Polio detected in Haiti

In the shadow of Haiti's ongoing turmoil, infectious disease tracker ProMed reported on Jan. 21 that polio had been detected in Port de Paix and Port au Prince.  Information on this outbreak remains scant, and containment remains possible. But if this report is only the tip of the iceberg, this mostly forgotten scourge could regain a foothold in Haiti. This is bad news for Haiti, the region, and a global polio eradication effort that in the last few years has come tantalizingly close to success.
Polio is highly contagious and can become entrenched in communities, like Haiti, with weak water and sanitation systems. There is no cure, and few supportive therapies exist. Most cases do not cause significant illness but approximately 1 percent of all cases result in some form of paralysis and approximately 10 percent of these cases result in death.
Oral polio vaccine (OPV) is included in Haiti's routine child immunization program, but coverage remains poor at only 52 percent, well below the percentage necessary to provide herd immunity. Before the earthquake, 25 percent of children were malnourished (a significant risk factor for polio infection) and 40 percent did not have access to basic health services. Add to this equation mass displacement and nonexistent infrastructure and the prognosis becomes even more worrying.
The Americas were certified polio free in 1994. Since then, the only verified outbreak in the region was 21 cases in Haiti and the Dominican Republic in 2000-01. Surveillance in Haiti is difficult in the best of times and while there were no cases reported since 2001 some have speculated that failure to completely eliminate polio during this outbreak may have left the door open for its return. 
Unless the Haitian Ministry of Public Health and the international community can act quickly and contain this outbreak, there is a considerable risk of it traveling to neighboring countries. Relations with the Dominican Republic, strained by decades of border disputes and the post-earthquake inflow of Haitian refugees, could worsen if polio, like cholera, makes its way into their country (on Friday the Dominican Republic reported its first cholera death). The Dominican Republic's polio immunization rate is considerably higher but still leaves them at the lower end of recommended levels. The United States has not had a polio case since 1993 and the vaccine coverage rate for 2009 was 93 percent, suggesting sufficient levels of herd immunity exist to prevent a significant outbreak. But coverage rates vary widely and growing vaccine skepticism in some communities has left large populations of children exposed to vaccine preventable diseases, making it impossible to rule out a limited return to the United States if there is a large uptick in cases within the Americas.
As we saw with H1N1 (swine flu) in Mexico, countries struggling to contain disease outbreaks in their own countries are quick to lay blame elsewhere. Regional spread of polio, if it occurs, will almost certainly see the majority of this blame placed on Haiti's shoulders. Travel restrictions and significant diplomatic disputes remain a very low likelihood scenario, but further demonization of Haitian communities can be expected if this outbreak is not contained.
After smallpox was eradicated in 1977, WHO pledged in 1988 that polio would be the next disease to be eliminated. 30 years later, endemic polio transmission is occurring in only four countries (Afghanistan, India, Pakistan, and Nigeria). However, politics and funding shortfalls threaten to thwart these efforts.  A 2003 drive to eliminate polio in Nigeria collapsed after a combination of rumor, mistrust and poor communication convinced local leaders to boycott polio immunization, and subsequently led to outbreaks throughout Africa and as far away as Indonesia, which had been polio free for ten years.  Vaccination drives in Afghanistan and Pakistan have been hampered by conflict, natural disasters, mobile populations, and religious refusals.  Additionally, the Global Polio Eradication Initiative (GPEI) is perpetually struggling to meet its funding needs.
Details of this outbreak in Haiti will likely emerge in coming days and weeks. If cases persist, it will once again raise questions regarding the short-term trajectory of the polio eradication campaign, and it will be another in a laundry list of reconstruction challenges for this troubled Caribbean nation.
Emily Hoch and Scott Rosenstein are analysts in Eurasia Group's Global Health practice.

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