Poliovirus Infections in Four Unvaccinated Children --- Minnesota,
August--October 2005
On September 29, 2005, the Minnesota Department of Health (MDH) identified poliovirus type 1 in an unvaccinated, immunocompromised infant girl aged 7 months (the index patient) in an Amish community whose members predominantly were unvaccinated for polio. The patient has no paralysis; the source of the patient's infection is unknown. Subsequently, poliovirus infections in three other children within the index patient's community have been documented. This report summarizes the ongoing investigation, provides information regarding poliovirus exposure risks and prevention measures in the United States, and offers recommendations to state health departments and clinicians.
Index Case Summary
The index patient was first admitted to a community hospital in central Minnesota for pneumonia in July 2005. Since August 22, this infant has been hospitalized continuously at three additional hospitals with failure to thrive, diarrhea, and recurrent infections. The infant was placed in strict isolation, and a diagnosis of severe combined immunodeficiency (SCID) was made on September 15. The infant is being clinically managed with intravenous immunoglobulin therapy and is being evaluated for bone marrow transplantation.Laboratory InvestigationAn enterovirus isolate from a stool specimen obtained on August 27, 2005, tested positive for a type 1 poliovirus at the MDH laboratory. Partial sequencing of the virus capsid protein coding region (VP1) of the poliovirus genome at the MDH laboratory identified it as a vaccine-derived poliovirus (VDPV). VDPVs are poliovirus strains derived from one of the three Sabin poliovirus strains in oral polio vaccine (OPV) that have >1% difference in nucleotide sequence from the prototype vaccine virus (1). Additional sequencing of the entire poliovirus genome at the CDC polio laboratory confirmed that this strain was a VDPV, with 2.3% divergence in the VP1 region from the parent Sabin type 1 strain. The viral genome demonstrates no recombination with other polioviruses or species C enteroviruses. Prospective serial stool samples from the infant are being tested to monitor ongoing infection and further mutations in the virus.
Epidemiologic InvestigationBecause viral genomic data suggest this poliovirus might have been transmitted to the index patient from another immunocompromised person, the initial investigation focused on identifying immunodeficient persons among community contacts, health-care workers, and patients with whom the infant had potential contact before the first positive poliovirus culture on August 27. Staff and patient records at the hospitals are being reviewed, and inquiries are being made with community members and health-care providers.
Investigations also are under way at the four hospitals where the infant has been treated to determine whether nosocomial transmission from the infant has occurred. At the hospital where the infant currently is a patient, health-care workers and other staff members who have had exposure (without protection from contact precautions) to the infant or the infant's environment are being surveyed regarding polio vaccination status, immune status, and recent relevant illnesses in themselves and their family members. Stool samples are being obtained for viral cultures. Vaccination with inactivated polio vaccine (IPV) is being offered to health-care workers who might have been exposed or who have an ongoing risk for exposure and whose polio vaccination status is not up to date or is unknown. Stool specimens also are being obtained from potentially exposed patients at the hospital where the infant currently is a patient. At the first three hospitals where the infant was admitted, health-care workers are being surveyed regarding immune status and recent illness in themselves or their family members.
To examine community transmission of poliovirus, family members and others in the index patient's community are being surveyed regarding polio vaccination status, immune status, and recent illnesses. To date, stool samples have been collected from 32 persons in five of 24 households, and serum samples have been obtained from eight persons in three households, including the index patient's household. Poliovirus type 1 has been confirmed in three of 32 stool specimens; partial sequencing of the VP1 region of these three isolates has indicated they also are VDPV type 1. The positive specimens were obtained from three unvaccinated siblings in one household (not the infant's household). None of these three children have been ill recently, and none were immunocompromised. Stool and serum samples are being requested from additional members of the community. Extended family members and community contacts from other areas who might have come into contact with the index patient are being identified and monitored for illness. IPV is being offered to community members who are not fully vaccinated for polio or whose polio vaccination status is unknown. Hospitals that serve this community and similar communities are being contacted, and retrospective and prospective surveillance is identifying patients whose diagnoses indicate conditions that are clinically consistent with poliovirus infection, including acute flaccid paralysis (AFP), Guillain-Barré Syndrome (GBS), transverse myelitis, and viral or aseptic meningitis.Leer más http://www.cdc.gov/mmwr/preview/mmwrhtml/mm54d1014a1.htm
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Vaccinations
Information by country
| Total cases | Year-to-date 2010 | Year-to-date 2009 | Total in 2009 |
| Globally | 608 | 817 | 1604 |
| - in endemic countries: | 82 | 601 | 1256 |
| - in non-endemic countries: | 526 | 216 | 348 |
Case breakdown by country
| Country | Year-to-date 2010 | Year-to-date 2009 | Total in 2009 | Date of onset of most recent case |
| India | 27 | 184 | 741 | 21 July 2010 |
| Pakistan | 36 | 31 | 89 | 20 July 2010 |
| DRC | 6 | 3 | 3 | 11 July 2010 |
| Afghanistan | 13 | 14 | 38 | 9 July 2010 |
| Tajikistan | 452 | 0 | 0 | 4 July 2010 |
| Angola | 19 | 18 | 29 | 2 July 2010 |
| Nigeria | 6 | 372 | 388 | 18 June 2010 |
| Nepal | 5 | 0 | 0 | 9 June 2010 |
| Chad | 14 | 13 | 64 | 22 May 2010 |
| Mali | 3 | 1 | 2 | 1 May 2010 |
| Senegal | 18 | 0 | 0 | 30 April 2010 |
| Mauritania | 5 | 0 | 13 | 28 April 2010 |
| Niger | 2 | 15 | 15 | 1 April 2010 |
| Liberia | 1 | 7 | 11 | 3 March 2010 |
| Sierra Leone | 1 | 0 | 11 | 28 February 2010 |
| Guinea | 0 | 15 | 42 | 3 November 2009 |
| Burkina Faso | 0 | 12 | 15 | 25 October 2009 |
| Cameroon | 0 | 0 | 3 | 15 October 2009 |
| Burundi | 0 | 0 | 2 | 12 September 2009 |
| CAR | 0 | 14 | 14 | 9 August 2009 |
| Côte d'Ivoire | 0 | 23 | 26 | 6 August 2009 |
| Kenya | 0 | 17 | 19 | 30 July 2009 |
| Sudan | 0 | 44 | 45 | 27 June 2009 |
| Uganda | 0 | 8 | 8 | 10 May 2009 |
| Benin | 0 | 20 | 20 | 19 April 2009 |
| Togo | 0 | 6 | 6 | 28 March 2009 |
Headlines
- Large areas of Pakistan continue to be affected by the worst floods in its history. The polio eradication infrastructure is continuing to help respond to the devastating floods affecting the country. Focus is on providing technical support, conducting rapid assessments, supporting disease surveillance and strengthening health logistics, including in camps for internally-displaced populations (IDPs).
- In Tajikistan, no new cases were reported in the past week, the first week with no cases since the outbreak was confirmed in April. It is further evidence that the outbreak is declining, however the risk of further international spread remains high.
- The Angola outbreak continues to expand - see 'Angola' and 'DR Congo' sections below for more information.
- The President of Chad, Idriss Deby Itno, received the prestigious Rotary 'Polio Eradication Champion Award', on 8 August. The award was given in recognition of the president's personal engagement in Chad's polio eradication efforts. Officially presenting the award at a ceremony at the presidential palace in N'Djamena, Bob Scott, Chairman of the Rotary's International PolioPlus Committee, said: "Your personal engagement in the fight against this disease has translated into concrete action which has led to the reduction in polio cases in your country." The President re-affirmed his commitment to polio eradication: "We will not let down our guard; we are remaining steadfast and multiplying our vaccination campaigns." Significant operational improvements have been noted in 2010, under the President's personal leadership.
Endemic countries
Afghanistan- One new case was reported in the past week (WPV1 from Kandahar), bringing the total number of cases this year to 13 (five WPV1 and eight WPV3). This is the most recent case, and had onset of paralysis on 9 July.
- Polio transmission in Afghanistan persists primarily in 13 highest-risk districts in the country's Southern Region. Efforts have focused on developing specific operational plans for these districts; targeted microplans are now finalized and are being implemented in eleven of the 13 districts.
- During recent activities, and as part of the district-level planning, improved access has been noted in some parts of Kandahar province.
- A surveillance review will be held on 22-29 August, to assess surveillance sensitivity for acute flaccid paralysis (AFP) detection in the highest-risk areas.
- The next National Immunization Days (NIDs) are scheduled for 26-28 September, but may potentially be postponed by one week due to upcoming parliamentary elections.
- The next Afghanistan/Pakistan Technical Advisory Group (TAG) is tentatively scheduled for 13-14 October (exact date and location to be confirmed).
- Two new cases were reported in the past week (a WPV1 from Maharashtra and a WPV3 from Jharkhand), bringing the total number of cases for this year to 27. The most recent case had onset of paralysis on 21 July (WPV1 from Maharashtra).
- This most recent case is probably linked to a previous case in the same area from January 2010, and - together with last week's reported WPV1 from Jharkhand (likely linked to WPV1 from neighbouring West Bengal from June 2010) and recent positive environmental samples from Delhi - is evidence of ongoing, low-level WPV1 transmission in the country. A response is currently being discussed.
- A special mop-up was held on 8 August, with bivalent OPV, in West Bengal and neighbouring districts of Jharkhand and Bihar. Subnational Immunization Days (SNIDs) are planned for September in Bihar, Uttar Pradesh, Delhi, and parts of Jharkhand, West Bengal and Maharashtra.
- The next India Expert Advisory Group on Polio Eradication (IEAG) is tentatively scheduled for 7-8 September.
- No new cases were reported in the past week. The total number of cases for 2010 is six (three WPV1 and three WPV3). The most recent case had onset of paralysis on 18 June (WPV1 from Borno).
- A special mop-up was held last week, in highest-risk Local Government Areas (LGAs) in northern states. Preparations had focused on updating all microplans for each participating LGA, and conducting refresher trainings for vaccinators and supervisors, and on securing full local religious and traditional leader engagement.
- In parts of Borno, the activity was hampered by heavy rains, which limited access to some populations. Discussions are underway to determine if an additional catch-up campaign could be implemented ahead of the next subnational Immunization Plus Days (IPDs), scheduled for 18-21 September. Borno is the state with the most recent WPV1 case in the country (onset of paralysis on 18 June).
- The next Expert Review Committee on Polio Eradication (ERC) is tentatively scheduled for early October. The group is expected to discuss strategies to capitalize on the current positive epidemiological situation, to interrupt the remaining chains of polio transmission as rapidly as possible in the country.
- Two new cases were reported in the past week (both WPV1s from North West Frontier Province, NWFP, now known as Khyber Pakhtunkhwa), bringing the total number of cases for 2010 to 36. The most recent case had onset of paralysis on 20 July (WPV1 from NWFP).
- Special targeted vaccination activities in high-risk union councils (sub-districts) of all four provinces had been planned for the first week of August, but have been postponed due to flooding in parts of NWFP, Federally Administered Tribal Areas (FATA) and Punjab. Parts of Punjab and Sindh conducted the activities, and in other areas, the SIAs have been re-scheduled for 15 August. In total, approximately two-thirds of the originally-planned activities took place, however in some areas, particularly Peshawar, NWFP; the quality was undermined as a result of the severe floods.
- SNIDs are scheduled for 27-29 September, using bivalent OPV, in coordination with Afghanistan and after the end of Ramadan.
Importation countries
Angola- Two new cases were reported in the past week (WPV1s from Huambo and Lunda Norte), bringing the total number of cases for 2010 to 19 (all WPV1s). The most recent case had onset of paralysis on 2 July (WPV1 from Huambo).
- The outbreak continues to expand, with widespread geographic extent of transmission across the country, as well as recently spreading to neighbouring DR Congo.
- NIDs were conducted last week (6-8 August); the activity was postponed until this weekend in Luanda and Kuanza Sul.
- No new cases were reported this week. The total number of cases for 2010 remains 14 (all WPV3s). The most recent case had onset of paralysis on 22 May (from Logone Oriental).
- An outbreak response SIA, using monovalent OPV type 1, was conducted two weeks ago in N'Djamena and Chari Baguirmi, in response to recent detection of a WPV1 in neighbouring Borno, Nigeria. A mop-up is currently planned for Lac province, in response to recent detection of a WPV3 there (onset of paralysis on 10 May). Lac was not covered during the activities two weeks ago.
- Further SNIDs are planned for August and September and NIDs for October and November.
- Four new cases were reported in the past week (one WPV1 from Katanga and three WPV1s from Kasai Occidental), bringing the total number of cases for 2010 to six. The most recent case had onset of paralysis on 11 July (WPV1 from Kasai Occidental).
- Genetic sequencing is ongoing of these most recent cases, including the case from Katanga in the east of the country, to determine if they are linked to previous transmission in DR Congo or new importations from Angola. Previous cases this year were linked to the expanding outbreak in Angola.
- SIAs in response to these latest cases will be held later in August, focusing on border areas and along the Congo River, with nationwide activities to follow in September and SNIDs in October. Activities will use a mix (depending on area) of trivalent OPV and monovalent OPV type 1.
- No WPV cases have been reported across the Horn of Africa for 2010. The most recent case in the Horn of Africa was more than a year ago (Kenya, 30 July 2009).
- A special SIA was held on 6-9 August in parts of southern and eastern Ethiopia, in response to an ongoing circulating vaccine-derived poliovirus this year.
- No new cases were reported in the past week. The total number of cases for this year remains five (all WPV1s). The most recent case had onset of paralysis on 9 June (from CDR).
- Genetic sequencing is ongoing to determine if this is a new importation, or ongoing transmission of previously imported cases (previous case had onset of paralysis on 5 June).
- A mop-up in 18 highest-risk districts, bordering Bihar, is planned for 14-15 August.
- No new cases were reported in the past week. The total number of cases for 2010 remains 452. The most recent case had onset of paralysis on 4 July 2010.
- All cases except the most recent case have been covered by at least two SIAs. Although the number of newly-reported cases continues to decline suggesting the outbreak has peaked, it is important to point out that the outbreak is not over and outbreak response activities must continue. Additionally, the risk of further international spread remains high.
- A mop-up in highest-risk districts is tentatively planned for early September, with additional NIDs with trivalent OPV in late September and late October.
- Neighbouring countries also continue to conduct SIAs, including in Kyrgyzstan, Kazakhstan, Turkmenistan and Uzbekistan.
- Results are being awaited from Russia, further to investigations conducted to determine the most likely source of infection of seven WPV cases in the country and their connections to Tajikistan and Uzbekistan.
- No new cases have been reported this week. The total number of cases for 2010 in west Africa is 30 (the bulk of which - 18 cases - are from Senegal, with others being reported from Liberia, Mauritania, Mali, Niger and Sierra Leone). The date of onset of paralysis of the last case was 1 May (from Mali).
- In response to the last case in Mali, a mop-up immunization activity was held on 30 July, synchronized across high-risk districts of Mali and Mauritania, with a special focus on targeting nomadic populations. The next synchronized immunization campaigns in 12 countries of west Africa are scheduled for 10 October.
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