed that the health department still awaited vaccines for XDR typhoid from the federal government as the province battles the outbreak caused by a bacterial strain resistant to most known antimicrobials. She added that the strain had claimed 4 lives since its outbreak from Hyderabad [Sindh] in November 2016, which later spread to Karachi and other cities and towns of the province.

Dr Pechuho said that the Sindh Health Department had asked the local governments to improve the chlorination in water supplies, noting that the disease had spread due to the lack of sanitation and the presence of open garbage dumps in Karachi and other places. More than 5000 children have been affected by this typhoid strain, she continued. XDR typhoid is caused by antimicrobial resistant (AMR) strains of _Salmonella enterica_ serotype Typhi (or _S._ Typhi) and has been declared by WHO as a notable public health concern.

A report by the Provincial Disease Surveillance and Response Unit (PDSRU) reported 5274 cases of XDR typhoid out of 8188 typhoid fever cases in Sindh from 1 Nov 2016 through 9 Dec 2018. 69 percent of these cases was reported in Karachi, while 27 per cent in Hyderabad district, and 4 percent in other districts across the province.

The WHO recommended typhoid vaccination in response to confirmed outbreaks of typhoid fever. These vaccinations should be implemented in combination with other efforts to control the disease. At present, azithromycin remains the only affordable first-line oral therapeutic option to manage patients with XDR typhoid in low-resource settings.
====================
[The following is extracted from the CDC notice regarding this multiply-resistant typhoid strain in Pakistan

"The XDR strain of _Salmonella_ Typhi is resistant to most antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone) used to treat typhoid fever. Healthcare providers should:
- Obtain a complete travel history (asking about travel to South Asia, including Pakistan) from patients with suspected typhoid fever.
- Collect stool and blood cultures from patients with suspected typhoid fever and request antimicrobial susceptibility testing on isolates.
- Be aware that the Pakistan outbreak strain remains susceptible to azithromycin and carbapenems. Azithromycin is effective for uncomplicated (diarrhea or bacteremia without secondary complications) typhoid fever and should be used to treat patients with suspected uncomplicated typhoid fever who have traveled to Pakistan. When culture and sensitivity results are available, adjust treatment accordingly. Adult azithromycin dosage is usually 1000 mg orally once, then 500 mg orally daily OR 1000 mg orally once daily for at least 5-7 days. Pediatric azithromycin dose is 20 mg/kg orally, once then 10-20 mg/kg orally once per day (maximum 1000 mg per day) for at least 5-7 days.
- Carbapenems should be used for patients with suspected severe or complicated typhoid fever who have traveled to Pakistan. Severe or complicated typhoid fever would include, but not be limited to, patients with gastrointestinal complications (such as typhoid-related intestinal perforation, peritonitis, intestinal haemorrhage, hepatitis), neurologic complications (such as typhoid encephalopathy, including altered consciousness, delirium, confusion), or bacteraemia with sepsis or shock. When culture and sensitivity results are available, adjust treatment accordingly. Consider getting an infectious diseases consultation for these patients.
- Be aware that relapses can occur, often 1-3 weeks after clinical improvement.
- Be aware that most (90%) _S._ Typhi isolates from patients coming from South Asia have decreased susceptibility or resistance to fluoroquinolones, including ciprofloxacin; therefore, fluoroquinolones should not be used as empiric treatment for suspected typhoid fever in patients who have traveled to this area.
- Report all cases of confirmed typhoid fever to the appropriate local or state health departments." - ProMED Mod.LL]

[HealthMap/ProMED-mail map of Pakistan:
Date: Tue, 19 Feb 2019 21:26:43 +0100

Geneva, Feb 19, 2019 (AFP) - An avalanche left four skiers injured Tuesday at a resort in the Swiss Alps where rescue operations went on after dark with police fearing people could still be trapped under the snow.   The authorities held a press conference to announce the injuries, including one person seriously hurt, after local reports said up to a dozen people were engulfed by the avalanche.   Police officers said that based on witness reports other skiers could still be buried and the search would continue into the night.

Swiss RTS television said the army had set up lighting to aid the 240 rescue workers at the site.   The police had earlier tweeted that several people were under the avalanche that hit early afternoon on a slope 2,600 metres (8,600 feet) up at Crans-Montana, which was busy with skiers during school holidays.   A local newspaper, Le Nouvelliste, had quoted the head of Crans-Montana's municipal government, Nicolas Feraud, as estimating that "between 10 and 12 people" were buried under the snow.   "We are shocked and hope for good news about these people," Feraud was quoted as saying. 

A first attempt at locating victims using sniffer dogs was unsuccessful, a rescue worker told Le Nouvelliste, with four helicopters joining the search from the air.   Pierre Huguenin, of the Institute for Snow and Avalanche Research, described the snow in the area as damp and dense.   According to statistics from his institute, after 15 minutes under an avalanche, the chances of survival are no more than 50 percent.   Le Nouvelliste said the avalanche swept over 300 to 400 metres (yards) of the lower section of the Kandahar piste.   It quoted rescue workers as saying the snow was compacted and more than two metres (seven feet) thick.

Crans-Montana's website had listed the risk of an avalanche at two on a scale that runs from one (lowest risk) to five.    As the victims were on a designated ski slope, they were unlikely to have detector equipment to help rescue workers locate them.   The vast majority of deadly avalanches in the Alpine nation hit people skiing off-piste.    "We don't know yet whether the avalanche detached by itself or was set off by skiers, or a rockfall," Swiss avalanche expert Robert Bolognesi told the daily 20 Minutes.
Date: Wed, 20 Feb 2019 16:17:29 +0100

Prague, Feb 20, 2019 (AFP) - Czech authorities said Wednesday they would slap checks on beef imported from Poland after veterinarians found the dangerous Salmonella bacteria in a 700-kilogramme batch of Polish beef.   "Tests have shown the presence of Salmonella enteritidis, which can cause serious diarrhoea and affect human health, in beef imported from Poland on February 13," Agriculture Minister Miroslav Toman told reporters.

Czech veterinary authorities have warned the European Commission and Polish authorities through a rapid warning system, he said, adding that they are also checking whether any of the meat has been consumed.   "The State Veterinary Administration (SVS) will immediately adopt an extraordinary measure -- all beef imported from Poland must be tested in a lab before hitting the market," Toman added.

SVS head Zbynek Semerad said meat from the 700-kilo (1,500-pound) batch had been distributed to five "places" in the Czech Republic and one in Slovakia.   "I will inform my Slovak counterpart. As far as we know, not all of the meat has been distributed to the end customer," Semerad said.   The case comes on the heels of a scandal which saw Poland export a total of 2.7 tonnes of suspect beef to around a dozen fellow EU members, triggering an EU probe.

The scandal erupted in January when the TVN24 commercial news channel aired footage of apparently sick or lame cows being butchered at a small slaughterhouse in northeast Poland in secret late at night when veterinary authorities were unlikely to visit.   Poland is a leading producer and exporter of meat in Europe, turning out around 600,000 tonnes of beef per year and exporting most of it mainly to the EU, according to meat producer associations.
Date: Wed, 20 Feb 2019 09:56:54 +0100

Kuala Lumpur, Feb 20, 2019 (AFP) - Six people, including three foreigners, were killed when a fire broke out Wednesday in a Malaysian karaoke centre, with rescuers describing scenes of chaos as the blaze engulfed the building.   The fire erupted before dawn on the fourth floor of an eight-storey building in the city of Ipoh, northern Perak state.

Firefighters rushed to the scene and found the bodies of six people who had died of smoke inhalation, Perak fire department acting director Sayani Saidon told AFP.   "We came across two locals, two Vietnamese women and a Bangladeshi man. We are still determining the identity of the sixth person," she said.

Firefighters rescued eight people alive, including two in critical condition, she added.     People inside were unable to find the way out after the fire erupted as exit lights did not come on, she said. Those that survived had run to an upper level to escape the flames.   "When the fire happened, all the electricity went out, and it was dark, so the exit signs weren't clear," she said.   The building was originally an office block, and had 30 karaoke rooms on the fourth and fifth floors.