SharecloseShare pageCopy linkAbout sharingimage copyrightReutersSeveral European countries are experiencing a new surge in coronavirus infections, while a number have also suspended use of the Oxford-AstraZeneca vaccine over safety concerns. The European Medicines Agency is standing by its decision to approve the vaccine and has reiterated there is “no indication” the jab causes blood clots. It is investigating further and its results are due to be released on Thursday. Correspondents in six cities explain how Europeans are reacting to the new wave of infections and the stuttering rollout.Vaccinations 857,792 |14.81 doses per 100 people | Increase in cases compared with last week +2,484Denmark was the first country in Europe to suspend the AstraZeneca vaccine as a precaution, followed by Norway and Iceland. It is yet another blow to its vaccine plans, writes Adrienne Murray in Copenhagen.About 1 in 10 people here have now received at least one vaccine dose, a quarter of which were supplied by AstraZeneca.All adults were expected to be vaccinated by the end of June, but delivery delays have seen that target pushed back a number of times. Health authorities on Wednesday suggested the end of July.Danes have expressed disappointment about the rollout on Twitter. “It’s simply going too slow,” writes Lone Juul Lang. But most have supported the government’s handling of coronavirus and a survey in January revealed that almost nine out of 10 Danes want to be vaccinated.Since the new year, infections have fallen sharply and Denmark is slowly emerging from a second lockdown. But signs of fatigue are beginning to show. Anti-lockdown protests have recently been held in some Danish cities and there’s political pressure to do more.However, concerns about new variants of coronavirus, have made the government hesitant to open up faster.Vaccinations 7,552,120 | 11.19 doses per 100 people | Increase in cases compared with last week +25,912After an unpromising start, the AstraZeneca jab has come to hold a key place in France’s inoculation programme, but a new poll on public confidence is not reassuring, writes Hugh Schofield in Paris.It’s the worst anniversary that Emmanuel Macron can have imagined, says Nicolas Beytout, editor of France’s L’Opinion newspaper.Exactly a year ago the president announced the first lockdown and said France was “at war” with the virus. But now his strategy has been knocked dangerously off course by the suspension of the AstraZeneca vaccine.In recent weeks the AstraZeneca jab has overtaken Pfizer/BioNTech in the number of doses delivered. But if people turn away from AstraZeneca, waiting for new vaccines like Johnson and Johnson, then Mr Macron’s calculations go awry. The sweet moment when immunity starts biting is postponed, leading to lockdowns and public anger. According to an Elabe survey conducted just as the suspension was announced, only 20% of the French have confidence in AstraZeneca. For Pfizer/BioNTech, the figure is 52%.Vaccinations 9,853,966 | 11.76 doses per 100 people | Increase in cases compared to last week +23,889Coronavirus infections are spreading fast again in Germany and there’s already growing dissatisfaction over a slow vaccine rollout, writes Jenny Hill in Berlin.”We wonder now when we will ever be vaccinated?” says kindergarten worker Tanya. Just 8% of the German population has received a first jab in a country which, most experts agree, is firmly in the grip of a third wave. Germany has relied largely on Pfizer/BioNTech, but ministers need AstraZeneca if they’re to keep their promises and speed things up.So the decision to suspend the jab has caused dismay, anger and concern.Not least because, even in a country that is broadly open to vaccination, AstraZeneca has a bit of an image problem; in part, because the government initially blocked its use in older age groups.Ministers argue now, as then, that they’re acting to create public trust. Many here would say they’ve had the opposite effect – undermining faith not just in the vaccine but, in an election year, the government itself.Vaccinations 4,557,060 | 12.04 doses per 100 people | Increase in cases compared to last week +29,557In Poland, new infections are rising at an alarming rate as the country’s third wave continues to gather momentum, writes Adam Easton in Warsaw.In response to the health ministry’s latest tweet about the number of new cases, which rose by 45% compared with a week earlier, some wanted tougher restrictions.”In Germany, a hard lockdown, in Poland indignation that you can’t go to the pub in the evening,” writes @JMojzych, adding that there is a higher rate of infection here than in Germany.In terms of the vaccination rollout, Poland has just fallen out of the top 10 EU countries with the highest rate of administering jabs. A recent opinion poll found that 53.1% of respondents agreed the EU had failed to provide sufficient vaccines to member states.Unlike many EU countries, Poland is continuing to administer the AstraZeneca vaccine.But people questioning, or deferring their AstraZeneca jab has become “a noticeable phenomenon”, Prof Agniezka Mastalerz-Migas, from Wroclaw Medical University, told broadcaster TVN24 . Vaccinations 7,039,518 | 11.64 doses per 100 people | Increase in cases compared to last week +12,018The timing could hardly have been worse for Italy, writes Mark Lowen in Milan.On the day that most of Italy entered another lockdown and new vaccine sites opened to ramp up rollout, they were abruptly shut again with the AstraZeneca suspension – and those waiting for their longed-for panacea were turned away. It’s fodder for Italy’s Eurosceptics.”Another failure by Europe,” cried Matteo Salvini, the leader of the far-right League. He adds that he hoped the Sputnik V vaccine would arrive soon – a comment not lost on those noting Mr Salvini’s pro-Russia sympathies.At a Pfizer vaccination centre in Milan, most seem unfazed.”If my mother had got AstraZeneca today, not Pfizer, it would be the same,” says Elena Grazena. “I trust the science.” Maria Polizzi tells me she is a little worried by the suspension. “Luckily AstraZeneca wasn’t the vaccine I got,” she says. “It’s right they’re suspending until they investigate.”Amid a third wave and frustration at a slow vaccine rollout, it’s as though this exhausted country has been kicked while it’s down.Vaccinations 1,079,144 | 11.98 doses per 100 people | Increase in cases compared to last week +1,876In Austria, there are mixed feelings about AstraZeneca, writes Bethany Bell in Vienna.On one of Vienna’s main shopping streets, I meet Angelika, who tells me she is relieved to have had her first jab of AstraZeneca last week.”I’m really happy and glad to have it because I’m a teacher,” she tells me. “I feel great. It was fine.” She says it is much better to be inoculated than to get a bad case of Covid-19.Austria halted one batch of the vaccine last week, while they investigate the death of a nurse who died several days after being inoculated.But vaccinations with AstraZeneca continue.Austria’s health minister Rudolf Anschober has called for a swift European solution, instead of individual national decisions.Everyone will have to make up their own minds, says Angelika. “I think we take a lot of other medicines where we don’t know what’s inside.”Another shopper, Manfred is more suspicious.”In general, I am pro-vaccination,” he tells me. But he says he won’t take AstraZeneca at the moment, “because of the serious adverse events. I’m a bit scared to get ill from the vaccine”.He says he might change his mind if the studies are okay.

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SharecloseShare pageCopy linkAbout sharingimage copyrightGetty ImagesA digital certificate to kick-start foreign travel should be given to citizens across the EU “without discrimination”, officials say.The aim is to enable anyone vaccinated against Covid-19, or who has tested negative or recently recovered from the virus to travel within the EU.The 27 member states will decide how to use the new digital certificate.Vaccine passports have faced opposition from some EU member states over concerns they might be discriminatory.Some argue that they would enable a minority to enjoy foreign travel without restrictions while others, such as young people who are not seen as a priority for inoculation, continue to face measures such as quarantine. European Commission officials have made clear they want to avoid discrimination.P&O Cruises says travellers will need vaccinationsBritish Airways plans app-based travel passEurope in vaccine race to save summerAnother issue raised has been that data on the efficacy of vaccines in preventing a person from carrying or passing on the virus is incomplete.Ahead of the EU’s announcement, the World Health Organization (WHO) said that it was working to “create an international trusted framework” for safe travel, but that vaccinations should not be a condition. What does the certificate mean for EU travel? Speaking in Brussels on Wednesday, European Justice Commissioner Didier Reynders said the proposed digital green certificate would be “for all EU citizens, their families when they’re leaving the EU or living abroad”. “It’ll also be for the European Economic Area (EEA), because we want to work with Norway and Iceland,” he said, adding that Switzerland would also be involved. Mr Reynders said there was still a lot to do to put the digital certificate in place, but the aim was to get it up and running before the summer tourist season. The European Commission proposal sets out that any EU member state permitting vaccinated travellers to bypass restrictions such as quarantine must accept certificates from other states within the bloc under the same conditions. The vaccines should be approved by the European Medicines Agency (EMA). These currently include drugs developed by Pfizer-BioNTech, Moderna, Oxford-AstraZeneca and Johnson & Johnson, but not Russia’s Sputnik V or China’s Sinovac and Sinopharm vaccines. However, the proposal adds that the guidelines “should not prevent member states from deciding to accept vaccination certificates issued for other Covid-19 vaccines”.Vaccine pause hits Europe rollout as Covid cases riseIs the Oxford AstraZeneca vaccine safe?Why is the EU having vaccine problems?Meanwhile, in the UK, Business Secretary Kwasi Kwarteng said the government was looking at the idea of vaccine passports and had been “discussing what the best way to proceed is”.”We are having debates, discussions about travel… but I think what we also have to do is be driven by the data, we’ve got to see how coronavirus develops,” he told the BBC.More than a third of the UK population – nearly 25 million people – have received at least one dose of coronavirus vaccine in the UK, which is no longer a member of the European Union.The rollout across the EU has been slower, and has been hindered by delayed deliveries as well as the current suspension in several countries of the use of the Oxford-AstraZeneca Covid-19 vaccine over fears of possible side effects. What do European countries make of the plan?The economies of countries such as Greece, Spain and Italy are unlikely to recover until the tourist industry is reopened, and they have been looking at ways to save the summer season while providing a safe environment for both travellers and local residents. Greek Prime Minister Kyriakos Mitsotakis on Wednesday welcomed the planned certificate, which he said would “significantly facilitate the movement of citizens and will help boost tourism and the economies that rely heavily on it”.Last month, Greece’s Deputy Prime Minister Akis Skertsos said that a common digital certificate was “not discriminatory”, and that non-vaccinated tourists could also visit Greece this summer – but the procedure for them would be slower as they would have to be tested and might have to self-isolate on arrival.A hotel manager in the Spanish resort of Benidorm, Ricardo Sánchez, told the BBC that the UK was its most important market, followed by Belgium, the Netherlands, and people arriving from Eastern Europe. “So many months working with so many restrictions and the restrictions are changing every 15 days,” he said, adding that would-be tourists were unsure what to do and were waiting for “good news” before booking reservations. Iceland has said it is opening its borders to visitors who have received the vaccine without the need for testing or quarantine later this week.

About half of all people surveyed by the American Psychiatric Association said they were worried about adjusting to in-person interaction.SAN FRANCISCO — When the pandemic narrowed the world, Jonathan Hirshon stopped traveling, eating out, going to cocktail parties and commuting to the office.What a relief.Mr. Hirshon suffers from severe social anxiety. In the past, casual get-togethers and meetings came with a rapid heartbeat and clenched fists. He preferred to interact virtually, and welcomed the Zoom meetings that others merely tolerated. Even as he grieved the pandemic’s toll, he found lockdown life to be a respite.“There is cognitive dissonance to feeling good in the middle of the pandemic,” he said.Now with normalcy about to return, Mr. Hirshon, a public relations consultant, finds himself with decidedly mixed feelings — “anticipation, dread and hope.”Mr. Hirshon, 54, belongs to a subset of the population that finds the everyday grind not only wearing, but also emotionally unsettling. These include people with clinical diagnoses of anxiety and obsessive compulsive disorder, but also run-of-the-mill introverts, who are socially uncomfortable.A new survey from the American Psychological Association found that while 47 percent of people have seen their stress rise over the pandemic, about 43 percent saw no change in stress and 7 percent felt less stress.Mental health experts said this fraction of the population found the quarantine protective, a permission slip to glide into more predictable spaces, schedules, routines and relationships. And the experts warn that while quarantine has blessed the “avoidance” of social situations, the circumstances are poised to change.“I am very worried about many of my socially anxious patients,” said Andrea Maikovich-Fong, a psychologist in Denver. That anxiety “is going to come back with a vengeance when the world opens up.”She doesn’t for a moment diminish the larger picture of the pandemic’s toll. Millions have died around the globe, and the plague itself has caused severe grief and anxiety — for parents and children, medical workers and those just trying to survive economically. The mental health industry, she said, “is struggling to keep up.”But for people with severe anxiety and obsessive compulsive disorder, these sharp restrictions in some ways reinforced their intense impulse to withdraw.Researchers found in a study conducted during the height of the pandemic that some children with social anxiety and learning disorders saw improvements in anxiety and depression.Ruth Fremson/The New York TimesEarly on in the pandemic, “these patients were feeling very vindicated,” said Ms. Maikovich-Fong. For people who feared contact with other people or germs, “even the government was telling them that everything they thought they should be doing was the social norm.”Now, she said, she’s already seeing the discomfort set in for “some kids going back to school or adults who were working remotely.”“There are a lot of people walking around with a false sense of security, who are a lot more comfortable than they were a year ago,” she said. “That’s not sustainable.”This counterintuitive dynamic is playing out for teenagers and children, too.A study published in February in European Child & Adolescent Psychiatry looked at the mental health impact on 1,000 young people in Canada during the pandemic, and found that 70 percent of study subjects aged 6 to 18 reported some negative impact. But 19.5 percent in that age group saw some improvement, leading the authors to conclude of the impact: “Mostly worse; occasionally better.”Researchers found that some children with social anxiety and learning disorders saw improvements in anxiety and depression. “The stay-at-home directives may have provided relief from sources of stress, therefore improving symptoms of anxiety or irritability,” according to a summary of the research by the Hospital for Sick Kids, which is affiliated with the University of Toronto and supported the research.Ryan Fenstermacher, a high school senior in Connecticut (who asked that his city of residence not be published), said school can increase his social anxiety. “Like group projects, they’re always terrible for me — my anxiety comes from not being able to predict what they’re going to do, what they’re going to say,” he said. “There’s no escape route.”Not so when he’s on Zoom. “You can turn off your camera, mute people online,” he said.For some students, the return to the classroom is proving challenging because they’ve gotten accustomed to being offline. In Mountain View, Calif., an intensive therapy group is tackling teenage mental health challenges, and its participants include a new member as of mid-March: a 15-year-old who started with the group this week to try to cope with social anxiety.Her mother, who asked that their names be withheld to protect the girl from embarrassment or bullying, said that the girl, who is in 10th grade, appeared to have essentially forgotten how to socially interact. The idea of returning to school makes the adolescent terribly anxious and, absent therapy, “would be terrible news for her,” her mother said.Mary Alvord, a psychologist who runs a large group practice in Maryland serving adolescents, said that many adolescents have suffered during the pandemic. “We don’t want to diminish that,” she said. But “there is a subset of kids who are doing better.”Some adolescents, Dr. Alvord said, have found a respite from bullying and social anxiety, and students struggling in school now get more help from their parents and worry less about their in-classroom performance.Then there are the little ones.“Kids will say, ‘My mom used to travel all the time. I never even saw her and she was so tired, and now my parents are home all the time and they even play games with us,’” Dr. Alvord said.Josh Bernoff, a public speaker and author in Arlington, Mass. “I don’t want this to go on forever,” he said, “but for just this year, this period, it’s been a little island of stability.”Katherine Taylor for The New York TimesFor some adults, the pandemic provided a glimpse into just how much anxiety they were experiencing on a regular basis. Josh Bernoff, a public speaker and author who lives in Arlington, Mass., said he was constantly stressed by traveling, figuring out where his next on-the-go meal was coming from and making socially awkward conversation with people he didn’t know that well.Now, he says, “all my interactions are virtual, so I don’t worry about shaking hands and the awkwardness of in-person.”“When I go to bed at night, I know what I’m doing the next day, and I don’t worry about it,” said Mr. Bernoff. He loves the predictability of life — like what time he’s having lunch and dinner and where it’s coming from. “I hate to sound paranoid about this, but I like being in the same place as my refrigerator.”Mr. Bernoff hastened to say he can’t wait for the pandemic to end — “and go to dinner with my wife.”“I don’t want this to go on forever,” he added, “but for just this year, this period, it’s been a little island of stability.”Mr. Bernoff is fortunate to have consistent work; research shows that anxiety and depression triggered by the pandemic can disproportionately impact those with shakier economic prospects. A large-scale study of 36,000 subjects in the United Kingdom, published in the December 2020 issue of The Lancet, found that mental health challenges were elevated for some people early in the lockdown and then eased in general as the lockdown eased, with some groups more susceptible than others.“Being female or younger, having lower educational attainment, lower income, or pre-existing mental health conditions, and living alone or with children were all risk factors for higher levels of anxiety and depressive symptoms at the start of lockdown,” the study found. That began to ebb, the researchers found, as people acclimated and lockdowns eased.By contrast, the anxiety-ridden people who experienced relief during the pandemic probably are in higher income brackets, said Ms. Maikovich-Fong, the therapist from Denver. They are more likely to have jobs they can do remotely, allowing them to remain employed but with less stress than before.In the end, that relief may not only prove temporary but also actually intensify anxiety as people try to re-engage.“The more you avoid something that makes you anxious, the harder it is to do,” said Martin Antony, a psychology professor at Ryerson University in Toronto and an expert in phobia and anxiety. He added of people with more extreme cases: “They may find when the pandemic ends, it’s much more difficult.”

Contracting the coronavirus while far from home is a frightening possibility. And sometimes it happens, with consequences that can be deadly.Late last year, Jose Arellano, a U.S. Navy veteran, and his wife, Gloria, traveled 2,000 miles from home to the resort town of Oaxaca, Mexico, to use up about $400 in plane tickets they had purchased at the start of the pandemic. The couple used masks, face shields and disinfectant, but not even a week into the trip, Mr. Arellano, 56, who had asthma, and then Mrs. Arellano, 54, began to get headaches and run a fever.They had both contracted the coronavirus and were battling it in a place where they had no doctors or health insurance, and no nearby family or friends to offer support.There is no way of knowing how many people have been infected with the virus on a trip, but one insurance provider, Seven Corners, has had 2,000 claims filed for related illnesses since June, said the company’s president, Jeremy Murchland. And, one medical evacuation business said it has averaged three flights a month for those with the coronavirus since the start of the pandemic.Only 10 percent of the U.S. population is fully vaccinated, but more people are traveling than any time in the past year. Most will return home healthy, but some will fall ill with Covid-19 and end up quarantining in a hotel or being ordered to a government facility. Others will become sick enough to be hospitalized away from home, and a few will face costly air ambulance flights — or worse.The growing number inoculated Americans face far less risk when they travel, but it is not entirely gone, especially with the new virus variations. “Not everybody achieves full responses to the vaccine, and the immunity to the variances may be lower,” said Dr. Michael S. Diamond, a professor of medicine at Washington University School of Medicine in St. Louis. A viral immunologist, his paper on the topic was published this month in the journal Nature Medicine.What happens to people who fall sick overseas can vary widely, in part based upon their pretrip planning. Some countries have mandatory quarantine facilities for those who test positive and people who are sent there are at the mercy of local standards. Even at the nicest hotels, policies for handling those with the virus can vary widely. Not all travel insurance covers illnesses related to the coronavirus, and most doesn’t include evacuation coverage. Some policies require travelers to be hospitalized before their coverage begins while others only require minor symptoms. And traveler expectations play a role, too.The flight attendant Kalina Collier, 22, caused an international incident when she told her 11,000 followers in an Instagram Live video in February that, after she had tested positive for the coronavirus, her four-star Jamaican resort transferred her to a dirty hotel room that had hidden cameras, and that she was being “held hostage” and “they tried to traffic me.”The allegations went viral, prompting the Jamaican Minister of Tourism, Edmund Bartlett, to issue a statement saying the Jamaican “brand” had been damaged. He said police confirmed that Ms. Collier had not been kidnapped, and noted that she had been allowed to stay at the hotel for free instead of being moved to a government quarantine facility.Ms. Collier was fired from JetBlue Airways. She did not respond to requests for comment on social media.In the Arellanos’ case, things quickly deteriorated, and on Dec. 28, after a month in the hospital with Covid-19, Mr. Arellano, who had worked for San Diego County for 30 years, died of a lung infection. Mrs. Arellano is still recovering at their home in Tijuana, Mexico, where they had settled full-time after retirement.Their son, Christian Arellano, 28, who flew from Tijuana to Oaxaca to help his parents, was also infected. “They were victims to the optimism bias that it’s not going to happen to them,” he said.‘Nice studios’ and dirty dorm roomsJeremy Salomon, 39, who runs the Privilege Luxury Club, a membership travel group, in Copenhagen, was at the tail end of a working trip in the Caribbean island of St. Barts when, on Jan. 17, he woke up feeling off. His coronavirus test came back positive and he was told to quarantine for at least seven days, so he arranged to pay for extended time at his hotel.The next day, however, the manager asked if he would move to “some nice studios” that the island had for those who needed to quarantine so the hotel wasn’t subject to rumors, he said. Mr. Salomon was transported by ambulance to a local sports center with basic suites.“It had a rubber sheet on the mattress. There were no towels. There were no blankets. There was no toilet seat,” he said. “The fridge was empty, there wasn’t even a bottle of water.”Luckily for him, the general manager of Eden Rock, a hotel where he had spent one night earlier in his trip, heard about his ordeal, picked him up and drove him to a villa with six bedrooms, indoor and outdoor saunas, a pool and a private beach. The hotel gave him the use of the villa for free.Unluckily for him, he quickly became too sick to enjoy any of it. “I spent 10 days basically in a fetal position in bed, coughing and brutal fever,” he said. “They brought breakfast every morning and I’d maybe eat it every second day. I can’t imagine what it would have been like to be in that prison cell. You don’t send someone there to recover.”Mr. Salomon said that now when he books clients into a hotel he asks about the quarantine policy, and if the guests won’t be allowed to stay, where they would be expected to go.Bilal Riazuddin, a 22-year-old university student from London, did not have Mr. Salomon’s connections. Mr. Riazuddin flew to Malaysia in late December to visit his parents and had to prebook an approved hotel for a mandatory 10-quarantine. He opted for the least costly option, the ibis Styles Kuala Lumpur Fraser Business Park Hotel about $40 a night, which he said was “comfy.”When he was tested for the coronavirus in anticipation of his discharge, the results came back positive on his ninth day, so within a few hours he was driven in an ambulance with three others to a government-run free quarantine dormitory that had soldiers posted out front.He said he was given a dingy room that came with a desk, bed, mattress, sheet, ceiling fan and shared bathrooms. There was no kitchen (the people living there got three meals a day), no running water in the room, no hand sanitizer, no pillow or blankets, no air conditioning and no laundry in the building. Most of the 20 or 30 men on the floor were assigned a roommate, but Mr. Riazuddin had a single. However, there was no lock on his door.“A couple of times people came into the wrong room. They just open up the door,” he said. “No one spoke English so I’d just stare at them and they’d leave.”His parents brought him supplies. He used bathrooms on a different floor because they were cleaner. As for his room, “There were a few bits of rubbish around so I could tell it hadn’t been fully cleaned,” he said.Still, he said, he was fortunate to remain asymptomatic, and, “there was no point in complaining. At least I knew I wasn’t going to go back home and give my parents Covid.”The inside of an air ambulance used to repatriate a woman and her daughter who had tested positive for the coronavirus from the MaldivesCourtesy Covac Global.A ride home on a private jetAmy, a travel adviser who asked to be identified only by her first name to protect her privacy, traveled to the Maldives with her 20-year-old daughter in mid January. They both tested negative before leaving the United States, came up negative again in Dubai, where they spent two nights en route, and then twice again in the Maldives, when they moved from one resort to another. Then, 12 days into their trip, the daughter’s fifth PCR test came back positive.“I was really shocked. Look at how many tests we had and all our travel was custom and private,” Amy said. “We asked for her to be tested again and they said, ‘No.’ ”Although her daughter’s only complaints were a headache and fatigue, and they were comfortable in a luxurious private overwater bungalow, Amy feared authorities would separate them. She decided to request an evacuation using her membership with Covac Global, a company founded to provide medical evacuations during the pandemic. Amy had paid $1,295 for 15 days of Covac Global’s coverage when she booked their trip.An air ambulance stationed in Qatar could have been ready to go quickly, but the staff wasn’t vaccinated. The daughter, who remained asymptomatic, would have had to spend the 24-hour flight on a stretcher in an isolation pod, a scenario Amy nixed. A different air ambulance was found with vaccinated staff who agreed the daughter only needed to stay in the pod for takeoff, landing, refueling and when being transferred between planes, said Ross Caldwell Thompson, the chief executive officer of Covac Global.All told, more than 30 people worked to make the flight happen, he said, including getting governmental permissions from six countries.Amy and her daughter began their evacuation on Feb. 9 in PPE with a 45- minute speedboat ride from the resort to the airport near Male, the capital. They boarded a twin-engine Hawker 800XP jet, which had the stretcher, medical equipment, lavatory and seating for seven. Along with them were two nurses and two pilots who could switch out during the 16 hours it took to get from the Maldives to Ireland with refueling stops in the United Arab Emirates and Greece.From Ireland, a second air ambulance and a third crew flew them to Canada, and finally to the United States. They arrived Feb. 10, three days after their originally scheduled return date. Amy tested negative throughout the trip, and her daughter tested negative before boarding the air ambulance and again upon returning to her home.The extra resort stay, plus phones calls and the cost of shipping back their luggage since the plane was too small to carry it cost Amy about $11,000. Had she not purchased Covac’s coverage, the repatriation would have cost about $200,000, said Mr. Thompson, whose company also does fee-for-service evacuations.The Centers for Disease Control and Prevention referred questions about the frequency of repatriation of Covid-19 positive people to the State Department, where a spokeswoman said those statistics aren’t collected. She did say that those who test positive for the virus while abroad “should prepare to remain overseas for an extended period and seek medical attention locally.”Scrambling to find careWhen a person gets ill far from home, even if they speak the language, knowing what to do in the midst of a developing crisis is daunting. “If you do decide to take the risk of going, especially taking a trip to a foreign place where you have nobody you know, have a plan just in case,” said Christian Arellano. “The thing that affected us the most was scrambling. To find where to go, who to talk to, where we could get the medicine, where we could stay,” he said.When the Arellanos first started feeling sick, they visited a medical clinic, where a doctor said they had asthma. A second physician eventually diagnosed Covid-19. Christian Arellano said that despite his mother’s illness, she “ran all over town getting all the medicine, thousands of dollars in just medicine.”As the situation worsened, the couple called the U.S. Consular Agency in Oaxaca, which said no area hospital beds were available. They suggested an oxygen tank. With Mr. Arellano’s condition deteriorating, the couple spent $25,000 for a Mexican air ambulance to take him to the Naval Medical Center in La Jolla, Calif.Meanwhile, Christian, a student at San Diego State University whose classes were remote, flew to Oaxaca to help his mother. He saw his father briefly before the older man was airlifted to the United States.“He was barely alive to be honest,” Christian Arellano said. “He was in such bad shape the doctors decided to sedate him and intubate him before the ambulance.”Mr. Arellano would never regain consciousness. He was transferred to Jacobs Medical Center, also in La Jolla, and given high-tech treatment.In Oaxaca, Mrs. Arellano’s condition worsened. A doctor drove Christian and his mother around the city in search of a hospital bed for her. The only thing available was in a private facility at a cost about $4,000 a night. A banking glitch prevented her son’s debit card from working, and his mother was nearly turned away, but he reached an uncle who offered a credit card. Mrs. Arellano was there three nights.Then, Christian Arellano developed gastrointestinal problems, and he too turned out to be positive for the virus.They flew back to Tijuana on Dec. 16. The Jacobs Center didn’t allow Mrs. Arellano to visit her husband until Dec. 27. The next day their daughter, Joselyn Arellano, 27, got to see him. They were all with him when he died the following day. He was buried Feb. 8 with full military honors.The family is facing over $1 million in bills, and expects insurance to cover about 60 percent. They are left wondering how something that was supposed to bring joy brought so much sorrow.“I know my parents decided to take the trip, but they tried to take the most precautions they had,” Christian Arellano said. “When I was in Oaxaca I would see all these foreign tourists walking round, no masks at all, just happy about life. It’s kind of infuriating when you see people who aren’t taking it seriously.”Follow Karen Schwartz on Twitter: @WanderWomanIsMeFollow New York Times Travel on Instagram, Twitter and Facebook. 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The clock was ticking. An M.R.I., a spinal tap and blood tests weren’t revealing the culprit. Could it be psychological? The 35-year-old man rose abruptly from the plastic chair in the waiting room at the Health Sciences Center Emergency Department in Winnipeg, Manitoba. He lurched toward the door, arms held stiffly before him as if warding off something only he could see. “I gotta get out of here,” he muttered. His eyes looked unfocused as he glanced at the family he didn’t seem to recognize. His mother hurried to his side. “It’s OK, Sean,” she murmured in his ear. “We’re here with you.” She took him over to his seat. And then, just as suddenly, he was back to normal, back to the man his family knew and loved. This was why Sean was in the E.D. that day. He had been completely healthy until the day before, when his brother-in-law found him wandering through the house, confused. He didn’t seem to know where he was, or even who he was. But by the time the ambulance reached the community hospital near their home, the confusion had cleared, and he seemed fine. The doctors in the E.D. ordered a few tests and, when they were unrevealing, sent him home. Only a few hours later, it happened again. That’s when they brought him here, to the biggest hospital in the city. By the time they arrived, the bizarre episode had subsided. A second attack in the waiting room lasted only a few minutes, so when the E.D. doctors saw him, he was fine. These doctors also wanted to send him home, but the mother was adamant. Her 30-year-old daughter, Andrea, was admitted to another hospital in the city just three months earlier. Andrea had episodes of confusion, too. And she died in that hospital 12 days later. No one understood what her daughter had or why she died, the mother told the doctors. She wasn’t about to let the same thing happen to her son. Re-enacting His Sister’s Symptoms?And so Sean was admitted for observation. Over the next two days, he had many of these strange episodes. He would try to leave the unit. He wouldn’t answer questions; he didn’t even seem to hear them. He looked afraid. And then it would be over. He was seen by specialists in internal medicine and neurology. He had an M.R.I., a spinal tap and many blood tests. When none of those tests provided an answer, the doctors worried that he had been so emotionally traumatized by his sister’s sudden death that he developed psychological symptoms, something known as conversion disorder. He was transferred to the psychiatric unit for further evaluation. What struck Dr. Kenneth Zimmer, the psychiatrist caring for Sean, was how normal he seemed between these episodes of confusion and fear. Zimmer reviewed the results of the tests done so far. The blood tests and spinal-tap results were unremarkable. Two head CTs were normal. The M.R.I. was hard to read because the patient moved in the scanner and blurred the images, but the radiologist said there wasn’t anything obviously abnormal. His EEG was interrupted when he sat up after the technician startled him. (It’s part of the study.) But what they got before that interruption seemed fine. With every normal test, the likelihood that this was a psychiatric disorder increased. And yet Zimmer was worried by Andrea’s similar illness and her sudden unexplained death. Zimmer had his resident reach out to the hospital where the sister died. What did they know about the cause of her death? Very little. An autopsy revealed the cause of death was swelling in her brain. The cause of the swelling was still unclear. Zimmer suspected this wasn’t a psychiatric disease and felt certain that the medicine and neurology teams would figure it out. Sean’s parents did not share that confidence. Andrea’s doctors had looked at all the usual suspects, they had been told. Sean’s doctors needed to look further, but it wasn’t clear that they would or even could. They sent a letter to the hospital’s patient advocate asking that their son be transferred to a facility capable of providing appropriate testing and expertise. A neurology resident recently assigned to the man’s case shared their concern. Andrea had been hospitalized for only 12 days. Sean had been in this hospital for four, and they were no closer to an answer than when he arrived. The resident tacked up a calendar in the neurology team’s work room. She figured they couldn’t count on his having more days than his sister. Photo illustration by Ina JangSomething Genetic?The patient had another EEG. He moved too much for the team to see a lot, but what could be seen was clearly abnormal. A second M.R.I. was even more revealing, showing a subtle abnormality in a region called the pons that was just like one noted in Andrea’s imaging. To the resident it was obvious that this was not psychiatric. But what was it? She had never seen or read about anything like this. Neither had the attending physician on the case. At the end of each day, the neurology team would meet to take stock of where they were and what more they could do as they crossed off one more day. It was the resident’s third or fourth day without an answer when someone on the team suggested consulting the metabolism service. Metabolic diseases are disorders that interrupt the processes that turn food into energy at the cellular level. Most of these disorders are inherited — caused by genetic mutations that alter the structure or function of one of the body’s tools needed to metabolize carbohydrates, fats, proteins and other nutrients. And while most of these diseases are rare, there are many of them. It is estimated that metabolic diseases affect up to one in 1,000 people. Still, most show up in infancy or childhood, not at age 35. The neurology resident called a friend on the metabolism service, Dr. Tyler Peikes, who immediately went to see Sean. He reviewed the records, examined the patient and got the story from Sean and his family. It didn’t sound like any of the metabolic diseases he knew. The rapid course of the sister’s illness was uncharacteristic. He ordered tests to look for those diseases that usually appear intermittently. The neurology resident continued to look for answers. And slowly the results trickled in. It wasn’t an exposure to a metal like arsenic or mercury. It wasn’t an autoimmune disease. It wasn’t an infection. At the end of each day, the resident made another X on her calendar and went home worried. The only hopeful sign was that the patient’s episodes were becoming less frequent. She wasn’t sure why but hoped it meant they would have enough time.Ordering the Right TestFinally, on Day 11, one of the tests that Peikes ordered came back positive. The patient had a rare form of a rare disorder called maple syrup urine disease (M.S.U.D.). Patients with M.S.U.D. are born with abnormalities in the machinery used to break down certain amino acids, the building blocks of proteins. This causes the accumulation of unmetabolized protein components, which can damage the body. Untreated, the disease can result in significant, often fatal swelling of the brain. The name comes from the smell of maple syrup in urine and sweat sometimes caused by the buildup of amino acids during episodes of protein overload. The patient never experienced this. The frequency of a patient’s attacks, and the age at which they begin, depend on how badly the machinery is broken. In intermittent M.S.U.D. — the version this patient had — the body can handle low levels of amino acids, but a high-protein meal or severe physiological stress can overwhelm the system and allow toxic components to build up. A simple blood test provided the answer. Eventually genetic testing revealed the specific defect. A subsequent test on Andrea’s tissue revealed the same abnormality. Patients with M.S.U.D. must maintain a low-protein diet. That’s the only way to prevent these crises. It has been more than two years since Sean got his diagnosis. He says he misses the occasional steak or burger, but the memory of what happened to him and his sister is enough to keep him away. It was Sean’s family that brought this story to my attention. His mother hoped that by sharing her children’s story she could help doctors and families consider the possibility of these rare metabolic diseases when patients present with a psychiatric or neurological disease that no one can figure out. “It’s not a hard test,” the mother said. “You just have to think of it.” Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share with Dr. Sanders, write her at Lisa .Sandersmd@gmail.com.

SharecloseShare pageCopy linkAbout sharingimage copyrightGetty ImagesThe disruption in healthcare services caused by Covid-19 may have led to an estimated 239,000 maternal and child deaths in South Asia, according to a new UN report. It’s focused on Afghanistan, Nepal, Bangladesh, India, Pakistan and Sri Lanka, home to some 1.8 billion people.The report found that women, children and adolescents were the worst-hit. South Asia has reported nearly 13 million Covid cases and more than 186,000 deaths so far. Many countries, including those in South Asia, responded to the pandemic with stringent lockdowns. While hospitals, pharmacies and grocers remained open, almost everything else shut down. The report – Direct and Indirect Effects of Covid-19 Pandemic and Response in South Asia – examines the effect of these government strategies on healthcare, social services, including schools, and the economy. It estimates that there have been 228,000 additional deaths of children under five in these six countries due to crucial services, ranging from nutrition benefits to immunisation, being halted. It says the number of children being treated for severe malnutrition fell by more than 80% in Bangladesh and Nepal, and immunisation among children dropped by 35% and 65% in India and Pakistan respectively.The report also says that child mortality rose the highest in India in 2020 – up by 15.4% – followed by Bangladesh at 13%. Sri Lanka saw the sharpest increase in maternal deaths – 21.5% followed by Pakistan’s 21.3%. image copyrightGetty ImagesIt also estimates that there have been some 3.5 million additional unwanted pregnancies, including 400,000 among teenagers, due to poor or no access to contraception. The full effect of the pandemic – and ensuing lockdowns – is just starting to become clear as countries take stock of their public health and education programmes. Experts in India already fear that malnutrition rates will be significantly worse across the country when the data pours in over the next few months. Some countries in South Asia, like India, are still battling a surge in infections. While the nation-wide lockdown ended in June last year, several states and districts have resorted to intermittent lockdowns to arrest the spread of the virus. The interruption to health services also affected those suffering from other diseases – the report predicts an additional 5,943 deaths across the region among adolescents who couldn’t get treated for tuberculosis, malaria, typhoid and HIV/Aids.

SharecloseShare pageCopy linkAbout sharingimage copyrightGetty ImagesFormer US President Donald Trump has urged his Republican supporters to be vaccinated against Covid-19, saying he would recommend it.In a TV interview, he said the vaccine was “safe” and “something that works”.Mr Trump’s conservative fan base has been one of the main groups resistant to the vaccine programme.The former president himself was criticised during his time in office for playing down the seriousness of the pandemic.As the vaccination programme has been rolled out across the US, all other living ex-presidents have spoken out, urging Americans to get the jab.However, Mr Trump has remained largely quiet on the subject.He and his wife, Melania, were vaccinated at the White House in secret in January.Moderna testing vaccine on babies and childrenIs Europe’s AstraZeneca jab decision-making flawed?Covid vaccines: How fast is worldwide progress?”I would recommend it,” Mr Trump said during an interview on Fox News Primetime on Tuesday.”I would recommend it to a lot of people that don’t want to get it and a lot of those people voted for me, frankly.”He added: “It’s a great vaccine, it’s a safe vaccine and it’s something that works.”A recent poll by CBS News, the BBC’s partner in the US, suggested that a third of Republican supporters would not have the vaccine when it was available to them, compared to 10% of Democrats.Mr Trump’s comments came a day after his successor, President Joe Biden, expressed frustration at the reluctance among some conservatives to get the jab.White House spokeswoman Jen Psaki said on Monday: “If former President Trump woke up tomorrow and wanted to be more vocal about the safety and efficacy of the vaccine, certainly we’d support that.”She added: “Every other living president… has participated in public campaigns. They did not need an engraved invitation to do so.”You may also be interested in:

More than 1,200 people with rare diseases have received a diagnosis thanks to the integration of large-scale genomics into the Stockholm region’s healthcare system. This is according to a study from Karolinska Institutet in Sweden that analysed the result of the first five years of collaboration on whole genome sequencing between Karolinska University Hospital and SciLifeLab. The work, published in Genome Medicine, constitutes a major leap forward in the emerging field of precision medicine.
“We’ve established a way of working where hospital and university collaborate on sequencing each patients’ entire genome in order to find genetic explanations for different diseases,” says the paper’s first author Henrik Stranneheim, researcher at the Department of Molecular Medicine and Surgery, Karolinska Institutet. “This is an example of how precision medicine can be used to make diagnoses and tailor treatments to individual patients.”
Large-scale whole genome sequencing technology, that is the process of determining an individual’s complete set of genetic material, has made rapid advances over the recent decade. Despite this, few clinics worldwide routinely use it to diagnose patients.
Just over five years ago, the Karolinska University Laboratory and the Clinical Genomics facility at SciLifeLab launched the Genomic Medicine Center Karolinska-Rare Diseases (GMCK-RD), which involves researchers from among others Karolinska Institutet and KTH Royal Institute of Technology.
In the first five years, the center carried out genome sequencing of 3,219 patients, which led to molecular diagnoses for 1,287 patients (40 percent) with rare diseases. The results are described in the paper now published.
The researchers found pathogenic mutations in more than 750 genes and discovered 17 novel disease genes. In some cases, the findings have enabled personalised treatment for patients with, for example, inherited metabolic diseases, rare epilepsies and primary immune deficiencies.
“Clinical whole genome sequencing has had huge implications for the area of rare diseases,” says Anna Wedell, professor at the Department of Molecular Medicine and Surgery, Karolinska Institutet, and one of the paper’s corresponding authors. “Used in the right way, targeted at each patient’s specific clinical situation, new groups of patients can receive the right diagnosis and treatment in a way that hasn’t been possible before.”
One of the main challenges of whole genome sequencing is to manage and interpret the millions of genetic variants that exist in each individual. The centre has therefore developed a model that directs the initial analysis to pathogenic variants in genes deemed relevant for each patient’s clinical symptoms. This means that doctors have an important part to play in deciding which genetic analyses should be done first.
If the first assessment fails to produce a result, the analysis is broadened to more gene panels until a diagnosis can be established and/or the whole genome is sequenced. This process has also enabled the identification of several previously unknown disease genes, which presents new opportunities for in-depth exploration of pathogenic mechanisms.
A significant undertaking is currently underway to implement a similar working method on a broader front in the Swedish healthcare sector. For example, Karolinska Institutet and Karolinska University Hospital recently established a joint center for precision medicine (PMCK) that will consolidate expand the collaboration around precision medicine.
“For us to succeed with precision medicine, a multidisciplinary collaboration between health care and academia is essential,” says the paper’s second corresponding author Anna Lindstrand, professor at the Department of Molecular Medicine and Surgery, Karolinska Institutet and consultant at Karolinska University Hospital’s Department of Clinical Genetics. “Through these initiatives we combine clinical expertise with bioinformatic tools and together deliver accurate diagnoses and individualized treatments.”
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Materials provided by Karolinska Institutet. Note: Content may be edited for style and length.

SharecloseShare pageCopy linkAbout sharingimage copyrightXiaohongshuIn the latest fad to rock Chinese social media, women have been flocking to Uniqlo stores to post pictures of themselves trying on clothes – from the children’s section.Platforms such as Xiaohongshu and Weibo – the Chinese equivalent of Instagram and Twitter – have been flooded with selfies of young women in fitting rooms, wearing tiny T-shirts from the popular Japanese retailer. On Weibo alone, the hashtag “adults trying on Uniqlo children’s clothes” has received more than 680 million views.Uniqlo China has yet to respond to BBC queries on the trend, which appears to have been started by netizens in recent weeks.It has sparked widespread debate online – not only because it’s reportedly resulted in ruined T-shirts – but also because it is the latest in a series of Chinese social media trends which observers say illustrate an unhealthy obsession among some Chinese women with looking thin. What is an eating disorder?Parents warned of ‘sharp rise’ in eating disordersBBC Action Line information on eating disordersOther trends which have gone viral in the past include the “belly button challenge”, where women wound their arms around their back to touch their belly button, and the collarbone challenge, which had girls balancing coins behind their collarbones. There was also the “A4 waist challenge”, where women shared photos of waists as wide as the narrow edge of an A4 piece of paper, which measures 21cm (8.2in).’BM Style’In fact, such extreme viral skinny challenges pop up so frequently on Chinese social media that there are even niche categories. The Uniqlo trend is an example of “BM Style”, a teen fashion aesthetic involving crop tops, slim jeans and short skirts. It takes its name from the Italian clothing brand Brandy Melville which mostly stocks one-size-fits-all pieces. Its standard size is comparable to the extra-small size from other brands.The trend started gaining popularity last year, after young Chinese women began sharing pictures of themselves in crop tops and dresses by the brand with the hashtag “test if you can wear the BM style”. One 22-year-old Weibo user who frequently posts such pictures told BBC Chinese that she liked the style as “it looks sexier and sweeter… and it makes one’s legs look longer.”image copyrightXiaohongshuBut the rise in popularity of such trends has sparked concern that they are fuelling pressure for women to be unnaturally thin.There has been criticism of a viral and unverified size chart indicating how much a “BM girl” should weigh according to her height – one example given was that a woman with a height of 160cm should weigh only 43kg.An online body mass index (BMI) calculator provided by Britain’s National Health Service says some of the figures on the chart could mean a person was underweight and advises they consult a doctor.On Weibo, the hashtag “how women should overcome body anxiety” has also received almost 70 million views. “The scary thing about the ‘BM style’ is that everyone knows it is unhealthy, and yet they feel pressured to pursue this aesthetic. Some people overlook their health for this – it’s just not worth it,” said one user.Fears TikTok videos may ‘trigger eating disorders”I was addicted to celebrity diet tea’Why would anyone take the A4 skinny waist challenge?He Jinbo of the Chinese University of Hong Kong, who studies mental health and body image, said his latest research on Chinese adolescents found that the more time a teenager spent on social media, the more likely the teen would be dissatisfied with his or her body.While it is not the only society grappling with this problem, experts have told the BBC that the issue is more fraught in China where notions of body positivity have yet to take root.A 2019 Ipsos online survey on global beauty standards found that out of 27 countries, China came out top in believing that body weight and shape are important attributes in making a woman beautiful. The Chinese were also the second most likely to pick the skinniest body types as “ideal” for women. ‘A good woman cannot weigh over 50kg’Chinese psychologist Ke Han from Singapore’s Nanyang Technological University noted that Chinese media tends to feature “very thin girls” and the public tends to favour waif-like female celebrities.”There is a popular Chinese saying which means ‘a good woman cannot be over 100 jin’ which is about 50kg [110lb],” Dr Ke said. “Women who are heavier than that are then considered lazy and lack self-discipline because they cannot seem to take care of themselves… some women believe this so much that they think it’ll affect their marriage prospects.”Many people still hold a patriarchal view which objectifies women, she said. “Being slim and beautiful implies ‘good value’ as an object.”The ‘punchline queen’ who offended Chinese men’Banshee, shrew’: An angry song wants women to be seenIt is also generally culturally acceptable to be direct when talking about someone’s weight. “The majority of Chinese people have not realised the damage that fat-shaming can have on someone’s well-being,” said Dr He Jinbo.But there are signs of change, and more “are beginning to be influenced by body positivity movements elsewhere… you can start to see some talk online,” said Dr Ke Han. Last year, lingerie brand Neiwai made headlines when it launched a body positive advertising campaign. The brand’s diverse sizing stood out among Chinese retailers which tend to carry items only in limited smaller sizes. Earlier this month, popular Chinese actress Zhang Meng sparked discussion online when she revealed on Weibo that she had to seek medical treatment after attending an awards ceremony, as she had worn a corseted dress that was so tight that it had caused severe pain in her ribs.image copyrightWeiboShe said the incident served as a wake-up call. “Our looks are only one part of us. Instead of complaining every day that we are not thin enough, it’s better to spend that time learning new things, enriching ourselves, and make ourselves more confident!”Many social media users responded with messages of support. Said one commenter: “This is really how it should be. So many women have body anxiety issues, but health is much more important. No matter what we look like, we are all the most beautiful.”If you, or someone you know, has been affected by this story you can get support and advice from BBC Action Line.