Why Polio, Once Eliminated, Is Testing N.Y. Health Officials

https://www.nytimes.com/2022/10/03/nyregion/polio-new-york-eradication.html

Health officials are facing a number of obstacles to containing polio as it continues to circulate in New York State and threatens to become endemic.

In the hamlet of Monsey, N.Y., where polio partially paralyzed the legs of a young unvaccinated man in June, only 37 percent of 2-year-olds were up to date with their polio vaccinations as of the beginning of August.

In the Amish farmlands in Cattaraugus County in the Southern Tier of New York State, just 9 percent of young children were up to date with their polio vaccines. And along the Pennsylvania border in nearby Steuben County, and in a small hamlet in the farmlands of Tompkins County, barely a quarter of 2-year-olds were up to date.

Because vaccinations are required to enroll students in public or private school in New York State, most children are caught up by age 5: Statewide, 99 percent of school-aged children are vaccinated for polio. Still, roughly 100 schools reported vaccination rates at or below 90 percent in the 2020-21 school year across the state. Sixty schools did not submit any vaccination data at all, including some tiny rural schoolhouses that serve Amish students.

The specter of polio becoming endemic in America again was once unthinkable. But as state public health officials embark on an urgent campaign to get more people vaccinated, the low rates among preschoolers in some pockets are evidence of both the challenges they face and the threat to the state’s youngest children — the very age group among whom polio is most likely to spread.

If vaccination rates do not increase, experts and health officials fear polio could continue to quietly circulate in the state and beyond within a pool of vulnerable people, leaving a fraction of them paralyzed — nearly 50 years after the disease was eliminated in the United States.

The disease, which in its current variant , used to kill and disable thousands of people a year in the United States, until polio vaccines were discovered and distributed to millions of Americans. But now, delayed childhood vaccination throughout the world caused by the Covid-19 pandemic, combined with a rising tide of government mistrust and vaccine misinformation, has caused the nation’s most sustained transmission of polio since 1979, experts say, creating an emergency for health officials.

Local health officials and community organizations have been appealing to parents to bring their youngest children in for vaccination, and since late July more than 6,400 doses have been given in Rockland County alone, where the original case was identified.

But even as pediatricians see some upticks in demand, “they’re also seeing plenty of people who are questioning the seriousness of the moment,” said Eli Rosenberg, the deputy director for science at the New York State Department of Health.

The largely silent nature of polio’s spread — in most people, it causes flulike symptoms or no symptoms at all — is fueling skepticism that this is a true emergency among some families, Dr. Rosenberg said.

In 2019, during a measles outbreak, New York City health officials took aggressive action. They designated outbreak ZIP codes, ordered adults and children who lived or worked in those areas to be vaccinated for measles within 48 hours and closed entire schools that did not exclude unvaccinated children.

But it can be hard to determine exactly where polio is spreading. Wastewater sampling, which captures traces of the virus found in fecal matter, can give a sense of a general area, but not precise location.

Besides the one case of paralytic polio so far, in a Hasidic Jewish man, the virus has now been detected in the state’s wastewater 69 times since April, indicating community spread downstate, including in Orange, Sullivan and Rockland Counties and in New York City.

While officials detected fewer positives statewide in September than in August, they said it is not possible to know from the sampling whether the outbreak is accelerating or decelerating, only that polio continues to be present.

Circulating polio poses virtually no risk to anyone who is vaccinated, because two doses of vaccine, which can be completed by the age of 4 months old, confer 90 percent protection against paralysis. Three or four doses, required for school enrollment, provide 99 percent protection.

“The risks are low. But boy, if it’s your kid, that’s really a hard thing to live with,” said Kimberly M. Thompson, a health care economist whose work focuses on polio eradication.

In early September, Gov. Kathy Hochul declared a state disaster emergency, and on Thursday, the New York State health commissioner, Dr. Mary T. Bassett, declared poliovirus an imminent threat to public health in the state, expanding funding to help local health departments establish immunization clinics.

The United States now appears on a World Health Organization list of nations with circulating polio virus for the first time since the list was established, Dr. Thompson said. If polio continues to circulate for a year, the United States could lose its distinction as a polio-free nation, a status it has held since 1979.

“It is very sad. We are so close to global eradication, but eradication is an elusive goal,” said Dr. Walter Orenstein, associate director of the Emory Vaccine Center and a former director of the United States Immunization Program.

State officials have asked medical providers to be on high alert for new cases of paralysis or limb weakness. They have also started additional surveillance programs.

One, which officials are informally calling the “diaper project,” will ask parents of unvaccinated children in affected areas for stool samples from healthy children who happen to soil diapers while in the pediatrician’s office. Another initiative is asking parents for permission to test unvaccinated children for polio who turn up with flulike symptoms.

Much of the problem in New York is vaccine hesitancy, not outright refusal, available data indicates.

“We know that there are some people who like to delay the vaccine series until right before the child enrolls in school,” said Dr. Emily Lutterloh, director of the epidemiology division at the New York State Department of Health. “But unfortunately that leaves very young children — with their less than ideal hygiene and the fact that they are often cared for in groups — it leaves them unprotected.”

Religious exemptions to childhood vaccination have been barred since a measles outbreak in 2019.

But the 2020-21 data, collected during the pandemic, showed 114 schools self-reported polio vaccination rates of 90 percent or less, representing less than 1 percent of schools in the state. The schools had diverse affiliations: Catholic, Lutheran and Mennonite, as well as Waldorf schools, private schools that have a high rate of vaccine hesitancy, and international schools. About 17 percent were Orthodox Jewish yeshivas, according to that data.

In Rockland County, six Orthodox Jewish schools of the 80 in the state database had vaccination rates below 90 percent, according to OJPAC, an Orthodox Jewish advocacy group. Taking the size of each school into account, 96 percent of all school-age Orthodox children in the county were vaccinated, the group said.

“Since virtually all kids at Jewish schools are fully caught up with their mandated vaccinations by the time they go to school, it is absurd to claim that this community as a collective has more anti-vaccination sentiments than elsewhere,” said Yossi Gestetner, the group’s co-founder.

In Oneida County, a tiny Amish school, Meadow Valley, reported that 11 percent of its students were vaccinated against polio. Dan Gilmore, the county’s director of public health, said he wasn’t sure that vaccinations were required in Amish schools, though he encourages them. In any case, he added, enforcement would fall to the state. The public health director in Cattaraugus County said that some 20 Amish schools in his area did not submit any vaccine information to the state.

The state Health Department confirmed that it is responsible for investigating complaints about vaccination reporting for private schools outside of New York City, conducting annual audits of a “select number” of schools and issuing corrective action plans. How often audits take place, however, is unclear.

After the state removed religious exemptions for vaccinations in 2019, one Amish family in rural Seneca County sued, saying they opposed vaccination because they believed “God made his children ‘right and good’ and to vaccinate his children is to lose faith in God,” according to the lawsuit.

Under state law, the family’s unvaccinated children should have been excluded from school. But although the family lost in a first round of the court battle, the state backed off and did not enforce the rule, said James G. Mermigis, the lawyer for the family, who dropped the action.

“Their lives returned to normal,” he said of the children, who attended the Cranberry Marsh School in Romulus.

The Health Department did not comment on whether any enforcement actions were taken against the school in the case.

For New York City schools, the city Department of Health is charged with enforcement. In August, the department sent out a letter to private schools, saying that if children were not catching up with their vaccinations, parents should be given a warning letter, followed two weeks later by a letter excluding children from class. Schools out of compliance would face fines.

As for adults, there has historically been no requirement to track their polio vaccinations, though that has started with the state’s emergency order. For now, each county has access to a supply of at least 50 doses for adults who are unvaccinated or not up to date with their initial polio vaccine series, a state spokeswoman said. The state is not recommending additional boosters for the general public.

Dr. Patricia Ruppert, the health commissioner of Rockland, said in an email that while she did not rule out stronger actions, for now the county was working collaboratively with physicians, other providers and community groups to increase vaccination uptake. Some rabbis have signed a letter encouraging vaccination.

The county is also working with the Centers for Disease Control and Prevention and with the state on a “long-term strategy to counteract the continued challenges of myths, misinformation, disinformation and hate speech on vaccines,” Dr. Ruppert said.