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Kenya

General Information:
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Kenya is situated on the east coast of Tropical Africa and is one of the most popular tourist resorts in the continent. The country is bounded by Ethiopia and Somalia in the north, Ugan
a on the west, Tanzania to the south and the Indian ocean to the east. The country has been regarded as one of the more stable in Africa but nevertheless recent events, as they head towards a multiparty democracy, have led to a spiralling devaluation in their currency and general unease and disturbances.
Climate:
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Nairobi is situated at approx. 6000' and has a mild climate throughout the year. Malaria prophylaxis is not usually recommended for those visiting Nairobi city alone. The main rains tend to fall in April and May or October and November. The annual rainfall tends to be about 39 inches but significant variations can occur. Mombasa, on the coast, has a much more tropical climate and travellers will need to take more care with regard to personal hygiene and also serious protection against mosquito bites.
Health Care Facilities:
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In general, travellers to Nairobi find that the level of health care facilities are good. All doctors in Kenya speak English and the level of care they provide is usually excellent for the holiday maker. As in many other countries in central Africa, the screening of blood against various viral agents cannot be assured and so travellers should avoid all but essential of blood transfusions. Sterile needles and syringes are in good supply in the major towns and so a syringe kit is not usually necessary. All of the larger hotels will have their own English speaking medical officer, though travellers are usually asked to pay cash. There are many hotels and restaurants providing excellent menu facilities and food borne disease can usually be traced to eating salads or undercooked bivalve shellfish.
Swimming in Kenya:
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In all the major tourist resorts throughout Kenya there are swimming pools and these are usually the best places to indulge. On the coast the sand is exceptionally fine and it feels as if you are walking on flour. Just be careful of local strong currents and don't swim out to the coral. Watch out for the sea urchins. Their spines are very uncomfortable and may need to be extracted by medical staff. Keep your children in view at all times and warn them to take care. If you are trekking around Kenya or on Safari don't go swimming in any fresh water rivers or lakes. There is a disease called Schistosomiasis (Bilharzia) which will penetrate through your skin and may cause serious problems in the future.
Rabies in Kenya:
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This viral disease occurs throughout Kenya and is a significant risk for travellers who are going away from the major tourist areas. Keep clear of all warm blooded animals and if you are bitten (even licked or scratched) wash out the area immediately, apply an antiseptic and get medical attention. Even though the risk of Rabies for the traveller is very small don't ever disregard a contact of this type. The beach hotels near Mombasa are favourite haunts for monkeys. Don’t feed them and stay clear. Report any bite (lick or scratch) immediately. Watch your children at all times.
Trekking through Kenya:
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Some travellers to Kenya will have no particular itinerary planned and so start their holiday from either Nairobi of Mombasa. Those planning to go off the beaten track should register with the Irish Counsel. Great care should always be exercised as each year too many tourists have significant problems while trekking off the usual routes. The major risks revolve around food and water borne disease, the risk of rabies, altitude sickness on Mount Kenya, being robbed or simply getting lost!

Tips for Trekkers
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Always plan your trip well in advance
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Make sure that you know about personal health and general food & water hygiene.
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Check in frequently
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Never travel alone
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Make sure you have plenty of clean water
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Stick to your itinerary
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If you are in trouble, admit it!
The Risk of Malaria:
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In Kenya, malaria poses a very real risk outside Nairobi. One of the highest risk areas is Mombasa which is where many travellers will find themselves at some time. Malaria is transmitted by the bite of an infected mosquito and so the first line of defence is to protect yourself against mosquito bites. (see leaflet on Protection against Insect Bites - Tropical Medical Bureau). Also it is essential to take your prescribed malaria tablets on a regular basis. Only stop your tablets under exceptional circumstances. Nevertheless, the traveller must remember that there is no perfect protection against malaria and the disease can still occur even after all the precautions have been taken. So be aware that any peculiar symptoms (especially 'flu) for at least a year after your trip will need to be checked out.
After your Journey:
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Just remember that some tropical diseases may not become evident for weeks or even months after your trip. If you are ill within a year of your journey always seek medical help.
Further Information:
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General travel health information may be obtained from the Tropical Medical Bureau at any of our centres. Please remember, every traveller will require a specialised consultation and this leaflet only contains general guideline information.

Travel News Headlines WORLD NEWS

Date: Sat 13 Apr 2019
Source: Standard Media [edited]

The State may have ignored recommendations on anthrax outbreaks at Lake Nakuru National Park, exposing animals and humans to grave danger. The disease has killed 14 buffaloes with unconfirmed reports indicating one human infection in Elburgon, Nakuru County.

In August [2018], the Kenya Zoonotic Disease Unit of the ministries of agriculture and health had declared the park an anthrax hotspot and directed routine vaccination of all animals at all times. In a study to establish the cause of repeated anthrax outbreaks in the area, since 1973, the unit had blamed kneejerk reactions by government agencies for unnecessary loss of human and animal lives. "Typically, the government responds to these anthrax outbreaks by immediately deep-burying dead livestock and wildlife, ring vaccinating livestock, and treating affected humans," said the report. Anthrax vaccination programmes in the area, the report [says], have been irregular and mostly planned as a response to outbreaks; "there is no routine vaccination practised."

True to the report, on Tuesday [9 Apr 2019], Kenya Wildlife Service (KWS) head of corporate communications Paul Gathitu said they had burned carcasses of the dead buffaloes, disinfected the sites and started vaccinating rhinos. "We will vaccinate 15 white rhinos and 67 black rhinos in a window of 10 days. So far, we have vaccinated 19 rhinos and 63 remaining while vegetation will be disinfected," said Susan Koech, the Principal Secretary for Wildlife, on Monday [8 Apr 2019]. The outbreak of anthrax was 1st identified on 29 Mar [2019] at the park, which has more than 4000 buffaloes.

On Sunday [7 Apr 2019], Nakuru County Minister for Agriculture Dr. Immaculate Njuthe said one case of suspected human anthrax had been reported in Elburgon. "If not managed well, the outbreak can spiral out of control and find its way into neighbouring communities," said Principal Secretary Koech.

The August [2018] study by local and international experts suggested inept handling of anthrax outbreaks in the past has not helped reduce recurrences. The experts had recommended the government develop an anthrax risk map for the country and maintain regular surveillance and vaccination of animals in and around the park. They had also recommended public education and awareness on the risk of anthrax outbreaks. The study traced 10 outbreaks around Lake Nakuru since 1973 including that of 2015, which killed 766 wild animals, including 745 buffaloes.  [Byline: Gatonye Gathura]
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Date: Tue 16 Apr 2019
Source: Standard Mail [edited]

The Nakuru County government has intensified inspection of meat products following reports of an anthrax outbreak in the county. Public health officials have been dispatched to all sub-counties to inspect meat supplied to butcheries and hotels to ensure it is safe for consumption. The officers are working together with those from the veterinary department to inspect at least 1000 licensed butcheries in the county. "Locals should not fear buying meat in any licensed butchery because we have intensified inspection and the supply channel for safety," Samuel King'ori, chief officer in charge of the Public Health department, said.

Two weeks ago, at least 14 people suspected to have contracted anthrax were treated at Elburgon Hospital. Samples were taken to Kenya Medical Research Institute (Kemri) in Nairobi for testing, but the results are yet to be released.

"Nobody should consume meat that has not been inspected because evil-minded people can sell infected livestock meat that can lead to deaths," said King'ori. In 2016, at least 70 people at Lengenet village contracted anthrax after they consumed the carcass of a cow.

Besides inspecting meat, the health workers are also inspecting food joints, shops and supermarkets to ensure food safety.

Dr. Enos Amuyunzu, County Chief Officer for Livestock, said at least 15 000 cattle have been vaccinated in Nakuru Town East Sub-County. Other areas where vaccination is ongoing include parts of Njoro and Elburgon in Molo Sub-County. Amuyunzu has asked farmers to monitor livestock and report any signs of anthrax, including high temperature, shivering or twitching, harsh dry coat, blood in dung or in nostrils, decrease or complete loss of milk, and also dejection and loss of appetite.  [Byline: Mercy Kahenda]
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[The 2018 expert advice was sound and experienced. It is hoped the present troubles will initiate the establishment of the necessary, and overdue, national programme of anthrax control and surveillance. Note that there has been another probable human case reported. - ProMED Mod.MHJ]

[HealthMap/ProMED-mail maps:
Nakuru County, Kenya: <http://healthmap.org/promed/p/47100>]
Date: Wed 10 Apr 2019
Source: Kenya News Agency [edited]

Some 27 people have been admitted at Laisamis Level 4 Hospital following an outbreak of kala-azar [visceral leishmaniasis] in Laisamis sub county in Marsabit.

The facility's Chief Executive Officer (CEO), Abshiro Hapicha however, said the patients, were responding well to treatment. A majority of the patients, he added are from Logo.

"A total of 27 patients who tested positive to kala-azar have been admitted in this hospital and are currently undergoing medication. I can say that their response is good," Hapicha said.

Consequently the CEO made an appeal for concerted efforts among the national and county governments and other agencies in eradicating the sand flies that transmits the disease. "There is need for massive awareness campaign to control the spread of the disease and if possible to eliminate it," he said.

He said pastoralist communities sleep on sand outside their houses during dry seasons which expose them to sand flies. "High levels of poverty and illiteracy among residents have also been established to be other factors that expose them to kala-azar," he added.

Kala-azar has an incubation period of between 2 weeks to 6 months with symptoms being fever, weight loss, anaemia, and swelling of the spleen and liver.

Meanwhile, Kargi MCA [Member of the County Assembly], Asunta Galgithelle has asked the government to consider establishing kala-azar control centres fully equipped with diagnostic facilities and testing kits in parts of the county that are prone to the disease. Galgithele urged partners in the health sector to join hands in bringing the menace under control.

According to records with the department of health, 44 cases out of 102 reported since 2016 turned positive.  [Byline: Sebastian Miriti]
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[In recent years, ProMED has reported an increasing rate of visceral leishmaniasis in South Sudan, which is highly endemic. Also visceral leishmaniasis is found in Somalia and the recent civil wars in both countries may be linked to an increase of cases in Northern Kenya.

A recent review of leishmaniasis worldwide, including Kenya, (Alvar J, Velez ID, Bern C, et al, and and the WHO Leishmaniasis Control Team. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012; 7(5): e35671; supporting information S50; <https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035671>), states that in Kenya "Since 1980, the number of reported cases increased considerably and expanded into new areas. In Baringo and Pokot area, there is a continuous high endemicity, which affects the very poor tribal nomadic population. In other areas, VL [visceral leishmaniasis] occurs in outbreaks that are associated with periods of drought, when the rate of malnutrition is high. The outbreaks are probably related to people movement from high to low endemic areas due to the lack of food security." - ProMED Mod.EP]

[Maps of Kenya: <https://goo.gl/pcUuf4> and
Date: Mon 8 Apr 2019
Source: The Star [edited]

Rhinos and giraffes are at a high risk of contracting anthrax after the disease killed 10 buffaloes at Lake Nakuru National Park, Kenya Wildlife Service said yesterday [Sun 7 Apr 2019]. KWS central Rift assistant director Aggrey Maumo said white rhinos and Rhode giraffes are highly susceptible to the outbreak because they have a close contact with buffaloes. "We have a total of 90 rhinos of which 14 are white and 66 black rhinos. We also had new births last year [2018] and the team is vaccinating all species susceptible to the disease," he said.

The officers also assured the tourists that they are safe to visit the park. "It's only when you come into direct contact with the carcasses that you'll be affected and we have a qualified team to handle the situation," he said.

Maumo however said a team of 15 officers are on the ground to monitor the situation. "On the ground we have a team of 15 officers who include 3 veterinary doctors, 4 scientists and 8 supporting officers to ensure they curb the spread of the outbreak. The team is conducting the aerial and ground inspection," he said. He said the team has managed to control the situation. He added that the 1st case was detected on [Mon 29 Mar 2019].  "The 1st case was detected on [Mon 29 Mar 2019]. We took the samples to the Nakuru government laboratory and the results turned positive. Since then we have had a total of 7 buffaloes dying from anthrax and 3 from anthrax-related diseases," said the KWS regional boss.

Maumo, who was accompanied by the park's deputy senior warden Collins Ochieng' on [Sun 7 Apr 2019], said they have taken preventive measures. "They are taking care on the way they are handling the carcasses, spraying the infected ground and burning the carcasses to prevent the spread," he said.  The KWS senior officials said the prolonged drought has triggered the spread of the outbreak. "A few animals have died as a result of direct food effects. If the food is too dry and doesn't have enough moisture, the animals' body systems won't be able to support or sustain themselves. To contain the trough situation, we have several borehole and water boozers to water the animals," he said. "The outbreak has seen the weak animals being the target and young buffaloes because of their low immunity," he said.

The outbreak was reported 1st 3 months ago in Nakuru, but the county government said it was in control. The park has more than 5000 buffaloes, which is more than the ideal capacity of 1000. "We have more buffaloes than the carrying capacity but plans are underway to relocate them to other parks," he said.

The residents said an open sewer near the park may contribute to the spread of the disease in Nakuru town and its environs. "The fencing of the sewer around Lake Nakuru will really help in curbing this disease. It is easy for the animals to come into contact with the bacteria because they drink water from the sewer," said Peter Yatich, a Nakuri farmer.  He said the animals also graze on fresh shoots of grass after rainfall, leading to anthrax outbreak due to the ingestion of organisms picked from contaminated soils.

In 2015, there was another outbreak of anthrax at the park. "There was an outbreak in 2015, however I cannot confirm the number of the animals that were affected," said Maumo. [28 Aug 2015 Anthrax - Kenya (03): (NK) wildlife, OIE http://promedmail.org/post/20150828.3608546, 23 Jul 2015 Anthrax - Kenya (02): (NK) wildlife, susp, RFI http://promedmail.org/post/20150723.3531277]  [Byline: Rita Damary]
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[Members please note this report was forwarded to us by Kunihiko Iizuka in Japan. Yes, you all are our eyes & ears out there. We depend on you, and you, and you. And many thanks to Kunihiko Iizuka.  I would not be surprised if these 2 incidents were not related epidemiologically. The logical supposition was that a haematophagious female tabanid fly found her way from the infected buffaloes to the Tegat village herd.

For years anthrax was seldom reported from Kenya. We knew it was there but nobody would say where it was. Now we are at the receiving end of multiple reports -- see the list in "See Also" below -- but I doubt whether it is anything more than just the normal occurrence, aided by too little routine vaccination of livestock and the careless consumption of sick animals. What is needed is the development of a national anthrax control & surveillance programme, with niche mapping to show the areas of high (potential) risk, targeted vaccination of these areas, and better public awareness of the real risks and procedures being applied. And in a few years we will see the livestock incidence drop significantly. Wildlife anthrax is another problem unfortunately but it does respond to the rapid and efficient processing of infected carcasses.

For a description of Molo, go to:
National Park <https://en.wikipedia.org/wiki/Lake_Nakuru>. - ProMED Mod.MHJ]
Date: Sat 6 Apr 2019
Source: Citizen Digital [edited]

More than 22 people from Tegat Village in Molo were admitted at the Nyayo hospital in Elburgon, with residents fearing they may have contracted anthrax after consuming milk from a sick cow. According to Emily Sang, the Nyumba Kumi chairperson of the area, the 22 include the owner of the cow, his wife and 2 children.

Elburgon assistant commissioner Naftali Korir says 18 people have been treated and discharged. Korir has further cautioned residents against eating or drinking un-inspected meat or milk.

A veterinary officer is reported to have confirmed that the meat was found to have anthrax and advised all those who had consumed to seek treatment immediately.  [Byline: Jathan Kamau]
Date: Wed 3 Apr 2019
Source: UNICEF [edited]

Bulletin: Cholera and AWD Outbreaks in Eastern and Southern Africa, Regional
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Approximately 3385 cholera / AWD cases including 19 deaths have been reported in 10 out of the 21 countries in Eastern and Southern Africa Region (ESAR), with an average case fatality rate (CFR) of 0.6%, since the beginning of 2019. These countries include Angola, Burundi, Kenya, Malawi, Mozambique, Tanzania, Somalia, Uganda, Zambia, and Zimbabwe. Kenya accounts for 35.4% (1198) of the total case load reported in 2019, followed by Mozambique at 31% (1048).

Of the 10 countries with reported cholera / AWD outbreaks in ESAR since week 1 of 2019, 6 (Mozambique, Tanzania, Somalia, Kenya, Zambia, and Burundi) have ongoing cholera outbreaks. During the week under review, Mozambique reported the highest number of new cases (1048 cases). Tanzania and Burundi have recorded the highest CFR in 2019 at 1.3% and 1%, respectively, of the countries with active outbreaks.

Mozambique: Cholera cases in cyclone-hit Mozambique and its associated flooding have risen to 1048 cases including 1 death (CFR 0.09%). The Ministry of Health declared an outbreak of cholera on 27 Mar 2019 with cases reported in Beira and Nhamatanda districts. Recent assessments have shown that health facilities have been destroyed by the cyclone, complicating response efforts. The disease is a major concern for the hundreds of thousands of cyclone survivors in the southern African nation now living in squalid conditions in camps, schools, or damaged homes. Some [people] drink from contaminated wells or filthy, stagnant water. The 1st round of an oral cholera vaccination (OCV) campaign is starting on 3 Apr 2019, with the 2nd round of vaccination planned in 3 months. The OCV campaign will target Beira, Buzi, Dondo, and Nhamatanda.

Tanzania: An increase in the epidemic trend has been noted in the last 2 weeks. During week 12 (week ending 24 Mar 2019), 38 new cases were reported, compared to 23 cases reported in week 11 (week ending 17 Mar 2019). This raises the total number of cholera cases reported since the beginning of 2019 to 154, including 2 deaths (CFR 1.3 %). All new cases emerged from Tanga region in the following areas: Korogwe DC (24), Korogwe TC (11), and Handeni DC (3). Cumulatively, a total of 33 475 cases including 552 deaths have been reported since the beginning of the outbreak in August 2015.

Somalia: A slight increase in the epidemic trend has been noted in the last 2 weeks. During week 11, 34 new cases were reported from Banadir region compared to 32 cases reported in week 10 (week ending 10 Mar 2019). Cumulatively a total of 635 cases with no deaths have been reported since the beginning of 2019. Children under 5 years bear the brunt of the cholera outbreak, representing 50% of the total case load reported in week 10 and 44% in epidemiological week 11. During the last 2 weeks, the most affected district in Banadir was Madina, accounting for 27.5% (12/32) of the total number of cases reported during week 10 and 26.5% (9/34) of total cases reported in week 11. Overall (from epidemiological week 8-11), the Banadir districts with the highest case numbers are Madina (36), followed by Daynile (24).

Kenya: Since January 2019, cholera outbreaks have been reported in Narok, Kajiado, Nairobi, Garissa, and Machakos counties. As of 1 Apr 2019, a cumulative total of 1198 cases including 4 deaths (CFR 0.3%) have been reported in these counties since the beginning of 2019. Nairobi and Machakos are the latest counties to report confirmed cases of cholera. During the week under review (epidemiological week 13), 26 new cases were reported from Nairobi (16), Garissa (6), and Machakos (4) counties.

Zambia: The latest cholera outbreak notified on 22 Mar 2019 hit Nsama district in Northern province. The index case, a 9-year-old child from Chaushi village, developed signs and symptoms on 16 Mar 2019. As of 31 Mar 2019, a cumulative total of 88 suspected cases and 4 deaths (CFR 4.5%) have been reported since the onset of the new outbreak.

Burundi: As of 1 Apr 2019, 206 cases including 2 deaths (CFR 0.97%) were recorded since the onset of the cholera epidemic on 18 Dec 2018. Of these, a total of 104 cases including 1 death (CFR 0.96%) have been reported since the beginning of 2019. Cases recorded since the beginning of 2019 emerged from 3 provinces: Bujumbura (56), Rumonge (45), and Cibitoke (3).
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[The mortality from cholera and most diarrheal illnesses is related to non-replacement of fluid and electrolytes from the diarrheal illness. As stated in Lutwick LI, Preis J, Choi P: Cholera. In: Chronic illness and disability: the pediatric gastrointestinal tract. Greydanus DE, Atay O, Merrick J (eds). NY: Nova Bioscience, 2018, 113-127, oral rehydration therapy can be life-saving in outbreaks of cholera and other forms of diarrhea:

"As reviewed by Richard Guerrant et al. (1), it was in 1831 that cholera treatment could be accomplished by intravenous replacement, and, although this therapy could produce dramatic improvements, not until 1960 was it 1st recognized that there was no true destruction of the intestinal mucosa, and gastrointestinal rehydration therapy could be effective, and the therapy could dramatically reduce the intravenous needs for rehydration. Indeed, that this rehydration could be just as effective given orally as through an orogastric tube (for example, refs 2 and 3) made it possible for oral rehydration therapy (ORT) to be used in rural remote areas and truly impact the morbidity and mortality of cholera. Indeed, Guerrant et al. (1) highlights the use of oral glucose-salt packets in war-torn Bangladeshi refugees, which reduced the mortality rate from 30% to 3.6% (4) and quotes sources referring to ORT as "potentially the most important medical advance" of the 20th century. A variety of formulations of ORT exist, generally glucose or rice powder-based, which contain a variety of micronutrients, especially zinc (5).

"The assessment of the degree of volume loss in those with diarrhea to approximate volume and fluid losses can be found in ref 6 below. Those with severe hypovolemia should be initially rehydrated intravenously with a fluid bolus of normal saline or Ringer's lactate solution of 20-30 ml/kg followed by 100 ml/kg in the 1st 4 hours and 100 ml/kg over the next 18 hours with regular reassessment. Those with lesser degrees of hypovolemia can be rehydrated orally with a glucose or rice-derived formula with up to 4 l [4.2 qt] in the 1st 4 hours, and those with no hypovolemia can be given ORT after each liquid stool with frequent reevaluation."

References
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1. Guerrant RL, Carneiro-Filho BA and Dillingham RA: Cholera, diarrhea, and oral rehydration therapy: triumph and indictment. Clin Infect Dis. 2003; 37(3):398-405; available at: <http://cid.oxfordjournals.org/content/37/3/398.long>.
2. Gregorio GV, Gonzales ML, Dans LF and Martinez EG: Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev. 2009; (2): CD006519. doi: 10.1002/14651858.CD006519.pub2; available at: <http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006519.pub3/full>.
3. Gore SM, Fontaine O and Pierce NF: Impact of rice based oral rehydration solution on stool output and duration of diarrhea: meta-analysis of 13 clinical trials. BMJ. 1992; 304(6822): 287-91; available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881081/>.
4. Mahalanabis D, Choudhuri AB, Bagchi NG, et al.: Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med. 1973; 132(4): 197-205; available at: <http://www.searo.who.int/publications/journals/seajph/media/2012/seajph_v1n1/whoseajphv1i1p105.pdf>.
5. Atia AN and Buchman AL: Oral rehydration solutions in non-cholera diarrhea: a review. Am J Gastroenterol. 2009; 104(10): 2596-604, doi: 10.1038/ajg.2009.329; abstract available at: <http://www.ncbi.nlm.nih.gov/pubmed/19550407>.
6. WHO. The treatment of diarrhea, a manual for physicians and other senior health workers. 4th ed. 2005; available at: <http://whqlibdoc.who.int/publications/2005/9241593180.pdf>. - ProMED Mod.LL]

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

Date: Fri, 19 Apr 2019 04:57:44 +0200
By Fran BLANDY

Udier, South Sudan, April 19, 2019 (AFP) - By the time he was brought into the remote clinic in northeastern South Sudan, two-year-old Nyachoat was already convulsing from the malaria attacking his brain.   After being given medication he lies fast asleep, naked and feverish, attached to a drip, his anxious mother sitting on the bed next to him.   Nyachoat could be saved, but others are not so lucky.   In South Sudan mind-bending horrors abound of war, ethnic violence, rape, hunger and displacement.

But for civilians living in the shadow of conflict, the greatest danger is often being cut off from health services, whether due to violence or lack of development in the vast, remote areas that make up much of the country.   According to the International Committee of the Red Cross (ICRC), which supports the tiny clinic where Nyachoat is recovering in Udier village, 70 percent of all illness deaths are due to easily treatable malaria, acute watery diarrhoea and respiratory infections.   In case of more serious illness there is "no place" to go, said Nyachoat's 22-year-old mother Buk Gader.

A study by the London School of Hygiene and Tropical Medicine (LSHTM) last year showed almost 400,000 people had died as a result of South Sudan's nearly six-year war.   Half of these were due to violent deaths, and half because of the increased risk of disease and reduced access to healthcare as a result of the conflict.   ICRC health field officer Irene Oyenya said the Upper Nile region was particularly affected.   "There were (aid) organisations which were supplying primary healthcare, but then during the war, most of the organisations got evacuated" and pulled out of the country, she said.

- Blocked by swamps -
Udier is a village with a dirt airstrip whose sun-baked sand, which when not used by twice weekly ICRC flights bringing medicine and supplies, serves as a football pitch for youths. It is also a pedestrian highway for those who come from far flung huts and cattle camps to market.   In the tiny market, there is little fresh food available. Villagers can buy red onions or sit for a strong Sudanese coffee, infused with ginger, while in the dry season nomadic Falata herdswomen in flowing dresses sell milk from their cattle.   A brick building next to the airstrip, its roof long blown off in a storm, is the village school, but for several days in a row no teacher shows up.   In the surrounding villages, women are hard at work mudding their huts and re-thatching the roof in anticipation of the rains to come within weeks.

When they do come, swelling the swampy marshlands and rivers for miles around, roads will become impassable.    It becomes "difficult for young children to swim or women or men to carry patients to reach here," said Oyenya.   Marginalised for decades prior to independence from Sudan in 2011, and engulfed in war since 2013, South Sudan has seen little development. The healthcare sector is one of many propped up by international aid organisations.   However, the country is also the most dangerous for humanitarian workers with around 100 killed over the past five years, according to United Nations figures. Dozens of organisations have been forced to pull out of areas they served due to the conflict.

The Upper Nile region, where Udier is situated near the borders of Sudan and Ethiopia, was wracked by conflict in 2017 as government forces waged a major offensive to seize the opposition-held town of Pagak.   The ICRC was forced to evacuate patients and staff from its hospital and health centre in the village of Maiwut which was looted, leaving "not even a needle on the ground", according ICRC's Oyenya.   Many relocated to Udier, which was spared from fighting.   A year later in 2018, angry protesters looted around 10 humanitarian agency compounds in the town of Maban, 72 kilometres (44 miles) north of Udier.   ICRC's head of delegation in South Sudan, James Reynolds, said a peace deal signed in September 2018 "has improved security, mobility, and access for humanitarian workers".   But fresh fighting in the southern Equatorias region "has made access to certain areas very difficult."

- Women bear the burden -
In opposition-held Udier, the clinic supported by the ICRC provides crucial healthcare support to the region, where like throughout South Sudan, maternal and child mortality is sky-high.   Every day a small group of patients sits outside under a fragrant Neem tree, waiting to be helped, some from nearby while others have walked for a day or two.   Oyenya says a major challenge is that women, who do all the heavy work and take care of up to 10 children, may delay bringing them to the centre in time. That can be deadly.

Sometimes the children come alone: a nine-year-old girl in a purple polka dot dress confidently tells Oyenya she is suffering from bloody diarrhoea and, she thinks, malaria. Her parents are nowhere in sight.   For anything more serious, such as pregnancy complications, blood transfusions and operations, the nearest hospital is in government-held Maban, a five-hour drive away or a three-day walk.   The other option is a three-day walk to Gambella in Ethiopia.   "They may reach there alive, or they may not reach there alive," said Oyenya.
Date: Fri, 19 Apr 2019 03:13:16 +0200
By Andrea PALASCIANO

Naftalan, Azerbaijan, April 19, 2019 (AFP) - Immersed up to her neck in a dark viscous liquid, Sulfiya smiles in delight, confident that the fetid substance will cure her painful condition.   Sulfiya, a Russian woman in her 60s, has travelled to Azerbaijan's north-western city of Naftalan in the hope that crude oil baths at a local sanatorium will end her years of suffering from polyarthritis, a disease affecting the joints.   "This is so pleasant," she enthuses, despite the reek of engine oil.

Her naked dip in oil heated to just above body temperature lasts 10 minutes, after which an attendant scrapes the brown oil off her skin and sends her into a shower.   The native of Russia's Tatarstan region said she and her friends "have long dreamed of coming" for treatment in Naftalan.   The petroleum spa resort in the oil-rich Caucasus country is a draw for visitors despite its proximity to Nagorny Karabakh, a region disputed between Azerbaijan and Armenia in a long-running armed conflict.

After 10 days of bathing in crude oil Sulfiya says she now feels "much better" and has even reduced her medication for the polyarthritis that she has had for 12 years.   "It is a gift from God," agrees 48-year-old Rufat, an Azerbaijani journalist and opposition party member who is undergoing treatment in the sanatorium called Sehirli, or "magic" in Azerbaijani.   Azerbaijan's vast oil deposits were discovered in the mid-19th century, making what was at the time part of the Russian Empire one of the first places in the world to start commercial oil production.

Oil exports to markets all over the world are the largest sector of Azerbaijan's economy, but the crude that comes from subsoil reservoirs in Naftalan is not suitable for commercial use.   Instead the local oil is used to treat muscular, skin and bone conditions as well as gynaecological and neurological problems.   According to a legend, which spa staff readily tell clients, the healing properties of Naftalan's "miraculous oil" were discovered by accident when a camel left to die near a pool of oil was cured.

The small town of Naftalan some 300 kilometres (185 miles) from the capital Baku became a popular health resort for Soviet citizens in the 1920s.   "In the past, when there weren't any hotels or sanatoriums, people would come to Naftalan and stay with locals," said one of the doctors at the Sehirli sanatorium, Fabil Azizov, sitting in her office under a portrait of strongman President Ilham Aliyev.   "But as time passed, sanatoriums were built and treatment methods developed."

- Controversial benefits -
Some specialists warn the method has dangerous side effects.   "Despite the stories of past cures, the use of crude oil for medicinal purposes has been condemned by Western doctors as potentially carcinogenic," former journalist Maryam Omidi wrote in a 2017 book published in Britain about Soviet-era sanatoriums.

In fact, the oil at Naftalan is almost 50 percent naphthalene, a carcinogenic substance found in cigarette smoke and mothballs that in large amounts can damage or destroy red blood cells.   But doctors and patients at Naftalan brush aside any misgivings and the sanatorium even has a small museum displaying crutches that once belonged to patients who have recovered from their illnesses.

- 'We heard gunshots' -
During its heyday in the 1980s, Naftalan would host more than 70,000 visitors a year.    But in 1988, a bloody war began with neighbouring Armenia for the control of Azerbaijan's separatist Nagorny Karabakh region, which unilaterally proclaimed independence from Baku in 1991.

The conflict claimed the lives of some 30,000 people from both sides and forced hundreds of thousands to flee their homes.   A 1994 ceasefire agreement ended hostilities, but the arch foes have yet to reach a definitive peace deal and there are frequent skirmishes along the volatile frontline.   During the war, the sanatoriums in Naftalan -- a few kilometres from the frontline -- were converted into hospitals for wounded soldiers and temporary accommodation for refugees.

Over the last two decades, the Azerbaijani authorities have worked hard to re-establish Naftalan's reputation as a health resort.    They resettled refugees in other regions, demolished decrepit Soviet-era sanatoriums and built brand-new tourist facilities.   Modern Naftalan is a blend of kitsch-looking high-end spas where a week's treatment costs some 1,000 euros, and modest sanatoriums where a week's treatment costs around 100 euros.   The simmering Karabakh conflict may be out of sight, but guests can still feel uncomfortably close to the military action.   During one of the deadliest recent bouts of fighting in April 2016, "we heard gunshots," said a member of staff at Naftalan's luxurious Garabag spa, adding quickly that "everyone stayed on."
Date: Fri, 19 Apr 2019 02:59:34 +0200

Montreal, April 19, 2019 (AFP) - Three world-renowned professional mountaineers -- two Austrians and an American -- were missing and presumed dead after an avalanche on a western Canadian summit, the country's national parks agency said Thursday.   American Jess Roskelley, 36, and Austrians Hansjorg Auer, 35, and David Lama, 28, went missing Tuesday evening in Banff National Park, according to media reports. Authorities launched an aerial search the next day.

The three men were attempting to climb the east face of Howse Pass, an isolated and highly difficult route, according to Parks Canada.   They were part of a team of experienced athletes sponsored by American outdoor equipment firm The North Face, the company confirmed to AFP.   Rescuers found signs of several avalanches and debris consistent with climbing equipment, Parks Canada said, leading them to presume that the climbers were dead.

Poor weather conditions have increased avalanche risks in the mountainous area on the border between Alberta and British Columbia, with the search halted for safety reasons.   It is unlikely the three men survived, John Roskelley, father of missing Jess Roskelley, told local media in the US state of Washington.   "This route they were trying to do was first done in 2000. It's just one of those routes where you have to have the right conditions or it turns into a nightmare. This is one of those trips where it turned into a nightmare," he told the Spokesman-Review.   Himself considered one of the best American mountaineers of his generation, John Roskelley climbed Mount Everest with his son in 2003, making then 20-year-old Jess Rosskelley the youngest person to have conquered the summit.
Date: Thu, 18 Apr 2019 17:35:41 +0200

London, April 18, 2019 (AFP) - Climate change activists on Thursday brought parts of the British capital to a standstill in a fourth consecutive day of demonstrations that have so far led to more than 400 arrests.   Hundreds of protesters continued to rally at several spots in central London, where they have blocked a bridge and major road junctions this week as part of a Europe-wide civil disobedience campaign over the issue.   The Metropolitan Police said, as of 0830 GMT on Thursday, that 428 people had been arrested since the protests began on Monday, with reports of further detentions during the day.   Meanwhile, a judge denied bail to three people who appeared in court charged with obstructing the transport system at financial hub Canary Wharf on Wednesday.

District judge Julia Newton ordered the trio, who allegedly glued themselves to a train, be held in custody until their next court appearance on May 16.   Under pressure in the media to crackdown on the distruptive demonstrations, interior minister Sajid Javid warned "unlawful behaviour will not be tolerated" after meeting Met Commissioner Cressida Dick.   "No one should be allowed to break the law without consequence," he said in a statement, adding he expected police "to take a firm stance".   Protesters have been snaring traffic and setting up impromptu encampments at Waterloo Bridge, Parliament Square and at Oxford Circus in London's busy West End entertainment and shopping district.   They laid trees in pots along the bridge's length and also set up camps in Hyde Park in preparation for further demonstrations.

More than 1,000 officers were being deployed to the streets of the capital each day this week, according to the interior ministry.   The police have ordered the protesters to confine themselves to a zone within Marble Arch, a space at the junction of the park, Oxford Street and luxury hotel-lined Park Lane.   The protests are being spearheaded by the "Extinction Rebellion" activist group, which was established last year in Britain by academics and has become one of the world's fastest-growing environmental movements.   It has vowed to maintain the protests for weeks in a bid to force state action over climate change, with Heathrow Airport -- Europe's busiest flight hub -- the latest site to be targeted on Friday.

The group wants the British government to declare a climate and ecological emergency, reduce greenhouse gas emissions to zero by 2025, halt biodiversity loss and be led by new "citizens' assemblies on climate and ecological justice".   Its protesters say they are practising non-violent civil disobedience and aim to get arrested to raise awareness of their cause.    The majority arrested this week were detained for breaching public order laws and obstructing a highway.   However, police seized three men and two women outside the UK offices of energy giant Royal Dutch Shell on suspicion of criminal damage after they allegedly daubed graffiti and smashed a window there.
Date: Thu, 18 Apr 2019 07:40:27 +0200

Taipei, April 18, 2019 (AFP) - A 6.0-magnitude earthquake jolted Taiwan on Thursday, the US Geological Survey said, shaking buildings and disrupting traffic.   In the capital Taipei, highrises swayed violently while some panicked school children fled their classrooms in eastern Yilan county, according to reports.      Local media said the quake had been felt all over the island and a highway connecting Yilan and Hualien was shut down due to falling rocks.    The quake struck at 13:01 pm (0501 GMT) at a depth of 19 kilometres (11.8 miles) in eastern Hualien county. There were no immediate reports of casualties.

The island's central weather bureau put its magnitude at 6.1.   The Japan Meteorological Agency warned people living near the coast could notice some effects on sea levels, but said there would be no tsunami.   "Due to this earthquake, Japan's coastal areas may observe slight changes on the oceanic surface, but there is no concern about damage," the agency said.   Hualien was hit by a 6.4 magnitude earthquake last year that killed 17 people.    Taiwan lies near the junction of two tectonic plates and is regularly hit by earthquakes.    The island's worst tremor in recent decades was a 7.6 magnitude quake in September 1999 that killed around 2,400 people.
Date: Thu, 18 Apr 2019 03:07:58 +0200

Canico, Portugal, April 18, 2019 (AFP) - Twenty-nine German tourists were killed when their bus spun off the road and tumbled down a slope before crashing into a house on the Portuguese island of Madeira.   Drone footage of the aftermath of the accident showed the badly mangled wreckage of the bus resting precariously on its side against a building on a hillside, the vehicle's roof partially crushed and front window smashed.

Rescue workers attended to injured passengers among the undergrowth where the bus came to rest, some of them bearing bloodied head bandages and bloodstained clothes, others appearing to be more seriously hurt.   Local authorities said most of the dead were in their 40s and 50s.   They were among the more than one million tourists who visit the Atlantic islands off the coast of Morocco each year, attracted by its subtropical climate and rugged volcanic terrain.   "Horrible news comes to us from Madeira," a German government spokesman tweeted after the crash.   "Our deep sorrow goes to all those who lost their lives in the bus accident, our thoughts are with the injured," he added.

German holidaymakers were the second largest group after British tourists to visit the islands -- known as the Pearl of the Atlantic and the Floating Garden in the Atlantic -- in 2017, according to Madeira's tourism office.    The islands are home to just 270,000 inhabitants.    Filipe Sousa, mayor of Santa Cruz where the accident happened, said 17 women and 11 men were killed in the crash, with another 21 injured.    A doctor told reporters another woman died of her injuries in hospital.   "I express the sorrow and solidarity of all the Portuguese people in this tragic moment, and especially for the families of the victims who I have been told were all German," President Marcelo Rebelo de Sousa told Portuguese television.   He said he would travel to Madeira overnight.

- 'Profound sadness' -
Portuguese Prime Minister Antonio Costa added on Twitter that he had contacted German Chancellor Angela Merkel to convey his condolences   "It is with profound sadness that I heard of the accident on Madeira," he wrote on the government's Twitter page.   "I took the occasion to convey my sadness to Chancellor Angela Merkel at this difficult time," he added.  The regional protection service in Madeira confirmed 28 deaths in the accident that happened at 6:30 pm (1730 GMT) Wednesday, while hospital authorities said another woman later died of her injuries.

The bus had been carrying around 50 passengers.   Regional government Vice President Pedro Calado said it was "premature" to speculate on the cause of the crash, adding that the vehicle was five years old and that "everything had apparently been going well".   Judicial authorities had opened an investigation into the circumstances of the accident, the Madeira public prosecutor's office told the Lusa news agency.   Medical teams were being sent from Lisbon to help local staff carry out post-mortems on the dead.
Tanzania - National. 11 Apr 2019

Tanzania on Thursday [11 Apr 2019] confirmed an outbreak of dengue fever, saying the business capital, Dar es Salaam, has reported 252 cases and Tanga has 55 diagnosed cases.
- La Reunion. 10 Apr 2019

From 800 confirmed cases the previous week, the dengue epidemic increased to 904 cases in the week.
<https://la1ere.francetvinfo.fr/reunion/dengue-barre-900-cas-confirmes-semaine-est-depassee-698934.html> [in French, trans. ProMED Corr.SB]

- La Reunion. 12 Apr 2019. Dengue La Reunion (French overseas territory): dengue cases near 5000 in Q1 2019. New transmission zones have been identified in Saint-Andre, Saint-Denis, Sainte-Marie, and Sainte-Suzanne. In addition, the number of hospitalizations is increasing with 25-30 recorded weekly.

- La Reunion. 27 Mar 2019. The circulation of the dengue virus continues at a sustained level, say the prefecture and the ARS. From 11-17 Mar 2019, 682 cases of dengue fever were confirmed. Since the beginning of the year [2019], 153 emergency room visits have been recorded and 80 patients have been hospitalized. In addition, 5 deaths have been reported since the beginning of 2019, of which 2 have been considered, after investigation, as directly related to dengue fever. The most active households are located at: the Saint-Louis River, Saint Louis, Saint Pierre, the Etang-Sale Cabris Ravine.
- Cook Islands. 12 Apr 2019

As of Wednesday [10 Apr 2019], the Ministry for Health has 18 confirmed and 12 probable dengue fever cases. This is a total of 30 cases compared to 24 previously identified.
- Taihiti (French Polynesia). 13 Apr 2019

DEN-2 confirmation of several autochthonous cases