Paralytic Polio Research Articles

Cluster Survey for Poliomyelitis and Neonatal Tetanus in Ilorin, Nigeria

The incidence of poliomyelitis and neonatal tetanus in Ilorin Local Government Area was estimated using a 40-cluster, retrospective survey of neonatal tetanus deaths and lameness from poliomyelitis in March and April 1988. The survey identified 19 neonatal tetanus deaths among 1601 livebirths, giving an incidence rate of 14.9/1000 livebirths. Some 31 residual paralytic polio cases were identified among 4576 children aged five to nine years, giving a prevalence rate of 6.8/1000 children in this age group and an annual incidence rate of 38.3/100,000 general population. Immunization of pregnant women with tetanus toxoid, had a greater impact on mortality from neonatal tetanus than delivery in hospital or birth at home attended by a traditional birth attendant. Antenatal coverage with two doses of tetanus toxoid was 62.6%. Poliomyelitis and neonatal tetanus still constitute important causes of childhood morbidity and mortality in Ilorin and antenatal tetanus immunization coverage is not yet sufficient to control neonatal tetanus in this population. The target age for immunization with tetanus toxoid should be extended to include all women of childbearing age. Further retrospective surveys from other Nigerian states are needed to determine the magnitude of the neonatal tetanus problem throughout the country.

Poliovirus Vaccine Policy-Reply

In Reply .—Dr Bader's thoughtful comments merit consideration now and for the future. If, indeed, the state of Washington has a vaccine-associated paralytic polio rate of 1 per 100 000, it differs markedly from the rest of the nation where careful surveillance and annual review of reported alleged cases by an expert committee have consistently disclosed an overall rate of 1 per 2.7 million poliovirus vaccine live oral trivalent (TOPV) doses or 1 per 560 000 first doses of TOPV. From 1975 to 1986, 107 cases were labeled vaccine-associated paralytic disease, of which 37 were in recipients and 48 in contacts. If Washington has a higher rate, it may resemble the unexplained geographic (or possibly genetic) aberrations observed in some other infectious diseases studies such as the unusual results in Minnesota with the initial studies of Haemophilus influenzae type B polyribose phosphate vaccines in contrast to the efficacy studies in

A ten-year experience in control of poliomyelitis through a combination of live and killed vaccines in two developing areas.

We describe a successful program of poliomyelitis control using a combination of killed and live polio vaccines over a 10-year period in two developing areas, the West Bank and Gaza, adjacent to a relatively developed country, Israel. During the 1970s, immunization using live trivalent oral polio vaccine (OPV) in these areas covered more than 90 percent of the infant population. Nevertheless, the incidence of paralytic polio continued to be high, with many cases occurring in fully or partially immunized persons. It was thought that this could be due to interference with OPV take by other enteroviruses present in the environment due to poor sanitary conditions in these areas. A new policy combining five doses of OPV with two doses of inactivated polio vaccine (IPV) was adopted and implemented in 1978. In the 10 years since then, immunization coverage of infants increased to an estimated 95 percent and paralytic poliomyelitis has been controlled, despite exposure to wild poliovirus from neighboring countries including an outbreak in Israel in 1988. This experience suggests that wide coverage using the combination of IPV and OPV is an effective vaccination policy that may make eradication of polio possible even in developing areas.

A new epidemiologic and laboratory classification system for paralytic poliomyelitis cases.

An epidemiologic classification of paralytic poliomyelitis cases (ECPPC) has been in use in the United States since 1976. In 1985, this classification system was reviewed because of recent changes in the epidemiology of paralytic poliomyelitis and improved laboratory capability to definitively characterize poliovirus strains. An alternative classification system was devised, the epidemiologic and laboratory classification of paralytic polio cases (ELCPPC), that incorporated virus isolation and strain characterization with epidemiologic information. Reported paralytic poliomyelitis cases for 1980-86 were classified by both the ECPPC and the ELCPPC classification systems. The new ELCPPC system classified 91 per cent of the reported cases as vaccine-associated, while the ECPPC system classified only 71 per cent of the reported cases as vaccine-associated. The proposed classification system provides more specific and useful information particularly concerning vaccine-associated paralytic poliomyelitis.

Polio Policy: A Bitter Pill to Swallow

Polio Policy: A Bitter Pill to Swallow

Temporary disability among independently living adults with major disabling conditions.

There is substantial evidence of the permanent disabling effects of such conditions as spinal cord and head injuries, cerebral palsy, paralytic polio, and such degenerative neurologic conditions as multiple sclerosis and muscular dystrophy.1 There is also considerable evidence that people with these conditions require extraordinary amounts of acute hospital care.1-7 However, there are few data on temporary morbidity or disability among those with major disabling conditions, particularly those who live independently in the community rather than in institutions.

Vaccination against poliomyelitis: present possibilities and future prospects.

As long as the World Health Organization continues to report that more than 250,000 cases of paralytic poliomyelitis occur annually in developing countries, the United States must be prepared for periodic exposures to wild virus.' Until poliomyelitis is brought under control throughout the world, it behooves us to maintain a high level of vaccine-induced immunity. Hinman and his colleagues from the federal Centers for Disease Control, in the first paper in this series,2 document how well this has been achieved in the nation through the widespread use of OPV. From more than 20,000 cases of paralytic poliomyelitis in 1952, we now have a situation where endogenous wild poliovirus seems to have disappeared from the United States; and when the few imported cases are considered, there is virtually no spread of virus from them. Unfortunately, OPV, like other vaccines, is not perfect, although it is more nearly perfect than most. About five or six vaccine-associated cases now occur per year. Over the past 15 years more cases have occurred in contacts, particularly household contacts, than in the vaccinees. This is not surprising since it was known even before licensing that the virus excreted by vaccinated children was less attenuated than the vaccine itself, having regained some neurovirulence in monkey tests.3 At that time, some recommended that families be vaccinated as units, to avoid exposing susceptibles to mutated virus from the vaccinee. Had that been done, contact cases would have been avoided. The issues raised by the foregoing Hinman/Salk papers2'4 hinge on the possible shift in immunization policy from OPV to IPV. One of the public health axioms on which I was brought up is that if a large-scale program is working wellsuch as reducing the burden of paralytic polio from 20,000 cases per year to less than 10 per year-it should not be tinkered with unless we are certain that the resultant effect will be an improvement. Ifwe had used IPV, it is doubtful that we would have been as successful as the Dutch and the Scandinavians-and even those homogenous populations with their excellent vaccine coverage have had some outbreaks during recent years which, if extrapolated to our large population, would have meant many hundreds of paralytic cases and over a million carriers of wild virus. There is reason to consider a properly timed combination of both IPV and OPV. Such a program would not have any possibility of raising the risk of OPV-associated poliomyelitis and indeed may eliminate cases altogether. Combined IPV/OPV vaccine regimens have proven successful in the tropics where the local population had been subjected to regular and high importation of virus from neighboring countries, resulting in frequent wild virus challenge very early in infancy5'6 In such environments, the killed poliovac-

Paralytic poliomyelitis in Benin city in Nigeria

Up to 1956, poliomyelitis was not recognised to be a major problem in the West African population. It was not surprising therefore that Gelfand and Miller in their published work in the same year did not recommend prophylactic polio vaccination for the 1 2 indigenous population. It was not until 1961 that Collis et al. established the fact that poliomyelitis was a major problem in the childhood population of Nigeria and strongly advocated polio vaccination as a public health measure. Bradford Hill and Knowelden 3 demonstrated an association between paralytic polio and intramuscular innoculation of diphtheria or combined vaccine within 28 days prior to onset of paralysis. Later in Australia, paralysis was observed to have followed intramuscular injections during a poliomyelitis epidemic. 4 In Nigeria, Collis et al. 2 also suggested that injections predisposed Nigerian children to paralytic polio. The purpose of this study is to examine the pattern of paralytic poliomyelitis in Benin City, an urban setting, and the association of intramuscular injection with the paralytic disease.

Infectious complications of the primary immunodeficiencies

The primary manifestation of the immunodeficiencies is undue susceptibility to infection. This means too many, too severe, too prolonged, too complicated, and too unusual infections. Infections in immunodeficiency have a characteristic cause depending on the nature of the immune deficiency. Antibody deficiencies are associated with infections with gram-positive infections. Cellular immune deficiencies are associated with mycobacterial, protozoan, fungus, virus, and opportunistic bacterial infection. Phagocytic disorders are associated with staphyloccoccal, fungal, and gram-negative organisms. Complement disorders are associated by neisserial infections. Infections have also been implicated in the pathogenesis of some immunodeficiencies in some circumstances. These include human T lymphotropic virus type III (HTLV-III), rubella virus, cytomegalovirus, and Epstein-Barr virus. Several infectious syndromes in specific immunodeficiencies have been identified. Examples include enteric cytopathic human orphan (ECHO) virus encephalitis in agammaglobulinemia, and meningococcal meningitis in C6 deficiency. Infections can also be induced by liver vaccines given in immunodeficiency (e.g., paralytic polio in agammaglobulinemia.) Unusual infectious syndromes will be illustrated including parainfluenza infection in severe combined and immunodeficiency. Legionella pneumonia in chronic granulomatous disease, and Cryptosporidium infection in hyper-IgM immunodeficiency.

Molecular approaches to vaccines.

Recombinant DNA (rDNA) and monoclonal antibody technologies are being used to develop new types of vaccines that are expected eventually to sup-plement or supplant conventional whole-agent vaccines for both animals and humans. Impetus for the new vaccines stems from findings that the surface proteins of most infectious agents possess immunogenic activity and that the corresponding genes can be manipulated to produce these products in quantity devoid of the infectious agents themselves. In addition, conventional vaccines that employ killed and attenuated viruses have certain limitations. For example, standard methods have failed to produce effective vaccines for many important diseases, including hepatitis A and B, and for most diseases caused by retroviruses, herpes viruses, and parasites, including those that cause malaria, trypanosomiasis, and anaplasmosis. Also, attenuated whole-agent vaccines can cause acute or slowly progressive diseases in immunodeficient individuals or in alternate animal hosts. Live poliovirus vaccine produces a few cases each year of paralytic polio in vaccinees or their contacts (91). Even so-called killed virus vaccines can contain infectious particles. This was the case with some of the early batches of commercially produced, inactivated poliovirus vaccine, and is still the case for foot-and-mouth disease (FMD) virus vaccines in wide use today. At least 44% of the outbreaks of FMD in Europe from 1968 to 1981 were caused by incomplete inactivation procedures or the escape of virus from vaccine manufacturing facilities (43). Whole-agent vaccines can also induce postvaccinal sequelae, including pyrogenic and allergic reactions, and Guillain-Barré and other neurological syndromes as well as immune enhancement of disease, e.g., dengue-2 virus infections of young children (62).KeywordsCold Spring Harbor LaboratoryBovine Viral Diarrhea VirusBovine Leukemia VirusInfectious Bronchitis VirusSubunit VaccineThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Vaccine preventable disease on campus.

Abstract Vaccine preventable diseases (VPD) have declined as a cause of morbidity and mortality in the United States. From more than 500,000 cases of measles reported annually in the prevaccine era, there were only 1,436 cases reported in 1983 (38% on college campuses); from more than 12.5 million reported cases of acquired rubella and 20,000 cases of congenital rubella syndrome (CRS) reported in 1964, there were only 954 reported cases of rubella (an unknown number occurred on campuses) and 4 cases of CRS reported in 1983. Only 6 cases of diphtheria (1 occurred on a campus), 8 cases of paralytic polio, and 75 cases of tetanus were reported in 1983 in the United States. While these declines have been dramatic, significant morbidity from these VPDs persist. Up to 25% of college age adults remain susceptible to measles and rubella. Most students would be eligible for their first booster (10 years after preschool dose) at the time of college entrance, 62% of young adults (18–39 years of age) are estimated to...

Did thalidomide promote poliomyelitis following oral poliovirus vaccination in West Berlin in 1960?

DID THAUDOMIDE PROMOTE POLIOMYELITIS FOLLOWING ORAL POUOVIRUS VACCINATION IN WEST BERUN IN 1960? H. V. WYATT* When the Cox-Lederle oral poliovaccine (OPV) was used in West Berlin, there were a number ofapparently coincident vaccine-associated cases (VAC) [I]. The Cox-Lederle vaccine was abandoned, but the explanations of the incident are unconvincing [2, 3]. In this paper, a new explanation is offered: that drugs or other agents may promote entry of poliovirus to the CNS and that provocation by injection is a special type of promotion. The West Berlin Incident, 1960 About 290,000 people were given OPV between May 1 1 and 20, 1960, and 25 cases ofpoliomyelitis occurred within the next 4 weeks [I]. These cases occurred 2-3 months earlier than the usual epidemic season [4, fig. 1], and the opinion has been that these cases were associated in some way with the vaccine [3, 4]. Raettig did not think that the vaccine was virulent enough to cause the cases [4], and virus recovered from cases was similar to or only very slightly changed from the vaccine virus [5]. Raettig considered that the vaccine virus stimulated wild virus to invade the bloodstream and CNS. There is no evidence that this invasion occurred in Berlin or anywhere else: Wilson was not convinced [3]. The peculiar features of the incident are puzzling and fit no simple explanation (table 1)· Nevertheless, let us consider the following hypothesis: (1) the vaccine virus caused the cases of illness, but the virus had not become more virulent; (2) the cases occurred in nonimmune persons who were tem- * Reader in microbiology, University of Bradford, Bradford, BD7 IDP, United Kingdom . On sabbatical as honorary research associate, Department of Bacteriology and Virology , University of Manchester, Manchester M13 9PT, United Kingdom. Present address : 1 Hollyshaw Terrace, Leeds LSI5 7BG, United Kingdom.© 1983 by The University of Chicago. All rights reserved. 0031-5982/84/2701-0364$01.00 Perspectives in Biology and Medicine, 27, 1 ¦ Autumn 1983 | 93 TABLE 1 Features of the West Berlin Incident Following Use of the Cox-Lederle OPV Berlin, I960 OPV Implicated 25 cases within 30 days of OPV Cases 2-3 months early ........ Abrupt cessation after 30 days . Cases more severe in contacts . . Cases randomly distributed Ages of the cases did not correspond with the age groups receiving OPV .......... Virus from cases still vaccine-like .......... First cases were vaccinées ................. No secondary cases from initial cases ...... Attack rate x 15 in vaccinées ............. Two-thirds of cases in adults .............. Yes Yes ? ? ? No No ? ? Yes ? Comments But cases also early in West Germany [1] Expected because contacts were mainly adults [1] Implicates OPV rather than wild virus but suggests no reversion of OPV Vaccinées were groups with low immunity Suggests no reversion to virulence Unexpected because more adults would be immune porarily more susceptible to vaccine virus; and (3) persons temporarily more susceptible were present in both West Berlin and West Germany. Most of the peculiar features of the incident would then be explained. It has recently been proposed that there is genetic susceptibility to poliomyelitis, and the model [6] has been tested against data from many epidemics [7]. Burnet has suggested that "there is good reason to believe that paralytic polio . . . dependfs] more on the presence of individual genetic susceptibility to an initiated infection than to the virulence or dose of the infecting strain" [8]. The genetic model predicts that more people become susceptible with age; this might explain the other peculiarities. A few hypogammaglobulinemics and perhaps those people who have a very slow synthesis of antibody are peculiarly susceptible to paralysis from vaccine strains of poliovirus [9, 10] and to infections of the CNS by ECHO virus [10]. An immunosuppressive agent might therefore allow entry ofvaccine virus to the CNS. It has also been suggested that entry of poliovirus to the CNS occurs following inflammatory reactions at peripheral nerve endings [H]. The chance reading that thalidomide caused peripheral neuritis [12] and immunosuppression [13, 14] and was widely sold in 1960 in West Berlin [12] suggested that thalidomide might have been associated with the use of the OPV in West Berlin. The hypothesis and the mechanism are tested in this...

Supracondylar Femoral Extension Osteotomies in the Treatment of Fixed Flexion Deformity of the Knee

Thirty-two supracondylar osteotomies of the femur were performed in 20 patients for the correction of fixed flexion deformity of the knee. The patients ranged in age from two to 36 years, with an average follow-up period of 4 1/2 years. Two-thirds of the patients had underlying paralytic disease, either meningomyelocele or polio. Generally, the procedure was employed only in recalcitrant cases in which other more conservative methods had failed. Femoral shortening was the key to success. Although there was a significant complication rate, including fractures, infection, and recurrence, there were no permanent neurologic sequelae or non-unions. All patients eventually obtained satisfactory correction and function. Despite the morbidity, supracondylar extension femoral osteotomy was an effective means of treatment when more conservative methods had failed or when the deformity was particularly severe.

Immunization: What's It All about?

Many of today's parents have not experienced the impact of the contagious diseases of childhood. Many believe that immunizations are unnecessary now because the diseases are disappearing. However, except for smallpox, the antigens to most childhood diseases cannot be eliminated from the environment. More than one-third of American children have not developed complete protection against measles, mumps, rubella, diptheria, pertussis, tetanus, and polio. This rises to almost 50 percent among the inner-city and disadvantaged populations. Not protecting children against these diseases is considered by some a form of child neglect. Nineteen million Americans are not immunized against polio, and yet paralytic polio was reported in the U.S. in 1980. Twelve to fifteen million Americans are not immunized against DPT and rubella. Twelve million Americans are not immunized against measles, and many more probably don't have sufficient titers. Americans have become lax in protecting their children from these communicable diseases, even though 48 states require immunization for entry into schools. Somehow, too many of our children are not being adequately immunized. We cannot afford this practice. Immunizations are vital to world health. What is an immunization? How does it work? What diseases should we protect against and why? The potential value of immunization was first recognized in 1796 by Edward Jenner when he developed an immunization against smallpox. This disease is the first one to be 100 percent eradicated. The goal of immunization, to prevent or lessen the severity of an infectious disease process by the administration of an antigen (active immunity) or an antibody (passive immunity), has not changed since Jenner's day. Immunity is defined as all those physiological mechanisms that endow the animal with the capacity to recognize materials as foreign to

The problem of paralytic poliomyelitis in the urban and rural population around Lucknow, India.

A house to house survey was done from October 1972 to March 1974, covering 528952 individuals of urban population at Lucknow and 50,156 individuals of rural population of Unnao district, to find out the incidence of polio-like paralysis in our population. Among 12874 urban children up to 8 years old 8.2/1000 had polio-like paralysis while 4.6/1000 children of the rural population of 13554 children were affected. The incidence was significantly higher in the urban population. In the preschool age group almost 1 out of every 100 children was affected. A higher number of children were affected during 1968-9 and 1971-2, though it did not reach epidemic proportion. The findings show that paralytic polio is a serious problem in our country where poliomyelitis is endemic: this is contrary to the views generally held so far.

Polio—Out of Sight, Out of Mind

An entire generation of Americans has grown up with only a faint concept of the meaning of the word poliomyelitis. Most physicians who began their medical practice after the mid-1950s have never seen a person with paralytic polio. In the major epidemic years of the 1940s and 1950s, as many as 50,000 or more cases of clinical polio, with many deaths, were reported. An even more grim aftermath was the thousands of children and young adults left (more or less) crippled. At one time, some 2,000 persons were permanent residents of the iron-lung respirators as a result of crippling polio. But widespread use of polio vaccines since 1955 has resulted in the virtual elimination of paralytic poliomyelitis in the United States. The number of reported cases of paralytic poliomyelitis declined from more than 18,000 in 1954 to 32 cases in 1970 to only eight cases in 1976. The mass polio

Live oral poliovirus vaccine, type 3.

To the Editor.— Early fears that live oral poliovirus vaccine, monovalent type III might produce disease in the young adult group have not been borne out in the military population. The US Army has administered type III live oral poliovirus vaccine to more than 3.5 million young adults since 1963. The vaccine initially used was monovalent, given four to six weeks after type I monovalent vaccine in either one of two schedules. Since 1966 trivalent oral poliovirus vaccine has been given either as two doses eight or more weeks apart or as two doses four weeks apart followed by a third dose eight or more weeks later. Since June 1964, no cases of paralytic polio have been reported in US Army personnel. During this same period several hundred thousand adult military dependents also received the vaccine. No vaccine-associated cases have been reported to us from among this group. Therefore, it

More Vaccines Promised

THE DECLINE of poliomyelitis among more than 350 million people of the world was cited at a meeting in Washington by speakers from many nations as offering a promise of vaccines that will soon be used against other diseases considered hopeless or untreatable until recently. Vaccines against some of the many viruses causing the common cold, as well as those causing rubella, mumps and other diseases are on the way. Although both Drs. Jonas Salk and Albert B. Sabin have taken part in polio vaccine campaigns, SCIENCE SERVICE learned in an interview with a husband and wife team from the Institute of Poliomyelitis and Virus Encephalitides, Moscow, that more than 160 million persons in the USSR and 30 other countries have been immunized with strains from the Sabin oral live vaccine introduced in Russia only six years ago. Dr. Mikhail P. Chumakov and his wife, Dr. Marina K. Voroshilova who served as translator in the interview, pointed out that their institute produces vaccine for distribution not only within the USSR but to Nigeria, Uganda, Greece, India and other countries trading with the USSR. Nevertheless, although paralytic polio has been largely conquered in the countries where vaccines have been given, these are mainly in areas of temperate climate and good health services. Much remains to be done in the underdeveloped countries and among people who do not avail themselves to the vaccines. The tropical countries especially present a problem, where polio cases have been increased from about 1,500 a year during the previous 10 years to 7,000 or more a year in the mid-nineteen-sixties. Dr. Sabin and Dr. Chumakov were among the speakers at the International Conference on Vaccines Against Viral and Rickettsial Diseases of Man. Rickettsial diseasestyphus, Q fever, Psitticosis, and the like-are caused by bacteria-like organisms-parasites carried by ticks, lice and other living creatures. The week-long meetings, sponsored by the Pan American Health Organization and the World Health Organization were introduced by Dr. Abraham Horwitz, director, who said that although the vaccines being studied today are complex, the problems are not insoluble. The conference is a continuation of discussions started a few years ago under the same sponsorship on live poliovirus vaccines. Dr. Sabin estimated that in the past six years more than 350 million people have received oral poliovirus vaccine in most of the countries of Europe and North America, and many countries or regions in South America, Africa, Asia and Oceana. Czechoslovakia, with a population of about 14 million, has been most outstanding in vaccination coverage. From 1960 to the present time there has not been a single confirmed case of paralytic polio of local origin, Dr. Sabin said, due to the vaccination since 1961 of new generations of children who were vaccinated each spring and revaccinated the following year. Spain and Italy, with larger and more diverse population groups and climates, show examples of the rapid effect of different kinds of mass campaigns with oral vaccine but without elimination of some centers of the naturally occurring polioviruses, Dr. Sabin explained. Japan is an example of a large country with highly developed health services in which governmentally directed mass use of oral vaccine during the past five years has almost completely eliminated the disease. In the United States, paralytic polio has been reduced from a disease numbered in thousands of cases annually to a mere 61 in 1965.

Poliomyelitis in Laos, 1962–1963: Epidemic and immunity survey

A poliomyelitis outbreak occurred among young children in Laos between October, 1962, and March, 1963. These children lived in towns in which no sanitary improvements or changes in pattern of life had been made. Postepidemic immunity studies suggested that polioviruses had been spreading extensively and that paralytic polio type 1 occurred at epidemic proportions in a population which normally might be expected to have a low incidence of paralytic disease. The occurrence and virulence of the 1962–1963 Laos outbreak can perhaps be explained by changes in the virulence of the prevalent polioviruses.

The Rape of the Phallus —A Sequel

To the Editor:— In recent years individuals as well as society in general have had great benefit from the practice of circumcision. I refer to the important role that foreskins played in the Robbins, Enders, and Weller early successful cultivation of poliovirus in nonnervous tissue ( Proc Soc Exp Biol Med 75 : 370, 1950). Virologists have long been aware of this unsung contribution to modern scientific research. W. K. C. M. : The incidence of paralytic poliomyelitis was much higher in those countries with the highest standards of hygiene, where circumcision was and is commonly practiced, particularly in the United States. On the other hand, the disease is rare in Nigeria and in most central African countries, where hygienic standards are low, and circumcision not in vogue. Does having a foreskin protect against paralytic polio? Dear Dr. Morgan :—I enjoyed your brief note in the July 19 issue of JAMA and quite