When Will It Rain Again Pacific Northwest 121317
mBio. 2019 Sep-Oct; 10(5): e02193-nineteen.
On the Emergence of Cryptococcus gattii in the Pacific Northwest: Ballast Tanks, Tsunamis, and Black Swans
David Thou. Engelthaler
aTranslational Genomics Research Institute, Flagstaff, Arizona, United states
Arturo Casadevall
bJohns Hopkins University, Baltimore, Maryland, U.s.a.
Françoise Dromer, Editor
Françoise Dromer, Institut Pasteur;
ABSTRACT
The appearance of Cryptococcus gattii in the North American Pacific Northwest (PNW) in 1999 was an unexpected and is still an unexplained consequence. Recent phylogenomic analyses strongly suggest that this pathogenic fungus arrived in the PNW approximately seven to ix decades ago. In this paper, nosotros theorize that the ancestors of the PNW C. gattii clones arrived in the area past shipborne transport, possibly in contaminated ballast, and established themselves in coastal waters early in the 20th century. In 1964, a tsunami flooded local coastal regions, transporting C. gattii to land. The occurrence of cryptococcosis in animals and humans 3 decades subsequently suggests that accommodation to local surroundings took time, perhaps requiring an increase in virulence and further dispersal. Tsunamis as a mechanism for the seeding of state with pathogenic waterborne microbes may take important implications for our understanding of how infectious diseases emerge in certain regions. This hypothesis suggests experimental work for its validation or refutation.
KEYWORDS: Cryptococcus gattii, Pacific Northwest, black swan, illness ecology, emerging infectious disease, epidemiology, mycology, tsunami
OPINION/HYPOTHESIS
Starting in 1999 and over the subsequent 2 decades, human and animate being cases of Cryptococcus gattii take been identified in the North American Pacific Northwest (PNW) (ane). Initial environmental studies found widespread fungal presence within the coastal forests and parks of Vancouver Island, near Victoria, Canada (2). Numerous studies have since plant the presence of the three unrelated outbreak clones (known as VGIIa, VGIIb, and VGIIc) in the larger PNW region, including the American states of Washington and Oregon (3,–5), with VGIIc largely restricted to the Willamette Valley in Oregon (half-dozen). In this essay, we employ the nomenclature for the C. gattii species complex (7) and major molecular type (i.east., VG) for consistency with the referenced studies in this written report, while beingness aware that the members of the species circuitous have been proposed to be designated separate species (8). The PNW disease emergence was unexpected, equally C. gattii was idea to be restricted primarily to tropical and subtropical zones, namely, in Due south America, Africa, Asia, and Australia (ix). The hunt to find the crusade of the dispersal to this temperate zone soon followed the showtime human cases, leading to a number of causal hypotheses, including shipment of eucalyptus trees (thought to be a possible dispersal machinery of C. gattii to parts of central and lower California and Mediterranean countries and even from Australia to South America [10]) or agricultural products (11), ecological niche changes due to global warming (2, 12), ocean and air current currents, movements of animals, and homo/mechanical transmission (east.m., contaminated tires, shoes, and crates) (13). Multiple causes may have occurred concurrently or sequentially. Multiple groups (xi, 12, 14) have proposed the possibility that C. gattii was dispersed to the region decades prior to the outbreak by some natural or anthropogenic means, which was followed by an unknown niche disturbance that led to subsequent human infections.
We previously described a hypothetical transport of C. gattii from eastern South American port cities (e.m., Recife, Brazil) to the PNW (including British Columbia, Washington, and Oregon) via contaminated ballast water, due to early shipping between the regions following the 1914 opening of the Panama Canal (15). The timing of this comports with the molecular clock analyses that suggest that the clonal populations of the three C. gattii subtypes identified in the PNW are between 66 and 88 years onetime (fifteen) (Fig. 1). This would have established populations of C. gattii in the coastal waters of the PNW (where C. gattii has been found and is known to survive for long periods [16]). We now farther hypothesize that the PNW littoral forests became contaminated with C. gattii about simultaneously from the tsunami waves immediately following the 27 March 1964 earthquake in Prince William Sound, AK.
Map of the C. gattii Pacific Northwest dispersal hypothesis. Locales of VGIIa endemicity are shaded dark-green, and the locale of VGIIc endemicity is shaded in orange. Dotted green lines correspond PNW maritime shipping routes from eastern South America, and short ruddy arrows correspond tsunami wave directions following the 1964 Alaskan Earthquake. Stars represent the capital cities of Portland, OR, Seattle, WA, Vancouver, British Columbia (B.C.), and Victoria, Vancouver Island (V.I.). Also shown is Port Alberni (P.A.) on Victoria Island.
The great Alaskan earthquake and tsunamis.
The 1964 Keen Alaskan Convulsion was the largest ever recorded in the Northern Hemisphere, registering M9.ii on the Richter scale, second simply to the M9.5 1960 earthquake in Chile (NOAA, National Centers for Ecology Information, https://www.ngdc.noaa.gov/nndc/struts/results?bt_0=1964&st_0=1964&type_7=Like&query_7=prince&d=7&t=101650&s=7). The Alaskan Earthquake was felt as far as 4,500 km away, with tidal furnishings recorded on the Hawaiian Islands. The tidal waves reported in nearby Shoup Bay, AK, were reported to be 67 m high (220 ft), causing significant shoreline devastation. Further to the south, the tsunamis caused significant water surges along western Vancouver Island, most notably in Port Alberni, where dozens of homes were destroyed or washed abroad. The tsunami continued southward, affecting much of the coastline of western North America, fifty-fifty causing several deaths on the beaches of northern California (USGS, Earthquake Hazards Programme, https://web.archive.org/spider web/20141011013757/http://earthquake.usgs.gov/earthquakes/states/events/1964_03_28.php).
Information technology stands to reason (see beneath) that there has been, and continues to be, a continual presence of C. gattii in the PNW coastal marine environs, again perchance originating from contaminated ballast water from ports from other locales where the organism is owned. However, the next dispersal leap, the large-scale contamination of the PNW forests, is less obvious. If the littoral marine environment was contaminated start, then there must accept been a wide-scale or continual mechanism for aquatic C. gattii to invade the coastal forest of Vancouver Isle and other areas of the PNW. If, on the other hand, the sea-outset hypothesis is incorrect and the coastal lands were first contaminated, leading to subsequent coastal and ocean contamination, then we must account for big-calibration contagion of the environmental region. Previous hypotheses of original contagion past transport of goods and materials (including plants and trees) require a mechanism for wide dispersal from such material to the larger landscape, including the coastal forests and waters. Ocean environments might be contaminated from snow melt and pelting runoff or from contamination from infected ocean birds (ii), although neither of these phenomena take previously been documented, except for a single report of a C. gattii-positive blue heron (17). It is important to note that, different Cryptococcus neoformans, which is classically associated with bird guano, C. gattii, while known to infect multiple bird species, is non shed or otherwise plant in guano (xviii). An alternate hypothesis has been the contact of ocean with contaminated air, equally early air sampling studies identified the presence of ambient fungi (probable desiccated yeast cells) in multiple locales on Vancouver Island (2). However, to date, in that location has been no feasible hypothesis promoted that allows for the initial large-calibration land-based contamination of the PNW.
We notation that tsunamis accept been associated with an increase in fungal diseases (19). Tsunami water can carry pathogenic fungi, equally evidenced by case reports of invasive fungal skin and pulmonary disease ("tsunami lung") in survivors of near-drowning episodes (twenty,–23). Anecdotal evidence for the ability of a seismic sea wave to transport C. gattii comes from a example of cutaneous VGII infection in a survivor of the 2004 Indonesian tsunami in Thailand in which peel injuries presumably became infected past contaminated water (23). These clinical experiences found that tsunamis tin can move pathogenic fungi in water flows and provide back up for the hypothesis that C. gattii in marine estuaries and other littoral waters in the Pacific Northwest may have reached the land through a tidal wave.
We therefore propose an ocean-outset hypothesis, essentially that PNW marine coastlines developed adequately wide-calibration marine C. gattii contamination in the decades after one or more initial ballast water-dumping events. And then, on 27 March 1964, the PNW coastal forests became contaminated from the tsunami water surges following the swell Alaskan earthquake on that date. This one result, like no other in recent history, caused a massive push of ocean water into the coastal forests of the PNW. Such an outcome may have caused a simultaneous forest C. gattii exposure upwards and down the regional coasts, including those of Vancouver Isle, BC, Canada, Washington, and Oregon. Local marine populations of select C. gattii strains would have caused local and wide-scale forest contagion events that would later spread more naturally in wooded environments, via other proposed mechanisms both natural (east.yard., airborne yeast movements) and anthropomorphic (east.g., fomite-contaminated vehicle tires and shoes) (12, 13, 17). Natural water cycling mechanisms (eastward.g., snow melt and rain runoff) may account for connected transport of fungi dorsum to the bounding main surround, causing cycling of local endemicity. Furthermore, we posit that transport to land in 1964 was followed by a menstruation of soil and tree colonization where C. gattii was exposed to biological and physical pick that possibly increased its infectiousness and virulence for animals, leading to the PNW outbreak 3 decades later.
Multiple pieces of testify support the ocean-first/tsunami dispersal hypothesis, including (i) show of phylogenetic diversification most 50 years ago; (ii) the prevalence of environmental C. gattii predominantly only in coastal forests, rather than further inland, suggesting a connection to the shoreline; (iii) the presence of C. gattii in soils on the Gulf Islands between Vancouver Island and mainland British Columbia; (iv) the presence of C. gattii in humans, mammals, and the forested environment most Port Alberni in central Vancouver Island, an area of the island that was greatly afflicted by the 1964 tsunami; and (v) the fact that the earliest known case of PNW C. gattii occurred nearly thirty years prior to the 1999 PNW outbreak, establishing a historical tape in the region that matches a terrestrial emergence in the 1960s.
(i) Phylogenetic evidence. Phylogenetic analysis of the PNW clones (VGIIa, VGIIb, and VGIIc) provides fairly conclusive testify of a single introduction consequence into the PNW followed by local evolution for both VGIIa and VGIIc, whereas VGIIb has a dominant PNW clade resulting from a single primary introduction with possibly i or more additional introductions, with express evolution and spread (24). The only not-PNW case belonging to the PNW VGIIa clade (also cases of nonresident travelers to the PNW) was a single isolate obtained from Recife, Brazil, in 1983; all other VGIIa isolates from outside the PNW clade originated from Brazil or elsewhere in the region (24). While not definitively established as originating from Brazil, both VGIIb and VGIIc are almost closely related to other VGII lineages from Brazil (and VGIIb has been identified in multiple geographic regions, including Brazil). These information support the "out of Amazon" theory for these subtypes (14, 24). All three PNW clades have been roughly estimated to be seventy to ninety years old using Bayesian statistical inference (Fig. 2) (xv), providing for the "Teddy Roosevelt event" hypothesis, which links the opening of the Panama Canal and subsequent shipping from Brazilian ports to the PNW equally a driver of dispersal to the PNW region (xv). While specific exported materials that may have been contaminated with C. gattii have not been identified, aircraft most certainly would have carried ballast water (and likely microbial contaminants) between the regions. While such molecular clock analyses can provide simply relative dating accuracy, closer analysis of the phylogenetic trees from these studies suggests that secondary diversification events, which define much of the current population structure, appear to accept initiated approximately 1 to 2 decades following the introduction of each of the clones (Fig. 1). A 1964 tsunami (54 years prior to the above-described analyses) may account for the timing of these population diversification events. Express tertiary structure suggests limited subsequent evolution across these secondary events; therefore, some phenomenon (e.g., simultaneous seeding of the terrestrial landscape) seems to have established multiple individual sublineages that have had restricted subsequent diversification.
Bayesian phylogenetic analyses of PNW C. gattii samples. The estimated times to the virtually recent mutual ancestors (1°; crimson boxes) were ∼88 years ago (VGIIa) (A), ∼81 years ago (VGIIb) (B), and∼66 years ago (VGIIc) (C). The x axis represents years before the present. Bluish boxes represent secondary (2°) population divergence events. (Adjusted from the work of Roe et al. [xv]).
(two) Environmental bear witness. (a) Copse and soils. The early environmental analyses of VGIIa in British Columbia identified that most C. gattii-positive environmental collections (soils and trees) were in the coastal Douglas fir forests and in coastal western hemlock forests bordering the littoral Douglas fir forest (16) (Fig. 1). While these studies were limited in geographical infinite, the identified contaminated landscapes did comprehend the known locations of human and fauna cases. Additionally, farther ecological analyses take identified higher levels of soil and tree contamination at low-lying elevations shut to ocean level (25). This is the expected pattern of a tsunami-caused dispersal from contaminated coastal waters.
(b) Water. C. gattii from the PNW has been shown to demonstrate long-term survival (at least 1 year) in bounding main water, and immediate environmental studies found multiple positive body of water samples near the Vancouver Island coastline (16). Additionally, dozens of infected cetaceans have been found along the PNW coasts, including on the shores of Vancouver Isle and the Gulf Islands (2), since the starting time of the 1999 outbreak (1, 26, 27); more recently infected pinnipeds take been documented in the region (28), all suggesting big-scale ongoing contamination of the marine surround. Numerous Cryptococcus species are adapted to and live in marine water (29,–32). Interestingly, C. gattii (and C. neoformans) has an intrinsic machinery to support cell buoyancy; specifically, its ability to increase sheathing production decreases jail cell density and supports buoyancy in marine salinity levels (33). Nearly all marine mammal infections have been pulmonary, suggesting infection via inhalation. As marine mammals exhale at the surface of the water, it is possible that C. gattii survives at the bounding main surface microlayer, as described for other Cryptococcus species (34, 35), and is subsequently inhaled during animate episodes. For this report, we besides undertook an initial scan of available metagenomic data sets collected in the PNW area for other purposes and have identified a recent metagenomic study of marine microbial communities from expanding oxygen minimum zones in the Saanich Inlet off southeast Vancouver Island (36), where multiple C. gattii VGII-specific kmer sequences were present in the multiple collected marine sample metagenomes (information non shown). These findings further support the concept of long-term ocean survival of C. gattii in the region. Alternatively, these findings may represent continued seeding of coastal waters by contaminated soil runoff and/or by dispersal of airborne yeast cells from nearby contaminated forests, as suggested previously (two).
(3) Geographic evidence. One of the regions on Vancouver Isle to receive the most significant tsunami damage was the town of Port Alberni, tied to an inlet on the west side of the island. Several hours afterwards the Slap-up Alaskan Earthquake struck, multiple waves flowed up the Alberni Inlet, cresting at viii thou and hitting the Port Alberni region, washing abroad 55 homes and damaging virtually 400 others (37). Kidd et al. (16) sampled the Port Alberni region, which is approximately twoscore km from the eastern border of the island, finding C. gattii in the forest near Port Alberni. Multiple environmental samples were establish to be positive in that report, and information technology identified homo and terrestrial animal cases in this locale (Fig. ane). Infected sea mammals accept also been found in the Alberni Inlet (25). Human and terrestrial and marine animal cases accept as well been reported along the western coast of Vancouver Isle, suggesting that coastline contamination has occurred across Vancouver'south port region and that contamination of the Port Alberni region may be due to its coastal contamination (i.e., from the 1964 tsunami event), rather than from terrestrial dispersal from the eastern side of the isle.
(iv) Patient testify. One of the confounders for a more than recent emergence of C. gattii in the PNW (i.e., <fifty years ago) is that the earliest known example of C. gattii VGIIa occurred nearly xxx years prior to the 1999 PNW outbreak, a Seattle patient in 1971 (ii). Unfortunately, no epidemiologic details exist for the instance (e.g., it remains unknown if the example had a history of travel to Vancouver Island); however, this isolate clearly belongs to the PNW VGIIa clade (24), and other cases, human and veterinary, have been later institute in the Puget Audio region (38). A scouring of medical records and archived samples has not been able to place any cases or records of possible C. gattii infection occurring in the region prior to 1970. While only circumstantial, this finding comports with the timeline of environmental seeding from the 1964 tsunami. Boosted subsequent infections may have been undetected prior to the 1999 outbreak, especially when viewed in light of the fact that cryptococcal infection can remain dormant after conquering (39,–41).
Much of the higher up discussion has focused on the dispersal of the VGIIa clone in the Vancouver/Puget Sound region. It is worth noting that the Oregon cases (and all findings of the VGIIc clone) are largely restricted to the Willamette Valley (four, 6, 42, 43), a large river valley south of the Columbia River, which is the main waterway for aircraft to the Pacific Bounding main (Fig. ane). The Columbia River inlet of the Pacific is not idea to have been every bit heavily afflicted by the 1964 seismic sea wave, with the largest impacts on coastlines occurring nearest the mouth of the inlet (44). However, the international shipping port of Portland, further upwards the Columbia inlet, at the oral cavity of the Willamette River, may withal have acted every bit a gateway for waterborne C. gattii. The seismic sea wave wave was recorded up to 145 km (ninety miles) upriver, including nearly 5-foot waves at the junction of the Columbia and Willamette Rivers (45), which may have transported contaminated estuarine waters upriver. Then a second fluvial effect in 1964 consisting of a major flood may accept provided another event contributing to the establishment of C. gattii in the expanse. The 240-km (150-mile)-long Willamette Valley is transected from Eugene to Portland by the Willamette River, which flows north and empties into the Columbia River at Portland Harbor. About 62,000 ha (153,000 acres) of the Willamette Valley was flooded in December 1964, in a devastating "hundred-year flood" (46), causing meaning inundation, saturation, and likely contamination of the surrounding region, acting possibly as a like, even so distinct, h2o-to-land dispersal mechanism in this southern region of the Pacific Northwest, ironically in the same year every bit the Alaskan tsunami.
PATHOGEN DISPERSAL AND Blackness SWANS
The mechanisms of pathogen geographic move and dispersal are of not bad interest to ecologists, epidemiologists, medical historians, and others who seek to sympathize the causes of infectious illness emergences. These mechanisms can be natural or anthropogenic and can include anything from displacement or migration of reservoirs to the landscape, geophysical change, and climate changes to occurrences of natural disasters (as proposed here) (Table 1).
TABLE 1
Possible mechanisms of pathogen dispersal to new locales of endemicity
| Dispersal mechanism(southward) | Natural mechanism(s) | Anthropogenic machinery(s) |
|---|---|---|
| Reservoir movement | Host/vector migration/expansion | Travel, migrations, animal merchandise |
| Material movement | Sea currents | Tires, plants, contaminated materials |
| Mural changes | Erosion, flooding | Deforestation, agronomics, cityscapes |
| Geophysical changes | Continental migrate | Major canals and dams |
| Climate, conditions | Ice ages, grit storms | Warming trends |
| Natural disasters | Earthquakes, tsunamis, floods, tornados, hurricanes | Post-disaster relief efforts (due east.yard., Haitian cholera) |
Many of these are even so theoretical mechanisms of dispersal; however, the point is that in that location are numerous biological, geological, and sociological dynamics on our planet that are likely involved in pathogen evolution and distribution and subsequent disease ecology and epidemiology. A careful written report of these dynamics helps us to empathize of import contributors to the emergence of disease. Our hypothesis of a tsunami-driven contagion of the PNW coastal landscape certainly involves numerous other biological (eastward.one thousand., the ability of fungi to adapt to coastal waters and littoral climates), geophysical (due east.g., the carving of the Panama Canal to allow for easier shipping from eastern South America to western North America), and other anthropogenic (e.g., transport of contaminated materials or anchor between aircraft ports) dynamics that would pb to such an unforeseen emergence.
Natural disasters take been well documented to direct and indirectly cause unexpected outbreaks from infectious pathogens, including fungi (19). Famous examples include the remarkable mucormycosis infections caused by deep implantation of Apophysomyces during the Joplin, MO, tornado in 2011 (47), the multiple waterborne infections due to exposure to ocean flooding from both the 2004 Indonesian and the 2011 Japanese tsunamis (23, 48, 49) and Hurricane Katrina (50), and increased coccidioidomycosis cases after the 1994 Northridge, CA, earthquake (51). What is less understood and certainly understudied is the effect that these events may have on the actual dispersal of pathogens (and other microbes) into new zones of endemicity, which may issue in exposure and disease years to decades later.
Here, we suggest that a tsunami was responsible for the big-scale movement of bounding main microbes into nearby coastal forests. While the evidence described above is largely circumstantial, the natural disaster dispersal hypothesis should be further explored and tested in other regions and with other microbial populations (run across "Hypothesis testing" below). For example, the tsunami hypothesis may also explain how Cryptococcus was established in Western Australia following some mechanism of water send from South America. Such mechanisms of dispersal can be considered "black swans."
A black swan event, popularized by American financial philosopher Nassim Taleb (52), is an unpredictable consequence of extreme consequence for which the human being tendency is to find oversimplified explanations after the fact. It stems from an aboriginal idea that all swans must exist white, because only white swans had ever been documented until black swans (Cygnus atratus) were eventually found in Australia, the discovery of which unraveled previous dogmas. Here, we advise a major new machinery of pathogen dispersal non previously documented and certainly not predicted, and if true, it will have a disruptive impact on previous dispersal theories, thereby being a prototypical example of a black swan. It is a fact that many major disease events are blackness swans and therefore typically belie the possibility of prediction. In hindsight, the 2014 outbreak of Ebola in western Africa is thought to take been inevitable, given the combination of considerable man travel and migration between African countries and the pervasiveness of under-resourced health intendance and public health systems. Notwithstanding, the probable start of the outbreak (i.e., migratory bats falling ill in a hollow tree where children play [53]) was certainly unpredictable, resulting in a high-consequence event and therefore a black swan (54). The continued roulette of influenza virus strain mixing will predictably continue to develop new infectious and possibly pandemic strains in unpredictable black swan means; east.g., the 2009 swine influenza pandemic originating out of Mexico was certainly not predicted. In fact, a review of history shows that most major emerging communicable diseases events were blackness swan events (due east.g., the emergence of HIV, severe acute respiratory syndrome/Eye Eastward respiratory syndrome [SARS/MERS], Nipa/Hendra virus, and monkeypox virus in the U.s., prenatal effects of Zika virus, and polio-like virus outbreaks from EV-D68, etc.). In that location is an enormous effort existence made with global infectious illness surveillance to identify the earliest fourth dimension points of emergence of new diseases and outbreaks. These surveillance tools are disquisitional for u.s. to exist able to apace reply and mitigate such events. Significant resources are also being expended for pathogen prediction model development: predicting what, when, and where diseases may emerge prior to detection (e.g., DARPA's PREEMPT programme; https://world wide web.fbo.gov/spg/ODA/DARPA/CMO/DARPA-SN-xviii-18/listing.html). These efforts are in effect looking for black swans; all the same, they may fail if such events are truly unpredictable. Taleb (52) argues that, in fiscal markets, with nearly space numbers of seemingly random actions that tin can deed every bit causes, black swans are truly unpredictable. The response is not to try harder to predict blackness swans but to work harder to be prepared to respond to them when they exercise happen, to get "black swan robust."
The near infinite number of small and big stochastic dynamics in the natural and anthropogenic world is probably a good indicator of where we should put our health research dollars when thinking about predicting versus preparing for new emerging infections. In the case of Cryptococcus in the PNW, in that location was a pervasive conventionalities that all C. gattii organisms were constitute in tropical and subtropical regions; nosotros only did not predict, nor could nosotros predict, the possibility of the PNW emergence. Withal, thankfully robust health care, public health, and academic research entities quickly identified and responded to the consequence. The aforementioned was true for HIV, hantavirus, and SARS coronavirus, all on shrinking timescales, due to improvements in technology and advice and advancements in scientific understanding. This cross-disciplinary one-health response between public health, medicine, ecology, and biomedical enquiry is a model that can and should exist followed globally to understand and mitigate the furnishings of the emerging infections that nosotros predict will keep to challenge global public health.
One final note: Western Commonwealth of australia is the region of the continent most decumbent to tsunamis (55), and it is becoming apparent that at least some populations of Australian C. gattii originated in the western region (i.e., Perth) and take been anthropogenically transported via infected animals (i.due east., koalas) to other parts of the continent (56). A tsunami-borne mechanism of transport from ocean to land in Western Australia is highly speculative but certainly possible if the coastal waters were previously contaminated. Ironically, the first actual black swan ever documented was in 1697 in Perth, Western Australia (52), where is it now the official state bird.
Hypothesis testing.
The hypothesis that C. gattii VGII reached the Pacific Northwest in transport anchor tanks from South America and and so became later on established on state past a tidal wave suggests several lines of experimentation. Considering South American ports are connected to other parts of the world by aircraft lanes, other ports must also have become contaminated with C. gattii. The likelihood that C. gattii will become established in a particular locale is probably dependent on the physical and biological conditions operating in that locale. For example, amoebas are of import biological control agents for C. neoformans in the environment (57, 58), and the type of microfaunas plant in different sites may decide the likelihood for the establishment of an invasive cryptococcal species. Although it is always possible that the marine ecology of the Pacific Northwest provided a unique surround for C. gattii, the more likely scenario is that other coastal areas are also contaminated. Hence, a sampling of h2o in other ports by deep sequencing may reveal C. gattii-specific genes, thus strengthening the case for shipborne transport. Similarly, sampling of waters in S American ports where rivers flow from the interior of the continent may reveal C. gattii, supporting the notion of fluvial send by country to body of water transport. A more intensive search for new S American isolates may reveal a genetically close relative of the PNW strains, which would support recent transport from that region. Finding C. gattii in other coastal waters without a concomitant increase in cryptococcosis would support the notion that something different happened in the PNW and provide powerful indirect evidence for an unusual consequence, such as a tsunami. In fact, if C. gattii was found in coastal waters of areas that accept suffered tsunamis in recent decades, such every bit following the Indonesian and Japanese earthquakes of 2004 and 2011, this could let real-time studies in those areas and maybe forbid time to come outbreaks of cryptococcosis in these locales. In this regard, it is noteworthy that the PNW seismic sea wave issue was separated from the C. gattii outbreak by 3 decades, suggesting that, if our hypothesis is right, a catamenia of land adaptation may be required before significant numbers of human and animal cases announced. For example, land adaptation and selection past soil amoeboid predators may have been a necessary condition for increased virulence for mammal infection (59). Prove for or against a seismic sea wave-related movement from bounding main to land might come by conscientious bio-geographic analysis of country areas affected by the tidal wave for the prevalence of C. gattii, with the expectation existence that flooded areas harbor more-established sites than nonflooded adjacent lands.
ACKNOWLEDGMENTS
We acknowledge Juan Monroy-Nieto and Jason Travis for their bioinformatic assay of publicly available metagenomic data sets, which confirmed the presence of C. gattii in recently collected marine samples described in the text. We besides gratefully acknowledge the hundreds of clinical, veterinary, public health, environmental, and academic professionals who have dedicated thousands of hours of work over the previous 2 decades to aid us understand the emergence of C. gattii in the Pacific Northwest. The ideas hither are a consequence of their work.
D.M.E. is supported in office by CDC contract 200-2016-92313, and A.C. is supported in function by NIH grants 5R01AI052733 and 5R01HL059842.
Footnotes
Citation Engelthaler DM, Casadevall A. 2019. On the emergence of Cryptococcus gattii in the Pacific Northwest: anchor tanks, tsunamis, and black swans. mBio 10:e02193-19. https://doi.org/10.1128/mBio.02193-xix.
REFERENCES
ane. Stephen C, Lester S, Blackness W, Fyfe K, Raverty S. 2002. Multispecies outbreak of cryptococcosis on southern Vancouver Island, British Columbia. Can Vet J 43:792–794. [PMC free article] [PubMed] [Google Scholar]
2. Kidd SE, Hagen F, Tscharke RL, Huynh Thou, Bartlett KH, Fyfe M, Macdougall L, Boekhout T, Kwon-Chung KJ, Meyer W. 2004. A rare genotype of Cryptococcus gattii caused the cryptococcosis outbreak on Vancouver Island (British Columbia, Canada). Proc Natl Acad Sci U S A 101:17258–17263. doi:ten.1073/pnas.0402981101. [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]
iii. Kidd SE, Guo H, Bartlett KH, Xu J, Kronstad JW. 2005. Comparative gene genealogies indicate that 2 clonal lineages of Cryptococcus gattii in British Columbia resemble strains from other geographical areas. Eukaryot Cell 4:1629–1638. doi:10.1128/EC.iv.10.1629-1638.2005. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
4. Byrnes EJ Three, Bildfell RJ, Frank SA, Mitchell TG, Marr KA, Heitman J. 2009. Molecular evidence that the range of the Vancouver Island outbreak of Cryptococcus gattii infection has expanded into the Pacific Northwest in the United States. J Infect Dis 199:1081–1086. doi:10.1086/597306. [PMC gratis commodity] [PubMed] [CrossRef] [Google Scholar]
5. Gillece JD, Schupp JM, Balajee SA, Harris J, Pearson T, Yan Y, Keim P, DeBess E, Marsden-Haug N, Wohrle R, Engelthaler DM, Lockhart SR. 2011. Whole genome sequence analysis of Cryptococcus gattii from the Pacific Northwest reveals unexpected diverseness. PLoS One 6:e28550. doi:10.1371/journal.pone.0028550. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
six. Byrnes EJ Three, Li Due west, Lewit Y, Ma H, Voelz Thou, Ren P, Carter DA, Chaturvedi V, Bildfell RJ, May RC, Heitman J. 2010. Emergence and pathogenicity of highly virulent Cryptococcus gattii genotypes in the northwest United States. PLoS Pathog half dozen:e1000850. doi:ten.1371/journal.ppat.1000850. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
7. Kwon-Chung KJ, Bennett JE, Wickes BL, Meyer W, Cuomo CA, Wollenburg KR, Bicanic TA, Castaneda Due east, Chang YC, Chen J, Cogliati M, Dromer F, Ellis D, Filler SG, Fisher MC, Harrison TS, Holland SM, Kohno S, Kronstad JW, Lazera M, Levitz SM, Lionakis MS, May RC, Ngamskulrongroj P, Pappas PG, Perfect JR, Rickerts V, Sorrell TC, Walsh TJ, Williamson PR, Xu J, Zelazny AM, Casadevall A. 2017. The case for adopting the "species complex" nomenclature for the etiologic agents of cryptococcosis. mSphere ii:e00357. doi:10.1128/mSphere.00357-16. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
8. Hagen F, Khayhan K, Theelen B, Kolecka A, Polacheck I, Sionov E, Falk R, Parnmen Due south, Lumbsch HT, Boekhout T. 2015. Recognition of seven species in the Cryptococcus gattii/Cryptococcus neoformans species complex. Fungal Genet Biol 78:xvi–48. doi:10.1016/j.fgb.2015.02.009. [PubMed] [CrossRef] [Google Scholar]
9. Sorrell TC. 2001. Cryptococcus neoformans variety gattii. Med Mycol 39:155–168. doi:ten.1080/mmy.39.two.155.168. [PubMed] [CrossRef] [Google Scholar]
10. Ellis DH, Pfeiffer TJ. 1990. Natural habitat of Cryptococcus neoformans var. gattii. J Clin Microbiol 28:1642–1644. [PMC free article] [PubMed] [Google Scholar]
11. Lockhart SR, McCotter OZ, Chiller TM. 2016. Emerging fungal infections in the Pacific Northwest: the unrecognized burden and geographic range of Cryptococcus gattii and Coccidioides immitis. Microbiol Spectr 4:EI10-0016-2016. doi:10.1128/microbiolspec.EI10-0016-2016. [PubMed] [CrossRef] [Google Scholar]
12. Datta One thousand, Bartlett KH, Baer R, Byrnes East, Galanis E, Heitman J, Hoang L, Leslie MJ, MacDougall Fifty, Magill SS, Morshed MG, Marr KA. 2009. Cryptococcus gattii Working Group of the Pacific Northwest. spread of Cryptococcus gattii into Pacific Northwest region of the United states of america. Emerg Infect Dis 15:1185–1191. doi:10.3201/eid1508.081384. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
13. Kidd SE, Bach PJ, Hingston AO, Mak S, Grub Y, MacDougall Fifty, Kronstad JW, Bartlett KH. 2007. Cryptococcus gattii dispersal mechanisms, British Columbia, Canada. Emerg Infect Dis xiii:51–57. doi:10.3201/eid1301.060823. [PMC gratis article] [PubMed] [CrossRef] [Google Scholar]
14. Hagen F, Ceresini PC, Polacheck I, Ma H, van Nieuwerburgh F, Gabaldón T, Kagan Southward, Pursall ER, Hoogveld HL, van Iersel LJ, Klau GW, Kelk SM, Stougie L, Bartlett KH, Voelz K, Pryszcz LP, Castañeda E, Lazera 1000, Meyer W, Deforce D, Meis JF, May RC, Klaassen CH, Boekhout T. 2013. Ancient dispersal of the human fungal pathogen Cryptococcus gattii from the Amazon rainforest. PLoS Ane eight:e71148. doi:10.1371/journal.pone.0071148. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
15. Roe CC, Bowers J, Oltean H, DeBess E, Dufresne PJ, McBurney S, Overy DP, Wanke B, Lysen C, Chiller T, Meyer W, Thompson GR Iii, Lockhart SR, Hepp CM, Engelthaler DM. 2018. Dating the Cryptococcus gattii dispersal to the North American Pacific Northwest. mSphere 3:e00499-17. doi:ten.1128/mSphere.00499-17. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
16. Kidd SE, Chow Y, Mak South, Bach PJ, Chen H, Hingston AO, Kronstad JW, Bartlett KH. 2007. Characterization of environmental sources of the homo and animal pathogen Cryptococcus gattii in British Columbia, Canada, and the Pacific Northwest of the United states of america. Appl Environ Microbiol 73:1433–1443. doi:10.1128/AEM.01330-06. [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]
17. Bartlett KH, Kidd SE, Kronstad JW. 2008. The emergence of Cryptococcus gattii in British Columbia and the Pacific Northwest. Curr Infect Dis Rep 10:58–65. doi:x.1007/s11908-008-0011-1. [PubMed] [CrossRef] [Google Scholar]
18. Springer DJ, Chaturvedi V. 2010. Projecting global occurrence of Cryptococcus gattii. Emerg Infect Dis 16:xiv–20. doi:10.3201/eid1601.090369. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
19. Benedict K, Park BJ. 2014. Invasive fungal infections afterward natural disasters. Emerg Infect Dis xx:349–355. doi:x.3201/eid2003.131230. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
20. Nakamura Y, Suzuki N, Nakajima Y, Utsumi Y, Murata O, Nagashima H, Saito H, Sasaki N, Fujimura I, Ogino Y, Kato G, Terayama Y, Miyamoto S, Yarita M, Kamei M, Nakadate T, Endo S, Shibuya K, Yamauchi Chiliad. 2013. Scedosporium aurantiacum brain abscess after nigh-drowning in a survivor of a seismic sea wave in Japan. Respir Investig 51:207–211. doi:10.1016/j.resinv.2013.07.001. [PubMed] [CrossRef] [Google Scholar]
21. Angelini A, Drago Thousand, Ruggieri P. 2013. Postal service-seismic sea wave primary Scedosporium apiospermum osteomyelitis of the knee in an immunocompetent patient. Int J Infect Dis 17:e646–e649. doi:10.1016/j.ijid.2013.02.011. [PubMed] [CrossRef] [Google Scholar]
22. Kawakami Y, Tagami T, Kusakabe T, Kido N, Kawaguchi T, Omura M, Tosa R. 2012. Disseminated aspergillosis associated with tsunami lung. Respir Care 57:1674–1678. doi:10.4187/respcare.01701. [PubMed] [CrossRef] [Google Scholar]
23. Leechawengwongs Chiliad, Milindankura S, Sathirapongsasuti Grand, Tangkoskul T, Punyagupta S. 2014. Primary cutaneous cryptococcosis acquired by Cryptococcus gattii VGII in a tsunami survivor from Thailand. Med Mycol Case Rep 6:31–33. doi:ten.1016/j.mmcr.2014.08.005. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
24. Engelthaler DM, Hicks ND, Gillece JD, Roe CC, Schupp JM, Driebe EM, Gilgado F, Carriconde F, Trilles L, Firacative C, Ngamskulrungroj P, Castañeda E, dos Santos Lazera One thousand, Melhem MSC, Pérez-Bercoff Å, Huttley G, Sorrell TC, Voelz M, May RC, Fisher MC, Thompson GR, Lockhart SR, Keim P, Meyer W. 2014. Cryptococcus gattii in Northward American Pacific Northwest: whole-population genome analysis provides insights into species development and dispersal. mBio five:e01464-14. doi:x.1128/mBio.01464-xiv. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
25. Mak S, Klinkenberg B, Bartlett 1000, Fyfe M. 2010. Ecological niche modeling of Cryptococcus gattii in British Columbia, Canada. Environ Wellness Perspect 118:653–658. doi:ten.1289/ehp.0901448. [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]
26. Norman SA, Raverty S, Zabek Eastward, Etheridge S, Ford JK, Hoang LM, Morshed M. 2011. Maternal-fetal manual of Cryptococcus gattii in harbor porpoise. Emerg Infect Dis 17:304–305. doi:10.3201/eid1702.101232. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
27. Fenton H, Daoust PY, Forzán MJ, Vanderstichel RV, Ford JK, Spaven L, Lair S, Raverty Due south. 2017. Causes of mortality of harbor porpoises Phocoena phocoena forth the Atlantic and Pacific coasts of Canada. Dis Aquat Org 122:171–183. doi:10.3354/dao03080. [PubMed] [CrossRef] [Google Scholar]
28. Rosenberg JF, Haulena M, Hoang LM, Morshed Thou, Zabek E, Raverty SA. 2016. Cryptococcus gattii type VGIIa infection in harbor seals (Phoca vitulina) in British Columbia, Canada. J Wildl Dis 52:677–681. doi:10.7589/2015-11-299. [PubMed] [CrossRef] [Google Scholar]
29. Nagahama T, Hamamoto K, Nakase T, Takaki Y, Horikoshi Chiliad. 2003. Cryptococcus surugaensis sp. nov., a novel yeast species from sediment collected on the abyssal floor of Suruga Bay. Int J Syst Evol Microbiol 53:2095–2098. doi:10.1099/ijs.0.02712-0. [PubMed] [CrossRef] [Google Scholar]
30. van Uden N, Castelo-Branco R. 1963. Distribution and population densities of yeast species in Pacific water, air, animals, and kelp off southern California. Limnol Oceanogr 8:323–329. doi:10.4319/lo.1963.8.iii.0323. [CrossRef] [Google Scholar]
31. Kutty SN, Philip R. 2008. Marine yeasts—a review. Yeast 25:465–483. doi:10.1002/yea.1599. [PubMed] [CrossRef] [Google Scholar]
32. Burgaud M, Arzur D, Durand Fifty, Cambon-Bonavita MA, Barbier G. 2010. Marine culturable yeasts in deep-sea hydrothermal vents: species richness and clan with fauna. FEMS Microbiol Ecol 73:121–133. doi:x.1111/j.1574-6941.2010.00881.x. [PubMed] [CrossRef] [Google Scholar]
33. Vij R, Cordero RJB, Casadevall A. 2018. The buoyancy of Cryptococcus neoformans is afflicted by sheathing size. mSphere 3:e00534-18. doi:10.1128/mSphere.00534-18. [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]
34. Chang CF, Lee CF, Liu SM. 2008. Cryptococcus keelungensis sp. nov., an anamorphic basidiomycetous yeast isolated from the sea-surface microlayer of the northward-east coast of Taiwan. Int J Syst Evol Microbiol 58:2973–2976. doi:10.1099/ijs.0.65773-0. [PubMed] [CrossRef] [Google Scholar]
35. Chang CF, Lee CF, Lin KY, Liu SM. 2016. Diversity of yeasts associated with the sea surface microlayer and underlying water along the northern declension of Taiwan. Res Microbiol 167:35–45. doi:10.1016/j.resmic.2015.08.005. [PubMed] [CrossRef] [Google Scholar]
36. Hallum SJ. 2018. Marine microbial communities from expanding oxygen minimum zones in the Saanich Inlet off of Southeast Vancouver island. Aureate Analysis Projection ID Ga0257127. Joint Genome Found, Walnut Creek, CA. [Google Scholar]
37. Fine IV, Cherniawsky JY, Rabinovich AB, Stephenson F. 2008. Numerical modeling and observations of tsunami waves in Alberni Inlet and Barkley Audio, British Columbia. Pure Appl Geophys 165:2019–2044. doi:10.1007/s00024-008-0414-nine. [CrossRef] [Google Scholar]
38. Upton A, Fraser JA, Kidd SE, Bretz C, Bartlett KH, Heitman J, Marr KA. 2007. Commencement contemporary case of human infection with Cryptococcus gattii in Puget Sound: evidence for spread of the Vancouver Island outbreak. J Clin Microbiol 45:3086–3088. doi:10.1128/JCM.00593-07. [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]
39. Dromer F, Ronin O, Dupont B. 1992. Isolation of Cryptococcus neoformans var. gattii from an Asian patient in France: evidence for dormant infection in healthy subjects. Med Mycol 30:395–397. doi:10.1080/02681219280000511. [PubMed] [CrossRef] [Google Scholar]
40. Garcia-Hermoso D, Janbon G, Dromer F. 1999. Epidemiological evidence for dormant Cryptococcus neoformans infection. J Clin Microbiol 37:3204–3209. [PMC gratis article] [PubMed] [Google Scholar]
41. Hagen F, van Assen Southward, Luijckx GJ, Boekhout T, Kampinga GA. 2010. Activated dormant Cryptococcus gattii infection in a Dutch tourist who visited Vancouver Island (Canada): a molecular epidemiological approach. Med Mycol 48:528–531. doi:10.3109/13693780903300319. [PubMed] [CrossRef] [Google Scholar]
42. DeBess East, Lockhart SR, Iqbal N, Cieslak PR. 2014. Isolation of Cryptococcus gattii from Oregon soil and tree bark, 2010–2011. BMC Microbiol 14:323. doi:10.1186/s12866-014-0323-2. [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]
43. Mortenson JA, Bartlett KH, Wilson RW, Lockhart SR. 2013. Detection of Cryptococcus gattii in selected urban parks of the Willamette Valley, Oregon. Mycopathologia 175:351–355. doi:x.1007/s11046-013-9614-7. [PubMed] [CrossRef] [Google Scholar]
44. Allan J, Zhang J, O'brien FE, Gabel L. 2018. Columbia River tsunami modeling: toward improved maritime planning response. Oregon Section of Geology and Mineral Industries Special Newspaper 51. ResearchGate doi:10.13140/RG.two.2.14868.14725. [CrossRef] [Google Scholar]
45. U.S. National Research Council, Committee on the Alaska Convulsion. 1972. The great Alaska convulsion of 1964. National Academy of Sciences, Washington, DC. [Google Scholar]
46. Gregory Southward, Ashkenas L, Jett S, Wildman R. 2002. Willamette River Basin planning atlas—inundation inundations/FEMA floodplains, 2d ed, p 28 Oregon Country University Press, Corvallis, OR. [Google Scholar]
47. Etienne KA, Gillece J, Hilsabeck R, Schupp JM, Colman R, Lockhart SR, Gade L, Thompson EH, Sutton DA, Neblett-Fanfair R, Park BJ, Turabelidze G, Keim P, Brandt ME, Deak E, Engelthaler DM. 2012. Whole genome sequence typing to investigate the Apophysomyces outbreak following a tornado in Joplin, Missouri, 2011. PLoS I vii:e49989. doi:10.1371/journal.pone.0049989. [PMC costless article] [PubMed] [CrossRef] [Google Scholar]
48. Othman N, Ismail IH, Yip R, Zainuddin Z, Kasim SM, Isa R, Noh LM. 2007. Infections in post-tsunami victims. Pediatr Infect Dis J 26:960–961. doi:x.1097/INF.0b013e3181257234. [PubMed] [CrossRef] [Google Scholar]
49. Shimizu J, Yoshimoto M, Takebayashi T, Ida K, Tanimoto K, Yamashita T. 2014. Atypical fungal vertebral osteomyelitis in a seismic sea wave survivor of the Corking East Japan Earthquake. Spine 39:E739–E742. doi:ten.1097/BRS.0000000000000317. [PubMed] [CrossRef] [Google Scholar]
50. Engelthaler D, Lewis K, Anderson S, Snow S, Gladden L, Hammond RM, Hutchinson RJ, Ratard R, Straif-Bourgeois S, Sokol T, Thomas A, Mena Fifty, Parham J, Manus S, McNeill M, Byers P, Amy B, Charns Yard, Rolling J, Friedman A, Romero J, Dorse T, Carlo J, Stonecipher S, Gaul LK, Betz T, Moolenar RL, Painter JA, Kuehnert MJ, Mott J, Jernigan DB, Yu PA, Clark TA, Greene SK, Schmitz AM, Cohn Air conditioning, Liang JL. 2005. Vibrio illnesses after Hurricane Katrina—multiple states, August–September 2005. MMWR Morb Mortal Wkly Rep 54:928–931. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5437a5.htm. [Google Scholar]
51. Schneider East, Hajjeh RA, Spiegel RA, Jibson RW, Harp EL, Marshall GA, Gunn RA, McNeil MM, Pinner RW, Businesswoman RC, Burger RC, Hutwagner LC, Crump C, Kaufman L, Reef SE, Feldman GM, Pappagianis D, Werner SB. 1997. A coccidioidomycosis outbreak following the Northridge, Calif, earthquake. JAMA 277:904–908. doi:10.1001/jama.1997.03540350054033. [PubMed] [CrossRef] [Google Scholar]
52. Taleb NN. 2007. The black swan: the impact of the highly improbable. Random Business firm Inc, New York, NY. [Google Scholar]
53. Marí Saéz A, Weiss Due south, Nowak Thousand, Lapeyre V, Zimmermann F, Düx A, Kühl HS, Kaba Chiliad, Regnaut Due south, Merkel Thou, Sachse A, Thiesen U, Villányi L, Boesch C, Dabrowski Pow, Radonić A, Nitsche A, Leendertz SAJ, Petterson S, Becker Southward, Krähling V, Couacy-Hymann E, Akoua-Koffi C, Weber N, Schaade L, Fahr J, Borchert M, Gogarten JF, Calvignac-Spencer S, Leendertz FH. 2015. Investigating the zoonotic origin of the West African Ebola epidemic. EMBO Mol Med 7:17–23. doi:ten.15252/emmm.201404792. [PMC gratis commodity] [PubMed] [CrossRef] [Google Scholar]
54. Dark-brown C, Arkell P, Rokadiya South. 2015. Ebola virus disease: the 'Black Swan' in W Africa. Trop Doct 45:2–v. doi:10.1177/0049475514564269. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
55. Davies Chiliad, Griffin J. 2018. The 2018 Australian probabilistic tsunami take chances assessment: hazard from earthquake generated tsunamis. Record 2018/41 Geoscience Commonwealth of australia, Canberra, Australia. doi:ten.11636/Record.2018.041. [CrossRef] [Google Scholar]
56. Schmertmann LJ, Danesi P, Monroy-Nieto J, Bowers J, Engelthaler DM, Malik R, Meyer W, Krockenberger MB. 2019. Jet-setting koalas spread Cryptococcus gattii VGII in Commonwealth of australia. mSphere 4:e00216-nineteen. doi:x.1128/mSphere.00216-19. [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]
57. Ruiz A, Neilson JB, Bulmer GS. 1982. Control of Cryptococcus neoformans in nature by biotic factors. Med Mycol twenty:21–29. doi:10.1080/00362178285380051. [PubMed] [CrossRef] [Google Scholar]
58. Rizzo J, Albuquerque PC, Wolf JM, Nascimento R, Pereira MD, Nosanchuk JD, Rodrigues ML. 2017. Analysis of multiple components involved in the interaction between Cryptococcus neoformans and Acanthamoeba castellanii . Fungal Biol 121:602–614. doi:10.1016/j.funbio.2017.04.002. [PubMed] [CrossRef] [Google Scholar]
59. Casadevall A, Fu MS, Guimaraes AJ, Albuquerque P. 2019. The 'amoeboid predator-fungal animal virulence' hypothesis. J Fungi (Basel) 5:E10. doi:10.3390/jof5010010. [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]
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