5 Cases of Polio in Amish Group Raise New Fears
By GARDINER HARRIS
Published: November 8, 2005
(must register to NY Times to view original article)
LONG PRAIRIE, Minn. - Polio was pronounced dead in the Western Hemisphere
years ago, after one of the most successful public health campaigns in
history. But now it is stealing through a tiny Amish community here in
central Minnesota, spreading from an 8-month-old girl to four children on
two neighboring farms.
So far, no one has been crippled by the disease; only 1 in 200 cases of
polio results in paralysis. But worried public health officials say it may
be only a matter of time.
The story of how polio came to this dairy farming community of 24 families,
with 19th-century ways that include a deep-rooted suspicion of vaccination,
is both a medical whodunit and a cautionary tale, suggesting that
eradicating polio may prove far harder than anyone thought, even in the
No one expects that the United States will be visited by the kind of
outbreaks that recently flared up in Africa and Asia, frustrating the
longstanding goal of eliminating polio for good by the end of this year. But
the Long Prairie cases highlight a weakness in the worldwide campaign.
The 8-month-old Amish girl, whose name has been withheld by health
officials, has an immune deficiency that makes her unable to rid her body of
How she contracted the virus remains a mystery. She may have been infected
in a hospital by another immune-deficient patient who nursed it for years. A
doctor or nurse may have served as a go-between. Or there may have been a
chain of carriers in the Amish community. The virus is spread from stool to
mouth, a surprisingly efficient form of transmission.
Regardless, the girl is now a wellspring for polio, a modern-day Typhoid
Mary who can pass it along to others. Anyone who has not been vaccinated is
vulnerable. And though vaccination rates in the United States are at
historic highs, an increasing number of parents are resisting inoculations
for their children, fearing that they may cause disorders like autism, a
connection scientists have almost universally discounted.
So health authorities are keeping a watchful eye on the girl and her
"If that child is a message in a bottle," said Bruce Aylward, coordinator of
the global polio eradication initiative at the World Health Organization,
"it has just washed up on shore."
The 24 families moved to this windswept stretch of prairie from Wisconsin
about three years ago. An Amish community generally includes only as many
families as can fit into one house for church services, and each community
must come to a consensus on what to accept from modernity.
This one allows windshields for its horse buggies, kitchen cupboards that
are attached to walls and some upholstered furniture - all somewhat unusual
for the Amish, said Dr. Susan Rutten, a physician from nearby Sauk Centre
who makes house calls in four Amish communities. Men can wear dark green
shirts, not just navy blue and black.
The farms could have come straight out of children's books. There are ducks
and chickens, cattle and hogs. Fence posts are columns of stones enclosed by
wire mesh. Lacking electricity, the farms are remarkably quiet. At one, the
children rarely yelled or even spoke in the presence of a stranger. The air
smelled of turned earth, manure and wood smoke.
The threat of polio seemed remote here - until this summer. That was when
the baby was hospitalized with an immune-system disorder.
As her care became increasingly complex, she was shuttled through four
hospitals. At the third, she developed diarrhea. On Aug. 27, doctors sent a
stool sample to the hospital's laboratory, which determined that the girl
had an intestinal virus. In many states, nothing more would have been done.
But in Minnesota, hospitals send such samples to a sophisticated state
laboratory. On Sept. 29, the tests matured. A laboratory supervisor called
Dr. Harry Hull, the state epidemiologist, to say they had isolated a polio
Dr. Hull was stunned. "I said, 'You have made a mistake,' " he recalled.
Tall and thin, with glasses and bushy eyebrows, Dr. Hull is one of the
world's foremost polio experts. Before coming to Minnesota, he worked for 10
years in the World Health Organization's global polio eradication effort. In
an interview, he scrawled circles and arrows on a sheet of paper as he
described the search for the virus.
The state laboratory redid the tests. The results were identical. Then it
sequenced the virus's genomic code. A supervisor plugged the code into a
national genomic database, comparing it with the genes of a polio virus.
"Bingo," said Dr. Norman Crouch, the laboratory's director. "It was a 98
percent match. We knew we had nailed it."
The Minnesota laboratory sent the sample to the Centers for Disease Control
and Prevention in Atlanta, which confirmed the results. Officials were
immediately concerned about where the virus originated and where it might
Confirming the presence of polio in a city with even one infected person is
not impossible, said Dr. Mark D. Sobsey, a professor of environmental
microbiology at the University of North Carolina. The stool of an infected
person contains so many viral particles that tests at a sewage treatment
plant can reveal it. Such tests helped track outbreaks in the Gaza Strip and
Haiti in recent years.
Since many Amish use outhouses, however, state officials geared up to go
door to door. They unearthed a public health form explaining how to collect
stool samples. The form had pictures of a flush toilet and a garbage can
with a plastic liner - things foreign to many Amish communities. Officials
changed the form.
Gary Wax, an epidemiologist for the Minnesota Department of Health,
contacted the leader of the Amish community where the child lives and asked
for his permission to seek stool samples from those in his community. The
leader gave his blessing, Mr. Wax said.
"We really tried to do it in a respectful way rather than just barge right
in there," Mr. Wax said.
Since the Amish have no phones, he could not call for appointments. He and
his colleagues knocked on doors. They had been warned against speaking
directly to Amish women without their husbands present, Mr. Wax said, and
the men were "running all over the place, helping each other with harvesting
and construction." So if the man was not at home, they left.
"We came back many times to some places," Mr. Wax said. After weeks of
effort, just 5 of 24 families in the community agreed to cooperate. Three of
the five, including the family of the 8-month-old, proved to have infected
"I would be surprised if we don't get a paralytic case someplace," Dr. Hull
In a neighboring community, a 38-year-old farmer who is also a sawyer agreed
to speak with a reporter only if his name would not be used, saying Amish
people avoided calling attention to themselves.
The farmer, who has seven children, explained that nothing in Amish law
forbade vaccinations, but that many Amish believed that vaccines weakened
the immune system. He added that as a result of the infections, he planned
to have his children vaccinated against polio, measles, mumps and rubella,
and that most of the families in his community were doing the same. "We'll
get vaccinated if we feel it's necessary," he said. "But our definition of
necessary may be very different from yours."
A further challenge for public health officials is that their surveillance
efforts cannot be confined to a few remote farming communities.
"My mental image of the Amish was that they don't travel at all because they
don't drive cars," Dr. Hull said. "That's not true."
The Amish commonly take buses and trains, and occasionally even planes.
Families from the baby girl's community recently attended a wedding in
Ontario, Canada, that health officials said drew more than 1,000 guests.
Some have visited Wisconsin in recent weeks.
Polio experts have long feared that an immune-deficient person could cause
an outbreak of paralytic polio. That is a particular hazard in poorer
In much of the developing world, children are given an oral vaccine made of
a live, nonparalytic polio virus. Two drops confer partial immunity, making
mass vaccination campaigns achievable in poor countries. To become fully
immunized, a child must be vaccinated several times. The vaccine causes an
infection that usually lasts a few weeks. The infection can spread to others
and immunize them, too.
But if the virus spreads too far among previously unvaccinated people, its
genes will change and the virus will regain its ability to cripple and kill.
Such a virus caused an outbreak of paralytic polio in Haiti and the
Dominican Republic in 2000 and 2001, crippling 21. (The outbreaks in Africa
and Asia began after many Nigerians refused vaccinations in 2003, suspecting
they were a Western plot to sterilize Muslim girls.)
The United States and much of the developed world used live-virus
vaccinations for decades, but switched in recent years to a dead virus that
is injected. The dead virus does not cause an infection or paralysis.
In people with poor immune systems like the 8-month-old Amish child, the
live polio vaccine can change to a paralytic form without being passed to
anyone else, since such people can nurse a mutating virus for years.
In most of the world, such patients die quickly because of poor medical
care. In the West, they can live for years, with a few of them shedding
polio viruses all the while. Among experts, these patients are called
"chronic excreters." That such a polio wellspring would be born among a
largely unvaccinated population like the Amish, Dr. Hull said, was a "random
"It's a model of what might happen if we stop vaccinating too soon," he
The Amish girl remains hospitalized in strict isolation. Health officials
will not say where. And they are still trying to figure out where she
contracted the virus.
Genetic testing showed that the virus was almost identical to that of the
oral polio vaccine given in much of the rest of the world but not in the
United States. The slight changes to the virus from that of the vaccine
suggested that it had been circulating for at least two years. The girl has
never traveled abroad.
A fear is that such a person could unwittingly incubate a polio infection
for a decade or more and then accidentally reintroduce it - years after
experts have declared it eliminated from the world and vaccinations have
That prospect has long seemed remote, because such children are so rare, Dr.
Aylward of the World Health Organization said. But an outbreak of paralytic
disease in Minnesota would prove that it was more likely than many had
believed, and it would demonstrate that work now under way to better
understand the risks posed by chronic excreters would have to be
"Or we may need to revisit the strategy and time frame for stopping the use
of the oral polio vaccine," Dr. Aylward said. "It's a tiny chance, but it's
something we need to keep an eye on."