Brian Altonen, MPH, MS

This section is a work in process –  completion expected in June 2018

[projected Dissertation defense date]

Introduction

The borders of the United States are always being monitored for the possible migration of foreign diseases into this country.  Most of this monitoring is performed using methods well-known to the general public.  The use of border gates and patrols have a number of protocols built-in with the goal of preventing the in-migration of unhealthy or disease-causing organisms, in particular those capable of infecting people, livestock and domestic plants or farming products.  In spite of these precautions designed to prevent the next Dutch Elm Disease or “Mad Cow disease” or Ebola from making its way into this country, many diseases still manage to make their way into this country.  As a natural biological and ecological feature of all living pathogens or zoonoses, these pathogens have the ability to find new ways to cross the borders, make their way through the quarantines and epidemic free zones, and yet still manage to develop new infections in plants, animals and people.   These cases are very infrequent and at times even very rare, yet they do exist.

Historically, we have taken to the belief that we completely understand how a disease-causing organism behaves, and use our understanding of these behaviors to predict the methods by which pathogens can manage to make this way into our daily lives.  When we were under the impression that we eliminated the recurring epidemic disease Asiatic cholera from our medical history during the late 1800s, this claim was made due to our understanding of the disease and its living organisms at the time.  Little did we know that there was a very unusual ecological relationship taking place between vibrio and its natural carriers in the deltas of the Ganges River.  As a result of this very limited knowledge of the ecology of vibrio in such systems, we as a country went by the belief that we had pretty much eliminated vibrio cholerae from America’s medical epidemiological history.  Little did we know at the time that this vibrio could exist without much knowledge or documentation of its existence within the deltaic settings in the Gulf of Mexico, even though periodic resurgences of vibrio cholera cases have taken place ever since this organism was in theory completely removed from the United States borderline settings.   We also knew very little about the ability of such an organism to pass its toxicity in the form of a vibriotoxin gene to other microorganisms.  It was these abilities of microbes that enabled the severe forms of E. coli to evolved, those capable of producing potentially fatal substances like vibriotoxin and shigellatoxin.

Due to these ongoing evolutionary changes in the taxonomy and nosology of the pathogenic microorganisms, it would not be a surprise to see new more toxic species develop in any of the dozens, perhaps hundreds of foreign born pathogenic microbes capable of causing new epidemics to develop in the United States.  Adding to this natural ecological skill of microbes are the human ecological truths about people and the way that they migrate.  It is natural for people to wish to travel about whenever and wherever they want to.  However, this freedom is somewhat limited by borderline posts and public health and environmental safety patrols.  In recent years, these activities have taken on a new name and function, assigning this job the responsibility of maintaining national security.

National security is not just the prevention of terrorists from coming into this country.  Preventing deaths due to arsonry, bombing, gunfire, and other means of injuring people is not the main reason potential terrorists have to be “watched.”  There are numerous less obvious ways in which the health and safety of this country can be put at risk, including some of the more important means for preventing these intrusions upon American culture and life, both medically and epidemiologically.

The introduction of foreign-born diseases that normally we are not accustomed to is a major concern of public health professionals and epidemiologists.    As the size and density of the US population grows, and as technology continued to improve giving way to faster modes of travel and communication, the rate at which a disease can travel across the earth’s surface has increase exponentially during the past century or two.  What originally took months or even a year to occur back in the colonial period can now take place in just 6 or 8 hours.  Even manmade methods of travel are capable of spreading naturally evolved diseases much faster than nature itself.  In just a half a day a disease that erupts halfway around the world could in theory make its way to the other side, infect some unsuspecting people, and result in the death of nearly everyone in that very small population, assuming the climate, living setting, activities, and status of the people infected by this disease made each and every one of them highly susceptible to such a disease and its fatality.

Foreign diseases have many ways of entering into this country.  They may travel by natural means, making their way into the interior by way of air, water and migrating animal population routes.  They may also make their way into the interior without living carriers or vectors, by way of infecting various goods ranging from foods and clothing to unusual products manufactured elsewhere by unsuspecting carriers.  The most common disease routes monitored are the human migration and natural water and airway routes.  People themselves sometimes serve as means for measuring these diseases, by the documentation of when and where new and unsuspecting cases erupt, and whether or not the aggregate of cases constitutes a possible epidemic problem.

There are also a number of fairly slow routes that are in need of monitoring as well.  These normally don’t result in major epidemics, but are known to have the potential for creating epidemics and the potential for numerous deaths.  Zoonotic diseases are monitored, managed and evaluated using GIS.  Carried by wild and domestic animals, these diseases are paid little attention to by the general public, but should such a disease advance to a new form with epidemic potential, animal-wise or human wise, people begin to learn the consequences of this intrusion into our public health and safety rights.   Foreign diseases, be they due to people migrating or due to animals migrating, can become potentially deadly, and if they are not monitored, develop into highly fatal epidemics, of either people or animals.

The effects of epizootics on people is two-fold.  The ability of a new pathogen to enter into our borders and infect animals can at times also facilitate the process by which this organism become capable of infecting people as part of its next evolutionary step.  This is how the E. coli harboring what was once another organism’s deadly toxin became so fatal to cattle first, followed by people through beef and later milk products, and how it became capable of harboring itself on the moist leaves of kale greens, before being introduced to the nearby salad bar or grocery store produce section.   The actual deaths induced of livestock and the change in the safety of eating certain farmed or factory farmed bioengineered  goods is also how we are influenced.  The potential reduction in food stores that livestock deaths result in, and the potential diseases that can prevail in areas rich in these deaths, ultimately have similar impacts upon our short-term and long-term health concerns.  Even if we survive the clean-up following the deaths of a significant number of meat sources in the food chain, we still have to deal with some long-term consequence like lack of adequate food supply, poor nutrition, malnutrition, and numerous other medical and health concerns that ensue in populations where these changes take place at such a large-scale.

This next section focuses on the foreign-born diseases that over time have appeared on and off in this country.  The question this study tries to answer is . . .

• What is the nature of the routes taken by these foreign diseases as they become introduced into our country? 

A review of the diseases as a single aggregate, rather than as unique disease types with just a few cases each, is the process engaged in to try to answer this question.  This aggregated disease data will also be assessed spatially or geographically to see if any particular routes of entry and migration stand out for particular ethnic groups or natural origins for these diseases.  We might also be able to answer such questions as

• Do tropical diseases favor tropical points of entry and settings?
• Do certain diseases with particular ethnic, country of continental backgrounds have preferred routes of entry?

There are a lot of common diseases often associated with foreign introduction of pathogens.  This methodology reviews only the rarest of diseases with foreign backgrounds and ecological origins.  These are assumed to be indicators of how diseases in such distant countries behave as a part of the intercontinental human migration process.  These diseases, due to their rarity and strong national association, should provide important insights into how people in general impact the migration process, in terms of location and density, and how the topography, climate and physical geography of the United States effect foreign disease introduction to this country.

Review of preliminary results

To date, preliminary studies have revealed some unusual disease behaviors spatially.  Approximately 150 zoonotic, and/or microbial of a foreign ecological origin were assessed.  The following are examples of the preliminary findings based on reviews of older aggregate datasets.  (Since maps are produced for some of these and some are covered on other pages, the placement of these results is still undecided.)

• Some diseases of a tropical nature and origin utilize the “back door approach” to create small localized case aggregates.  I fall short of calling these “epidemics” due to their nature, probable causes, and temporal histories.  They never prevail for long periods of time and do not evolve into recurring, spatially and ecologically linkable disease patterns.
• New York-New Jersey area and Los Angeles and San Francisco are the east and western points of entry.  A central nidus for these foreign born diseases has been identified next to and east of the Rocky Mountains, and a very high nexus of these diseases in the Great Plains, south of the Great Lakes.  This midwest nexus is more than 100 fold higher than the remaining country based on a weighted, krigged spatial analysis technique applied to this grid modelling.
• Certain diseases have understandable, and in retrospect predictable niduses or places of origin, such as the single eastern and single western port identified as the sources for foreign animal in-migration or black marketed products induced bird fancier’s lung disease.
• Florida demonstrates a tendency for Carribean disease in-migration.  The inmigration of disease across the southern border, representing Mexican and Central American pathologies, have one very well defined route of migration, and two secondary routes, and possibly a third, indirect route.  These routes are defined by population density, and the alignment of small areas of these diseases.  The direct South-north route has a stopping point where many diseases for a peak in areal incidence/prevalence rates.

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NOTES (work in progress – NO LINKS until completion/publication in 2017)

Partial Disease List

Regional Infectiousness

• Coccidiomycosis [114]
• European Cryptococcus [117.5]
• Elephantiasis [Africa – 125.9, 457.1]
• Histoplasmosis [115]
• Buruli Ulcer (Mycobacterium ulcerans) [031.1 – Africa]
• Strongyloidiasis (Strongyloides stercoralis) [127.2 – Tropical and Subtropical]
• Neurocysticercosis (Taenia solium) [123.1 – Africa]
• Dracunculiasis (Dracunculus medinensis) [125.7 – Africa]
• African Trypanosomiasis [086.5]
• Trepanomatosis (Trepanoma spp.) [see Syphilis, Yaws, Pinta, Bejel]
• Leptospirosis (Leptospira) [100]
• Scabies (Sarcoptis scabiei) [133.0]

Infectious/Parasitic

• CHOLERA [001]
• TYPHOID [002.0, 002.1-3 (Paratyphoid)]
• SHIGELLOSIS [004]
• AMOEBIASIS [006]
• TUBERCULOSIS [010-018]
• LISTERIOSIS [027.0]
• ERYSIPELOTHRIX (E. Indiosa infection) [027.1]
• PASTEURELLOSIS [027.2]
• LEPROSY [030]
• MENINGOCOCCAL INFECTION [036.*; 036.0 Meningitis; 036.1 Encephalitis; 036.2 meningococcemia; 036.3 Waterhouse-Frederichsen Syndrome; 036.4 Carditis]

Viral Diseases with Exanthema

• SMALL POX [050]
• COW POX & PARAVACCINIA [051, 051.1 milker’s nodule or pseudocopox; 051.01 cowpox;  051.2 contagious pustular dermatitis]
• CHICKEN POX [052]
• MEASLES [055]
• RUBELLA [056]

OTHER VIRAL

• VIRAL HEPATITIS [070]
• MUMPS [072]
• ORNITHOSIS/PSITTACOSIS [073 – Europe]
• COXSACKIE [074.*; 074.2 coxsackie carditis; 074.3 hand, foot and mouth disease]
• TRACHOMA (Chlamydia sp.) [076]
• EPIDEMIC KERATOCONJUNCTIVITIS [077.*; Swimming Pool Conjunctivitis 077.0; Shipyard Eye 077.1]
• SWEATING FEVER [078.2]
• CAT-SCRATCH DISEASE [078.3]
• FOOT AND MOUTH DISEASE [078.4]
• CYTOMEGALOVIRUS [078.5]
• KOREAN/RUSSIAN HEMORRHAGIC NEPHROSONEPHRITIS [078.6]
• ARENOVIRAL HEMORRHAGIC FEVER [Argentine, Bolivian, Junin, Machupo) [078.7]

Arthropod-born

• MALARIA  [084]
• YELLOW FEVER  [060 – Orig. Africa, then Americas]  *
• Rat-bite Fever [026.*, 026.0 Spirillary; 026.1 Streptobacillary; 026.9 Unspecified]
• DENGUE [061 – Asia, Africa, North America]
• MOSQUITO-BORN ENCEPHALITIDES
  • Japanese Encephalitis   [062.0 – Japan]
  • California Encephalitis  [062.5 – U.S.]
  • St. Louis Equine Encephalitis [EE]  [062.3 – U.S.]
  • Eastern EE  [062.2 – U.S.]
  • Western EE  [062.1 – U.S.]
  • Venezuelan Encephalitis   [066.2 – South America, Venezuela]
  • Australian Encephalitis  [062.4 – Australia]
• TICK-BORNE ENCEPHALITIDES
  • Russian [Taiga] Spring-Summer Encephalitis (RSSE)  [063.0 – Russia]
  • Central European Encephalitis  [063.2 – Eastern Europe]
  • Louping Illness  [063.1 – Western European (Scottish history)]
  • Colorado Tick Fever   [Colorado, NW U.S.]
  • Tick-borne Relapsing Fever, Old World [087]
  • Tick-borne Relapsing Fever, New World [North and South America]
  • Lyme Disease    [Sweden, U.S.]
  • Tick-borne Typhus (Rocky Mountain Spotted Fever)  [North America]
  • Tick-borne Typhus (Old World)
  • Endemic Typhus
• Viral
  • Viral Encephalitis [064]
  • Crimean Hemorrhagic Congo Virus [065.0]
  • Omsk Hemorrhagic [065.1 – Russia]
  • Kyasanur Forest Disease [065.2 – India]
  • West Nile [066.4 – Egypt]

RICKETTSIOSES

• OTHER TYPHUS
• MURINE TYPHUS [081.0]
• BRILL’S DISEASE [081.1, NYC]
• SCRUB TYPHUS [Japan, Kedani Fever, mite-born typhus, tustsugamushi-081.2]
• TICK-BORN RICKETTSIAS
  • SPOTTED FEVERS [082.0]
  • BOUTONNEUSE FEVER [African, Indian, Kenyan, Marseilles, Mediterranean Tick Fever; 082.1]
  • NORTH ASIAN TICK FEVER [082.2 – Russia]
  • QUEENSLAND TICK TYPHUS [082.3 – Australia]
  • LONE STAR FEVER [082.8]
  • EHRLICHIOSIS [082.4 — ]
• Q-FEVER (Coxiella burnetii) [083.0 — Australia origins]
• TRENCH FEVER [083.1–Europe to Egypt, Urban]
• RICKETTSIALPOX [083.2, Russia, Japan]
• Chigger-born Rickettsia (Rickettsia tsutsugamushi, in chiggers of Leptotrombidium (Trombicula) akamushi and Leptotrombidium deliense. In Japan, some cases transmitted by mites of Leptotrombidium scutellare and Leptotrombidium pallidum) [Russia, Japan]
• MALARIA [084]
  • BLACKWATER FEVER [084.8]
  • QUARTAN [084.2]
  • MALIGNANT [084.0]
• Louse-borne Rickettsia Typhus (Rickettsia prowazekii, transmitted by the human body louse (Pediculus humanus corporis).  Associated with Brill-Zinnser Disease  [worldwide]  See http://en.wikipedia.org/wiki/Brill%E2%80%93Zinsser_disease.  [ICD9-080.*; 087.0]
• Scrub Typhus    [081.2 — Russia, Australia, Pakistan, Afghanistan (tsutsugamushi triangle)]
• Trypanosomiasis  (African Sleeping Sickness)  [Africa]  [086]
• RELAPSING FEVER [087; Louse-born 087.0; Tick born 087.1]
• American Trypanosomiasis  [North and South America]
• LEISHMANIASIS [085]
  • VISCERAL (post kala-azar, Mediterranean- [085.0]
  • Asian Leishmaniasis   [Asia] [085.2]
  • Ethiopian Leishmaniasis   [Africa] [085.3]
  • American Leishmaniasis  [North(?) and South America] [085.4,5]
  • CUTANEOUS LEISHMANIASIS [085 – Aleppo, Baghdad, Delhi]
• PLAGUE (Yersinia pestis) [worldwide]
• Murine Flea-borne Rickettsia or Typhus [080-083 — America, Pacific Rim, worldwide urban settings]
• Onchoceriasis [125.3 — Africa]
• Loasis [125.2 — Africa]

Non-arthropod-borne

• Pinta   [103 – Mexico, Central America] *
• Crimean Hemorrhagic Congo Virus  [Africa]
• Omsk Hemorrhagic Virus  [065.1 –  western Siberia, in places including Omsk, Novosibirsk, Kurgan, and Tyumen]
• Kyanasur Forest Disease [065.2 – South Asia; Kyasanur Forest of Karnataka in India (1957), Saudi Arabia, China]
• West Nile Fever [066.4 – Africa]
• Anthrax    *
• Bejel  [104 – Middle East, esp. Bedouin Tribes]
• Yaws  [102 – originated in tropical Africa]
• Chagas  [103 – South America] *
• Brazilian Blastomycosis [116.1 – Brazil] *
• Cestodes Tapeworm [122, 123]
• Chicago Disease (Blastomyces dermatitidis-fungus)[U.S.]
• Chiclero Ulcer  [Mexico, some of Central America] *
• Coccidiomycosis  [114 – North and South America]
• Creutzfeld Jakob Disease (Mad Cow)  [046.11]
• Eyeworm Disease of Africa  [Africa]
• Filaria 
• Guinea Worm  (Northern Africa, formerly Asia)
• Giardia [007.1]
• Ancyclostomiasis  [126.9 ]
• Histoplasmosis – “spelunker’s lung” fungus  [115 – North American caves, fungus]
• Coccidiomycosis [104]
• Hookworm (Necator spp.) [New World – 126.9]
• Hookworm (Ancyclostoma sp.) [Old World – 126.9]
• Gnathostomiasis (Gnathostoma spp.) [128.1 — England]
• Korean Hemorrhagic Fever   [078.6 — Korea]
• Machupo Virus (Bolivian) Hemorrhagic Fever  [078.7 — Bolivia, western South America]
• Hanta Virus and allies [079.81 — Korea, US]
• Ebola   [065.8 – Zaire, Sudan, Ivory Coast, Bundibugyo; reported in Reston, Va.] 
• Monkey Pox/Yaba Pox [059.22 — Africa]
• Yatapox /Tanapox [059.21 – Africa, Kenya/Zaire]
• Kala Azar [085.0, tropical]
• Asian Leishmaniasis [085.2]
• Ethiopian Leishmaniasis [085.3]
• American Leishmaniasis [085.4]

Non-infectious Diseases, Other Cultures

• Noma [528.1]
• Kwashiorker [260]
• African Idiopathic Cardiomegaly [425.4]
• Kuru  [046.0 – Papua New Guinea]
• Takot Subo  [429.3 — Japan]
• Takayasu’s Arteritis [446.7 – Japan]
• Moya Moya [437.5 – Japan, Hawaii]
• .

DISEASES WITH SPECIFIC CULTURAL GROUPS/ORIGINS

South American/Central American/Mexico

• American Leishmaniasis [085.4]
• Machupo Virus (Bolivian) Hemorrhagic Fever  [078.7 — Bolivia, western South America]
• Chiclero Ulcer  [Mexico, some of Central America] *
• Coccidiomycosis  [114 – North and South America]
• Brazilian Blastomycosis [116.1 – Brazil] *
• Pinta   [103 – Mexico, Central America] *
• ARENOVIRAL HEMORRHAGIC FEVER [Argentine, Bolivian, Junin, Machupo) [078.7]
• Venezuelan Encephalitis   [066.2 – South America, Venezuela]
• American Trypanosomiasis /Chagas [086 – North and South America] *

Asian

• Asian Leishmaniasis [085.2]
• Kyanasur Forest Disease [065.2 – South Asia; Kyasanur Forest of Karnataka in India (1957), Saudi Arabia, China]
• Korean Hemorrhagic Fever   [078.6 — Korea]
• Hanta Virus and allies [079.81 — Korea, US]

Middle East

• Bejel  [104 – Middle East, esp. Bedouin Tribes]

India

• CUTANEOUS LEISHMANIASIS [085]
• Kyasanur Forest Disease [065.2 – India]
• BOUTONNEUSE FEVER [African, Indian, Kenyan, Marseilles, Mediterranean Tick Fever; 082.1]
• Cholera [001.*]

Russian

• Omsk Hemorrhagic Virus  [065.1 –  western Siberia, in places including Omsk, Novosibirsk, Kurgan, and Tyumen]
• Crimean Hemorrhagic Congo Virus  [063.0 — Africa, Russia]
• Russian [Taiga] Spring-Summer Encephalitis (RSSE)  [063.0 – Russia]
• Central European Encephalitis  [063.2 – Eastern Europe]
• NORTH ASIAN TICK FEVER [082.2 – Russia]
• RICKETTSIALPOX [083.2, Russia, Japan]
• Chigger-born Rickettsia (Rickettsia tsutsugamushi, in chiggers of Leptotrombidium (Trombicula) akamushi and Leptotrombidium deliense. In Japan, some cases transmitted by mites of Leptotrombidium scutellare and Leptotrombidium pallidum) [Russia, Japan]
• Scrub Typhus    [081.2 — Russia, Australia, Pakistan, Afghanistan (tsutsugamushi triangle)]

Japan

• Takot Subo   [429.3 — Japan]
• Takayasu’s Arteritis [446.7 – Japan]
• Moya Moya [437.5 – Japan, Hawaii]
• Japanese Encephalitis   [062.0 – Japan]
• SCRUB TYPHUS [Japan, Kedani Fever, mite-born typhus, tustsugamushi-081.2]
• RICKETTSIALPOX [083.2, Russia, Japan]

Australian

• QUEENSLAND TICK TYPHUS [082.3 – Australia]
• Australian Encephalitis  [062.4 – Australia]
• Q-FEVER (Coxiella burnetii) [083.0 — Australia origins]
• Scrub Typhus    [081.2 — Russia, Australia, Pakistan, Afghanistan (tsutsugamushi triangle)]

African

•  Kuru  [046.0 – Papua New Guinea]
• African Idiopathic Cardiomegaly [425.4]
• Ethiopian Leishmaniasis [085.3]
• West Nile Fever [066.4 – Africa]
• Yatapox /Tanapox [059.21 – Africa, Kenya/Zaire]
• Monkey Pox/Yaba Pox [059.22 — Africa]
• Yatapox /Tanapox [059.21 – Africa, Kenya/Zaire]
• Eyeworm Disease of Africa  [Africa]
• Guinea Worm  (Northern Africa, formerly Asia)
• Crimean Hemorrhagic Congo Virus  [Africa, Russia]
• Onchoceriasis [125.3 — Africa]
• Elephantiasis [Africa – 125.9, 457.1]
• Buruli Ulcer (Mycobacterium ulcerans) [031.1 – Africa]
• Strongyloidiasis (Strongyloides stercoralis) [127.2 – Tropical and Subtropical]
• Neurocysticercosis (Taenia solium) [123.1 – Africa]
• Dracunculiasis (Dracunculus medinensis) [125.7 – Africa]
• Trypanosomiasis  (African Sleeping Sickness)  [Africa]  [086]
• African Trypanosomiasis [086.5]
• Kyasanur Forest Disease [065.2 – India]