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Argentina - Outbreak of bilateral pneumonia: 22 cases, 6 deaths, Tucumán - September 1, 2022 - Legionella confirmed

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  • #16

    Mystery cluster of pneumonia cases in Argentina being monitored by World Health Organisation

    Saturday 3 September 2022 18:37, UK

    The World Health Organisation is monitoring a cluster of pneumonia cases from an unknown cause in Argentina, in an outbreak that so far has included three deaths.

    The 10 cases are linked to a single private clinic in the city of San Miguel de Tucuman in the country's northwest, according to the Pan American Health Organisation (PAHO), the regional office of the WHO.

    ... Biological samples have been sent to Argentina's National Administration of Laboratories and Health Institutes for additional testing, which will include an analysis for the presence of toxins.

    Dr Michael Osterholm, an infectious disease expert at the University of Minnesota, said given that the lungs are heavily involved, the cause is likely something the patients inhaled.

    He first suspected Legionnaires' disease, which is caused by inhaling droplets of water containing Legionella bacteria, but tests have ruled that out.

    Dr Osterholm said "mystery illnesses" do sometimes happen, and most often they can be explained by some local outbreak that does not have pandemic implications.

    He said he expects more definitive information from Argentine health officials in the next five to seven days.

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    • #17
      Translation Google


      DERIVATIONSeptember 3, 2022
      Completed the transfer of 12 patients to the public sector

      listen to this note

      After the meeting led by the Minister of Health of the Nation, Dr. Carla Vizzotti, her counterpart from the province of Tucumán, Dr. Luis Medina Ruiz, and the PAHO representative in Argentina, Dr. Eva Llopis, the health portfolios agreed on the transfer of patients who remained hospitalized in the private sanatorium for various pathologies.

      These are 12 people housed in intensive care and other hospital rooms who were referred to the Centro de Salud hospital as part of the contingency health plan, following the outbreak of legionella detected in that institution.

      The purpose of the transfer responds to the continuity of the evolution of these patients and to various monitoring and environmental control actions. The operation was carried out by the Directorate of Health Emergencies 107 and had the collaboration of the Tucumán Police.

      To date, the infectious outbreak of bilateral pneumonia already identified by the Legionella bacterium amounts to eleven cases, of which four died; four are hospitalized (three in MRA and one with non-invasive ventilation); and three persist under outpatient treatment with home monitoring.



      https://msptucuman.gov.ar/culmino-el...ector-publico/

      --------------------------------------------------------------


      EPIDEMIOLOGICAL SITUATIONSeptember 4, 2022
      OFFICIAL COMMUNICATION

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      The Ministry of Public Health reports the death of a patient linked to the cluster of pneumonia cases

      This is a 64-year-old male patient with comorbidities, who was hospitalized in serious condition, in the public sector.



      Se trata de un paciente del sexo masculino de 64 años de edad, con comorbilidades, que se encontraba internado en grave estado, en el sector público.


      "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
      -Nelson Mandela

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      • #18
        Source: https://www.who.int/emergencies/dise...em/2022-DON407


        Legionellosis - Argentina

        5 September 2022


        Outbreak at a glance
        As of 3 September 2022, a cluster of 11 cases of severe pneumonia,including four deaths, have been reported in San Miguel de Tucumán city, Tucuman Province, Argentina. Legionella spp. was isolated in the samples from four cases. Legionellosis is a pneumonia-like illness that varies in severity from mild febrile illness to a serious and sometimes fatal form of pneumonia. Cases were initially reported as being pneumonia of unknown cause. Legionella bacteria was identified as the causative organism on 3 September.
        All cases presented with bilateral pneumonia, fever, myalgia, abdominal pain, and dyspnea between 18 and 25 August 2022 and are epidemiologically linked to one health facility. Of the 11 cases, eight are health workers of the facility; three are patients of the health facility. Three of the four deaths were among health workers.
        Health authorities are coordinating cluster investigation activities, active case finding to identify additional cases, contact tracing and public health activities to limit further spread.
        Outbreak overview
        On 29 August 2022, WHO was notified by the Ministry of Health of Argentina of a report from the Ministry of Public Health of Tucumán Province, of a cluster of six cases of bilateral pneumonia without an etiological cause identified in San Miguel de Tucumán city, Tucuman Province, Argentina 1. All six cases were linked to one private health facility in the city of San Miguel de Tucumán, with the onset of symptoms between 18 and 22 August 2022. The six cases included five health workers and one patient who was admitted to the clinic for an unrelated condition and then subsequently to the intensive care unit after developing pneumonia. In addition to bilateral pneumonia, all cases presented with fever, myalgia, abdominal pain, and dyspnea.
        On 1 September, three additional cases were identified through active case finding - all health workers from the same private health facility, aged 30 to 44 years - with similar signs and symptoms to the initial six cases identified 2. The onset of symptoms for these cases was between 20 and 25 August 2022.

        Between 2 and 3 September, two additional cases were identified, an 81-year-old male and a 64-year-old male, both with comorbidities, who were hospitalized and presented similar clinical presentation as the previous cases 3.
        As of 3 September 2022, 11 cases have been identified, four of whom have died (three health workers). Eight of the 11 reported cases are health workers of the same health facility. The median age of the cases is 45 years; seven are male. Ten cases had underlying conditions and/or risk factors for severe disease, including the four reported deaths. Four cases are still hospitalized as of 3 September. Contacts of the cases are under follow-up and, to date, none have developed symptoms.
        Laboratory results
        Blood, respiratory and tissues samples were obtained from the 11 cases. Preliminary tests conducted at the local Public Health Laboratory were negative for respiratory viruses, and other viral, bacterial, and fungal agents. On 31 August, samples from the initial six cases were sent to the National Reference Laboratory - the Administration of National Laboratories and Health Institutes (Administración Nacional de Laboratorios e Institutos de Salud - ANLIS per its acronym in Spanish) - for additional testing 4 . As of 3 September 2022, negative results have been obtained for COVID-19 (RT-PCR), Influenza, detection of antibodies for Coxiella, urinary antigen for Legionella spp., panel of 12 respiratory viruses, hantavirus (Elisa IgM), histoplasma (RT-PCR), Yersinia pestis (PCR) and micro agglutination for leptospirosis.
        Further analyses of two bronchoalveolar lavage samples by highly sensitive total DNA sequencing (metagenomics) found readings compatible with Legionella spp. On 3 September 2022, ANLIS reported that amplification products of the 16S ribosomal gene for Legionella spp. from the two samples of bronchoalveolar lavage sequenced by metagenomics and analyzed by four different bioinformatic methods, produced results compatible with Legionella pneumophila. Confirmation of these results is expected upon completion of the sequencing processes. This laboratory result supports evidence compatible with Legionnaires’ disease. Blood culture and seroconversion tests continue to be conducted to complement the diagnosis of Legionella infection.
        Epidemiology of Legionellosis
        Legionellosis is a generic term describing the pneumonic and non-pneumonic forms of infection with the Legionella species of bacteria.Legionellosis varies in severity from mild to serious and can sometimes be fatal.
        Legionnaires’ disease, the pneumonic form, has an incubation period of 2 to 10 days (but up to 16 days have been recorded in some outbreaks). It is an important cause of community- and hospital-acquired pneumonia; and although uncommon, Legionnaires may cause outbreaks of public health significance. Initially, symptoms are fever, mild cough, loss of appetite, headache, malaise and lethargy, with some patients also experiencing muscle pain, diarrhoea and confusion. The severity of Legionnaires’ disease ranges from a mild cough to rapidly fatal pneumonia. Untreated Legionnaires’ disease usually worsens during the first week.
        Mortality from Legionnaires’ disease depends on the severity of the disease, the use of antibiotic treatment, the setting where Legionella was acquired, and whether the patient has underlying conditions, including immunosuppression. The death rate may be as high as 40–80% in untreated immunosuppressed patients and can be reduced to 5–30% through appropriate case management, depending on the severity of the clinical signs and symptoms. Overall, the death rate is usually between 5–10%.




        Public health response

        In response to the detection of the cluster of bilateral pneumonia, health authorities in Tucuman Province coordinated cluster investigation activities including the follow-up of cases, search for the source(s) of infection, active case finding to identify additional cases, and contact tracing. Preliminary investigations indicated no secondary cases were identified.
        As Legionella spp. has been identified as the etiology of this outbreak, the following public health measures were implemented:
        • Risk assessment and suspension of healthcare activities in the health facility.
        • Enhanced surveillance including active and passive case finding.
        • Biological and environmental sampling, and laboratory testing, including bacteria isolation, and metagenomics.
        • Case isolation and clinical care of patients.
        • Contact identification, support and monitoring.
        • Risk communication
        With the support of national health authorities, environmental samples are being collected to define the source of contamination and urgently implement prevention and control measures. The health authorities are also implementing internal and external communication strategies for health professionals and the community.
        The Pan American Health Organization (PAHO)/WHO is providing technical support for the outbreak investigation, including advice on sampling, environmental assessment, clinical management, and Infection and Prevention Control (IPC) measures.


        WHO risk assessment

        Legionellosis varies in severity from a mild febrile illness to a serious and sometimes fatal form of pneumonia and is caused by exposure to Legionella species found in contaminated water and potting mixes. The most common form of transmission of Legionellosis is inhalation of contaminated aerosols from contaminated water sources. Sources that have been linked to both the transmission of Legionella via aerosols and outbreaks of Legionellosis include air conditioning cooling towers or evaporative condensers associated with air conditioning and industrial cooling, hot and cold water systems, humidifiers, and whirlpool spas. Infection can also occur by aspiration of contaminated water or ice, particularly in susceptible hospital patients. To date, there is no reported direct human-to-human transmission.
        Sporadic outbreaks of legionellosis pneumonia have been reported in Argentina before. There are robust surveillance activities being implemented in the affected health facility. Nonetheless, in the absence of an identified source of Legionella bacteria, the risk of developing Legionellosis for people working or hospitalized at the same health facility is currently moderate.
        Countries with cases of Legionellosis reported after travel to Argentina should notify their regional IHR focal point.


        WHO advice

        WHO recommends the continuation of laboratory analyses, case identification and clinical care, contact tracing, outbreak investigation to identify the source(s), implementation of measures to prevent further infections and enhancement of Infection Prevention and Control (IPC) measures. IPC measures in health facilities have been enhanced during the COVID-19 pandemic and should be reinforced to prevent healthcare-associated transmission. Precautions that are recommended for COVID-19 should continue to be followed.
        WHO does not recommend any specific different measures for travelers. In case of symptoms suggestive of respiratory illness either during or after travel, travelers are encouraged to seek medical attention and share their travel history with their healthcare provider.
        WHO advises against the application of any travel or trade restrictions on Argentina based on the current information available on this event.

        Further information
        • Pan American Health Organization / World Health Organization. Informative Note: Update cases of pneumonia due to Legionella – Tucumán, Argentina. 3 September 2022, Washington, D.C.: PAHO/WHO; 2022. Available at: https://bit.ly/3AN00e9
        • Infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care, WHO guidelines: https://bit.ly/3AMk14G
        • Ministry of Public Health of the Government of Tucumán Official Communication. Available at: https://bit.ly/3TJaHac
        • Ministry of Public Health of the Government of Tucumán Official Communication. Available at: https://bit.ly/3cOjKWT
        • Argentina Ministry of Health press release, “ANLIS-MALBRÁN analyzes samples from cases of pneumonia of unknown cause in Tucumán”. Available at: https://bit.ly/3cLPqw0
        • Ministry of Public Health of the Government of Tucumán Official Communication. The Minister of Public Health led a virtual meeting with Carla Vizzotti to analyze the situation of pneumonia of unknown origin. Available at: https://bit.ly/3RC3XZS
        • Ministry of Public Health of the Government of Tucumán Official Communication, “Vizzotti confirmed that the outbreak of pneumonia in Tucumán was due to Legionella”. Available at: https://bit.ly/3cJhxvV
        • World Health Organization. Legionellosis fact sheet. Available at: https://bit.ly/3KMmZL9
        • World Health Organization. Legionellosis Outbreak Toolbox. Available at: https://bit.ly/3KMIdZd


        [1] Ministry of Public Health of the Government of Tucumán Official Communication. Available at: https://msptucuman.gov.ar/comunicado-oficial-18/

        [2] Ministry of Public Health of the Government of Tucumán Official Communication. Available at: https://msptucuman.gov.ar/el-ministe...nia-bilateral/

        [3] Ministry of Public Health of the Government of Tucumán Official Communication. Available at: https://msptucuman.gov.ar/comunicado-oficial-21/

        [4] Argentina Ministry of Health press release, “ANLIS-MALBRÁN analyzes samples from cases of pneumonia of unknown cause in Tucumán”. Available at: https://www.argentina.gob.ar/noticia...ida-en-tucuman


        Citable reference: World Health Organization (5 September 2022). Disease Outbreak News;Legionellosis in Argentina . Available at: https://www.who.int/emergencies/dise...em/2022-DON407



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        • #19

          EPIDEMIOLOGICAL SITUATIONSeptember 4, 2022
          OFFICIAL COMMUNICATION

          listen to this note


          The Ministry of Public Health reports the death of an 81-year-old male patient, with comorbidities, who was hospitalized in serious condition, in the public sector. It is linked to the cluster of pneumonia cases.


          El Ministerio de Salud Pública informa el fallecimiento un paciente del sexo masculino de 81 años … Leer +
          "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
          -Nelson Mandela

          Comment


          • #20
            Translation Google

            PUBLIC HEALTH 5 September, 2022
            The Minister announced the new inclusion criteria for the detection of the outbreak of legionella pneumophila

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            Within the framework of a new press conference, the person in charge of the Sanitary portfolio, Dr. Luis Medina Ruiz, explained that the change in the criteria includes patients, health personnel, and caregivers who have been in the sanatorium in August private, or has received a surgical intervention and has some compatible symptom such as fever or respiratory symptoms.

            "We want to report that, having a known etiology of this outbreak linked to the private sanatorium, we have considered together with the Minister of the Nation, Dr. Carla Vizzotti, a change in the inclusion criteria within this outbreak. Initially, when we detected two patients with bilateral pneumonia that coincided with the common workplace and that we also could not find its etiology, that was what we had as inclusion criteria. Today, knowing that it is a bacterium that does not always cause bilateral pneumonia, we are including any health personnel, patient or family caregiver who has been in the month of August or has received a surgical intervention in the selection criteria for patients. in this private sanatorium and who has some compatible symptom such as fever or respiratory symptoms, not necessarily bilateral pneumonia, "he reported.
            “That is why today we are including at least 8 new patients, of which 1 is a patient, 2 are health personnel and 5 are caregivers of patients who were hospitalized, post-surgical or with neurological problems. Of these 8 patients, there is one who has severe comorbidity, due to a cerebrovascular accident and is also suffering from pneumonia, he is the only one who is serious. We are very sorry for the death of the two patients yesterday, who were on mechanical respiratory assistance for their bilateral pneumonia, and very seriously ill with severe comorbidities. One of them was 81 years old and the other 64, in summary today we have 6 deceased, 9 patients who are at home with outpatient medical follow-up, since the clinic they present is of moderate or mild severity,
            Likewise, the official stressed that it is a bacterium that is not transmitted from person to person and the fact of having found the cause gives them great certainty about the measures to be taken. “Initially we had taken the measure of isolating the sanatorium without removing the patients, since not knowing the etiology it could have been a virus or a battery that could have spread in the community. Knowing today that it is a bacterium, has allowed us to take other measures regarding this outbreak.”
            Regarding the private sanatorium, the Minister stressed: "First of all we have to analyze responsibility, today we are with the sanatorium closed, patients cannot enter, neither outpatients nor inpatients, and as of today or tomorrow a team of experts will come since Legionella is not an easy-to-find bacterium, a special technique is needed”.
            At the same time, Medina Ruiz clarified that the Ministry carries out tests on the condition of the water, if it is drinkable, if it has residual chlorine, if it has germs and that has not been found; since the conditions were within the adequate. “The public sector has a permanent epidemiological surveillance, in case of seriously ill patients, the cause is sought, that does not happen everywhere. Here we saw patients who came from the private sector, we took action on the matter and we have thoroughly investigated what the cause is. And not finding it is when all this is triggered. I think the next steps will depend on the findings in the coming weeks."
            At the same time he added: “There are no patients who are not related to the private sanatorium in the month of August, and that is the situation where the limits are. Today we have a little more certainty. This disease has the characteristic that it is self-limited; it is very different from COVID that one does not know when it ends. With this bacterium no, most people can have an asymptomatic or mild symptomatic picture, and it is self-limited. That means that when the disease begins, the body itself limits it and cures it. He will not have relapses because he has no new contact with the germ, ”he detailed.
            In the same way, he remarked: “Anyone who begins with symptoms such as fever, symptoms compatible with the flu: body aches, headache, cough, cold, dyspnea. In some patients diarrheal pictures. We are going to control them for at least two weeks, from the closure of the sanatorium and that there is no other person working inside, until we are certain that there are no more patients.

            Medina Ruiz, remarked that the patients who are hospitalized are receiving a specific treatment. Pneumonia is a very frequent cause of death in older people and with comorbidities, the cause is not always known and that is every year and winter. Pneumonia is usually fatal, due to the Influenza virus.
            “Today all the patients who are compromised are under strict surveillance, in therapy with professionals with a lot of experience and of course we are going to have a very fluid communication with the family. It will be opportune, we are going to have a press conference once a day, and then with official communications when some relevant information appears, ”she warned.
            Finally, the official explained: “The way this disease is spread is through water vapor, air conditioning, the shower when it disperses the water, when it is breathed. The bacteria do not enter through the mouth when one touches the water, it has a special way of contagion and entry into the body. In a certain way, it generates outbreaks and this way of contagion does not give rise to interhuman contagion, that is, for the person next to me to become infected, they need a cloud of particles that enter the lung.”


            ...
            https://msptucuman.gov.ar/el-ministr...a-pneumophila/
            "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
            -Nelson Mandela

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            • #21
              Translation Google


              OFFICIAL COMMUNICATION5 September, 2022
              Epidemiological situation

              listen to this note
              Case update on the pneumonia outbreak.

              The Ministry of Public Health reports the current epidemiological situation linked to the outbreak of pneumonia.
              Total Cases Deceased boarding schools MRA Ambulatory
              22 6 6 3 10
              "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
              -Nelson Mandela

              Comment


              • #22
                Translation Google

                VIRTUAL MEETING September 9, 2022
                They analyzed the evolution of the Legionella outbreak in Tucumán

                listen to this note
                National and provincial health authorities together with national and international experts are working on the investigation and control of the outbreak. In the ANLIS-Malbrán laboratories, the diagnostic evaluation of the samples of the suspected cases included was extended.

                The meeting, chaired by the Nation's Minister of Health, Dr. Carla Vizzotti , together with the representative of the Pan American Health Organization (PAHO), Dr. Eva Jané Llopis , was attended by the Minister of Public Health, Dr. Luis Medina Ruiz , the medical executive secretary, doctor Miguel Ferre Contreras , the undersecretaries of Health, doctors Eliana Molina and Cristina Majul, Environmental Health authorities, Epidemiology, among others. The press conference was to report on the evolution of the Legionella outbreak in Tucumán and the actions that are being developed to respond in an articulated effort between the Nation, the jurisdiction and local and international experts.

                Medina Ruiz said that what was done these days was discussed: “First of all, we ratify that the outbreak was generated in the private clinic, and it is an outbreak limited to the clinic that generated contagion to the people who circulated within it. . This disease does not spread from person to person, now we have to wait 14 to 16 days from the last contact of those who have passed through that institution to assess whether symptoms appear or not.

                On the other hand, he said that they sent water samples and swabs from different parts of the clinic to evaluate if legionella is found. "We are waiting for the results that have already begun processing at the Malbrán Institute," he added, while congratulating the health team that was treating the patients and following them by phone, carrying out epidemiological surveillance in the laboratories, sending the samples, making a survey of the infrastructure and carrying out interrelation with the different institutions of the country.

                On the occasion, Vizzotti highlighted "the support from the first day of the Pan American Health Organization through its representative in the country and with the arrival this week of an expert and advisory team for the environmental study of the building." And he clarified that “in this bacterium the source of infection is by inhalation when it is in the air conditioning tabulators and the pipes. So, the situation is absolutely localized in a health center, which is what usually happens with outbreaks of this bacterium."

                On the other hand, the minister listed the steps to follow that include the search for more cases among the people who may have been exposed; complete laboratory studies of all detected cases; clinical follow-up of exposed cases; and the final classification of all cases to assess the final determination of the magnitude of the outbreak. On the other hand, the clinic facilities will also be disinfected to evaluate their rehabilitation and the strengthening of the infection control and facility inspection committees will continue.

                In her turn, the PAHO representative in Argentina, Eva Jané Llopis, highlighted “the rapid action of the national authorities and the province of Tucumán to detect, evaluate, and respond to this outbreak; as well as the very rapid notification made to the WHO through the necessary channels and complying with all health regulations. And she remarked that "this action demonstrates Argentina's commitment to international public health."

                According to the epidemiological investigation, as of September 8, 22 suspected cases of Legionella disease (6 people deceased) have been identified, of which 4 results are compatible with Legionella pneumophila and one with Legionella spp. Epidemiological investigation continues (monitoring, evaluation, and classification of cases, monitoring of exposed persons), laboratory surveillance, and environmental surveillance, to finally determine the magnitude of the outbreak.

                Legionella is a bacteria that is found in water and multiplies more easily in buildings with high volume water systems.

                The most common form of transmission is inhalation of contaminated aerosols produced in conjunction with sprays, jets, or mists of water. Sources of these aerosols include cooling towers for air conditioning, hot and cold water systems, humidifiers, and whirlpool installations. It is important to mention that it is not transmitted from person to person.

                Illness caused by this bacterium has an incubation period of 2 to 10 days and people may develop mild self-limited illness (Pontiac Fever) or more severe illness with pneumonia known as Legionnaire's disease. People over 50 years of age, those who smoke or have smoked, those who are immunocompromised, and those with chronic diseases are at increased risk of severe disease.


                Evolution of the outbreak and actions taken

                In a chronology on the origin of the outbreak and the work carried out, the minister explained that on August 29, the Epidemiology Directorate of Tucumán notified the national health portfolio about the detection of a conglomerate of two cases of bilateral pneumonia without identification of the cause and related to the same private sanatorium.

                Since then, they have worked together on the investigation. The first step was to verify the existence of a possible outbreak and preventive isolation was carried out so that no new patients were admitted to the institution. In addition, a case definition was agreed upon to search for new cases and a protocol was drawn up to determine the possible origin.

                Thus, new cases were identified and samples were taken that were analyzed at the Tucumán Public Health Laboratory for respiratory viruses, other viral, bacterial and fungal agents, all with negative results.

                In turn, the samples were sent to laboratories of the National Administration of Laboratories and Health Institutes (ANLIS) “Dr. Carlos Malbrán” to expand the diagnostic analysis. They were studied for legionellosis, hantavirus, panel of 12 respiratory viruses and pancoronavirus, histoplasmosis and panfungal, leptospirosis, Q fever, mycoplasma and psittacosis.

                All patients were transferred to another hospital and there are no workers in the institution, so there are no people who could be in contact with the source of transmission.

                Finally, last Saturday, ANLIS-Malbrán reported that a viral genome was detected through PCR, sequencing and metagenomic analysis, compatible with legionella pneumophila in 4 patients and with legionella sp in 1 case.

                In relation to environmental surveillance in the sanatorium, 59 samples were taken from 27 different sites, of cold and hot water and swabs from taps and showers. The samples will be derived for analysis at ANLIS-Malbrán. Additionally, the disinfection process of the facilities will begin.


                ...
                Del encuentro, presidido por la ministra de Salud de la Nación, doctora Carla Vizzotti, junto a la representante de la Organización Panamericana de la Salud (OPS), doctora Eva Jané Llopis, […]
                "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
                -Nelson Mandela

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