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Update: Poliomyelitis Outbreak -- Netherlands, 1992

The outbreak in the Netherlands of poliomyelitis among unvaccinated persons who are members of religious groups that generally do not accept vaccination is continuing (1). From September 17 through December 5, 1992, 54 cases of poliomyelitis were reported to the Netherlands' Office of the Chief Medical Officer of Health (Figure 1). Of the 54 patients, 41 (76%) had paralytic manifestations of this illness; one neonate died, and 12 patients had aseptic meningitis. Fifty-one (94%) of the cases have been laboratory confirmed: 40 patients had wild poliovirus type 3 isolated from stool, and 11 had IgM-specific antibody to poliovirus type 3 suggestive of recent infection. All of the reported cases have occurred among unvaccinated (n=53) or inadequately vaccinated (n=1) persons belonging to a religious denomination that routinely does not accept vaccination. Patients ranged in age from less than 1 month to 56 years (mean age: 18.9 years). Of the 12 provinces in the Netherlands, seven have reported cases of poliomyelitis; the most severely affected provinces are South Holland and Gelderland. Reported by: JK van Wijngaarden, MD, Div of Infectious Diseases, Office of the Chief Medical Officer of Health; AM van Loon, PhD, P Oostvogel, MD, MN Mulders, MSc, Laboratory of Virology, National Institute for Public Health and Environmental Protection; J Buitenwerf, PhD, Laboratory of Virology, CF Engelhard, MD, Dept of Infectious Diseases, Municipal Health Svcs, Rotterdam, the Netherlands. World Health Organization, Geneva. Div of Immunization, National Center for Prevention Svcs; Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The poliomyelitis epidemic in the Netherlands continues despite control measures initiated by the Dutch health authorities, including offering oral poliovirus vaccine to all previously unvaccinated persons belonging to affected religious groups and to other previously unvaccinated persons aged less than 41 years and offering one dose of enhanced-potency inactivated poliovirus vaccine to persons who are incompletely vaccinated. Based on the ratio of cases of asymptomatic infection to paralytic disease for persons infected with poliovirus type 3 (at least 1000:1) (2), an estimated 54,000 persons in the Netherlands may have been infected with wild poliovirus type 3 during this outbreak. Therefore, the risk for infection may be greater than previously assumed for unvaccinated or inadequately vaccinated travelers to the Netherlands. In addition, the potential for spread of this poliovirus to other areas (including the North American continent) by asymptomatically infected travelers from the Netherlands -- even if not directly linked to a clinical case -- also may be higher than previously assumed.

To prevent transmission of imported polioviruses and cases of paralytic disease in the United States, increased efforts are necessary to vaccinate all unvaccinated or inadequately vaccinated persons in the United States in accordance with recommendations of the Advisory Committee on Immunization Practices (3,4). Public health agencies and health-care providers should intensify outreach, especially to unvaccinated persons in these religious communities who do not routinely accept vaccination.

The risk for acquiring poliomyelitis while in the Netherlands is considered small because of the excellent sanitation in the country and because transmission of the poliovirus has been limited primarily to unvaccinated religious groups. Nonetheless, the polio immunity of travelers to the Netherlands should be evaluated, and persons with inadequate protection should complete a primary vaccination series with three doses of poliovirus vaccine before departure. For travelers with a completed primary series of poliovirus vaccine, it may be prudent to obtain one dose of poliovirus vaccine before departure, especially if extensive travel in the Netherlands or contact with persons in the affected religious groups is anticipated.


  1. CDC. Poliomyelitis -- Netherlands, 1992. MMWR 1992;41:775-8.

  2. Salk JE. Requirements for persistent immunity to poliovirus. Tr Ass Am Physicians 1956; 69:105-14

  3. CDC. Poliomyelitis prevention. MMWR 1982;31:22-6,31-4.

  4. CDC. Poliomyelitis prevention: enhanced-potency inactivated poliomyelitis vaccine--supplementary statement. MMWR 1987;36:795-8.

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