Science

Outbreak of Polio Alarms Officials

By LAWRENCE K. ALTMAN Published: October 08, 1991

IN a major step toward a goal of eradicating polio from the world by 2000, health workers have virtually stopped the spread of the paralytic infection in the Americas. But the World Health Organization's campaign to wipe out polio as it did smallpox has recently been threatened by a large and surprising outbreak of polio among an immunized population in the Middle Eastern country of Oman. Experts say the reasons for the failure in Oman are mysterious and that without the prospect of an explanation no one can say if the outbreak represents a one-time anomaly or will prove to be the Achilles heel of the global effort. But one gauge of the problem is that a proposed remedy would add some $1.5 billion to the campaign's cost. Experts from the W.H.O., the Centers for Disease Control in Atlanta and Oman investigated the outbreak and were perplexed to find that 118 children, including many who were vaccinated, developed polio despite a program that immunized 87 percent of Oman children by age one year. A few similar outbreaks have occurred in Taiwan, Gambia and Brazil. But experts said Oman was the most dramatic and best documented. Nevertheless, health officials and experts said in interviews that they do not intend to abandon the goal of eradicating polio. New, Costly Tools "We expected a number of surprises when we undertook the program, and we are fully confident we can develop the tools to overcome them," said Dr. Ralph H. Henderson, an assistant director general of the W.H.O. in Geneva. In a recent report in The Lancet, a respected medical journal, the investigators of the Oman outbreak warned that extra techniques may be needed to eradicate polio. Among them are these: *Mass immunization campaigns to bombard everyone at once. *Use of the injectable Salk-type vaccine as well as extra doses of the usual Sabin vaccine, taken by swallowing. *The development of new vaccines. These techniques could cost an additional $1.5 billion during the decade due to the extra doses of vaccine and its rising cost, said Dr. Nicholas A. Ward of the W.H.O. In the case of the smallpox eradication campaign, to which the United States contributed $32 million over 10 years, the savings from ceasing vaccinations are many times the cost of eradication. Some experts believe polio cannot be eradicated without improving the vaccine. One is Dr. Donald A. Henderson, who ran the W.H.O. smallpox eradication program and who now is associate director for life sciences of the Office of Science and Technology Policy in the White House. The Hendersons are not related. Only 4 Cases in Americas Dr. James O. Mason, the assistant secretary of the Federal Department of Health and Human Services, said he "would not back off the goal" because of the Oman outbreak. But Dr. Mason urged W.H.O. to convene experts to address the question. "If it isn't eradicable and you just plunge ahead, then you will just lose credibility," Dr. Mason said. Around the world, about 200,000 children a year are estimated to contract polio. In the United States, the last outbreak due to natural infection occurred in 1979. Health officials extended the vaccination program to the rest of the Americas, with spectacular success. The Pan American Health Organization in Washington says that only four cases of polio have been detected in the Americas this year -- three in Colombia and one in Peru -- and none since April. Experts are meeting this week to review data on polio eradication in the Americas, including a program this summer to improve vaccine delivery in Colombia. "Transmission may already have stopped in Colombia" and possibly Peru, said Dr. Ciro A. DeQuadros, who heads the program for the Pan American Health Organization. Polio had disappeared from Oman until January 1988, when the latest outbreak was detected. Although Oman was not immunizing according to W.H.O.'s recommended schedule, experts said they doubted that that breach alone explained the outbreak. Striking a Protected Area One reason is that polio struck hardest in the region of Oman that had one of the highest immunization rates. "What was new in Oman was an outbreak of this magnitude after the vaccine was administered properly and indeed had a fairly high efficacy," said Dr. Peter A. Patriarca, an epidemiologist at C.D.C. who investigated the outbreak. Dr. Patriarca's team said an exhaustive search found no probable cause for the outbreak. The vaccine was stored properly, no breaks in technique could be identified, and tests showed its potency met W.H.O. standards. Studies showed that the virus had not mutated. The strain PM Generated by www.PDFonFly.com at 6/27/2011 9:10:03
URL: http://www.nytimes.com/1991/10/08/science/outbreak-of-polio-alarms-officials.html?pagewanted=print&src=pm

causing the outbreak had been imported from Asia. The scientists concluded that a substantial proportion of fully vaccinated children were somehow involved in the chain of transmission, Dr. Patriarca said. "You could not explain it solely by the virus going from one unvaccinated kid to the next," he said. Dr. deQuadros, the Pan American Health Organization official, strongly disagreed. "If that explanation was correct, the Americas would be full of polio and it would be impossible to eradicate polio," he said. "If they are correct, they deserve the Nobel Prize and we will have to stop the program in the Americas because what we are doing would be nonsense. They had the wrong strategy and they did not have a model immunization program." Dr. deQuadros believes that mass vaccination programs are needed to eradicate the infection. "Polio was eliminated from the industrialized countries by mass vaccination programs and in the end it was a mass vaccination program that stopped the outbreak in Oman," he said. A Better Vaccine Epidemiologists have noted that a complete series of polio immunizations protect almost 100 percent of recipients in developed countries but only about 70 percent in developing countries. The reasons for the difference are not known. But scientists are exploring several explanations, including the way the vaccine is given and interference from other viruses and components of breast milk, said Dr. Peter F. Wright, head of pediatric infectious diseases at Vanderbilt University in Nashville. Epidemiologists have also noted that polio immunization programs give better protection in dry seasons when fewer viruses are circulating and children are relatively free of diarrhea. The potency and stability of the polio vaccine remains a problem. "It is an article of faith that we can eradicate polio with the existing vaccine," Dr. Donald Henderson said. He noted that improvements were needed to keep polio vaccine potent for long periods without refrigeration in tropical areas and to protect 90 percent of recipients after two administrations. Most infectious diseases are not candidates for eradication because they also infect animals or the microbes exist in nature. Attempts have been made to eradicate a few diseases, like malaria, yellow fever and measles. All but the smallpox effort failed, in part because such attempts were explorations in uncharted waters and were thwarted by unexpected problems. Even with smallpox, health workers had to change tactics midstream to overcome obstacles. "We thought we knew everything about polio," said Dr. Ralph Henderson in Geneva. "But there is a lot we didn't know and a lot we have to learn." Oman has shown that a key will be finding the right strategy.

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