Volume 25, Number 7—July 2019
Historical Review
Facility-Associated Release of Polioviruses into Communities—Risks for the Posteradication Era
Table 1
Year | Location (reference) | Source | Poliovirus type | No. cases* | Exposure |
Description | ||
---|---|---|---|---|---|---|---|---|
Primary | Secondary | Tertiary | ||||||
1933 |
United States (20,21) |
Lab |
Not indicated |
1 |
Physician |
NA |
NA |
Bitten (cutaneous disruption) by a normal macaque while doing work on poliomyelitis (paralysis); filterable virus capable of reproducing the disease in rabbits was isolated from the case; case was fatal |
1935 |
United States (22) |
Vaccine production facility |
Not indicated |
12 |
Vaccine trial patients, age 5 mo to 20 y |
NA |
NA |
12 cases of paralytic poliomyelitis in patients receiving trial vaccination against poliomyelitis; natural infections ruled out as cause; 6 deaths |
1941 |
United States (19,20,23) |
Lab |
Not indicated |
1 |
Lab staff |
NA |
NA |
Lab staff member experienced paralysis after preparation of infected tissues for inoculation into monkeys; cutaneous inoculation; no polio outbreaks reported in place of residence or areas of travel |
1945 |
United States (20,23) |
Lab |
Not indicated |
1 |
Lab staff |
NA |
NA |
Lab staff member scratched on hand by noninoculated monkey during transport; subsequent virus contamination of hands might have occurred while feeding or inoculating monkeys; patient experienced paralysis and later died |
1946 |
Zimbabwe (formerly Rhodesia) (20,25) |
Lab |
Not indicated |
1 |
Lab staff |
NA |
NA |
Infection acquired during inoculation of monkeys with polio virus; paralysis occurred, case was fatal |
1949 |
United States (20,24) |
Lab |
WPV2 (mouse- adapted Lansing strain) |
2 |
Lab staff |
NA |
NA |
Two lab technicians were infected in the eyes and nose with Lansing (Armstrong) strain while inoculating mice during polio experiments; both experienced paralysis |
1950 |
Canada (20,25) |
Lab |
Not indicated |
1 |
Physician |
Na |
NA |
Doctor acquired poliomyelitis while performing autopsy on poliomyelitis patient; intracutaneous inoculation; residual weakness; case was not fatal |
1954 | United Kingdom (20,26) | Lab | WPV2 (MEF-1) strain | 1 | Lab staff | NA | NA | Lab technicians infected by cutaneous inoculation while performing necropsy on animals infected with wild type-2 (MEF-1) strain; subsequent paralysis; cases were not fatal |
*Cases defined as laboratory positive (with or without paralysis) for poliovirus by standard methods of virus isolation or known exposure to poliovirus. Lab, laboratory; MEF-1, wild poliovirus type 2 laboratory reference strain; NA, not applicable; WPV2, wild poliovirus type 2.
References
- World Health Organization. World Health Assembly resolution WHA41.28. Global eradication of poliomyelitis by the year 2000 [cited 2018 Oct 10]. http://www.who.int/ihr/polioresolution4128en.pdf
- Global Polio Eradication Initiative. Global wild poliovirus 2012–2018 [cited 2018 Oct 10]. http://polioeradication.org/wp-content/uploads/2018/08/global-wild-poliovirus-2013-2018-20180807.pdf
- Martín J. Vaccine-derived poliovirus from long term excretors and the end game of polio eradication. Biologicals. 2006;34:117–22. PubMedGoogle Scholar
- de Silva R, Gunasena S, Ratnayake D, Wickremesinghe GD, Kumarasiri CD, Pushpakumara BA, et al. Prevalence of prolonged and chronic poliovirus excretion among persons with primary immune deficiency disorders in Sri Lanka. Vaccine. 2012;30:7561–5. DOIPubMedGoogle Scholar
- Global Polio Eradication Initiative. Polio eradication and endgame strategic plan 2013–2018 [cited 2018 Nov 2]. http://polioeradication.org/wp-content/uploads/2016/07/PEESP_EN_A4.pdf
- World Health Organization. WHO global action plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine use (GAPIII) [cited 2018 Nov 2]. http://www.polioeradication.org/wp-content/uploads/2016/12/GAPIII_2014.pdf
- Global Polio Eradication Initiative. Global eradication of wild poliovirus type 2 declared [cited 2018 Nov 2]. http://polioeradication.org/news-post/global-eradication-of-wild-poliovirus-type-2-declared
- Global Certification Commission for the Eradication of Poliomyelitis. Report from the sixteenth GCC meeting, Paris, France, 4–5 July 2017 [cited 2018 Nov 2]. http://polioeradication.org/wp-content/uploads/2017/09/GCC-16th-meeting-report-0405072017.pdf
- Global Certification Commission for the Eradication of Poliomyelitis. Report from the special meeting of the GCC on poliovirus containment, Geneva, Switzerland, 23–25 October 2017 [cited 2018 Nov 2]. http://polioeradication.org/wp-content/uploads/2018/01/polio-global-certification-commission-report-2017-10-final-en.pdf
- Rijksinstituut voor Volksgezondheid en Milieu (National Institute for Public Health and the Environment, the Netherlands). Employee vaccine manufacturer infected with polio virus [cited 2018 Nov 2]. https://www.rivm.nl/en/Documents_and_publications/Common_and_Present/Newsmessages/2017/Employee_vaccine_manufacturer_infected_with_polio_virus
- Bilthoven Biologicals. Employee infected with polio virus [cited 2018 Nov 2]. https://www.bbio.nl/nieuws/2017/april/medewerker-besmet-met-poliovirus
- Duizer E, Ruijs WL, van der Weijden CP, Timen A. Response to a wild poliovirus type 2 (WPV2)-shedding event following accidental exposure to WPV2, the Netherlands, April 2017. Euro Surveill. 2017;22:30542. DOIPubMedGoogle Scholar
- World Health Organization. Guidance to minimize risks for facilities collecting, handling, or storing materials potentially infectious for polioviruses. WHO/POLIO/18.03 [cited 2019 Jan 27]. http://polioeradication.org/wp-content/uploads/2018/06/polio-containment-guidance-for-non-poliovirus-facilities-20180614-en.pdf
- Dowdle WR, Birmingham ME. The biologic principles of poliovirus eradication. J Infect Dis. 1997;175(Suppl 1):S286–92. DOIPubMedGoogle Scholar
- Van Rooyen CE, Rhodes A. Virus diseases of man. New York: Thomas Nelson & Sons; 1948.
- Byers K, Harding A. Viral agents of human diseases: biosafety concerns. In: Wooley D, Byers K, editors. Biological safety: principles and practices. 5th edition. Washington: ASM Press; 2017. p. 187–220.
- Pike RM. Laboratory-associated infections: summary and analysis of 3921 cases. Health Lab Sci. 1976;13:105–14.PubMedGoogle Scholar
- Pike RM. Laboratory-associated infections: incidence, fatalities, causes, and prevention. Annu Rev Microbiol. 1979;33:41–66. DOIPubMedGoogle Scholar
- Sulkin SE, Pike RM. Viral infections contracted in the laboratory. N Engl J Med. 1949;241:205–13. DOIPubMedGoogle Scholar
- Pike RM, Sulkin SE, Schulze ML. Continuing importance of laboratory acquired infections. Am J Public Health Nations Health. 1965;55:190–9. DOIPubMedGoogle Scholar
- Sabin AB, Wright AM. Acute ascending myelitis following a monkey bite, with the isolation of a virus capable of reproducing the disease. J Exp Med. 1934;59:115–36. DOIPubMedGoogle Scholar
- Leake JP. Poliomyelitis following vaccination against this disease. Cal West Med. 1936;44:141–2.PubMedGoogle Scholar
- Sabin AB, Ward R. Poliomyelitis in a laboratory worker exposed to the virus. Science. 1941;94:113–4. DOIPubMedGoogle Scholar
- Beller K. Laboratory infection with the Lansing virus [in German]. Zentralblatt für Bakteriologie, Parasitenkunde. Infektionskrankheiten und Hygiene. 1949;153:269–73.
- Burns JS. Poliomyelitis: a case possibly due to intracutaneous inoculation. Can Med Assoc J. 1950;63:498–9.PubMedGoogle Scholar
- McMATH WFT. Accidental inoculation with poliomyelitis virus. Lancet. 1955;268:702–3. DOIPubMedGoogle Scholar
- Nathanson N, Langmuir AD. The Cutter incident: poliomyelitis following formaldehyde-inactivated poliovirus vaccination in the United States during the spring of 1955. II. Relationship of poliomyelitis to Cutter vaccine. Am J Hyg. 1963;78:29–60.PubMedGoogle Scholar
- Offit PA. The Cutter incident, 50 years later. N Engl J Med. 2005;352:1411–2. DOIPubMedGoogle Scholar
- Dowdle WR, Wolff C, Sanders R, Lambert S, Best M. Will containment of wild poliovirus in laboratories and inactivated poliovirus vaccine production sites be effective for global certification? Bull World Health Organ. 2004;82:59–62.PubMedGoogle Scholar
- Mulders MN, Reimerink JHJ, Koopmans MPG, van Loon AM, van der Avoort HG. Genetic analysis of wild-type poliovirus importation into The Netherlands (1979-1995). J Infect Dis. 1997;176:617–24. DOIPubMedGoogle Scholar
- Deshpande JM, Nadkarni SS, Siddiqui ZA. Detection of MEF-1 laboratory reference strain of poliovirus type 2 in children with poliomyelitis in India in 2002 & 2003. Indian J Med Res. 2003;118:217–23.PubMedGoogle Scholar
- World Health Organization. Wild poliovirus type 2—reference strains isolated in India. Wkly Epidemiol Rec. 2003;78:88 [cited 2018 Oct 10]. https://apps.who.int/iris/bitstream/handle/10665/232120/WER7812_88-88.PDF
- World Health Organization. Update on actions taken following the isolation of MEF-1 reference poliovirus associated with acute flaccid paralysis cases in India in late 2002 and early 2003. Wkly Epidemiol Rec. 2003;78:277–84 [cited 2018 Oct 10]. https://www.who.int/wer/2003/wer7832
- Duizer E, Rutjes S, de Roda Husman AM, Schijven J. Risk assessment, risk management and risk-based monitoring following a reported accidental release of poliovirus in Belgium, September to November 2014. Euro Surveill. 2016;21:30169. DOIPubMedGoogle Scholar
- Duizer E. Laboratory analysis of environmental samples taken following the reported release of live poliovirus. RIVM letter report 2015–0032 [cited 2018 Oct 10]. http://www.rivm.nl/bibliotheek/rapporten/2015-0032.pdf
- Wenner HA, Paul JR. Fatal infection with poliomyelitis virus in a laboratory technician; isolation of virus from lymph nodes. Am J Med Sci. 1947;213:9–18. DOIPubMedGoogle Scholar
- Gear JH, Rodger LM. Studies in poliomyelitis; poliomyelitis in Northern Rhodesia, with special reference to an outbreak occurring on the Roan Antelope Copper Mine, Luanshya, in 1946. S Afr Med J. 1946;20:670–3.PubMedGoogle Scholar
- Sushmi Dey. Contaminated vaccines put India’s “polio free” status at risk. The Times of India. October 1, 2018 [cited 2018 Nov 2]. http://timesofindia.indiatimes.com/articleshow/66021197.cms
- Upfill-Brown A, Taniuchi M, Platts-Mills JA, Kirkpatrick B, Burgess SL, Oberste MS, et al. Nonspecific effects of oral polio vaccine on diarrheal burden and etiology among Bangladeshi infants. Clin Infect Dis. 2017;65:414–9. DOIPubMedGoogle Scholar
- Her Majesty’s Stationery Office. Report on an investigation into the cause of the 1978 Birmingham smallpox occurrence. London: Her Majesty’s Stationery Office; 1980 [cited 2018 Nov 2]. https://biotech.law.lsu.edu/blaw/bt/smallpox/refs/report_1978_london.pdf
- Bandyopadhyay AS, Garon J, Seib K, Orenstein WA. Polio vaccination: past, present and future. Future Microbiol. 2015;10:791–808. DOIPubMedGoogle Scholar
- Sutter RW. Unraveling the mucosal Immunity of inactivated poliovirus vaccine. J Infect Dis. 2018;217:344–6. DOIPubMedGoogle Scholar
- McKinlay MA, Collett MS, Hincks JR, Oberste MS, Pallansch MA, Okayasu H, et al. Progress in the development of poliovirus antiviral agents and their essential role in reducing risks that threaten eradication. J Infect Dis. 2014;210(Suppl 1):S447–53. DOIPubMedGoogle Scholar
- World Health Organization. World Health Assembly resolution WHA71.16. Poliomyelitis—containment of polioviruses. In: Seventy-first World Health Assembly, Geneva, Switzerland; May 20–26, 2018 [cited 2018 Nov 2]. http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_R16-en.pdf
Page created: June 17, 2019
Page updated: June 17, 2019
Page reviewed: June 17, 2019
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.