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Israel

General Information:
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The Middle East is a favourite destination for many Irish holiday makers. The combination of a beautiful climate linked with such historical richness is hard to beat. Unfortunately the
security situation throughout the region has led to some significant concerns over the years. Nevertheless, in the vast majority of cases those visiting the region will not encounter any particular concerns in this regard. It is a wise precaution to ensure that your passport is valid for at least a further six months beyond the time of your holiday as otherwise you may be refused entry.
Security Situation:
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Security throughout the Middle East is generally tight. Carry some means of identification at all times in case you are requested to produce it by police or army personnel. In Jerusalem the city has been divided and it is sensible to remember which quarter you are in at all times.
Health Facilities:
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Generally the health facilities throughout the region are excellent. However, when visiting certain rural regions you may find it difficult to obtain hospital care similar to that at home. In Israel, travellers can find information in English about emergency medical facilities and after-hours pharmacies in the "Jerusalem Post" and English language "Ha'aretz" newspapers.
Food & Water Facilities:
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Again, this depends on your location and the facilities which are there at the time of the year you visit. Bottled water is easily available and food hygiene is usually excellent throughout all the main tourist destinations. However, it is generally wiser not to drink hotel tap water and only to use it for brushing your teeth if there is a clear smell of chlorine. When on organised trips tourists are sometimes offered local tea or other drinks. Generally this will be safe as the water is boiled but take care that the cup hygiene is acceptable.
Sun Exposure:
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The climatic conditions in the Middle East vary considerably throughout the year. Many tourists visit in late autumn or early spring. At these times the climate is much cooler and the evenings can be distinctly chilly. However, during the main tourist season (May to September) the temperatures rise high into the 80’s or 90’s and dehydration can easily occur. Increasing fluid and salt intake is important under these circumstances. It is essential that travellers are aware of the climatic conditions which should be present for their trip and that sensible clothing is used at all times.
Rabies:
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Tourists should avoid all animals as this viral disease is transmitted through the bite, lick or scratch of any infected warm blooded animal. In Israel the most common animals involved are foxes and jackals and in Jordan, dogs tend to be the main culprits.
Exploring the Region:
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Leaving the main tourist routes is unwise. There are a number of security risks which have to be considered and there are also significant health concerns which may be encountered. In July 2000 an 18 year old American tourist died of sunstroke when she became separated from her group in the Dead Sea region of Israel. Those exploring caves and parts of the desert areas also run the risk of diseases like Borreliosis and Rabies.
Walking & Trekking:
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For many going to these countries their trip will involve visiting some of the major ruins and archeological sites. This will involve a good deal of walking and trekking. Good supporting foot wear is essential and it would be wise to carry a crepe bandage in case of a sprained ankle. Having a suitable painkiller or anti-inflammatory medication would also be advantageous. Check your health will be up to the journey.
Swimming:
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Pools are usually very well maintained and the risk of disease is small. Those swimming in the sea should remember that the Mediterranean is home to many jelly fish. Swim with others and never alone and especially after alcohol or a heavy meal.
Anthrax:
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This bacterial disease is rare in the Middle east though travellers should be aware that it can be transmitted through unprepared leather goods usually bought in the local market places. Typically the disease may then present with a black ulcerated skin lesion.

Malaria:
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Fortunately this disease does not occur in Israel or Jordan. However other mosquito and sandfly diseases do occur and so protection against their bites should be used when necessary.
Hepatitis:
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There are many forms of this disease but the most common is Hepatitis A, often known as Infectious Jaundice. This disease can keep an infected individual off work for many weeks and it is wise to consider vaccination cover before exposure. In Israel approx 65% of the population will have been infected before 18 years of age.
Vaccinations:
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There are no essential vaccines for entry/exit however most Irish tourists are recommended to receive cover against; Poliomyelitis, Typhoid, Tetanus and Hepatitis A. Those living in these countries or planning an extended trip should also consider cover against Hepatitis B and Rabies.
Summary:
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Due to the unrest within Israel there are concerns regarding the safety of tourists at this time. If you are travelling to this region it is wise to ensure that your insurance policy is sufficient if your circumstances or travel plans change.

Travel News Headlines WORLD NEWS

Date: Sat 27 Feb 2016
Source: Hachaklait Clinical Veterinary Services, head veterinarian's weekly report No 34/2018 [in Hebrew, trans. & summ. ProMED Mod.AS, edited]
<http://www.hachaklait.org.il> [subscription required]

The regional veterinary office [in Rosh-Pinna, a unit of Israel's State Veterinary Field Services] has begun sampling of sera from cattle herds on the Golan Heights, for serological surveillance addressing leptospirosis. Preliminary results are indicative of high infection rate in the Yehudiya beef herd. Vaccination against leptospirosis in this herd has commenced.
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[Since 2011, vaccination of Israel's beef cattle herds against leptospirosis has been privatized. During the 5 years preceding 2011, namely 2006-2010, the mean annual number of beef cattle vaccinations, in the Upper Galilee and the Golan heights, as performed by the State Veterinary Service (VSAH) personnel, was around 4000 (about 25 percent of the total beef cattle population in the region).The (killed) vaccine used was monovalent _L. hardjo_.

Following the privatization, no data on cattle vaccinations against leptospirosis have become anymore available. Leptpspirosis in animals is a notifiable disease in Israel. It is not included in OIE's list.

After the 2011 privatization, a considerable part of cattle vaccinations, previously performed by State personnel, has been taken over by the practitioners of 'Hachaklait' cooperative for clinical veterinary services.

In response to ProMED-mail's request we received from Hachaklait's Head veterinarian, Dr Gabi Kenigswald, the following information:

"The 1st beef cattle herd indicated by VSAH to be vaccinated is the round 1100-head herd in Yehudiya (map at <https://tinyurl.com/ya3d6rlr>), which was found extensively infected by serological tests and some clinical signs (abortions). The applied (killed) vaccine is pentavalent, including the leptospira serovars pomona, hardjo, grippotyphosa, canicola and icterohaemorrhagiae. All ages are to be vaccinated. Though booster vaccination is not prescribed by the producer, such vaccination, 6-8 weeks after the initial vaccination, is being considered. The entire herd is planned to undergo a single annual vaccination each future year, while young calves are to be vaccinated at the age of 6 and 12 weeks. Similar vaccination regime is to be soon undertaken in another beef herd in the region, in Gonen, where abortions have been recorded. Vaccination of additional herds in the Golan will be applied if/when permitted by the VSAH."

According to the Ministry of Health, as cited by YNet News on [Mon 27 Aug 2018], 42 people have so far been diagnosed with leptospirosis while 462 presented symptoms of the disease. Swimming is still prohibited in the following parks: Zaki Stream, Yehudiya, Meshushim stream, the Majrasa estuary, the Jilabun Stream, the Arik Bridge in the Jordan River, and the Abukayak site  (<https://www.ynetnews.com/articles/0,7340,L-5335802,00.html>).

While _L. Pomona_ remains the main suspect of the event, final identification of the serovar involved by the investigating national reference laboratory at Ness Ziona is yet to be completed/published.

For additional information on an earlier (2017) _L. pomona_ event in Israel's cattle and its background, please refer to post

The identity of the serovar, as well as the results of the serosurveillance currently performed by the Field Veterinary Services and the Kimron Veterinary Institute in grazing beef cattle in the affected region, are anticipated as soon as completed. - ProMed Mod.AS]

[HealthMap/ProMED map available at:
Date: Thu 23 Aug 2018
Source: The Times of Israel [summ., edited]

Environmental Protection minister Zeev Elkin announced on Thursday [23 Aug 2018] a plan to curb leishmaniasis, which has spread in Israel in the past 2 years. Elkin's office said that sandflies, which transmit the disease to humans, get the virus [sic] by stinging rock hyraxes who carry it.

Therefore, according to Hadashot [TV News], the ministry was dropping the hyrax from the list of protected animals for 3 years to enable authorities to decrease their numbers and contain the disease, which doesn't have a vaccine.

The Nature and Parks Authority and some in the Environmental Protection Ministry were said to have opposed the move, fearing the harm done to the animal would be too severe.  [Byline: Michael Bachner]
==================
[For the leishmaniasis page of Israel's Ministry of Environmental Protection, including information and pictures of rock hyraxes (_Procavia capensis_), which serve as reservoir hosts for _Leishmania tropica_, one of the 2 causative agents of cutaneous leishmaniasis in Israel, please see <http://www.sviva.gov.il/English/env_topics/Pest%20Control/Pages/Sand-Fly-and-Leishmania.aspx>. Rock hyraxes are found in rocky areas of Judea, Samaria, and the Galilee (map included).

The step undertaken by the ministry, decided upon following further spread of the disease, has caused lively debate in Israel's media and social networks.

For an alternative approach to tackle the hyrax population dynamics, which is currently in early investigation phase, see

A 2008 WHO review of Israel's leishmaniasis situation is available at <http://www.who.int/leishmaniasis/resources/ISRAEL.pdf>. Since 2008, cutaneous and visceral leishmaniasis have increased their spread in the country. - ProMED Mod.AS]

[It is proposed to control the sandfly population by adding piperonyl to feeds for the Rock hyraxes instead of reducing the population of rock hyraxes. This strategy has two concerns: 1. to distribute the piperonyl tainted food pellets to the wild rock hyrax population, and 2. the piperonyl is not in itself an insecticide which kills the sandfly. Piperonyl inhibits enzymes in the sandfly (and mosquitoes) that break down other insecticides, for instance the pyrethroids. Thus piperonyl has little effect if there is no resistance to the pyrethroids. Data are also needed on the blood levels obtained after such haphazard administration (tainted food pellets). - ProMED Mod. EP]

[HealthMap/ProMED-mail map:
Date: Thu 23 Aug 2018 6:28 pm IDT
Source: Times of Israel [edited]

Two Israelis have died in the past few weeks from West Nile fever, the Health Ministry said [Thu 23 Aug 208], amid the biggest outbreak of the mosquito-transmitted disease in recent years.

The ministry said in a statement that 68 cases have been reported -- twice as much as last year [2017] -- and that 14 of the patients were in serious condition.

Two people have died, it added, including an 85-year-old man with what the ministry described as "preexisting health problems."

The 2nd fatality is reportedly a 76-year-old man who died in the Assuta hospital in Ashdod 3 weeks ago. The Health Ministry was criticized [Wed 22 Aug 2018] of failing to report the case, which was revealed by the Kan public broadcaster.

The hospital confirmed the death and said it had been reported to the ministry, which didn't make it known to the public.

An 18-year-old resident of southern Israel who contracted the disease is currently in critical condition, suffering from organ failure and being kept sedated and on a respirator in Beersheba's Soroka Medical Center, reports said on [Wed 22 Aug 2018].

Earlier this week [week of 20 Aug 2018], tests confirmed that mosquitoes carrying the virus were found in coastal areas, including the Menashe Regional Council, Alona regional council, Pardes Hannah, Binyamina, and Caesarea.

The Environmental Protection Ministry warned residents to protect themselves against insect bites and called on the local authorities to spray insecticide in areas where there are large numbers of mosquitoes or larvae.

The peak season for the West Nile fever in Israel is between August and October. The incubation period in humans is 3-15 days.

Symptoms include fever, rash, headache, and, rarely, more serious side-effects such as meningitis could develop.
======================
[This is the 1st report of human cases of WNV from Israel for 2018, with 68 cases reported in the country. A worrisome trend of more intense WNV activity that is also being observed in Europe and Americas. - ProMED Mod.UBA]

[Clinical WNF cases were initially suspected in Israel in 1941; the virus was isolated and identified in 1951, during an extensive outbreak which recurred in 1952-1953. WNF in Israel is seasonal, recurring annually. During 2017, a total of 39 human cases and 3 cases in horses were reported. According to today's (22 Aug 2018) information, the number of human cases this year is about twice the number during the same period in 2017. - ProMED Mod. AS]

[HealthMap/ProMED-mail map of Israel:
Date: Tue 16 Aug 2018 9:56 am IDT
Source: Hamodia [edited]

The Environment Ministry has issued orders to local authorities around the country to act to reduce the mosquito population in their jurisdictions, after mosquitoes infected with West Nile virus were discovered at a number of locations in Israel. The infected mosquitoes were discovered in areas that included Pardes Chana, Caesarea, Binyamina, and the Menashe [Haifa district], Mateh Yehudah [Jerusalem district] and Gezer [Central district] regional councils.

The infected mosquitoes were discovered over the past 2 weeks in routine inspections by the ministry. However, officials said, because the infected mosquitoes were found in distinct geographic regions, it is likely that they are present in other areas. The ministry ordered that pesticides and other materials be sprayed in rural and suburban areas around the country to prevent further spread of the disease.

Dr Uri Shalom of the ministry said that residents should avoid collected water sources in backyards and on the sides of roads, as well as in parks and bomb shelters -- anywhere standing water could harbor mosquito nests. The use of anti mosquito creams and formulas is also encouraged, as is wearing long-sleeved clothing and avoiding shorts. The virus is spread by mosquitoes that have fed on birds and animals infected with West Nile virus, and it is then transmitted to humans when mosquitoes bite them.  [Byline: Dror Halavy]
========================
[West Nile virus (WNV) is endemic in Israel, with 40-160 cases reported annually. One of the primary routes of WNV transmission is via migrating birds and Israel is located on a central migratory path between Africa and Eurasia (Leshem Y, Yom-Tov Y. Routes of migrating soaring birds in Israel. International J Avian Sci. 1998; 140: 41-52). Most West Nile fever (WNF) cases reported in recent years were among residents of the coastal plain (Bassal R, Shohat T, Kaufman Z, et al. The seroprevalence of West Nile Virus in Israel: A nationwide cross sectional study. PLoS One. 2017; 12(6): e0179774. doi: 10.1371/journal.pone.0179774; <https://doi.org/10.1371/journal.pone.0179774>)

Diverse WNV lineages clades and clusters has been isolated from mosquitoes in Israel during the past 15 years and the Mediterranean subtype of WNV lineage 1 has been found to permanently circulate in the region (Lustig Y, Hindiyeh M, Orshan L, et al. Mosquito surveillance for 15 years reveals high genetic diversity among West Nile Viruses in Israel. J Infect Dis. 2016; 213: 1107-14. pmid:26597260; <https://academic.oup.com/jid/article/213/7/1107/2912151>).

A nationwide cross sectional study by Bassal et al, reported high (11.1 percent) seroprevalence of WNV in Israel in 2017 (<https://doi.org/10.1371/journal.pone.0179774>).

As no WNV vaccine is currently available for humans, the most effective way to avoid WNV infections is to raise the awareness of the population on reducing the risk of mosquito bites by using insect repellents, wearing protective clothing, and reducing mosquito breeding sites. At the national level, the mosquito surveillance program can help minimize the transmission of the virus all over Israel, but should focus especially at high risk areas. - ProMed Mod.UBA]

[HealthMap/ProMED-mail map of Israel:
Date: Sat 18 Aug 2018
From: Jacob Moran-Gilad <giladko@post.bgu.ac.il> [edited]

[Leptospirosis outbreak, Golan Heights, Israel]
-----------------------------------------------
The Israeli Ministry of Health [MOH] is currently managing an outbreak of human leptospirosis linked to recreational water exposure in Northern Israel.

The investigation began following reports of several suspected cases who presented to several hospitals across Israel during the weekend of 9-11 Aug 2018, following touristic excursions.

According to current active surveillance data and following public notification, over 250 individuals were identified as suspected cases per MOH case definition, after seeking medical advice for acute febrile illness following travel to the specific locations which are currently defined as possible exposure sites in Northern Israel.

Suspected cases are being evaluated and treated for possible infection at community clinics and hospitals. Of those, 32 cases have been initially confirmed by means of molecular and serological tests performed at the National Reference Laboratory for Leptospirosis. The infecting serovar is expected to be identified over the next days.

The epidemiological investigation suggests recreational exposure to natural water sources over the last weeks in certain locations (recreational natural water sources) in Northern Israel as the common risk factor.

The MOH is conducting an outbreak investigation targeting all suspected cases. Guidance to healthcare professionals on diagnosis, treatment, and reporting of leptospirosis has been issued and guidance concerning prevention of exposure to possible contaminated water sources has been communicated to the public.

Currently, 7 adjacent water sites, have been linked to clusters of suspected and confirmed cases and as a result were closed to the public, including the Jilbon, Majrase, Meshushim, Yarden (Jordan) Park, Yehudiya, Zakhi, and Zavitan. Environmental monitoring of surface water quality has identified varying abnormal levels of faecal coliforms at those sites, suggesting fecal contamination. Molecular testing for presence of pathogenic leptospira is ongoing and has identified at least 2 positive sites, thus substantiating the epidemiological link.

The MOH estimates that the current incident is related to the combination of long-standing drought conditions in the area, seasonally low water levels at the implicated sites and high incidence of leptospirosis in free-ranging cattle or wild boar reported in the area.

The MOH is working with a wide range of stakeholders in Israel as part of the incident management, including the entire healthcare sector, the Nature and Parks Authority, the Ministries of Agriculture and Rural Development and Environmental Protection and the National Water Authority and Mekorot. [Mekorot is the national water company of Israel.]

Leptospirosis is an uncommon illness in Israel with only a handful of autochthonous cases reported annually. This incident constitutes the largest cluster of human leptospirosis ever reported from Israel.
--------------------------------------------
Prof Jacob Moran-Gilad, MD, MPH
The MOH Leptospirosis outbreak management team
=========================
[ProMED-mail thanks Dr Jacob Moran-Gilad and the Israeli Ministry of Health for the current situation report with regard to the leptospirosis outbreak associated with certain recreational water sites in the Golan Heights. Updated data would be welcome as it becomes available.

The Golan Heights has several hiking paths through streams and pools that attract many travellers; 7 such recreational water sites have been linked to the outbreak and as a result are closed to the public, including Jilbon, Majrase, Meshushim, Yarden (Jordan) Park, Yehudiya, Zakhi, and Zavitan:
- Yehudiya Nature Reserve is the largest nature reserve in the Golan Heights (see map at <https://goo.gl/maps/wshPXRS9hDK2>). There are several streams in the reserve including Zavitan and Yehudiya (<http://www.beentheredonethattrips.com/yehudiya-and-zavitan-route-87-golan-heights/>).
- The Jordan River National Park has walking trails that pass by water sources, aqueducts, pools, and sites of archaeological interest, such as the ancient Bethsaida
- Zakhi stream hike is 4 km (2.5 mi) that involves 1.5 km (1 mi) of wading and swimming in streams and lagoons
- The Meshushim Nature Reserve is a small pool in the southwest of the Golan Heights (see map at <https://goo.gl/maps/BXovfW2zom22>). - The Majrase-Beteha (Bet Tsayda Valley) Nature Reserve drains the delta formed by a number of the major streams of the Golan on their way to the Sea of Galilee (TripAdvisor <https://tinyurl.com/ycogrjy8>). - ProMED Mod.ML]

[HealthMap/ProMED-mail map of Israel:
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World Travel News Headlines

Date: Mon, 10 Sep 2018 07:28:56 +0200

Wellington, Sept 10, 2018 (AFP) - A strong 6.9 magnitude earthquake struck New Zealand's remote Kermadec Islands on Wednesday but authorities said there was no tsunami threat.   The quake struck at 4.19pm (0419GMT) at a depth of 111 kilometres (69 miles), with its epicentre 770 kilometres northeast of Auckland, the US Geological Survey said.   "Based on all available data, there is no tsunami threat from this earthquake," the Hawaii-based Pacific Tsunami Warning Center said.   The uninhabited Kermadecs are New Zealand's northernmost islands.   They are part of the Pacific Ring of Fire, a hotbed of volcanic and earthquake activity at the intersection of several tectonic plates.
Date: Mon, 10 Sep 2018 07:17:20 +0200

Tokyo, Sept 10, 2018 (AFP) - The death toll from a powerful earthquake that triggered massive landslides in northern Japan rose to 44 on Monday with tens of thousands of police and troops still on the ground to support survivors.   Chief Cabinet Secretary Yoshihide Suga said no one was left on a missing list, which suggested the figure could be the final death toll.   Around 40,000 police, fire fighters, troops and maritime safety officials were providing assistance, with more than 2,700 people still forced to stay in shelters after the killer quake struck the northern Japanese island of Hokkaido last week.

The majority of the dead are from the small rural town of Atsuma, where a cluster of dwellings were wrecked when a hillside collapsed from the force of the 6.6-magnitude quake, causing deep brown scars in the landscape.   "The government will strive to get hold of what is needed on the ground and take every possible measure so that people can return to a normal, safe life as soon as possible," Suga told a news conference.   He also warned that islanders should remain on alert as rainfall was forecast in the region, which could trigger fresh landslides.

The quake was the latest in a string of natural disasters to batter the island nation.   Western parts of the country are still recovering from the most powerful typhoon to strike Japan in a quarter of a century, which claimed 11 lives and shut down the main regional airport.   Launching a campaign for another term as head of his ruling party, Prime Minister Shinzo Abe reiterated his government will "do its best" to restore the disasters-hit regions.
Date: Mon, 10 Sep 2018 07:13:22 +0200
By Gregory DANEL, Romain FONSEGRIVES

Paris, Sept 10, 2018 (AFP) - Seven people including two British tourists were wounded in Paris late Sunday by a knife-wielding man, a terrifying attack that bystanders tried to stop by throwing petanque balls at the assailant.   Four of the victims were in a critical condition, police said, after the man brandishing a large blade and and iron bar went on the rampage next to a canal in the northeast of the capital.   The suspect is believed to be an Afghan national and has been arrested, said a source close to the enquiry, adding he had targeted "strangers" but that "nothing at this stage shows signs of a terrorist nature".

Chaos erupted on the banks of the Bassin de la Villette, an area popular with locals and visitors who frequent the cafes, cinemas and other cultural venues along its banks, just after 11:00pm (2100 GMT).   Eyewitness Youssef Najah, 28, said he was walking beside the canal when he saw a man running and holding a knife about 25-30 cm (10-11 inches) long.   "There were around 20 people chasing him. They started throwing petanque balls at him," Najah said, referring to the sport popular in France also known as boules.   "Around four or five balls hit him in the head, but they weren't able to stop him," he added.

According to the same witness, the attacker then dived into an alleyway, where the man "tried to hide behind two British tourists. We said to them: 'Watch out, he has a knife". But they didn't react".    The pair were then attacked, he said.   A security guard at one of two cinemas on either side of the water said he had seen the attacker running away from two men who were trying to stop him.   "He had an iron bar in his hand which he threw at the men chasing him, then he took out a knife," he told AFP.   The UK foreign office said it was aware of reports of the attack and was "urgently investigating this incident" in cooperation with French authorities, British media reported.

- High alert -
A police investigation has been launched for attempted murder, according to a judicial source.   It is the latest of several knife attacks France has seen in recent months, with terrorism being ruled out in most cases.   On August 23, a man stabbed his mother and sister to death and seriously injured another person in a town near Paris before being shot dead by police.

The motive for the violence remained unclear despite a claim by the Islamic State (IS) group that it was an attack by one of its fighters responding to the terror organisation's propaganda.   Authorities said the 36-year-old had serious mental health problems and had been on a terror watch list since 2016.   That attack came days after an Afghan asylum-seeker was arrested in town of Perigueux for a drunken rampage with a knife in which four people were wounded, one seriously.   Police said investigators had "very quickly" dismissed a terrorist motive after the August 13 incident.

And on June 17, two people were hurt in another southern town when a woman shouting "Allahu akbar" (God is greatest) attacked them in a supermarket with a boxcutter knife.   France has been on high alert following a string of jihadist attacks in recent years, often by people who have become radicalised or claim to have acted in the name of the IS group.   More than 240 people have been killed by Islamist extremists since a massacre at the Charlie Hebdo satirical magazine in Paris in January 2015.
Date: Mon, 10 Sep 2018 06:41:23 +0200

Miami, Sept 10, 2018 (AFP) - Hurricane Florence is expected to become a dangerous "major hurricane" by late Monday as it heads toward the US East Coast, the National Hurricane Center said, as states of emergency were declared in preparation for the storm.   The center of Florence was located about 685 miles (1,100 kilometres) southeast of Bermuda, the NHC in its 0300 GMT Monday advisory.   Florence had maximum sustained winds of 90 miles per hour, making it a Category 1 storm on the five-level Saffir-Simpson hurricane scale.

The NHC warned that Florence "is forecast to rapidly strengthen to a major hurricane by Monday night, and is expected to remain an extremely dangerous major hurricane through Thursday."   The storm is moving towards the west at seven miles per hour, and is forecast to drench a large swath of the US East Coast running from northern Florida to New Jersey.   On its current track Florence is expected to slam the Carolinas and Virginia the hardest -- and all three states have issued emergency declarations to speed preparations.

Virginia Governor Ralph Northam's office described Florence as possibly the state's "most significant hurricane event in decades," warning of "catastrophic inland flooding, high winds and possible widespread power outages."   It added: "The largest threat to life from hurricanes is not the high winds. Flooding is the deadliest result of these storms."   The US navy has ordered ships at its major base in Hampton Roads, Virginia, base to put to sea, saying "the forecasted destructive winds and tidal surge are too great to keep the ships in port."

- Two more hurricanes -
North Carolina Governor Roy Cooper's office said that Florence is already being felt along the state's coast, with large sea swells resulting in life-threatening rip currents and surf.   "Everyone in North Carolina needs to keep a close eye on Florence and take steps now to get ready for impacts later this week," Cooper said.

The storm "is too powerful and its path is too uncertain to take any chances," South Carolina Governor Henry McMaster said in issuing his state's emergency declaration.   Florence was producing large swells expected to reach from the northern Caribbean to the southern coasts of Canada's Maritime provinces.   At this statistical height of the Atlantic hurricane season, Florence was being trailed on east-to-west paths by two hurricanes, Helene and Issac.   Helene -- currently just southeast of the Cabo Verde islands off the African coast -- had winds of 85 miles per hour, and was expected to turn northwest and then north into the open Atlantic by midweek, the NHC said.

Hurricane Isaac -- which late Sunday became the fifth hurricane of the season -- is heading west towards the Caribbean.   At 0300 GMT Issac was about 1,305 miles east of the Windward Islands -- a region still recovering from last year's powerful Hurricane Maria -- with winds of 75 miles per hour.   Issac is expected to gain strength in the next days, but then weaken by the middle of the week when it approaches the Caribbean.   Maria -- which killed at least 3,057 people, most in Puerto Rico -- is elieved to be the third costliest tropical cyclone on record.
Date: 9 Sep 2018
Source: ProMED-mail promed@promedmail.org

[There has been significant chatter on social media from individuals working in Haiti and their colleagues, friends and family, suggesting there is a "new, as yet undiagnosed outbreak," possibly of a mosquito-borne disease, in the expat and local Haitian communities. Some of the content of this social media chatter is excerpted below [edited for clarity/readability - CopyEd.MSP]. - ProMED Mod.MPP]

"...there is some sort of new mosquito-borne virus in Haiti. Do I know for sure that it is a virus caused by a flying insect? No. Do I have a lot of unqualified and under-documented personal research to back up my belief nonetheless? Yes. If you know a guy or gal at the CDC, tell them to come chat with me. Something is going around, and many people are not well. It is eerily similar to chikungunya and malaria."

"Mayaro virus?"

"I have been saying the same thing! Well, when my fever brain has been capable of putting thoughts together this week. 2014 was ChikV; 2016 was Zika, so it does seem time for a new one. This new one is no fun at all."

"My person is negative for everything, Zika, chikV, malaria, dengue. It started with high fever, aches, joint pain, then progressed to stomach ache, headache. Now it's just persistent joint aches and sharp stabbing pain."

"We have this all over Mirebalais as well. Here, it also seems to be often accompanied by severe lower abdominal pain."

"Yes! My son just asked me if there is another mosquito borne illness yesterday!"

"Several of our girls have been sick with these same symptoms! It's awful."

"We all had it too and are seeing a lot of patients at our clinic with it!"

"I was sick for days before the uprising in July [2018] ... totally felt like malaria but tested negative. My BP was 80/40 at best, and it was pa bon [not good]."

"Yes! I've been sick this week as well as a few others I know! Lots of body pain."

"People thought that I was crazy!"

"You're not crazy! Several cases showing up at the Maternity Center here, and I also think there is influenza A going around. Some cases have respiratory stuff (to me that is the flu/influenza A), and several cases have nothing respiratory but have the fever and aches and terrible headache."
======================
[According to Wikipedia (in an unsubstantiated report without references) "Mirebalais is a commune in the Centre department of Haiti, approximately 60 km northeast of Port-au-Prince on National Road 3. The city was established in 1702. During the United Nations occupation of 2005, Nepalese troops were stationed in the city, using the city jail as their headquarters,"  (<https://en.wikipedia.org/wiki/Mirebalais>).

"Mirebalais is served by the teaching hospital Hopital Universitaire de Mirebalais, the largest solar-operated hospital in the world," a hospital that is run by the US-based Partners in Health,  (<https://www.pih.org/pages/mirebalais>).

>From the sound of the social media chatter, there is an as yet undiagnosed outbreak affecting parts of Haiti. Trying to connect the dots, there is concern that it is malaria-like (fever, chills and headaches), but in those that have been tested for malaria, laboratory results have not supported the diagnosis, and possibly dengue- or chikungunya-like (fever, headache, joint pains) with the addition of complaints of lower abdominal pain (notably described in Mayaro virus disease.

If the symptoms are similar to those of dengue, chikungunya, and Zika virus infections, they need to be ruled out by laboratory testing. There is the possibility that Mayaro virus (MAYV) may be circulating in Haiti. Mayaro virus was isolated from a child with acute febrile illness in rural Haiti. The case report stated that "on 8 Jan 2015, an 8-year-old boy was examined at the school clinic because of fever and abdominal pain. His temperature was 100.4 F [38 C]; lung sounds were clear, and his abdomen was soft and not tender. He had no rash and no conjunctivitis. On the basis of this clinical presentation, the clinic physician empirically diagnosed typhoid and administered co-trimoxazole... MAYV was detected in viral RNA extracted from infected Vero cells.

A question now is: if this is another MAYV infection, is this a continuation of the 2015 transmission or a new introduction into Haiti? Clearly, laboratory follow up is needed to establish the etiology of the current cases of febrile disease to determine an etiology and rule out other pathogens. If MAYV presence is established, surveillance is needed to determine the extent of its distribution, and health care providers and laboratories in Haiti, the Dominican Republic, and other countries in the Caribbean Basin need to be informed to be on the alert and to be prepared to make a diagnosis should any cases occur there.

Of additional curiosity is a recent media report in the Jamaican Star relating a tale of 3 Haitians recently arrived claiming illness, with malaria suspected in one of them. Testing is still pending, but given the social media chatter, one can't help but wonder whether this isn't malaria. Could it be part of the same as of yet undiagnosed outbreak reported in the above chatter? ...

References:
1- Lednicky J, De Rochars V, Elbadry M, Loeb J, Telisma T, Chavannes S, et al. Mayaro Virus in Child with Acute Febrile Illness, Haiti, 2015. Emerg Infect Dis. 2016;22(11):2000-2002.

2- Mavian C, Rife BD, Dollar JJ, Cella E, Ciccozzi M, Prosperi MCF, Lednicky J, Morris JG, Capua I, Salemi M. Emergence of recombinant Mayaro virus strains from the Amazon basin. Sci Rep. 2017 Aug 18;7(1):8718. doi: 10.1038/s41598-017-07152-5.

A HealthMap/ProMED map of Haiti can be found at:

More information from knowledgeable sources would be greatly appreciated, especially results of laboratory testing on individuals presenting with the above-mentioned symptoms, and results of clinical as well as epidemiologic investigations. - ProMED Mods.MPP/TY]
Date: Sun, 9 Sep 2018 14:04:57 +0200

Rome, Sept 9, 2018 (AFP) - Authorities have issued health alert after 150 cases of pneumonia were recorded in a week, mainly in towns near the northern Italian city of Brescia.   Suspecting the presence of a pneumonia-causing virus in the water supply, they have taken samples from the distribution network for analysis.   Results are expected in several days.

Autopsies will be conducted on a 69-year-old woman and an 85-year-old man who died this week to determine whether they died from pneumonia, according to local media reports.   Pneumonia is usually caused when bacteria, viruses or fungi infect the lungs.   It can be life-threatening, especially among the elderly and those with serious health conditions.

Provincial health services have called on residents to take precautions, including disinfecting tap filters and shower hoses and to let hot water run for a period of time with the windows open before using it.   Hospital emergencies in several municipalities to the south and east of Brescia identified 121 cases of pneumonia, the health officer in the Lombardy region Giulio Galera said on television.   A survey of general practitioners found at least 30 other people had been affected.
Date: Sun, 9 Sep 2018 10:04:14 +0200

Tokyo, Sept 9, 2018 (AFP) - Japan is suffering its first outbreak of pig cholera in more than 25 years, authorities said Sunday after culling more than 600 animals and suspending pork exports.    A farm in central Japan saw 80 pigs die last week after catching the highly-contagious disease, an agricultural ministry official told AFP.

Early tests showed negative results for classical swine fever, as the illness is officially known.   But follow-up tests came out positive Sunday, prompting the cull of all 610 pigs at the farm, he added.   "We are now processing the livestock there and disinfecting the farm," he said, adding that officials had set up sterilisation points on access roads to the affected farm.

The government has set up a team of specialists to analyse possible infection routes, the agricultural ministry said in a statement.   Tokyo halted pork exports after the outbreak was confirmed. The nation sold roughly $9 million in raw pork meat to foreign markets last year.   Japan saw its last case of classic swine fever, which does not affect humans, in 1992.   The disease continues to rage in many parts of Asia, Europe and Latin America.
Date: Sat, 8 Sep 2018 21:58:47 +0200

Kinshasa, Sept 8, 2018 (AFP) - Health authorities in Kinshasa declared the Ebola virus under control five weeks after the latest outbreak left 89 people dead in eastern Democratic Republic of Congo.   The health ministry announced the outbreak on August 1 in North Kivu province and on Thursday revealed that it had spread to Butembo, a city of a million people.

But Health Minister Dr Oly Ilunga Kalenga said: "Since August 13, there have been practically no more cases, we can say that the situation has been brought under control at the epicentre (of Mabalako)."   The latest outbreak of the virus is 10th to strike DR Congo since 1976, when the disease was first identified and named after a river in the country's north.   "To date, we have 129 cases (31 probable and 98 confirmed), 89 deaths and 33 patients cured," Dr Oly Ilunga said.   Fears that the disease might  spread further had been expressed Thursday after news of two deaths in Butembo, a commercial hub and popular transit point for neighbouring Uganda.

A woman and one of the medical staff who had been treating her died ini the city.   "Even at Butembo, the situation is not critical," the minister told a news conference also attended by Congolese professor and leading Ebola researcher Professor Jean-Jacques Muyembe, who urged people to report any sign of the disease.   "The Ebola virus is circulating here and in Africa in general ... we must be vigilant," Muyembe said.

Complicating the battle against the spread of the disease is the fact it is afflicting an area of Congo wracked by insecurity owing to the presence of armed groups.   Even so, Dr Oly Ilunga said teams treating sufferers had enjoyed army and police backing as well as support from the UN mission Monusco.   The previous outbreak of Ebola, which left 33 people dead in the northwestern province of Equateur, was decreed over on July 24.
Date: Sat, 8 Sep 2018 13:02:52 +0200

Seoul, Sept 8, 2018 (AFP) - South Korea reported its first case of Middle East Respiratory Syndrome (MERS) in three years, health officials said on Saturday.   A 61-year-old businessman was diagnosed with the highly contagious viral respiratory illness, according to officials at the Korea Centers for Disease Control and Prevention (KCDC).   He returned to South Korea Friday from a business trip in Kuwait where he stayed for three weeks, the KCDC said a statement.

"Authorities have traced and separated 20 people who have come in close contact with the infected person," KCDC head Chung Eun-gyeong told journalists.   They include medical staff, flight attendants and passengers of the plane the man flew back to South Korea on, she said.    He was hospitalised with fever and phlegm and has been quarantined at a university hospital, she added.   It is the first case of MERS diagnosed in South Korea since 2015, when an outbreak killed 38 people and triggered widespread panic.
Date: Wed 5 Sep 2018
Source: El Comercio [in Spanish, machine trans. edited]
<https://elcomercio.pe/mundo/latinoamerica/chile-brote-hepatitis-suma-201-casos-region-antofagasta-noticia-nndc-554166>

Health authorities in the region of Antofagasta in northern Chile are on alert for an outbreak of hepatitis A that adds 201 cases so far in 2018, 2 more than those recorded throughout 2017, they said today, 5 Sep 2018. "Unfortunately, we are having about 5 cases every 2 weeks, which means that we are facing an epidemic," Cooperativa Rossana Díaz, ministerial regional Secretary of Health, told Radio. It is a situation "that is controllable with the help of the community," which, in his opinion, has a fundamental role in the prevention of this disease, which can "be fulminating, create a risk to life, and require organ transplantation." Diaz stressed that hepatitis A can be prevented with simple measures, such as constant hand washing and optimal handling and preparation of food.

The authorities must combat street food sales and control businesses, "but we do not get anything if people continue to consume food on the street or in places that do not have sanitary authorization for that," he said. The profusion of cases, according to the official, corresponds to the increase in the consumption of food in unauthorized places and the lack of vaccinated personnel or strict hygiene regulations in establishments that do have a permit.

The authorities have set up an Outbreak Response Committee in the region and questioned contacts of the confirmed cases and of the suspects in order to find the origin of transmission. The cases registered in Antofagasta range from 2 to 60 years, with an average of 23 years, of which 62% are men and 38% are women, and although the presence of immigrants is large in the region, 98% of the cases are Chileans, the regional authorities reported.

Hepatitis A, according to the Institute of Public Health, can be prevented with a vaccine, and its detection requires a medical diagnosis in addition to laboratory tests or diagnostic imaging studies. It is transmitted through water, contaminated food, or through contact with an infected person. It is considered a disease with worldwide distribution that occurs sporadically or epidemically with a seasonal cycle, which in Chile is an intermediate endemic, with epidemic outbreaks every 4 or 5 years, and there are no chronic carriers.
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[It seems to be the case that the cases are occurring at a low, steady rate rather than from a specific recent exposure.

Antofagasta (<https://en.wikipedia.org/wiki/Antofagasta>) is a port city in northern Chile, about 1100 km (700 mile) north of Santiago. It is the capital of Antofagasta province and the Antofagasta region. Formerly part of Bolivia, Antofagasta was captured by Chile in the War of the Pacific (1879-83), and the transfer of sovereignty was finalized in the 1904 Treaty of Peace and Friendship between the 2 countries. - ProMED Mod.LL]

[HealthMap/ProMED map available at: Antofagasta, Antofagasta, Chile:
<http://healthmap.org/promed/p/11048>]