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Dr. Amesh A. Adalja: Undocumented immigrants, open borders are not an infectious disease risk

| Monday, Sept. 10, 2018, 9:39 a.m.
EL PASO, TX - JULY 26: A woman, identified only as Heydi and her daughter Mishel,6, and a man, identified only as Luis, and his daughter, Selena ,6, relax together in an Annunciation House facility after they were reunited with their children on July 26, 2018 in El Paso, Texas. Heydi originally from Guatemala and Luis originally from El Salvador were reunited at an I.C.E processing center about two months after they were separated when they tried to cross into the United States. Today, is a court-ordered deadline for the U.S. government to reunite as many as 2,551 migrant children ages 5 to 17 that had been separated from their families.  (Photo by Joe Raedle/Getty Images) *** BESTPIX ***
EL PASO, TX - JULY 26: A woman, identified only as Heydi and her daughter Mishel,6, and a man, identified only as Luis, and his daughter, Selena ,6, relax together in an Annunciation House facility after they were reunited with their children on July 26, 2018 in El Paso, Texas. Heydi originally from Guatemala and Luis originally from El Salvador were reunited at an I.C.E processing center about two months after they were separated when they tried to cross into the United States. Today, is a court-ordered deadline for the U.S. government to reunite as many as 2,551 migrant children ages 5 to 17 that had been separated from their families. (Photo by Joe Raedle/Getty Images) *** BESTPIX ***

Economist Walter Williams’ recent column making a case against illegal immigration, “Open borders would mean further spread of disease” (Aug. 31, TribLIVE) is based on the threat of infectious disease. This argument is a very obviously veiled attempt to use the prestige of science and medicine coupled with the real issue of health security in order to bolster a political position.

Williams’ main line of argument is that because immigrants and refugees entering the United States are subject to medical screening examinations prior to or shortly after entry, there is a real risk of contagious diseases entering the United States by way of undocumented immigrants who are not screened. Though Williams cites the Immigration and Nationality Act to support his position regarding infectious diseases, he omits substantial, important context.

While the government indisputably has been delegated the right to protect the individual rights of those in its geographic jurisdiction from contagious infectious diseases, does the arrival of undocumented immigrants pose a real health security risk to the U.S. population?

Current disease screening

An adult immigrant (over age 15) to the U.S. is screened for several infectious diseases including active tuberculosis (via a simple chest X-ray), Hansen’s disease/leprosy (via physical examination), syphilis (by blood testing) and gonorrhea (by urine or swab testing).

Contrary to what Williams posits, HIV, which was formerly subject to an ineffective and ill-advised travel ban, is not on the list. Also, immigrants are given age-appropriate vaccines if they have not yet received them or are not already immune. These include vaccines against tetanus, diphtheria, whooping cough, polio, measles, mumps, rubella, rotavirus, Haemophilus influenzae type b (Hib), pneumococcus, meningococcus, hepatitis A, hepatitis B, influenza, and chickenpox. Would that native-born Americans universally get all these life-saving vaccines instead of having chickenpox parties.

Breaking down this list yields several important insights. First, each of the non-vaccine preventable infections (pulmonary tuberculosis, Hansen’s disease, gonorrhea and syphilis) are treatable, as are many of the vaccine-preventable infections. Also, a couple of the listed conditions are not communicable at all or only poorly communicable (Hansen’s disease and tetanus). Lastly, almost all of the listed conditions, including the vaccine-preventable diseases and, especially, the sexually transmitted ones, all occur in the U.S. domestic population naturally (rubella and measles are tied to travel-related acquisition and wild polio has been eliminated from both American continents).

In any case, immigration is not barred for anyone who screens positive for any of these infections. Instead, they are to be linked to treatment and admitted after treatment is completed, or in some cases, started. With respect to disease importations, they are more likely to occur as a result of tourism, regular travelers, or health care workers, not migrants.

Real risks or false fear?

These diseases should not be belittled but they are not the high-consequence infectious diseases that should keep you up at night as if they were an Andromeda strain that threatens your very existence. These are well characterized infectious diseases that are managed on a daily basis in the U.S. by physicians and public health authorities. A few of the other diseases Williams cites — especially scabies — are almost laughable.

While it is true that for a disease like tuberculosis, the rates have precipitously fallen in those born in the U.S., it is also true that the overall annual U.S. rate in 2017 has also fallen to an all-time low of about 9,000 cases. This statistic is despite the looming threat Williams paints of illegal immigration contaminating our population.

It is also essential to remember where undocumented immigrants are originating from: Most estimates place the majority of countries of origin as Mexico or central American nations. These nations, which may not have vaccination rates as high as our own are, thankfully, less plagued by the primitive anti-vaccine forces that have made some residents of American counties more of a clear and present danger for the spread of vaccine-preventable diseases than any immigrant.

In fact, Guatemala and Mexico’s MMR vaccination rate is comparable to that of Arizona in 2015 and higher than some counties in California. The risk of measles, for example, does not originate primarily from south of our border but from places like Italy, France, England, and Greece — all subject to CDC travel warnings — where illegal immigrants to the U.S. are unlikely originate from. During the all-American Disneyland measles outbreak in 2014, imported cases from the U.S. hit Mexico.

Even if one grants Williams’ premises, it cannot be overlooked that the reason why undocumented immigrants are not screened like other immigrants is because U.S. laws have criminalized them and driven them into hiding. The risk that Williams’ mistakenly fears is entirely abetted by the current illegal status the government confers on these individuals.

The solution is not to further demonize them as carriers of what are not-so-exotic infections, but instead enable them to seek health care if needed, free from the worry that they will be damned back to whatever place they fled because they just want to get a flu shot.

Dr. Amesh A. Adalja is a Pittsburgh-based infectious disease physician and a senior scholar at the Johns Hopkins Center for Health Security. Follow him on Twitter: @AmeshAA.

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