Polio in the Marshall Islands / by Deborah A. Goebert

PoHo in the Marshall Islands 1l he Marshal! Islands, isolated in the Pacific Ocean, experienced a polio epidemic well after the first develop- ment of the polio vaccine. In 1963, a young Marshallese visiting the Kwa- jalein military base became conta- mined with the polio virus. The disease spread out across the virtually un-immunized population, causing impairment in nearly 200 people. Dozens remained permanently dis- abled. Today, over 25 years after the epidemic, new problems related to polio are appearing. With a total land area of about 70 square miles, the islands are spread out across half a millon square miles of the West-Central Pacific Ocean, and lie a few degrees above the equator. The Republic of the Marshal! Islands is comprised of over 1 ,000 islands, atolls and islets, but only a few are inhabited on a permanent basis. The total population is around 43,000, and the capital is Majuro. An epidemic of gastro-intestinal ill- ness resulting in transient muscle weakness in children and adolescents was reported in 1958 in the Marshal! Islands, which were then a district of the U.S. Trust Territory of the Pacific Islands. The outbreak occurred after a regional meeting which was attended by delegates from all areas of the Pacific. Although the clinical diag- nosis of poliomyelitis could not be confirmed, a Salk vaccine immuni- zation programme was begun among the residents of Majuro. Unfortu- 28 by Deborah A. Goebert nately, all efforts had ceased by the end of 1959, partly because there had been no formal reports of paralytic polio. In the latter part of 1962, several families from areas which had suffered recent outbreaks of poliomyelitis moved to the Marshal! Islands. In January 1963, an American girl developed a non-specific illness with symptoms which included fever, malaise, headache, dizziness and vomiting . Three days later, she experi- enced paralysis which would later be confirmed as polio virus Type 1. And five days after the onset of this initial case, a Marshallese boy developed a similar illness. In the next two months, polio spread throughout the Marshal! Islands -following in the wake of two cargo ships and a local schooner. At each of the atolls visited by the ships, the passengers (including children) would disembark, spend a few nights ashore, and then continue the journey. Not long after the ships' visits, new cases of paralytic polio were identi- fied . A total of 196 cases were recog- nised in the Marshal! Islands during the 1 963 epidemic. Of these, 1 94 occurred among the indigenous population, who numbered only 16,000 at that time; 90 per cent of those afflicted were children under the age of seven . After polio was confirmed, the authorities used vaccination and quar- antine to limit the outbreak and con- fine it to the island group. But of course these efforts could not help those already contaminated and impaired by the virus. A clinical appra isal on all the people who had polio, made some 30 days after the onset of paralysis, rated each person on a 1 to 5 scale according to the severity of involvement. As a result, 37 individuals (19 per cent) were classified as Class 1 - paralytic polio with no residual paralysis; 68 individuals (35 per cent) as Class 2 - minor residual paralysis; 51 individuals (26 per cent) as Class 3 - significant residual paralysis leading to functional impairment of one or more limbs; and 29 individuals (15 per cent) as Class 4 -severe involvement leading to one or more limbs being extremely involved or severe trunk musculature involve- ment, or both. Eleven persons (five per cent) died. Rehabilitation care Persons classed as 3 and 4 required extensive rehabilitation care and follow-up because of the severity of disease. So the health authorities met this need by developing a rehabili- tation programme and opening a rehabilitation centre where medical treatment, surgery and physical therapy were available. Despite limita- tions in staff and facilities, the therapy programme had good results in terms of recovery of function. For some people, therapy still continues today. In 1988, the Pacific Basin Rehabili- tation Research and Training Centre of the University of Hawaii, John A. Burns School of Medicine, conducted clinical evaluations and interviews among 73 Marshallese who had had polio in the 1963 epidemic. Informa- tion collected included demographic factors (such as sex and age) ; what it felt like to experience polio; and identification of muscle weakness, new health problems and service needs. This study was in response to concern about increasing evidence from the United States that persons who had polio are now experiencing new problems related to the disease. Remote as they are, the Marshal/ Islands still proved susceptible to the devastation of polio in 1963. WOR LD HEALTH. March 1990 These new polio-related problems are thought to begin 30 or more years after the onset of the initial polio episode. They include progressive loss of mobility; decreased functional independence; increased fatigue and intolerance to cold; and increased muscle and joint pain, muscle weakness and atrophy in both affected and what were believed to be unaffected limbs. Mrs Deborah A. Goebert is a Research Speciali st at the Pacific Basin Rehabilitati on Research and Training Center. John A. Burns Schoo l of Medicine. University of Hawaii. USA. lt turned out that. 25 years after the epidemic, new polio-related problems were appearing in the Marshal! Islands. More than half of those examined were found to have residual muscle weakness. Sixteen per cent reported increased muscle pain; eight per cent increased muscle weakness; eight per cent increased fatigue; and six per cent increased joint pain . Few individuals needed assistance in completing daily activities like walking, climbing stairs, feeding, dressing, bathing or grooming. There had not been an increase in the use of mobility aids - braces, crutches or canes - since maximum recovery occurred. Although only a few Marshallese show signs of these polio-related problems, the studies in the United States suggest that these numbers will be increasing. About 20 per cent are expected eventually to develop disabling conditions and other late effects of polio. For those who must live with this progressive deterioration, the future outlook is frightening. Further research needs to be done in order to find ways to better under- stand the onset of polio-related prob- lems and to prevent any new loss of function . At present there is some controversy about the best therapy measures. Some believe that energy- conservation techniques should be taught to polio victims so as to minimise over-use of muscles and joints, while others believe that exer- cise programmes should be developed in order to strengthen and maintain muscles and joints. The evidence so far has suggested that both methods may be appropriate, but no clear criteria have been developed for effective case-management of people who had polio. WORLD HEALTH. March 1990 A polio victim in the Marshall Islands at the time of the outbreak. Today, new polio-related problems are appearing. Immunization is now being aggressively pursued in the Marshal! Islands, particularly on the more iso- lated outer atolls where it was discovered that as many as 90 per cent of the children had not been vaccinated against polio. The new "cold pack" -method of packing the vaccine, supplied by UNICEF, enables the potency of the shots to be main- tained for two weeks in the warm climate, and makes immunization possible even in the remotest atolls. In addition, health service personnel are training assistants from the outer atolls in primary health care, including immunization and the use of the "cold chain" recommended by WHO as a means of keeping vaccine safe from extreme temperatures. These continuing efforts should allay fears that another major epidemic will spread rapidly through their young population. With those individ- uals who were stricken with polio serving as a constant reminder, the Marshal! Islands authorities are now dedicated to immunizing 100 per cent of their population . There is much that can be learned from the Marshal! Islands polio epi - demic. First, no matter how remote an area of the world may be, it is still susceptible to the devastation of polio. Secondly, eradication is pos- sible but it requires constant efforts to immunize all the people. Finally, reha- bilitation needs to be provided to those who are disabled from polio, both immediately after - in order to maximise recovery - and throughout their life span - in order to minimise the possible late effects of polio. • 29