Multiple sclerosis in time and space--geographic clues to cause.

Geographically MS describes three frequency zones. High frequency areas (prevalence 30+ per 100 000) now comprise most of Europe, Israel, Canada, northern US, southeastern Australia, New Zealand, and easternmost Russia. Medium frequency areas include southern US, most of Australia, South Africa, the southern Mediterranean basin, Russia into Siberia, the Ukraine and parts of Latin America. Prevalence rates under 5 per 100 000 are found in the rest of Asia, Africa and northern South America. Migrants from high to lower risk areas retain the MS risk of their birth place only if they are at least age 15 at migration. Those from low to high increase their risk even beyond that of the natives, with susceptibility extending from about age 11 to 45. Thus MS is ordinarily acquired in early adolescence with a lengthy latency before symptom onset. MS occurred in epidemic form in North Atlantic islands: probably in Iceland and the Shetland-Orkneys; clearly in the Faroe Islands. In the Faroes first symptom onset was in 1943, heralding the first of four successive epidemics at 13 year intervals. The disease was presumably introduced by occupying British troops during World War II, with the postwar occurrences representing later transmissions to and from consecutive cohorts of Faroese. What was transmitted is thought to be a specific, widespread, persistent infection called PMSA (the primary multiple sclerosis affection) which only rarely leads years later to clinical MS. Search for PMSA is best attempted on the Faroes where there are regions still free of MS after 50 years.