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Japan

General
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Japan is a highly developed country with excellent tourist facilities. The country covers a number of islands and the population is estimated at over 125 million. English is widely spoken in the main tourist a
d urbanised centres.
Weather Profile
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Due to the strong influence from the sea, Japan tends to have a high rainfall but milder winters than the adjacent mainland of China. This is similar to the climate experienced in Ireland by comparison to the rest of Europe. Spring and Autumn are usually the most pleasant months but during the Summer the climate can be significantly humid and tiring. During this time it will be essential that fluid intake is increased and that salt (lost through perspiration) is replaced - usually by increasing the amount eaten on your food providing this is not contraindicated by any personal medical condition such as blood pressure etc.
Alcohol Consumption
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The Japanese authorities have limited patience with those arrested while under the influence of alcohol. For some travellers visiting the country this may mean a prolonged stay in the local jail and the subsequent missing of important appointments.
Natural Disasters
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Japan is situated in a region of the world which regularly experiences earthquakes and other climatic changes including typhoons. A number of relatively small earthquakes are reported each year but, to date, this has seldom affected any tourist itinerary. However, further information is available at http://www.tokyoacs.com
Safety and Security
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The risk to personal security for tourists while travelling throughout Japan is small though commonsense care of personal belongings is always essential. Where available, use the hotel safety boxes to store valuables and your passport, return air tickets. During the mid 1990’s a number of terrorist incidents occurred but no recent serious problems are being reported.
Airport Taxes
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Many countries now include the cost of their ‘departure tax’ within the ticket. In Japan this will depend on which airport you leave from. The fee is collected in Yen at Kansai - Osaka International Airport but usually included in the ticket cost if flying via Narita - Tokyo International Airport.
Cost of living
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Japan is not a cheap country for tourists. The cost of living is one of the highest throughout the world. Credit cards may be used in main cities but the ATM’s machines may not be available at all hours. Before taking a taxi from the airport it would be wise to check the costs and then assess whether or not it might be more prudent to use the local bus transport!
Medical Care
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The level of medical care throughout most tourist regions in Japan is excellent. However, there may be limited English-speaking doctors in some more rural areas and even where this facility is available in the main cities the cost of healthcare can be very expensive. It is wise to carefully check your travel health insurance premium before you leave home.
Local Medications
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Some commonly used European over-the-counter medications
may not be available in Japan. Also, there are strict laws governing the importation of certain medications which can be strictly enforced. Certain inhalers, sinus preparations etc may be confiscated on arrival. If you are taking any personal medications it may be wise to check before you leave. Obviously never carry packages for anybody else while travelling unless you are certain of the contents.
Avoiding Prickly Heat
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The term prickly heat is used in a variety of ways but the cause is generally the same. In a hot climate the body perspires to maintain the internal temperature at a correct level. In the perspiration there will be fluid and your personal salts. The fluid evaporates but the salt dries against the skin. It is your individual reaction to this salt that leads to the ‘prickly heat rash’. The reaction to these salts can be minimised by removing the salts from the skin surface as soon as possible. Change your clothes regularly, use plenty of talcum powder to absorb the perspiration and dry off well after showering.
Food & Water Care in Japan
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Any international traveller should recognise the risks of a ruined trip from unwise indulgence in local food and beverages. In Japan the level of food hygiene is high but the consumption of Sushi (uncooked raw fish) is unwise. Bivalve shellfish also carry a significant risk due to the limited level of sterilisation during the cooking process.
Malaria & Mosquitoes
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No malaria transmission occurs throughout Japan although avoiding mosquito bites during the humid months is wise.
Airborne Disease
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In any situation where you will be crowded together with many others the risk of a variety of airborne diseases will be higher. This will include serious diseases such as Meningococcal Meningitis but also others such as Influenza and the common cold. The risk of Meningococcal Meningitis in Japan is regarded as small and vaccine is not routinely recommended. However, having the Flu vaccine may be a wise precaution. It is also sensible to carry a small supply of lozenges to treat the inevitable sore throat which may occur.
Driving in Japan
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The road system throughout Japan is excellent but unfortunately the road signs may prove too much of a hurdle for those unfamiliar with the language! The congestion within the cities tends to be high and tolls on some of the major roads may be quite expensive. The traffic moves on the left side of the road but for many tourists it will be wiser to consider using local transportation rather than risking a ruined holiday.
English Help Lines
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Tourists can obtain important information and assistance in English while visiting Japan through the following numbers;
In Tokyo - 03-3968 4099
Rest of Japan - 0120-461 997
Vaccines for Japan
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For the majority of short-term travellers visiting Japan no particular vaccines will be recommended. Those planning to live for longer periods within the country will need to discuss this through in greater detail.

Travel News Headlines WORLD NEWS

Date: Wed 7 Nov 2018
Source: FNN.JP [online trans., summ., edited]

The number of people infected with "acute relaxation" [disease] in which paralysis appears in the limbs of children is rapidly increasing. [The disease] is one of infectious diseases in which the hands and feet of children suddenly [become paralyzed].

According to the National Institute of Infectious Diseases, 86 ["acute relaxation"] infections have been reported since May [2018], of which 28 have been onset since October [2018], and the number of reports has increased rapidly in the past few weeks. The [disease starts] with symptoms similar to a cold, such as a fever, then [appears in] the limbs. One of the causes is infection with a virus called "enterovirus D68."

It is important to thoroughly wash hands every day as a precautionary measure [against the disease]. The Ministry of Health, Labor and Welfare has continued warning and monitoring, as infections are rapidly increasing.
*************************************
Date: Tue 6 Nov 2018
Source: Asahi.com [online trans., summ., edited]

The number of reports of "acute relaxation" [disease], in which paralysis suddenly enters the limbs of children, has increased since around October [2018]. Reports of paralysis have been reported successively for 3 years, since the epidemic of enterovirus D68 infection. In May [2018], the Ministry of Health, Labor and Welfare asked for reports from medical institutions nationwide as well as strengthened monitoring. Connections are pointed out this time as well. Experts are calling for thorough washing and early consultation with medical institutions.

According to the National Institute of Infectious Diseases, 9 cases were reported nationwide in the latest week [22-28 Oct 2018] [compared to a few cases per week]. Ten cases were reported the previous week. Kakoko Tashiya, head of the Center for Infectious Diseases Epidemiology, points out that "there are 10 cases in a week" and 86 cumulative since May [2018]. Infection with enterovirus D68 has been pointed out as a cause. It is related to a virus that causes polio and hand, foot & mouth disease, also called childhood paralysis. It is contagious with a [wet] cough and is most prevalent from summer to autumn.

There is only symptomatic treatment, and there is no vaccine to prevent infection. Since it takes time to examine pathogens, it is detected only from a [sample] of patients with paralysis at the present time. However, from medical institutions in various places this year, 26 cases of virus detection including respiratory illness were reported this month [November 2018]. Ryutaro Kira, chief of Paediatric Neurology at Fukuoka City Children's Hospital, who participates in the research group, said, "This illness is not fully known yet; if [the infection appears in] a limb after a symptom like a cold, consult a medical institution. Washing and gargling are indispensable for prevention."
=====================
[Like poliovirus and hand, foot & mouth disease (HFMD), only a small fraction of EV-D68 infection cases manifest neurological symptoms [Global emergence of enterovirus D68: a systematic review. Lancet Infect Dis 2016; 16: e64-75]. An earlier study by Chong et al. reported strong temporal correlation with EV-D68 detection from pathogen surveillance  [<https://www.researchgate.net/publication/320264264_Clinical_Features_of_Acute_Flaccid_Myelitis_Temporally_Associated_With_an_Enterovirus_D68_Outbreak_Results_of_a_Nationwide_Survey_of_Acute_Flaccid_Paralysis_in_Japan_August-December_2015/download>].

Early general clinical management of children with AFM should be intensive nursing for children with severe neurological disease, and physical and occupational therapy should be initiated as soon as the child is physically stable to optimize functional outcomes. Treatment with intravenous immunoglobulin (IVIG) and/or pulse steroid therapy have been reported to have little impact on the final prognosis. - ProMED Mod.UBA]

[HealthMap/ProMED-mail map:
Date: Tue 23 Oct 2018
Source: NHK World-Japan [edited]

US health officials have warned that pregnant women who are not protected against rubella, or German measles, through either vaccination or previous infection, should not travel to Japan during the current outbreak in the country.

The number of patients with the viral infection is increasing, mostly in Tokyo and neighboring prefectures.

The US Centers for Disease Control and Prevention on [Mon 22 Oct 2018] raised its advisory level for the rubella outbreak in Japan to "alert," the 2nd highest of 3 levels.

The health officials say that travelers to the country should make sure they are vaccinated against the infection before travel.

Babies born to women who contract the disease during pregnancy are at risk of having birth defects, such as eye, ear, or heart disorders.

The World Health Organization announced in 2015 that the Americas are the world's 1st region to eliminate rubella and congenital rubella syndrome.

Japan's health ministry says that at the moment, the US is the only country to call for pregnant women not to travel to Japan.
****************************************
US CDC: travel alert
Date: Mon 22 Oct 2018
Source: Travelers' Health CDC [edited]

Rubella in Japan, alert - level 2, practice enhanced precautions
----------------------------------------------------------------
Key points
- There is an outbreak of rubella in Japan.
- Travelers to Japan should make sure they are vaccinated against rubella with the MMR (measles, mumps, and rubella) vaccine before travel.
- Rubella is very dangerous for a pregnant woman and her developing baby. Pregnant women who are not protected against rubella through either vaccination or previous rubella infection should not travel to Japan during this outbreak.

What is the current situation?
Health officials in Japan have reported an outbreak of rubella. Most cases continue to be reported in the Kanto region (Tokyo, Kanagawa, Chiba, and Saitama).

What can travelers do to protect themselves?
- Make sure you are fully vaccinated or otherwise protected against rubella.*
- People who cannot show that they were vaccinated or are otherwise protected against rubella should get vaccinated before leaving the United States:
- Infants (6-11 months of age) should have 1 dose of MMR (measles, mumps, and rubella) vaccine. Children in the United States routinely receive MMR vaccination at age 12-15 months.
- Adults and children 1 year of age or older should have 2 doses of MMR vaccine separated by at least 28 days.
- Avoid contact with people who are sick.
*Those who are otherwise protected include people who were born before 1957 and those who have been tested and have confirmed immunity. Talk to a doctor to see if you are protected against rubella.

Special advice for pregnant women
When rubella infection occurs during early pregnancy, serious consequences -- such as miscarriages, stillbirths, and severe birth defects in infants, congenital rubella syndrome, CRS [<https://www.cdc.gov/rubella/pregnancy.html>] -- can result.

See more about pregnancy and rubella at

Pregnant women should
- talk with their healthcare providers before traveling to Japan to check whether they are protected against rubella and whether it is advisable to travel;
- avoid traveling to Japan during this outbreak if not protected against rubella, through either vaccination or previous rubella infection. This is especially important during the 1st 20 weeks of pregnancy;
- get MMR vaccine after they have given birth, if they are not already protected against rubella.

Learn more about preventing rubella and what to do if you think you have it on the rubella page for travelers

What can clinicians do?
- Check that your patients 6 months of age or older who will be traveling internationally are protected against rubella.
- Think Travel: keep rubella in mind when treating patients with fever and rash, especially if the patient has recently travelled internationally.

Traveler information
- Rubella webpage for travelers:
- CDC rubella homepage: <https://www.cdc.gov/rubella/index.html>
- MMR (measles, mumps, rubella) vaccine information statement:
- MMRV (measles, mumps, rubella, varicella) vaccine information statement:

Clinician information
- Rubella in CDC's Yellow Book (Health Information for International Travel):
- Advisory Committee on Immunization Practices (ACIP) Recommendations for MMR vaccine
(<http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html>)
and MMRV vaccine
- Rubella information for healthcare professionals
- Think Travel homepage <https://www.cdc.gov/thinktravel/>

What is rubella?
Rubella, also called German measles, is a disease spread by the coughs and sneezes of infected people. Symptoms include rash and fever for 2-3 days. Rubella is very dangerous for a pregnant woman and her developing baby. If a pregnant woman gets rubella virus, her baby could have birth defects such as deafness, cataracts (blurred vision), heart defects, mental disabilities, and organ damage.
=======================
[Maps of Japan:
Date: Tue 16 Oct 2018
Source: The Mainichi [edited]

More than 1100 rubella cases have been reported this year [2018] in Japan, raising concern about serious health impacts on unborn babies who could be infected with the disease by their mothers during pregnancy, a national institute said [Tue 16 Oct 2018].

The 1103 cases so far in 2018 represent a nearly 12-fold jump from the entire previous year and also an increase of 135 in the 1st week of October [2018] from the previous week, according to the National Institute of Infectious Diseases.

Mothers with children born with congenital rubella syndrome in the past are calling on people to get vaccinations as infection in the early stages of pregnancy can cause birth defects such as hearing impairments, cataracts and heart disorders.

"We need to keep monitoring the situation carefully to see if it will develop into a major epidemic," health minister Takumi Nemoto said at a news conference. He also said the ministry will urge women who want to get pregnant to undergo a rubella antibody test.

In a 2012-2013 rubella epidemic in Japan, which saw more than 16,000 rubella patients, 45 babies developed congenital rubella syndrome and 11 of them died.

Kayo Kani, a 64-year-old co-head of a group working to stop rubella infections, warned that the latest epidemic could also result in the birth of babies with the syndrome, although no cases have been reported so far this year [2018]. 17 years ago, Kani lost her daughter who was born with heart problems due to the syndrome. Having learned that women of her daughter's generation are now at risk of giving birth to children with similar problems, Kani said, "I feel like my daughter is telling me to eliminate rubella infections."

To prevent serious health repercussions arising from the contagious disease, which is often transmitted through coughing and sneezing, vaccinating people around pregnant women is important, according to the institute.

Women who are already pregnant cannot be inoculated as the vaccine itself is feared to have an impact on the child. Notable rubella symptoms are fever, sore throat, and a rash. Its incubation period is 2-3 weeks.

Many patients found this year [2018] have been men in their 30s to 50s, a group who has not been vaccinated sufficiently.
==========================
[The cumulative incidence this year (2018) is highest in Chiba prefecture (37.6 cases per million population), followed by Tokyo (32 cases per million population), and Kanagawa prefecture (17.9 cases per million population).

In the past 6 weeks, 914 cases were reported, making up most of the 1289 cases recorded this year as of last Wed 18 Oct 2018. In comparison, only 93, 126, and 163 cases were recorded in 2017, 2016, and 2015 respectively. - ProMED Mod.LK]
Date: Tue 9 Oct 2018
From: Satoshi Kutsuna <skutsuna@hosp.ncgm.go.jp> [edited]

Rubella patients are increasing in Japan, mainly in the Kanto region (Tokyo, Kanagawa, Chiba, Saitama).

In 2018, 777 patients were reported by 26 Sep 2018, more than 8 times last year's [2017] reported number. Patients are frequently males in their 30s and 40s who are not inoculated with rubella vaccine as routine immunization, and the majority of patients have no or unknown history of rubella vaccination.

Rubella was epidemic in Japan in 2012-2013; more than 14,000 rubella patients and more than 40 congenital rubella syndrome patients were reported.

Rubella immunity should be confirmed before traveling to Japan.

The latest information about rubella in Japan is available from
--------------------------------------
Satoshi Kutsuna
Disease Control and Prevention Center
National Centre for Global Health and Medicine
=====================
[The URL listed here has excellent figures in Japanese and English.

Rubella is a mild, contagious disease caused by the rubella virus, genus _Rubivirus_, family Togaviridae.

The National Institute of Infectious Diseases warned that a potential rubella outbreak could affect the 2020 games and is urging people -- mainly men in their 30s to 50s -- to get vaccinations, as many have not been vaccinated fully against the disease. The vaccine is given as part of a combination vaccine, called the MMR vaccine, that protects against measles, mumps, and rubella.

Japan saw a major rubella outbreak in 2013, with over 10 000 people infected. Cases of infection have since declined, but there has been a resurgence since late July this year [2018], with many of the patients being men in their 30s and older. - ProMED Mod.LK]

[HealthMap/ProMED map available at:
Date: Mon, 1 Oct 2018 03:05:45 +0200

Tokyo, Oct 1, 2018 (AFP) - Two people have been killed in a powerful typhoon that battered Japan over the weekend, officials said Monday, as the storm's aftermath brought travel chaos to Tokyo's morning commute.   By Monday morning, Typhoon Trami had cleared Japan, but its powerful winds and heavy rainfall caused damage that blocked roads and train lines.

Local officials and police said two people had been killed in the storm. One was engulfed by a landslide in western Japan's Tottori and the another drowned in high waters in Yamanashi, west of Tokyo.   Both men were believed to have died on Sunday, when the storm made landfall in western Japan.   Two more people were reported missing, and more than 120 people were injured in the powerful storm, public broadcaster NHK said.   Trami made landfall in western Japan Sunday night, bringing fierce winds and torrential rain to areas already battered by a string of recent extreme weather episodes.

The typhoon sparked travel disruption in the world's third-biggest economy on Sunday, with bullet train services suspended, more than 1,000 flights cancelled and Tokyo's evening train services scrapped.   The turmoil continued Monday, as fallen powerlines and trees blocked railway tracks and around 200 flights remained grounded.   Huge crowds built up at Tokyo train stations, people battling for spots in jam-packed commuter trains.   Over 400,000 households, mainly in eastern Japan, were still without power on Monday morning.

After pummelling Japan's outlying islands including Okinawa, Trami made landfall south of the city of Osaka on Sunday night.   Local residents described "incredible winds and rain" that made it impossible to venture outside.   At its height, Trami packed gusts of 216 kilometres (134 miles) per hour, though it weakened as it moved over land.   The storm's strength prompted rail authorities to take the highly unusual step of cancelling Sunday night train services in Tokyo, one of the world's busiest networks.

The capital avoided a direct hit in the storm, but still saw fearsome winds and lashing rain that left the streets deserted.   Kansai Airport, which is situated on reclaimed land offshore in Osaka and suffered extensive damage in a storm earlier in September, reopened early Monday after closing its runways the previous day as a precaution.   Trami is the latest in a string of extreme weather and natural disasters to hit Japan, which has suffered typhoons, flooding, earthquakes and heatwaves in recent months, claiming scores of lives and causing extensive damage.

Some western regions are still recovering from Typhoon Jebi in early September, the most powerful typhoon to strike the country in a quarter of a century. It claimed 11 lives and shut down Kansai Airport.   Deadly record rainfall hit western Japan earlier this year, killing over 200 people, and the country also sweltered through one of the hottest summers on record.   And last month, a magnitude-6.6 earthquake rocked the northern island of Hokkaido, sparking landslides and killing more than 40 people.
More ...

World Travel News Headlines

Date: Thu, 15 Nov 2018 04:25:14 +0100
By Javier TOVAR

Paradise, United States, Nov 15, 2018 (AFP) - The toll in the deadliest wildfires in recent California history climbed to 59 on Wednesday as authorities released a list of 130 people still missing.   Most of those unaccounted for are from the Butte County town of Paradise, in northern California, which was virtually erased from the map by the so-called "Camp Fire" blaze that erupted last week.   Butte County Sheriff Kory Honea told journalists Wednesday evening that 461 search and rescue personnel and 22 cadaver dogs were involved in the effort to locate those missing and DNA testing was being expedited to identify the victims.

"Beginning Thursday, anyone who believes a family member perished can provide a DNA sample" to the sheriff's office, Honea said.    Paradise, a town of around 26,000 in the foothills of the Sierra Nevada mountains, was popular with retirees and many of those reported missing by the sheriff's office are elderly -- in their 70s, 80s and 90s.

Virtually every home in Paradise, located 80 miles (130 kilometers) north of the state capital Sacramento, was destroyed by the fast-moving fire fueled by high winds.   At least 59 deaths have been reported so far from the devastating wildfires and body recovery teams were going house-to-house with cadaver dogs in Paradise on Wednesday.   "We are in the midst of a catastrophe," Governor Jerry Brown told a press conference. "The fire was unprecedented, overwhelming, so a lot of people got caught."

Brock Long, head of the Federal Emergency Management Agency (FEMA), said Paradise was looking at a "total rebuild" with many homes, businesses and infrastructure destroyed.   "This is going to be a very long and frustrating event for the citizens of Paradise," Long said. "We're going to have to find a new normal."   "You're not going to be able to rebuild Paradise the way it was."   An AFP reporter in Paradise on Wednesday saw crews removing trees, repairing fences along roads and towing away cars.    Authorities said livestock owners were being allowed in to restricted areas for brief periods to feed the animals but it was unclear when residents would be allowed back in.

- Tales of courage, survival -
Fifty-six deaths have been reported from the "Camp Fire," mostly in Paradise, while three people have died in the "Woolsey Fire."   Honea said that of the 56 human remains found in his county, 47 had been identified.   While the cause of the "Camp Fire" is still under investigation, a lawsuit has been filed against the local power company, PG&E, by fire victims claiming negligence by the utility.

The complaint alleged that the fire began on November 8 when a high voltage transmission line failed, igniting a vegetation fire.   As thousands of firefighters fought the fires, incredible tales have emerged of courage and survival.   A man who asked to be identified by only his first name, Scott, told the San Francisco Chronicle that when the "Camp Fire" surrounded his home in Concow in Butte County he and his family plunged into a reservoir along with a 90-year-old neighbor, Bruno.   "Bruno was saying, 'Just leave me. I can't do this,'" Scott, 51, told the newspaper. "I said, 'Bruno, we're not going to leave you. And I'm not going to burn, so you better hurry.'"   They remained in the cold water as flames licked the shore and made their way to a small island in the reservoir after finding a pair of rowboats.

- 'I was terrified' -
Allyn Pierce, a nurse in Paradise, told The New York Times and CNN how his life was saved by a bulldozer driver as he fled the town in his pickup truck along with other residents on Thursday.   Pierce said cars were catching fire around him and he dictated a goodbye message to his family, expecting his vehicle to catch fire next.   "I stayed calm but I was terrified," Pierce said.   "Then all of a sudden this bulldozer comes out of nowhere and knocks this burning truck out of the way," he said.   Instead of fleeing to safety, however, Pierce turned around and went back to the Adventist Health Feather River Hospital, where he works as an intensive care nurse, and helped evacuate patients to the hospital's helipad.   Pierce displayed pictures of his Toyota pickup truck which he said was still working despite lights which had melted and a rear passenger door which had been welded shut by the heat from the fire.

The "Camp Fire" has ravaged 135,000 acres (54,632 hectares) of land and is 35 percent contained, according to Cal Fire.   It has destroyed some 7,600 homes and 260 commercial properties. Battling the blaze are more than 5,600 fire personnel, some from as far away as Washington state and Texas.   The "Woolsey Fire" has razed 97,620 acres (39,505 hectares) and has been 47 percent contained.    Cal Fire said more than 3,500 fire personnel were battling the "Woolsey Fire," which has destroyed the Malibu homes of several celebrities including Miley Cyrus, Neil Young, Robin Thicke, Shannen Doherty and Gerard Butler.
Date: Wed, 14 Nov 2018 18:14:50 +0100

Kinshasa, Nov 14, 2018 (AFP) - A cholera epidemic in the Democratic Republic of Congo has claimed 857 lives since the start of the year, the World Health Organization (WHO) said Wednesday.   Health authorities have so far recorded 25,170 cases, occurring in 21 out of the country's 26 provinces, the WHO's office in the DRC said.

The provinces of East Kasai and Lomami, in the centre of the country, and South Kivu, Tanganyika and Upper Katanga in the east, are those most affected.   Last year, the country had 55,000 cases of cholera, resulting in 1,190 fatalities.   Cholera is a highly contagious bacterial infection, which can kill within hours if left untreated. It thrives in conditions of poor sanitation and contaminated water or food.    The DRC is also battling an outbreak of Ebola in two eastern provinces, North Kivu and Ituri, that has killed 212 people since August.
Date: Wed, 14 Nov 2018 18:00:49 +0100

Madrid, Nov 14, 2018 (AFP) - The Spanish government declared war on alternative medicine like acupuncture or homeopathy Wednesday, announcing it plans to eliminate from health centres what it considers a health risk.   The plan, unveiled by the science and health ministers, aims to avoid the "potential harmful effects" of these practices "when they are used as an alternative or a complement to treatment" which itself is based on "proof and scientific rigour," the government said in a statement.   It did not detail what it included as alternative medicine, but gave the examples of acupuncture and homeopathy.   "Many people still believe that some treatments work despite there being no scientific proof available," it read.   According to a 2016 poll, "59.8 percent believe that acupuncture is of therapeutic use and 52.7 percent think that homeopathic products work," the plan read.

The government said it wants to "eliminate" alternative medicine from health centres where all treatment must be given by "recognised" professionals.   The plan also wants to avoid alternative medicine being taught in Spanish universities by developing alliances with deans, chancellors or Spanish regional authorities to not give out diplomas linked to these practices.   Madrid also wants to modify legislation to fight "false advertising" with regard to alternative medicine online.   The issue has taken centre stage in Spain recently, with health and science professionals pressuring the health ministry to take action after several high-profile deaths.

One such case, as reported by Spain's Association to Protect Patients against Pseudo-scientific Therapies, involved 21-year-old Mario Rodriguez who died after dropping his hospital treatment for leukemia in favour of a supposed naturopath who said he could cure cancer with vitamins.   "Dad, I made a mistake," his father Julian Rodriguez quoted him as saying on his deathbed.   The association has a long list of treatment it considers alternative medicine, which includes aromatherapy, acupuncture -- in use in China for centuries -- and even psychoanalysis as created by Sigmund Freud.
Date: Mon 12 Nov 2018, 9.54 AM EST
Source: The Guardian [edited]

A Briton has died after contracting rabies while visiting Morocco, public health officials have said. The UK resident was infected with the disease after being bitten by a cat, Public Health England (PHE) said on [Mon 12 Nov 2018]. PHE did not release any further details but reassured the public there was no wider risk. It said health workers and close contacts of the deceased were being assessed and offered vaccination where necessary.

Jimmy Whitworth, the professor of international public health at the London School of Hygiene and Tropical Medicine, told the Press Association: "My understanding is that this is somebody who had contact with a cat that was behaving abnormally and sought care, I believe in Morocco and in the UK, but unfortunately didn't receive vaccination until it was too late. I believe that the cat bit this person a few weeks ago."

He said that symptoms typically took 2 to 3 months to appear but could materialise in as little as a week. "That's why seeking prompt care and getting vaccination is so important," he said. "In this tragic case the person didn't get the vaccine in time." Given the lack of information, Whitworth said it was impossible to know whether the delay was in the UK or Morocco but it illustrated the importance of health workers being aware of the possibility of the disease.

There are no documented instances of direct human to human transmission of rabies. The disease does not circulate in either wild or domestic animals in the UK, although some species of bats can carry a rabies-like virus.

[Rabies] is common elsewhere, including in parts of Asia and Africa. PHE said the case was a reminder to travellers to rabies-affected countries to avoid contact with dogs, cats and other animals wherever possible, and seek advice about the need for a rabies vaccine prior to travel.

Dr Mary Ramsay, the head of immunisations at PHE, said: "This is an important reminder of the precautions people should take when travelling to countries where rabies is present. If you are bitten, scratched or licked by an animal you must wash the wound or site of exposure with plenty of soap and water and seek medical advice without delay."

It is only the 6th case of human rabies in the UK since 2000, all but one caused by animal exposure overseas. The last was in 2012, when a woman in her 50s died in London after being bitten by a dog in South Asia. She was reportedly turned away twice by doctors at a hospital in Kent before she was finally diagnosed.  [byline: Haroon Siddique]
======================
[According to another media source, the victim, a 58 year old man from Aylesbury Bucks, was staying 30 miles away from the Moroccan capital Rabat, visiting family, when he was infected with the disease. He did receive treatment but allegedly was not given anti-rabies serum in time;  <https://www.dailymail.co.uk/news/article-6382379/PICTURED-British-father-two-died-rabies-UK.html>.

The following statistics on rabies in animals were submitted by
Morocco for 2016 (last available annual report):
Official vaccinations in dogs: 71 759
Rabies outbreaks: 76

species / cases / deaths / killed
dogs / 41 / 28 / 13
cats / 12 / 11 / 1
bovine / 71/ 62 / 9
equine / 44/ 38/ 6
ovine / 6 / 5 / 1

The numbers of human cases, as reported to the OIE for the years 2010-2015, were 19, 18, 19, 24, 20, and 19, respectively. The number of human cases during 2016 (the most recent available data) was 17.

The tourism industry is well developed in Morocco; in 2017, Morocco was Africa's top tourist destination, with 10.3 million tourist arrivals, most of them from Europe, predominantly France and Spain. In the past, cases of rabies in animals illegally introduced from Morocco with returning visitors were recorded in France

The event is being investigated. - ProMED Mod.AS]

[HealthMap/ProMED maps available at:
England, United Kingdom: <http://healthmap.org/promed/p/279>
Date: Tue 13 Nov 2018
Source: BC Centre for Disease Control [edited]

The BC [British Columbia] Centre for Disease Control (BCCDC) is alerting British Columbians to discard or return to the place of purchase any Little Qualicum Cheeseworks' Qualicum Spice cheese that they currently have at home. Products in the marketplace have a best before date up to and including 24 Apr 2019.

A total of 5 people in BC have been affected by an _Escherichia coli_ outbreak between August and October 2018. Qualicum Spice cheese samples were tested and found to be contaminated with _E. coli_. The investigation is ongoing to determine the source and extent of contamination.

Qualicum Spice is an unpasteurized cheese. It is distributed throughout BC and sold in grocery stores, farmers' markets, wineries, restaurants, and at the Little Qualicum Cheeseworks farmgate store. Little Qualicum Cheeseworks has voluntarily recalled the affected product. Little Qualicum Cheeseworks produces several other types of dairy products. No other products are being recalled at this time and consumers do not need to discard them.

People who become ill from _E. coli_ can have a wide range of symptoms. Some may have no symptoms and some may become seriously ill and be hospitalized. The following symptoms can appear within 1 to 10 days after infection:
- severe stomach cramps;
- diarrhea or bloody diarrhoea;
- vomiting;
- headache; and
- little or no fever

If you have eaten this product but have no symptoms, there is no need to do anything. If you become ill after consuming this cheese:
- practice good hand washing with warm water and soap to prevent the spread of illness;
- drink lots of clear fluids to stay hydrated;
- anyone who has bloody diarrhea or is concerned about their symptoms should see a health care provider or call HealthLinkBC at 811;
- antibiotics and anti-diarrhoea medications should not be used to treat this infection unless prescribed by your health care provider.
====================
[Although not specifically stated, the link to unpasteurized cheese and the description of the symptoms make it clear that the pathogen here is a member of the enterohemorrhagic _E coli_ pathotype.

Unpasteurized dairy products remain a potential risk for a variety of pathogens including enterohemorrhagic _E. coli_, either the prototypic serotype or one of the other serotypes. In analyzing the genetic and phenotypic profiles of non-O157 groups of EHEC [enterohemorrhagic _E. coli_], it has been found that they belong to their own lineages and have unique profiles of virulence traits different from the prototypic O157 strain (1). The serogroups appearing to be most prominent are O26, O111, O128, and O103 (2). As noted in the post, suspected cases of EHEC should not be treated with antimicrobials.

The following was extracted from Lutwick LI. Enterohemorrhagic _E. coli_ infections. In: Confronting emerging zoonoses: the One Health paradigm. Yamada A, Kahn LH, Kaplan B, Monath TP, Woodall J, Conti LA (editors). Tokyo, Japan: Springer, 2014, 77-112:

Risk factors for the subsequent development of HUS after EHEC include children less than 10 years of age, elevated white blood cell counts, persistent low platelet counts without reversal and the use of either antimicrobial agents or antimotility agents during the diarrhea stage before or after bloody diarrhea develops. Since fever is generally not part of the presentation but significant abdominal pain is, patients with diarrhea, significant abdominal pain and no fever should be considered to have EHEC infection, and antimicrobial or antimotility agents should be avoided. Additionally, certain strains -- for example, the so-called clade 8 and the chimeric organism _E. coli_ O104:H4 -- can be associated with a higher risk of HUS.

HUS itself is a thrombotic illness primarily caused by the effects of the EHEC produced Shiga toxin acting on the vascular endometrium of organs where the toxin's receptors are expressed, particularly the kidney and brain. The syndrome consists of the combination of prominent low platelet counts (thrombocytopenia), intravascular red blood cell destruction (hemolysis) and diminished kidney function that can require hemodialysis. Neurological involvement occurs mostly in those who develop renal failure and the central nervous system involvement portends much higher mortality. Indeed, most of the acute mortality relates to neurological disease. Most patients will recover, but some, perhaps 10 percent, remain with renal failure and require chronic hemodialysis.

References
----------
1. Schmidt H, Geitz C, Tarr PI, et al. Non-O157:H7 pathogenic Shiga-toxin producing _Escherichia coli_: phenotypic and genetic profiling of virulence traits and evidence for clonality. J Infect Dis. 1999; 179(1): 115-23; available at <https://academic.oup.com/jid/article/179/1/115/877122>.
2. Bettelheim KA. Role of non-O157 VTEC. Symp Ser Soc Appl Microbiol. 2000; (29): 38S-50S; abstract available at <http://www.ncbi.nlm.nih.gov/pubmed/10880178>. - ProMED Mod.LL]

[HealthMap/ProMED map available at:
British Columbia Province, Canada:
Date: Sun 4 Nov 2018
Source: Nigeria Center for Disease Control (NCDC) [edited]

Highlights
===========================
- In the reporting week 44 (29 Oct-4 Nov 2018) 5 new confirmed cases were reported from Edo (3), Ondo (1) and Ebonyi (1) state with 2 new deaths in Edo (1) and Ebonyi (1).
- From 1 Jan-4 Nov 2018, a total of 2950 suspected cases have been reported from 22 states. Of these, 553 were confirmed positive, 17 probable, 2380 negative (not a case).
- Since the onset of the 2018 outbreak, there have been 143 deaths in confirmed cases and 17 in probable cases. Case fatality rate (CFR) in confirmed cases is 25.9%.
- 22 states have recorded at least one confirmed case across 90 Local Government Areas (Edo, Ondo, Bauchi, Nasarawa, Ebonyi, Anambra, Benue, Kogi, Imo, Plateau, Lagos, Taraba, Delta, Osun, Rivers, FCT, Gombe, Ekiti, Kaduna, Abia, Adamawa and Enugu); 18 states have exited the active phase of the outbreak while 4; Edo, Ondo, Ebonyi and Delta states, remain active - figure 1 [see source URL above].
- In the reporting week 44 (29 Oct-4 Nov 2018), one new health care worker was affected; 42 health care workers have been affected since the onset of the outbreak in 7 states - Ebonyi (16), Edo (15), Ondo (6), Kogi (2), Nasarawa (1), Taraba (1) and Abia (1) with 10 deaths in Ebonyi (5), Kogi (1), Abia (1), Ondo (2) and Edo (1).
- 82% of all confirmed cases are from Edo (46%), Ondo (23%) and Ebonyi (13%) states.
- 10 patients are currently being managed at Irrua Specialist Teaching Hospital (ISTH) treatment Centre (4), Federal Medical Centre (FMC) Owo (4), and Federal Teaching Hospital Abakiliki (2).
- A total of 8587 contacts have been identified from 22 states. Of these 512 (6%) are currently being followed up, 7946 (92.5%) have completed 21 days follow up while 15 (0.2%) were lost to follow up. 114 (1.3%) symptomatic contacts have been identified, of which 36 (0.4%) have tested positive from 5 states (Edo - 20, Ondo - 8, Ebonyi - 3, Kogi - 3, Bauchi - 1 and Adamawa - 1).
- National RRT team (NCDC staff and NFELTP [Nigeria Field Epidemiology and Laboratory Training Program] residents) deployed Ondo state to support response.
- Lassa fever international Conference registration, abstract submission and travel scholarship now open to the public on the conference website <www.lic.ncdc.gov.ng> with the date for abstract submission extended to the 14 Nov 2018.
- Lassa fever national multi-partner, multi-agency Technical Working Group (TWG) continues to coordinate response activities at all levels

Figure 1 [map]: Distribution of confirmed Lassa fever cases in Nigeria as at 4 Nov 2018.
Figure 2 [map]: Distribution of suspected and confirmed Lassa fever cases in Nigeria by LGA.
Figure 3 [graph]: Epicurve of Lassa fever confirmed (548) and probable (17) cases in Nigeria week 1-44, 2018.
Figure 4 [graph]: Weekly trends of Lassa fever confirmed cases in Nigeria, 2016-2018, week 44.
Figure 5 [graph]: Confirmed Lassa fever cases in Nigeria with state-specific case fatality rates (CFR) as at 4 Oct 2018.
=======================
[Although the graphs in the above report clearly show that the Lassa fever virus transmission peak has passed, the 5 new confirmed cases and 2 new deaths indicate that Lassa fever virus transmission continues, and a few more cases might occur. Unfortunately, one health care worker was infected during this reporting period. This outbreak has been widespread, occurring in 22 states and 90 local government areas. It would be interesting to know whether the prevalence of Lassa fever virus has been increasing in populations of rodent hosts in this area.

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

The maps and graphs in the report above are interesting and provide a good picture of how the outbreak has progressed over time. They can be accessed at the source URL above.

Maps of Nigeria:
Date: Mon 12 Nov 2018
Source: OIE, WAHIS (World Animal Health Information System), weekly
disease information 2018; 31(46) [edited]

Anthrax, Namibia
----------------
Information received on [and dated] 12 Nov 2018 from Dr Adrianatus Florentius Maseke, chief veterinary officer, Veterinary Services, Ministry of Agriculture, Water and Forestry, Windhoek, Namibia

Summary
Report type: immediate notification
Date of start of the event: 25 Oct 2018
Date of confirmation of the event: 1 Nov 2018
Reason for notification: recurrence of a listed disease
Date of previous occurrence: 13 Feb 2018
Manifestation of disease: clinical disease
Causal agent: _Bacillus anthracis_
Nature of diagnosis: clinical, laboratory (basic)
This event pertains to a defined zone within the country

New outbreaks (3)
Outbreak 1: Omiriu, Opuwo, Sesfontein, Kunene
Date of start of the outbreak: 25 Oct 2018
Outbreak status: continuing (or date resolved not provided)
Epidemiological unit: village
Affected animals
Species / Susceptible / Cases / Deaths / Killed and disposed of / Slaughtered
Goats / 537 / 25 / 23 / 2 / -
===================
[The location of the outbreaks can be seen on the interactive map included in the OIE report at the source URL above. Kunene is in north west Namibia, and Kavango East is between Angola & Botswana in the north east.
========================
[Remember it is summer in the southern hemisphere, which means that it is now their anthrax season. Livestock anthrax is sporadic in Namibia but a constant concern in their national parks. - ProMED Mod.MHJ]

[HealthMap/ProMED-mail map of Namibia:
Date: Tue, 13 Nov 2018 20:01:56 +0100

Tampa, Nov 13, 2018 (AFP) - Puzzled by a rise in US children with sudden paralysis in their arms or legs, health officials said Tuesday they are probing whether a virus or auto-immune disorder may be to blame.   A total of 252 cases of the disorder known as acute flaccid myelitis (AFM) are currently under investigation nationwide, an increase of 33 since last week, said Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at the US Centers for Disease Control and Prevention (CDC).

With 80 confirmed cases so far this year, 2018 looks to be on pace with prior peak years like 2014 (120 cases) and 2016 (149 cases), Messonnier said.    More than 400 cases have been confirmed through lab tests since 2014, the first year the syndrome emerged.   A couple dozen cases were confirmed in 2015 and 2017.   Messonnier said she understands parents' alarm but stressed that the disorder remains "rare."   Most cases involve children aged two to eight. Almost all complained of fever and respiratory illness three to 10 days before suddenly experiencing paralysis in their arms or legs.   For some, the paralysis went away, but at least half have not recovered, said Messonnier.

The CDC has tested 125 spinal cord fluid samples, and half were positive for rhinovirus or enterovirus, which commonly cause symptoms like fever, runny nose, vomiting, diarrhea and body aches.    Yet scientists are still stumped about the precise cause of the sudden paralysis, since these viruses are common but AFM is not.   "We are trying to figure out what the triggers are that would cause someone to develop AFM," Messonnier told reporters.   "It may be one of the viruses we have already detected. It may be a virus that we haven't yet detected. Or it could be that the virus is kicking off another process that is actually triggering -- through an auto immune process -- AFM," she said.    "CDC is a science-driven agency. Right now, the science doesn't give us an answer."

Perhaps most frustrating for parents, there is no way to prevent it, and no targeted therapies or interventions.   "Parents and caregivers are urged to seek immediate medical care for a child who develops sudden weakness of the arms or legs," said the CDC latest report on AFM, released Tuesday.    Messonnier said the CDC has not been tracking every case of AFM since 2014, leading to gaps in the federal agency's knowledge of the illness, which experts are now trying to fill.   One child with AFM is reported to have died in 2017.
Date: Mon, 12 Nov 2018 15:54:12 +0100

London, United Kingdom, Nov 12, 2018 (AFP) - A Briton has died after being bitten by a cat with rabies in Morocco, officials said Monday, only the seventh known case in the United Kingdom since 2000.   England's health service issued a reminder Monday for travellers to avoid coming into contact with animals when travelling to rabies affected countries, particularly those in Asia and Africa.

Rabies has been effectively eradicated in Britain, although they do still spread among some bats.   "There is no risk to the wider public in relation to this case but, as a precautionary measure, health workers and close contacts are being assessed and offered vaccination when necessary," said Mary Ramsay, the health service's chief of immunisation.   The Press Association news agency said the person was bitten a few weeks ago and not given potentially life-saving treatment early enough.

Rabies is a viral disease that causes an inflammation of the brain. It is usually fatal by the time the first symptoms emerge.   England's health service said that no cases of humans acquiring the disease from any animal other than a bat have been recorded within the country since 1902.   One person acquired it from a bat in Scotland in 2002, and five people contacted while travelling between 2002 and 2017, the health service said.
Date: Tue, 13 Nov 2018 07:02:37 +0100

Hanoi, Nov 13, 2018 (AFP) - Vietnam's newest carrier Bamboo Airways has been granted a licence to fly, officials and the airline said, paving the way for its inaugural flight in a region crowded with competitors.    Run by one of the country's richest men, Bamboo will compete with well-established heavy hitters such as national carrier Vietnam Airlines and budget carrier Vietjet to serve a mushrooming middle class with growing appetites, and budgets, for travel.    Vietnam's Transport Ministry said Bamboo's official aviation license had been approved and that it would aim to operate 100 routes, including to lesser-travelled destinations in Vietnam and elsewhere in Asia, with plans to eventually fly to North America.   "The first domestic flights... are aimed at reducing pressure on aviation infrastructure in major cities, strengthening regional links (and) promoting tourism to Vietnam," the Transport Ministry said in a statement Tuesday.

The airline is owned by Trinh Van Quyet, who heads the FLC property empire that includes lush beachside resorts, golf clubs and luxury condos across Vietnam, a country still under one-party communist rule.   Bamboo has already signed up to buy 20 of Boeing's 787 Dreamliners worth $5.6 billion and committed a further $3.2 billion to buy 24 Airbus A321neo planes.    The airline said its inaugural flight, originally scheduled for last month, should take place before the end of the year.    "We have conducted a flight test, the results show that the aircraft fully meets technical specifications (and is) ready to go into operation," CEO Dang Tat Thang said in a statement.

Bamboo is hoping to steal customers from competitors by luring them to off-the-beaten-path destinations in Vietnam such as Quy Nhon and Thanh Hoa and by offering bundled travel packages to FLC resorts.   But analysts say the outdated model may not work in an era where most travellers can easily tailor holidays online, and wonder whether Bamboo's big bet will pay off in Southeast Asia's busy aviation market.    Quyet told AFP in an interview earlier this year that he is certain the airline "will be huge" and expects to make a profit soon after launch.   Born to a poor rural family near Hanoi where life among bamboo trees inspired the airline's name, he now runs FLC Group with a market capitalisation of around $200 million.

Vietnam's aviation sector has soared in recent years, with passenger numbers jumping to 62 million last year from 25 million in 2012.   There are already six commercial aviation licenses granted in Vietnam, including for a chartered helicopter service and a seaplane carrier.   Faced with increasingly squeezed airport capacity and tough competition across the region, in particular from budget airlines like AirAsia and TigerAir, the market has shown signs of cooling.    In 2009, Vietnam's first operational private airline Indochina Airlines ceased operation after just one year in the market due to financial troubles.