Tag Archives: Disease

Presidents, billionaires battle World’s deadliest creature

Workers look for holes in mosquito netting at the A to Z Textile Mills factory producing insecticide-treated bednets in Arusha, Tanzania

By Katy Migiro

ARUSHA, Tanzania (Thomson Reuters Foundation) – Jakaya Kikwete, the former president of Tanzania, recalled arriving at his cousin’s house to find the family arguing about taking their feverish teenage daughter to hospital.

“They were saying: ‘No, no, no, it’s not malaria’,” he said, describing how the family had sought advice from a traditional medicine man who said a jinni, or spirit, had invaded her body.

“They said: ‘If you take this girl to the hospital, if she gets an injection, then that jinni (spirit)… will… suck all her blood’,” Kikwete said.

Ignoring their protests, he took the girl to hospital but it was too late. She died from malaria.

Kikwete, who also lost his brother to malaria as a child, is committed to eradicating the disease, which killed an estimated 438,000 people globally in 2015 – making the mosquito, which transmits it, the world’s deadliest creature.

He and his wife even appear in television adverts, urging Tanzanians to prepare their bednets before they sleep.

“We are looking at 2040 as the most probable date for a malaria-free Africa,” Kikwete, who stepped down as president in November, told reporters at a recent dinner in Dar es Salaam.

“If we continue with the interventions that we have been doing here relentlessly, we should be able to get there.”

THE “E-WORD”

Global plans to eliminate malaria were abandoned in 1969 as the goal was seen as prohibitively complicated and expensive, despite success in eradicating the disease in the 1950s in parts of Europe, North America and the Caribbean.

The “e-word” has been revived in recent years, with support from the world’s richest couple Bill and Melinda Gates and U.S. President Barack Obama, who called malaria a “moral outrage”.

Bill Gates, who Kikwete describes as a “good friend”, aims to eradicate malaria by 2040 and has called for a doubling of funding by 2025.

His goal of permanently ending transmission of the disease between humans and mosquitoes is more ambitious than the Sustainable Development Goal of ending epidemic levels of malaria by 2030.

Spending on malaria, mostly by the United States, surged to $2.7 billion in 2015 from $130 million in 2000, while death rates in Africa have fallen by 66 per cent, according to the World Health Organization (WHO).

The most important investment was the roll out of one billion free bednets. Some 68 percent of malaria cases prevented since 2000 were stopped by these bednets, according to a study by the University of Oxford.

Money was also poured into improved diagnostic tests, better drugs, indoor spraying with insecticide and educating the public to use these tools – rather than blaming witchcraft or buying medication blindly over the counter every time they got a fever.

EVERYTHING IS FREE

In the Tanzanian town of Arusha, overlooked by the dormant volcano Mount Meru, donor-funded bednets and free tests and medicines have made a significant impact.

In a country with a powerful faith in witchcraft and traditional medicine, health officials have worked hard to persuade people to adopt proven methods of preventing and treating the disease.

“There are very few cases of malaria nowadays,” said Pius Dallos, the officer in charge of Kijenge Dispensary, where women sat on wooden benches, cradling their babies.

“Previously… if you didn’t have money, you could die from malaria. But nowadays, everything is free.”

But donors’ ability to maintain – and increase – funding is by no means certain given sluggish global growth and uncertainties over U.S. funding under a new administration.

“The political will to go that final mile may be hard to sustain because it will remain expensive until the end,” Dyann Wirth, a tropical disease expert at Harvard T.H. Chan School of Public Health, told the Thomson Reuters Foundation.

“It’s a question of priority.”

It is unlikely that Africa, which accounted for nine out of 10 of the 214 million cases of malaria in 2015, according to the WHO, could foot the bill itself.

On the edge of Arusha, Africa’s largest bednet manufacturer, A to Z Textile Mills, has been the main source of 50 million free bednets given to Tanzanians between 2009 to 2016.

Giant, noisy warehouses produce insecticide-treated fibres which are woven into round and square blue bednets. Women in green T-shirts work in fast-moving pairs, folding and cutting panels ready for stitching.

Donor funding drives production of the much-needed nets, as many ordinary Tanzanians cannot afford them.

“Demand is not driven by the need (but) by the funding,” said factory director Kalpesh Shah, sitting in front of framed photographs of visits by celebrity campaigners like Bono and Will Smith on the boardroom wall.

Commercial customers account for less than one percent of sales, he said. The Gates-funded Global Fund To Fight HIV, Tuberculosis and Malaria is their main buyer, followed by the U.S. President’s Malaria Initiative.

“The question of sustainability is on everyone’s mind,” said Daniel Moore, acting mission director for the U.S. Agency for International Development (USAID) in Tanzania.

“Right now, we are carrying the load.”

RISK

The failure of the global eradication programme that began in the 1950s casts a shadow over the latest campaign.

As mosquitoes and parasites developed resistance to insecticides and drugs in the 1960s, malaria rebounded in countries like Sri Lanka where once it had been virtually eliminated.

Resistance is becoming a major problem again. But greater efforts are being made to invest in new products that will keep humans one step ahead of evolution.

New tools are also required to eliminate the parasite from ‘asymptomatic carriers’ – people with a few parasites in their blood who don’t fall sick but can act as reservoir and spread the disease when they get bitten again by mosquitoes.

As the number of malaria cases falls, it will become harder to maintain the momentum among donors, governments and ordinary people in endemic regions.

“Without the long term investment of funds and the political commitment to continue the fight, we risk wasting the entire investment,” said Wirth.

“We are going to go back to the situation where we are losing one million children a year in Africa.”

The International Center for Journalists and Malaria No More provided a travel grant for this report

(Reporting by Katy Migiro; Editing by Ros Russell; Please credit the Thomson Reuters Foundation, the charitable arm of Thomson Reuters, that covers humanitarian news, women’s rights, trafficking, property rights and climate change. Visit http://news.trust.org to see more stories.)

Dead Illinois resident had bacteria linked to Wisconsin outbreak

(Reuters) – A northern Illinois resident who died after being diagnosed this year with a blood infection known as Elizabethkingia had the same strain of the bacteria linked to more than a dozen deaths in Wisconsin, health officials said on Tuesday.

Neither the resident’s age nor many other details were released, but Melaney Arnold, spokeswoman for the Illinois Department of Public Health (IDPH), said the individual had suffered from underlying health issues.

IDPH officials have sent alerts to hospitals requesting they report all cases of Elizabethkingia and save any specimens for possible laboratory testing, Arnold added in a statement.

The infection has infected 48 mostly elderly people in Wisconsin, killing 15. Both Michigan and Illinois have each reported one death and one person infected, the statement said.

The patients who died in Wisconsin had serious underlying conditions, health officials have said, and it remains unclear whether the bacteria caused all the fatalities.

Wisconsin, Michigan and Illinois investigators are working with Atlanta-based The Centers for Disease Control and Prevention to determine the possible source of the bacteria.

Elizabethkingia bacteria are rarely reported to cause illness in humans, and can sometimes be found in the respiratory tract. Symptoms can include fever, shortness of breath and chills or cellulitis. Confirmation of the illness requires a laboratory test.

(Reporting by Justin Madden; Editing by Daniel Wallis and James Dalgleish)

Zika mystery deepens with evidence of nerve cell infections

Aedes aegypti mosquitoe

By Julie Steenhuysen

CHICAGO (Reuters) – Top Zika investigators now believe that the birth defect microcephaly and the paralyzing Guillain-Barre syndrome may be just the most obvious maladies caused by the mosquito-borne virus.

Fueling that suspicion are recent discoveries of serious brain and spinal cord infections – including encephalitis, meningitis and myelitis – in people exposed to Zika.

Evidence that Zika’s damage may be more varied and widespread than initially believed adds pressure on affected countries to control mosquitoes and prepare to provide intensive – and, in some cases, lifelong – care to more patients. The newly suspected disorders can cause paralysis and permanent disability – a clinical outlook that adds urgency to vaccine development efforts.

Scientists are of two minds about why these new maladies have come into view. The first is that, as the virus is spreading through such large populations, it is revealing aspects of Zika that went unnoticed in earlier outbreaks in remote and sparsely populated areas. The second is that the newly detected disorders are more evidence that the virus has evolved.

“What we’re seeing are the consequences of this virus turning from the African strain to a pandemic strain,” said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.

The Zika outbreak was first detected in Brazil last year and is spreading through the Americas. It has been linked to thousands of suspected cases of microcephaly, a typically rare birth defect marked by unusually small head size, signaling a problem with brain development. Evidence linking Zika to microcephaly prompted the World Health Organization to declare a global health emergency in February.

The suspicion that Zika acts directly on nerve cells began with autopsies on aborted and stillborn fetuses showing the virus replicating in brain tissues. In addition to microcephaly, researchers reported finding other abnormalities linked with Zika including fetal deaths, placental insufficiency, fetal growth retardation and injury to the central nervous system.

Doctors also are worried that Zika exposure in utero may have hidden effects, such as behavioral problems or learning disabilities, that are not apparent at birth.

“If you have a virus that is toxic enough to produce microcephaly in someone, you could be sure that it will produce a whole series of conditions that we haven’t even begun to understand,” said Dr. Alberto de la Vega, an obstetrician at San Juan’s University Hospital in Puerto Rico.

First discovered in the Zika forest of Uganda in 1947, the virus circulated quietly in Africa and Asia, causing rare infections and producing mild symptoms. A 2013 outbreak in French Polynesia, the largest at that time, led researchers to make the Guillain-Barre link. Other neurological effects were noted but scientists made little of them at the time.

A rare and poorly understood condition, Guillain-Barre can weaken muscles and cause temporary paralysis, often requiring patients to need respirators to breathe.

An estimated 32,000 people in the French Polynesia Zika outbreak were infected, and 42 patients were confirmed to have Guillain-Barre, a 20-fold increase in incidence over the previous four years, the WHO reported. Another 32 patients had other neurological disorders, including encephalitis, meningoencephalitis, myelitis and facial paralysis.

Guillain-Barre is an autoimmune disorder, in which the body attacks itself in the aftermath of an infection. But the newly discovered brain and spinal cord infections are known to be caused by a different mechanism – a direct attack on nerve cells. That has prompted scientists to consider whether the Zika virus also may infect nerves directly in adults, as they already have suspected in fetuses.

In medical journals published last month, doctors described neurological syndromes in two patients that they attributed to Zika. Doctors in Paris diagnosed meningoencephalitis, an infection of both the brain and spinal cord, in an 81-year-old man who was hospitalized after being exposed to Zika on a cruise.

Another French team reported acute myelitis, a paralyzing infection of the spinal cord, in a 15-year-old girl who had been infected with Zika on the French Caribbean island of Guadeloupe.

In its latest surveillance report, the WHO said the two cases “highlight the need to better understand the range of neurological disorders associated with Zika-virus infection.”

Other mosquito-borne viruses – including dengue, Japanese encephalitis and West Nile – are known to directly infect nerve cells in the brain and spinal cord. But such viruses are seldom associated with Guillain-Barre, and never with microcephaly, said Baylor’s Hotez.

POSSIBLE EVOLUTION

In a recent paper, WHO researcher Mary Kay Kindhauser wrote that Zika “appears to have changed in character,” noting its transition from a mild infection to one causing “large outbreaks linked with neurological disorders.”

Scientists studying Zika in Brazil now are reporting the same neurological disorders seen in French Polynesia. From April through July 2015, doctors in Brazil identified a spike in Guillain-Barre cases.

In Salvador, there were roughly 50 reported cases of Guillain-Barre in July alone, far more than would typically be expected, Dr. Albert Ko, a tropical disease expert from Yale University who is studying Zika in the coastal city of Salvador, recently told a research symposium.

“Throughout Brazil, doctors have seen strange, atypical, neurological manifestations,” Ko said told the symposium.

Zika exposed patients have had other neurological problems as well, including acute disseminated encephalomyelitis, which causes inflammation of the myelin, the protective sheath covering nerve fibers in the brain and spinal cord. Other patients experienced tingling, prickling or burning sensations, which are often markers of peripheral nerve damage.

In addition to Brazil and French Polynesia, at least 11 more countries and territories have reported hundreds of cases of Guillain-Barre syndrome linked to Zika. In Brazil, Guillain-Barre cases jumped 19 percent to 1,708 last year.

El Salvador, a country that has an annual average of 196 cases of Guillain-Barre, reported 118 cases in six weeks in December and January.

Zika’s arrival in Colombia in October 2015 was associated with another increase in Guillain-Barre cases. The country typically reports 242 cases of the syndrome a year, or about five a week. But in the five weeks starting in mid-December, Colombia reported 86 cases of Guillain-Barre, or about 17 a week.

Dr. Carlos Pardo-Villamizar, a neurologist at Johns Hopkins University School of Medicine, is studying Zika complications with colleagues in five Colombian research centers. They have seen cases of encephalitis, myelitis and facial paralysis associated with Zika and want to understand what is triggering these complications.

They also want to study whether prior infection with dengue or chikungunya – two related viruses – are contributing to neurological disorders seen in patients with Zika.

Scientists are turning their attention next to Puerto Rico, where Zika is expected to infect hundreds of thousands of residents by year-end.

More cases hold the potential for “a better sense of the full spectrum of disease that Zika is capable of causing,” said Dr. Amesh Adalja of the Center for Health Security at the University of Pittsburgh Medical Center.

(Reporting by Julie Steenhuysen; additional reporting by Anthony Boadle in Brasilia, Brazil; Editing by Michele Gershberg and Lisa Girion)

Zika Spreading in Puerto Rico

A health worker prepares insecticide before fumigating a neighborhood in San Juan

By Julie Steenhuysen

SAN JUAN (Reuters) – The United States faces its first real challenge with the Zika virus on the island territory of Puerto Rico, a part of the nation that is perhaps least prepared to cope with what is expected to be its worst outbreak.

Zika is spreading rapidly in Puerto Rico and is expected to peak in late summer and early fall. By year’s end, public health officials estimate, hundreds of thousands of people will have been infected.

It is the only part of the country that is experiencing a major local outbreak, but the virus is expected to reach southern U.S. states within weeks with warmer temperatures and rising mosquito populations.

Health officials from across the United States are gathering today at the headquarters of the Centers for Disease Control and Prevention in Atlanta to outline a national strategy for combating Zika. In a measure of the concern surrounding the outbreak in Puerto Rico, CDC director Tom Frieden toured the island, meeting with top health officials and local experts last month to assess the situation first-hand.

Puerto Rico is beset with problems already hampering the response: abundant mosquitoes, high levels of insecticide resistance and economic woes that have left vector control in shambles.

“We don’t have good surveillance” here, Frieden said in an interview at the Puerto Rican health department in San Juan during his tour. “We don’t have good control measures.”

First detected in Brazil last year, the Zika outbreak is spreading through the Americas. The World Health Organization declared a global health emergency last month because of growing evidence that Zika can cause microcephaly, a rare birth defect defined by an unusually small head. In adults, the virus has been linked to the typically rare autoimmune disorder, Guillain-Barre syndrome.

EARLY LESSONS

Fighting Zika in Puerto Rico is complicated by the toll of a decade-long recession. Nearly half of its 3.5 million residents live in poverty, and mosquitoes are an accepted nuisance. Puerto Rico has seen repeated outbreaks of dengue and more recently, chikungunya. Both viruses are carried by Aedes aegypti, the same species of mosquito that carries Zika.

“Here in Puerto Rico, we’re really starting from square one,” said Audrey Lenhart, a CDC vector control expert in an interview at the CDC’s Emergency Operations Center in San Juan.

In its latest report, the Puerto Rican health department said there are now 350 confirmed cases of Zika infection, including 40 pregnant women.

“We have a very serious combination of problems,” said Dr. Alberto de la Vega, an obstetrician specializing in high-risk pregnancies at San Juan’s University Hospital at the Puerto Rico Medical Center.

“If you don’t have access to money to buy repellent, to sleep with an air conditioner on so mosquitoes won’t bite you, to have mosquito nets around you and you live in areas where there’s more stagnant water, obviously you have higher risks,” he said.

To mitigate the risk of microcephaly among newborns, the CDC and the Puerto Rican government are distributing Zika protection kits to pregnant women that include condoms to prevent sexual transmission from an infected partner, insect repellent, bed nets and larvicide tablets for standing water that cannot be drained.

De la Vega says many locals are resigned to the idea that everyone in Puerto Rico will be infected. He said he won’t accept that people are “surrendering like that.”

NO VECTOR CONTROL

Government mosquito abatement resources are scarce, with fewer than a dozen trucks equipped with insecticide sprayers. Of the municipalities that do have trucks, most are used to kill nuisance mosquitoes that bite but do not carry disease, said Manuel Lluberas, a Puerto Rico-born entomologist who works at H.D. Hudson Manufacturing, a maker of spraying equipment.

Lluberas, who advises the WHO and the World Bank on vector control programs, said there are a few municipalities that spray insecticide once every seven to 10 days or once every few weeks. Spraying “needs to be done a lot more frequently” to be effective, he said.

Scientists at CDC’s Dengue Laboratory in San Juan have been testing insecticides on mosquitoes gathered from 17 sites on the island. Frieden said in one of the experiments, mosquitoes placed in bottles coated with a commonly effective insecticide “were happily flying around.”

Eliminating Zika will require spraying insecticide indoors on walls, under beds, behind furniture and inside closets, where Aedes aegypti hide. So far, only two insecticides – deltamethrin and bifenthrin – are approved for indoor residual spraying, and researchers have found high levels of resistance to bifenthrin in Puerto Rico.

Mosquito experts have found similar resistance in parts of Texas and California.

“You find resistance in mosquitoes in one locale, and 20 miles away they are not resistant,” said Joseph Conlon, technical advisor for the American Mosquito Control Association, which represents researchers, public health officials and pesticide makers.

Dr. Janet McAllister, a CDC entomologist, said indoor spraying campaigns will be carried out by local contractors, who will target only areas where the mosquitoes hide instead of coating entire walls, as is typically done to control mosquitoes that carry malaria. “People would not really be coming into direct contact with those surfaces,” McAllister said.

She said the CDC does not plan to use experimental methods, including genetically modified mosquitoes, such as those from Intrexon’s Oxitec now being tested in Brazil, or those infected with Wolbochia bacteria that prevent Zika transmission.

Given the urgency of the outbreak, health officials need to focus on known methods of curbing mosquitoes “rather than doing research on things that may or may not work,” she said.

(Reporting by Julie Steenhuysen; Editing by Michele Gershberg and Lisa Girion)

Zika reported in travelers who returned to California, Arkansas and Virginia

Travelers who recently returned to California, Arkansas and Virginia from foreign countries have tested positive for the Zika virus, health officials in those states announced Tuesday.

The Centers for Disease Control and Prevention (CDC) maintains that there haven’t been any people who have contracted the mosquito-borne virus in the United States, though there have been several cases where travelers got infected overseas and brought the virus back with them.

Zika is collecting the attention of public health officials because scientists are studying a possible link between the virus and a rare condition called microcephaly, in which children are born with smaller-than-usual heads. The birth defect can also be caused by other factors, the CDC says.

Still, the CDC has issued travel notices for 22 countries or territories where Zika is currently being spread, urging pregnant women to consider postponing any planned travel to those areas and asking all would-be travelers to “practice enhanced precautions” to prevent mosquito bites.

The three cases announced Tuesday all involved foreign travel.

In a statement, the Virginia Department of Health said the infection was confirmed in “an adult resident of Virginia who recently traveled to a country where Zika virus transmission is ongoing,” but did not elaborate. The infected individual was the state’s first imported Zika case, but isn’t at risk of transmitting the virus because it isn’t currently mosquito season in Virginia.

The Arkansas Department of Health said one of the state’s residents “recently traveled out of the country and had a mild case of Zika.” Officials confirmed the diagnosis late Monday afternoon.

“Arkansas has the kind of mosquitoes that carry Zika virus, so mosquitoes here in Arkansas can become infected with the virus if they bite someone who has Zika,” Dr. Nate Smith, the Arkansas Department of Health Director and State Health Officer, said in a statement. “For this reason, people traveling to countries with Zika should avoid mosquito bites for 10 days after they return.”

The Los Angeles County Department of Public Health said an adolescent girl who traveled to El Salvador last November was the county’s lone confirmed case of Zika, but she has recovered.

“At this time, local transmission is unlikely,” the department said in a statement. “It would require an Aedes mosquito biting a Zika infected person and then biting others.”

The CDC says only about 20 percent of people who are infected with Zika become ill and develop symptoms like fever, rash and joint pain. Most people fully recover from the illness in a week.

The possible link between Zika and microcephaly is a key component of the travel warnings.

The Brazilian Ministry of Health has investigated more than 4,100 microcephaly cases in the past 13 months, according to data released Wednesday. The ministry used to see fewer than 200 cases of the condition every year, though the numbers have surged since Zika arrived in May.

The Hawaii Department of Health has said a child who was recently born with microcephaly there had been infected with Zika, and his mother likely got the virus when she lived in Brazil.

The CDC says it will also be conducting a study to examine a possible link between Zika and Guillain-Barre Syndrome, a nerve disorder than can lead to muscle weakness and paralysis. Many fully recover from the syndrome, the CDC says, though it can be fatal in rare instances.

The World Health Organization is holding an information session on Zika tomorrow.

The organization says it’s possible the virus could cause epidemics in new areas it reaches because people don’t have immunity to it. There’s also currently no vaccine to prevent it.

CDC issues more travel notices about Zika virus

The Centers for Disease Control and Prevention (CDC) on Friday issued more travel notices about the Zika virus, warning travelers about the potential risks of the mosquito-borne illness.

The notices were issued one week after the CDC advised pregnant women who were planning to travel to 14 countries and territories where outbreaks of the virus were occurring to consider postponing their trips while scientists probe a potential tie between Zika and a rare birth defect.

The notices issued Friday added eight additional countries or territories to the list, bringing the total to 22. The warnings are spread throughout the globe and include places in South America, the Caribbean, Central America, Polynesia and more.

Travelers heading to those areas are asked to “practice enhanced precautions” to prevent mosquito bites, which is how the virus is spread. Pregnant women are advised to rethink their travel plans because of Zika’s potential impact on their unborn children.

Last week, the Hawaii Department of Health announced a child born with microcephaly — a birth defect marked by a smaller-than-usual head — had previously been infected with Zika. The department said his mother likely contracted the virus when she was living in Brazil last May.

The Brazilian Ministry of Health reports that there have been 3,893 cases of microcephaly in the country since the virus arrived in May. The country used to see fewer than 200 cases per year.

Children with microcephaly can develop seizures, vision problems and have developmental delays, the CDC says, but it only occurs in 2 to 12 out of every 10,000 births in the United States.

Scientists are still trying to find a conclusive link between Zika and microcephaly, which can be caused by several other factors. Last week, Dr. Lyle Petersen, the director of CDC’s division of vector-borne diseases, told a news briefing the CDC had “the strongest scientific evidence to date” of a link between Zika and “poor pregnancy outcomes,” though more tests were needed.

Still, the warnings and advice for pregnant women continue. Earlier this week, the CDC issued new guidelines about how healthcare providers in the United States should care for pregnant women who had traveled or were planning to travel to areas where Zika was being transmitted.

Only about 1 in 5 people infected with the virus display any signs of illness, the CDC says, and symptoms are generally mild. They include fever, rash and joint pain, and most people recover within a week. The illness is seldom severe and rarely requires hospitalization.

There haven’t been any reports of people contracting the virus in the United States, the CDC says, though there have been some instances where travelers got bit by infected mosquitos overseas and returned home. The mosquitos that transmit Zika are found in the United States, though Dr. Petersen told the news briefing it’s unclear exactly how or if the virus may spread here.

He told reporters the country has seen improvements in anti-mosquito measures, like using air conditioning and window and door screens, which have helped reduce the spread of other mosquito-borne illnesses, like dengue and malaria, in the past. The CDC encourages all travelers to Zika-prone areas to sleep in screened or air-conditioned rooms, as well as wear long clothing and insect repellant, as there is no vaccine or medicine that can currently prevent an infection.

Countries and territories where the CDC has issued travel notices for Zika include Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Suriname, Venezuela, Barbados, Guadeloupe, Haiti, Martinique, Saint Martin, Samoa, Cape Verde, El Salvador, Guatemala, Honduras, Panama, Mexico and Puerto Rico.

Liberia declared Ebola-free, though threat of flare-ups remain

MONROVIA (Reuters) – Liberia was declared free of the Ebola virus by global health experts on Thursday, a milestone that signaled an end to an epidemic in West Africa that has killed more than 11,300 people.

But the World Health Organisation (WHO) warned there could still be flare-ups of the disease in the region, which has suffered the world’s deadliest outbreak over the past two years, as survivors can carry the virus for many months and could pass it on.

Health specialists cautioned against complacency, saying the world was still underprepared for any future outbreaks of the disease.

Liberia was the last affected country to get the all-clear, with no cases of Ebola for 42 days, twice the length of the virus’s “incubation period” – the time elapsed between transmission of the disease and the appearance of symptoms.

“All known chains of transmission have been stopped in West Africa,” the WHO, a U.N. agency, said on Thursday.

The other affected countries, Guinea and Sierra Leone, were declared Ebola-free late last year. There were cases in seven other countries including Nigeria, the United States and Spain, but almost all the deaths were in the West African nations.

“It is the first time since the start of the … epidemic in West Africa two years ago that the three hardest-hit countries had zero cases for at least 42 days,” said WHO’s Liberia representative Alex Gasasira.

The WHO announcement on Thursday is a major step in the fight against a disease that began in the forests of eastern Guinea in December 2013 before spreading to Liberia and Sierra Leone. It overwhelmed medical infrastructure in the region which was ill-equipped to deal with the outbreak, and at its height in late 2014 sparked global fears among the general public.

However the agency urged caution – Liberia had previously twice been declared virus-free, in May and September of 2015, but each time a fresh cluster of cases unexpectedly emerged.

Its capital Monrovia was badly hit during the worst of the epidemic. Inadequate care meant patients lay strewn on the streets or pavements waiting hours for tests and treatment; medical holding pens became growth centers for the disease.

With those memories still fresh, and society and the economy still reeling from the outbreak, the reaction to Thursday’s announcement was muted. There was no signs of celebration such as the “Ebola free” T-shirts that people wore after previous WHO announcements.

“After the first declaration, people were dancing in the street,” said Vivian Lymas Tegli, child protection officer for UNICEF in Monrovia. “But I don’t think there will be any celebrations today. People are tired of Ebola. They feel it is here to stay.”

‘WORLD UNDERPREPARED’

Experts said progress had been made in the region’s response to Ebola, with new cases having dwindled due to public health campaigns, efforts to trace and isolate potential sufferers and the safe treatment and burial of patients and victims.

But it said the countries would still struggle to deal with any future large outbreak of Ebola, which is passed on through blood and bodily fluids and killed around 40 percent of those who contracted the virus.

Hundreds of healthcare workers in both urban and rural communities were among those killed by the disease, a major blow to medical systems in countries which already had among the lowest numbers of doctors per head of population in the world.

“Today’s WHO announcement is welcome news but we must learn from Ebola’s devastating impact and ensure we are better prepared for infectious disease outbreaks,” said Dr Seth Berkley, head of Gavi, the Vaccine Alliance, an organization that aims to increase access to vaccines in poor countries.

“The world is still worryingly underprepared for potential future health threats and a change of mind-set is required to ensure we invest in research and development today to protect ourselves in years to come.”

Experts also warned other tropical diseases posed future threats, including the previously little known mosquito-borne Zika virus, which has been linked to head-related birth defects and is spreading in South America.

Hilde de Clerck, a doctor with Medecins Sans Frontieres who has assisted with five Ebola outbreaks including in Congo, Uganda and the latest epidemic in West Africa, said vigilance was crucial to prevent the re-emergence of the disease, for which there is no proven drug treatment, although researchers have developed a vaccine.

“I think we should not forget about the risk of other outbreaks,” she said. “I am most concerned about some of the basics: hygiene, equipment and training.”

While WHO and other health specialists say another outbreak of this magnitude is unlikely, and much has been learned in terms of monitoring patients and responding to outbreaks, problems remain, including with simple hygiene, such as not washing hands.

“I do really believe that there is a much better understanding, an acceptance that this is a real disease, and what the cause is of this disease, and that is much more embedded in society than before,” said Peter Graaff, head of Ebola operations at the WHO’s headquarters in Geneva.

Mohammed Kamara, who lives in Monrovia, lost two relatives and a friend to Ebola in 2014. “I know exactly what it means to have the disease in the country,” he said.

“We must be grateful to God and then to the government and its partners for the country to be declared free of Ebola. I only hope that it is the last time that we experience Ebola.”

(Additional reporting by Keiran Guilbert, Stephanie Nebehay, Tom Miles, Emma Farge, Matt Mpoke Bigg, Kate Kelland and Ben Hirschler; Writing by Edward McAllister; Editing by Jeremy Gaunt and Pravin Char)

CDC Issues Travel Notice After Zika Virus Arrives in Puerto Rico

Health officials are warning would-be travelers about the spread of a mosquito-borne illness that might be causing a growing number of children to be born with smaller-than-usual heads.

Late last week, the Centers for Disease Control and Prevention (CDC) issued a travel notice for Puerto Rico after the island reported its first locally contracted case of the virus. The advisory encourages travelers to take proactive steps to prevent mosquito bites, like wearing insect repellant and long clothing. The CDC has issued similar warnings for Mexico, Central America and South America, as several other countries have said the virus has sickened humans there.

Zika often causes people to experience fever, joint pain, rashes and red eyes for up to a week, the CDC says, but the illness seldom results in hospitalization. However, the Brazilian Ministry of Health recently said it was investigating about 3,000 cases of microcephaly, a neurological disorder in which children are born with unusually small heads and underdeveloped brains.

Before this year, the ministry said it usually saw about 150-170 annual cases of microcephaly. But since the Zika virus arrived in May, the ministry said the number of suspected cases have surged to 2,975. Authorities are currently examining if there’s a conclusive link between the two.

The CDC said test results have shown that some Brazilian babies with microcephaly were infected with Zika, but other babies developed microcephaly and tested negative for the virus. There are other possible causes for the defect, so it will take some time to determine the culprit. Still, the CDC says woman who are pregnant should be extra careful to prevent mosquito bites.

There isn’t any vaccine that can prevent the virus or any medicine that can treat it, according to the CDC. Because the mosquitos that transmit Zika live all across the planet, the organization says it’s likely that the virus could spread to new regions where illnesses have yet to be reported.

The virus can remain in the bloodstreams of infected individuals for about a week, according to the CDC, during which time it’s extra important to avoid mosquito bites to prevent transmission. While the organization reports no one has acquired Zika in the United States, there has been at least one instance where a traveler got sick while visiting a foreign country and returned home.

California, Minnesota Health Officials Warn of Norovirus Outbreaks

Public health officials in California and Minnesota are warning about norovirus outbreaks, cautioning that the intestinal disease could sicken lots of people in those states this winter.

The California Department of Public Health announced last week that there had been 32 confirmed outbreaks of the disease since October, a number that greatly exceeds the total reported in the same window last year. Hundreds likely fell ill from the disease, officials said.

In Minnesota, the state Department of Health cautioned that the arrival of a new strain of the disease could cause some additional norovirus illnesses this winter. The department said it has investigated at least 20 outbreaks of the GII.17 Kawasaki strain since September. The strain is the same one that spurred many outbreaks in Asia last winter, officials said in a news release.

“Every few years, a new strain of norovirus emerges and causes many illnesses,” Amy Saupe, a foodborne disease epidemiologist with the department, said in a statement. “We don’t know yet if this new strain will lead to an increase in the number of outbreaks reported, but it could.”

According to the Centers for Disease Control and Prevention (CDC), norovirus is the top cause of stomach flu in the United States. The highly contagious virus sickens between 19 million and 21 million people, hospitalizes 56,000 to 71,000 and kills between 570 and 800 every year. Common symptoms include fever, diarrhea and vomiting. Most people recover within 1 to 3 days.

People get norovirus from eating tainted food or touching contaminated surfaces, making it relatively easy for the disease to spread in places like schools, daycares and nursing homes.

The Boston Globe reported a sick employee came to a Chipotle restaurant in the city earlier this month and 136 people — including some Boston College students — fell ill. There were some initial fears that outbreak was linked to an E. Coli outbreak at Chipotle restaurants in nine states, but the paper reported health officials ultimately determined that norovirus was at fault.

The CDC and other public health officials say proper disinfection, hand hygiene and food-handling techniques are vitally important to help prevent norovirus from spreading.

“One of the most important things you can do to avoid norovirus and other illnesses this holiday season is to wash your hands frequently with soap and running water for at least 20 seconds,” Dr. Karen Smith, the director of the California Department of Public Health, said in a statement. “This is especially important after using the bathroom, changing diapers, and before preparing or eating food. Hand sanitizers are not effective against norovirus.”

California Hospital Warns 350 Newborns May Have Been Exposed to Tuberculosis

A California hospital is warning that about 350 infants might have been exposed to tuberculosis.

Santa Clara Valley Medical Center in San Jose issued a news release Friday saying that a female employee who worked near the newborn nursery had been diagnosed with the potentially deadly disease.

The hospital said in the news release that it is contacting mothers who visited its Mother & Infant Care Center between mid-August and mid-November of this year. The hospital will screen them and their infants for tuberculosis and give them antibiotic medicine that kills the disease.

The hospital said its employee underwent an annual tuberculosis test in September and did not show any signs of the disease — including any symptoms. But when the employee later saw her doctor for an unrelated issue, the physician discovered the employee had in fact been infected.

According to the Centers for Disease Control and Prevention (CDC), tuberculosis is transmitted when an infected person coughs, sneezes or speaks. Nearby people can breathe in the bacteria. If the bacteria multiplies enough, they can develop symptoms like a bloody cough and chest pain.

The CDC said tuberculosis was once the leading cause of death in the United States, but there were fewer than 10,000 reported cases of the disease in 2013. Tuberculosis usually affects the lungs, but it can also affect other parts of the body including the brain, kidneys and spine.

Santa Clara Valley Medical Center said it placed the infected employee on leave to cut down the risk of exposing its patients, visitors and staff.

“While the risk of infection is low, the consequences of a tuberculosis infection in infants can be severe,” the hospital’s pediatrics chair, Dr. Stephen Harris, said in a statement. “That’s why we decided to do widespread testing and start preventative treatments for these infants as soon as possible.”