May 2, 2005

Polio Detected in Indonesia, Indicating It Crossed an Ocean

By DONALD G. McNEIL Jr.

NY Times

A case of polio has been detected in Indonesia, World Health Organization officials said today, indicating that an outbreak spreading from northern Nigeria since 2003 had crossed an ocean and reached the world's fourth-most-populous country.

The virus, found in a village in Java, is most closely related to a strain that was found in Saudi Arabia in December, they said, and the most likely explanation is that it was brought back either by an Indonesian working there or by a pilgrim who went to Mecca in January.

Indonesia's last case was in 1995, and it is now the 16th country to be re-infected by a strain of the virus that broke out of northern Nigeria when vaccinations stopped there, then crossed Africa and the Red Sea.

Officials recommended that Indonesia immediately vaccinate five million children on the western end of Java, including the capital, Jakarta, to control the virus. The country began planning such a drive last week, they said.

Indonesia has more Muslims than any other nation, and polio is now found almost exclusively in Muslim countries or regions.

Many people from northern Nigeria to the Pakistan frontier have resisted getting polio vaccines because of persistent rumors that it is a Western plot to render Muslim girls infertile or to spread AIDS. (Paradoxically, after several states in Muslim northern Nigeria halted vaccinations in 2003, it was purchases of Indonesian vaccine that finally convinced wary imams and politicians to drop their opposition, because it came from a Muslim country.)

With each new case, the W.H.O.'s goal of eradicating polio by the end of this year slips farther away. Its emergency response fund is virtually depleted and the agency has begun pleading with donors for help controlling new outbreaks in Ethiopia, Yemen and other very poor countries.

At the disease's low point, in early 2003, it was endemic in only six countries: Nigeria, Niger, Egypt, Pakistan, Afghanistan and India.

The current case was found in an 18-month-old boy in a village in Sukabhumi province in West Java who became paralyzed in mid-March, said Dr. Bruce Aylward, coordinator of the polio eradication campaign for the W.H.O.

Genetic typing, just completed in Bombay, India, clearly shows that the original source of the strain was northern Nigeria, said Dr. David L. Heymann, the W.H.O. director general's representative for polio eradication.

Comparison to databases at the Centers for Disease Control and Prevention in Atlanta shows that is about 99.2 percent similar to a strain circulating in Saudi Arabia and 99.1 percent similar to a strain in Sudan, suggesting that it came from Saudi Arabia, "but they're so close that it's a hard call," Dr. Aylward said.

Dr. Christopher P. Maher, chief of technical support in the W.H.O.'s polio division, visited Sukabhumi last week and found that the child had no family members who had traveled to polio-endemic areas, but other families had members who went recently to Saudi Arabia as guest workers or pilgrims.

Other cases of paralysis in the village "are very hot - they clinically look like polio," Dr. Aylward said.

That suggests widespread circulation, since only 1 case in 200 produces paralysis. Confirmation takes time because each requires two stool samples taken at least 24 hours apart and then chilled, shipped to a qualified laboratory and grown out for days or weeks before testing.

But vaccination should start as soon as possible, the officials said. Reaching five million children "doesn't sound like 'targeted' vaccination," Dr. Aylward conceded, "but in a country of 250 million, it is."

Only 75 to 80 percent of Indonesia's children get routine polio vaccinations, he said, and some areas have better coverage than others. Indonesia is a large chain of islands, and parts of it, including northern Sumatra, are in rebellion against Jakarta's rule. When polio gets into war-torn areas, as it has in Sudan and Ivory Coast, it can become much harder to eliminate.

Until recently, the country also lacked a polio emergency plan that provides for vaccinating at least half a million children within four weeks, going house to house.

Still, Dr. Aylward said, "I'd rather take the virus on in Indonesia than in a Sudan or a Yemen or the Horn of Africa, where you've got less than 50 percent baseline coverage."

Many countries stopped vaccinating or cut back substantially when they eliminated polio in the 1990's.

"We're paying a penalty for that now," Dr. Aylward said.

During the 11 months it took until northern Nigeria began vaccinations again, the disease spread across Africa from Guinea on the Atlantic Coast to Sudan on the Red Sea. One case was found as far south as Botswana. Some outbreaks have been contained quickly, but those in Sudan, Ivory Coast and a new one in Yemen all appear to be spreading faster than vaccinators can head them off.

The infection routes followed African highways that skirt the southern edge of the Sahara Desert and ferry routes on the Red Sea.

The disease was found in Jidda and Mecca in Saudi Arabia late last year, and polio eradication officials said in February that they feared the annual pilgrimage could spread it around the world.

In 1988, when polio was endemic in 125 countries, the annual assembly of national health ministers, meeting in Geneva, declared their intent to eradicate polio by 2000. That target was missed, but a $3 billion campaign had it contained in six countries by early 2003.