Citation:Hotez PJ (2011) America’s Most Distressed Areas and Their Neglected Infections: The United States Gulf Coast and the District of Columbia. PLoS Negl Trop Dis 5(3): e843. doi:10.1371/journal.pntd.0000843
Published: March 29, 2011
Copyright: © 2011 Peter J. Hotez. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding:The author received no specific funding for this work.
Competing interests: The author has declared that no competing interests exist.
PJH is Co-Editor-in-Chief of PLoS Neglected Tropical Diseases. He is Distinguished Research Professor at George Washington University, and President of the Sabin Vaccine Institute.
The neglected infections of poverty represent the latest threat to the poorest people living on the Gulf Coast of the United States and in Washington, District of Columbia.
Together, Hurricanes Katrina and Rita and the BP oil disaster have shed light on a tragic level of poverty in the northern Gulf of Mexico, especially for the African Americans living in Louisiana, Mississippi, and Alabama. According to the National Center for Children in Poverty at Columbia University, more than 40% of black children in each of these states currently live in poor families, and over 12% of children from Louisiana and Mississippi live in extreme poverty, defined as families with incomes that are less than half of the federal poverty level . Overall, the 12 million people living in Louisiana, Mississippi, and Alabama suffer from the lowest incomes and educational attainment, as well as the shortest life expectancy, compared to anywhere else in the United States . The finding that combined these Gulf Coast states have the nation’s lowest human development index scores has prompted a call by the American Human Development Project to launch a Marshall Plan for the Gulf, referring to a comprehensive reconstruction plan that resembles US efforts to reconstruct Europe in the devastation that followed World War II .
In previous papers I have noted high rates of parasitic and related neglected infections among the poorest Americans living in distressed areas, but especially in inner cities, the American South, the border with Mexico, and Appalachia –. Indeed, the rates of some of these neglected infections of poverty among African Americans are comparable to the rates found in Nigeria . These and other findings led to the 2009 National Summit on Neglected Infections of Poverty in the United States held in Washington, D.C. . The summit coincided with new bipartisan legislation introduced in the US House of Representatives by Representative Hank Johnson (Georgia) asking for a report from the Department of Health and Human Services Secretary on the full spectrum of the neglected infections of poverty in America’s distressed areas, with emphasis on enhanced surveillance and efforts to determine the level of autochthonous transmission, i.e., transmission occurring within US borders .
A fresh look at the neglected infections of poverty reveals the extreme vulnerability of the US Gulf Coast to these conditions, which includes Louisiana, Mississippi, and Alabama, as well as neighboring regions of Texas and Florida (Figure 1). Among the vector-borne neglected infections, there is now evidence of Chagas disease transmission in Louisiana, including a rural area within the borders of New Orleans , , and the emergence of cutaneous leishmaniasis in South Texas . Among the most important factors responsible for the emergence of these diseases is extreme poverty associated with poor housing without plumbing, air conditioning, or window screens , .
Source: Map created by Jessica Schwartz, The George Washington University; population data obtained from .
Since I first wrote about neglected infections in the US two years ago, the prospect of dengue and its most serious complication, dengue hemorrhagic fever, have emerged as additional and now imminent threats to the people living on the Gulf Coast. Between 1946 and 1980, no cases of dengue occurred in the continental US . Beginning in 1981, however, dengue hemorrhagic fever first appeared in the Caribbean , and almost 5 million cases of dengue were reported in the Caribbean and Central America between 2000 and 2007 , . During this period, dengue virus type 2 (DENV-2) and dengue hemorrhagic fever appeared in the Gulf coast cities of Matamoros and Brownsville in Mexico and Texas, respectively , . The significantly higher dengue rates on the Mexican side were associated with higher levels of poverty and poor sanitation and housing, which promote breeding habitats of Aedes mosquitoes . In 2009, DENV-1 appeared suddenly in the Florida Keys, representing the first dengue case acquired locally in Florida since 1934 . Together with widespread dengue in the Caribbean and Central America, the emergence of dengue on the Gulf coasts of Florida and Texas could portend widespread dengue outbreaks, including the possibility of dengue hemorrhagic fever, in areas of extreme poverty along the northern Gulf of Mexico.
Non-vector-borne neglected infections are also now highly prevalent among the poorest people living on the Gulf Coast. Trichomoniasis exhibits a 10-fold higher prevalence among African American women , and rates of this parasitic infection are particularly high among women who attend outpatient HIV and family planning clinics in New Orleans, Louisiana –. Trichomoniasis was shown to be an important co-factor in the HIV/AIDS epidemic in New Orleans and presumably elsewhere on the Gulf Coast, where it is associated with increased HIV shedding , , and there is additional concern that metronidazole drug resistance strains of this parasitic protozoan have emerged in New Orleans . When they were last examined during the 1970s, ascariasis and other intestinal parasitic helminth infections were found to be highly prevalent in southern Louisiana (Lafayette, Baton Rouge, and Independence, Louisiana), especially among African Americans , , but these neglected diseases have not been studied since . Toxocariasis, a related helminth infection transmitted from dogs, is likely the most common helminth infection in the US , with a prevalence among African Americans that exceeds 20%, especially in the South . There are no recent toxocariasis prevalence estimates reported for the Gulf Coast states, although Toxocara eggs have been detected in soil samples in Baton Rouge . Toxocara was recently noted to frequently occur with toxoplasmosis co-infections . Both toxoplasmosis and cytomegalovirus (CMV) infection are important congenital infections that disproportionately affect African American populations and are associated with severe neurological deficits , .
Although the District of Columbia does not have statehood, as a unique federal district it is often treated as an autonomous region and compared in rankings with the 50 US states. Today, Washington, D.C., rivals Louisiana, Mississippi, and Alabama as among the worst in terms of life expectancy and health index ; with respect to poverty indices, a recent report entitled “DC’s Two Economies” revealed that in terms of employment status, income, and poverty levels, Washington, D.C., currently exhibits some of the greatest disparities between whites and blacks of any city in the US . An astonishing 6.5% of African American males in the District of Columbia are also HIV positive  (Table 1). Data for neglected infections of poverty in Washington, D.C., are practically non-existent, although some information from neighboring Baltimore indicates that trichomoniasis is extremely common . Thus, we urgently need a program for active surveillance for the most common neglected infections of poverty in the District of Columbia.
If reconstruction plans for the Gulf Coast and Washington, D.C., are ever implemented, an important component should be directed towards the neglected infections of poverty in these areas. I am particularly concerned about the Gulf’s vulnerability to emerging dengue fever infections, while for both the Gulf Coast and Washington, D.C., we must urgently address neglected diseases that disproportionately affect African American populations, including toxocariasis, toxoplasmosis, trichomoniasis, and congenital CMV infection; and those that affect Hispanic Americans, including Chagas disease and cysticercosis. The fact that we know so little about the neglected infections of poverty in America’s most distressed areas is representative of just how glaring these conditions are as health disparities.
In 2008, I suggested that we must urgently address the neglected infections through programs of active surveillance and assessments of disease burdens, studies to examine the mechanisms of transmission in poor communities, efforts to control or eliminate these infections through public health interventions that include treatment or vaccination and health education, and a program of research and development to create a new generation of drugs, diagnostics, and vaccines . Since then, little has changed except for the National Summit and the re-introduction of Rep. Johnson’s bill to the House.
- 1. National Center for Children in Poverty, Columbia University, Mailman School of Public Health (2005) Child poverty in 21st century America: child poverty in states hit by Hurricane Katrina. Fact sheet No. 1, September 2005. Available: http://www.nccp.org/publications/pdf/text_622.pdf. Accessed 28 February 2011.
- 2. Burd-Sharps S,Lewis K,Borges Martins E (2008) The measure of America: American human development report 2008-2009. A Columbia/SSRC book. New York: Columbia University Press. 245 p.
- 3. Hotez PJ (2008) Neglected infections of poverty in the United States of America. PLoS Negl Trop Dis 2: e256. doi:10.1371/journal.pntd.0000256.
- 4. Hotez PJ (2009) Neglected diseases amid wealth in the United States and Europe. Health Aff (Millwood) 28: 1720–1725.
- 5. Hotez PJ (2009) One world health: neglected infections in a flat world. PLoS Negl Trop Dis 3: e405. doi:10.1371/journal.pntd.0000405.
- 6. Hotez P,Stillwaggon E,McDonald M,Todman L,DiGrazia L (2010) National summit on neglected infections of poverty in the United States. Emerg Infect Dis 16: e1. Available: http://www.cdc.gov/EID/content/16/5/e1.htm. Accessed 28 February 2011.
- 7. Johnson H (30 July 2010) Rep. Johnson proposes bill to deal with neglected infections of poverty [press release]. Available: http://hankjohnson.house.gov/2010/07/rep-johnson-proposes-bill-to-deal-with-neglected-infections-of-poverty.shtml. Accessed 28 February 2011.
- 8. Dorn PL,Perniciaro L,Yabsley MJ,Roellig DM,Balsamo G,et al. (2007) Autochthonous transmission of Trypanosoma cruzi, Louisiana. Emerg Infect Dis 13: 605–607.
- 9. Diaz JH (2007) Chagas disease in the United States: a cause for concern in Louisiana? J La State Med Soc 159: 21–23, 25-29.
- 10. Wright NA,Davis LE,Aftergut KS,Parrish CA,Cockerell CJ (2008) Cutaneous leishmaniasis in Texas: a northern spread of endemic areas. J Am Acad Dermatol 58: 650–652.
- 11. Reiter P,Lathrop S,Bunning M,Beggerstaff B,Singer D,et al. (2003) Texas lifestyle limits transmission of dengue virus. Emerg Infect Dis 9: 86–89.
- 12. Centers for Disease Control and Prevention (2010) Locally acquired dengue – Key West, Florida, 2009-2010. MMWR Morb Mortal Wkly Rep 59: 577–581.
- 13. Pinheiro F,Nelson M (1997) Re-emergence of dengue and emergence of dengue haemorrhagic fever in the Americas. Dengue Bull 21: December 1997. Available: http://www.searo.who.int/en/Section10/Section332/Section519_2381.htm. Accessed 28 February 2011.
- 14. San Martín JL,Brathwaite O,Zambrano B,Solórzano JO,Bouckenooghe A,et al. (2010) The epidemiology of dengue in Americas over the last three decades: a worrisome reality. Am J Trop Med Hyg 82: 128–135.
- 15. Ramos MM,Mohammed H,Zielinski-Gutierrez E,Hayden MH,Lopez JL,et al. (2005) Epidemic dengue and dengue hemorrhagic fever at the Texas-Mexico border: results of a household-based seropepidemiologic survey, December 2005. Am J Trop Med Hyg 78: 364–369.
- 16. Brunkard JM,Robles Lopez JL,Ramirez J,Cifuentes E,Rothenberg SJ,et al. (2007) Dengue fever seroprevalence and risk factors, Texas-Mexico border, 2004. Emerg Infect Dis 13: 1477–1483.
- 17. Sutton M,Sternberg M,Koumans EH,McQuillan G,Berman S,et al. (2007) The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001-2004. Clin Infect Dis 45: 1319–1326.
- 18. Kissinger P,Schmidt N,Mohammed H,Leichliter JS,Gift TL,et al. (2006) Patient-delivered treatment for Trichomonas vaginalis infection: a randomized controlled trial. Sex Transm Dis 33: 445–450.
- 19. Kissinger P,Secor WE,Leichliter JS,Clark RA,Schmidt N,et al. (2008) Early repeated infections with Trichomonas vaginalis among HIV-positive and HIV-negative women. Clin Infect Dis 46: 994–999.
- 20. Kissinger P,Amedee A,Clark RA,Dusmestre J,Theall KP,et al. (2009) Trichomonas vaginalis treatment reduces vaginal HIV-1 shedding. Sex Transm Dis 36: 11–16.
- 21. Gatski M,Mena L,Levison J,Clark RA,Henderson H,et al. (2010) Patient-delivered partner treatment and Trichomonas vaginalis repeat infection among HIV-infected women. Sex Transm Dis 37: 502–505.
- 22. Blumenthal DS,Schultz MG (1975) Incidence of intestinal obstruction in children infected with Ascaris lumbricoides. Am J Trop Med Hyg 24: 801–805.
- 23. Hubbard DW,Morgan PM,Yaeger RG,Unglaub WG,Hood MW,et al. (1974) Intestinal parasite survey of kindergarten children in New Orleans. Pediatr Res 8: 652–658.
- 24. Won KY,Kruszon-Moran D,Schantz PM,Jones JL (2008) National seroprevalence and risk factors for zoonotic Toxocara spp. infection. Am J Trop Med Hyg 79: 552–557.
- 25. Smith RE,Hagstad HV,Beard G (1984) Visceral larva migrans: a risk assessment in Baton Rouge, Louisiana. Int J Zoonoses 11: 189–194.
- 26. Jones JL,Kruszon-Moran D,Won K,Wilson M,Schantz P (2008) Toxoplasma gondii and Toxocara spp. co-infection. Am J Trop Med Hyg 78: 35–39.
- 27. Jones JL,Kruszon-Moran D,Sanders-Lewis K,Wilson M (2007) Toxoplasma gondii infection in the United States, 1999-2004, decline from the prior decade. Am J Trop Med Hyg 77: 405–410.
- 28. Colugnati FA,Staras SA,Dollard SC,Cannon MJ (2007) Incidence of cytomegalovirus infection among the general population and pregnant women in the United States. BMC Infect Dis 7: 71.
- 29. Lazere E (2010) DC’s two economies: many residents are falling behind despite the city’s revitalization. Washington (D.C.): DC Fiscal Policy Institute. Available: http://www.dcfpi.org/10-24-07dc.pdf. Accessed 28 February 2011.
- 30. Government of the District of Columbia, Department of Health (2008) District of Columbia HIV AIDS epidemiology update. Washington (D.C.): Government of the District of Columbia. Available: http://www.dcwatch.com/issues/health090316.pdf. Accessed 28 February 2011.
- 31. Johnson HL,Erbelding EJ,Zenilman JM,Ghanem KG (2007) Sexually transmitted diseases and risk behaviors among pregnant women attending inner city public sexually transmitted diseases clinics in Baltimore, MD, 1996-2002. Sex Transm Dis 34: 991–994.
- 32. US Census Bureau (2010) State & county quick facts. Available: http://quickfacts.census.gov/qfd/index.html. Accessed 28 February 2011.
- 33. NeighborhoodInfo DC (2010) NeighborhoodInfo DC web site. Available: http://www.neighborhoodinfodc.org/index.html. Accessed 28 February 2011.