Date: Tue 4 Jul 2017
Source: Khaleej Times [edited]
<http://www.khaleejtimes.com/nation/dubai/flying-to-dubai-legionnaires-disease-warning-issued>

Travellers have been issued a Legionnaires' disease warning after an Irish person contracted the disease on a recent visit to Dubai, international news reports said.

The reports published last week [week of 25 Jun - 1 Jul 2017] said that though risk of contracting the disease is low, it may be increased for those aged over 50, those with underlying breathing problems or weakened immune systems and smokers.

Most of those who contracted the disease stayed in hotels or apartments in Dubai, some as recently as late May [2017], they said.

Since last October [2016], 65 cases of the disease originating in Dubai have been reported to the European Centre for Disease Prevention and Control, one of them by Ireland, said the Irish Times.

The government of UK also updated its travel advisory but said that the overall risk of Legionnaires' disease for UK travellers to Dubai is low except for persons with established risk factors for Legionnaires' disease
[<https://www.gov.uk/government/publications/legionnaires-disease-associated-with-travel-to-dubai>].

The paper said that as the source of the outbreak had not been identified, anyone visiting or living in Dubai could still be at risk of exposure to the _Legionella_ bacteria. Local health authorities could not be reached for comments.

Till the end of last year [2016], the European Centre for Disease Prevention and Control reported 44 cases in travellers. Cases were reported by the United Kingdom (20 cases), Sweden (6), the Netherlands (5), France (3), Denmark (3), Germany (3), Austria (1), Belgium (1), Hungary (1) and Switzerland (1). Nine of 44 cases (20 percent) spent time in another location in UAE or in a country other than their home country during their incubation period. One of the notified cases is reported as a fatal case. All cases are laboratory confirmed, reported ECDPC.

As per ECDPC, UAE authorities have informed that there was no increase observed in notifiable pneumonia cases in Dubai during the period October to December 2016 when these cases were observed.

Public health authorities in the UAE also said that environmental investigations were undertaken at the notified hotels and _Legionella_ count results within the Dubai Municipality showed acceptable levels for water systems.

In 2011, a top hotel in Dubai faced a lawsuit after 2 guests claimed that they had contracted the disease while staying on the property. The Dubai Health Authority (DHA) had then also formed a committee to probe the outbreak.

If travellers develop symptoms within 2 weeks of returning home, they should seek medical care and inform the healthcare provider of the travel history.  [Byline: Asma Ali Zain]
------------------------------------------
Communicated by:
Denis Green
legion@q-net.net.au
========================
[ProMED-mail thanks Denis Green for his continued contributions.

ProMED-mail previously reported on this outbreak when there were 60 cases among European travelers who developed legionnaires' disease within 2 weeks of returning home from Dubai (see ProMED-mail post Legionellosis - Europe: ex United Arab Emirates (Dubai) http://promedmail.org/post/20170602.5079438). No source of the outbreak has been identified.

Dubai is one of the 7 emirates and the most populous city of the United Arab Emirates (UAE) (<http://en.wikipedia.org/wiki/Dubai>). Dubai has been ruled by the Al Maktoum dynasty since 1833.

Dubai can be located on the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/promed/p/3442>. - ProMED Mod.ML]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/40>.]
Date: Sun, 2 Jul 2017 21:53:43 +0200

Washington, July 2, 2017 (AFP) - The United States has lifted a ban on passengers taking laptops and tablet computers on Etihad Airways flights from its base in the Emirati capital Abu Dhabi, authorities said Sunday.   The move -- welcomed by Etihad -- comes more than three months after the United States prohibited such devices on direct flights from 10 airports in Turkey, the Middle East and North Africa.   Etihad is the first airliner to benefit from a lift in the ban, which specified that carry-on laptops and other electronic devices larger than cellphones would not be permitted in the cabin on direct flights from the airports, including Abu Dhabi.   The ban was implemented after intelligence officials learned of efforts by the Islamic State group to fashion a bomb that could be secreted inside such devices.

The decision to lift the ban on US-bound Etihad flights from Abu Dhabi came after the airline implemented enhanced security measures, said David Lapan, spokesman for the US Department of Homeland Security.   "We commend Etihad for working swiftly to implement these additional measures," he said. "Their efforts are a model for both foreign and domestic airlines looking to adopt the new measures."   Lapan said the specific measures that were put in place were confidential, but added that passengers and electronic devices would face additional screening.   Etihad Aviation Group applauded the decision.   "We welcome the decision by the US Department of Homeland Security to lift the electronic devices ban on flights between Abu Dhabi and the United States, following the successful validation of security measures at the US Preclearance facility at Abu Dhabi airport earlier today," a statement said.   "Effective immediately, the removal of the restrictions allows passengers flying to the US to carry all laptops, tablets, and other electronic devices onto the aircraft, subject to enhanced security measures," it added.

Etihad said its passengers flying to the United States from Abu Dhabi International Airport "clear US Immigration and Customs at the US Preclearance facility in Terminal 3".   "When guests land in the US, they arrive as domestic passengers with no requirement to queue for immigration and custom checks again," it added, saying the facility was the only one of its kind in the region.   In addition to the 10-airport ban, the United States announced on June 28 that it would impose stricter security measures on all US-bound flights, regardless of origin.   Washington has promised to lift its March ban affecting the 10 airports when airliners adhere to additional security measures.   Britain announced a similar ban on personal electronic devices for flights originating from six countries, but not the United Arab Emirates.
Date: Sat 27 May 2017
Source: Outbreak News Today [edited]
<http://outbreaknewstoday.com/legionnaires-disease-cases-60-europe-linked-dubai-travel-61691/>
---------------------------------------------------------------
In recent months, there has been an increase in the number of cases of legionnaires' disease among European travelers returning from Dubai. As the source has not yet been identified, there could still be a risk for exposure to legionella for people visiting or living in Dubai.

Between 1 Oct 2016 and 23 May 2017, 60 cases of legionnaires' disease with a history of travel to Dubai have been reported to the European Centres for Disease Prevention and Control (ECDC). The majority of cases stayed in commercial accommodation sites.

The number of cases reported during February and April 2017 are still higher than in previous years. The most recent case became ill on 11 May 2017. These recent cases suggest there is still an ongoing exposure risk.

The risk of legionnaires' disease to travelers to Dubai is considered to be low. However, the risk may be increased for the following groups:
- those aged over 50;
- those with underlying breathing problems;
- those who have weakened immune systems; and
- smokers.

If you are travelling to Dubai, be aware of the symptoms of legionnaires' disease. If symptoms develop while in Dubai you should seek medical care. If symptoms develop within 2 weeks of returning home you should seek medical care and inform your healthcare provider of your travel history.

Legionnaires' disease is a type of pneumonia caused by the bacterium _Legionella pneumophila_ and other _Legionella_ species. The illness usually starts with flu-like symptoms including fever, tiredness, headache, and muscle pains. This is followed by a dry cough and breathing difficulties which may progress to a severe pneumonia. The disease is spread through the air from a water source. People become infected when they breathe in aerosols (tiny droplets of water) which have been contaminated with the bacteria.
====================
[The last ProMED-mail post on these cases -- dated 30 Dec 2016 -- (Legionellosis - EU: EU travelers, ex United Arab Emirates (Dubai) susp http://promedmail.org/post/20161230.4733569) reported on 26 symptomatic cases in travelers from the European Union linked to Dubai.

The following is a good review on the history of this infection, which came into the public view after an outbreak of pneumonia related to an American Legion convention at a hotel in Philadelphia during the summer of 1976.

Winn WC Jr. Legionnaires disease: historical perspective. Clin Microbiol Rev. 1988; 1(1): 60-81;
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC358030/>.

Abstract
--------
In the summer of 1976, a mysterious epidemic of fatal respiratory disease in Philadelphia launched an intensive investigation that resulted in the definition of a new family of pathogenic bacteria, the _Legionellaceae_. In retrospect, members of the family had been isolated from clinical specimens as early as 1943. Unsolved epidemics of acute respiratory disease dating to the 1950s were subsequently attributed to the newly described pathogens. In the intervening years, the _Legionellaceae_ have been firmly established as important causes of sporadic and epidemic respiratory disease. The sources of the infecting bacteria are environmental, and geographic variation in the frequency of infection has been documented. Airborne dissemination of bacteria from cooling towers and evaporative condensers has been responsible for some epidemics, but potable water systems are perhaps more important sources. The mode of transmission from drinking water is unclear. The _Legionellaceae_ are Gram negative, facultative, intracellular pathogens. The resident alveolar macrophage, usually an effective antibacterial defense, is the primary site of growth. Cell-mediated immunity appears to be the most important immunological defense; the role of humoral immunity is less clear.  -  ProMED Mod.LL]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/132>.]

May 2017
http://ndsc.newsweaver.ie/epiinsight/1nbmza5lu36-126emz232s?email=true&a=2&p=51784310&t=17517804

In recent months, the European Centre for Disease Prevention and Control (ECDC) has observed an increase in the number of cases of Legionnaires’ disease among European travellers returning from Dubai compared to previous years (1, 2). As the source has not yet been identified, there could still be a risk for exposure to Legionella for persons visiting or living in Dubai.

What is Legionnaires’ disease?
Legionnaires’ disease is a type of pneumonia caused by the bacteria Legionella pneumophila and other Legionella species. The illness usually starts with flu-like symptoms including fever, tiredness, headache, and muscle pains. This is followed by a dry cough and breathing difficulties which may progress to a severe pneumonia. Death occurs in 10-15% of otherwise healthy people and may be higher in some groups of patients. All ages can be affected. However, most cases occur in people who are over 40 years of age. Men are more at risk than women, as are smokers, those with excessive alcohol intake, and people with chronic illnesses or people whose immune system is weakened.

The disease is spread through the air from a water source. People become infected when they breathe in aerosols (tiny droplets of water) which have been contaminated with Legionella bacteria. Legionella bacteria are found in many types of water systems. They multiply in warm, and stagnant water, such as can be found in air conditioning cooling towers, certain plumbing systems especially showers, spa pools, decorative fountains, sprinklers and nebulisers. Sporadic cases and outbreaks are frequently associated with commercial accommodation such as hotels due to the nature of the plumbing systems in such buildings, and also the presence of aerosolising water features such as spa pools and fountains. There is no evidence that spread from person-to-person can occur.

Further information on LD is available here.

Because the incubation period is 2-10 days, cases associated with commercial accommodation overseas may not be diagnosed until their return to their home country. For this reason ECDC operates an EU wide surveillance system for travel associated Legionnaires’ disease in order to identify any clusters of LD associated with commercial accommodation sites (3). This system is called ELDSNet.

Epidemiological situation
Up to the 6 April 2017, 50 cases with a history of travel to Dubai within 2–10 days prior to illness and with onset since 1 October 2016, have been reported to ECDC (1). The majority of cases stayed in commercial accommodation sites. However, a number did stay in private accommodation. Because the ELDSNet does not require cases which stayed in private accommodation to be notified, the number of European cases who stayed in private accommodation may be underestimated (2). Twenty percent of the cases spent time in another location in the United Arab Emirates (UAE) or in a country other than their home country during their incubation period, and therefore they may not have been infected in Dubai.

Reported cases are associated with different accommodation sites dispersed geographically across Dubai, which suggests that cases may have been exposed to a common source other than their accommodation site. The UAE authorities have informed ECDC that there has been no increase observed in pneumonia cases in the local community during the period October to December 2016. They have also informed ECDC that environmental investigations at hotels where European cases stayed showed that Legionella count results were within acceptable limits. These two factors could possibly indicate an environmental exposure in areas frequently visited by tourists, e.g. airports, shopping malls or tourist attractions. No information from the UAE authorities has been provided to ECDC as to whether environmental investigations have been carried out in such sites in Dubai.

ECDC published a rapid risk assessment on the situation in December 2016. The assessment outlined in this still stands. In the absence of identified and controlled sources of Legionella bacteria exposure, there could still be a risk for exposure to Legionella for persons visiting or living in Dubai.

Advice for travellers to Dubai or those recently returned

The WHO has not issued any advice against travel to Dubai. The risk of LD to travellers to Dubai is considered to be low. However, the risk may be increased for those who are at an underlying increased risk for LD. This includes:

  • Those aged over 50
  • Those with underlying breathing problems
  • Those who have weakened immune systems
  • Smokers

If you are travelling to Dubai, be aware of the symptoms of LD. If symptoms develop while in Dubai you should seek medical care. If symptoms develop within two weeks of returning home you should seek medical care and inform your healthcare provider of your travel history.

Travellers to the UAE should also be aware of the symptoms and the advice on Middle East respiratory syndrome coronavirus (MERS-CoV), a different respiratory infection which is ongoing in the Arabian peninsula. Travel advice on MERS-CoV is available here.


Advice for healthcare providers
Healthcare providers should consider LD in patients presenting with pneumonia with a travel history to Dubai or the UAE in the two weeks prior to symptom onset.

Guidance information on LD for healthcare providers is available here.

On diagnosis of a travel associated case of LD healthcare providers should inform the Department of Public Health in their area (contact details are available here).

Sporadic cases and outbreaks of MERS-CoV continue to occur in the Arabian peninsula, including the UAE. As symptoms of MERS-CoV and LD may be similar, MERS-CoV should also be considered in a person presenting with respiratory symptoms and a travel history to Dubai or the UAE in the two weeks prior to symptom onset. Guidance on the assessment and appropriate management of a possible case of MERS-CoV is available here.

 
Eve Robinson, Tara Mitchell, HPSC

References

1. European Centre for Disease Prevention and Control. Increase of cases of Legionnaires’ disease in EU travellers returning from Dubai, October−December 2016 – 22 December 2016. Stockholm: ECDC; 2016. Available here

2. European Centre for Disease Prevention and Control (ECDC). Epidemiological update: Legionella in Dubai [online]. Stockholm: ECDC; 2017 [updated April 7 2017; cited 2017 April 21]. Available here 

3. European Centre for Disease Prevention and Control (ECDC). European Legionnaires’ Disease Surveillance Network (ELDSNet) − Operating procedures. Stockholm: ECDC; 2012.

Date: Wed, 22 Mar 2017 18:34:51 +0100
By Natacha Yazbeck

Dubai, March 22, 2017 (AFP) - Travellers across the Middle East expressed frustration Wednesday at a ban on large electronic devices for flights to the United States and Britain that has sparked confusion and speculation.   From Saturday, passengers on flights to the United States and Britain from major hubs in Turkey and the Arab world will have to check in any device larger than a smartphone, including laptops and tablets.   The United States and Britain have cited intelligence indicating passenger jets could be targeted via explosives planted in electronic devices.

Caught in the middle of the ban are thousands of travellers growing increasingly frustrated with what they see as an absurd measure.   "Is there anything else I should know before flying back home? Navy blue boxers not allowed? Should I shave?" asked an American expat living in Abu Dhabi with a direct flight to the United States next week.   As the March 25 enforcement deadline looms, passengers are growing increasingly wary of restrictions on living in and travelling from the Middle East.   "They took my laptop and my camera," said Mustafa, who did not give his second name, as he boarded a plane out of Dubai to the United States.   The US ban affects nine airlines from eight countries: Turkey, Morocco, Jordan, Egypt, the United Arab Emirates, Qatar, Saudi Arabia and Kuwait.   The British ban, meanwhile, targets flights out of Egypt, Turkey, Jordan, Saudi Arabia, Tunisia and Lebanon.   Canada and France have also said they are looking into similar regulations.

- 'Why?' -
At the Tunis airport, a passenger flying to Canada via London said he was confused by the new measure.   "I mind because I need my laptop or my iPad. It's a personal thing. Why do I have to put them in hold?" said Riadh, 33, adding he now feared they would be damaged or stolen.   Many were quick to flag a lack of logic behind justifications of the ban.   "Every criminal in the Middle East: 'Oh no! We can't take the direct flight to the US! I hate connecting flights! *Cancels criminal plans*," Egyptian analyst Mohamed El Dahshan wrote on Twitter.   Ankara has said it plans on requesting that the US repeal the measure.

Turkish Foreign Minister Mevlut Cavusoglu criticised the ban as a unilateral, temporary move better replaced by "permanent" measures.   The British ban has sparked concern in tourism-dependant Tunisia, which is trying to recover from 2015 jihadist attacks that killed holidaymakers.   "It will have a negative impact on tourism," said Mohamed Ali Toumi, the head of a Tunisian travel agents federation.   American officials have publicly cited security concerns.   "From what we know, the ban is linked to intelligence on Al-Qaeda in the Arabian Peninsula gathered by the US military," said Mustafa Alani, a security analyst at the Dubai-based Gulf Research Center.

- 'Time is money' -
The US has conducted intense air raids on AQAP targets across Yemen since January. The Pentagon has confirmed 40 strikes this month.   The US Department of Homeland Security has also cited an explosion on a flight out of Somalia in February last year, in which the suspected bomber was killed.   The attack was claimed by the Shabaab insurgent group.   But experts do not rule out other motives behind the ban, including business lost to increasingly popular Gulf carriers Emirates, Etihad and Qatar Airways.

US airlines do not have direct flights from the airports affected by its new restrictions.   "American airlines are going to benefit simply because airlines make their business from the business travellers, so on these long flights that are in excess of eight or 12 hours, time is money -- but there are definitely more pressing considerations linked to security," said aviation analyst Kyle Bailey, president of the US-based consultancy KL Bailey Associates.

The UK ban will affect British Airways and easyJet, as well as airlines from targeted countries.   Critics have also raised lithium batteries -- which are covered by strict regulations on domestic flights in the United States -- as a point of concern.   "There is some concern around the lithium batteries in the cargo compartment, which could be highly explosive if they overheat," Bailey said.   But "from what we hear, the terrorism risk outweighs the risk of fire at this point."
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