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Immigrant infections
IMMIGRANT INFECTIONS* By J O H N
WALTERS,
M.D., F.R.C.P.
Consultant Physician, Hospitalfor Tropical Diseases, London, and Tropical Unit, Queen Mary's Hospital, Roehampton THE 1961 census showed that almost 1½ million persons now resident here had been born outside the British Isles. These included nearly 110,000 Africans, 172,000 West Indians, 188,000 from the Indian subcontinent and some 42,000 Cypriots. (Birthplace and Nationality Tables, Census 1961, quoted in Brit. med. J. 1964, 2, 1081). In 1961 itself immigrants arrived from these regions as follows: Africa, West and East 8,100, West Indies 66,300, India and Pakistan 48,850 and Cyprus 6,850. The negotiations which preceded the passing of the Commonwealth Immigration Act in early 1962 brought a flood of new arrivals, and during the first six months of this year 90,000 entered Britain. Part I of the Act came into force on 1st July, 1962, and reduced the inflow during the second half of this year to 9,000. Thereafter immigrants had to apply to the Ministry of Labour for an entry voucher, and were divided into three categories, A those who had a job to come to, B those who had a special craft or skill, and C all others, though less than one quarter of the number of applications from any country were accepted. This Act operates until the end of this year, and in the Tight of an election result, it seems probable that it will be extended. In 1963 the number of immigrants selected in this way was 52,500 from the regions in which I am interested. Preference was granted to men who had served in the Forces, and one third of the Indians and one fifth of the Pakistani applicants had been members of the former British Indian forces. These men, of yeoman stock, are, I think very desirable immigrants, for, having served with them as a doctor in the Indian Medical Service for fourteen years I know them to be dean, honest, reliable and industrious. In giving these figures, which of course include women and their children and also students, I hope I have indicated the size of the inflow of persons coming from areas in which important infections are commonplace; the immigrants cannot but help bring examples of these diseases with them. Thereafter accurate figures cease, and estimates of the relative importance of various diseases are my own and are, of course, mere impressions. I have excluded from my review smallpox, which I do not now see, and tuberculosis, which is out of my personal ambit, but I would remind you that the immigrant to Great Britain, unlike one entering the U.S.A. is not required to bring a chest X-ray, or the results of a Wassermann test. WASSERMANN I would now like to discuss the four main regions from which immigrants come with reference to their major endemic disease. First, the Caribbean area. *A paper read at the October 1964 meeting of the Fever Hospital Medical Services Group of the Society.
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In this area, lighthearted irresponsibility is the key not¢~ and promiscuity is the rule. Venereal diseases of all types are widespread and of these, two, lymphogranuloma inguinale and granuloma venereum, which are scarcely indigenous in these islands, are prominently represented. Filariasis due to Wuchereria bancrofii is intensely endemic in the coastal sugar growing regions of British Guiana, and about 80 per cent. of the population of Georgetown are affected. Schistosomiasis was introduced in the bodies of the West African slaves. Infection with Schistosoma mansoni is now confined to the British island of St. Lucia (it also occurs in the adjacent French islands of Martinique and Guadeloupe) while occasional humans are infected with S. hcematobium in Antigua, in which island the population of West African green monkeys (Circopithecus cethiops sabceus) carries the parasite. Leprosy is widely distributed. India and Pakistan form a single epidemiological unit. Amcebiasis and intestinal worms, notably hookworms, also the intestinal protozo6n, Giardia lamblia, are very commonly found and leprosy is common but venereal diseases are rare among immigrants. Filarial diseases may be encountered, comprising infection with IV. bancrofti, guineaworm and non-human filarial larvae giving rise to the syndrome of tropical pulmonary eosinophilia. Dermal leishmaniasis is confined to the dry areas of West Pakistan, while visceral leishmaniasis may occasionally be encountered in immigrants coming from regions east of a vertical line joining Meerut to Madras. Malaria has almost been eliminated, but late relapses of benign tertian may be encountered. East and West Africa form a parasitological paradise. Intestinal helminths are harboured in almost every immigrant, and include hookworms, ascaris, Trichuris trichuria, the whipworm, and Strongyloides stercoralis. Entamceba histolytica and Giardia lamblia are commonly found. Filarial infections are a l s o widespread and include IV. bancrofti, Loa loa, Onchocerca volvulus, guineaworm and Acanthocheilonema perstans, which causes no symptoms. Infections with S. mcmsoni and S. t~matobium are quite common. Venereal diseases and yaws are well represented in immigrants and leprosy also is relatively frequently seen. From the Mediterranean basin, leprosy, venereal diseases and dermal leishmaniasis may reach this country. Very occasionally examples of the glandular type of leishmaniasis occur, and very rarely the Mediterranean strain of the parasite may invade the whole reticulo-endothelial system. I now wish to say a few words about individual diseases. Leprosy has been notifiable since 1951. In 1962 there were 87 known active examples of the disease, and this number is now t:onsiderably larger. In 1963 and so far this year over 40 fresh patients have been notified. Two special units exist for their treatment, the Jordan Hospital outside Red.hill, which is run by the Hospital for Tropical Diseases and has 24 beds, and the Homes of St. Giles, near Romford in Essex, which has 15. The cost per patient per week to the country at
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the former is £24.12.8, and over the past ten years the average cost of maintaining a patient during his period of hospital treatment has been £1,441. The disease is not highly infective--not at all so in its well-resisted tuberculoid forms--which is a good thing as no powers of compulsory segregation can be used to isolate the infective lepromatous and dimorphous or intermediate forms. Susceptibility is maximum in infancy but decreases with age, so that only about 5 per cent. of adults remain susceptible. The florid nodular types of lepromatous disease should be easy to diagnose yet are often missed, but the more subtle infiltrative types of lesion may prove very difficult to recognise. Annular dimorphous lesions may be mistaken for ringworm but tuberculoid lesions, with asymmetrical distribution, a defined raised edge and an anaesthetic surface usually cause no problems. Peripheral nerve involvement may be prominent in either type; it is always asymmetrical in tuberculoid leprosy and always symmetrical if it occurs in dimorphous and lepromatous disease. Lymphogranuloma inguinale, due to a virus of the psittacosis group, characteristically presents in a male patient as a suppurative inguinal lymphadenitis, the small primary ulcer having healed. It may, however, in either sex extend to the ano-rectal region, where it may cause a severe sclerosing proctitis; while a chronic submucous granulomatous inflammation may give rise to strictures extending as high up as the splenic flexure of the colon. Granuloma venereum (ulcerating granuloma of the pudenda) in the female often simulates epithelioma of the vulva, vagina or cervix, but the causal organism, Klebsiella granulomatis, is readily found within histiocytes in biopsy specimens, and is usually referred to as the Donovan body. Urinary schistosomiasis should be suspected in an African who has any abnormality of micturition, but infection with S. mansoni is often asymptomarie. However, in Europeans, especially in children, it may be the cause of failure to thrive together with hepatomegaly, and very occasionally, as in the case of a general practitioner living in South London, it may present as a febrile illness with dysenteric symptoms. He had taken a cold bath in the Murchison Falls National Park of Kenya 52 days before. Either species of schistosome may deposit eggs in the central nervous system, and I have seen two examples of transverse myelitis due to this disease in London. Of the filarial diseases, the lymphcedema resulting from infection with W. bancrofti or IF. malayi is well known, but the syndrome of tropical pulmonary eosinophilia, which is due to the accidental invasion of man by fitarial larvae of animal origin is often puzzling. W. malayi, var. pahangi from cats is one agent which can cause this syndrome, in which a very high absolute eosinophilia is associated with asthmatic bronchitis and miliary pulmonary infiltrations. Giant urticaria occurring on the hands or forearms or round the ankles in someone from the forested areas of West Africa will almost certainly prove to be due to loiasis, while the Nigerian who says he has a worm which crawls across his eye or nose should not be dismissed as an hysteric, for this will
130
PUBLIC
HEALTH
VOL.
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NO.
3
probably be an adult Loa loa. Onchocerciasis is a common cause of an irritant thickened and papular skin in an African, which is most evident over the legs and thighs and may be accompanied by depigmented patches. In the European, a faint eruption of irritant pink papules over the thighs and buttocks may have the same cause, and may be associated with a characteristic nummular keratitis. I would like you to bear in mind the gay promiscuity of the West Indian, the probability that an immigrant from British Guiana will carry W. bancrofti while an unusual skin lesion may be due to leprosy. An African may carry a full house of intestinal parasites, may well be infected with schistosomiasis and filarial diseases while leprosy and yaws may be other causes of skin lesions. An Indian or Pakistani will probably carry hookworms and perhaps amoebae, may suffer from leprosy and perhaps develop a malarial relapse. A Cypriot or Maltese may suffer from leprosy while a Chinese patient may be a valuable acquisition in a teaching ward, for he may carry a fascinating range of intestinal parasites and may show a cirrhotic or even a neoplastic liver from clonorchiasis.
WALTERS,
M.D., F.R.C.P.
Consultant Physician, Hospitalfor Tropical Diseases, London, and Tropical Unit, Queen Mary's Hospital, Roehampton THE 1961 census showed that almost 1½ million persons now resident here had been born outside the British Isles. These included nearly 110,000 Africans, 172,000 West Indians, 188,000 from the Indian subcontinent and some 42,000 Cypriots. (Birthplace and Nationality Tables, Census 1961, quoted in Brit. med. J. 1964, 2, 1081). In 1961 itself immigrants arrived from these regions as follows: Africa, West and East 8,100, West Indies 66,300, India and Pakistan 48,850 and Cyprus 6,850. The negotiations which preceded the passing of the Commonwealth Immigration Act in early 1962 brought a flood of new arrivals, and during the first six months of this year 90,000 entered Britain. Part I of the Act came into force on 1st July, 1962, and reduced the inflow during the second half of this year to 9,000. Thereafter immigrants had to apply to the Ministry of Labour for an entry voucher, and were divided into three categories, A those who had a job to come to, B those who had a special craft or skill, and C all others, though less than one quarter of the number of applications from any country were accepted. This Act operates until the end of this year, and in the Tight of an election result, it seems probable that it will be extended. In 1963 the number of immigrants selected in this way was 52,500 from the regions in which I am interested. Preference was granted to men who had served in the Forces, and one third of the Indians and one fifth of the Pakistani applicants had been members of the former British Indian forces. These men, of yeoman stock, are, I think very desirable immigrants, for, having served with them as a doctor in the Indian Medical Service for fourteen years I know them to be dean, honest, reliable and industrious. In giving these figures, which of course include women and their children and also students, I hope I have indicated the size of the inflow of persons coming from areas in which important infections are commonplace; the immigrants cannot but help bring examples of these diseases with them. Thereafter accurate figures cease, and estimates of the relative importance of various diseases are my own and are, of course, mere impressions. I have excluded from my review smallpox, which I do not now see, and tuberculosis, which is out of my personal ambit, but I would remind you that the immigrant to Great Britain, unlike one entering the U.S.A. is not required to bring a chest X-ray, or the results of a Wassermann test. WASSERMANN I would now like to discuss the four main regions from which immigrants come with reference to their major endemic disease. First, the Caribbean area. *A paper read at the October 1964 meeting of the Fever Hospital Medical Services Group of the Society.
127
128
PUBLIC
HEALTH
VOL.
LXX1X
NO.
3
In this area, lighthearted irresponsibility is the key not¢~ and promiscuity is the rule. Venereal diseases of all types are widespread and of these, two, lymphogranuloma inguinale and granuloma venereum, which are scarcely indigenous in these islands, are prominently represented. Filariasis due to Wuchereria bancrofii is intensely endemic in the coastal sugar growing regions of British Guiana, and about 80 per cent. of the population of Georgetown are affected. Schistosomiasis was introduced in the bodies of the West African slaves. Infection with Schistosoma mansoni is now confined to the British island of St. Lucia (it also occurs in the adjacent French islands of Martinique and Guadeloupe) while occasional humans are infected with S. hcematobium in Antigua, in which island the population of West African green monkeys (Circopithecus cethiops sabceus) carries the parasite. Leprosy is widely distributed. India and Pakistan form a single epidemiological unit. Amcebiasis and intestinal worms, notably hookworms, also the intestinal protozo6n, Giardia lamblia, are very commonly found and leprosy is common but venereal diseases are rare among immigrants. Filarial diseases may be encountered, comprising infection with IV. bancrofti, guineaworm and non-human filarial larvae giving rise to the syndrome of tropical pulmonary eosinophilia. Dermal leishmaniasis is confined to the dry areas of West Pakistan, while visceral leishmaniasis may occasionally be encountered in immigrants coming from regions east of a vertical line joining Meerut to Madras. Malaria has almost been eliminated, but late relapses of benign tertian may be encountered. East and West Africa form a parasitological paradise. Intestinal helminths are harboured in almost every immigrant, and include hookworms, ascaris, Trichuris trichuria, the whipworm, and Strongyloides stercoralis. Entamceba histolytica and Giardia lamblia are commonly found. Filarial infections are a l s o widespread and include IV. bancrofti, Loa loa, Onchocerca volvulus, guineaworm and Acanthocheilonema perstans, which causes no symptoms. Infections with S. mcmsoni and S. t~matobium are quite common. Venereal diseases and yaws are well represented in immigrants and leprosy also is relatively frequently seen. From the Mediterranean basin, leprosy, venereal diseases and dermal leishmaniasis may reach this country. Very occasionally examples of the glandular type of leishmaniasis occur, and very rarely the Mediterranean strain of the parasite may invade the whole reticulo-endothelial system. I now wish to say a few words about individual diseases. Leprosy has been notifiable since 1951. In 1962 there were 87 known active examples of the disease, and this number is now t:onsiderably larger. In 1963 and so far this year over 40 fresh patients have been notified. Two special units exist for their treatment, the Jordan Hospital outside Red.hill, which is run by the Hospital for Tropical Diseases and has 24 beds, and the Homes of St. Giles, near Romford in Essex, which has 15. The cost per patient per week to the country at
IMMIGRANT
INFECTIONS
129
the former is £24.12.8, and over the past ten years the average cost of maintaining a patient during his period of hospital treatment has been £1,441. The disease is not highly infective--not at all so in its well-resisted tuberculoid forms--which is a good thing as no powers of compulsory segregation can be used to isolate the infective lepromatous and dimorphous or intermediate forms. Susceptibility is maximum in infancy but decreases with age, so that only about 5 per cent. of adults remain susceptible. The florid nodular types of lepromatous disease should be easy to diagnose yet are often missed, but the more subtle infiltrative types of lesion may prove very difficult to recognise. Annular dimorphous lesions may be mistaken for ringworm but tuberculoid lesions, with asymmetrical distribution, a defined raised edge and an anaesthetic surface usually cause no problems. Peripheral nerve involvement may be prominent in either type; it is always asymmetrical in tuberculoid leprosy and always symmetrical if it occurs in dimorphous and lepromatous disease. Lymphogranuloma inguinale, due to a virus of the psittacosis group, characteristically presents in a male patient as a suppurative inguinal lymphadenitis, the small primary ulcer having healed. It may, however, in either sex extend to the ano-rectal region, where it may cause a severe sclerosing proctitis; while a chronic submucous granulomatous inflammation may give rise to strictures extending as high up as the splenic flexure of the colon. Granuloma venereum (ulcerating granuloma of the pudenda) in the female often simulates epithelioma of the vulva, vagina or cervix, but the causal organism, Klebsiella granulomatis, is readily found within histiocytes in biopsy specimens, and is usually referred to as the Donovan body. Urinary schistosomiasis should be suspected in an African who has any abnormality of micturition, but infection with S. mansoni is often asymptomarie. However, in Europeans, especially in children, it may be the cause of failure to thrive together with hepatomegaly, and very occasionally, as in the case of a general practitioner living in South London, it may present as a febrile illness with dysenteric symptoms. He had taken a cold bath in the Murchison Falls National Park of Kenya 52 days before. Either species of schistosome may deposit eggs in the central nervous system, and I have seen two examples of transverse myelitis due to this disease in London. Of the filarial diseases, the lymphcedema resulting from infection with W. bancrofti or IF. malayi is well known, but the syndrome of tropical pulmonary eosinophilia, which is due to the accidental invasion of man by fitarial larvae of animal origin is often puzzling. W. malayi, var. pahangi from cats is one agent which can cause this syndrome, in which a very high absolute eosinophilia is associated with asthmatic bronchitis and miliary pulmonary infiltrations. Giant urticaria occurring on the hands or forearms or round the ankles in someone from the forested areas of West Africa will almost certainly prove to be due to loiasis, while the Nigerian who says he has a worm which crawls across his eye or nose should not be dismissed as an hysteric, for this will
130
PUBLIC
HEALTH
VOL.
LXXIX
NO.
3
probably be an adult Loa loa. Onchocerciasis is a common cause of an irritant thickened and papular skin in an African, which is most evident over the legs and thighs and may be accompanied by depigmented patches. In the European, a faint eruption of irritant pink papules over the thighs and buttocks may have the same cause, and may be associated with a characteristic nummular keratitis. I would like you to bear in mind the gay promiscuity of the West Indian, the probability that an immigrant from British Guiana will carry W. bancrofti while an unusual skin lesion may be due to leprosy. An African may carry a full house of intestinal parasites, may well be infected with schistosomiasis and filarial diseases while leprosy and yaws may be other causes of skin lesions. An Indian or Pakistani will probably carry hookworms and perhaps amoebae, may suffer from leprosy and perhaps develop a malarial relapse. A Cypriot or Maltese may suffer from leprosy while a Chinese patient may be a valuable acquisition in a teaching ward, for he may carry a fascinating range of intestinal parasites and may show a cirrhotic or even a neoplastic liver from clonorchiasis.