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Greece

Background
Greece offers a great variety of attractions for the international traveller. A beautiful climate linked with great beaches, a vibrant nightlife and historical monuments to rival any other location throughout the world. All of this located
within western Europe and a short flight away from many of the cooler northern destinations - like Ireland. Travellers from these regions descent on Greece in very significant numbers each year and for the vast majority of them they will have a splendid and healthy time. However for some this may not be the case and serious illness and accidents are regularly reported. Following some commonsense rules would go a long way to avoiding disaster and ensuring that this trip is truly one to be remembered for all the right reasons.
Climate
Situated in southern Europe the country enjoys mild winters but very hot summers. There may be occasional cool breezes (meltemia) but these can serve only to fool the traveller into thinking that they are unlikely to burn. Rain is very uncommon during the height of summer (July and August) and all travellers should be advised to use very adequate sun-block lotion at all times.
Slip, Slop, Slap
Following the Australian mantra of Slip, Slop and Slap makes perfect sense. Slip on a shirt, slop on sunscreen and slap on a hat when out and about during the day and this should help protect against the intense suns rays. Nevertheless, despite all their best intentions, travellers get burnt. This is particularly a problem in the first few days after their arrival when they do not realise the intensity of the suns rays and how easily they can be exposed. Falling asleep beside the hotel's swimming pool or on the beach is a very common problem and must be avoided against. The tips of the ears, shoulders (especially along the bra-strap line, ankles and behind the knees are commonly exposed and forgotten areas.
After Sun care
To treat significant sunburn it is important to increase fluid intake but also to take extra salt on your food (unless medically contraindicated for some specific condition like high blood pressure etc). Soothing water soluble lotions (especially ones containing a mild anaesthetic and/or steroid cream) are probably best but certainly avoid any of the ones which paste the skin with a thick layer - which is almost impossible to remove without causing serious pain! The more severe sunburn cases may need medical care and even hospitalisation which really ruins a holiday.
Food & Water
As a European destination Greece has a good level of food and water hygiene. Unfortunately this can vary - especially as you move away from the main tourist destinations and also as the summer temperatures rise and food goes 'off' more quickly. Eating hot food, avoiding cold foods (side-salads, lettuce etc) and never eating undercooked bivalve shellfish (mussels, oysters, clams etc) makes perfect sense. Eating food or taking fruit juice drinks from street vendors is a risk just not worth taking.
Insect bites
There may be both mosquitoes and sandflys about so having good repellents (DEET based ones) is worthwhile. The biggest problem will be early in the morning and towards the end of the daylight hours. However sitting in the shade while having lunch may be nice and cool but it is also often a place where these insects tend to hover looking for their next meal. Just don't allow that meal to be the blood in your unguarded ankle!
Seeing the Monuments
As mentioned previously Greece is covered with ancient monuments and these attract many thousands of tourists each year. The ruins are often not the most hospitable places for sun-sensitive tourists so taking care against the suns rays is essential - especially while standing carefully listening to the tour guide explain some complicated piece of history while the back of your legs get roasted! The other issue, for those trekking through the ruins, is the distinct possibility of a nasty twisted ankle.
Laser Night shows
Many of the ancient sites have beautiful night shows which depict something of the past splendour and are definitely worth seeing. However it is wise to wear good shoes as stumbling across loose stones is a particular problem at night and also bring a small torch, if possible, to guide your way. Getting separated from your travelling companions, or not being able to find your return bus, can lead to some understandable panic so listen carefully to any instructions and look out for some land marks before you get too far away into the night time crowd.
Animal bites
Some tourists may forget that rabies is a problem in many countries throughout the world and, even though Greece is regarded as rabies-free', there is always a problem if someone should get bitten. The possibility that this animal could have been recently smuggled into the country cannot be out ruled and so many would advise full post exposure treatment should this contact occur. Children may be at particular risk due to their inquisitive nature.
Swimming
Sunburn and swimming go hand in hand but drowning can also occur all too frequently within this region. Strong currents, swimming after meals (or alcohol) and the ever popular romantic midnight swim are all serious risk factors. Also children running around the deep end of the pool may lose their footing and topple in without warning. Unfortunately a very small child sinks instantly with very little sign of the emergency to those close by. Parents need to keep aware of this risk at all times.
The summer working holiday
Many of our students head towards Greece for 2 to 3 months during the summer to work. The attractions are obvious but commonsense and sensible life-style choices are needed throughout their stay to lessen the risk of illness or them returning home with an infection they had not bargained for. Unfortunately many return home with life-long illnesses which have been contracted from a single unprotected sexual contact.
Vaccinations for Greece
As a general rule the usual travel vaccines are not recommended for most short-term travellers to this region. However for the student planning to spend a more prolonged period it would be sensible to consider cover against both Hepatitis A and Hepatitis B and also to check that their Tetanus cover is up-to-date.
Summary
This is still one of the most popular destinations for northern European travellers and, in the vast majority of cases, they will have a fantastic time with only good memories. Unfortunately some less prepared folks will end up with serious sunburn and other illnesses or diseases which perhaps are frequently associated with their own lack of care and protection rather than anything specific to this beautiful country.

Travel News Headlines WORLD NEWS

Date: Tue, 13 Aug 2019 11:40:19 +0200 (METDST)

Athens, Aug 13, 2019 (AFP) - Dozens of firefighters Tuesday battled a major wildfire that forced the evacuation of a monastery on the Greek island of Evia as smoke from the blaze reached as far as Athens, authorities said.   Authorities also placed on alert two villages threatened by the blaze on the island, Greece's second largest after Crete and located northeast of Athens.   The fire started at about 3 am (0000 GMT) at the side of a road and was quickly spread by strong winds through the dry and dense vegetation in the centre of the island, the semi-official news agency ANA said.

The monastery of Panagia Makrymallis was evacuated as a precaution and residents of the villages of Kontodespoti and Stavros were told to be ready to leave also, TV SKAI said.   "Everything is ready in case it is necessary to evacuate the villages. The evacuation can be done in a few minutes. We are totally prepared," Fani Spanos, the governor of central Greece who was coordinating the operations, told SKAI.   He warned the fire was not yet under control and was spreading in an area that was inaccessible overland.

Around 80 firefighters were fighting the blaze backed by some 40 fire trucks and two water-bombing helicopters and a plane.   The strong winds blew the smoke from the blazing pine forest north toward the Magnesia region and south to the Attica peninsula and Athens.   ANA said the pine forests on Evia are part of the "Natura 2000" European network of protected areas and habitats.   Greece has been hit by a spate of wildfires since the weekend amid gale-force winds and temperatures of 40 degrees Celsius (104 F).

On Monday, a major forest fire threatening homes in Peania, an eastern suburb of Athens, was brought under control. At least two houses were burned but there were no reports of injuries.   On Sunday, a fire on the small island of Elafonissos, in the Peloponnese region, was brought under control after a two-day battle.   Two more fires were doused on Saturday in Marathon, close to Mati, the coastal resort where last year 102 people died in Greece's worst fire disaster.
Date: Sun, 11 Aug 2019 14:32:21 +0200 (METDST)

Athens, Aug 11, 2019 (AFP) - A French man was charged in Greece on Sunday over a boat accident that left two dead and another person seriously injured, state TV ERT reported.   The 44-year-old was charged with negligent manslaughter by a prosecutor and given 24 hours to prepare his defence, ERT said.  The man's lawyer Nikos Emmanouilidis had earlier told reporters that his client "will assist in every way any request by the Greek authorities."

The suspect has admitted to driving a 10-metre (32-foot) speedboat which struck a smaller wooden fishing boat on Friday evening near the Peloponnese resort of Porto Heli, 170 kilometres (105 miles) southwest of Athens.   The collision killed two elderly Greek men on board. A 60-year-old Greek woman, reportedly their sister, was seriously injured and taken to Athens for treatment.

The suspect could not be located for several hours after the incident before turning himself in on Saturday.   He has denied trying to evade arrest, and claims he was also injured in the incident and had sought first aid.   The suspect has said he did not see the fishing boat, which may have had insufficient lighting, state news agency ANA reported.   He has taken a blood alcohol test, with the results to be available on Monday.   "The first indications point to excessive speed by the powerboat driver," Merchant Marine Minister Yiannis Plakiotakis told ERT on Saturday.

Ten other French nationals who were also on the speedboat -- two men, three women and five children aged three to 14 -- were initially taken to Porto Heli for questioning after helping to bring the injured woman and one of the bodies to shore, the coastguard said.   They were all released on Saturday.   Speedboat accidents involving swimmers or other boats are common in Greece during the busy summer holiday season.

Another speedboat on Friday injured a 32-year-old swimmer at the Athens coastal suburb of Glyfada. The driver was arrested.   In 2016, four people including a four-year-old girl were killed when a speedboat sliced into their wooden tourist vessel near the island of Aegina.   Nobody was sanctioned as the prime suspect, an elderly Greek man, died a year after the accident.
Date: Sat, 10 Aug 2019 19:32:52 +0200 (METDST)

Athens, Aug 10, 2019 (AFP) - Greece on Saturday battled over 50 wildfires nationwide, including a major blaze near Athens, in a dangerous mix of high temperatures and strong winds unseen in nearly a decade.   The fire department said it had mobilised more than 450 firemen and 23 aircraft nationwide to tackle the fires, including one on the island of Elafonissos and two around Marathon, near Athens.   A camping site and a hotel on Elafonissos and a children's summer camp near Marathon were evacuated as a precaution, state news agency ANA reported.

Marathon is a short distance from Mati, the coastal resort where last year 102 people died in Greece's worst fire disaster.   Temperatures in some areas are expected to hit 40 degrees Celius (104 degrees Fahrenheit) on Sunday, accompanied by gale force winds.   On Friday, civil protection chief Nikos Hardalias said it was the first time since 2012 that the country had faced such a mix of high temperatures, strong winds and low humidity.   "We are called upon to manage extreme weather conditions over the next three days... we must all be careful," Hardalias told reporters as he placed emergency services on high alert.
Date: Fri 2 Aug 2019
Source: French.Cnina.org.cn [in French, trans. Corr.SB, edited]

Two people over 80 were the 1st victims of West Nile virus in Greece this year [2019], according to the weekly epidemiological surveillance report published by the National Public Health Organization (EODY).

From the beginning of epidemiological surveillance until today [2 Aug 2019], 25 cases of West Nile virus infection have been diagnosed and studied in Greece. In 17 of the patients reported, the central nervous system (CNS) was affected (encephalitis and/or meningitis/acute flaccid paralysis), while 8 had mild symptoms, such as fever.

The median age of patients with CNS symptoms is 77 years old. Of the 25 patients, 10 are hospitalized.

The areas where virus cases have been recorded in the country are Pieria, Katerini, Pella, Xanthi, Kavala, Larissa, Karditsa as well as East Attica and Mesogia.

West Nile virus is spread mainly through the bites of infected mosquitoes, experts say.

The implementation of mosquito control and personal protection programs is most appropriate for controlling the disease, the EODY noted.
====================
[Greece has had both human and equine cases of West Nile virus in recent years. Mosquito control can be difficult and expensive, especially over such a broad geographic area. For humans, the best preventive measure is avoidance of mosquito bites. There is a vaccine for equine animals, but not for humans. - ProMED Mod.TY]

[HealthMap/ProMED map available at:
Date: Sat, 3 Aug 2019 14:22:20 +0200 (METDST)

Athens, Aug 3, 2019 (AFP) - Another earthquake shook Greece on Saturday, this time off the Aegean island of Karpathos, the Greek Geodynamic Institute said, although there were no immediate reports of damage or injuries.    The epicentre of the 4.8-magnitude quake, which occurred at 0951 GMT, was 71 kilometres (44 miles) off the coast of Karpathos at a depth of around 10 kilometres, the institute said.    It came just three days after a 5.2-magnitude quake on the island of Crete and just under a week after a 4.2-magnitude tremor some 20 kilometres northwest of Athens.

Greece lies on major fault lines and is regularly hit by earthquakes, but they rarely cause casualties.   In 2017, a 6.7-magnitude earthquake killed two people on the island of Kos in the Aegean sea, causing significant damage.   In 1999, a 5.9-magnitude quake left 143 people dead in Athens and the region northwest of the capital.
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Anguilla

Anguilla US Consular Information Sheet
March 03, 2009
COUNTRY DESCRIPTION: Anguilla is a British overseas territory in the Caribbean, part of the British West Indies. It is a small but rapidly developing island with particularly well-developed
ourist facilities.

ENTRY/EXIT REQUIREMENTS:
The Intelligence Reform and Terrorism Prevention Act of 2004 requires all travelers to and from the Caribbean, Bermuda, Panama, Mexico and Canada to have a valid passport to enter or re-enter the United States. U.S. citizens must have a valid U.S. passport if traveling by air, including to and from Mexico.
If traveling by sea, U.S. citizens can use a passport or passport card. We strongly encourage all American citizen travelers to apply for a U.S. passport or passport card well in advance of anticipated travel.
American citizens can visit travel.state.gov or call 1-877-4USA-PPT (1-877-487-2778) for information on how to apply for their passports.

In addition to a valid passport, U.S. citizens need onward or return tickets, and sufficient funds for their stay.
A departure tax is charged at the airport or ferry dock when leaving. For further information, travelers may contact the British Embassy, 19 Observatory Circle NW, Washington, DC
20008; telephone (202) 588-7800; or the nearest consulate of the United Kingdom in Atlanta, Boston, Chicago, Dallas, Los Angeles, New York, Denver, Houston, Miami, Orlando, Seattle, or San Francisco. Visit the British Embassy web site for the most current visa information.

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:
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 A Safe Trip Abroad.

CRIME:
While Anguilla's crime rate is relatively low, both petty and violent crimes
do occur. Travelers should take common-sense precautions to ensure their personal security, such as avoiding carrying large amounts of cash or displaying expensive jewelry. Travelers should not leave valuables unattended in hotel rooms or on the beach. They should use hotel safety deposit facilities to safeguard valuables and travel documents. Similarly, they should keep their lodgings locked at all times, whether they are present or away, and should not leave valuables in their vehicles, even when locked.

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 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 emergency line in Anguilla is 911.
See our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION:
There is only one hospital, Princess Alexandra Hospital (telephone: 264-497-2551), and a handful of clinics on Anguilla, so medical facilities are limited.
Serious problems requiring extensive care or major surgery may require evacuation to the United States, often at considerable expense.

There are no formal, documented HIV/AIDS entry restrictions for visitors to and foreign residents of Anguilla, but there have been anecdotal reports of exclusion.
Please verify this information with the British Embassy 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 Anguilla is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

Unlike the U.S., traffic in Anguilla moves on the left. The few roads on the island are generally poorly paved and narrow. While traffic generally moves at a slow pace, with the increasing number of young drivers in Anguilla, there are occasional severe accidents caused by excessive speed. Although emergency services, including tow truck service, are limited and inconsistent, local residents are often willing to provide roadside assistance. For police, fire, or ambulance service dial 911.

Please refer to our Road Safety page for more information.
Visit the Government of Anguilla web site for further road safety information.

AVIATION SAFETY OVERSIGHT:
Civil aviation operations in Anguilla fall under the jurisdiction of British authorities. The U.S. Federal Aviation Administration (FAA) has assessed the Government of the United Kingdom’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Anguilla’s air carrier operations.
For more information, travelers may visit the FAA web site.

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 Anguilla laws, even unknowingly, may be expelled, arrested or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in Anguilla 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 Anguilla are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration web site and to obtain updated information on travel and security within Anguilla. 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 with consular responsibility over Anguilla is located in Bridgetown, Barbados in the Wildey Business Park in suburban Wildey, southeast of downtown Bridgetown.
The main number for the Consular Section is (246) 431-0225; after hours, the Embassy duty officer can be reached by calling (246) 436-4950.
Visit the U.S. Embassy Bridgetown online for more information.
Hours of operation are 8:30 a.m. – 4:30 p.m. Monday through Friday, except Barbadian and U.S. holidays.
* * *
This replaces the Country Specific Information for Anguilla dated April 2, 2008, to update sections on Country Description, Entry/Exit Requirements, Information for Victims of Crime, and Medical Facilities and Health Information.

Travel News Headlines WORLD NEWS

Date: Sat, 9 Sep 2017 19:31:32 +0200

Paris, Sept 9, 2017 (AFP) - France's meteorological agency on Saturday issued its highest warning for the Caribbean islands of St Martin and St Barts as Hurricane Jose bore down, three days after they were hit by Hurricane Irma.   The alert warned of a "dangerous event of exceptional intensity," with winds that could reach 120 kilometres (75 miles) per hour, and strong rains and high waves.

St Barts is a French overseas territory, as is the French part of St Martin, which is divided between France and the Netherlands.   Twelve people were killed on the two islands by Hurricane Irma, thousands of buildings were flattened and the authorities are struggling to control looting.   The French state-owned reinsurer CCR on Saturday estimated the damage at 1.2 billion euros ($1.4 billion).   Irma is now heading for Florida, where a total of 6.3 million people have been ordered to evacuate, according to state authorities.
Date: Tue 29 Apr 2014
Source: National Institute for Public Health and the Environment [edited]

1 Oct 2013-29 Apr 2014 (week 18) St Maarten - Since the last report (week 15 [17?]) 52 new cases have been confirmed among St Maarten residents. Up to 29 Apr 2014, now a total of 343 confirmed cases have been reported. One of these confirmed cases was hospitalized.

The median age of the confirmed patients was 44 years, range 4-92 years. Of those cases for which gender was available, 201 were female and 130 were male.

- On 6 Dec 2013, the 1st indigenous chikungunya [virus infection] case of St Maarten was reported. Retrospectively, the 1st patient with suspected complaints was reported in mid-October 2013 in St Martin.
------------------------------------
Communicated by:
Roland Hubner
Superior Health Council
Brussels
Belgium
=====================
[The report also has graphs showing case numbers over time.

Maps of St Martin/St Maarten can be accessed at
Date: 5-11 May 2014
Source: Institut de Veille Sanitaire (French Institute for Public Health Surveillance, InVS) [edited]

Cases since the beginning of the outbreak in December 2013:
- St Martin: (susp) 3240 cases; deaths 3; stable.
- St Barthelemy: (susp) 500 cases; stable.
- Martinique: (susp) 24 180; deaths 3; increasing.
- Guadeloupe: (susp) 13 600 cases; deaths 1; increasing.
- French Guiana: (susp) not available; (probable or confirmed) 122 cases with 83 locally acquired; increasing, with a new cluster in Kourou and 2 near Cayenne.
======================
[The 16 May 2014 report from Guyaweb (<http://www.guyaweb.com/actualites/news/sciences-et-environnement/le-chik-revient-kourou-setend-cayenne-desormais-saint-laurent/>) states that there are 2 new cases in Saint-Laurent-du-Maroni, overlooking the Suriname River, of which one is certainly autochthonous, and a new focal point occurred in Kourou with 4 cases.

Maps of the area can be seen at
and <http://healthmap.org/promed/p/35574>. - ProMed Mod.TY]
Date: 7-13 Apr 2014
Source: INVS Point Sanitaire No. 14 [in French, trans. ProMed Mod.TY, edited]

Cases since the beginning of the outbreak in December, 2013:
- St. Martin: (susp.) 2980 cases, (probable and conf.) 793 cases; Deaths 3; Decreasing.
- Saint Barthelemy: (susp.) 460 cases, (probable or confirmed) 135 cases; Decreasing.
- Martinique: (susp.) 16 000, (probable or confirmed) 1473 cases; Deaths 2; Increasing.
- Guadeloupe: (susp.) 4710 cases, (probable or confirmed) 1261 cases; Deaths 1; In epidemic status.
- French Guiana: (susp.) 7 cases with 4 locally acquired, (probable or confirmed) 39 cases with 26 locally acquired) 30 cases; (imported) 16 cases; Moderate to increasing; Half of probable and confirmed cases are located in Kourou; however indigenous cases have also been recorded from the Cayenne Matoury, Remire and Macouria communities.
=================
[Maps showing case distributions on each island can be accessed at the above URL. - ProMed Mod.TY]
Date: Thu 27 Mar 2014
Source: The Daily Herald [edited]

As St. Maarten continues to take measures to combat the spread of the chikungunya virus, the number of cases continues to climb.

Health Minister Cornelius de Weever announced on Wednesday [26 Mar 2014], that the total number of confirmed chikungunya cases thus far stood at 224.

De Weever also announced that government will be signing a Memorandum of Understanding (MOU) with French St. Martin as a means of collectively responding to the mosquito threat that puts the population at risk. He said both sides have been working closely together to address the dengue and chikungunya threats.

The MOU will cover, amongst other things, a regular exchange of epidemiological information on vector-borne diseases and collectively publishing and representing data collected under the agreement.

The need for collective information campaigns and enhancement of the mosquito vector-control programme will also be included in the MOU. The MOU also describes the need for planning execution and evaluation of collective responses to the chikungunya threat.
=========================
[The increase in the number of chikungunya virus infections over the past week in St. Maarten is of concern, rising from 123 cases to 224 cases. This number is confirmed in another report that also indicates that there are an additional 325 suspected cases (<http://www.rivm.nl/dsresource?type=pdf&disposition=inline&objectid=rivmp:239786>).  - ProMed Mod.TY]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/35574>.]
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Pakistan

Pakistan - US Consular Information Sheet
October 02, 2008
COUNTRY DESCRIPTION:
Pakistan is a parliamentary federal republic in South Asia, with a population of nearly 170 million people. Following successful elections in February 2008, Pak
stan has a coalition government led by Prime Minister Yousef Gilani. Pakistan is a developing country, with some tourist facilities in major cities but limited in outlying areas. The infrastructure of areas of Kashmir and the Northwest Frontier Province was devastated as a result of the October 8, 2005 earthquake and is not yet recovered. Read the Department of State Background Notes on Pakistan for additional information.

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ENTRY/EXIT REQUIREMENTS: All U.S. citizens traveling to Pakistan for any purpose are required to have valid U.S. passports and Pakistani-issued visas. Further information on entry requirements can be obtained from the Embassy of Pakistan at 3517 International Court Avenue NW, Washington, DC 20008; telephone: 202-243-6500; e-mail: info@pakistan-embassy.org; web site: http://www.pakistan-embassy.org/.

Travelers may also contact one of the Consulates General of Pakistan in:
Boston: 20 Chestnut Street, Needham, MA 02492; telephone: (781) 455-8000; fax: (617) 266-6666; email: pakistan@tiac.net
Chicago: 333 North Michigan Ave., Suite 728, Chicago, IL, 60601; telephone: (312) 781-1831; fax: (312) 781-1839; email: parepchicago@yahoo.com
Houston: 11850 Jones Road, Houston, TX, 77070; telephone: (281) 890-2223; fax: (281) 890-1433; email: parephouston@sbcglobal.net
Los Angeles: 10850 Wilshire Blvd., Suite 1100, Los Angeles, CA 90024; telephone: (310) 441-5114; fax: (310) 441-9256; email: info@pakconsulatela.org
New York: 12 East 65th St., New York, NY 10021; telephone: (212) 879-5800; fax: (212) 517-6987; web site: www.pakistanconsulateny.org
If a traveler plans to stay longer than the time listed on the visa, he or she must extend the stay with the local passport office of the Ministry of Interior. Visit the Embassy of Pakistan web site at http://www.pakistan-embassy.org/ for the most current visa information.

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:
A number of extremist groups within Pakistan continue to target American and other Western interests and high-level Pakistani government officials. Terrorists and their sympathizers have demonstrated willingness and capability to attack targets where Americans are known to congregate or visit. Terrorist actions may include, but are not limited to, suicide operations, bombing -- including vehicle-borne explosives and improvised explosive devices -- assassinations, carjacking, assault or kidnapping. U.S. Government personnel are not permitted to stay at or frequent major hotels in Islamabad, Karachi, Lahore and Peshawar.

Government personnel have also been advised to restrict the number and frequency of trips to public markets, and to avoid public restaurants in Islamabad, Karachi, and Peshawar.

In September 2008, over fifty people, including three Americans, were killed and hundreds were injured when a suicide bomber set off a truck filled with explosives outside a major international hotel in Islamabad. In August 2008 gunmen stopped and shot at the vehicle of an American diplomat in Peshawar. In March 2008, a restaurant frequented by westerners in Islamabad was bombed, killing one patron and seriously injuring several others, including four American diplomats. On March 2, 2006, an American diplomat, his locally employed driver, and three others were killed when a suicide bomber detonated a car packed with explosives in front of the U.S. Consulate General in Karachi. Fifty-two others were wounded in the attack.

Sectarian and extremist violence has resulted in fatal bomb attacks in Islamabad, Rawalpindi, Karachi, Peshawar, Quetta, Lahore, and other Pakistani cities since 2006. Since 2007, over 1,000 bombings have killed more than 1,000 people throughout Pakistan and injured many more. Rallies, demonstrations, and processions occur from time to time throughout Pakistan on very short notice and have often taken on an anti-American or anti-Western character. Because of the possibility of violence, Americans are urged to avoid all public places of worship and areas where Westerners are known to congregate.

During the Islamic (Shi’a) religious observance of Moharram, rivalries and hostilities often increase.

In 2007 and 2008, several American citizens throughout Pakistan were kidnapped for ransom or for personal reasons. Kidnappings for ransom are particularly common in some parts of Pakistan, such as the Northwest Frontier Province and Sindh Province.

It is best to avoid public transportation. For security reasons, U.S. Mission personnel are prohibited from using taxis or buses. (See the Traffic Safety and Road Conditions section below.)

Women are advised to dress conservatively, with arms and legs covered, and avoid walking around alone. It is unwise for anyone to travel on the streets late at night. Visitors to Pakistan should attempt to maintain a low profile, blend in, be aware of their surroundings, and seek security with their family or sponsoring organization.

Northern Areas – While we continue to discourage non-essential travel to Pakistan, we advise Americans wishing to trek in Gilgit, Hunza or Chitral to use only licensed guides and tourist agencies. While overall crime is low, there have been occasional assaults on foreign visitors.

Northwest Frontier Province - The Federally Administered Tribal Areas (FATA) along the Afghan border, and certain areas within the Northwest Frontier Province (NWFP), are designated as tribal areas and are not subject to normal government jurisdiction. The Government of Pakistan requires all citizens of countries other than Pakistan and Afghanistan to obtain permission from the Home and Tribal Affairs Department prior to visiting these locations. The permit may stipulate that an armed escort must accompany the visitor. Even in the settled areas of the NWFP there is occasional ethnic, sectarian, and political violence. There have been dozens of bombings in Peshawar of varying sophistication since September 2006. Members of the Taliban and Al-Qaida are known to be in the FATA, and may also be in the settled areas.

Kashmir - While direct military hostilities between India and Pakistan across the Line of Control (LOC) are infrequent, militant groups engaged in a long-running insurgency on the Indian side of the LOC are reported to have bases and supporters operating from the Pakistani side. Most of these groups are anti-American, and some have attacked Americans and other Westerners. The Government of Pakistan restricts access to many parts of this region and requires that visitors obtain a permit from the Ministry of Interior before traveling.

Punjab Province - Violence has increased in Punjab Province. Since September 2007, several suicide operations have taken place, including attacks in Rawalpindi and Lahore. As a precaution against these possible dangers, U.S. citizens are cautioned to avoid public transportation and crowded areas. The Wagah border crossing into India near Lahore remains open daily (from 9:30 a.m. to 3:30 p.m.) for travel to and from India if the passport holder has a valid visa for both countries. Visitors are advised to confirm the current status of the border crossing prior to commencing travel.

Sindh Province - In Karachi and Hyderabad, there has been recurring violence characterized by bombings, violent demonstrations and shootings. An October 2007 suicide attack on former Prime Minister Benazir Bhutto killed more than 130 and injured approximately 375 people in Karachi. In the aftermath of her December 2007 death, rioting in Karachi led to multiple deaths and injuries, as well as widespread property damage. In May 2008, clashing groups of lawyers burned buildings and vehicles in several areas of the city, resulting in at least 11 fatalities. Americans and other westerners continue to be a particular target of hostility and occasional anti-Western mob violence. The Consulate General in particular has been the target of several major terrorist attacks or plots in recent years, including the deadly March 2006 suicide attack described above. Non-essential travel to these cities is strongly discouraged. In rural Sindh Province, the security situation is hazardous, especially for those engaged in overland travel. The Government of Pakistan recommends that travelers limit their movements in Sindh Province.

Balochistan Province - The Province of Balochistan, which borders both Iran and Afghanistan, is notorious for narcotics and other forms of cross-border smuggling. Members of the Taliban and Al-Qaida are also believed to be present there. Tribal unrest sometimes turns violent. Because provincial police presence is limited, travelers wishing to visit the interior of Balochistan should consult with the province’s Home Secretary. Advance permission from provincial authorities is required for travel into many areas. Local authorities have detained travelers who lacked proper permission. Quetta, the provincial capital, has experienced an increase in bombings, occasional gun battles in the streets, and the imposition of curfews. Terrorist attacks against Pakistani government installations and infrastructure have been reported throughout 2005 and 2006.

For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov, where the current Travel Warnings, including the Travel Warning for Pakistan, 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: Crime is a serious concern for foreigners throughout Pakistan. Carjacking, armed robberies, house invasions, and other violent crimes occur in many major urban areas. Petty crime, especially theft of personal property, is common. American travelers to Pakistan are strongly advised to avoid traveling by taxi and other forms of public transportation, and have members of their host organizations or families meet them at the airport.

In many countries around the world, counterfeit and pirated goods are widely available. Transactions involving such products may be illegal under local law. In addition, bringing them back to the United States may result in forfeitures and/or fines. More information on this serious problem is available at http://www.cybercrime.gov/18usc2320.htm
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 Pakistan is: 15
See our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION: Adequate basic non-emergency medical care is available in major Pakistani cities, but is limited in rural areas. Facilities in the cities vary in level and range of services, resources, and cleanliness, and Americans may find them below U.S. standards; facilities in rural areas are consistently below U.S. standards. Medical facilities require prepayment and do not accept credit cards.

Water is not potable anywhere in Pakistan and sanitation in many restaurants is inadequate. Stomach illnesses are common.

Effective emergency response to personal injury and illness is virtually non-existent in Pakistan. Ambulances are few and are not necessarily staffed by medical personnel. Any emergency case should be transported immediately to a recommended emergency receiving room. Many American-brand medications are not widely available, but generic brands from well-known pharmaceuticals usually are. The quality of the locally-produced medications is uneven.

The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to or foreign residents of Pakistan.
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. As noted above, emergency medical care in Pakistan is very limited. Medical evacuations from Pakistan may cost in excess of $45,000 for uninsured travelers requiring emergency assistance. 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 Pakistan is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

Traffic in Pakistan moves on the left, opposite of U.S. traffic. In addition to this source of potential confusion, travel by road in Pakistan has a variety of other risks. Roads are crowded, drivers are often aggressive and poorly trained, and many vehicles, particularly large trucks and buses, are badly maintained. Donkeys, cattle, horse carts, and even the occasional camel can pose roadside hazards in some areas. Roads, including most major highways, also suffer from poor maintenance and often have numerous potholes, sharp drop-offs and barriers that are not sign-posted. Drivers should exercise extreme caution when traveling at night by road, as many vehicles do not have proper illumination or dimmers nor are most roads properly illuminated or signed. Driving without experienced local drivers or guides is not recommended.

It is best to avoid public transportation. For security reasons, U.S. Mission personnel are prohibited from using taxis or buses. (See Safety and Security section above.)

Please refer to our Road Safety page for more information. Visit the website of Pakistan’s national tourist office at http://www.tourism.gov.pk/ and the national authority responsible for road safety at http://www.nha.gov.pk/.

AVIATION SAFETY OVERSIGHT: The U.S. Federal Aviation Administration (FAA) has assessed the Government of Pakistan’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Pakistan’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.

SPECIAL CIRCUMSTANCES:
Pakistan is largely a cash economy. Personal checks are not commonly accepted. Most Pakistanis do not use checking accounts for routine transactions. Outside major cities, even credit cards and travelers’ checks are generally not accepted, and there have been numerous reports of credit card fraud. There are bank branches as well as registered moneychangers in all international airports. ATMs can also be found in major airports. English is widely spoken by professional-level airport staff.

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 Pakistani laws, even unknowingly, may be expelled, arrested or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in Pakistan 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 Pakistan 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 Pakistan. 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 in Islamabad is located at Diplomatic Enclave, Ramna 5; telephone: (92-51) 208-0000; Consular Section telephone: (92-51) 208-2700; fax: (92-51) 282-2632; website: http://islamabad.usembassy.gov/
The U.S. Consulate General in Karachi, located at 8 Abdullah Haroon Road, closed its public operations indefinitely due to security concerns. U.S. citizens requiring emergency assistance should call the Consular Section in Karachi; telephone: (92-21) 520-4200; fax: (92-21) 568-0496; web site: http://karachi.usconsulate.gov/
The U.S. Consulate in Lahore is located on 50 Sharah-E-Abdul Hamid Bin Badees (Old Empress Road), near Shimla Hill Rotary; telephone: (92-42) 603-4000; fax: (92-42) 603-4200; web site: http://lahore.usconsulate.gov/; email: amconsul@brain.net.pk
The U.S. Consulate in Peshawar is located at 11 Hospital Road, Cantonment, Peshawar; telephone: (92-91) 526-8800; fax: (92-91) 528-4171; web site: http://peshawar.usconsulate.gov/
* * *
This replaces the Country Specific Information dated August 7, 2008 to update the section on Safety and Security.

Travel News Headlines WORLD NEWS

Date: Sat, 7 Sep 2019 03:40:09 +0200 (METDST)
By Ashraf KHAN

Karachi, Sept 7, 2019 (AFP) - Swarms of flies are descending on Pakistan's commercial capital in what residents say are record numbers this rainy season, adding to the misery of Karachi's monsoon "hell".   Heavy rains have inundated the sprawling port city of nearly 20 million people for weeks, overwhelming shoddy drainage systems clogged with mountains of uncollected garbage and flooding neighbourhoods with raw sewage.    "I have never seen such a fierce presence of flies in my life," Karachi resident Abdul Aziz, 45, told AFP.    "Clouds of flies keep covering the food at the market. It's repulsive -- they cover the fruit so much that you can't see beneath them."

At a market in Surjani town, meat trader Zahid Ali looked on as flies engulfed the area.    "If the customers come, they impulsively leave after seeing the swarms of flies," said Ali, adding that an increasing number of people working in the market had fallen ill.    Shershah Syed, a health rights activist and prominent surgeon in Karachi, said many illnesses were on the rise because of flies and mosquitoes.   "This time (the flies are) the worst ever as rain water is unable to drain and the garbage heaps are not dealt with," Syed said.    "The number of children entering hospitals for diarrhea or dysentery has jumped several fold this year. The number of children -- who are the most vulnerable to the fly-borne diseases -- has increased by about 10 times."

While Karachi is responsible for 60 percent of Pakistan's economic output, the city has long endured creaky infrastructure, illegal construction and failing municipal services.    This week, the Economist Intelligence Unit ranked Karachi as one of the least liveable cities in the world along with the likes of war-torn Libya's Tripoli and the crisis-hit Venezuelan capital Caracas.    "People in Karachi are numb to the idea of living with medical waste, overflowing gutters, broken down roads, and a complete lack of any kind of respectable public transport system," wrote Saadat Ali Zia on Twitter.    "We live in hell," tweeted Farooq Afridi.
Date: Sat 24 Aug 2019
Source: The News [edited]

A 16-year old boy is battling for life at a private hospital in Karachi after he was diagnosed on [Fri 23 Aug 2019] with primary amoebic meningoencephalitis (PAM), a rare disease caused by _Naegleria fowleri_, a microorganism also referred to as brain-eating bug, health officials said.

"[MS], 16, a resident of the Mahmoodabad area of the city has been diagnosed with _Naegleria fowleri_ infection. He is still alive and undergoing treatment at a private hospital in Karachi," an official of the Sindh health department told The News on [Fri 23 Aug 2019].

According to the experts, PAM is a disease of the central nervous system. PAM is caused by _Naegleria fowleri_, a free-living amoeba. It is a rare disease with a very high mortality rate as only 4 of 145 patients of PAM in the United States between 1962 and 2018 survived.

According to health department officials, 11 people have so far died in 2019 in Karachi due to PAM caused by the brain-eating bug. [MS] is the year's 12th patient of the disease. They said _Naegleria fowleri_ infects the brain when a person ingests water through his or her nostrils while making ablution or when water enters into the nasal cavity while swimming in non-chlorinated swimming pools or lakes.

Officials said the boy infected with the deadly microorganism was unable to talk or respond to and they had formed a team of experts that would investigate the case and ascertain the cause of infection so that precautionary measures could be adopted.  Doctors at the private hospital near Kalapul where the teenager has been admitted said the condition of [MS] was "not good" as he had been put on life support and they were trying their best to save his life.
"Patient [MS] was brought in unstable condition to us and medical investigations revealed that he is infected with _Naegleria fowleri_. Currently, he is on ventilator," a doctor said on condition of anonymity.  [Byline: M. Waqar Bhatti]
===========================
[This is the 4th reported case of primary amoebic meningoencephalitis (PAM) from Karachi in 2019.

Different measures recommended to prevent infection include avoiding water activities in pools that include immersion particularly in ponds or untreated water; using a nose clip when the water is warm or the temperature is near or above 80 deg F [27 deg C]; using distilled, sterile or previously boiled and cooled water for nasal rinses; periodic cleaning of water reservoirs/tanks and chlorination of water supply. - ProMED Mod.UBA]

[HealthMap/ProMED map available at:
Date: Mon 26 Aug 2019
Source: Relief Web [edited]

A total of 5 more children -- 3 from Khyber Pakhtunkhwa and 2 from Sindh -- have tested positive for poliovirus, it emerged on Sunday [25 Aug 2019].

With the latest addition, the number of polio cases in the country has climbed to 58 this year [2019], indicating a sharp increase of 383.33% from last year's [2018] figure of 12. It may be recalled that only 8 cases had been confirmed in 2017.

Of the 58 victims found this year [2019], 44 belonged to Khyber Pakhtunkhwa alone, whereas Sindh and Punjab shared 5 cases each and Balochistan reported 4 cases.

All 5 new victims are girls, and 4 of them had not received a single dose of vaccine, according to an official of [the] Polio Virology Laboratory at the National Institute of Health, Islamabad. [The] 3 cases [from] Khyber Pakhtunkhwa were reported from Bannu, Hangu and North Waziristan, while both cases [from] Sindh were reported from Hyderabad, he said while requesting anonymity.

Sharing details of the cases reported from Khyber Pakhtunkhwa, the official said: "3 girls were paralysed in KP." They included an 18-month-old resident of Hangu's tehsil Thal, a 30-month-old resident of North Waziristan's tehsil Mirali, and another 18-month-old girl from Bannu's tehsil Wazir. "All 3 had not received a single dose of polio vaccine during routine immunisation," he said.

About the cases from Hyderabad, the official said one of the girls had missed [the] polio vaccine during routine immunisation. She was a resident of Quetta Town, Hala Nakka area. The other girl, a resident of [the] Liaquat Colony area of Latifabad, had received 3 doses of polio vaccine during routine immunisation, the official confirmed. The victims were identified as a 12-month-old and a 12-year-old.

None of the victims from Khyber Pakhtunkhwa was identified.

When contacted, [the] Prime Minister's Focal Person on Polio Eradication Babar Bin Atta confirmed to Dawn that 5 more children were infected with the virus [causing the] crippling disease.

Just over 2 [weeks] ago, 5 polio cases had been confirmed from Khyber Pakhtunkhwa. So far this year [2019], 44 cases have been reported from KP, 5 each from Punjab and Sindh, while 4 cases have been reported from Balochistan. Last year [2018] when the country recorded a total of 12 polio cases, 8 of them were reported from KP.

The latest cases have been confirmed only a day before the resumption of a province-wide vaccination campaign after 4 months. Earlier during a nationwide polio campaign in April [2019], students of a school in Mashokhel were rushed to the Hayatabad Medical Complex, Peshawar, with complaints about drug reaction. However, [the] initial probe indicated that a drama had been staged to spread propaganda against polio drives, as all the children were found to be safe.

While some of the culprits were arrested and legal action was taken against them, resistance to polio vaccination has increased since then. To counter the propaganda against vaccine, the authorities have decided to launch the drive from the same village of Mashokhel.

Nearly 2 dozen [24] cases have been reported from Bannu district, followed by North Waziristan and Torghar, where at least 8 and 5 cases have been detected, respectively. Lakki Marwat and Hangu have witnessed 2 cases each this year [2019], while Shangla, Charsadda, Bajaur and Khyber districts have recorded at least one case each.

In the endemic areas, too, the government is struggling to counter the new challenge of fake markings of children by their parents amid reluctance shown against vaccination.

The province has been experiencing outbreaks since the environmental samples started testing positive in October 2018. The 1st outbreak was witnessed in Bajaur in November [2018] that lasted till January [2019]. The 2nd outbreak initially recorded in March [2019] in Bannu division is still the focus of attention.

In Torghar, the district administration will spearhead the campaign under tight security because the vaccinators are gripped by fear in the areas known for opposition to vaccination. However, the authorities claimed that elaborate arrangements had been made to run the campaign after a break of several months to ensure that all the children are administered polio drops.

Polio is a highly infectious disease caused by virus mainly affecting children under the age of 5 [years]. It invades the nervous system, and can cause paralysis or even death. While there is no cure for polio, vaccination is the most effective way to protect children from the crippling disease. Each time a child aged below 5 years is vaccinated, their protection against the virus is increased. Repeated immunizations have protected millions of children from polio, allowing almost all countries, except Pakistan and Afghanistan, to become polio free.

Published in Dawn, [26 Aug 2019]
[Byline: Ikram Junaidi]
===========================
[These cases were confirmed on the End Polio Pakistan website (see <http://www.endpolio.com.pk/polioin-pakistan/polio-cases-district-wise-2019>). Transmission of the WPV1 continues in both Pakistan and Afghanistan (a newly confirmed case was reported last week in Afghanistan). As this article clearly states, a key problem has been the growing antivaccination groups that are convincing parents not to vaccinate their children. How does one effectively deal with this? We haven't been successful in the western cultures, as seen with the ongoing measles outbreaks. A major dilemma.

The HealthMap/ProMED map of Pakistan can be found at

A good map showing the provinces and districts of Pakistan can be found at
Date: Thu 22 Aug 2019
Source: Pakistan Today [edited]

Two more Crimean-Congo haemorrhagic fever (CCHF) cases surfaced in the city [Karachi] on Thursday [22 Aug 2019], taking the reported toll of cases to 27 in the provincial metropolis during the current year (2019).

The patients have been identified as 54-year-old [ZS] and 32-year-old [MK]. [They] are being treated in different private hospitals after testing positive for the CCHF.

The recent cases took the number of Congo patients to 27; however, the number of people [who] died from the disease reached 13.
***************************************
Punjab
Date: Sat 24 Aug 2019
Source: ARY News [abridged, edited]

The National Institute of Health (NIH) has confirmed Congo virus infection in a patient who died at a hospital in Lahore, ARY News reported on Saturday [24 Aug 2019].

The NIH lab has confirmed Congo virus in a Lahore resident [A], 46, who was admitted at Mayo Hospital of the city, and his blood samples were sent to the NIH for medical tests. The patient later died at the hospital.

Sindh health department had recently confirmed 14 deaths in Karachi from Crimean-Congo haemorrhagic fever (CCHF) cases in the city during the ongoing month (August 2019). An official said that a total of 26 cases were reported at different private and public healthcare facilities, where 14 of them died.

The ailment, a viral infection transmitted to humans through ticks that live on cattle, is said to have an average of 40% mortality rate, but can be largely prevented through timely and proper management.

In 2018, at least 16 deaths had been reported in Karachi from the life-threatening virus, whereas 41 patients -- majorly from Quetta, Balochistan -- were diagnosed with it.

On [25 Jul 2019], a Congo virus alert had been issued for the metropolis, stipulating precautionary instructions for all those people who are visiting cattle farms. The alert was issued by the Karachi Metropolitan Corporation (KMC) to hospitals, directing the management to adopt special precautions for a Congo-affected patient. The letter of the KMC further asked hospitals to establish special wards for Congo patients, and run awareness campaigns about the virus.
======================
[The total number of suspected and confirmed CCHF cases from Punjab is not available; while the media reports generally give a running tally, the exact number of cases reporting to healthcare facilities in regions and provinces needs to be reported regularly in order to monitor disease trends, investigate/follow up on suspected cases and contacts, as well as to improve capacity of healthcare providers to recognize and safely manage new cases. - ProMED Mod.UBA]

[HealthMap/ProMED-mail maps:
Punjab Province, Pakistan: <http://healthmap.org/promed/p/941>]
Date: Mon 19 Aug 2019
Source: ARY News [edited]

One more case of Congo virus [has been] reported in Karachi as a young boy was diagnosed with the disease after being admitted at a hospital in Nazimabad area, ARY News reported on Sunday [18 Aug 2019]. Doctors confirmed that the 17 year old boy, named as [QS] who is [a] resident of Sohrab Goth and worked at a dairy farm, was diagnosed with Congo virus during the initial medical examination tests.

It is pertinent to mention here that the 1st case of Congo virus was reported on [11 Feb 2019] in the metropolis as a woman, [TF], [who] had been brought to Jinnah Hospital in critical condition.

In 2018, at least 16 deaths were reported in Karachi from the life-threatening virus, and 41 patients -- mainly from Quetta, Balochistan -- were diagnosed with it.

Earlier on [25 Jul 2019], a Congo virus alert had been issued for the metropolis, stipulating precautionary instructions for all those people who visit cattle farms. The alert was issued by Karachi Metropolitan Corporation (KMC) to hospitals, directing the management to adopt special precautions for a Congo-affected patient. The letter of the KMC further asked hospitals to establish special wards for Congo patients, and run awareness campaigns about the virus through banners and posters.

The disease is caused when a tick attaches itself to the skin of cattle, and when that infected tick or animal comes in contact with people, the highly contagious virus is transmitted into the human body and the person falls ill. This disease has a 40% to 50% mortality rate. The initial symptoms of Congo fever include headache, high fever, rashes, back pain, joint pain, stomach pain and vomiting.

Precautions: people should wear light-coloured and airy clothes while going to cattle farms. Use of mask and gloves is also recommended while touching animals.
More ...

World Travel News Headlines

12th September 2019
Communication from a medical colleague based in Kathmandu
=======================
Dear friends,  I would like to alert you to a dengue outbreak in Nepal including in Kathmandu. It started in May 2019 in eastern Nepal but has come to Kathmandu in a big way in the past 2 weeks or so. Government figures (http://www.edcd.com.np/) indicates total of 5095 cases in Nepal including 1170 cases from Kathmandu. The government figures underestimate the problem due to underreporting issues. Kathmandu hospitals seem stretched to capacity due to dengue visits and admissions.

This problem is new to Kathmandu as we have had only sporadic cases of dengue in previous years. The public in Kathmandu has never taken mosquito bites seriously since we have not had major vector borne diseases in the past. We hope that the current dengue outbreak has peaked and will slow down once we get cooler nights from end September - early October.

If you have travellers coming this way, please alert them to this and send them with insect repellents and information on mosquito protection measures. DEET is not readily available and other repellent supplies have been depleted. 

Thank you. 
Prativa
======================
Dr. Prativa Pandey
Medical Director
CIWEC Hospital I Travel Medicine Center
prativapandey@ciwec-clinic.com
+977
98510-36742 I
http://www.ciwec-clinic.com/
Date: Mon, 9 Sep 2019 12:11:43 +0200 (METDST)
By Kyoko HASEGAWA

Tokyo, Sept 9, 2019 (AFP) - A powerful typhoon that battered Tokyo overnight with record winds killed two people, police said Monday, as cancelled trains caused commuter chaos and more than 100 flights were scrapped, leaving thousands stranded at the airport.   Typhoon Faxai, packing winds of up to 207 kilometres (129 miles) per hour, made landfall in Chiba just east of the capital before dawn, after barrelling through Tokyo Bay.   The transport disruptions unleashed by the storm came less than two weeks before the start of the Rugby World Cup, and delayed the arrival of the Australian team -- a reminder that Japan's typhoon season could present challenges for organisers.

Police confirmed two people were killed in the storm -- a woman in her fifties who was found dead in Tokyo and an elderly man in the neighbouring Chiba prefecture.   Security camera footage showed that high winds pushed her across a street and into a wall, while the 87-year-old man was found dead in the woods under a fallen tree.   The storm injured more than 30 people, including a woman who sustained serious injuries after gusts toppled a protective netting structure at a golf driving range onto nearby houses.   Non-compulsory evacuation orders were issued to hundreds of thousands and authorities said more than 2,000 people had taken refuge in shelters at one point.

- Commuters stranded -
The strong winds downed trees and power lines. Nearly 760,000 households were still without electricity in the Tokyo area Monday evening.    Scaffolding was ripped from buildings and protective sheeting hung to keep construction debris off the streets was crumpled and torn by the storm.

While the damage was relatively light given the wind speeds, it was enough to cause chaos in the capital's notoriously busy morning commute.   The overland East Japan Railway train system was largely halted in the early hours of operation while tracks were checked for fallen trees and other debris.   The storm also caused delays and stoppages on subway lines, leading to massive crowds at some stations in the busy metropolitan area that is home to 36 million people.

Bullet train services that were suspended during the storm had largely resumed, though some were operating on a reduced schedule. Some roads were blocked by downed trees.   And trains running to and from Narita International Airport were halted, with buses and taxis the only options left to those arriving or hoping to fly out.   Thousands of people were stranded at the airport Monday evening, with officials preparing to distribute blankets and food.

- Wallabies arrival delayed -
At least 138 domestic flights were cancelled, with the weather even delaying the arrival of the Wallabies in Tokyo on Monday ahead of the World Cup that kicks off on September 20.   The French team managed to sneak in just ahead of the typhoon and reach their training camp near Mount Fuji.

By mid-Monday morning, the storm had moved back offshore and was headed northeast away from Japan, back into the Pacific.   The weather agency warned that landslides were still possible in Chiba as well as the northern Fukushima region as the storm headed away from land.   Japan is used to severe tropical storms and typhoons during late summer and autumn.   Strong typhoon Krosa lashed western Japan in mid-August, bringing strong winds and torrential rain that claimed one life.   And in late August, heavy rains left three people dead when massive floods also hit western Japan.

But this year, the typhoon season coincides with the Rugby World Cup, presenting a possible headache for teams and organisers.   Tournament rules say that if a pool match has to be scrapped due to extreme weather, it is classed as a draw, which could have a major impact on what is set to be a very close competition.   Nicholas van Santen, a spokesman for Rugby World Cup organisers, said they were working closely with the teams to minimise any disruption to their training schedules.   "In the days and hours leading up to the typhoon making landfall, the organising committee monitored the situation closely with the tournament's weather information provider and the relevant authorities," said Van Santen.
Date: Mon, 9 Sep 2019 11:49:46 +0200 (METDST)

Kuala Lumpur, Sept 9, 2019 (AFP) - Malaysia prepared to seed clouds after air quality in parts of the country reached unhealthy levels due to smog from forest fires in neighbouring Indonesia, an official said Monday.   Smog regularly blankets parts of Southeast Asia during the dry season when burning is used to clear Indonesian land for palm oil, paper plantations and other crops, sparking ire from regional neighbours.   In the latest outbreak, parts of Malaysia's eastern state of Sarawak on Borneo island have been blanketed over the past few days.

The pollutant index in some places has reached "very unhealthy levels", said Gary Theseira, special functions officer with the environment ministry.   "It is extremely severe in Kuching," Theseira told AFP, referring to a city of half a million people.   He said Malaysia is prepared to carry out cloud seeding to induce rain in an effort to ease the smog.   "The moment the cloud situation is right, the chemicals will be loaded and the aircraft will take off and proceed with the seeding," he said.

Some countries conduct seeding during prolonged dry spells to induce rain and clear the air by releasing certain chemicals into the clouds, although some experts have questioned its efficacy.   Boo Siang Voon, a 47 year-old engineer in Kuching described the skies as "hazy, hot with smoky smell".   "This year the smog is getting worse. Residents are using face masks. We should not pay the price of our health for the open burning. We want a solution," he told AFP.   The Malaysian capital Kuala Lumpur and neighbouring Singapore were also experiencing hazy conditions on Monday, with the air laced with the smell of burning foliage, although the pollutant index remained at moderate levels.   Some Kuala Lumpur residents complained about eye and throat irritation.

Malaysia's meteorological department Sunday warned that hot conditions will prevail for another week, and the monsoon season is only expected to arrive at the end of September or early October.   The ministry of science, technology and innovation on Friday said it would lodge a complaint with Indonesia for the haze and called for quick action to be taken to put out the fires.   Indonesian authorities have deployed thousands of extra personnel since last month to prevent a repeat of the 2015 fires, which were the worst for two decades and choked the region in haze for weeks.   Under pressure from neighbours, Indonesian leader Joko Widodo last month warned that officials would be sacked if they failed to stamp out forest fires.
Date: Mon, 9 Sep 2019 11:25:29 +0200 (METDST)

Paris, Sept 9, 2019 (AFP) - Some 13,000 passengers, mainly booked on flights to and from Algeria, are still stranded after France's second-largest airline Aigle Azur went into receivership, a senior French official said Monday, adding that several potential buyers had been identified.   The airline, which employs almost 1,200 staff, filed for bankruptcy and suspended flights last week after losses which prompted a shareholder coup that ousted the chief executive.   "Out of 19,000 passengers who found themselves in difficulty at the peak of the crisis, there are still 13,000" who have yet to be repatriated, the secretary of state for transport, Jean-Baptiste Djebbari, told the Le Parisien daily.

He said these included 11,000 passengers booked on flights into and out of Algeria, 600 on Mali flights as well as other destinations ranging from Russia to Lebanon.   Air France chartered two special flights on Saturday and then again on Sunday to help passengers booked on Algeria flights, which flew out one quarter full but were full on the return.   "The hardest moment of the crisis will be over before the end of the week. At least half the passengers (affected) will have been repatriated," Djebbari said.

The airline transported last year some 1.9 million passengers, with destinations in Algeria making up half of its operations that brought in 300 million euros ($329 million) of revenue.   "There needs to be a serious buyer who is capable of offering guarantees for a maximum number of employees. The good news is that many (potential buyers) have expressed interest," said Djebbari.

He said the former chief executive of Air France's subsidiary Hop!, Lionel Guerin, was among interested parties, backed by a team of aviation professionals with financial support.   He added that Air France itself also appeared interested in making an offer.    "This shows there is still an interest in Aigle Azur," he added. Neither party has so far publicly confirmed an interest, with Air France declining to comment on an "evolving" situation.

According to union officials, Air France could be interested in the medium-haul routes to Algeria and the Dubreuil group, the majority shareholder in Air Caraibes, the long haul routes to destinations like Brazil and Mali.   The largest shareholder in Aigle Azur is the Chinese conglomerate HNA Group, which owns Hainan Airlines, with a 49-percent stake.    David Neeleman, an American airline entrepreneur whose companies include JetBlue and TAP Air Portugal, owns 32 percent, and French businessman Gerard Houa owns 19 percent.
Date: Mon, 9 Sep 2019 10:34:22 +0200 (METDST)
By Roland JACKSON

London, Sept 9, 2019 (AFP) - British Airways on Monday cancelled almost all flights departing and arriving into the UK, as the airline's first-ever pilots' strike began, sparking travel chaos for tens of thousands of passengers.   The industrial action over pay on Monday and Tuesday by members of the British Airline Pilots Association (BALPA) trade union follows around nine months of failed talks.   On the first day of the strike, some 145,000 passengers are facing cancelled international and domestic flights mainly at London's Gatwick and Heathrow airports.

The carrier, owned by London-listed International Airlines Group (IAG) and which operates about 850 flights per day in Britain, said it had no option but to cancel nearly all scheduled flights.   "Unfortunately, with no detail from BALPA on which pilots would strike, we had no way of predicting how many would come to work or which aircraft they are qualified to fly, so we had no option but to cancel nearly 100 percent of our flights," British Airways said in a statement.   The airline stressed that it remained willing to return to talks but the union -- which is seeking a bigger share of company profits -- accuses BA for not wanting to negotiate.

- Customer frustration -
"We understand the frustration and disruption BALPA's strike action has caused our customers," BA added.    "After many months of trying to resolve the pay dispute, we are extremely sorry that it has come to this."    BA and its 4,300 pilots have been locked in a long-running pay dispute that could disrupt the travel plans of nearly 300,000 people in total over the two days.

Pilots are also threatening to strike for one more day on September 27 -- and then possibly again closer to the winter holidays -- should the dispute drag on.   BALPA has rejected a pay increase of 11.5 percent over three years that the airline proposed in July.   BA says the offer would see flight captains receive "world-class" pay and benefits of around £200,000 ($246,000 or 220,000 euros) a year.   The airline pointed out also that two other unions representing 90 percent of the airlines' workers have accepted the 11.5-percent raise.   BALPA counters that co-pilots' salaries average around £70,000 -- and that of junior ones drops down to just £26,000.   This leaves some in heavy debt since they must first undergo training that the BBC estimates costs around £100,000.

- BA 'not budging' -
BALPA boss Brian Strutton also apologised for the travel chaos -- but defended the historic industrial action and blamed the company for failing to negotiate.   "We are very sorry for all the disruption that's been caused by the industrial action," he told BBC Radio 4.   "I think British Airways took the decision some weeks ago that they would close down the airline operation and it's up to them to do things that way.   "They could have made alternative plans. That's caused a lot of disruption for passengers," Strutton added.   The union had sought a profit-sharing scheme that would apply to all BA employees -- but Strutton said BA had "point blank refused" to consider the proposal.   BALPA pointed to a nearly 10-percent jump in pre-tax profits reported by BA-parent IAG last year.   "What the pilots have asked for is to have a share of the success of British Airways," Strutton said.   "We are prepared to negotiate. We are prepared to move on our position, but so far British Airways has said to me: 'We are not going to budge'. And that's the problem."
Date: Sun, 8 Sep 2019 14:18:07 +0200 (METDST)

Seoul, Sept 8, 2019 (AFP) - North Korean state media said Sunday five people had been killed in a powerful typhoon that destroyed farmland and damaged hundreds of buildings.   Typhoon Lingling, called Typhoon-13 in North Korea, hit the reclusive nuclear-armed state on Saturday afternoon, reported the official KCNA news service.

The impoverished and isolated country is vulnerable to natural disasters, especially floods, due in part to deforestation and poor infrastructure.   "According to data available from the State Emergency Disaster Committee, five persons were dead and three persons injured. The injured persons are now under treatment at hospitals," KCNA said.   More than 460 houses and at least a dozen public buildings were "completely or partly destroyed or inundated" by the typhoon, it said.

Crops were wiped out or damaged in 46,000 hectares (110,000 acres) of farmland -- roughly the area of the small European country of Andorra -- the report said, adding that recovery efforts were underway.   It came after South Korea's disaster agency reported three deaths caused by the same typhoon, according to Yonhap news agency.   On Saturday, KCNA reported that North Korean leader Kim Jong Un had berated officials for their "easygoing" attitude to the approaching storm.   According to that dispatch, Kim had convened an emergency meeting on Friday and said "dangerous circumstances" caused by the typhoon were "imminent", but that many in positions of authority were ill-prepared.
Date: Sat, 7 Sep 2019 03:40:09 +0200 (METDST)
By Ashraf KHAN

Karachi, Sept 7, 2019 (AFP) - Swarms of flies are descending on Pakistan's commercial capital in what residents say are record numbers this rainy season, adding to the misery of Karachi's monsoon "hell".   Heavy rains have inundated the sprawling port city of nearly 20 million people for weeks, overwhelming shoddy drainage systems clogged with mountains of uncollected garbage and flooding neighbourhoods with raw sewage.    "I have never seen such a fierce presence of flies in my life," Karachi resident Abdul Aziz, 45, told AFP.    "Clouds of flies keep covering the food at the market. It's repulsive -- they cover the fruit so much that you can't see beneath them."

At a market in Surjani town, meat trader Zahid Ali looked on as flies engulfed the area.    "If the customers come, they impulsively leave after seeing the swarms of flies," said Ali, adding that an increasing number of people working in the market had fallen ill.    Shershah Syed, a health rights activist and prominent surgeon in Karachi, said many illnesses were on the rise because of flies and mosquitoes.   "This time (the flies are) the worst ever as rain water is unable to drain and the garbage heaps are not dealt with," Syed said.    "The number of children entering hospitals for diarrhea or dysentery has jumped several fold this year. The number of children -- who are the most vulnerable to the fly-borne diseases -- has increased by about 10 times."

While Karachi is responsible for 60 percent of Pakistan's economic output, the city has long endured creaky infrastructure, illegal construction and failing municipal services.    This week, the Economist Intelligence Unit ranked Karachi as one of the least liveable cities in the world along with the likes of war-torn Libya's Tripoli and the crisis-hit Venezuelan capital Caracas.    "People in Karachi are numb to the idea of living with medical waste, overflowing gutters, broken down roads, and a complete lack of any kind of respectable public transport system," wrote Saadat Ali Zia on Twitter.    "We live in hell," tweeted Farooq Afridi.
Date: Thu, 5 Sep 2019 13:22:33 +0200 (METDST)

Mumbai, Sept 5, 2019 (AFP) - A six-year-old boy was among four people killed after severe flooding hit India's financial hub Mumbai, resulting in dozens of cancelled or delayed flights, officials said Thursday.   Mumbai -- home to 20 million people -- has been hit by torrential downpours over the past two months amid the annual monsoon deluge.   Non-stop rain over several hours on Wednesday paralysed traffic, halted trains and delayed airport operations at the western city.   "We recovered a six-year-old boy Abubakar's body from the drains after yesterday's flooding," Mumbai police official Shashikant Awghade told AFP on Thursday.   Awghade said the child fell into a drain during the deluge on Wednesday. His parents searched for him through the night, but his body was only found by police early Thursday.

Two municipal officers died after "falling in rainwater" and another man drowned in a river on Wednesday, the city's disaster management cell spokesman Tanaji Kamble told AFP.   Residents spoke of being trapped in traffic for several hours amid chaotic scenes.   "It was a nightmare and the entire city came to a standstill," chartered accountant Kevin Gogri told AFP.    Maharashtra state government minister Ashish Shelar said schools would be closed on Thursday "as a precautionary measure".   Many office workers stayed at home amid warnings of heavy rain from the meteorological department, although conditions eased later in the day.
Date: Fri 6 Aug 2019 3:20 PM IST
Source: News 18 [edited]

A 14-year-old girl from Pangasinan province in the northern Philippines died of the mosquito-borne disease, Japanese encephalitis (JE). It is the 1st such fatality in the province. According to a PhilStar report, the girl was hospitalised for several days for suspected dengue at a Dagupan hospital, before succumbing to it.

Health officials in Pangasinan are working with officials in Tarlac, where the girl studied, to see if other students are infected as well.

Japanese encephalitis is a mosquito-borne viral disease and is the leading cause of viral encephalitis (inflammation of the brain) in Asia. Children are more prone to this vector-borne disease.

According to the Philippines Department of Health, one in in every 250 infected with the JE virus succumb due to severe illness. The onset is characterised by flu-like symptoms (sudden onset of high fever, chills, headache, and tiredness). Disease may rapidly progress to severe encephalitis (infection of the brain). At this stage, the patient may experience symptoms such as mental disturbances and progressive decline in consciousness to coma.

More than half of those who are diagnosed with JE show serious residual neurologic, psychosocial, intellectual, and/or physical disabilities such as paralysis, recurrent seizures, or inability to speak. The Japanese encephalitis virus is transmitted by _Culex_ mosquitoes that breed in water pools and flooded rice fields. People who live close to rice fields and pig farms are more prone to fall prey to this vector-borne disease.

The Philippines is endemic for Japanese encephalitis, with a number of cases tested positive in every region in the country. According to the data by the Department of Health (DoH) Epidemiology Bureau, Japanese encephalitis virus is the cause of encephalitis in 15 percent of all cases of acute encephalitis. DoH recorded 122 lab confirmed Japanese encephalitis cases in 2016, while 275 cases were reported in 2017. The year 2018 witnessed 340 confirmed cases of Japanese encephalitis cases, with Region III reporting the highest number of cases (110), followed by Regions I and II.
===================
[Pangasinan province is on the west side of Luzon Island. Cases of Japanese encephalitis (JE) occur sporadically in various parts of the Philippines, including Luzon Island. This is the 1st report of JE on Luzon this year (2019). The report above does not mention if the localities where the 14 year old student had been were in ecological situations where Japanese encephalitis virus might be transmitted, with abundant populations of _Culex_ vector mosquitoes. Ardeid water bird hosts such as herons and pigs serve as amplifying hosts. Presumably, the girl had not been vaccinated against Japanese encephalitis. - ProMED Mod.TY]

[Maps of Philippines: <https://goo.gl/vVg7ht> and
Date: Sat 7 Sep 2019
Source: Outbreak News Today [edited]

Blastomycosis is a fungal infection usually acquired by breathing in the spores of the fungi, _Blastomyces dermatitidis_ or _Blastomyces gilchristii_.  In Minnesota from 1999-2018, 671 laboratory-confirmed cases of human blastomycosis were reported. Officials note that each year, a median of 34 cases of blastomycosis are reported in Minnesota. Recently these numbers have increased; in 2018, 58 cases were reported, more than any single year during this time frame.

In Minnesota, about 1/3 of cases live and are diagnosed in a different county than where they were exposed to _Blastomyces_. While most people are exposed in northern counties, or those along the Mississippi or St. Croix rivers, people can be exposed to _Blastomyces_ in many counties across the state.  Approximately 10% of cases die of blastomycosis.  _Blastomyces dermatitidis_ can be found throughout the world but is most common in parts of North, Central, and South America. In the United States, the fungus is endemic in the Southeast and the Midwest.

The time between exposure to the spores and when symptoms develop varies widely, ranging from 21-100 days. About 50% of infections are asymptomatic (no symptoms). When symptoms of blastomycosis are present, they may include fever, cough, cough with blood, shortness of breath, muscle aches, bone pain, back pain, chest pain, fatigue, weight loss, chills and/or night sweats, and skin sores.
======================
[The following is extracted from my moderator comments in ProMED-mail post Blastomycosis - USA: (WI) tubing, RFI

"Blastomycosis is a potentially fatal infection caused by the soil-based dimorphic fungi _Blastomyces dermatitidis_ [or Blastomyces gilchristii_], which exist in the environment at ambient temperature as a mold and in the animal host at body temperature as a yeast. The fungus likely resides in moist soil with decomposing organic debris. It appears that only under quite specific conditions of humidity, temperature, and nutrition can the fungus grow and produce the infecting spores. The spores become airborne when soil in which the fungus is growing is disturbed. Fungal spores may be inhaled and initiate an acute or chronic lung infection, which, if untreated, may disseminate to the skin, bone, joints, urinary tract, prostate, and brain. The incubation period can range from 3 weeks to 3 months, but many infected people remain asymptomatic.

"The diagnosis of blastomycosis is based on isolation of _Blastomyces dermatitidis_ from specimens obtained from sputum, skin, or tissue biopsy (growth of organisms in cultures may take at least 4 weeks), or the demonstration of characteristic broad-based budding yeast cells by direct microscopic examination of wet unstained clinical specimens, cytology preparations, or histopathology slides. PCR-based assays may also be available to detect DNA of _B. dermatitidis_ in cultures or clinical specimens (<http://jcm.asm.org/content/50/5/1783.full>). The drug itraconazole is used to treat mild or moderate disease, and amphotericin B is used for patients with central nervous system involvement, patients who are severely immunocompromised, or patients who do not respond to itraconazole therapy (<https://academic.oup.com/cid/article/46/12/1801/296953>). Blastomycosis more commonly affects people involved with outdoor activities, in proximity to waterways (<http://www.cdc.gov/Mmwr/PDF/wk/mm4528.pdf>), and the symptoms may be more severe in people with a weakened immune system.

"The infection is endemic throughout much of the Midwestern USA, including the area on both the Canadian and US sides of the Great Lakes and the St Lawrence River valley. Most cases are sporadic, but clusters of cases have occurred in a close geographic area within a short period of time."

Although blastomycosis is not nationally notifiable in the US, it is now reportable in 5 US states: Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin (<https://www.cdc.gov/fungal/fungal-disease-reporting-table.html>). According to the CDC, in states where blastomycosis is reportable, yearly incidence rates are approximately 1-2 cases per 100,000 population, but Wisconsin may have the highest incidence of blastomycosis of any state, with yearly rates ranging from 10-40 cases per 100 000 persons in some northern counties (<https://www.cdc.gov/fungal/diseases/blastomycosis/statistics.html>). Although most cases are sporadic, outbreaks do occur; a large blastomycosis outbreak occurred in 2015 that involved 89 confirmed and suspected cases and was linked to rafting on the Little Wolf River in southeast Marathon County and Waupaca counties of Wisconsin (<https://en.wikipedia.org/wiki/Little_Wolf_River>). See the "See Also's" below.

The reasons for the recent increase in cases in Minnesota are not stated in the news report above but could include increased reporting, an increase in high-risk activities, an increase in exposure of certain segments of the population that are more susceptible to blastomycosis, and a change in climate that favors proliferation of this fungus in the environment. - ProMED Mod.ML]

[HealthMap/ProMED-mail map:
Minnesota, United States: <http://healthmap.org/promed/p/354>]