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Poliomyelitis -- Netherlands, 1992
From September 17 through October 9, 1992, five cases of poliomyelitis were reported in the Netherlands among members of religious groups that generally do not accept vaccination. This report summarizes investigations of these five cases by the Netherlands' Office of the Chief Medical Officer of Health, the Laboratory of Virology, National Institute for Public Health and Environmental Protection, and the Municipal Health Services in Rotterdam. The investigation indicated that none of the cases were epidemiologically linked; two of the cases (cases 1 and 2) had some history of receipt of polio vaccine, while three (cases 3-5) had no history of polio vaccination. This report summarizes the investigation of these cases. Case Reports
Case 1. A 14-year-old boy from the province of South Holland had onset of paralysis on September 16. He reported travel to Germany and Belgium during the 3 weeks before onset of paralysis but no travel to known polio-endemic regions. Even though he is a member of a religious group that does not accept vaccination, he had received one dose of monovalent oral poliovirus vaccine (OPV) type 1 during the 1978 polio outbreak that affected his religious group (1,2). Laboratory diagnosis was made by detection of IgM antibodies to poliovirus type 3 in blood and cerebrospinal fluid (CSF) and confirmed by isolation of wild poliovirus type 3 from stools of the patient and three of his siblings. Partial genomic sequencing showed that these isolates are closely related (95% nucleotide homology) to a 1991 isolate from southern Asia. Based on detection of poliovirus type 3-specific IgM antibody, poliovirus type 3 infection was demonstrated in 38 (23%) of 163 children who were members of the same religious group and who attended the same school as the patient's younger siblings, but in three (2%) of 163 children who attended a neighboring school in the same village and who had received a primary series of enhanced-potency inactivated poliovirus vaccine (eIPV) as part of the infant vaccination schedule.
Case 2. A 23-year-old male student nurse from South Holland had onset of paralysis on September 26. He had no history of travel to known polio-endemic regions. He had received a first dose of eIPV 1 day before onset of paralysis as part of a vaccination program for health-care workers. Laboratory diagnosis was initially made by detection of poliovirus type 3-specific IgM antibody in blood and confirmed by isolation of poliovirus type 3.
Case 3. A 6-year-old boy from the province of Utrecht had onset of meningitis on October 6. Laboratory diagnosis was initially made by detection of poliovirus type 3-specific IgM antibody in blood and CSF and confirmed by virus isolation.
Case 4. A 39-year-old man from South Holland had onset of paralysis on October 6. Laboratory diagnosis was initially made by detection of poliovirus type 3-specific IgM antibody in blood and CSF and confirmed by virus isolation.
Case 5. A 33-year-old man from South Holland had onset of paralysis on October 7. Laboratory diagnosis was initially made by detection of poliovirus type 3-specific IgM antibody in blood and CSF and confirmed by virus isolation. Investigation and Follow-up
Investigations of the extent of transmission are being conducted in the unvaccinated groups. Environmental sampling studies for poliovirus are in progress within the areas with persons considered to be at highest risk and are planned for areas elsewhere in the Netherlands.
Since the first case was identified, public health officials in the Netherlands have initiated intensive efforts to vaccinate members of the groups at risk, including one dose of trivalent OPV to persons aged less than 41 years who have never been vaccinated and one dose of diphtheria and tetanus toxoids and poliovirus vaccine or eIPV to persons less than 41 years who were incompletely vaccinated.
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: In the United States, the last outbreak of wild poliovirus occurred in 1979, when 10 cases of paralytic poliomyelitis were reported in four states among unvaccinated Amish persons and members of other religious groups who did not accept vaccination (3). Epidemiologic and virologic studies suggested that the wild poliovirus type 1 involved in that outbreak was imported -- through contacts in Canada (4,5) -- from an unvaccinated religious group in the Netherlands, among whom 80 cases of acute paralytic poliomyelitis had occurred in 1978 (2).
Recent studies in the Netherlands indicate that more than 97% of infants receive the first three doses of eIPV, and more than 94% receive all five doses of eIPV by the age of 1 year. OPV is used only to control outbreaks. Since the last outbreak in 1978, no indigenous cases of poliomyelitis had been reported in the Netherlands before the five cases reported here (6).
Because the ratio between infection and paralytic disease for poliovirus type 3 exposure can be as high as 1000:1, the detection of five cases in the Netherlands suggests a much larger number of infections has occurred within the country (7). The high degree of homology of this virus and a recent isolate from southern Asia again demonstrates that wild virus can be spread to populations of susceptible persons living far from endemic regions, and reinforces the need to intensify efforts to achieve the World Health Assembly goal of global polio eradication by the year 2000 (8).
At present, the risk for acquiring poliomyelitis in the Netherlands is minimal because of the excellent sanitary conditions and the high nationwide coverage for polio vaccination. Therefore, CDC does not recommend special precautions for U.S. travelers who have received a primary series of poliovirus vaccine as part of the infant vaccination schedule.
The 1979 polio outbreak illustrated the risk for unvaccinated members of religious groups in the United States who have direct or indirect contact with members of religious groups elsewhere in North America or the Netherlands among whom poliovirus is circulating. Such persons should continue to be warned of the potential risk for poliomyelitis resulting from this outbreak and should be encouraged to accept polio vaccination according to recommendations of the Advisory Committee on Immunization Practices (9,10). Recommendations include a primary series of three doses of OPV for unvaccinated persons aged less than 18 years, three doses of eIPV for unvaccinated persons aged greater than or equal to 18 years, and either OPV or eIPV for incompletely vaccinated persons aged greater than or equal to 18 years. Booster doses of either OPV or eIPV may be considered for persons who have completed a primary series of polio vaccination.
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