Polio: A Persistent, Perplexing Pathogen Most baby boomers share a common memory of being herded into lines at school

in order to receive a shot or a sugar cube containing a vaccine against poliovirus. I remember a sugar cube in a tiny paper cup. The schoolhouse lines and mass vaccinations have since disappeared, and polio has more or less disappeared too. But sporadic cases still appear mysteriously, and Third World outbreaks can occur for the most foolish of reasons. Polio was a disease made famous—and infamous—by its tragic crippling power (remember leg braces and iron lungs?), its victims (FDR), its conquerors (Salk and Sabin), and its organized enemies (the March of Dimes). Polio is a virus spread from person-to-person. Most polio infections are inapparent. It’s the one percent that spread from the intestinal tract to the nervous system to cause paralysis that made polio such a tragic disease. The legs are affected more often than the arms, and damage to the nerves that control breathing and swallowing could be fatal. In the U.S., polio outbreaks came to an end with the development of the Salk vaccine in 1955 and Sabin’s oral vaccine in 1963. By the end of 1994, North and South America were declared polio-free. Today, that polio-free status is maintained by routine vaccination of children. In Maryland, for example, polio immunization is required for entry into public schools and pre-school programs. (The state’s last case of wild-type polio was 30 years ago.) In 2000, the U.S. Advisory Committee on Immunization Practices recommended switching from the oral Sabin vaccine to the injectable Salk vaccine. Why switch from a few painless drops in the mouth to a series of injections? Well, to prevent the vaccine from causing rare cases of paralytic polio. The oral Sabin vaccine is a live, but weakened variant of the poliovirus. It is capable of causing rare cases of paralysis. (Maryland had six cases of vaccine-

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associated polio between 1978 and 1994.) The injected Salk vaccine is a killed virus preparation and is not capable of causing polio or paralysis. So with polio eradicated in the Americas and a killed vaccine in use in the U.S. since 2000, how would an eight-month-old Amish girl in Minnesota contract polio in the fall of 2005? It’s a mystery with important public health implications for the U.S. and the world. The girl is infected with the oral Sabin vaccine strain of polio. Yet, she has never been vaccinated, and never traveled outside the United States where the live vaccine is still in use. Worse, she has an immune disorder that causes her to shed the virus in her stool. In effect, she is a 21st century version of Typhoid Mary and therefore a potential threat to other unvaccinated or immunodeficient people. That threat is real. Other cases of polio have appeared among Amish farm families in Minnesota. None of them have been paralytic cases, but given enough time to spread among other people the Sabin poliovirus may mutate to a more pathogenic form. That’s what happened several years ago in Haiti and the Dominican Republic when the oral vaccine virus regained its ability to cause paralysis and crippled about two dozen children. Should people continue to use and receive the live Sabin vaccine? The experts are not sure. When the World Health Organization agreed to try to eradicate polio in 1988 they decided to use the Sabin vaccine. It was cheap and easy to administer to children in the developing world. And it worked. When the eradication program began, polio was endemic in 125 countries and crippled 1000 children a day. By 2003, only six countries were still reporting cases of polio. Then disaster struck. Muslim clerics and politicians in northern Nigeria decided the polio eradication program was an infidel plot and halted local vaccinations. David Heymann, the head of polio eradication

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at WHO said, “Nigeria claimed the oral vaccine caused sterility and was part of a Western campaign against Muslims. As a result, the virus spread freely across borders as far away as Yemen and Indonesia, re-infecting 18 countries that had been free of polio.” As of January 3, Nigeria had 675 cases of polio, Yemen had 478 and Indonesia had 297. Immunizations have resumed in Nigeria, but the damage to an 18-year, $3 billion dollar program involving 20 million volunteers in 200 countries may be hard to repair. Can polio be eradicated as smallpox was in 1979? There are serious obstacles, including large numbers of immunosuppressed people, the ability of the live vaccine to cause disease, and the suspicions of people like Nigeria’s Dauda Abdullahi who said, “Only Allah can save us. I don’t trust medicine.” Ironically, Mr. Abdullahi is crippled. From polio.

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