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Sierra Leone

Sierra Leone - US Consular Information Sheet
June 11, 2007
COUNTRY DESCRIPTION: Sierra Leone is a developing country in western Africa still recovering from a ten-year civil war that ended in 2002.
English is the official language, but Kri
, an English-based language, is widely used.
Tourist facilities in the capital, Freetown, are limited; elsewhere, they are rudimentary or nonexistent.
Read the Department of State Background Notes on Sierra Leone for additional information.

ENTRY/EXIT REQUIREMENTS:
A passport and visa are required.
Visitors are strongly encouraged to obtain visas in advance of travel to Sierra Leone.
Visitors to Sierra Leone are required to show International Certificates of Vaccination (yellow card) upon arrival at the airport with a record of vaccination against yellow fever. See our Foreign Entry Requirements brochure for more information on Sierra Leone and other countries.
The Embassy of Sierra Leone is located at 1701 19th Street NW, Washington, DC 20009; telephone (202) 939-9261.
The Embassy also maintains a website at www.embassyofsierraleone.org.
Information may also be obtained from the Sierra Leonean Mission to the United Nations, 245 East 49th St., New York, NY 10017; telephone (212) 688-1656 and from the website of the Sierra Leonean High Commission in London at http://www.slhc-uk.org.uk/.
Overseas, inquiries should be made at the nearest Sierra Leonean embassy or consulate.

See Entry and Exit Requirements for more information pertaining to dual nationality and the prevention of international child abduction.
Please refer to our Customs Information to learn more about customs regulations.

SAFETY AND SECURITY:
Security in Sierra Leone has improved significantly since the end of the civil war in 2002.
The United Nations Peacekeeping Mission in Sierra Leone (UNAMSIL) withdrew in December 2005 and Sierra Leone resumed responsibilities for its own security. The Sierra Leonean police are working to improve their professionalism and capabilities, but fall short of American standards in response time, communications, and specialty skills.

Areas outside Freetown lack most basic services. Embassy employees are free to travel throughout Sierra Leone.
Travelers are urged to exercise caution, however, especially when traveling beyond the capital.
Road conditions are hazardous and serious vehicle accidents are common.
Emergency response to vehicular and other accidents ranges from slow to nonexistent.

There are occasional unauthorized, possibly armed, roadblocks outside Freetown, where travelers might be asked to pay a small amount of money to the personnel manning the roadblock.
Because many Sierra Leoneans do not speak English, especially outside of Freetown, it can be difficult for foreigners to communicate their identity.
Public demonstrations are rare but can turn violent.
U.S. citizens should are advised to avoid large crowds, political rallies, and street demonstrations, and maintain security awareness at all times.

For the latest security information, Americans traveling abroad should regularly monitor the Department's Internet web site where the current Worldwide Caution Public Announcement, Travel Warnings and Public Announcements 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., 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:
Entrenched poverty in Sierra Leone has led to criminality.
There has been an increase in homicide, armed robbery, and residential burglary.
Petty crime and pick pocketing of wallets, cell phones, and passports are very common.
Law enforcement authorities usually respond to crimes slowly, if at all.
Police investigative response are often incomplete and don’t provide support to victims.
Inefficiency is a serious problem at all levels within the government of Sierra Leone.
Americans traveling to or residing in Sierra Leone should maintain a heightened sense of awareness of their surroundings to help avoid becoming the victims of crime.

Business fraud is rampant and the perpetrators often target foreigners, including Americans.
Schemes previously associated with Nigeria are now prevalent throughout West Africa, including Sierra Leone, and pose a danger of grave financial loss.
Typically these scams begin with unsolicited communication (usually e-mails) from strangers who promise quick financial gain, often by transferring large sums of money or valuables out of the country, but then require a series of "advance fees" to be paid, such as fees for legal documents or taxes.
Of course, the final payoff does not exist; the purpose of the scam is simply to collect the advance fees.
A common variation is the scammer’s claim to be a refugee or émigré of a prominent West African family, or a relative of a present or former political leader who needs assistance in transferring large sums of cash.
Still other variations appear to be legitimate business deals that require advance payments on contracts.
Sometimes victims are convinced to provide bank account and credit card information and financial authorization that drains their accounts, incurs large debts against their credit, and takes their life savings.

The best way to avoid becoming a victim of advance-fee fraud is common sense – if a proposition looks too good to be true, it probably is.
You should carefully check and research any unsolicited business proposal before committing any funds, providing any goods or services, or undertaking any travel.
It is virtually impossible to recover money lost through these scams. Please see the Department of State’s brochures on Advance Fee Business Scams and on International Financial Scams for more information.

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 can, for example, assist you to find appropriate medical care, contact family members or friends and explain how funds could be transferred.
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 our information on Victims of Crime.

MEDICAL FACILITIES AND HEALTH INFORMATION:
Quality and comprehensive medical services are very limited in Freetown, and are almost nonexistent for all but most minor treatment outside of the capital.
Persons with unstable chronic medical conditions that require on-going medical treatment or medications are discouraged from traveling to Sierra Leone.
Medicines are in short supply and due to inadequate diagnostic equipment, lack of medical resources and limited medical specialty personnel, complex diagnosis and treatment are unavailable.
The quality of medications in Sierra Leone is inconsistent and counterfeit drugs remain a problem.
Local pharmacies are generally unreliable. In the event medications are needed, such as over-the-counter medication, antibiotics, allergy remedies, or malaria prophylaxis, travelers may contact U.S. Embassy Health Unit personnel to receive general information about reliable pharmacies.

Medical facilities in Sierra Leone are scarce and for the most part sub-standard; outside the capital, standards are even lower.
There is no ambulance service in Sierra Leone, trauma care is extremely limited, and local hospitals should only be used in the event of an extreme medical emergency.
Many primary health care workers, especially in rural areas, lack adequate professional training.
Instances of misdiagnosis, improper treatment, and the administration of improper drugs have been reported.
Life-threatening emergencies often require evacuation by air ambulance at the patient's expense.
For a list of hospitals, visit our website at http://freetown.usembassy.gov/ .

Gastrointestinal diseases and malaria pose serious risk to travelers in Sierra Leone.
For additional information on malaria, including protective measures, see the CDC Travelers’ Health web site at http://www.cdc.gov/malaria/.

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 internet site at http://www.cdc.gov/travel.
For information about outbreaks of infectious diseases abroad consult the World Health Organization’s (WHO) website 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 policy applies overseas and whether it will cover emergency expenses such as a medical evacuation.
Please see our information 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 Sierra Leone is provided for general reference only, and may not be totally accurate in a particular location or circumstance.

Most main roads in Freetown are narrow and paved but have potholes; extremely narrow unpaved side streets are generally navigable.
Most roads outside Freetown are unpaved and are generally passable with a 4-wheel drive vehicle.
However, certain stretches of mapped road are often impassable during the rainy season, which usually lasts from May to September.
During the rainy season, add several hours to travel time between Freetown and outlying areas.
There is a major road repair and resurfacing program going on throughout the country that is slowly improving the quality of roads.
Public transport (bus or group taxi) is erratic, unsafe, and not recommended.
U.S. government employees are prohibited from using public transportation except for taxis that operate in conjunction with an approved hotel and that are rented on a daily basis.

Many vehicles on the road in Sierra Leone are unsafe and accidents resulting from the poor condition of these vehicles, including multi-vehicle accidents, are common.
Many drivers on the road in Sierra Leone are inexperienced and often drive without proper license or training.
Serious accidents are common, especially outside of Freetown, where the relative lack of traffic allows for greater speeds.
The chance of being involved in an accident increases greatly when traveling at night, and Embassy officials are not authorized to travel outside of major cities after dark.

Please refer to our Road Safety page for more information.

AVIATION SAFETY OVERSIGHT: As there is no direct commercial air service between the United States and Sierra Leone, the U.S. Federal Aviation Administration (FAA) has not assessed Sierra Leone’s Civil Aviation Authority for compliance with International Civil Aviation Organization (ICAO) aviation safety standards.
For more information, travelers may visit the FAA’s Internet website at http://www.faa.gov/safety/programs_initiatives/oversight/iasa.

Passengers departing Freetown on certain airlines should expect to pay an airport tax of $40.00 (payable in U.S. Dollars).
Several regional airlines service Freetown’s Lungi International Airport; however, it is not uncommon for them to alter scheduled stops, cancel or postpone flights on short notice, and overbook flights.
Travelers may experience unexpected delays even after checking in and must be prepared to handle alternate ticketing and/or increased food and lodging expenses.
European carriers are typically more reliable.
American citizens departing Lungi Airport have reported incidents of attempted extortion by officials claiming that travel documents were not in order.
Luggage can often be lost or pilfered.

Lungi Airport is located across a large body of water from Freetown.
There are helicopter and ferry services in connection with most major flights to transport passengers to the capital; however, the ferry service has frequent delays.
It should be noted that the ferry terminal is located in East Freetown, which has a higher crime rate than other parts of the capital.
Embassy personnel use available helicopter services, which usually cost $50 each way, to transit from Freetown to the airport.


SPECIAL CIRCUMSTANCES:
Sierra Leone is a cash economy; however, an anti-money laundering law passed in July 2005 prohibits importing more than $10,000 in cash except through a financial institution.
Travelers are advised not to use credit cards in Sierra Leone because very few facilities accept them and there is a serious risk that using a card will lead to the number being stolen for use in fraudulent transactions.
There are no ATMs connected to international networks.
Travelers' checks are not usually accepted as payment; however, travelers’ checks can be cashed at some banks including Sierra Leone Commercial Bank, Standard Chartered Bank and Rokel Commercial Bank.
The traveler must, however, have proof of identification and a signed receipt by the institution where the travelers’ checks were purchased.
Currency exchanges should be handled through a bank or established foreign exchange bureau.
Exchanging money with street vendors is dangerous because criminals may "mark" such people for future attack and there is the risk of receiving counterfeit currency.

Sierra Leone's customs authorities enforce strict regulations concerning the export of gems and precious minerals, such as diamonds and gold.
All mineral resources, including gold and diamonds, belong to the State and only the government of Sierra Leone can issue mining and export licenses.
The legal authority for the issuance of licenses is vested in the Ministry of Mines and Mineral Resources.
Failure to comply with relevant legislation can lead to serious criminal penalties.
For further information on mining activities in Sierra Leone, contact the Ministry of Mines and Mineral Resources:
The Director of Mines, Ministry of Mines and Mineral Resources, Fifth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone; tel. (232-22) 240-420 or 240-176; fax (232-22) 240-574.

Corruption is a problem in Sierra Leone.
Travelers requesting service from government officials at any level may be asked for bribes.
You should report corrupt government officials to the Anti-Corruption Commission at one of the following locations:
The Sierra Leone Anti-Corruption Commission, 3 Gloucester Street, Freetown; 14a Lightfoot Boston Street, Freetown; 37 Kissy Town Road, Bo, Southern Province; Independence Square, Rogbaneh Road, Makeni; tel. (232- 22) 229-984 or 227-100 or 221-701; fax (232-22) 221-900; email: acc@sierratel.sl or info@anticorruption.sl;
and websites www.anticorruptionsl.org/anonymous.html and www.anticorruptionsl.org.

You must obtain official permission to photograph government buildings, airports, bridges, or official facilities including the Special Court for Sierra Leone and the American Embassy.
Areas where photography is prohibited may not be clearly marked or defined.
People sometimes do not want to be photographed for religious reasons or may want to be paid for posing.
Photographers should ask permission before taking someone’s picture.

U.S. citizens who are also Sierra Leonean nationals must provide proof of payment of taxes on revenues earned in Sierra Leone before being granted clearance to depart the country.
The Government of Sierra Leone now recognizes dual U.S.-Sierra Leonean citizenship; however; the U.S. Embassy may have difficulty assisting American citizens involved in legal or criminal proceedings if they entered the country on a Sierra Leonean passport.


Please see our 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.
Sierra Leone’s judiciary is under-funded and overburdened, and offenders often must endure lengthy pre-trial or pre-hearing delays and detention.
Penalties for breaking the law can be more severe than in the United States for similar offenses.
Persons violating Sierra Leone laws, even unknowingly, may be expelled, arrested or imprisoned.
Penalties for possession, use, or trafficking in illegal drugs in Sierra Leone 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 our information on Criminal Penalties.

Travelers should carefully check their passport to see the length of time they are permitted to remain in the country and the validity of their visa.
Travelers leaving the country with an expired visa may incur additional charges.
Any Sierra Leonean visa issues can be regulated at the immigration office at Rawdon Street in Freetown.

CHILDREN'S ISSUES:
For information on international adoption of children and international parental child abduction, see the Office of Children’s Issues website.

A significant number of American prospective adoptive parents have found that Sierra Leonean children offered for adoption are not orphans under U.S. immigration law, which has ultimately resulted in denials of U.S. immigrant visas for children they adopt in Sierra Leonean courts.
Please refer to the Sierra Leone adoption flyer for more information.

REGISTRATION / EMBASSY LOCATION:
Americans living or traveling in Sierra Leone are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department’s travel registration website and to obtain updated information on travel and security within Sierra Leone.
Americans without Internet 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 Leicester Square, Regent; tel. (232) (22) 515 000 or (232) (76) 515 000; fax (232) (22) 515 355.
The Embassy maintains a home page on the Internet at http://freetown.usembassy.gov/.
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This replaces the consular information sheet dated October 31, 2006, to update sections on Entry/Exit Requirement; Crime; Medical Facilities and Health Information; Aviation Safety Oversight; Special Circumstances; Criminal Penalties; and Registration/Embassy Location.

Travel News Headlines WORLD NEWS

Date: Thu 28 Nov 2019
Source: World Health Organization Disease Outbreak News [edited]

Sierra Leone health officials, supported by WHO, the US Centers for Disease Control and Prevention (CDC), and other partners, are responding to an outbreak of Lassa fever. On 20 Nov 2019, WHO was informed by the Netherlands' International Health Regulations (IHR) National Focal Point of one imported case of Lassa fever from Sierra Leone. The patient was a male doctor, a Dutch national who worked in a rural Masanga hospital in Tonkolili district, Northern province in Sierra Leone.

The probable route of transmission is believed to be through exposures during a surgical procedure he performed on 2 patients in Masanga hospital on 4 Nov 2019. Both patients died following surgical interventions; one died on 4 Nov [2019] and the 2nd on 19 Nov 2019. Both surgical patients are considered probable cases, and the patient who died on 4 Nov [2019] is believed to be the index case for this outbreak, likely the source of infection of the Dutch doctor.

The doctor's symptoms started on 11 Nov [2019], a week after performing the surgery, and included malaise and headache, followed by fever, diarrhoea, vomiting, and cough. While symptomatic, he attended a surgical training event in Freetown, Sierra Leone, on 11-12 Nov [2019]. This event was also attended by several international participants from the Netherlands and United Kingdom in addition to 35 local participants. On 19 Nov [2019], the symptomatic doctor was medically evacuated to the Netherlands after he did not respond to treatment with antimalarials and antibiotics. The evacuation was managed by a dedicated ambulance plane with 4 staff from a German organization. During the journey, the plane stopped in Morocco (Agadir Airport). As the illness was initially thought to be malaria or typhoid fever, personal protective equipment, other than gloves, were not used, and no specific containment procedures were used during the medical evacuation.

Laboratory specimens from the patient tested positive for Lassa fever by polymerase chain reaction (PCR) and sequencing at Erasmus University Medical Centre in Rotterdam on 20 Nov 2019.

The patient died on the night of 23 Nov 2019.

On 22 Nov 2019, WHO was informed of a 2nd laboratory-confirmed case of Lassa fever in another Dutch healthcare worker, who also worked in the Masanga hospital. Samples from this 2nd case were sent to the Erasmus University Medical Centre in Rotterdam and tested positive for Lassa fever by PCR. The 2nd case also participated in one of the surgical procedures performed by the medically evacuated Dutch doctor. The date of onset of symptoms of the 2nd case was 11 Nov [2019]. This case was subsequently medically evacuated in high containment isolation to the Netherlands and is currently under treatment. Isolation precautions have been implemented.

The Masanga hospital in Sierra Leone where the Dutch doctor worked is supported by several non-governmental organizations with international healthcare workers including staff from countries including Denmark, the Netherlands, and the United Kingdom, alongside national healthcare workers.

Contact tracing and monitoring activities have been initiated in these countries as required.

Sierra Leone
An outbreak investigation and response is ongoing under leadership of the Ministry of Health (MoH), supported by CDC and WHO. As of 24 Nov 2019, in addition to the 2 Dutch cases, 2 further cases among national healthcare workers, one confirmed and another suspected, have been reported from Masanga hospital. Both healthcare workers were involved in the management of the 2 surgical patients operated by the Dutch doctor on 4 Nov [2019]. All high-risk contacts in Masanga hospital are being monitored.

The Netherlands
Several high- and low-risk contacts have been identified among personal contacts and healthcare workers. According to Dutch protocols, they will be monitored until 21 days after the last potential exposure. Five high-risk Dutch contacts who were in Sierra Leone have been repatriated through a dedicated flight and are now under monitoring. Dutch low-risk contacts in Sierra Leone have been advised to perform self-monitoring in situ.

Germany
The 4 medical evacuation flight staff (2 pilots and 2 healthcare workers) spent 8 flight hours in a confined space in the ambulance plane without any barrier between the cockpit and cabin. They have been assessed as moderate-risk contacts. According to German recommendations, they are being monitored for 21 days following the last potential exposure on 19 Nov (until 10 Dec 2019).

United Kingdom (UK)
UK authorities have identified 18 UK nationals as contacts of the 1st Dutch case. Of these 18, 8 are high-risk contacts and were exposed in Masanga hospital while working alongside the doctor or may have been exposed to the 2 patients he operated on 4 Nov [2019]. Of these 8 high-risk contacts, 7 returned to the UK and one went to Uganda. In addition, 13 UK nationals attended a surgical training event in Freetown, Sierra Leone, on 11-12 Nov [2019], which was also attended by the 1st Dutch case while already symptomatic. Of these 13 participants, 3 came from Masanga hospital and belong to the above group of 8 high-risk contacts. The remaining 10 participants were possibly exposed during the training and are considered low-risk contacts. Of these 18 contacts identified (8 high-risk and 10 low-risk contacts), 17 have returned to the UK and are under public health follow-up for 21 days; one high-risk contact went to Uganda. There were also several Dutch and 35 local participants who attended this event. UK authorities are in contact with the organizers, and the names of participants from Sierra Leone and the Netherlands have been shared with respective National IHR Focal Points.

Uganda
One contact, a UK national, who may have been exposed in Masanga hospital on 15 Nov [2019] and subsequently travelled to Uganda on 16 Nov [2019], is now being followed up by the Uganda authorities, and the UK authorities are providing support remotely though public health and consular channels.

The National IHR Focal Point of the Netherlands has also informed their counterpart in Morocco about the potential risk of exposure at the Agadir Airport. Morocco National IHR Focal Point confirmed that the investigation is conducted, and control measures have been implemented to ensure there was no transmission in Agadir.

Sierra Leone is endemic for Lassa fever. Previously, sporadic cases have been exported to Europe from endemic countries in Africa, such as Togo, Liberia and Nigeria. In 2018, a total of 23 confirmed Lassa fever cases with 14 deaths (case fatality rate 61%) were reported from 2 districts of Sierra Leone: Bo district (2 cases; 2 deaths) and Kenema district (21 cases; 12 deaths).

From 1 Jan-17 Nov 2019, of the 182 suspected cases, 10 cases with 6 deaths (case fatality ratio 60%) have been confirmed for Lassa virus infection. All confirmed cases during this period were reported from Kenema district, which has been reporting cases of Lassa fever every year.

Public health response
The International Health Regulations Focal Points and Health Authorities in Denmark, Germany, Morocco, the Netherlands, Sierra Leone, Uganda, and the UK have been collaborating to share information about this event, together with the WHO and US CDC. Contact tracing and monitoring activities for 21 days following the last potential exposure have been initiated in Sierra Leone, Germany, the Netherlands, Uganda, and the UK. Investigations are ongoing in Sierra Leone in Masanga hospital and surrounding areas in Tonkolili district with a deployment of a national rapid-response team, supported by US CDC and WHO.

WHO risk assessment
Lassa fever is an acute viral haemorrhagic fever illness that is transmitted to humans via contact with food or household items contaminated with rodent urine or faeces. Human-to-human infections and laboratory transmission can also occur through direct contact with the blood, urine, faeces, or other bodily secretions of a person with Lassa fever. The overall case fatality rate is 1%; it is 15% among patients hospitalized with severe illness.

Sierra Leone is endemic for Lassa fever, and sporadic cases have been exported to Europe from endemic countries in Africa, such as Togo, Liberia and Nigeria in recent years. However, in general, the secondary transmission of Lassa fever through human contacts is rare.

Data from recent imported cases show that secondary transmission of Lassa fever is rare when standard infection-control precautions are observed. Further, epidemiological investigations are ongoing: human-to-human transmission occurs in both community and healthcare settings, where the virus may spread by contaminated medical equipment. Healthcare workers are at risk if caring for Lassa fever patients in the absence of appropriate infection prevention and control measures. Considering the seasonal flare-ups of cases in humid zones between December and March, countries in West Africa that are endemic for Lassa fever are encouraged to strengthen their related surveillance systems.

WHO advice
Prevention of Lassa fever relies on community engagement and promoting hygienic conditions to discourage rodents from entering homes.  There is currently no approved vaccine. Early supportive care with rehydration and symptomatic treatment improves survival. Family members and healthcare workers should always be careful to avoid contact with blood and body fluids while caring for sick persons.

According to WHO guidance for viral haemorrhagic fever, healthcare staff should consistently implement standard precautions when caring for all patients to prevent infections acquired in a healthcare setting and strictly apply contact precautions, including isolation, when caring for suspected or confirmed Lassa fever patients or handling their clinical specimens or body fluids. Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. Standard precautions are recommended in the care and treatment of all patients regardless of their perceived or confirmed infectious status. They represent the basic fundamental level of infection prevention and control and include hand hygiene, use of personal protective equipment to avoid direct contact with blood and body fluids, prevention of needle stick and injuries from other sharp instruments, and a set of environmental controls. Sterilization and environmental cleaning should also be particularly strengthened and undergo quality control assessments.

In order to avoid any direct contact with blood and body fluids and/or splashes onto facial mucosa (eyes, nose, mouth) when providing direct care for a patient with suspected or confirmed Lassa virus, personal protective equipment should include
1) clean non-sterile gloves,
2) a clean, non-sterile fluid-resistant gown, and
3) protection of facial mucosa against splashes (mask and eye protection, or a face shield).

Given the nonspecific presentation of viral haemorrhagic fevers, isolation of ill travellers and consistent implementation of standard precautions are key to preventing secondary transmission. When consistently applied, these measures can prevent secondary transmission even if travel history information is not obtained, not immediately available, or the diagnosis of a viral haemorrhagic fever is delayed.

WHO continues to advise all countries in the Lassa fever belt due to the need to enhance early detection and treatment of cases to reduce the case fatality rate as well as strengthen cross-border collaboration. WHO advises against any restrictions on travel or trade to or from Sierra Leone based on the current available information.
======================
[The above report provides the details and timelines related to the 2 confirmed cases of the Dutch physicians and the many suspected contacts. The 2 confirmed cases illustrate the difficulty in identifying Lassa fever cases when the infected individuals are early in the course of the disease so that barriers to transmission of the virus can be implemented. The 1st Dutch physician initially was thought to have malaria or typhoid fever, diseases more common in the area than Lassa fever. It will be interesting to learn if any of the contact individuals in the UK, Germany, or Uganda become infected. - ProMED Mod.TY]

[HealthMap/ProMED-mail map of Sierra Leone:
Date: Sun, 24 Nov 2019 12:56:47 +0100 (MET)

The Hague, Nov 24, 2019 (AFP) - A Dutch doctor who contracted Lassa haemorrhagic fever in Sierra Leone after treating patients has died in hospital, while a second doctor is undergoing treatment, the top Dutch health official said Sunday.

The unnamed doctor was flown back to the Netherlands on Tuesday and had been treated at a special isolation ward at a hospital in Leiden near Schiphol airport.   "The patient... which has been treated in strict isolation, has died last night," Dutch Health Minister Bruno Bruins said.   "A second doctor also has Lassa fever and has been repatriated to the Netherlands. Both doctors were infected in Sierra Leone, most likely during medical treatment," the minister said.

The second patient has been admitted to a hospital in the central Dutch city of Utrecht in an isolation unit which was also used to treat a patient who contracted Ebola in 2014.   In a statement, the Sierra Leonean Health Ministry said the deceased Dutch doctor developed Lassa fever symptoms after performing a cesarean section on a pregnant woman at the Masanga Hospital in central Sierra Leone.

The doctor also helped with the evacuation of a second woman who suffered from a septic wound after an abortion.   Both the women died shortly afterwards.    "He developed signs of fever, headache, and general malaise... and was treated for typhoid, malaria and influenza but symptoms persisted."   He was then flown back to the Netherlands where he tested "positive for Lassa fever on the same day."   The second doctor helped in both the cases and tested positive for the disease. 

Dutch minister Bruins said the Netherlands "is in close contact with those involved in Sierra Leone" and that Dutch nurses who had been in contact with the two Sierra Leonean patients are being flown back.   Lassa fever -- named after the place in Nigeria where it was first discovered in 1969 -- is caused by a haemorrhagic virus which belongs to the same family as Marburg and Ebola, according to the Centres for Disease Control (CDC).    It is mainly spread by rodents and is endemic to parts of West Africa including Sierra Leone, Guinea, Liberia and Nigeria.
Date: 24 Nov 2019
Source: BBC [edited]

A Dutch doctor who was evacuated from Sierra Leone after contracting Lassa fever has died in hospital. The medic was flown home on Tuesday [19 Nov 2019] after being infected in the northern town of Masanga, an area not previously known to have been affected.  He reportedly developed symptoms of the viral haemorrhagic illness after operating on a pregnant woman.  A 2nd Dutch doctor who was also evacuated is being treated for the disease.

Described as a cousin of Ebola [a very distant one virologically - ProMED Mod.TY], Lassa fever is endemic in eastern Sierra Leone, but cases have also been reported in northern and southern parts of the country in the last 5 years. It is also endemic in neighbouring Liberia, Guinea and several other West African states.

The doctor died while being treated in "strict isolation" at a hospital in the city of Leiden, Dutch Health Minister Bruno Bruins was quoted by AFP news agency as saying.

The minister confirmed that a 2nd doctor was in an isolation ward in hospital in the central city of Utrecht after being infected with the virus.

The doctors, who have not been named, were linked to a medical charity and had been working at a hospital in Masanga. In a statement, Sierra Leone's Health Ministry said the deceased doctor showed symptoms of Lassa fever after performing a Caesarean section.  "He developed signs of fever, headache, and general malaise ... and was treated for typhoid, malaria, and influenza but symptoms persisted," it said. He was then airlifted to the Netherlands where he was diagnosed with the disease.

The doctor had also helped with the evacuation of a 2nd woman who suffered from a septic wound after an abortion, AFP reports. Both women died shortly afterwards.
======================
[Lassa fever virus is endemic in Sierra Leone, and cases occur there sporadically. It is unfortunate that these physicians became infected while attending to Lassa fever virus-infected patients. Nosocomial transmission of Lassa fever virus in healthcare facilities, especially hospitals, is not unusual.

It is curious that the BBC report says nothing about the other 5 Dutch nationals and the 3 British doctors who were evacuated also who were mentioned in the tweet. - ProMED Mod.TY]

[ProMED also acknowledges a reader who prefers to remain anonymous for submitting this information from a Dutch news media report.  - ProMED Mod.LM]

[HealthMap/ProMED map available at:
Date: Wed, 7 Aug 2019 21:56:59 +0200 (METDST)

Freetown, Aug 7, 2019 (AFP) - Seven people have died and more than 8,000 have been made homeless after torrential rain in Sierra Leone caused massive floods, officials said.   "We can confirm the death of seven people, with 8,000 people severely affected by the flooding in Freetown and other parts of the country since last Friday," John Vandy, director of the Disaster Management Office in the National Security Office told AFP on Wednesday.   "The majority of the flood victims are from slum communities and swampy areas," Vandy said.   The government is working with development partners to assess the damage and offer relief, with more heavy rain forecast.   The authorities have urged people to leave flood-prone areas in Freetown after reports of a minor mudslide in an area where more than 1,100 people died in a landslip in 2017.
Date: Sat 11 May 2019
Source: Today [edited]

A 5-year-old girl was brought to the emergency room at Evelina London Children's Hospital [UK] with itchy, rather unsightly sores on both legs. She had recently returned from a weeks-long trip to Sierra Leone, and the lesions, which 1st appeared 3 weeks into her stay there, had become larger and ulcerated.

Diagnosis: cutaneous diphtheria, a disease rarely seen in many industrialised countries, including Britain and the United States, where most children are protected by the diphtheria toxoid vaccine, DTaP, and a booster shot of the tetanus-diphtheria-pertussis vaccine, Tdap.

Still, as more and more Americans of all ages travel abroad, often to less developed areas, travellers and doctors in this country need to be alert to unusual and often perplexing skin infections.

Even though cutaneous diphtheria is not a notifiable disease here [the U.S.], from September 2015 to March 2018, 4 cases were reported to the Centers for Disease Control and Prevention [1]. The patients, 2 from Minnesota and 1 each from Washington and New Mexico, had recently returned from Somalia, Ethiopia and the Philippines. The CDC noted in a weekly report in March [2019] [1] that reported cases of this highly contagious infection had recently increased 10-fold, from an average of only 3 a year during the period 1998 to 2011, to 33 a year during 2012 to 2017.

Still, the agency said, these numbers underestimate the true incidence of such infections. Although the 4 new cases were confined to the skin, the lesions can be a source of a life-threatening respiratory infection in people not adequately immunised against diphtheria. Thus, people who might have had close contact with the patients needed to be checked, perhaps treated with antibiotics, and if they lacked immunity to diphtheria, immunised with diphtheria toxoid-containing vaccine.

Before travelling to developing countries, people often check with the CDC or a travel health clinic to determine what immunisations they may need to update and which health precautions -- like drinking only bottled water -- are recommended. But having visited some pretty wild areas in the last 5 decades, I know that many people neglect to consult travel health experts in advance of their trips and are lax about updating needed vaccines.

Upon returning home with a health complaint, they often consult physicians who may have never seen the condition before or even heard of it since medical school, if then.

While emerging diseases like SARS and Ebola rightly garner widespread attention, Dr Jay S. Keystone of the Toronto Medisys Travel Health Clinic has noted that "skin problems are among the most frequent medical problems in returned travellers."

In a large series of traveller-related skin problems analysed by the GeoSentinel Surveillance Network, Dr Keystone reported that among ill travellers who sought medical care, cutaneous larva migrans, insect bites and bacterial infections were the most common disorders, making up 30 per cent of 4742 cases [<https://wwwnc.cdc.gov/travel/yellowbook/2018/post-travel-evaluation/skin-soft-tissue-infections-in-returned-travelers#5024>]. He added that the reported cases did not include those that were easily treated during travel or that cleared up on their own, probably many more.

=====================
[The rest of the news article mostly concerns infections acquired by travellers, such as cutaneous larva migrans (a parasitic skin disease) and infections transmitted by the bites of insects, like malaria, dengue fever, filariasis, and leishmaniasis. The full article can be found at the source URL. - ProMED Mod.ML]

[1. Griffith J, Bozio CH, Poel AJ, et al. Imported Toxin-Producing Cutaneous Diphtheria -- Minnesota, Washington, and New Mexico, 2015-2018. MMWR Morb Mortal Wkly Rep 2019;68:281-284. DOI: <http://dx.doi.org/10.15585/mmwr.mm6812a2External>.]
=====================
[The following has been extracted from my moderator comments in a prior ProMED-mail post, Diphtheria - Norway ex Mozambique: cutaneous, traveler; archive number:  http://promedmail.org/post/20140621.2556752.

"Either toxigenic or nontoxigenic strains of _C. diphtheriae_ can cause cutaneous diphtheria. Cutaneous diphtheria due to toxigenic strains is endemic in tropical countries and has been responsible for infections in travelers to these countries, even in those who are vaccinated. In the United States, cutaneous diphtheria has been most often associated with homeless persons [poor sanitation, poverty, and crowded living conditions] and the organisms isolated from recent cases were nontoxigenic (<http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/dip.pdf>). Cutaneous diphtheria is characterized by skin ulcers, which are usually chronic and may become coinfected with other pathogens such as _Staphylococcus aureus_ and _Streptococcus pyogenes_. Cutaneous diphtheria is uncommonly complicated by toxic cardiac or neurologic manifestations.

Humans are the only reservoir of _C. diphtheriae_. Transmission of _C. diphtheriae_ can occur through respiratory droplets, direct contact with cutaneous infections, and articles soiled with discharges from the respiratory tract or skin lesions. Organisms can be shed for up to 4 weeks without antibiotics, but chronic carriers may shed organisms for 6 months or more. Effective antibiotic therapy promptly terminates shedding. The organisms can survive in dust and clothing for up to 6 months (<http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/dip.pdf>). Shedding from cutaneous lesions can cause respiratory and cutaneous infections in contacts.

Cutaneous diphtheria is treated with erythromycin or penicillin for 14 days. The disease is usually not contagious 48 hours after starting antibiotics. Elimination of the organism should be documented by 2 consecutive negative cultures after therapy is completed. Management of contacts of cutaneous diphtheria should include screening for possible respiratory or cutaneous diphtheria and obtaining nasopharyngeal cultures for _C. diphtheriae_. For close contacts, especially household contacts, a diphtheria booster, appropriate for age, is given. Contacts should also receive antibiotics -- benzathine penicillin G or a 7- to 10-day course of oral erythromycin. Identified carriers in the community should also receive antibiotics. However, if the strain is shown to be nontoxigenic, the CDC recommends that investigation of contacts can be discontinued (<http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/dip.pdf>). Since 1980, cutaneous diphtheria is not a nationally reportable disease in the U.S.  (<http://www.cdc.gov/vaccines/pubs/surv-manual/chpt01-dip.html>)." - ProMED Mod.ML]
More ...

World Travel News Headlines

Date: Fri, 24 Jan 2020 12:26:57 +0100 (MET)

Beijing, Jan 24, 2020 (AFP) - China has quarantined cities and shut major tourist attractions from Disneyland to the Forbidden City and a section of the Great Wall as it scrambles to stop a deadly SARS-like virus from spreading further.   The drastic moves come as hundreds of millions of people criss-crossed the country in recent days to celebrate the Lunar New Year holiday, which officially started Friday and is typically a joyous time of gatherings and public celebration.   Here is a rundown of the measures taken so far in an unprecedented quarantine effort:

- Cities under lockdown -
Public transport has been stopped in 13 cities in central Hubei province, with train stations shut, events cancelled and theatres, libraries and karaoke bars closed in some locations.   The epicentre of the outbreak is provincial capital Wuhan, the biggest city on lockdown, where the government has halted all travel out of the Yangtze River metropolis of 11 million.   Wuhan residents have been told to stay home and authorities are limiting the number of taxis allowed on roads. There are few flights available to the city, deepening the isolation.   Similar quarantine measures are being taken in the other, smaller cities. These include strict controls on weddings and funerals, temperature screening of people as they arrive and the suspension of online taxi services.   More than 41 million people in total are affected by the city shutdowns.

- Festivities cancelled -
Wuhan and Beijing have cancelled public events that usually attract hundreds of thousands of people to temples during the New Year holiday.   Gao Fu, head of the Chinese Center for Disease Control and Prevention, has asked China's 1.4 billion citizens to forego New Year gatherings and confine themselves at home until all is clear.   To discourage nationwide travel, the government also said all tickets for rail, air, road, or water transport could be refunded.

- Attractions closed -
The historic Forbidden City, a sprawling imperial palace in Beijing that is one of the country's most revered cultural sites, will temporarily close from Saturday.   Other famous landmarks including a section of the Great Wall, the Ming Tombs and Yinshan Pagoda are also not open to visitors.   Shanghai Disneyland said it would shut for an indefinite period "to ensure the health and safety of our guests and cast".   Women's Olympics football qualifiers scheduled for February 3-9 in Wuhan have been moved to the eastern city of Nanjing.

- Temperature checks -
Staff in full body protective suits were seen checking the temperatures of people entering a subway station in Beijing on Friday.   The country has ordered sterilisation and ventilation at airports and bus stations, as well as inside planes and trains, while travellers are being screened for fever.   Health authorities are urging people to wash their hands regularly, avoid crowded places, get plenty of fresh air and wear a mask if they have a cough.   In Wuhan, city authorities have made it mandatory to wear a mask in public places.   In response to skyrocketing demand for masks -- starting to sell out at pharmacies and on some popular websites -- China's industry and information technology ministry said it would "spare no effort in increasing supply".

- A new hospital -
In Wuhan, authorities are rushing to build a new hospital in a staggering 10 days as a rising number of patients are infected by the new coronavirus.   The facility is expected to be in use by February 3 and will have a capacity of 1,000 beds spread over 25,000 square metres, according to state media.   Dozens of excavators and trucks were filmed working on the site by state broadcaster CCTV.   Its construction began after reports surfaced of bed shortages in hospitals designated as dealing with the outbreak, which has now infected 830 people across China.
Date: Fri, 24 Jan 2020 11:22:00 +0100 (MET)

Beijing, Jan 24, 2020 (AFP) - China announced Friday it will close a section of the Great Wall and other famous Beijing landmarks to control the spread of a deadly virus that has infected hundreds of people across the country.   A range of Lunar New Year festivities have been cancelled to try to contain the virus, and Beijing's Forbidden City and Shanghai's Disneyland have also been closed temporarily.

The Ming Tombs and Yinshan Pagoda will also be closed from Saturday, the authority that oversees the sites said, while the Bird's Nest stadium -- the site of the 2008 Olympic Games -- was shuttered from Friday.   The Great Wall attracts around 10 million tourists a year and is a popular destination for visitors during the New Year holiday.   The Juyongguan section will close, while the Great Wall temple fair was cancelled at the Simatai section of the famous landmark.

Tourists at the Gubei water town by the Simatai section will have their temperature tested, the authority said in a statement on the WeChat social media app.   The Bird's Nest will be closed until January 30 in order to "prevent and control" the spread of the virus, authorities said. An ice and snow show taking place on the pitch will be closed.   The measures in the capital are the latest to try and control the outbreak of the new coronavirus, after authorities rapidly expanded a mammoth
quarantine effort that affected 41 million people in central Hubei province.

The previously unknown virus has caused alarm because of its similarity to SARS (Severe Acute Respiratory Syndrome), which killed hundreds across mainland China and Hong Kong in 2002-2003.   Although there have only been 29 confirmed cases in Beijing, city authorities have cancelled large-scaled Lunar New Year events this week.   The city government said it would call off events including two popular temple fairs, which have attracted massive crowds of tourists in past years.   Beijing's Forbidden City -- which saw 19 million visitors last year -- is usually packed with tourists during the Lunar New Year festival, when hundreds of millions of people travel across China.
Date: Fri, 24 Jan 2020 10:40:12 +0100 (MET)
By Sébastien RICCI

Wuhan, China, Jan 24, 2020 (AFP) - Chinese authorities rapidly expanded a mammoth quarantine effort aimed at containing a deadly contagion on Friday to 13 cities and a staggering 41 million people, as nervous residents were checked for fevers and the death toll climbed to 26.

While the World Health Organization (WHO) held off on declaring a global emergency despite confirmed cases in half a dozen other countries, China expanded its lockdown to cover an area with a total population greater than Canada's.   A range of Lunar New Year festivities have been cancelled, while temporary closures of Beijing's Forbidden City, Shanghai's Disneyland and a section of the Great Wall were announced to prevent the disease from spreading further.   The previously unknown virus habeis caused alarm because of its similarity to SARS (Severe Acute Respiratory Syndrome), which killed hundreds across mainland China and Hong Kong in 2002-2003.

The WHO said China faced a national emergency but stopped short of making a declaration that would have prompted greater global cooperation, including possible trade and travel restrictions.   The outbreak emerged in late December in Wuhan, an industrial and transport hub of 11 million people in China's centre, spreading to several other countries including the United States.   China is in the midst of its Lunar New Year holiday, a typically joyous time of family gatherings and public festivities.   But on Friday Wuhan was a ghost town, its streets deserted and stores shuttered.

- Worried patients -
Hospitals visited by AFP journalists bustled with worried patients being screened by staff wearing full-body protective suits.   At a temperature-check station, a medical staffer in bodysuit, face mask and goggles took a thermometer from a middle-aged woman, pausing to examine the reading before quickly turning back to the patient.   "Have you registered? Then go and see the doctor," the staffer said.   One 35-year-old man surnamed Li voiced the fears of many.   "I have a fever and cough, so I'm worried that I'm infected," he said.   "I don't know the results yet."

With hundreds of millions of people on the move across China for the holiday, the government has halted all travel out of Wuhan, shut down its public transport and told residents to stay home. Deepening the isolation, there were few flights available to the city.   "This year we have a very scary Chinese New Year. People are not going outside because of the virus," said a taxi driver in the city, who asked not to be named.   But said a prolonged shutdown should not pose food-shortage problems because many Chinese had stocked up for the holiday.

Besides Wuhan, 12 other smaller cities nearby have battened down the hatches, with most of them going public on Friday with various measures ranging from closing public venues and restricting large gatherings to halting public transportation and asking citizens not to leave their cities.   Several of the cities have populations numbering several million, led by Huanggang, which has 7.5 million.    The pathogen -- 2019 Novel Coronavirus (2019-nCoV) -- has caused many outlets in Shanghai, Beijing and other cities to sell out their stocks of face masks.   As reports surfaced of bed shortages in Wuhan hospitals, state media said authorities were rushing to build a new facility devoted to the outbreak in a mind-blowing 10 days.

The Wuhan hospital is targeted to be ready by February 3. Dozens of excavators and trucks were filmed working on the site by state television.   To discourage nationwide travel, the government has said all tickets for rail, air, road, or water transport could be exchanged for a refund.   On Friday, staff in full body protective suits were seen checking the temperatures of people entering a subway station in Beijing.   Thermal cameras scanned passengers arriving at Beijing's West Railway Station.

- 'Work as one' -
Chinese authorities said the number of cases leapt overnight to more than 800, with 177 in serious condition. There were another 1,072 suspected cases.   Officials also said that a virus patient died in Heilongjiang province in China's far northeast, the second death outside the Wuhan epicentre.   Beijing has been praised for its response in contrast to SARS, when it took months to report the disease and initially denied WHO experts any access.

Gao Fu, head of the Chinese Center for Disease Control and Prevention, asked China's people to forego New Year gatherings this year and confine themselves at home until the all-clear.    "If we all work as one, we can contain the virus in Wuhan and add no more cases exported from Wuhan, so as to stem the virus nationwide," Gao told state TV.   Beijing has cancelled popular New Year public events at temples in the capital, the historic Forbidden City will close from Saturday, and Shanghai Disneyland said it also will shut down for an indefinite period from Saturday to protect visitors and staff.
Date: Fri, 24 Jan 2020 07:46:42 +0100 (MET)

Shanghai, Jan 24, 2020 (AFP) - Shanghai Disneyland will close until further notice this weekend due to a deadly virus outbreak that has infected hundreds of people in China, the amusement park said Friday.   The closure comes as China entered its nearly week-long Lunar New Year holiday, and the home of Mickey Mouse had prepared special "Year of the Mouse" celebrations for its guests.

But the park and resort said on its website it would temporarily close from Saturday "in response to the prevention and control of the disease outbreak and in order to ensure the health and safety" of its guests and staff.   "We will continue to carefully monitor the situation and be in close contact with the local government, and we will announce the reopening date upon confirmation," it said, adding that guests who had purchased tickets or booked a resort hotel would be reimbursed.   The entertainment conglomerate opened its $5.5 billion theme park in Shanghai in June 2016, Disney's sixth amusement park and third in Asia.
Date: Fri, 24 Jan 2020 03:33:13 +0100 (MET)
By Rusmir SMAJILHODZIC with Emmy VARLEY in Belgrade

Sarajevo, Jan 24, 2020 (AFP) - As winter grips the Balkans, the poor are caught in a cruel bind, being forced to light fires at home for heating while fuelling a pollution crisis smothering the region.   In recent weeks, Balkan capitals from Belgrade and Sarajevo to Skopje and Pristina have been ranked among the world's top 10 most polluted major cities, according to the monitoring application AirVisual.

While these are small cities compared to leading Asian polluters like New Delhi and Dhaka, a combination of coal-fired power plants, old cars and fires to heat homes are pumping the air with toxins.   "I know it is polluting. I am not an idiot but my only other choice would be to heat this home with electricity and that is damn expensive," said Trajan Nestorovski, who like many in his working-class Skopje neighbourhood burns wood to stay warm in winter.   His wife Vera added: "There are a couple of factories near our neighbourhood that are burning God knows what in the evenings".

Thanks to the rise of mobile phone apps that measure air quality, like the local Moj Vozduh (My Air) created by a Macedonian developer, citizens are finally grasping the full extent of the crisis.    "Serbia is suffocating, has anyone seen the minister of the environment?", said a recent headline in Belgrade's local Blic newspaper, speaking of the fog and dirty air enveloping the city.   Protests have been erupting around the region in recent days.

In Skopje, the capital of North Macedonia, young people have taken inspiration from Swedish activist Greta Thunberg by holding a spate of protests on Fridays.    "Greta inspired all of us," said 17-year-old Iskra Ilieska.   "In winter, half of my school class is absent because of lung problems. That is not normal," she said.

In neighbouring Bosnia, several hundred people wearing face masks gathered in the city of Tuzla to demand a plan from authorities to tackle pollution and phase out coal-fired plants in the next five years.   "The only recommended measures are that we stay shut up at home... when you go out on the streets, in the playgrounds, you won't see children anywhere," said Alisa Kasumovic, a mother in her forties.

- Silent killer -
According to a recent UN environment report, air pollution causes nearly 20 percent of premature deaths in 19 Western Balkan cities.   The main sources of the dust, soot and smoke are low-grade coal plants and household heating, the report said.    More than 60 percent of people in the region rely on coal and firewood to heat their homes, the report said. Only 12 percent of buildings are connected to district heating systems.

Governments need to make "clean energy more accessible", ban old polluting vehicles and tighten regulations on industry emissions and power plants, the UN urged.    Many people cannot afford cleaner heating options at home in countries where average wages are around 500 euros or less.   Sali Ademi, a 78-year-old in Kosovo's capital Pristina, uses coal.     "There's no worse thing, but what can you do?" he said in a city whose air is already poisoned by two nearby coal-fired power plants running on outdated technology.

- Cable car escape -
Those who warm their homes with fires also bear the brunt of health risks, according to experts.   "Some of the emissions from these stoves stay in the house and poison them," warned Anes Podic, president of an environmental group in Bosnia who has called on the government to replace inefficient wood stoves in the country.

In cities like Sarajevo and Skopje, a circle of mountains helps trap the hazardous air in the valleys where residents live.   Sakiba Sahman, 60, is a Sarajevan taking advantage of a recent reduction on ticket prices for a cable car that rides to the top of the 1,160-metre-high (3,800-foot-high) Mount Trebevic, which peaks above the smog over the Bosnian capital.   "We've come to spend a few hours to ventilate the lungs," she told AFP.   Down below, "the pollution is enormous, there are a lot of cars, everything is dirty, grey and depressing."
Date: Fri, 24 Jan 2020 00:46:15 +0100 (MET)

Lima, Jan 23, 2020 (AFP) - Peru's government promised on Thursday to protect the Machu Picchu sanctuary and other Inca ruins when building a new airport to serve the ancient civilization's capital of Cusco.   Machu Picchu and the Inca road system are UNESCO World Heritage sites, and the UN agency has previously expressed concerns over the proposed airport at Chinchero, less than 60 kilometers from the Inca sanctuary that was built in the 15th century.   "We have made a commitment that before work begins on constructing the Chinchero airport, in June of this year, we will present the heritage impact study that UNESCO demands," Transport Minister Edmer Trujillo, who is responsible for the project, told journalists.

UNESCO has told Peru that even though the airport will be built outside of the archeological areas, it is necessary to study how a potential increase in tourists would affect them.   The new airport will be able to receive six million passengers per year -- 60 percent more than the current Cusco airport, which has a capacity for 3,000 passengers a day but receives 5,000.

The existing airport cannot grow because it is inside Cusco, a major Andean city in southeast Peru.   Machu Picchu -- the most iconic site from the Inca empire that ruled a large swathe of western South America for 100 years before the Spanish conquest in the 16th century -- is Peru's most popular tourist attraction, located about 100 kilometers (60 miles) from Cusco.   Trujillo said construction of the new airport would be constantly monitored
by culture ministry experts in case archeological ruins are found.

The airport will be built at 3,780 meters above sea level in the old Inca Sacred Valley.   Many have criticized the impact it could have not only on the country's national treasures but on rural communities.   "Building an airport in the Sacred Valley will have irreparable effects in terms of noise, increase in traffic and uncontrolled urbanization," historian Natalia Majluf said in August.   But local Cusco authorities say it will bring in vital tourism revenue, which the region depends on.
Date: Tue 21 Jan 2020
Source: Channels TV [edited]

In Ondo state, 16 people have been confirmed killed as a result of a Lassa fever outbreak. The state chief epidemiologist, Dr Steven Fagbemi, disclosed this on Tuesday [21 Jan 2020] at the governor's office in the Government House in Akure, the state capital.

Dr Fagbemi made the disclosure while briefing Governor Oluwarotimi Akeredolu as well as the local government chairmen from Ondo North and Central senatorial districts of the state. He also revealed that 84 cases have been reported so far in the state since 1 Jan 2020.

According to the epidemiologist, 16 of the patients have passed on, as their cases had reached the advanced stage before they were taken to the hospital. He added that 47 patients on admission were responding to treatment, while 21 others had already been treated and discharged.

The outbreak is said to have affected Owo, Akoko South-West, Akure South, and Ondo West LGAs of the state.

Also confirming the outbreak, the commissioner for health, Dr Wahab Adegbenro, noted that the disease has been occurring in the state for some years, especially during the dry season. He therefore advised Nigerians to visit hospitals when they noticed symptoms of fever.

Earlier, Governor Akeredolu advised the local government chairmen in the state to deploy cleaners to markets and public places to prevent the outbreak of diseases. He also called on residents to maintain a high level of hygiene to curtail further spread of the Lassa virus in the state.
====================
[The 81 new confirmed and 159 suspected cases in week 3 of 2020 indicate that Lassa fever (LF) virus transmission is continuing to accelerate. The 1st report above confirms that Ondo state has the majority of cases, tied with Edo state. Nigeria is now entering the period of the year when fewer cases usually occur, as illustrated in the graph in Figure 6 (at the source URL above). There has been a peak in case numbers between weeks 1 and 11 (January-March) over the past 3 years and probably will be the case again this year (2020).

Transmission of LF virus occurs when individuals are in contact with rodent reservoir host 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_: <https://www.inaturalist.org/taxa/45326-Mastomys-natalensis>
_Mastomys erythroleucus_ and _Hylomyscus pamfi_: <http://punchng.com/nigerias-large-rat-population-threatens-lassa-fever-war/>

The pygmy mouse (_Mus baoulei_) has recently been implicated as a reservoir species in West Africa but not in Nigeria.

There is no specific mention in the plans above of public education for avoidance of contact with these rodents and their excreta. - ProMED Mod.TY]

[Maps of Nigeria:
Date: Tue 21 Jan 2020
Source: Ahora Noticias, Costa Rica [in Spanish, machine trans., edited]
<https://www.ahoranoticiascr.com/2020/01/21/autoridades-cerraron-pizzeria-debido-a-casos-de-hepatitis-a-en-san-ramon/>

As many as 22 people suffered from hepatitis A infection in San Ramon de Alajuela, and consequently the Health authorities closed a pizzeria in the area. A source close to this media confirmed the existence of the cases which were detected since 13 Jan 2020.

The cases were thought to be related to food consumption in that establishment 4 of patients were employees of the pizzeria. In statements to the media La Nación, Azalea Espinoza of the Directorate of Surveillance of the Ministry of Health, said they intervened in the business, issued a closing health order, and proceeded to cleaning and disinfecting it. [Byline: Carlos Miranda]
========================
[Although the eating establishment was identified as a pizzeria, pizza itself is not likely to be the vehicle of transmission as it is cooked before serving unless ingredients are added after the cooking process. It is unclear if the pizzeria employees were the source of, or just part of, the outbreak.

With an incubation period averaging 28 but up to 45 days, more cases may occur. The cases are not broken down in regard to age. In children, most cases of HAV infection are subclinical so it is likely that the cases reported were in adults. In the developing world, HAV is not reported much in adults as most children have been infected, and therefore immune to subsequent infection, by the age of 10. That outbreaks are occurring in the area suggests improvement in potable water so fewer children are infected and therefore still susceptible to HAV as adults. - ProMED Mod.LL]

[HealthMap/ProMED map available at: Costa Rica:
<http://healthmap.org/promed/p/17>]
Date: Thu, 23 Jan 2020 17:57:34 +0100 (MET)
By Eva XIAO

Beijing, Jan 23, 2020 (AFP) - The first fatality of China's new virus would come to represent a common set of traits for those who died to the disease: he was over the age of 60 and in poor health.   Since China reported the emergence of a new coronavirus at the end of December, the SARS-like virus has infected more than 500 and killed 17.   So far, the majority of the victims were elderly individuals with pre-existing health conditions, such as diabetes and liver cirrhosis.   All hailed from central Hubei province, where a local seafood market in the capital city of Wuhan is believed to be the epicentre of the epidemic.   But while older individuals have died from the Wuhan virus, some younger patients -- including a 10-year-old boy -- have since been released from the hospital.   Here's what we know so far about the deaths:

Most victims were over 60
According to details released by China's National Health Commission (NHC) on Thursday, the 17 victims of the virus were between 48 and 89 years old.   Only two were under the age of 60, while the average age of the victims was 73.   Most of them died this week, according to the NHC.   Among those who have been discharged from the hospital were younger patients, including a 35-year-old man from Shenzhen, a bustling tech hub in southern Guangdong province.   He was released from the hospital on Thursday, according to the local health commission, as well as the 10-year-old boy who had visited relatives in Wuhan before falling ill.

Many had pre-existing health conditions
Many of those who died from the virus also had pre-existing health issues before contracting the Wuhan disease, such as diabetes and hypertension.   One man, an 86-year-old who was hospitalised on January 9, had surgery for colon cancer four years prior, on top of suffering from high blood pressure and diabetes.   Another, an 80-year-old woman surnamed Hu, had Parkinson's Disease and more than 20 years of high blood pressure and diabetes in her medical history.

Some were hospitalised for weeks before dying
Several of the 17 victims were hospitalised for weeks before dying -- raising questions on the preparedness of hospitals that may have to treat patients for long periods of time.   The youngest victim of the Wuhan virus, a woman surnamed Yin, was hospitalised for more than a month before succumbing to the virus.   On December 10, the 48-year-old woman reported a fever, coughing, body soreness, and fatigue, and underwent anti-infection treatment for two weeks, according to the NHC.   Later in the end of the month, Yin suffered shortness of breath and chest tightness, and she passed away on January 20.

Not all of them had a fever
Currently, Wuhan authorities are screening passengers for fever at the airport, railway stations, and bus terminals.   At four airports in Thailand, authorities introduced mandatory thermal scans of passengers arriving from high-risk areas of China.   But not all those who died after being infected reported a fever before being hospitalised, according to the NHC.   A 66-year-old man surnamed Luo reported a "mainly dry cough" but no fever on December 22 before suffering from shortness of breath more than a week later.

By mid-January, Luo required a ventilator to help him breathe.   "A major concern is the range of severity of symptoms this virus is causing," said Dr Jeremy Farrar, Director of the Wellcome Trust.   "It is clear some people are being affected and are infectious while experiencing only very mild symptoms or possibly without experiencing symptoms at all," he said in an emailed statement.   "This may be masking the true numbers infected and the extent of person to person transmission," he added.
Date: Thu, 23 Jan 2020 16:05:30 +0100 (MET)

Singapore, Jan 23, 2020 (AFP) - Singapore Thursday confirmed its first case of the new SARS-like virus which has killed 17 people in China and spread to multiple countries including the United States.   The Ministry of Health (MOH) said the patient was a 66-year-old man from Wuhan who arrived in Singapore with his family on Monday.    He was immediately isolated after arriving at a hospital with a fever and cough, and test results later confirmed he was infected with the coronavirus.   One of his travelling companions, a 37-year-old man from Wuhan, has also been admitted to hospital as a suspect case.

Prior to admission, they had stayed at a hotel on the resort island of Sentosa, the ministry said.   It added that Singapore was expecting more cases and alarms "given the high volume of international travel".   Singapore's Changi Airport started screening flights from Wuhan at the beginning of the month, and on Wednesday extended the checks to all flights from China.   The travel hub receives over 430 flights from China every week.   The virus has caused alarm in China and abroad because of its genetic similarities to Severe Acute Respiratory Syndrome (SARS), which killed nearly 650 people across mainland China and Hong Kong in 2002-2003.

Singapore was among the hardest hit by SARS with 33 deaths.   Prime Minister Lee Hsien Loong, who is in Davos for the World Economic Forum, said there was "no need to panic".   Speaking to reporters travelling with him, Lee said Singapore has beefed up its hospital facilities and laid out response measures since the SARS epidemic.   "I think we are much better prepared now," he said in remarks carried by the Straits Times newspaper.