- It looks like polio is spreading...due to polio oral
- I also note that one of the patients who was flown to
North Carolina may have put the community at risk in North Carolina as
the hosital was originally given the diangosis of Guillain Barre Syndrome
and not told of possible polio caused by the vaccine with live virus.
- In this day and age, it bogglese my mind that we rely
on a vaccine that has a live virus and can spread polio...rather than spend
the money on common municipal sanitation measures.
- This is a rather long post but it is well worth the read
as it does show oral polio vaccine can cause polio outbreaks.
- Given the sanitation situation in Haiti, I feel that
we could see a major outbreak of polio and many deaths. Th polio
virus will exist in the environment of Haiti for years to come.
- ACUTE FLACCID PARALYSIS - HAITI: REQUEST FOR INFORMATION
- Date: Mon 17 Jan 2011
- From: James Wilson firstname.lastname@example.org
- ProMED-mail regrets the delay in posting. - Mod.MPP
- Subject: Haiti: Suspected VDPV Type I Cases
- I realize many of you are waiting anxiously for the diagnostic
results of the suspected VDPV [vaccine derived poliovirus] Type I
cases that presented as reported "ascending paralysis"/Acute
Flaccid Paralysis (AFP).
- Here are updates as we understand them:
- 1. Three adult cases were identified at a medical facility
in Port de Paix last week [week of 10 Jan 2011]. Two were fatal,
and one remains paralyzed and ventilator-dependent at an ICU in Port
au Prince. Several samples were acquired from this patient for diagnostic
testing. The surviving patient was initially diagnosed with Guillan-Barre
- 2. An additional pediatric case was identified as having
been medivac'ed to Charlotte, North Carolina, where she remains
ventilator-dependent in an ICU. This case was found to have been ill
originally in October ; she lived in Petionville. It is notable
the medical team involved in this case had diagnosed the child with
Guillan-Barre syndrome. ... Once the question of VDPV was raised,
there was concern about the safety of the Charlotte community, given
the nationwide problem of childhood vaccination compliance.
- 3. An anonymous HEAS [Haiti Epidemic Advisory System]
partner reported seeing a "16-18 year old from Fermate die of
acute flaccid paralysis but had no idea at that time the government
reported such things. We spent a long time trying to sort out what
part of spinal cord might have given him an ascending flaccid paralysis
causing death from respiratory failure over the course of about 24
hours and could not come up with a medical, physiological answer
except Guillan-Barre. Polio never entered my brain. He had a fracture
in his lower leg and had a spinal anesthetic which resolved, but
he came back the next day complaining of weakness and trouble breathing."
- 4. Investigation by officials has uncovered multiple
additional suspect cases for diagnostic testing in both the Port
de Paix and Port au Prince areas.
- As reported previously, Hispaniola (starting in Haiti,
with spread to the Dominican Republic) was the site of a large outbreak
of Vaccine-Derived PolioVirus (VDPV) Type I from 1998-2001 that debunked
the previously held belief that oral polio vaccine only caused rare
single-case reversions. Both Port de Paix and Port au Prince were
involved in the outbreak. Several environment samples provided evidence
of environmental contamination. The virus, an unstable reverted mutant,
was found to have recombined with 4 indigenous enteroviruses. This
series of mutations resulted in a novel virus now capable of aggressive
transmission, severe neurological disease, and fatalities. It is
unclear what the actual case fatality rate is when compared to wild
type polio. My personal opinion is it is likely higher given this
was/is an unstable mutant still adapting to both the environment
and the host population.
- The good news is rapid emergency vaccination with OPV
in 2001 was thought to have brought the situation under control.
However, the current situation challenges the notion of whether the
virus was truly contained, hence the absolute need for definitive,
credible laboratory evaluation of both environmental and human samples.
- We were dismayed to realize the number of people involved
in the initial care and transport of the Port de Paix patient cluster
who did not provide warning of the situation. They were interviewed
after discovery of a You Tube video depicting the transfer of one
of the patients by one of our astute HEAS members on [9 Jan 2011].
Potentially exposed Haitian and non-Haitian personnel included the
staff of the Port de Paix and Port au Prince facilities and 2 transport
teams. We are fortunate none of the involved personnel have reported
symptoms. It is key to note that personnel vaccinated appropriately
for polio are immune; however, Haitian personnel and the surrounding
community are an entirely different matter...
- Laboratory results are still pending. We hope this will
turn out to be a false alarm, but as the appearance of cholera has
shown us, complacency costs lives.
- James M. Wilson V, MD
- Haiti Epidemic Advisory System (HEAS)
- Executive Director
- Praecipio International
- Washington-Houston-Port au Prince
- The above email is the 1st information that ProMED-mail
has received on the apparent outbreak of acute flaccid paralysis
in Haiti, and we are grateful to Dr. Wilson for sending this alert.
On searching the web, this moderator was able to find the earlier
alerts related to the identification of a "cluster" of
acute flaccid paralysis cases posted on a blog known as the Haiti
Medical and Public Health Information Sharing Environment at
- The outbreak of VDPV in Hispanola was covered by ProMED
and can be reviewed through reading the prior posts referenced below.
At the time of this outbreak (2000-2001), there was a total of 21
cases of VDPV-associated paralysis on Hispanola (Haiti 8 and the
Dominican Republic 13), of which 12 cases were reported in 2000 and
9 cases were reported in 2001.
- Kew et al demonstrated that the viruses responsible for
the paralytic poliomyelitis outbreak in the Dominican Republic and
Haiti were derivatives from an attenuated poliovirus vaccine (OPV)
in use during 1998-1999. (See Kew O, et al. Outbreak of Poliomyelitis
in Hispaniola Associated with Circulating Type 1 Vaccine-Derived
Poliovirus. Science 12 Apr 2002: 356-359. Abstract available at
- Kew mentions that it is common for vaccine viruses
to "back mutate" (revert to wild poliovirus-like neurovirulence),
but the concerns arise in areas with low vaccination coverage and,
therefore, low herd immunity, so that these reverted viruses are
in an environment favorable for circulation and propagation of an
outbreak of paralytic disease. (See prior ProMED postings on other
events associated with VDPVs.)
- As part of the global polio eradication initiative activities,
all cases of acute flaccid paralysis (AFP) in individuals less than
15 years of age are to be reported and investigated. A benchmark
indicator of adequate surveillance activities is a reported AFP rate
of at least 1 per 100 000 population annually. According to monitoring
data available on the WHO immunization monitoring website, during
the period 1996 through 2010, non-polio AFP rates reported in Haiti
were less than 1 per 100 000 population under age 15 years for all
years during this period, including 2000 and 2001, the 2 years during
which there were cVDPV (circulating vaccine derived poliovirus) associated
paralytic cases, and AFP surveillance was significantly increased
(from rates of 0.0/0.1 up to 0.6 and 0.8 in 2000/2001 respectively)
(data available through an interactive page at: http://apps.who.int/immunization_monitoring/en/diseases/poliomyelitis/case_count.cfm.
- These figures suggest that surveillance for paralytic
disease in Haiti has been suboptimal and may well not rule out the
possibility of having had some "below the radar" circulation
of poliovirus, either wild poliovirus (WPV) or vaccine derived poliovirus
(VDPV). In addition, as seen with the recent experience with cholera
in Haiti, the possibility of introduction of WPV is there, as there
has been significant influx of international workers in the post
earthquake relief activities.
- Unfortunately, laboratory confirmation at this point
in time may be challenged as 2 of the identified cases were fatal
cases, one had onset of illness in October 2010, so a negative virus
isolation study will not definitively rule out a viral infection,
leaving the one case presently hospitalized in Haiti on a respirator
as the only case in which there is a reasonable likelihood of successful
virus isolation studies. That being said, the possibility of a several
cases of Guillain-Barre syndrome (GBS) occurring in close temporal
proximity also exists. GBS has been associated with gastrointestinal
and respiratory infections (both viral as well as bacterial), and
following vaccination, all 3 pre-disposing events/conditions have
been coexisting in the present environment in Haiti.
- ProMED-mail awaits further information on the results
- investigations and laboratory studies.
- For the interactive HealthMap/ProMED map of Haiti, see
- http://healthmap.org/r/00Yn. - Mod.MPP
- Patricia A. Doyle DVM, PhD Bus Admin, Tropical Agricultural
Economics Univ of West Indies Please visit my "Emerging Diseases"
message board at:http://www.emergingdisease.org/phpbb/index.php Also
my new website: http://drpdoyle.tripod.com/ Zhan le Devlesa tai
sastimasa Go with God and in Good Health
- Benjamin Franklin said, "They that can give
up essential liberty to obtain a little temporary safety deserve neither
liberty nor safety."