Date: Sun, 21 Oct 2018 07:19:57 +0200

San José, Oct 21, 2018 (AFP) - Four American tourists were killed and a fifth Costa Rican tourist is missing after a river rafting accident in the Central American country on Saturday, the Red Cross said.   The alarm was raised Saturday afternoon following the accident in a swollen river on Costa Rica's Pacific Coast, Alexander Morales of the Red Cross told AFP.   "Fourteen tourists and three guides on board three rafts, and a kayaker, were on the Naranjito river in Quepos, Puntarenas when the accident occurred," Alexander Morales told AFP.   Another spokesman, Johnny Zamora, confirmed the American tourists had yet to be identified.

Costa Rica's President Carlos Alvarado expressed his "dismay" at the incident and said in a statement that he had instructed authorities to provide all necessary support to the victims' families.    The statement added that Costa Rica's foreign ministry has been in communication with the US consulate in the capital San Jose, some 55 kilometers (35 miles) from Quepos.   Rafting is hugely popular with tourists in Costa Rica, which is currently in its wet season, causing waterways to flood.
Date: Wed 19 Sep 2018
From: Marton Szell <docmarton@gmx.at> [edited]

We report a case of leptospirosis in a 26-year-old Austrian backpacker returning from Costa Rica. The infection occurred most likely at a waterfall near the village of Montezuma on the Pacific coast of Costa Rica. This waterfall is a popular place especially with backpackers; therefore, other tourists could be affected, too.

The patient returned on 28 Aug 2018 after traveling for 5 weeks in Panama and Costa Rica. He had a high fever and a feeling of overall weakness 2 days before his return to Austria. He consulted a local doctor who ruled out dengue fever (point-of-care test) because of a high blood leukocyte count; the doctor prescribed a 5-day course of oral ciprofloxacin as an antibiotic treatment. No other tests were performed.

After the patient's return to Austria, his general condition improved and his body temperature returned to normal. The fever reappeared 9 days after the initial onset of the disease, and the patient complained of severe headache and flulike symptoms. His family doctor initiated a broad diagnostic check-up. In the end, only leptospirosis serology yielded positive [results].

We carried out a complete blood check. All parameters, except slightly elevated liver enzymes, [were] normal. We repeated tests for leptospirosis: [Leptospiral] DNA in blood and urine was undetectable and serology showed normal IgG, but a 4-fold increase of IgM antibodies (enzyme immunoassay) confirmed the diagnosis.

Our patient could recall having contact with fresh water 7 to 10 days before the onset of fever. He took a bath in a waterfall near Montezuma on the Nicoya peninsula of Costa Rica. The patient had no contact with animals. Because of the patient's remaining symptoms (slightly elevated body temperature and general weakness), we prescribed a 7-day course of oral doxycycline therapy. With this treatment, all symptoms have disappeared.
---------------------------------------------------
Communicated by:
Dr. Marton Szell
Infectious Diseases Consultant
Dr. Verena Sperl
Infectious Diseases Resident
Emergency Department
Danube Hospital
Vienna, Austria
marton.szell@wienkav.at
=============================
[Leptospirosis is caused by exposure to _Leptospira_ bacteria in fresh (not salty) water, wet soil, or vegetation that has been contaminated by urine of animals chronically infected with one of the several hundred serovars of the spirochete _Leptospira interrogans_. Rodents, dogs, cattle, and pigs are the usual reservoirs for this organism.

Leptospirosis is an occupational hazard for people who work outdoors or with animals; for example, workers in wet agricultural settings (such as rice field workers), ranchers, slaughterhouse workers, trappers, loggers, sewer workers, veterinarians, fishery workers, dairy farmers, or military personnel.

Leptospirosis is also a risk during recreational activities such as camping, fresh water swimming, canoeing, kayaking, rafting, golfing, and trail biking that involve exposure to water in lakes, rivers, or ponds contaminated by urine from leptospire-infected animals, as well as a risk from household exposure to infected pet animals or rodents. - ProMED Mod.ML]

[HealthMap/ProMED maps available at:
Austria: <http://healthmap.org/promed/p/109>
Costa Rica: <http://healthmap.org/promed/p/17>]
Date: Thu 26 Jul 2018
Source: TN8 TV Nicaragua [in Spanish, machine trans. edited]
<https://www.tn8.tv/america-latina/454135-costa-rica-llama-prevencion-ante-brote-hepatitis/>

The Costa Rican Ministry of Health reported today [26 Jul 2018] that it is responding to an outbreak of hepatitis A in a town in the eastern sector of San Jose and asked the population to take hygienic preventive measures. So far, there are 3 confirmed cases and 8 suspected in the canton of Goicoechea, located in the eastern sector of the capital. Health authorities have made an active search in recent days in the areas close to the outbreak, the Health Ministry said in a statement.

In addition, health officials called in primary health care technical assistants to receive more information about hepatitis A, including the mechanisms of transmission, symptomatology, and prevention. The authorities also provided educational material to the population in shopping centres and common areas, and it is planned that tomorrow [27 Jul 2018] they will begin activities in educational centres so that students know the preventive measures.

The Ministry of Health ordered people with hepatitis A to refrain from attending study or work centres for at least 12 days and, upon their return, to attend to extreme hygiene measures, especially handwashing. To the population in general, the authorities urged frequent handwashing with soap and water, especially after going to the bathroom, before preparing or consuming food, or changing diapers.
=======================
[No information is given about the age of those affected. In much of the developing world, where hepatitis A is quite endemic, the population is almost all seropositive for HAV by the age of 10. I would wonder whether the infection was confirmed by a specific IgM anti-HAV antibody. - ProMED Mod.LL]

[HealthMap/ProMED map available at: Costa Rica: <http://healthmap.org/promed/p/17>]
Date: Thu 24 May 2018
From: Henry Wu [edited] <henry.m.wu@emory.edu> [edited]
[re: ProMED-mail Malaria - USA: ex Costa Rica: (PU)
http://promedmail.org/post/20180514.5790914]
----------------------------------------------------------------------
The American traveller reported to ProMED on May 9, 2018 to have acquired _P. falciparum_ malaria during travel to Costa Rica has been determined to have not been infected with malaria. Although rapid diagnostic testing (RDT) performed at the hospital and PCR testing performed at the state health department were positive for _P. falciparum_, further testing by CDC on the specimen using multiple tests (antigen, PCR, and serology) has been negative, indicating that the initial positive results were false positives.

CDC has rescinded the malaria notice posted on [10 May 2018] that recommended chemoprophylaxis for travellers to the Osa Peninsula area of Puntarenas Province in Costa Rica. No chemoprophylaxis is recommended for travellers to Costa Rica at this time.

The rescind notice is posted at <https://www.cdc.gov/malaria/new_info/2018/Costa_Rica_5_22_2018.html>
---------------------------------
Henry Wu, MD GeoSentinel Site Director Atlanta <henry.m.wu@emory.edu>
Patricia Schlagenhauf, PhD Tracking and Communication Working Group GeoSentinel, EuroTravNet
David Hamer, MD GeoSentinel PI
==================
[ProMED thanks Henry Wu and the GeoSentinel team for the prompt communication, that the case was misdiagnosed as malaria. If malaria microscopy had been done the false diagnosis could probably have been avoided.

The microscopy of a Giemsa stained thick blood film is more sensitive than a rapid diagnostic test and would have been negative. - ProMED Mod.EP]
 
[HealthMap/ProMED-mail map Penansula de Osa, Puntarenas, Costa Rica:
<http://healthmap.org/promed/p/39539>]
Date: Wed 9 May 2018
From: Henry Wu [edited]

Henry Wu from the GeoSentinel Atlanta site recently reported a case of _Plasmodium falciparum_ malaria in an American tourist returning from Costa Rica. The traveller was a tourist from the United States, without significant recent travel history. He visited a less travelled area in eastern Costa Rica, near Panama.

The patient's Costa Rica itinerary (7-20 Apr 2018) was as follows: Drake Bay, La Tarde, and El Remanso. The patient did not use repellents. Illness onset was the night 28 Apr 2018 with fever on 29 Apr 2018.

Prior travel reported: St Thomas, Virgin Islands June 2017, and a trip to Tanzania in 2015 (for which he took Malarone prophylaxis).

This patient had a positive RDT [rapid diagnostic test] for _P. falciparum_ but surprisingly, 2 thick smears, one before and another 24 hours after treatment was started, were both negative.

Initially the case was considered to be a false positive RDT (T1 band), but PCR done at the US CDC was positive. He recovered after treatment with Malarone. CDC is considering it a confirmed case for their surveillance at this point. The case is unusual because this area is not considered a malaria risk area and only mosquito bite avoidance is recommended.

Furthermore, it underscores how unpredictable malaria epidemiology can be, particularly in areas of migration movement. From the travel and illness onset dates, it does appear most likely that this American tourist contracted falciparum malaria in an area of Costa Rica that is not considered a risk area for malaria. When it comes to travellers' malaria, always expect the unexpected.
===========================
Henry Wu, MD GeoSentinel Site Director Atlanta
Patricia Schlagenhauf, PhD Chair, Tracking and Communication Working Group GeoSentinel
David Hamer, MD GeoSentinel PI
===========================
[As underlined in the comment above, Costa Rica is considered to be free of malaria. We assume that the patient was infected my mosquitoes and therefore there must be other cases close to his itinerary. Alternatively, he was infected by migrants in Costa Rica from malaria endemic areas. All of these locations are on the Osa Peninsula, Puntarenas Province.

In 2004, PAHO reported 1289 cases of all species of malaria in Costa Rica of which 5 were mixed _P. falciparum_ malaria cases; all the remaining were _P. vivax_. In 2006, Costa Rica reported an outbreak of 13 cases of falciparum malaria in the Caribbean province of Limon.

ProMED will be interested in posting further information. - ProMED Mod.EP]

[HealthMap/ProMED-mail map Península de Osa, Puntarenas, Costa Rica:
<http://healthmap.org/promed/p/39539>]
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