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Back Critics of the immunization program contend -- in the highly-publicized race to wipe out the disease and then stop vaccinating against it -- that more vaccine-induced polio cases are sure to come. Public health officials sometimes complain that new parents, and even young pediatricians, have no memory of the dread that paralyzed entire American communities half a century ago -- a fear bolstered by knowledge in almost every family of some friend or relative who had a child in an ``iron lung'' or leg brace. Polio was a scourge that at its peak in the United States in 1952 afflicted nearly 58,000 in one year. Its suffering was alleviated only when Dr. Jonas Salk developed an injectable vaccine in the mid-1950s and Dr. Albert Sabin followed with an oral polio vaccine, OPV, in the early 1960s. The last U.S. case of ``wild'' polio, polio caused by a naturally occurring virus, was reported in 1979. Since eradication, or from 1980 on, aside from six imported cases, the only reported polio cases in this country have been caused by the oral vaccine itself: a total of 141. That figure may be low. ``Those are only reported cases,'' noted John B. Salamone of Oakton, Va., a member of the Advisory Commission on Childhood Vaccines. ``There are probably hundreds and hundreds of cases out there that are called SIDS or Guillain-Barre syndrome. Not one person I have ever spoken with was diagnosed properly the first time. That is mostly because: How many doctors have seen polio?'' Since 1961, when OPV first became available, 316 people in the United States have contracted the paralytic form of the disease from the vaccine, the federal Centers for Disease Control and Prevention reports. Some of those cases include vaccinated children who contracted the disease. Others are ``contact'' polio cases -- usually other kids, relatives or caretakers who contracted it from children taking the oral vaccine dose, and then passing on the disease unintentionally by ``shedding'' the live virus through their feces or body fluids. In developing countries -- where polio was widespread until recent years, but now numbers about 4,000 cases worldwide -- the risk of vaccine-induced cases is somewhat diminished. That's because up to 100 percent of adults in many of those nations have antibodies for the disease from being exposed to it, but not necessarily paralyzed by it, said Dr. Benjamin Nkowane, a medical officer for the World Health Organization's polio office. According to Nkowane, once there are no more cases of wild polio -- an aim for the year 2000 -- all immunization will come to a worldwide halt five to 10 years later. According to the congressional General Accounting Office here, which studied the subject in April, WHO may be optimistic by about two years in that polio won't be eradicated until 2002. The GAO said the $1.6 billion WHO eradication effort will save the United States about $74 million annually in foreign aid for vaccinations. And, says the GAO, it will save about $230 million spent each year on polio vaccination in this country, still necessary while nonimmunized persons fly in and across the United States. But national and global health officials don't publicize the fact that if certain children continue to shed the live virus in their saliva or stool, they could spread the disease to nonimmunized children in the first several decades of the 21st century. Dr. Mark Geier, a Maryland physician and geneticist, is a strong critic of the World Health Organization's efforts to stop immunizing against polio, even once they show the wild polio virus is nonexistent. Geier claims health officials lack studies proving how long children shed the virus. `Let's say it is Jan. 1, 2000, and there is no wild polio and they stop giving the vaccine,'' Geier said. ``What about the kids who got the oral vaccine on Dec. 31 and are shedding? They shed in their feces, and could spread it in a swimming pool.'' World Health Organization officials answer by pointing to studies in Cuba and Finland that show the disease normally sheds three to four weeks in healthy children. But in children with immunodeficiency disorders -- disorders that damage the immune system's ability to fight off disease and infection -- the polio virus has been shown to shed up to eight years. Of the 141 vaccine-associated paralytic polio cases in the United States, reports the CDC, at least 30 occurred in individuals with damaged immune systems. Some immunodeficiencies are inherited, but others are acquired diseases, such as HIV infection and severe malnutrition, which are common in developing countries in Africa and Asia. The United Nations this summer estimated almost 1.1 million children have HIV or full-blown AIDS in Africa and Asia, target regions in the WHO polio eradication campaign. Of all the world's infants afflicted with HIV, 87 percent live in Africa. These numbers worry some scientists. Dr. Samuel Katz, a pediatric infectious disease specialist at Duke University, and a scientist of tremendous influence in the federal immunization heirarchy, has raised the question of HIV-positive children shedding the disease for long periods of time. ``What about AIDS? Those kids are immunodeficient,'' Katz said. But Katz said health officials tell him this ``should not be a problem.'' Nkowane admits that just two years shy of WHO's polio-eradication deadline, studies still are under way to determine how long shedding lasts and how children with immunodeficiencies can stop excreting the virus, possibly by administering antiviral treatments. Until there are some answers, Geier advises using only the injected, inactivated polio vaccine, called IPV, until every recipient who got the live, oral vaccine dies. ``It would have to be the year 2120 until they could eliminate the vaccine,'' he said. If the World Health Organization succeeds in eradicating wild polio, as they did with smallpox two decades ago, Geier said, ``They get a feather in their cap. If they lose, we have thousands of handicapped kids.'' The oral vaccine proved immensely popular with parents and pediatricians as soon as a choice was available. It is currently in use in 71 percent of the 20 million annual polio vaccinations in the United States. The CDC, which purchases vaccines for 60 percent of U.S. children, buys two-thirds OPV and one-third IPV. Kaiser, one of the nation's largest HMOs, buys 75 percent OPV. One reason for OPV's dominance is the cost. The oral vaccine is cheaper, costing the government $2.85 a dose, compared with $6.54 for the injected version. Another reason: No scary needles are involved and therefore less crying, a big consideration in mass vaccination venues. Scientists liked it for a more subtle reason -- one that has been the subject of vaccine policy debate by federal health officials for years. In 1977 and again in 1988, the prestigious Institute of Medicine, a nongovernmental entity, was asked by the Advisory Committee on Immunization Practices to make recommendations for vaccine use. On both occasions the committee chose an all-oral vaccination schedule for the nation, knowing that the choice would equate to about eight to 10 cases of vaccine-associated paralytic polio a year. Manhattan lawyer Martin W. Edelman is attorney for Dominick Tenuto, who contracted polio from changing his then-infant daughter's diaper, and who made case law in successfully suing the estate of his daughter's doctor for failing to warn him about the dosage. Edelman points to a little-publicized 1977 New England Journal of Medicine article as proof that public health scientists knew at least two decades ago they were exposing unwary Americans to polio risk. Authored by Dr. Elena O. Nightingale -- who ran the polio study at the Institute of Medicine -- the article acknowledged the risk of unvaccinated persons passively contracting the disease from those who had taken the oral vaccine. But more importantly, thought the committee members, those who did not contract the paralytic disease would be passively immunized by exposure to the live virus -- through changing diapers, or kissing a slobbering baby, for instance -- albeit without their knowledge or consent. In 1997, only 60 to 70 percent of the American populace was immunized against polio, and this was thought to be a great way to get that figure up over 90 percent. ``OPV vaccination results in shedding of vaccine viruses and in their spread to unvaccinated persons,'' Nightingale wrote. The panel unanimously recommended continued use of OPV as the principal vaccine. The primary reason was ``the spread of immunogenic agents from vaccinated to nonvaccinated persons is maintained,'' Nightingale said. The 1988 panel again voted to keep an all-OPV schedule until a shot was available that would combine IPV with another childhood vaccine, DTP, diptheria, tetanus and pertussis (whooping cough). That shot was never developed. In September 1996, the Centers for Disease Control and Prevention -- urged by its Advisory Committee on Immunization Practices -- came out with a different U.S. recommendation. Because polio was eradicated in the Western Hemisphere in 1991, and the importation of wild polio was therefore decreased, they recommended a sequential schedule of two doses of the injected vaccine followed by two doses of the oral one. The American Academy of Pediatrics, and its influential Committee on Infectious Diseases, the Red Book Committee, did not follow suit. Their current recommendation is that both vaccines are safe and effective, and it is up to parents and their pediatricians to choose an option. The academy ignored the CDC and said any of the schedules are OK, complained Salamone, also the president of Informed Parents Against Vaccine-Associated Paralytic Polio, a Washington-based advocacy group that lobbies for the exclusive use of the safer injectable Salk vaccine. ``While we are waiting for polio eradication it is needless to have sacrificial lambs in industrialized countries, like the U.S.,'' said Salamone, whose 8-year-old son David has polio as a result of the oral vaccine. For those who contract polio from the oral vaccine in this country, a federal compensation program is supposed to smooth the way. But it's no slam dunk. Mick Rowe, 44, of Hagerstown, Md., knows. Rowe thought himself an unlikely candidate to contract polio. He received the inactivated vaccine, the Salk injectable, in 1958 at age 5. Two years ago Rowe became wheelchair bound. He was told by doctors that he had contracted the disease from changing his daughter's diaper. The girl, Salina, had received the oral version of the vaccine. Rowe soon after lost all use of his limbs. Last year, the Rowes filed a claim with the National Vaccine Injury Compensation Program, a federal program established a decade ago by Congress to compensate victims of vaccine injuries. The program's medical analysts recommend denying compensation to Rowe because tests prove negative for polio. The government experts suggest that Rowe has Guillain-Barre syndrome, a sometimes paralytic neural disease believed caused by allergic reaction or bacterial-viral triggering. Under the federal program, Guillain-Barre syndrome is not a compensable injury, but a 1997 article in the Brazilian Journal of Medical and Biological Research says the disease has been shown in rare cases to be a result of the oral polio vaccine. Attorney Edleman is considered by many colleagues the country's foremost legal advocate for vaccine-damaged polio victims. He also believes Guillain-Barre syndrome can be induced by polio virus derived from the Sabin vaccine. He thinks the strain of polio virus shed by those orally vaccinated is not a tested immunization agent because the viruses mutate in the child's intestinal tract and can ``change into a type of paralytic virus.'' Pharmaceutical firms, he contends, don't want to take responsibility for the product. The National Vaccine Injury Compensation Program director, Thomas Balbier, said that a case will be compensated if the clinical findings correlate with polio. ``If the medical findings correlate with something else, then it is not a vaccine-related injury,'' he said. A Gannett News Service analysis of the program's database, obtained through a Freedom of Information request, shows that 101 families, of the 196 that have sought compensation, have been compensated for contracting polio from the oral vaccine. Together, they have received nearly $60 million. The program's top three awards, of more than $5 million each, went to polio victims. The program's database shows the average award for a vaccine-associated polio case is $589,000. As the countdown to a 21st century absent of polio continues -- ultimate eradication continues to be clouded by certain unresolved issues. A 1998 National Institutes of Health report raises the following issues:
Polio reintroduction by immune-suppressed individuals in a
post-eradication era ``is enough of a problem that we are working on an
anti-viral to treat such people,'' said Dr. George Curlin, deputy director of
the National Institutes of Health's Division of Microbiology and Infectious
Diseases. ``We have a lot of things on the book to pursue that question.'' |
