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Volume 25, Number 7—July 2019

Historical Review

Facility-Associated Release of Polioviruses into Communities—Risks for the Posteradication Era

Ananda S. BandyopadhyayComments to Author , Harpal Singh, Jacqueline Fournier-Caruana, John F. Modlin, Jay Wenger, Jeffrey Partridge, Roland W. Sutter, and Michel J. Zaffran
Author affiliations: Bill & Melinda Gates Foundation, Seattle, Washington, USA (A.S. Bandyopadhyay, J.F. Modlin, J. Wenger, J. Partridge); World Health Organization, Geneva, Switzerland (H. Singh, J. Fournier-Caruana, R.W. Sutter, M.J. Zaffran); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (R.W. Sutter)

Main Article

Table 2

Reported incidents of poliovirus release from laboratories and vaccine production facilities in the post–polio vaccine era*

Year Location (reference) Source Poliovirus type No. cases Exposure
 Description
Primary Secondary Tertiary
1955
 United States (27,28)
 Vaccine production facility
 Not indicated
 164
 Vaccine recipients(≈40,000 children)
 113 contacts of the children
 NA
 “Cutter incident”; inadequate formaldehyde virus inactivation during poliovirus vaccine production (≈120,000 doses); ≈40,000 children experienced muscle weakness, of whom 51 experienced paralysis; 5 deaths; 113 contacts of the children were also paralyzed, of whom 5 died
1991
 France (29)
 Lab and
vaccine production facility
 WPV3 (Saukett) strain
 1
 No definitive information on exposure of case
 Saukett strain isolated in France from a woman from Algeria; source of this lab strain could not be confirmed
1992
 Netherlands (30)
 Vaccine production facility
 WPV1 (Mahoney) strain
 1
 Father (worker at facility)
 Son
 NA
 Boy (age 19 mo) with respiratory symptoms (no paralysis); father with history of accidental exposure to Mahoney strains while working in a poliovirus vaccine production facility
1993
 Netherlands (30)
 Vaccine production facility
 WPV3 (Saukett) strain
 1
 No definitive information on exposure of case
 Child with gastroenteritis (no paralysis); had travel history to France; no epidemiology established to trace lab exposure; Saukett strains typical for IPV production in France isolated from the stool samples
2000
 India (31–33)
 Lab and
vaccine production facility
 WPV2 (MEF-1) strain
 3
 No definitive information on exposure of case
 WPV2 isolates found in Sep 2000 and Nov 2002–Feb 2003 from 10 children with AFP, 1 healthy contact, and 1 environmental sample; isolates unrelated to all previous WPV2 strains found in India; because this was a lab reference strain and not a community-derived wild strain, lab source was suspected
2002–2003
 India (31–33)
 Lab and
vaccine production facility
 WPV2 (MEF-1) strain
 8
 No definitive information on exposure of case
2014
 Belgium (34,35)
 Vaccine production facility
 WPV3 (Saukett) strain
 0
 NA
 NA
 NA
 ≈1013 infectious WPV3 particles accidentally released into sewage system from production plant in Belgium; no poliovirus detected in environmental or human samples
2017 Netherlands (12) Vaccine production facility WPV2 (MEF-1) strain 1 Worker None None Accidental leakage in vaccine production room; 1 of 2 exposed staff members tested positive by RT-PCR

*Cases are defined as laboratory positive (with or without paralysis) for poliovirus by standard methods of virus isolation or known exposure to poliovirus. AFP, acute flaccid paralysis; IPV, inactivated poliovirus vaccine; lab, laboratory; MEF-1, wild poliovirus type 2 laboratory reference strain; NA, not applicable; RT-PCR, reverse transcription PCR; WPV, wild poliovirus; WPV1, wild poliovirus type 1; WPV2, wild poliovirus type 2; WPV3, wild poliovirus type 3.

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Page updated: June 17, 2019
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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.
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