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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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Thailand



*****
Travel in Health in Thailand
*****
General Introduction:
Irish travellers are going to Thailand in great numbers. The relatively cheap cost and also the contrast in culture has captured many hearts. Some are travelli
g for a once off 2 week trip and for others the exploration of Thailand will take longer. It is truly a beautiful country and the people have a charm all of their own but nevertheless your journey can be so very easily ruined by taking health risks.
Water-Borne Disease:
In most of the major cities of Thailand the water supply is well chlorinated and so the risks associated with drinking mains tap water are limited. However many of the bedrooms will not be supplied with mains water so take care. Smell the water and if there is a distinct chlorine odour then it should be safe. Also remember that when you travel around the country, especially around the northern regions, the water supply may be grossly contaminated and so never drink the water or use it for brushing your teeth. Also no ice in your drinks under these circumstances.
Food-Borne Disease:
There is a good selection of food in Thailand and you should have no great difficulty in finding food to suit your taste. In the majority of the restaurants the food is well cooked and maintained in a healthy sterile fashion. These are the places to eat. As you walk around the cities you will see many street traders selling food stuffs from their carts. The level of hygiene is very low and frequently the food will be contaminated. Never indulge yourself by eating from street vendors.
Mosquito-Borne Disease:
Under this title most travellers will only consider the possibility of developing malaria. This is of course one of the most important illnesses transmitted via mosquitoes but by no means the only one in Thailand. For most travellers to Thailand there will be no need to take malarial prophylaxis as the cities are deemed to be free of malaria. This does not mean that you will not be bitten by mosquitoes and develop some of the other diseases such as Dengue Fever or perhaps Japanese Encephalitis. Many travellers also develop a very severe reaction to the mosquito bite and so for all these reasons it is prudent to avoid being bitten whenever possible.
Entertainment-Borne Disease:
It would be wrong not to emphasize the very high risk which travellers face if they are unwise enough to indulge in any form of sexual activity in Thailand. The percentage of street girls with the Aids virus is rising each year and is now thought to be over 80%. This figure may be an underestimate. Be especially careful if you have taken any alcohol. The cities of Bangkok and Pattaya are thought to be among the main centres of HIV transmission throughout the world and within the next few years the extent of the Aids problem in S.E. Asia will have exceeded Africa. There is limited availability of condoms.
Road-Borne Disease:
The traffic situation in Thailand is severe. The motorbikes have no insurance as they are too often involved in accidents. Use only regular taxi cabs and fix your price before you leave.
Vaccination Schedule:
There are no compulsory vaccines for entry into Thailand from Ireland. Nevertheless the usual recommended vaccines include Polio, Typhoid, Tetanus and Hepatitis A cover. For those trekking or staying for longer periods then cover against Hepatitis B and Rabies would be worth discussing.
Most travellers should start their vaccines about 4 to 5 weeks before they leave Ireland.
Note:
For the vast majority of Irish travellers a holiday in Thailand will be a time of great pleasure and, later, fond memories of the people, their customs and the countryside. Just remember that illness can occur so follow some good common sense rules and so you can enjoy yourself
and Travel in Health.

Thailand

Travel News Headlines WORLD NEWS

Date: Tue, 18 Jun 2019 06:14:38 +0200

Mae Sai, Thailand, June 18, 2019 (AFP) - Tourists snap selfies by a bronze statue of the diver who died trying to save the 'Wild Boars' football team from a flooded cave, while momentos from their rescue fly off the shelves -- scooped up by the 1.3 million people who have descended on a once serene mountainside in northern Thailand.   "It's amazing what happened here. I followed everything from Australia," tourist John McGowan told AFP after taking photos at the visitor centre around 100 metres from the Tham Luang cave entrance.   "I wanted to see it with my own eyes," the 60-year-old said, adding he was a little disappointed the cave is still off limits to visitors.

For a few dollars tourists can get framed photos at the site, pick up posters of the footballers and take home a souvenir t-shirt  -- some printed with the face of Saman Gunan the Thai diver who died in the bid to save the group.   There has been extraordinary global interest in the picturesque rural backwater of Mae Sai since 12 youngsters -- aged between 11 and 16 -- and their coach entered the Tham Luang cave on June 23, 2018.   They quickly became trapped by rising water levels and the daring, unprecedented mission to extract them through twisting flooded passageways captivated the world for 18 nail-biting days.   When they emerged -- after being heavily sedated and manoeuvered out by expert divers -- they did so into the centre of a global media frenzy.

The cave, which previously received around 5,000 visitors a year, has since been inundated by visitors both Thai and foreign.   "A miracle has happened here with these children," Singaporean tourist Cheong, giving one name, said but adding Tham Luang "must still have a spiritual side" despite the mass popularity.   - Tragedy and luck -   Mae Sai district, where the cave is located, was considered off the beaten track for foreign visitors.    But between October 2018 and April this year alone "1.3 million people visited," site manager Kawee Prasomphol told AFP.

The government now has big plans for the area around the storied cave, Kawee added, allocating a total of 50 million baht ($1.6 million) including a shopping complex, restaurants, hotels and several campsites outside the national park.   Vans disgorge streams of tourists who explore a visitor hub where the centrepiece is a mural entitled "The Heroes".   It depicts the young footballers, stars of the rescue, and junta chief Prayut Chan-O-Cha -- a reminder of the governmental fingerprints in aiding their cause.   At the heart of the mural is the beaming face of Saman Gunan, the Thai Navy SEAL diver who ran out off oxygen attempting to establish an air line to the children and their coach -- the only fatality across the near three-week rescue mission.

Laying white flowers at the foot of his bronze statue, Thai nurse Sumalee, who travelled four hours to the site, described him as "the hero of the whole country" in a sobering reminder of the risks involved in the rescue amid the blizzard of marketing opportunities now attached to the cave story.    Nearby lottery ticket vendors are capitalising on the perceived good fortune linked to the boys' survival and the folkloric appeal of a nearby shrine. The number of stalls has mushroomed from a few dozen to around 250.    Kraingkrai Kamsuwan, 60, who moved his stall to the site weeks after the rescue, sells 4,000 tickets a month ($2.5) but reckons more will visitors will arrive once the cave reopens.    He told AFP: "People want to gamble after wishing for luck from the shrine."
Date: Fri 24 May 2019
Source: CGTN [edited]

Syphilis has become a serious public health concern in Thailand. An alarming rise in syphilis cases in the country underscores the need for a public health education campaign. But it's a topic rarely discussed freely in Thailand, where sexual dialogue is received with embarrassment, mockery or laughter in sex education classes.

According to the Thai Health Ministry, the average age of the 1st sexual encounter of Thais has fallen to 13-15 years old. Fifty percent report to have not used a condom. Teens are becoming complacent about sexually transmitted infections. Syphilis in Thailand has now reached alarming rates, and about 37% of new infections recorded last year [2018] were found among those aged between 15 and 24 [years old].

We asked a group of 18-year-old students what they knew about syphilis and were met with shaking heads, faces of confusion and blank stares. They can be forgiven for not knowing much about syphilis. It is, after all, considered to be a practically ancient ailment. But its incidence has been rising almost every year for the past 10 years in Thailand from 2 to 3 cases to now 12 people out of 100,000 who have been infected. That's almost a 300% increase.

Unfortunately, this trend is also seen around the world. Cases in Japan have hit a 50-year high. Western Europe saw increases of over 50% in new cases, while the US saw a 73% increase of infection rates from 2013 to 2017.

Rossaphorn Kittiyaowamarn, a medical doctor at Bangrak STI [sexually transmitted infection] Clinic in Bangkok, believes that this is because "having sexual relationships now is a lot easier." In a conservative country like Thailand, she continues, "people used to go and pay for sexual services. Now, society has changed and encounters can happen everywhere and are becoming more casual."

The disease is curable with antibiotics, but it's a bit of a secret agent, transmissible through almost all sexual means and erupting as a tiny lesion about a month after exposure. At various stages of the infection, it might cause no symptoms or a puzzling array of them. If gone undiagnosed, it can cause everything from disfigurement to seizures.

Mond* happens to be one of the unlucky ones. He came to Bangrak STI Clinic in Bangkok as rashes started to appear. His tests came back positive for syphilis, a disease he knew nothing about. "I've never heard about this disease. I only just found out about this on the posters on the wall while I was waiting for the doctor."

But that is essentially the problem. Today, syphilis has somewhat been forgotten. And that is what makes it so dangerous. Because after all, it hasn't disappeared. London today, Tokyo or Bangkok tomorrow and a different bedmate at each stopover. And with that, the chance of getting infected with syphilis increases as containment becomes virtually impossible.

*Name has been changed to protect identity.  [Byline: Dusita Saokaew]
==========================
[The rising incidence of syphilis and other sexually transmitted diseases (STDs) is an international issue. The reasons for the increase in incidence of STDs are varied and likely differ by locality and the patient population affected. Increased diagnostic testing for STDs could contribute to some extent to the increased incidence in some groups, such as men who have sex with men (MSM). Some of the factors that could promote unprotected sex include lack of sex education and access to condoms for teenagers; the opioid epidemic and sale of sex for drugs; the popularity of cell phone geolocating dating apps that facilitate sexual activity with multiple anonymous partners; use of Internet chat rooms to meet sex partners; use of psychoactive "party drugs"; and use among MSM of pre-exposure HIV prophylaxis, or PrEP, which is a way to prevent HIV infection for people who do not have HIV but who are at substantial risk of getting it by engaging in risky condomless sexual activity (<https://www.cdc.gov/hiv/pdf/PrEP_fact_sheet_final.pdf>).

The news report above says that about 37% of new infections recorded last year [2018] were found among those aged 15 to 24 years old. Syphilis and other sexually transmitted infections in this age-group in Thailand are being attributed to a lack of education about STDs and the necessity of safer sexual practices to prevent these diseases. STDs in teenagers and young adults has been similarly attributed to lack of education in the US (see ProMED-mail post Syphilis, gonococcal disease, chlamydia: USA, Argentina http://promedmail.org/post/20170507.5019549), where the CDC reports that in the years 2013 and 2017 -- the latest year for which data are available -- about 23% to 25% of new primary and secondary syphilis infections occurred in those aged 15 to 24 years old (Table 34, <https://www.cdc.gov/std/stats17/tables/34.htm>). - ProMED Mod.ML]

[HealthMap/ProMED-mail map:
Date: Sun 19 May 2019
Source: Nation Multimedia [edited]

As many as 249 babies were born with syphilis in Thailand this year [2019], according to the Public Health Ministry. "The babies were affected because their mothers were infected," the ministry's permanent secretary, Dr Sukhum Karnchanapimai, said yesterday [18 May 2019].

Sukhum said that between 1 Jan and 13 May 2019, 3080 people of all ages were diagnosed with syphilis. Of them, 40.42 per cent are between 15 and 24 years old. Some 24.48 per cent of others are between 25 and 34 years old. "The number of syphilis patients is rising. The increase reflects that many teenagers and people in the reproductive age group have engaged in unsafe sex," he said.

Sukhum said he has instructed provincial public-health chiefs to closely monitor the situation and to prevent the disease from spreading. He urged people to protect themselves by using condoms, refraining from having several sex partners, and regularly undergoing blood tests. "Pregnant women, along with their husbands, should take blood tests too," he said.
=====================
[Thailand was said to have eliminated congenital syphilis by the WHO just a few years ago (2016) (See Sidibe M, Singh PK below.) Thailand thus joins the countries that now report a rise in incidence of congenital syphilis. In the U.S., for example, after syphilis reached historic lows in 2000, with less than 6000 reported cases and an incidence rate of only 2.1 cases per 100 000 people, the United States has since experienced a rising incidence of primary and secondary (P&S) syphilis (<https://www.cdc.gov/std/sam/2017syphilis.htm>). Initially, during 2000-2015, the rise in the rate of reported P&S syphilis in the US was primarily attributable to increased cases among men, specifically among gay, bisexual, and other men who have sex with men (MSM). More recently, syphilis also increased among women. For example, during 2014-2015, the rate increased 18.1 percent among men, but increased 27.3 percent among women  (<http://www.loopcayman.com/content/syphilis-cases-increase-1>).

These increases among women are of particular concern because congenital syphilis cases tend to increase as the rates of primary and secondary syphilis increase among women  (<https://www.cdc.gov/std/stats16/figures/44.htm>).

Transmission of _Treponema pallidum_, the organism that causes of syphilis, to the fetus occurs via the bloodstream when the foetus is exposed in utero to a mother with untreated early syphilis. Transmission may also occur during delivery if maternal genital lesions are present. Late abortion, stillbirth, and neonatal death may result from congenital infection in untreated pregnancies. Among survivors, manifestations that develop in the 1st 2 years of life are called "early" and are similar to adult secondary syphilis; manifestations that develop after age 2 years are called "late" and include tooth abnormalities (Hutchinson teeth), bone changes (saber shins), "Clutton's joints" (bilateral painless swelling of the knee joints), neurological involvement, blindness, and deafness.

We are not told in the news report above about the factors responsible for the changing epidemiology of syphilis in Thailand, which could account for their increasing incidence of congenital syphilis. In the U.S. and Canada, the recent increasing incidence of syphilis in heterosexual men and women has been linked to illicit drug use, which is reminiscent of the increase in syphilis among heterosexuals during the crack cocaine epidemic of the 1980s and 1990s, when the practice of trading sex with multiple partners for drugs, especially crack cocaine, played a major role in the transmission of syphilis. Under these circumstances, the identities of sex partners are often unknown, which weakens the traditional syphilis-control strategy of partner notification.

Control of congenital syphilis is achieved by antenatal screening and treatment of mothers who are infected. Routine serologic screening should be done at the 1st prenatal visit in all pregnant women and in communities and populations in which the risk for congenital syphilis is high; serologic testing and a sexual history also should be obtained at 28 weeks gestation and at delivery. Groups at high risk include uninsured women, women living in poverty, sex workers, illicit drug users, women diagnosed with sexually transmitted diseases, and those living in communities with high syphilis morbidity (<http://www.ahrq.gov/clinic/uspstf09/syphilis/syphpgsum.htm>). No mother or neonate should leave the hospital without maternal serologic status having been documented at least once during pregnancy and, if the mother is considered high risk, also at delivery.

Reference:
Sidibe M, Singh PK. Thailand eliminates mother-to-child transmission of HIV and syphilis. The Lancet 2016: 387(10037);2488-2489, June 9, 2016 DOI: <https://doi.org/10.1016/S0140-6736(16)30787-5>. - ProMED Mod.ML]

[HealthMap/ProMED map available at:
Date: Thu, 9 May 2019 10:07:07 +0200

Bangkok, May 9, 2019 (AFP) - The closure of the glittering Thai bay made famous by the movie "The Beach" has been extended for another two years to allow a full recovery of its corals and wildlife, an official said Thursday, drawing a sharp rebuke from the tourism industry.    Maya Bay, ringed by cliffs on Ko Phi Phi Ley island and surrounded by azure waters, was made famous when it featured in the 2000 film starring Leonardo Dicaprio.    It was shut last June by Thai authorities due to worries the white-sand paradise was suffering from the pressure of thousands of day-trippers arriving by boat. 

Authorities had initially said the beach -- a massive draw for Thailand's more than 38 million tourists -- was going to be closed for four months, but the re-opening was repeatedly postponed.    Thon Thamrongnawasawat, advisor to the Department of National Parks, told AFP on Thursday the ban on visitors will be extended until mid-2021.   "The resolution of the Department of Parks yesterday is to extend the closure of Maya Bay for another two years to allow its ecology to fully recover," he said.    After it is re-opened, measures such as limiting the number of daily visitors and banning boats from parking within the bay's waters will be enacted, Thon said.

Before Maya Bay's closure, up to 5,000 tourists visited daily, causing trees and smaller vegetation to be uprooted, creeping soil erosion, and severe damage to the corals in the bay.    A majority of the visitors were ferried there from tourist hotspot Krabi province by local longtail boatmen or tour operators who touted the movie-famous bay as a key attraction for day trips.    "Maya Bay is the heart of our tourism," said Wattana Rerngsamut, chairman of Krabi Provincial Tourism Association which represents some 200 tourism and hotel operators.    Calling the two-year extension "unfair", Wattana said the Department of National Parks should conduct public hearings so they can find "common ground... so that local people can earn a living".   Chinese visitors, making up a quarter of Thailand's tourists, have "plunged 50 percent (in Krabi)", he added.

Thailand experienced a three-month slowdown in tourism last year, most noticeably since July when a ferry sank and killed 47 Chinese visitors off nearby Phuket.    Since the tragedy, the government has rolled out inducements aimed at regaining trust and making travel easier -- including exempting Chinese visitors from paying a visa-on-arrival fee.    Less than a year after its closure, blacktip reef sharks have been sighted swimming in Maya Bay, with conservationists saying their return signals signs of a recovery to the ecology.
Date: Tue 30 Apr 2019
Source: Outbreak News Today [edited]
<http://outbreaknewstoday.com/diphtheria-cases-thailand-86317/>

The Thailand Department of Disease Control (DDC) with the Ministry of Public Health (MOPH) reports a diphtheria incidence rate that is 2 times higher than the same period of last year (2018) and also the median of the past 5 years (2014­2018). Through [27 Apr 2019], there had been 9 confirmed diphtheria cases of which 2 died. The patients were found in 6 provinces including Uttaradit, Tak, Suratthani, Sonkhla, Satun, and Yala.

The highest incidence rates occurred among infants and young children less than 5 years old, followed by the 10­19 years age group. Officials say there is a continued risk of sporadic diphtheria in crowded places such as child day-care centres and boarding schools especially in some areas with low diphtheria vaccination coverage.

Diphtheria is an acute bacterial infection of respiratory system, which can cause mild to severe illness. Symptoms develop 2­5 days after infection and include fever, sore throat, and swollen lymph glands in the neck. Severe illness presents with swollen neck and thick grey or white patches of dead tissue in the throat and tonsils caused by the bacterial toxin. Complications are blocking of the airway and absorption of the toxin into the blood stream that may cause damage to the heart, kidneys, and peripheral nerves and thus can lead to death. The severely ill patient must visit a hospital for special medical care immediately to save life.

Diphtheria is spread from person to person, usually through respiratory droplets, from coughing, sneezing, and close contact. A person can also become infected by contact with shared utensils contaminated with the bacteria. Some mild cases can transmit the bacteria to people around them. Recovered patients might not develop immunity against the disease. The best way to prevent diphtheria is to get vaccinated. The DDC therefore advises parents to bring their children to get the complete vaccination series against diphtheria (DTP [diphtheria, tetanus, pertussis] vaccine) as per the MOPH recommended immunization schedule. Pregnant women should also get the dT vaccine as per the schedule.
===========================
[Thailand implemented a routine infant immunization program in 1977, with 2 doses of diphtheria-tetanus toxoids-whole cell pertussis (DTP) vaccine recommended for all infants; in 1982, the recommendation was changed to 3 doses of DTP vaccine for infants; in 1992, the schedule was modified to 5 doses of DTP vaccine at ages 2, 4, 6, and 18 months and 4-6 years; a dose of tetanus and diphtheria toxoids (Td) was recommended at ages 12-16 years (<https://academic.oup.com/jid/article/184/8/1035/807141>).

The number of diphtheria cases initially dropped dramatically after the introduction of the vaccine. However, after reporting cases in the single digits for many years, the number of cases reported more recently jumped. For example, 63 people in Thailand had diphtheria in 2013 and 16 people had the disease in 2014 (<http://outbreaknewstoday.com/thailand-to-begin-diphtheria-vaccination-campaign-27989/>).

A diphtheria vaccine coverage rate of 80-85 percent is thought to be necessary to stop transmission (<http://www.who.int/immunization/sage/meetings/2017/april/2_Review_Diphtheria_results_April2017_final_clean.pdf>). In Thailand, 99% of the infant population is said to have received 3 doses of diphtheria-tetanus toxoid and pertussis vaccine in 2017 (<https://www.who.int/immunization/monitoring_surveillance/data/tha.pdf>).

However, although vaccination rates may be this high in Thailand as a whole, vaccination rates may be much lower in some communities where sporadic diphtheria cases occur. Most complications of diphtheria, including death, are attributable to effects of the toxin. The toxin, when absorbed, affects organs and tissues distant from the site of invasion. The most frequent complications of diphtheria are myocarditis and neuritis, and focal necrosis of liver and kidneys.

Myocarditis may present as abnormal cardiac rhythms and can occur early in the course of the illness or weeks later and can lead to heart failure. Neuritis most often affects motor nerves and usually resolves completely. Paralysis of the soft palate, eye muscles, limbs, and diaphragm can occur. Secondary pneumonia and respiratory failure may result from diaphragmatic paralysis.

Other complications include otitis media and respiratory insufficiency due to airway obstruction, especially in infants. However, _Corynebacterium diphtheriae_ infective endocarditis is mostly due to non-toxigenic strains (<https://www.sciencedirect.com/science/article/pii/S1201971211000920> and <https://www.ncbi.nlm.nih.gov/pubmed/21641260>). - ProMED Mod.ML]

[Maps of Thailand: < http://en.wikipedia.org/wiki/Provinces_of_Thailand>
and <http://healthmap.org/promed/p/151>]
More ...

World Travel News Headlines

Date: Fri, 16 Aug 2019 03:38:45 +0200 (METDST)
By Paulina ABRAMOVICH

Santiago, Aug 16, 2019 (AFP) - Once deep in powder this time of year, Chile's ski stations are fighting the ravages of climate change and pollution that have brought less and less snow to the central Andes.   Just a few decades ago, the Andes mountain range could be buried under four meters of snow, forcing the closure of access roads and requiring the use of tractors to get around.

But this year, it's snowed only three times in the Chilean Andes, and never more than 30 centimetres.   It's not just Chile affected, but the whole of the Andes where the area of snow cover in the central zone has diminished by five to 10 percent each decade, according to Raul Cordero, an academic at the University of Santiago.   "But it's not just snow cover that's decreasing, the thickness of the snow cover is also reducing," he said.   "So when we talk about a decrease of the cover of five to 10 percent, this probably signifies a much greater reduction in the volume of available snow over the Andes."

Rising temperatures mean the snow line -- above which snow never melts all year round -- keeps creeping upwards.   The snow melt is even more pronounced in the central zone due to pollution from the Chilean capital, one of the most contaminated urban areas in the region.   A recent study led by Cordero found that soot, or black carbon, from Santiago was settling in the Andes and accelerating the snow melt.   As it's black, it absorbs more solar radiation and heats up quicker.   "When this pollution is over the cities it poisons people and when the wind blows, this pollution goes and is deposited on the mountains and contributes to the snow melt," said Cordero.

- Essential snow cannons -
The upshot is that Chile's ski stations have had a difficult season.    But thanks to the snow cannons, the erection of fences and a tailored piste management policy, the resorts have managed to stay open throughout a winter in which there has been almost no snow.   "All the ski centers in the central zone are without natural snow. However, thanks to the fabrication of snow we've been able to keep open pistes that without this fabrication would not have been able to stay open," Fernando Montenegro, the operations director at Andacor, which operates the El Colorado and Parque Farellones ski stations, told AFP.

El Colorado is 50 kilometers from Santiago and sits at 2,800-meters. It pumps out snow whenever the conditions allow it.   Low temperatures and high humidity is what's needed for the snow cannons to chug into gear and churn out snowflakes from water.   This technology has been around since 1994, but it's never before been in use as much as it is now -- and even then the ski station is only operating at 70 percent capacity.   But even if the situation gets worse, the ski stations will manage, according to Montenegro.   "There's no risk. However, we need to manage the snow and manage the water in the mountain range in a good way."   El Colorado has already invested almost $4 million in buying snow cannons and hopes to increase that to $10 million over the coming years.

- 'Variety so important' -
Last weekend, some 7,000 people descended on El Colorado where ski and snowboard national teams come to train -- although, they're not necessarily happy.   "If there's not enough snow, there's not as many hills. We don't get the variety, we don't get steepness, (or) different slopes: it's so important for us to have that variety," Megan Farrell, a member of the Canadian snowboard team, told AFP.   Amateur skiers also noticed the difference from previous years.   "You can see that the snow is harder. It's not very deep, there are a lot of stones and snow made by the cannons, which makes it feel like you're skiing on a different type of snow," said Chilean Rado Milosevic, 24.
Date: Thu, 15 Aug 2019 20:21:28 +0200 (METDST)

Tokyo, Aug 15, 2019 (AFP) - A powerful tropical storm lashed Japan on Thursday, bringing strong winds and torrential rain that claimed at least one life, prompted warnings of landslides and flooding, and sparked evacuation advisories and travel chaos at a peak holiday period.   Severe Tropical Storm Krosa -- one notch below a typhoon -- slammed into the southern Hiroshima region, packing wind gusts of up to 126 kilometres (78 miles) per hour.   Dramatic television footage showed violent winds uprooting trees, snapping lampposts and spinning pods on a Ferris wheel.

Meanwhile, high waves smashed into a breakwater, engulfing a 10-metre lighthouse, while swollen rivers broke their banks and swamped nearby roads.  Authorities issued a voluntary evacuation advisory to around 430,000 people in the storm's path, although few appeared to have heeded the warning.

A 82-year-old man was confirmed dead after he fell in the sea in Hiroshima while trying to moor his boat, a local government spokesman said.    Japanese news agency Kyodo reported that a total of 49 people were injured from Wednesday to Thursday.   "We still have intermittent downpours," said Takayoshi Sugimoto, a disaster management official in the southwestern province of Tokushima.   "We will remain vigilant," he told AFP.

The national disaster management agency said a party of 18 people, including children, were stranded during a barbeque in a valley when a river rose rapidly on Wednesday. They were rescued Thursday morning.   Krosa also sparked travel chaos as people battled to return to major cities following the Obon holiday.   More than 800 domestic flights were cancelled to and from cities in western Japan, and bullet train services were either scrapped or sharply reduced.   Ferries connecting the southern Shikoku island and other parts of Japan were also cancelled as high waves lashed the coast.

The storm brought strong winds and downpours to the capital Tokyo.   Several ceremonies commemorating the end of World War II were cancelled in western Japan due to bad weather.    Krosa weakened significantly from earlier in the week as it stalled in the Pacific Ocean but it boasts an unusually large eye, meaning it is likely to dump rain over a wide area.   It was moving north at 35 kilometres (22 miles) per hour and the rain was expected to last for an extended period.   The storm crossed Japan's mainland and hit the Sea of Japan late Thursday.
Date: Thu, 15 Aug 2019 15:36:40 +0200 (METDST)

Tripoli, Aug 15, 2019 (AFP) - Flights at the Libyan capital's sole functioning airport were suspended Thursday after deadly overnight rocket fire, a spokesman for the country's unity government said.   Wednesday night's rocket fire "killed a guard and wounded several security agents tasked with protecting the airport," said Moustafa al-Mejii, spokesman for the Tripoli-based Government of National Accord (GNA).   He blamed the attack on "the militias of (Khalifa) Haftar" whose forces launched an offensive on the Libyan capital in April.   Arrivals and departures at Mitiga airport were suspended as a result, Mejii said.   Located east of Tripoli, Mitiga is a former military airbase that has been used by civilian traffic since Tripoli international airport suffered severe damage during fighting in 2014.

Mitiga is in a zone under the control of forces loyal to the GNA and has often been targeted, leading to repeated suspensions of flights.   United Nations envoy Ghassan Salame, in a report to the UN Security Council last month, urged "authorities in Tripoli to cease using the (Mitiga) airport for military purposes and for the attacking forces to halt immediately their targeting of it."   The GNA protested at what it said were "untruths" in the envoy's report.   Haftar's self-styled Libyan National Army (LNA) has encountered fierce resistance from pro-government forces in the battle for Tripoli.   A stalemate on the ground in the capital's southern outskirts has led to a greater reliance on air strikes by both sides.

The fighting since April has killed 1,093 people and wounded 5,752 others, according to the World Health Organization.   More than 120,000 people have been displaced.   The LNA said Thursday its air force carried out a strike against an airfield in Zuwara, a town west of Tripoli, and destroyed two hangars allegedly used to house Turkish drones.   "The runway and terminals were spared" at the airfield, which is not open to commercial flights, LNA spokesman General Ahmed al-Mesmari wrote on Facebook.   The GNA, however, posted pictures of a huge crater and debris on the tarmac.   Libya has been mired in chaos since a NATO-backed uprising that toppled and killed dictator Moamer Kadhafi in 2011.
Date: Thu, 15 Aug 2019 14:11:31 +0200 (METDST)

Hong Kong, Aug 15, 2019 (AFP) - Hong Kong's government unveiled HK$19.1 billion (US$2.44 billion) worth of economic relief measures and downgraded its growth forecasts on Thursday as the international hub reels from simmering pro-democracy protests and the US-China trade war.   Last week city leader Carrie Lam warned that 10-weeks of anti-government protests were hitting businesses like a "tsunami".    On Thursday, financial chief Paul Chan predicted the city's economy would grow by a miserly zero to one percent this year, the worst rate since 2009 after the global crash hit.

But as he announced a raft of sweeteners in a surprise "mini-budget", he denied the move was linked to the roiling unrest.   "The measures that we have just announced... trying to tackle the current economic difficulties and the coming economic headwinds, is not related to the political difficulties that we are facing," Chan told reporters.   Instead, he said, the primary headwinds remained ongoing trade tensions between Washington and Beijing -- two major markets for Hong Kong -- and the possible impact of Brexit.    "Based on the latest developments and assessments on the outlook, the Hong Kong economy will continue to face an austere environment for the rest of the year," he said.

Nonetheless, the sweeteners seemed to be aimed at winning over support from moderate Hong Kongers as the city reels from the protests.    The measures included financial breaks for small businesses, more generous student subsidies and goodies for low-income households.  Ten weeks of unprecedented rallies, demonstrations and occupations in Hong Kong have seen millions of people take to the streets in the biggest challenge to China's rule of the semi-autonomous city since its 1997 handover from Britain.   The social and political unrest was triggered by a controversial bill which would have allowed extraditions to mainland China, but has evolved into a call for wider democratic reforms and a halt to sliding freedoms.

The retail and tourism sectors have been especially hit by the drop in arriving visitors to the city, but the property market remains strong.   At a "citizens press conference" on Thursday, one protest group blamed the city's economic woes on the local leaders who they accused of undermining the city's business appeal by kowtowing to Beijing.
Date: Thu, 15 Aug 2019 11:07:44 +0200 (METDST)

Johannesburg, Aug 15, 2019 (AFP) - South Africa on Thursday announced visa waivers for four countries in a bid to boost tourism amid an economic crisis and falling visitor numbers.   Visitors from Qatar, Saudi Arabia, United Arab Emirates and New Zealand will no longer require a visa to visit for holiday, conferencing and business purposes, Home Affairs Minister Dr Aaron Motsoaledi said.

The unilateral decision comes as official tourism figures released in May reflected a dip in the overall number of visitors to South Africa from Europe and the Middle East in the first financial quarter of the year, normally one of the most popular times to visit.   Foreign traveller arrivals decreased by more than 10 percent between April and May 2019 alone.   Motsoaledi said the South African government was engaging with Qatar, Saudi Arabia, United Arab Emirates and New Zealand about a similar relaxation of entry requirements for SA citizens.   He argued the move by his department would boost tourism "and by extension growing the economy and creating jobs".

South Africa's economy has hit trouble, with gross domestic product (GDP) contracting by 3.2 percent in the first three months of 2019 and unemployment at a record high of 29 percent.   The government estimates there is potential to create 2.1 million jobs in the tourism sector by 2028.   South Africa is in talks to extend the visa waiver to Ghana, Cuba and Principe and Sao Tome.    The country has already waived the visa requirement for 82 of the 193 countries who are UN members.
Date: Tue 13 Aug 2019, 18:22 PM
Source: The News Minute (TNM) [edited]

In early July [2019], 2 children from Sathyamangalam in Tamil Nadu's Erode district succumbed to diphtheria. Around this time, several other cases of diphtheria were being reported from the state. The latest information shows that at least 50 people have been admitted to the Coimbatore Medical College and Hospital with diphtheria.

Health officials in the state have begun stepping up measures to ensure that the spread of the disease is contained and that more people are vaccinated. The Directorate of Public Health (DPH) even issued an alert to doctors in Chennai to treat all children presenting with sore throat with an antibiotic used to treat the disease, without waiting for the confirmation of a diagnosis.

Despite several campaigns to raise awareness about the importance of vaccination and ensuring that children are vaccinated according to the immunisation schedule, officials note that discrepancies in immunisation have played a large role in the current outbreak of diphtheria.

Tamil Nadu's Deputy Director of Public Health, Dr. K Kolandaswamy, had earlier told TNM that the current spike in the number of cases had to do with lack of immunisation. While several parents had skipped vaccinating their children at a young age, many others had not ensured that the booster dose was taken at a later age. However, in light of the recent outbreak in which both young people and adults have been affected, preventive measures have been stepped up. Not only are children being given the vaccine and booster doses (as deemed necessary), but so are adults.

Diphtheria is a disease caused by the organism _Corynebacterium diphtheriae_ and is highly contagious. Symptoms of diphtheria are often very similar to that of a common cold or any mild respiratory infection, which makes it difficult to differentiate between diphtheria and a more generic infection.

An infected individual may begin to present with symptoms anywhere from 2 to 10 days after exposure to the bacteria. The infected person usually develops a sore throat, which aggravates and will generally develop other respiratory issues as well, if left untreated. While the treatment for diphtheria consists of antibiotics and supportive measures as necessary (painkillers, fluids, etc), it has been determined that the best course of action is to take preventive measures.

The vaccine against diphtheria is given as a pentavalent vaccine (offers immunisation against 5 diseases: diphtheria, pertussis, tetanus, hepatitis B and Hib-Haemophilus influenza type b). It is given at 1.5, 2.5 and 3.5 months of age. The DPT vaccine (trivalent, covers 3 diseases: diphtheria, pertussis and tetanus) is given between 16 to 24 months of age. When the child is around 6 years old, another booster dose is required. In addition, the Centre has also advised that children be given the Td vaccine (covers tetanus and diphtheria) at age 10 and age 15.  [Byline: Dr Nimeshika Jayachandran]
========================
[Erode, with a population of about 2.25 million residents in 2011, is the largest district in the Indian state of Tamil Nadu, located in the state's westernmost region; its headquarters is the city of Erode (<https://en.wikipedia.org/wiki/Erode_district>).

A map showing the location of Erode District in south-central India can be found at
<https://www.google.com/maps/place/Erode,+Tamil+Nadu,+India>.

Diphtheria is caused by toxin-producing strains of _Corynebacterium diphtheriae_, an aerobic Gram positive bacillus. _C. diphtheriae_ causes respiratory tract or cutaneous diphtheria. Toxin production occurs only when the bacillus is infected (lysogenized) by a specific bacteriophage that carries the gene encoding the toxin. The most common sites of diphtheria infection are the pharynx and the tonsils, where an adherent pseudomembrane forms, which may result in respiratory obstruction. The toxin is responsible for the major complications, myocarditis (such as cardiac arrhythmias and heart failure) and neuritis (such as paralysis of the soft palate, eye muscles, limbs, and diaphragm). The overall case fatality rate for diphtheria is 5-10% but is higher (up to 20%) among persons younger than 5 and older than 40 years of age.

Close contacts, especially household contacts, should receive a diphtheria booster, appropriate for age, and antibiotics, such as benzathine penicillin G or a 7-10-day course of oral erythromycin. - ProMED Mod.ML]

[HealthMap/ProMED-mail map of India:
Date: Tue 13 Aug 2019 2:21 AM CDT
Source: MPR [Minnesota Public Radio] News [edited]

[Minnesota] state health officials said [Tue 13 Aug 2019], 3 children are sick from _E. coli_ bacteria after swimming in a Minneapolis lake. The children have tested positive for the same strain of _E. coli_ after swimming at Lake Nokomis beaches between [26 Jul and 2 Aug 2019]. 2 beaches of the lake are closed until further notice, the Minnesota Department of Health said. The children, all under the age of 10, were not hospitalized.

Minneapolis Park Board Superintendent Al Bangoura said it's the 1st time someone has fallen ill after swimming in a Minneapolis lake in more than 20 years. "We take this very seriously and are working closely with the Minnesota Department of Health as they conduct their investigation," Bangoura said in a news release.

Symptoms of illness caused by _E. coli_ bacteria include stomach cramps and diarrhea, with mild or no fever. People typically become ill 1 to 8 days after exposure. It's rare, but the infections sometimes lead to a serious complication involving kidney failure. Health officials say children younger than 10 years old, the elderly, and those with weakened immune systems have a higher chance of developing complications from _E. coli_ infections.

"This is also an important reminder that anyone who is experiencing diarrhoea should not go swimming while they are sick," said Trisha Robinson, waterborne disease supervisor at the Health Department.

Officials also want to hear from anyone else who may have become ill after swimming in Lake Nokomis.

"If there are other people who have gone swimming and are concerned about their symptoms of illness, we very much encourage them to contact their health care providers," Robinson said.
===================
[It is important to understand that there are many different kinds of _E coli_. The organism is an important component of the human intestinal tract and can perform important functions helpful to its host. These strains can cause human infections if they "escape" from the usual location into the urinary tract, gall bladder, or abdominal cavity. They are also what are mentioned when a beach is closed for _E. coli_ contamination. In this circumstance, officials are measuring the organism or "coliforms" in the water to reflect human sewage contamination.

Additionally, there are some strains of _E. coli_ that can produce toxins that can produce diarrhea, and much of so-called travellers' diarrhoea is caused by these strains. All of these strains are human bacteria, not zoonotic organisms, that is, not spread from animal hosts. One _E. coli_ group called Shiga toxin producing or enterohemorrhagic _E. coli_ (EHEC) is the organism likely to be involved here, are zoonotic. Spread in a number of ways, including via undercooked ground beef, contaminated vegetables, and direct or direct contact with farm animals including contaminated water, EHEC can cause significant disease and even death.

In the spring of 2000, in Walkerton, a town of 5000 in southern Ontario, an outbreak of _E. coli_ O157:H7 infection claimed 7 lives -- 6 adults and a child -- and over 200 were seen at local area hospitals.

Swimming-associated transmission is illustrated in the following references:

1. Keene WE, McAnulty JM, Hoesly FC, et al. A swimming-associated outbreak of hemorrhagic colitis caused by _Escherichia coli_ O157:H7 and _Shigella sonnei_. N Engl J Med. 1994; 331(9): 579-84; available at <http://www.nejm.org/doi/full/10.1056/NEJM199409013310904>.
2. CDC. Lake-associated outbreak of _E. coli_ O157:H7 - Illinois. MMWR 1996; 45(21): 437-9; available at <https://www.cdc.gov/mmwr/preview/mmwrhtml/00042070.htm>.
3. Ackman D, Marks S, Mack P, et al. Swimming-associated hemorrhagic colitis due to _Escherichia coli_ O157:H7 infection: evidence of prolonged contamination of a fresh water lake. Epidemiol Infect. 1997;119:1-8; available at <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2808815/>. - ProMED Mod.LL]

[HealthMap/ProMED-mail map of Minnesota, United States:
Date: 13 Aug 2019
Source: RFI France [edited]

38 children in France, including babies, living near what was once Europe's largest gold mine have tested positive for arsenic poisoning.

Children in the Orbiel Valley, in the southern department of Aude, were examined when families became concerned that flooding in October last year [2018] had carried arsenic and heavy metals from the nearby Salsigne mine.

After testing 103 children aged under 11 years, the Occitanie Regional Health Agency confirmed on Tue [13 Aug 2019] that 38 of them had returned positive test results for above-average levels of arsenic.

Salsigne, the world's largest arsenic mine, had been operating for almost a century when it closed in 2004. Millions of tons of toxic waste, which local NGOs say have not been properly sealed, are in storage at 5 nearby sites.

In October 2018, 14 people were killed when the Aude was hit by violent floods. Media reports say the Orbiel river and its tributaries have spread pollutants from the old mine.  [Byline: Eric Cabanis]
=========================
[There are a number of ways products can enter the body: inhalation, absorption, ingestion, and injection. Absorption is often thought of as products being absorbed through the GI tract, but it is also most significantly through the skin (such as a bath if arsenic is in the water). The integument (skin) is one of the largest organs of the body.

There are different forms of arsenic. There are 2 forms of inorganic arsenic: the reduced or trivalent arsenic (+3) or arsenite, and the oxidized or pentavalent (+5) form known as arsenate. Both of these forms can be absorbed and accumulated in tissues and body fluids.

There are also organic arsenics, but these are generally regarded as less harmful, by orders of magnitude.

Arsenic is a known carcinogen. The article does not tell us whether the exposure was to organic or inorganic arsenic. The form of arsenic is important with regard to toxicity. We are not told the specific ages of the children or babies. However, children, babies, and even pregnant women metabolize arsenic differently than non-pregnant adults.

Exposure to higher than average levels of arsenic occur mostly in the workplace, near hazardous waste sites, or in areas with high natural levels. At high levels, inorganic arsenic can cause death. Exposure to lower levels for a long time can cause a discoloration of the skin and the appearance of small corns or warts. In the United States, arsenic has been found in at least 1149 of the 1684 National Priority List sites identified by the Environmental Protection Agency (EPA).

Arsenic is a naturally occurring element widely distributed in the earth's crust. In the environment, arsenic is combined with oxygen, chlorine, and sulfur to form inorganic arsenic compounds. Arsenic in animals and plants combines with carbon and hydrogen to form organic arsenic compounds.

Inorganic arsenic compounds are mainly used to preserve wood. Copper chromated arsenate (CCA) is used to make "pressure-treated" lumber. CCA is no longer used in the U.S. for residential uses; it is still used in industrial applications. Organic arsenic compounds are used as pesticides, primarily on cotton fields and orchards.

What happens to arsenic when it enters the environment?
- Arsenic occurs naturally in soil and minerals and may enter the air, water, and land from wind-blown dust and may get into water from runoff and leaching.
- Arsenic cannot be destroyed in the environment. It can only change its form.
- Rain and snow remove arsenic dust particles from the air.
- Many common arsenic compounds can dissolve in water. Most of the arsenic in water will ultimately end up in soil or sediment.
- Fish and shellfish can accumulate arsenic; most of this arsenic is in an organic form called arsenobetaine that is much less harmful.

How might I be exposed to arsenic?
- Ingesting small amounts present in your food and water or breathing air containing arsenic.
- Breathing sawdust or burning smoke from wood treated with arsenic.
- Living in areas with unusually high natural levels of arsenic in rock.
- Working in a job that involves arsenic production or use, such as copper or lead smelting, wood treating, or pesticide application.

How can arsenic affect my health?
Breathing high levels of inorganic arsenic can give you a sore throat or irritated lungs.

Ingesting very high levels of arsenic can result in death. Exposure to lower levels can cause nausea and vomiting, decreased production of red and white blood cells, abnormal heart rhythm, damage to blood vessels, and a sensation of "pins and needles" in hands and feet.

Ingesting or breathing low levels of inorganic arsenic for a long time can cause a darkening of the skin and the appearance of small "corns" or "warts" on the palms, soles, and torso. Skin contact with inorganic arsenic may cause redness and swelling.

Almost nothing is known regarding health effects of organic arsenic compounds in humans. Studies in animals show that some simple organic arsenic compounds are less toxic than inorganic forms. Ingestion of methyl and dimethyl compounds can cause diarrhea and damage to the kidneys.

Several studies have shown that ingestion of inorganic arsenic can increase the risk of skin cancer and cancer in the liver, bladder, and lungs. Inhalation of inorganic arsenic can cause increased risk of lung cancer. The Department of Health and Human Services (DHHS) and the EPA have determined that inorganic arsenic is a known human carcinogen. The International Agency for Research on Cancer (IARC) has determined that inorganic arsenic is carcinogenic to humans.

There is some evidence that long-term exposure to arsenic in children may result in lower IQ scores. There is also some evidence that exposure to arsenic in the womb and early childhood may increase mortality in young adults.

There is some evidence that inhaled or ingested arsenic can injure pregnant women or their unborn babies, although the studies are not definitive. Studies in animals show that large doses of arsenic that cause illness in pregnant females, can also cause low birth weight, fetal malformations, and even fetal death. Arsenic can cross the placenta and has been found in fetal tissues. Arsenic is found at low levels in breast milk.

How can families reduce their risk for exposure to arsenic?
- If you use arsenic-treated wood in home projects, you should wear dust masks, gloves, and protective clothing to decrease exposure to sawdust.
- If you live in an area with high levels of arsenic in water or soil, you should use cleaner sources of water and limit contact with soil. - If you work in a job that may expose you to arsenic, be aware that you may carry arsenic home on your clothing, skin, hair, or tools. Be sure to shower and change clothes before going home.

There are tests available to measure arsenic in your blood, urine, hair, and fingernails. The urine test is the most reliable test for arsenic exposure within the last few days. Tests on hair and fingernails can measure exposure to high levels of arsenic over the past 6-12 months. These tests can determine if you have been exposed to above-average levels of arsenic. They cannot predict whether the arsenic levels in your body will affect your health.

The EPA has set limits on the amount of arsenic that industrial sources can release to the environment and has restricted or cancelled many of the uses of arsenic in pesticides. EPA has set a limit of 0.01 parts per million (ppm) for arsenic in drinking water.

The Occupational Safety and Health Administration (OSHA) has set a permissible exposure limit (PEL) of 10 micrograms of arsenic per cubic meter of workplace air (10 ug/m3) for 8 hour shifts and 40 hour work weeks.

Reference:
Agency for Toxic Substances and Disease Registry (ATSDR). 2007. Toxicological Profile for Arsenic (Update). Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service.

Portions extracted from Agency for Toxic Substance and Disease Registry;
<https://www.atsdr.cdc.gov/toxfaqs/tf.asp?id=19&tid=3>. - ProMED Mod.TG]

[HealthMap/ProMED map available at:
Date: Sat 10 Aug 2019
Source: Nigeria CDC [edited]

The Nigeria Centre for Disease Control (NCDC) is aware of a suspected outbreak of yellow fever in Ebonyi state and has had a rapid response team supporting Ebonyi state's response since [Tue 30 Jul 2019], in partnership with the World Health Organization (WHO).

Following a report of cases and deaths from fever of unknown origin in Izzi local government area (LGA) in Ebonyi state, the state public health team commenced an investigation. As at [Wed 31 Jul 2019], 3 cases had tested positive for yellow fever at NCDC's national reference laboratory, which triggered an immediate response.

The Ebonyi State Epidemiology Team is leading the response with support from the Nigeria Centre for Disease Control (NCDC), the National Primary Health Care Development Agency (NPHCDA), and the World Health Organisation (WHO). In the course of investigation, it was discovered that between 1 May-7 Aug 2019, there had been cases that fit into the case definition for yellow fever and 20 deaths in Izzi LGA, Ebonyi state, indicating that the outbreak may have been going on for a few months, undetected by local health authorities. It was too late to collect samples for confirmation from these cases.

Immediately [after] it was notified, NCDC deployed a rapid response team to support Ebonyi state with contact tracing, case finding, risk communications, and the management of cases. Detailed analysis and plans are in advanced stages to apply to the international vaccine stockpile to enable a reactive vaccination campaign in Ebonyi state, in response to the cluster of cases.

Yellow fever virus is spread through bites of an infected mosquito. There is no human-to-human transmission of the virus. Yellow fever is a completely vaccine-preventable disease, and a single shot provides immunity for a lifetime. The yellow fever vaccine is available for free in primary health care centres in Nigeria as part of the routine immunisation schedule. Every child is protected for life if vaccinated. We encourage every family to ensure that children receive all their childhood vaccines.

In addition to the vaccine, the public is advised to keep their environments clean and free of stagnant water to discourage the breeding of mosquitoes and to use insecticide-treated mosquito nets as well as screens on windows and doors to prevent mosquito bites. It is important to avoid self-medication. Visit a health facility immediately if you feel ill.

Since September 2017, Nigeria has recorded suspected cases of yellow fever in all states in the country. As at [Wed 31 Jul 2019], 78 cases have been laboratory confirmed in Nigeria in 2019 alone. A multi-agency yellow fever technical working group coordinated by NCDC has been leading the investigation and response to yellow fever cases. The National Primary Health Care [Development] Agency is leading efforts to provide an additional opportunity of vaccination through preventive vaccination campaigns across the country.

Healthcare workers are reminded that the symptoms of yellow fever include yellowness of the eyes, sudden fever, headache, and body pain. If you have these symptoms or notice someone in your community displaying them, please contact your nearest health centre.
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[The yellow fever [YF] virus is endemic in Nigeria, and cases occur there sporadically. This has been an active year (2019) for YF in Nigeria. The previous ProMED-mail post indicated that 930 suspected cases have been reported this year from 1 Jan-30 Apr 2019. There are 332 suspected cases during the April 2019 reporting period, up from 254 suspected cases on 19 Feb 2019. There are 3 new presumptive and 3 new confirmed yellow fever cases during the April 2019 reporting period.

The current focus of transmission is in Ebonyi state. The above report indicates that YF vaccine is available without cost in primary healthcare centers but does not mention if an organized vaccination campaign is underway or being planned, nor the proportion of the Ebonyi state population that is unvaccinated and, hence, at risk for YF. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Ebonyi state, Nigeria: <http://healthmap.org/promed/p/1306>]
Source: Arutz Sheva 7 [edited]
Date: Tue 13 Aug 2019

A stewardess of Israel's El Al airline died Tuesday [13 Aug 2019], following a months-long battle with measles. The 43-year-old stewardess was infected with the measles virus during a flight from New York to Israel 5 months ago.

After she was infected, the stewardess was hospitalized in serious condition at Meir Medical Center in Kfar Saba in central Israel after she was found unconscious and struggling to breathe. During her hospitalization, the stewardess' condition deteriorated, and she was transferred to the quarantine section of the hospital's intensive care wing.

On Tuesday [13 Aug 2019], doctors at Meir hospital declared her death, following the 5-month struggle.  [Byline: Orly Harari]
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[This is a very sad outcome, and our condolences go out to the family of the flight attendant, who worked for El Al, the Israeli national airline. It is not clear whether she contracted the virus in New York, in Israel, or on a flight between the two locations. The flight attendant received only one dose of the measles vaccine when she was a child. It wasn't discovered until later that one dose is only about 93% effective. More recently -- in the USA, starting in 1989 -- children have been given 2 doses, which is about 97% effective, according to the CDC. See Measles update (27) http://promedmail.org/post/20190418.6429834 for an earlier report on the flight attendant. - ProMED Mod.LK]