Volume 25, Number 7—July 2019
Historical Review
Facility-Associated Release of Polioviruses into Communities—Risks for the Posteradication Era
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.
References
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