The expansion of Israel's ground operation in the Gaza Strip raises the risk of regional escalation from Iran and its proxy forces, while amplifying the threat of violence in the West Bank and sporadic attacks in Israel. On the evening of Oct. 28, Israeli Prime Minister Benjamin Netanyahu announced that his government's war against Hamas in the Gaza Strip had entered a ''second phase,'' simultaneously calling it Israel's ''second war of independence'' and telling Israelis that the ground war would be ''long and difficult.'' Since then, ground troops from the Israel Defense Forces (IDF) — backed by tanks, artillery and airstrikes — have entered the northern part of the strip. Although the IDF has not commented on the number of troops or their precise locations, photos and videos circulating on social media on Oct. 30 show them on the outskirts of Gaza City, the largest city in the territory, where they appear to have engaged in heavy combat. Shortly after Netanyahu's statement, the account of Iranian President Ebrahim Raisi shared a post on X (formerly Twitter) stating that Israel's actions had ''crossed red lines, which may force everyone to take action.''
Malaria in Florida and Texas
For the first time in two decades, locally contracted malaria cases have been reported in the United States, specifically in Texas and Florida. Authorities in Florida have confirmed four cases in Sarasota County, and an additional case has been identified in Cameron County, Texas.
It can't happen here?
This unexpected occurrence serves as a stark reminder that "it can't happen here" is a dangerous mindset when it comes to medical crises. The U.S. was declared malaria-free in 1970, but these recent cases prove that vigilance and preparedness are always necessary.
Why this is different
Unlike the typical scenario where travelers contract malaria abroad and are diagnosed upon their return, these cases involve individuals who contracted the disease locally, with no recent travel history. This situation is reminiscent of the early days of the COVID-19 pandemic when the disease was primarily associated with international travel.
Stay Informed: Mosquitoes transmit malaria. Avoid mosquitoes with insect repellent and protective clothing. Be aware of the symptoms of malaria. These include fever, chills, headaches, muscle aches, fatigue, nausea, and vomiting. In severe cases, symptoms can escalate to unusual bleeding, jaundice, and difficulty breathing. Most people with malaria need to be admitted to a hospital for treatment to avoid kidney failure, seizures, coma, and death. If you are experiencing symptoms, seek emergency medical attention.
Pakistan: Widespread Violent Protests
Widespread, violent protests and civil unrest in response to the political situation have been reported throughout the country, including in Karachi, Lahore, Islamabad, Peshawar, and Quetta. Further unrest is likely. Section 144, prohibiting public assembly of more than 4 people, has been imposed nationwide. Disruptions to transportation (including road travel) and mobile and internet services should be expected. Extreme vigilance is recommended; bystanders are at risk of harm from violence or from the response by authorities. Travelers should avoid demonstrations, carry a fully charged communication device, follow the advice of local authorities, and monitor the situation through local media and embassy communications.
Costa Rica: Malaria in Limón Province
According to Costa Rica's Ministry of Health, 60 cases of Plasmodium falciparum malaria have been reported since January 1, 2023, in Limón Province, mainly in Pococí (32 cases) and Limón (26 cases) cantons; cases have also been reported in Siquirres (1 case) and Matina (1 case) cantons. More than half of these cases have been reported since March 26, 2023. Shoreland now recommends chemoprophylaxis (atovaquone-proguanil, chloroquine, doxycycline, mefloquine, or tafenoquine) for all travelers going to Pococí, Limón, Siquirres, and Matina cantons, including all cities and towns within these areas. Travelers should observe insect precautions in areas with any level of transmission.
Lithuania: State of Emergency
A state of emergency is in place until May 2, 2023, for border checkpoints and areas within 5 km (3.1 mi) of Lithuania's border with Belarus and Kaliningrad. The state of emergency was declared in response to a build-up of Russian forces near the border. Travelers should maintain a high level of security awareness, carry photo identification, carry a fully charged communication device, follow the advice of local authorities, and monitor the situation through local media and embassy communications.
Equatorial Guinea: First Ever Cases of Marburg Virus
According to WHO's regional office, 25 cases of Marburg virus disease (MVD; including 1 laboratory-confirmed by WHO reference laboratory and 9 deaths) have been reported since February 7, 2023, in Kié-Ntem Province. The source of acquisition is unknown. Contact tracing is underway. MVD had never been reported in Equatorial Guinea. MVD is a filovirus that is distinct from Ebola. Travelers going to the affected area should avoid contact with bats and direct contact with blood or bodily fluids of acutely ill patients.
Turkey: Elevated Risk of Terrorist Attack in Istanbul
According to consular sources, the risk of terrorist attacks is elevated at churches, synagogues, and diplomatic missions in Istanbul or other places Westerners frequent, especially in the Beyoglu, Galata, Taksim, and Istiklal areas. Extreme vigilance is recommended. Travelers should maintain a high level of security awareness, follow the advice of local authorities, carry a fully charged communication device, and monitor the situation through local media and embassy communications.
Brazil: Heightened Security Risks
On January 8, 2023, violent protests occurred at the central government district of Brasília, including the Supreme Federal Court, the presidential palace, and the National Congress. A heightened threat of additional violent protests, roadblocks, and civil unrest exists throughout the country following the presidential inauguration on January 1, 2023. Travelers should avoid the Plaza of the Three Powers and other government buildings, carry a fully charged communication device, follow the advice of local authorities, and monitor the situation through local media.
United States: Influenza Antiviral Treatment Availability and Prioritization
Oseltamivir (Tamiflu [Genentech/Roche] and generic) is in limited supply nationwide due to increased demand. The US government is making additional supply of oseltamivir available to jurisdictions, including through state and national stockpiles, and the US CDC has issued the following antiviral prioritization
When antivirals are available, a clinical diagnosis of influenza without testing is adequate to support empiric outpatient antiviral treatment. However, if oseltamivir is unavailable or if availability is limited, influenza testing is highly recommended to guide antiviral use.
If oseltamivir is unavailable, other antivirals such as oral baloxavir marboxil (Xofluza; Genentech), inhaled zanamivir (Relenza; GSK), or intravenous peramivir (Rapivab; Seqirus) can be used for outpatient treatment. Limited data exist on the use of these antivirals in hospitalized patients.
When availability of oseltamivir or other antivirals is limited, treatment should be prioritized for hospitalized patients and for outpatients who are at high risk of complications (e.g., at extremes of age [younger than 2 years or ≥ 65 years]), have uncontrolled chronic disease or immunocompromise of any cause, or are pregnant (or ≤ 2 weeks postpartum). Persons with clinically mild influenza who are not at increased risk of complications can be managed with supportive care without antiviral treatment.
Outpatient treatment should be prioritized for persons who test positive for influenza within 2 days of symptom onset and for persons with progressive or severe influenza who do not require hospitalization, even if they test positive for influenza > 2 days from symptom onset.
United States: Multistate Norovirus Outbreak Due to Raw Oysters from Texas
According to the US CDC, more than 210 cases of acute gastrointestinal illness caused by norovirus have occurred since late November 2022 in Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, Tennessee, and Texas. Infection has been linked to the consumption of raw oysters from Texas. Travelers should avoid consumption of raw or improperly cooked oysters originating from Texas (or if the origin is unknown) and observe hand hygiene (frequent, thorough handwashing).
