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Nigeria

Nigeria US Consular Information Sheet
June 02, 2008
COUNTRY DESCRIPTION:
Nigeria is a developing country in western Africa that has experienced periods of political instability. It has the largest population on the continent, estimated at
44 million people, and its infrastructure is not fully functional or well maintained. Read the Department of State’s Background Notes on Nigeria for additional information.

ENTRY/EXIT REQUIREMENTS: A passport and visa are required. The visa must be obtained in advance from a Nigerian Embassy or Consulate. Visas cannot be obtained on arrival at the airport. Promises of entry into Nigeria without a visa are credible indicators of fraudulent commercial schemes in which the perpetrators seek to exploit the foreign traveler's illegal presence in Nigeria through threats of extortion or bodily harm. U.S. citizens cannot legally depart Nigeria unless they can prove, by presenting their entry visas, that they entered Nigeria legally. Entry information may be obtained at the Embassy of the Federal Republic of Nigeria, 3519 International Court NW, Washington, DC 20008, telephone (202) 822-1500, or at the Nigerian Consulate General in New York, telephone (212) 808-0301. Overseas, inquiries may be made at the nearest Nigerian embassy or consulate.

Visit the Embassy of Nigeria web site at http://www.nigeriaembassyusa.org/ for the most current visa information.

Information about dual nationality or the prevention of international child abduction can be found on our web site. For further information about customs regulations, please read our Customs Information sheet.

SAFETY AND SECURITY:
The Department of State continues to caution U.S. citizens about the possible dangers of travel to some parts of Nigeria. [Please also see the Crime Section below.] In light of the risk of kidnapping, crime, militant activity, or armed attacks, the U.S. Mission restricts the travel of U.S. government personnel to the following states to official travel only: Delta, Bayelsa, Rivers and Akwa Ibom in the Niger Delta, and Edo and Imo in the south. Only essential travel by non-official Americans is recommended to these areas. In addition, the military's Joint Task Force patrols the creeks in the Niger Delta because of ongoing militant and piracy incidents, especially against oil-related facilities or infrastructure, so individuals may be questioned, detained or arrested when traveling in these sensitive areas without evidence of permission from the Nigerian government or for carrying electronic equipment such as cameras, recorders, etc. Periodically, travel by U.S. mission personnel is restricted in certain parts of Nigeria based on changing security conditions, often due to crime, general strikes, or student/political demonstrations or disturbances. See the Department of State’s Travel Warning for Nigeria for more information.

For the latest security information, Americans traveling abroad should regularly monitor the Department of State, Bureau of Consular Affairs’ web site at http://travel.state.gov, where current Travel Warnings, Travel Alerts, and the Worldwide Caution can be found.

Up-to-date information on safety and security can also be obtained by calling 1-888-407-4747 toll free in the U.S. and Canada, or for callers outside the U.S. and Canada, a regular toll-line at 1-202-501-4444. These numbers are available from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).

The Department of State urges American citizens to take responsibility for their own personal security while traveling overseas. For general information about appropriate measures travelers can take to protect themselves in an overseas environment, see the Department of State’s pamphlet A Safe Trip Abroad.

CRIME: Violent crime committed by individual criminals and gangs, as well as by some persons wearing police and military uniforms, is a problem, especially in Lagos, Abuja and other large cities, although it can occur anywhere. Some visitors and resident Americans have experienced armed muggings, assaults, burglary, carjacking, kidnappings and extortion, often involving violence. Home invasions are on the rise in Lagos, with armed robbers accessing even guarded compounds by following, or tailgating, residents or visitors arriving by car into the compound, subduing guards and gaining entry into homes or apartments. Armed robbers in Lagos also access waterfront compounds by boat. U.S. citizens, as well as Nigerians and other expatriates, have been victims of armed robbery on roads to airports during both daylight and evening hours. Law enforcement authorities usually respond to crimes slowly or not at all, and provide little or no investigative support to victims. U.S. citizens and other expatriates have experienced harassment and shakedowns at checkpoints and during encounters with Nigerian officials.

Nigerian-operated fraud scams, known as 419s, are noted for their cleverness and ingenuity. These scams target foreigners worldwide, posing risks of both financial loss and personal danger to their victims. Scams are often initiated through internet postings or from internet cafes, by unsolicited emails, faxes, and letters, or can involve credit card use. As anywhere else, no one should provide personal or financial information to unknown parties or via Nigerian telephone lines. The expansion of bilateral law enforcement cooperation, which has resulted in numerous raids on commercial fraud premises, has reduced the overall level of overt fraud activity, but new types of sophisticated scams are introduced daily.

American citizens are very frequently the victims of Nigerian confidence artists offering companionship through internet dating websites. These confidence artists almost always pose as American citizens visiting or living in Nigeria who unexpectedly experience a medical, legal, financial or other type of “emergency” that requires the immediate financial assistance of the American citizen in the United States. In these cases, we strongly urge the American citizen in the United States to be very cautious about sending money to any unknown person purportedly acting on their behalf, or traveling to Nigeria to meet someone with whom their sole communications have been via the internet. Other common scams involve a promise of an inheritance windfall, work contracts in Nigeria, or an overpayment for goods purchased on-line. For additional information on these types of scams, see the Department of State's publication, International Financial Scams.

Commercial scams or stings that targets foreigners, including many U.S. citizens, continue to be a problem. One needs to be alert to scams that may involve U.S. citizens in illegal activity, resulting in arrest, extortion or bodily harm. These scams generally involve phony offers of either outright money transfers or lucrative sales or contracts with promises of large commissions or up-front payments, or improperly invoke the authority of one or more ministries or offices of the Nigerian government and may cite, by name, the involvement of a Nigerian government official. In some scams, government stationery and seals are also improperly used to advance the scam. The ability of U.S. consular officers to extricate U.S. citizens from unlawful business deals or scams and their subsequent consequences is extremely limited. U.S. citizens have been arrested by police officials and held for varying periods on charges of involvement in illegal business activity or scams. Nigerian police or other law enforcement officials do not always inform the U.S. Embassy or Consulate immediately of the arrest or detention of a U.S. citizen. The U.S. Department of Commerce has advisories to the U.S. business community on a variety of issues that should be seriously reviewed with respect to doing business in Nigeria. To check on a business’s legitimacy while in the United States, contact the Nigeria Desk Officer at the International Trade Administration, Room 3317, Dept. of Commerce, Washington, D.C. 20230, telephone 1-800-USA-TRADE or (202) 482-5149, fax (202) 482-5198. If you are abroad, contact the nearest U.S. Embassy or Consulate.

The Department of State encourages all travelers abroad to register their travel. The most convenient way to do so would be through the online travel registration page. Travelers may also register in person at the U.S. Embassy in Abuja or the U.S. Consulate General in Lagos. See the section on Registration / Embassy Location below.

INFORMATION FOR VICTIMS OF CRIME: The loss or theft abroad of a U.S. passport should be reported immediately to the local police and the nearest U.S. Embassy or Consulate. If you are the victim of a crime while overseas, in addition to reporting to local police, please contact the nearest U.S. Embassy or Consulate for assistance. The Embassy/Consulate staff, for example, can provide you with a list for appropriate medical care, or contact family members or friends and explain how funds could be transferred to you to cover unexpected costs. Although the investigation and prosecution of the crime is solely the responsibility of local authorities, consular officers can help you to understand the local criminal justice process and to find an attorney if needed.

See the Department of State’s information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION: While Nigeria has many well-trained doctors, medical facilities in Nigeria are in poor condition, with inadequately trained nursing staff. Diagnostic and treatment equipment is most often poorly maintained, and many medicines are unavailable. Caution should be taken as counterfeit pharmaceuticals are a common problem and may be difficult to distinguish from genuine medications. This is particularly true of generics purchased at local pharmacies or street markets. Hospitals often expect immediate cash payment for health services.

Information on vaccinations and other health precautions, such as safe food and water precautions and insect bite protection, may be obtained from the Centers for Disease Control and Prevention’s hotline for international travelers at 1-877-FYI-TRIP (1-877-394-8747) or via the CDC’s web site at http://wwwn.cdc.gov/travel/default.aspx. For information about outbreaks of infectious diseases abroad, consult the World Health Organization’s (WHO) web site at http://www.who.int/en. Further health information for travelers is available at http://www.who.int/ith.

MEDICAL INSURANCE: The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their health insurance policy applies overseas and whether it will cover emergency expenses such as a medical evacuation from a foreign country to the United States or another location. Please see the our brochure on medical insurance overseas.

TRAFFIC SAFETY AND ROAD CONDITIONS: While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States. The information below concerning Nigeria is provided for general reference only and may not be totally accurate in a particular location or circumstance.

Roads in many areas are generally in poor condition, causing damage to vehicles and contributing to hazardous traffic conditions. There are few working traffic lights or stop signs. The rainy season from May to October is especially dangerous because of flooded roads and water-concealed potholes.

Excessive speed, unpredictable driving habits, and the lack of basic maintenance and safety equipment on many vehicles are additional hazards. Motorists seldom yield the right-of-way and give little consideration to pedestrians and cyclists. Gridlock is common in urban areas. Chronic fuel shortages have led to long lines at service stations, which disrupt or block traffic for extended periods.

Public transportation vehicles are unsafe due to poor maintenance, high speeds and overcrowding. Motorbikes, known in Nigeria as "okadas," are a common form of public transportation in many cities and pose particular danger to motorists, their own passengers and pedestrians. Motorbike drivers frequently weave in and out of traffic at high speeds and observe no traffic rules. Motorbikes are banned within Abuja's city limits. Passengers in local taxis have been driven to secluded locations where they were attacked and robbed. Several of the victims required hospitalization. The U.S. Mission advises that public transportation throughout Nigeria be avoided.

It is recommended that short-term visitors not drive in Nigeria. A Nigerian driver's license can take months to obtain, and to date an international driving permit is not recognized. Major hotels offer reliable car-hire services complete with drivers. Reliable car-hire services can also be obtained at the customer service centers at the airports in Lagos, Abuja, and Kano. Inter-city travelers must also consider that roadside assistance is extremely scarce, and as noted above medical facilities and emergency care are poor, meaning that being involved in a traffic incident might result in a lack of available medical facilities to treat either minor or life-threatening injuries.

All drivers and passengers are reminded to wear seat belts, lock doors, and raise windows. It is important to secure appropriate automobile insurance. It is also important to be aware that drivers and passengers of vehicles involved in accidents resulting in injury or death have experienced extra-judicial actions, i.e., mob attacks, official consequences such as fines and incarceration or involvement with the victim's family. Night driving should be done with extreme caution, but it is recommended to avoid driving between 6:00 p.m. and 6:00 a.m. as bandits and police roadblocks are more numerous at night. Streets are very poorly lit, and many vehicles are missing one or both headlights, tail lights, and reflectors.

The Government of Nigeria charges the Federal Road Safety Commission with providing maps and public information on specific road conditions. The Federal Road Safety Commission may be contacted by mail at: Ojodu-Isherri Road, PMB 21510, Ikeja, Lagos; telephone [243] (1) 802-850-5961 or [234] (1) 805-684-6911.
Please refer to our Road Safety page for more information.

AVIATION SAFETY OVERSIGHT: As there is no direct commercial air service to the United States by carriers registered in Nigeria, the U.S. Federal Aviation Administration (FAA) has not assessed Nigeria’sCivil Aviation Authority for compliance with International Civil Aviation Organization (ICAO) aviation safety standards. For more information, travelers may visit the FAA’s web site at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.

The Port Harcourt International Airport, which was closed in mid-2006 for rehabilitation, resumed operations in December 2007 for domestic daylight flights. Installations and improvements needed for international flights and night operations are expected to be completed in 2008.

For additional information on aviation safety concerns, see the Department of State’s Travel Warning for Nigeria.
SPECIAL CIRCUMSTANCES:
Permission is required to take photographs or videotape any government buildings, airports, bridges, and in areas where the military is operating throughout the country. These sites include, but are not limited to, Federal buildings in the Three Arms Zone (Presidential palace area, National Assembly, Supreme Court/Judiciary) of the capital of Abuja, other government buildings around the country and foreign Embassies and Consulates. Many restricted sites are not clearly marked, and application of these restrictions is subject to interpretation by the Nigerian security services and can result in detention. Permission may be obtained from Nigeria's State Security Services, but even permission may not prevent the imposition of penalties or detention. Penalties for unauthorized photography or videography may include confiscation of the still or video camera, exposure of the film or deletion of film footage, a demand for payment of a fine or bribe, and/or detention, arrest, or physical assault. For these reasons, visitors to Nigeria should avoid taking still photos or videotaping in and around areas that are potentially restricted sites, including any government sites.

The Nigerian currency, the naira, is non-convertible. U.S. dollars are widely accepted. Nigeria is a cash economy, and it is usually necessary to carry sufficient currency to cover the expenses of a planned visit, which makes travelers an attractive target for criminals. Credit cards are rarely accepted beyond a few upscale hotels. Due to credit card fraud in Nigeria and by cohorts in the United States, credit card use should be considered carefully. While Citibank cashes some traveler’s checks, most other banks do not. American Express does not have offices in Nigeria; however, Thomas Cook does. Inter-bank transfers are often difficult to accomplish, though money transfer services such as Western Union are available. For further information, visitors may contact the U.S. Embassy or Consulate.

Please see the Department of State’s information on Customs Information.

CRIMINAL PENALTIES: While in a foreign country, a U.S. citizen is subject to that country's laws and regulations, which sometimes differ significantly from those in the United States and may not afford the protections available to the individual under U.S. law. Penalties for breaking the law can be more severe than in the United States for similar offenses. Persons violating Nigerian laws, even unknowingly, may be expelled, detained, arrested or imprisoned. Penalties for possession, use, or trafficking in illegal drugs in Nigeria are severe, and convicted offenders can expect long jail sentences and heavy fines. Engaging in sexual conduct with children or using or disseminating child pornography in a foreign country is a crime, prosecutable in the United States. Please see the Department of State’s information on Criminal Penalties.

CHILDREN'S ISSUES: For information see the Department of State’s Office of Children’s Issues web pages on intercountry adoption and international parental child abduction.

REGISTRATION / EMBASSY LOCATION:
Americans living or traveling in Nigeria are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration website so that they can obtain updated information on travel and security within Nigeria and other general information.Americans withoutInternet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.

The U.S. Embassy is located at 1075 Diplomatic Drive, Central Area, Abuja. American citizens can call [234] (9) 461-4176 during office hours (Monday through Thursday, 7:30 a.m. to 4:30 p.m.; Friday, 7:30 a.m. to 1:30 p.m.). For after-hours emergencies, call [234] (9) 461-4000. The email address for the Consular Section in Abuja is ConsularAbuja@state.gov.

The U.S. Consulate General is located at 2 Walter Carrington Crescent, Victoria Island, Lagos. American citizens can call [234] (1) 261-1215 during office hours (7:30 a.m. to 4:00 p.m.). For after-hours emergencies, call [234] (1) 261-1414, 261-0050, 261-0078, 261-0139, or 261-6477. The e-mail address for the Consular Section in Lagos is Lagoscons2@state.gov.

The Embassy and Consulate website is http://nigeria.usembassy.gov/.
* * *
This replaces the Consular Information Sheet dated April 16, 2007, to update sections on Country Description, Safety and Security, Crime, Traffic Safety and Road Conditions, Aviation Safety Oversight, Special Circumstances and Registration / Embassy Location.

Travel News Headlines WORLD NEWS

Date: Tue 14 May 2019
Source: Devax [edited]

In the departure hall of Nigeria's busiest airport, Murtala Muhammed International in Lagos, passengers get their travel documents ready for check-in. In addition to a passport, ticket, and visa, travellers to many destinations need a yellow fever vaccination card, as Nigeria struggles with an ongoing outbreak. The cards are automatically issued following immunization at a government hospital and are validated with a signature and stamp from the port health authority. But although 1 in 5 people who contract yellow fever in Nigeria die from it, not everyone gets immunized, and some are finding ways to bypass the travel requirements, increasing the risk of the epidemic-prone disease spreading to other countries.  One way to do it is to buy a falsified vaccination card, readily available at the airport for those who either don't want to be immunized or don't have enough time before they travel.

The Nigerian government told Devex the cards are fake, while evidence at the airport suggests they are authentic but fraudulently obtained. Airport staff and travelers said the cards had been bought at the port health authority's store, duly stamped and signed as a way of generating underhand revenue for staff. Devex was able to buy one for 3000 Nigerian naira [USD 8.50] with no evidence of immunization.  The port health authority denied the involvement of their staff and said that banners at the airport warn travelers of the dangers of fake cards.  "I don't think we are doing a bad thing," an airport worker told Devex. "Without the card, you might miss your flight and that will be [a] waste of money over an ordinary card."

Desperate travellers continue to request them. "Some will even call you to get one for them on their way to the airport. We also have friends and relatives that want to travel and know that we have access to the cards," she said. One traveler who has used such a card on trips to South Africa, Kenya, and Ethiopia said none of the embassies had flagged the card as falsified, nor denied him a visa. He suggested the lengthy process of obtaining the card legally -- which means scheduling a hospital appointment and then waiting 10 days after immunization for the card to become valid -- means many travelers are not able to get it on time.  "I see it as an outcome of a systemic failure. Why will I be going from one office to another and be intentionally delayed because I want to do the right thing when I can get the same card within 2 minutes at the airport for less amount?" he said.

But as the situation at the airport shows, even those who have ready access to vaccines are failing to get them.  At the end of last year [2018], the Nigerian health ministry took steps to introduce electronic verification into the vaccination card system. "The introduction of an electronic version of the yellow card stemmed from the ubiquitous fake versions of the card that are notoriously being issued by unauthorized personnel for years," a health ministry spokesperson told Devex. Although the new system was expected to kick in from 1 Apr [2019], the deadline has been extended to the end of June 2019 to give people more time to sign up.

Dr. Lawal Bakare, founder of EpidAlert, a Nigerian nonprofit working on disease prevention, said it will be more easily available, affordable, and verifiable, with registration and payment made online.  To prevent health authority staff selling falsified documents, cash has been removed from the system. "You cannot pay cash. Money goes directly to government wallet. A reference code is generated and is linked to a traveler's passport number which can be checked against [a] database which those that are selling the fake cards will not have access to," Bakare explained.

Despite the government's investment in the new portal, adoption has been limited. "People were not aware of the new card and we advocated for the shift of the deadline," Bakare said, adding that the distraction of the Nigerian election at the start of the year "did not allow the new yellow cards to get much attention."  His organization is now planning awareness sessions for frequent travelers, multinational companies, universities, and embassies to drive adoption. "We have a duty as a country to protect the global health system," he said. But he added that the new system does not directly tackle the underlying problem behind the emergence of a market for fake vaccine cards, the hesitancy among travellers to be immunized.
 
To tackle that, Bakare said travelers need to know the dangers of falsifying vaccine cards and be encouraged to apply for legitimate cards earlier. "There is no excuse for not receiving necessary immunization and we need a sense of patriotism, doing the right thing and not putting others at risk," he said.  Wonodi advocated for good, regular data and strong coordinating platforms to ensure vaccination programs are reaching the right areas, and that work is happening to engage communities. She expressed optimism about the future of vaccination in Nigeria and across Africa but added that hesitancy remains a risk with the rise of technologies that can spread false information [about vaccine risk] fast.  "The good news is that this same technology ... can also be used to coordinate a response fast. It can also be used to train health workers and community volunteers to deliver services better. It can be used to remind parents to vaccinate their children. It can be used to educate community leaders to support immunization and religious leaders to preach immunization," Wonodi said.  [Byline: Paul Adepoju]
==================================
[Fake yellow fever (YF) vaccination cards have been a recurring problem in several African countries in the recent past, including in Nigeria. The above report indicates that the problem of sale of fake YF vaccination cards persists in Nigeria up to the present time. The sale of fake yellow fever vaccination cards to individuals who did not receive the vaccine presents a serious public health risk inside Nigeria and outside of it. Susceptible, unvaccinated individuals can contribute to a YF outbreak within the country.

YF virus is endemic in Nigeria, and transmission is active this year (2019). From 1 Jan to 3 Mar 2019, there have been 364 suspected YF cases reported in 177 local government areas. An unvaccinated, viraemic individual with a fake card who becomes infected in Nigeria could carry YF virus to localities where vector mosquitoes are present and initiate an outbreak of this serious disease in countries where YF does not occur and the population is unvaccinated, such as tropical South and South East Asia. One wonders whether these countries will deny visas to or admittance of individuals coming from Nigeria unless they can prove that their cards are legitimate. Fortunately, the Nigerian government authorities are initiating an electronic system for card issuance that should assure that vaccination has been accomplished that would put a stop to these false practices. - ProMED Mod.TY]

[Maps of Nigeria:
Date: Sun 21 Apr 2019
Source: Nigeria Center for Disease Control (NCDC) Situation Report [edited]

Highlights
----------
- In the reporting week 16 (15-21 Apr 2019) 6 new confirmed cases were reported from 4 states -- Edo (2), Ondo (2), Taraba (1) and Kebbi (1) states with one new death in Kebbi state
- From 1 Jan-21 Apr, 2019, a total of 2289 suspected cases have been reported from 21 states. Of these, 546 were confirmed positive, 15 probable and 1728 negative (not a case)
- Since the onset of the 2019 outbreak, there have been 123 deaths in confirmed cases. Case fatality ratio in confirmed cases is 22.5%
- 21 States (Edo, Ondo, Bauchi, Nasarawa, Ebonyi, Plateau, Taraba, FCT, Adamawa, Gombe, Kaduna, Kwara, Benue, Rivers, Kogi, Enugu, Imo, Delta, Oyo, Kebbi and Cross River) have recorded at least one confirmed case across 81 Local Government Areas -- Table 1, Figure 1
- 93% of all confirmed cases are from Edo (36%), Ondo (28%), Ebonyi (8%), Bauchi (8%), Taraba (7%) and Plateau (6%) states -- Figure 1
- Predominant age-group affected is 21-40 years (Range: >1 month to 89 years, Median Age: 32 years) -- Figure 6
- The male to female ratio for confirmed cases is 1.2:1 -- Figure 6
- In the reporting week 16 (15-21 Apr 2019), no new health care worker was affected. A total of 17 health care workers have been infected since the onset of the outbreak in 7 States -- Edo (7), Ondo (3), Ebonyi (2), Enugu (1), Rivers (1), Bauchi (1) Benue (1) and Plateau (1) with 2 deaths in Enugu and Edo States
- 13 patients are currently being managed at various treatment centres across the country: Federal Medical Centre Owo (8), Taraba (3) and Plateau (2)
- A total of 7193 contacts have been identified from 20 States. Of these 654 (9.1%) are currently being followed up, 6475 (90.1%) have completed 21 days follow up, while 8 (0.1%) were lost to follow up. 116 (1.6%) symptomatic contacts have been identified, of which 56 (0.8%) have tested positive
- National Lassa fever multi-partner, multi-sectoral Emergency Operations Centre (EOC) continues to coordinate the response activities at all levels

Figure 1 [map]. Distribution of confirmed Lassa fever cases in Nigeria as at 21 Apr 2019
Figure 2 [map]. LGA attack rate of confirmed Lassa fever cases in Nigeria as at 21 Apr 2019
Figure 3 [graph]. Epicurve of Lassa fever confirmed (546) cases in Nigeria - week 1 2019 to week 16 2019
Figure 4 [graph]. Weekly trends of Lassa fever confirmed cases in Nigeria, week 1 2019 to week 16 2019
Figure 5 [graph]. Confirmed Lassa fever cases in Nigeria with state specific case fatality rates (CFR) as at 21 Apr 2019
Figure 6 [graph]. Age-Sex distribution of Confirmed Lassa fever cases in Nigeria as at 21 Apr 2019
=========================
[The 6 new confirmed and 2217 suspected cases (up from 3 confirmed and up to 2289 suspected cases from 2217 cases in the previous report) indicate that Lassa fever virus transmission is continuing but perhaps with reduced incidence. Nigeria is still well within the period of the year when more cases usually occur, as illustrated in the graph in Figure 3. There has been a peak in case numbers between weeks 1 and 11 (1 Jan-17 Mar 2019) over the past 3 years and probably will be the case again this year (2019). There are 123 confirmed deaths, up one from 122 in the previous reporting period. Fortunately, there are no new healthcare workers infected during this reporting period, and the total number of infected healthcare workers remains at 17. This outbreak remains widespread so far in 2019, with confirmed cases occurring in 21 states, and the number of affected LGAs remains at 81.

Transmission of Lassa virus occurs when individuals are in contact with rodent reservoir hosts' excreta or are within healthcare facilities. It would be interesting to know whether the prevalence of Lassa fever virus has been increasing in populations of rodent hosts in areas where human cases are occurring.

Images of the rodent reservoirs of Lassa fever virus:
_Mastomys natalensis_:
_Mastomys erythroleucus_ and _Hylomyscus pamfi_:

The maps and graphs in the report above are interesting and provide a good picture of how the outbreak has progressed over time. - ProMED Mod.TY]

[Maps of Nigeria:
Date: Sun, 21 Apr 2019 23:36:53 +0200

Kano, Nigeria, April 21, 2019 (AFP) - Two people including a British aid worker have been shot dead and four tourists abducted in an attack by armed gunmen on a holiday resort in north-western Nigeria, police said on Sunday.   Police and aid agency Mercy Corps named the dead woman as Faye Mooney.   "Faye was a dedicated and passionate communications and learning specialist", Chief executive Neal Keny-Guyer said in a statement posted on social media, adding that colleagues were "utterly heartbroken".   Mooney had "worked with Mercy Corps for almost two years, devoting her time to making a difference in Nigeria", Keny-Guyer added.

Gunmen stormed the Kajuru Castle resort, 60 kilometres (40 miles) southeast of Kaduna City at 11.40 pm (2240 GMT) on Friday, Kaduna state police spokesman Yakubu Sabo told reporters.   The Briton "was gunned down from the hill by the kidnappers who tried to gain entrance into the castle but failed", Sabo said.   "They took away about five other locals but one person escaped," he said.   A Nigerian man believed by local residents in Kajuru to be Mooney's partner was also killed in the attack on the resort where a group of 13 tourists had arrived from Lagos, southwest Nigeria the police spokesman said.   In Kaduna and the wider northwest region, kidnapping for ransom has become an increasingly rampant, particularly on the road to the capital, Abuja, where armed attacks have thrived.

Kidnapping in Nigeria's oil-rich south, has long been a security challenge, where wealthy locals and expatriate workers are often abducted.   Yet the problem has escalated in northern areas too, like Kaduna where criminal gangs made up of former cattle rustlers have been pushed into kidnapping after military crackdowns on cattle theft.   Kajuru is also flash point in the deadly conflict over increasingly limited land resources in Africa's most populous country, between herders and farmers, predominantly across central and northern Nigeria.    The conflict has increasingly taken on ethnic and religious dimensions in the region, with the Fulani Muslim herders in conflict with Christian Adara farmers in Kajuru.

Tourists are rarely affected by the herder-farmer violence and Kajuru Castle resort has attracted many foreign and local visitors.   Yet police have struggled to thwart kidnappers in the region. The latest attack comes in a resort in northern Nigeria, particularly popular amongst foreign and well-to-do local tourists.   In January four western tourists -- two Americans and two Canadians -- were also abducted in Kaduna by gunmen in an ambush in which two of their police escorts were killed.   Earlier in April, recently re-elected President Muhammadu Buhari, ordered his most senior security chiefs to curb kidnapping in the region.
Date: Sun 3 Mar 2019
Source: Nigeria CDC Yellow fever situation report in Nigeria [edited]

Highlights
----------
In this reporting week, 25 Feb to 3 Mar 2019:
- 88 suspected cases were recorded.
- 2 new presumptive positive cases were recorded: NCDC Central Public Health Laboratory (CPHL) reported 2 new presumptive positive cases from Edo State - 2 (Uhunmwode local government area [LGA]).
- No new confirmed case from the Institute Pasteur (IP) Dakar.
- Last IP Dakar confirmed cases were 20 Feb 2019.
- 18 states have recorded at least one confirmed case from IP Dakar since the onset of the outbreak in 2017.
- Yellow fever response activities are being coordinated by the Yellow Fever Technical Working Group (YF TWG).

From 1 Jan to 3 Mar 2019:
- 364 suspected cases have been reported in 177 (22.9%) LGAs.
- All suspected cases had blood samples collected.
- 14 presumptive positive and one inconclusive cases from 4 states in 10 LGAs: Edo (8), Ondo (4), Kebbi (1), Imo (1), and the inconclusive case from Imo (1).
- 5 confirmed cases were reported from 2019 samples sent to IP Dakar: Edo (2), Ondo (2), and Imo (1).
- No death has been recorded.

Summary of outbreak
-------------------
A yellow fever outbreak has been active in Nigeria since September 2017:
- From 2017 to 2018, 139 cases were confirmed in 17 states: Kwara (8), Kogi (10), Kano (1), Zamfara (19), Kebbi (7), Nasarawa (3), Niger (1), Katsina (2), Edo (69), Ekiti (2), Rivers (1), Anambra (1), FCT [Federal Capital Territory] (10), Benue (1), Delta (1), Ondo (2), and Abia (1) in 46 LGAs.
- From September 2017 to December 2018, 276 samples (presumptive positive, 239; inconclusive, 37) were sent to IP Dakar for reconfirmation.
- All Nigerian states (36 plus FCT) reported 4100 suspected cases in 604 (78%) LGAs.
- Of all suspected, probable, and confirmed cases, 80 deaths were recorded with 29 deaths among confirmed cases.
- The case fatality rate (CFR) for all cases (suspected, probable, and confirmed) is 2%, and 21% for confirmed cases.
- Yellow fever preventive mass vaccination campaign (PMVC) has been completed in 12 states, led by NPHCDA:
-- 2013 PMVC phase 1: Nasarawa, Cross River, Akwa Ibom.
-- 2018 phase 2a: Kogi, Kwara, and Zamfara and in 58 political wards in 25 LGAs in Borno State.
-- 2018 phase 2b PMVC: Sokoto, Kebbi, Niger, FCT, Plateau, and Borno (3 LGAs: Askira/Uba, Chibok, Konduga) states.
-- Yellow fever reactive vaccination campaigns were implemented in Katsina (Danja LGA), Edo (13 LGAs), and Benue (Vandekeiya).
-- 2019 phase 3 PMVC will be implemented in all LGAs where no yellow fever campaigns have been implemented in Edo, Ekiti, Katsina, and Rivers states.

EPI - summary [table, graphs, and maps]

Table 1: Showing all affected states and cases with yellow fever as of week 9, 25 Feb to 3 Mar 2019 [with data for categories that interested readers can see at the source URL]:
- Total number of cases in the line list
- Attack rate per 100 000 population
- Number of LGAs with suspected cases
- Number of LGAs with presumptive/inconclusive cases
- Number of LGAs with confirmed cases from IP Dakar
- Number suspected cases with blood sample collected in Nigeria
- Number of presumptive positives in Nigeria
- Number with inconclusive results in Nigeria
- Total number of samples sent to IP Dakar
- Number positive cases from IP Dakar
- Total number negative in IP Dakar
- Number awaiting result from IP Dakar
- Number of deaths from all cases
- Number of deaths among presumptive positives
- Number of deaths from IP Dakar confirmed

Figure 1 [graph]: Epidemic curve of suspected/presumptive cases of yellow fever in Nigeria as of week 8, 18-24 Feb, 2019
Figure 2 [graph]: Trend of confirmed cases of yellow fever in Nigeria 2017-2019
Figure 3 [graph]: Epicurve of yellow fever cases in Edo state (Sep 2018 to Feb 2019)
Figure 4: Map of Nigeria showing states with suspected/presumptive cases as of week 9, 25 Feb to 3 Mar 2019
Figure 5 [graph]: 2018 Phase 2 Nov to Dec 2018 preventive mass vaccination campaigns admin vaccination coverage by state
=====================
[The yellow fever (YF) outbreak peaked in weeks 48-51 of 2018. Numbers of confirmed cases fell abruptly on 1 Jan 2019, and confirmed cases have remained a low level to date but suspected cases have continued between weeks 1 and 6. The ongoing mass vaccination campaign in affected states in 2019 has reached or exceeded 90% in 5 cases and nearly so in Plateau state. That coverage has undoubtedly contributed to the decline in case numbers, and its continuation is prudent, as YF virus will not disappear from the country. - ProMED Mod.TY]

[Maps of Nigeria:
Date: Tue 5 Mar 2019
Source: Nigeria Center for Disease Control, situation report [edited]

2018-2019 Cerebrospinal meningitis outbreak in Nigeria/Epi Week 10: highlights
----------
- This is the 12th situation report for 2018/2019 season.
- The National Cerebrospinal Meningitis Emergency Operations Centre has been monitoring cases and ensuring preparedness and coordination of response across the states.
- States in the meningitis belt were formally placed on alert on 8 Nov 2018.
- As at epi week 9 [ending Sat 2 Mar 2019] 9 new suspected cases were reported.
- Beginning from 1 Oct 2018 to 5 Mar 2019, a total of 285 suspected cases have been reported from 14 states.
- 25 samples were positive for bacterial meningitis. - _Neisseria meningitidis_ serogroup C (NmC) accounted for 32.0% (8) of the positive cases.
- So far, 22 deaths (CFR=7.7%) have been recorded among all suspected cases.
- In the last 4 weeks (Epi Week 6 [ending 9 Feb 2019] to Epi Week 9, 2019), no LGA [local government area] is in the alert threshold.
- Media messages have been developed and disseminated via conventional and social media.
- The multi-agency CSM Emergency Operation Centre (EOC) has been activated.
- Monitoring of the situation continues across the high-risk states.

[The epidemic curve and a map of Nigeria showing the distribution of cerebrospinal meningitis cases by Nigerian states as at 5 Mar 2019 is available at the source URL. - ProMED Mod.ML]
===================
[Northern Nigeria lies within the African meningitis belt, the semi-arid areas of sub-Saharan Africa, where epidemics of meningococcal meningitis recur each year during the hot, dry season, between December and June. _Neisseria meningitidis_ serogroup A had been the main cause of epidemic meningococcal disease in this region (<http://www.who.int/csr/resources/publications/meningitis/whoemcbac983.pdf>).

Since
the introduction of the meningococcal A conjugate vaccine in countries of the African meningitis belt beginning in 2010, however, WHO has noted a decrease in the number of cases of meningitis; in fact, the number of cases in 2013 was the lowest recorded during the epidemic season in the prior 10 years (<http://www.who.int/csr/don/2013_06_06_menin/en/>), and _N. meningitidis_ serogroup A was noted to be no longer the predominant pathogen, having been replaced by other serogroups, notably serogroup C. - ProMED Mod.ML]

[HealthMap/ProMED map available at:
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World Travel News Headlines

Date: Tue, 21 May 2019 12:37:30 +0200

Khartoum, May 21, 2019 (AFP) - Sudanese protest leaders called on their supporters Tuesday to prepare for a general strike after talks with the country's military rulers stalled on who will lead an agreed three-year transition.   Protest leaders had reached agreement with the ruling military council on the other main aspects of the transition.   But early on Tuesday, the generals who overthrew veteran president Omar al-Bashir last month baulked at protesters' demands for a civilian head and a civilian majority for an agreed new sovereign council to lead the transition.

"In order to achieve a full victory, we are calling for a huge participation in a general political strike," said the Sudanese Professionals Association, which took the lead in organising the four months of nationwide protests that led to Bashir's ouster.   "The strike is our revolutionary duty and the participation in the sit-in ... is a crucial guarantee to achieve the goals of the revolution."

Protest leader Madani Abbas Madani told AFP the preparations for a "general political strike and civil disobedience" were already under way.   "Whenever we will decide on applying these plans, we will make an announcement," said Madani, a prominent leader of protest umbrella group the Alliance for Freedom and Change.   The two sides launched what had been billed as a final round of talks on the transition late on Sunday.

The military council has faced pressure from Western government and the African Union to agree to a civilian-led transition -- the central demand of the thousands of demonstrators who have spent weeks camped outside army headquarters in Khartoum.   When talks broke up early on Tuesday, neither side said when they would resume.

Protest leader Siddiq Yousef told reporters they had been suspended.   "The main point of dispute that remains is concerning the share of representatives of the military and the civilians in the council and who will be the head of the new body," the two sides said in a joint statement.   The military council has been pushing for its chairman General Abdel Fattah al-Burhan to head the new sovereign council but protest leaders want a civilian.
Date: Tue, 21 May 2019 05:22:30 +0200
By John WESSELS with Samir TOUNSI in Kinshasa

Butembo, DR Congo, May 21, 2019 (AFP) - People in Ebola-hit eastern DR Congo are struggling to come to terms with high-security burials that are part of a hard-pressed strategy to roll back the disease.   Anyone who dies of the highly infectious haemorrhagic fever has to be buried in carefully-controlled conditions designed to minimise the risk of infection from body fluids.   But that means ceremonies are carried out in sanitised conditions, with relatives and friends kept at a distance -- for many, a traumatic break with traditions that demand the body of a loved-one be seen or touched.   "We're astonished she's being buried like this," said Denise Kahambu as she watched the specially-prepared burial in Butembo of her 50-year-old cousin, Marie-Rose.   "They said she died of Ebola," she said sceptically.   First declared last August, the epidemic has now claimed nearly 1,200 lives -- 200 of them in May alone.    The outbreak is the second deadliest on record, after an epidemic that killed more than 11,300 people in West Africa in 2014-16.

The burial in Butembo followed strict precautions. A pick-up truck delivered the coffin to the burial site, where a grave had been prepared, as the family stood by at a distance.   Gloved Red Cross workers handled the burial, which took place in silence and without a religious ceremony.   A family member or loved one was allowed only to place a cross on the tomb, once they too had donned protective gloves.   Half a dozen police officers escorted the convoy and remained on guard throughout.    On Friday, two burial teams from the treatment centres were attacked by stone-throwing crowds at Butembo and Bunia, a little further north in Ituri province, according to the health ministry. One burial worker was injured.

- Culture shock -
"The custom is that the body of the deceased first returns to the home. And once people have mourned, they have the chance to touch the body for the last time," said Seros Muyisa Kamathe, a guide and interpreter in Beni and Butembo.   "Before going to the cemetery, you open the coffin so people can take one last look at the deceased."

And normally it would be the family and neighbours who would take responsibility for digging the grave -- and deciding where if should be.   Ebola experts say denial and resistance were familiar obstacles in the 2014-16 epidemic in the West African states of Guinea, Liberia and Sierra Leone.   The World Health Organization (WHO) has a 12-step protocol for dealing with burials so that handling of the remains is kept to a minimum, but it also emphasises the importance of respect and mourning.   "The burial process is very sensitive for the family and the community and can be the source of trouble or even open conflict," it acknowledges.    No burial should begin until family agreement has been obtained, and workers should engage with the community "for prayers to dissipate tensions
and provide respectful time," it says.

- Armed escorts -
The burial process is part of the notoriously time-consuming and labour-intensive task of combatting Ebola.   And in this troubled region, the challenge has been further complicated by bloody deadly attacks on Ebola treatment centres by local militias.   Suspicion, political infighting in the capital Kinshasa and militia violence provide a fertile breeding ground for the virus.   Sometimes local people cover the graves overnight as a sign of their opposition, the ministry said.   In Butembo, health workers need an armed escort when they go looking for cases of Ebola in some neighbourhoods, an AFP photographer noted during one outing Saturday evening.

WHO Director-General Tedros Adhanom Ghebreyesus, at the opening of the organisation's annual assembly on Monday, described the outbreak as "one of the most complex health emergencies any of us have ever faced."   "Unless we unite to end this outbreak we run the risk it will become more widespread and more expansive and more aggressive," he said.   "We are not just fighting a virus," Tedros insisted. "We're fighting insecurity. We're fighting violence. We're fighting misinformation... and we're fighting the politicisation of an outbreak."   On the plus side, health officials are keen to emphasise some important gains. More than 118,000 have been vaccinated against the virus, and no cases have been recorded in neighbouring Rwanda and Uganda.
Date: Mon, 20 May 2019 15:09:54 +0200

Milan, May 20, 2019 (AFP) - Alitalia has scrapped around half its flights scheduled for Tuesday after a call to strike by Italian pilots, cabin crew and ground staff.   The industrial action by employees of Alitalia, Blue Air and Blue Panorama was confirmed Monday over the future of the sector and specifically that of the troubled national carrier.   Alitalia has cancelled around half its flights on Tuesday, as well as some late Monday and early Wednesday. The company said it hoped to get 60 percent of passengers to their destination.

Unions lamented "on the one hand, a rising number of passengers and flights, and on the other a proliferation of bankruptcies", a statement said.   They are worried about Alitalia's future and want their jobs protected.   The Italian government earlier this month extended to June 15 a deadline for the state railway to submit a concrete takeover offer, following a request from Alitalia's administrators for more time.   Italy's state railway Ferrovie dello Stato (FS) floated a bid to buy Alitalia at the end of October, but it does not want to hold more than 30 percent in the airline.   The railway has been discussing a potential partnership with Atlanta-based Delta airlines, which is interested in a 15-percent stake.
Date: Sun, 19 May 2019 21:55:33 +0200

Giza, Egypt, May 19, 2019 (AFP) - A bomb blast hit a tourist bus near Egypt's famed Giza pyramids on Sunday, wounding some of them, including South Africans, in the latest blow to the country's tourism industry.   The roadside bomb went off as the bus was being driven in Giza, also causing injuries to Egyptians in a nearby car, medical and security sources said.   Security and medical sources in Egypt said 17 people were injured, without giving a breakdown of their nationalities. No deaths were reported.   South Africa said in a statement that the "bus explosion" injured three of its 28 citizens who were part of the tourist group.   They would remain in hospital while the rest would return home on Monday, said the statement from the department of international relations.   "A device exploded and smashed the windows of a bus carrying 25 people from South Africa and a private car carrying four Egyptians," the security source said.

Video footage captured by AFP showed the bus and car with broken windows on the side of the road.   According to the security source, the wounded were being treated for scratches caused by the broken glass.   Sunday's incident comes after three Vietnamese holidaymakers and their Egyptian guide were killed when a roadside bomb hit their bus as it travelled near the Giza pyramids outside Cairo in December.   It also comes just little more than a month before the African Cup of Nations hosted by Egypt is to kick off.   Egypt has been battling an insurgency that surged especially in the turbulent North Sinai region following the 2013 military ouster of Islamist president Mohamed Morsi, who was replaced by former army general Abdel Fattah al-Sisi.   In February 2018, the army launched a nationwide operation against militants, focusing mainly on the North Sinai region.

- Tourism recovery -
Some 650 militants and around 45 soldiers have been killed since the start of the offensive, according to separate statements by the armed forces.   Since first being elected in 2014, Sisi has presented himself as a bulwark against terrorism, promising stability and increased security.   Recently, the country's vital tourism industry has started to slowly rebound after suffering strong blows due to deadly attacks targeting tourists following the turmoil of the 2011 uprising that toppled longtime ruler Hosni Mubarak.   Figures by the official statistics agency showed that tourist arrivals reached 8.3 million in 2017, compared with 5.3 million the previous year.    Authorities have gone at great lengths to lure tourists back, touting a series of archaeological finds and a new museum next to the pyramids, as well as enhanced security at airports and around ancient sites.    But that figure was still far short of the record influx of 2010 when more than 14 million visitors flocked to see the country's sites.
Date: Sun, 19 May 2019 05:17:37 +0200

Tegucigalpa, May 19, 2019 (AFP) - Four Canadians and an American pilot died Saturday when their small plane plunged into the sea off the Honduran island of Roatan where they were vacationing, firefighters said.   The plane crashed near the town of Dixon Cove, a few minutes after taking off from the island's airport, rescuers said.   The dead were identified as Bradley Post, Bailey Sony, Tomy Dubler and pilot Patrick Forseth.

The other Canadian pilot, Anthony Dubler, briefly survived the crash but died at the Roatan hospital of his injuries.   The causes of the crash and the registration information for the aircraft were not immediately available.   It occurred as the tourists were headed toward the city of Trujillo, about 77 kilometres (48 miles) from Roatan.
Date: Fri, 17 May 2019 16:32:13 +0200

London, May 17, 2019 (AFP) - London warned British-Iranian dual nationals against all travel to Iran on Friday due to Tehran's "continued arbitrary detention and mistreatment" of such citizens.   The move comes as Britain continues to try to secure the release from jail of dual national Nazanin Zaghari-Ratcliffe.   Tehran has also recently sentenced an Iranian British Council employee, Aras Amiri, to 10 years in prison on charges of spying.   In a statement, the Foreign Office said British-Iranian dual nationals faced an "unacceptably higher risk of arbitrary detention and mistreatment" than nationals of other countries.   "The security forces may be suspicious of people with British connections, including those with links to institutions based in the UK, or which receive public funds from, or have perceived links to, the British government," the statement said.   British-Iranian mother Zaghari-Ratcliffe was arrested by Iranian authorities in 2016 as she was leaving Tehran.

Zaghari-Ratcliffe, who worked for the Thomson Reuters Foundation, was put on trial and is now serving a five-year jail sentence for allegedly trying to topple the Iranian government.   "Dual nationals face an intolerable risk of mistreatment if they visit Iran," Foreign Secretary Jeremy Hunt said.   "Despite the UK providing repeated opportunities to resolve this issue, the Iranian regime's conduct has worsened.   "Having exhausted all other options, I must now advise all British-Iranian dual nationals against travelling to Iran.   "The dangers they face include arbitrary detention and lack of access to basic legal rights, as we have seen in the case of Nazanin Zaghari-Ratcliffe, who has been separated from her family since 2016."   The Iranian government does not recognise dual nationality, meaning the Foreign Office's ability to provide consular support is limited.   Hunt added: "Regrettably, I must also offer a message of caution to Iranian nationals resident in the UK -- but who return to visit family and friends -- especially where the Iranian government may perceive them to have personal links to UK institutions or the British government."
Date: Fri, 17 May 2019 11:42:01 +0200

Nairobi, May 17, 2019 (AFP) - Flooding in Tanzania has killed five people and forced about 2,500 to flee their homes after a week of torrential rain in the country's south, an official said Friday.   Schools have closed in Kyela, a district on the border of Lake Malawi, and families fled to shelters after losing everything in the rising waters.   "The damage from these floods is enormous," Salome Magambo, the district's administrative secretary, told AFP.   "Since the beginning of the week we have reported five people killed and 2,570 homeless, some of whom are staying with friends or in schools and churches."

Food and medical services have been extended to those stranded, she added.   Farming land in the district known for its rice production has also been inundated, destroying crops and raising fears of food shortages in coming months.   In April 2018 at least 14 people were killed in torrential rains and flooding in Dar es Salaam, Tanzania's economic capital.
Date: Thu, 16 May 2019 23:41:35 +0200

Washington, May 16, 2019 (AFP) - The Church of Scientology said Thursday all the passengers from a cruise ship that was quarantined over a measles case had been cleared to leave.    "All passengers and crew (100%) of the Freewinds have been fully cleared of any possible risk of being infected by the measles or infecting others," the organization said in a statement.   "All passengers and crew are free to come and go as they wish," a spokesman added to AFP.

The infected individual was a member of the crew who, according to the Church, had fully recovered and was given a clean bill of health a week ago. She had been earlier confined on the ship.   The ship, which is based in Willemstad on the island of Curacao in the Dutch West Indies, was quarantined after its arrival in Saint Lucia on April 30.   It remained there for two days before returning to Willemstad on May 4 where local authorities ordered a fresh quarantine to give them time to confirm the passengers were either immunized or had no risk of contracting the virus.
Date: Thu, 16 May 2019 18:37:39 +0200

Bamako, May 16, 2019 (AFP) - Heavy floods claimed 15 lives Thursday in the Malian capital Bamako along with serious property damage, authorities said.   A statement said the flooding claimed a "provisional toll" of 15 dead and two injured.   "Teams are in place to rescue the distressed people," the government said, calling on residents to be "prudent" in the face of the disaster.   Flooding is common in Mali, located in the semi-desert Sahel region.
Date: Thu, 16 May 2019 04:40:13 +0200
By Ashraf KHAN

Rato Dero, Pakistan, May 16, 2019 (AFP) - Parents nervously watch as their children wait to be tested for HIV in a village in southern Pakistan, where hundreds of people have been allegedly infected by a doctor using a contaminated syringe.   Dispatched to keep order, police scan the anxious crowd as families hustle into one of five different screening rooms set up in the last month in the village of Wasayo, on the outskirts of Larkana in Sindh province.

Health officials say more than 400 people, many of them children, have tested HIV positive in recent weeks as experts warn of a surge in infection rates across Pakistan, due to the use of unsanitary equipment and rampant malpractice -- often at the hands of quack doctors.   Anger and fear continue to swell in the desperately poor village hit hard by the epidemic, which authorities say could be linked to either gross negligence or malicious intent by a local paediatrician.   "They are coming by the dozens," says a doctor at the makeshift clinic, beset by a lack of equipment and personnel to treat the surging number of patients.

Mukhtar Pervez waits anxiously to have her daughter tested, worrying a recent fever may be linked to the outbreak. For others, their worst fears have already become a reality.   Nisar Ahmed arrived at the clinic in a furious search for medicine after his one-year-old daughter tested positive three days earlier.   "I curse [the doctor] who has caused all these children to be infected," he says angrily.   Nearby Imam Zadi accompanies five of her children to be examined after her grandson tested positive.   "The entire family is so upset," she tells AFP.   Others worry their children's futures have been irreparably harmed after contracting HIV, especially in a country whose masses of rural poor have little understanding of the disease or access to treatment.   "Who is she going to play with? And when she's grown up, who would want to marry her?" asks a tearful mother from a nearby village, who asked not to named, of her four-year-old daughter who just tested positive.  

- 'Helpless'-
Pakistan was long considered a low prevalence country for HIV, but the disease is expanding at an alarming rate, particularly among intravenous drug users and sex workers.    With about 20,000 new HIV infections reported in 2017 alone, Pakistan currently has the second fastest growing HIV rates across Asia, according to the UN.   Pakistan's surging population also suffers the additional burden of having insufficient access to quality healthcare following decades of under-investment by the state, leaving impoverished, rural communities especially vulnerable to unqualified medical practitioners.    "According to some government reports, around 600,000 quack doctors are operating across the country and around 270,000 are practicing in the province of Sindh," said UNAIDS in a statement.

Provincial health officials have also noted that patients are at particular risk of contracting diseases or viruses at these clinics, where injections are often pushed as a primary treatment option.   "For the sake of saving money, these quacks will inject multiple patients with a single syringe. This could be the main cause of the spread of HIV cases," said Sikandar Memon, provincial programme manager of the Sindh Aids Control Programme.

The large number of unqualified doctors along with the "reuse of syringes, unsafe blood transfusions, and other unsafe medical practices" have all led to the spike in HIV cases in recent years, explains Bushra Jamil, an expert on infectious diseases at the Aga Khan University in Karachi.   "Rampant medical malpractices without any effective checks and balances are causing repeated outbreaks in Pakistan," said Jamil.   Authorities investigating the outbreak in Sindh say the accused doctor has also tested positive for HIV.

From a ramshackle jail cell in the nearby city of Ratodero, he denied the charges and accusations he knowingly injected his patients with the virus, while complaining of being incarcerated with common criminals.   But for the parents of the newly diagnosed, the ongoing investigation means little if they are unable to secure access to better information and the necessary drugs that can help stave off the deadly AIDS virus.   "We are helpless. I have other children and I am afraid they might catch the disease," says another mother whose daughter recently tested positive for HIV.   "[Please] send some medicine for our children so that they can be cured. If not, all of our children will die, right?"