The outbreak in the Netherlands of poliomyelitis among
unvaccinated persons who are members of religious groups that
generally do not accept vaccination is continuing (1). From
September 17 through December 5, 1992, 54 cases of poliomyelitis
were reported to the Netherlands' Office of the Chief Medical
Officer of Health (Figure 1). Of the 54 patients, 41 (76%) had
paralytic manifestations of this illness; one neonate died, and 12
patients had aseptic meningitis. Fifty-one (94%) of the cases have
been laboratory confirmed: 40 patients had wild poliovirus type 3
isolated from stool, and 11 had IgM-specific antibody to poliovirus
type 3 suggestive of recent infection. All of the reported cases
have occurred among unvaccinated (n=53) or inadequately vaccinated
(n=1) persons belonging to a religious denomination that routinely
does not accept vaccination. Patients ranged in age from less than
1 month to 56 years (mean age: 18.9 years). Of the 12 provinces in
the Netherlands, seven have reported cases of poliomyelitis; the
most severely affected provinces are South Holland and Gelderland.
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
Editorial Note: The poliomyelitis epidemic in the Netherlands
continues despite control measures initiated by the Dutch health
authorities, including offering oral poliovirus vaccine to all
previously unvaccinated persons belonging to affected religious
groups and to other previously unvaccinated persons aged less than
41 years and offering one dose of enhanced-potency inactivated
poliovirus vaccine to persons who are incompletely vaccinated.
Based on the ratio of cases of asymptomatic infection to paralytic
disease for persons infected with poliovirus type 3 (at least
1000:1) (2), an estimated 54,000 persons in the Netherlands may
have been infected with wild poliovirus type 3 during this
outbreak. Therefore, the risk for infection may be greater than
previously assumed for unvaccinated or inadequately vaccinated
travelers to the Netherlands. In addition, the potential for spread
of this poliovirus to other areas (including the North American
continent) by asymptomatically infected travelers from the
Netherlands -- even if not directly linked to a clinical case --
also
may be higher than previously assumed.
To prevent transmission of imported polioviruses and cases of
paralytic disease in the United States, increased efforts are
necessary to vaccinate all unvaccinated or inadequately vaccinated
persons in the United States in accordance with recommendations of
the Advisory Committee on Immunization Practices (3,4). Public
health agencies and health-care providers should intensify
outreach, especially to unvaccinated persons in these religious
communities who do not routinely accept vaccination.
The risk for acquiring poliomyelitis while in the Netherlands
is considered small because of the excellent sanitation in the
country and because transmission of the poliovirus has been limited
primarily to unvaccinated religious groups. Nonetheless, the polio
immunity of travelers to the Netherlands should be evaluated, and
persons with inadequate protection should complete a primary
vaccination series with three doses of poliovirus vaccine before
departure. For travelers with a completed primary series of
poliovirus vaccine, it may be prudent to obtain one dose of
poliovirus vaccine before departure, especially if extensive travel
in the Netherlands or contact with persons in the affected
religious groups is anticipated.
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