Outbreaks of acute flaccid myelitis in the US
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5246 (Published 19 December 2018) Cite this as: BMJ 2018;363:k5246
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To me the IDEA that “provocation paralysis“ is a possibility, was not a surprise. I am ancient and in my youth, provocation paralysis was recognised. And we the doctors did not sweep the possibility under the carpet when discussing between ourselves or even with lay people.
But these are the times when public health specialists - medical graduates or not - ignore such things. They see not, they hear not.
Evidence in support of my diagnosis of facultative deafness, facultative blindness, facultative dumbness?
No one has responded to Dr Cunningham.
Is it possible, or likely, that public health experts hope that by not discussing, by avoiding any record of discussion in Medline or PubMed, they will be able to pretend that nobody ever raised such questions?
DR JK ANAND
Long retired. Proponent of active immunisation and of informed consent
Competing interests: No competing interests
As of February 18 the CDC had confirmed 215 US cases of AFM in 2018; an additional 156 possible cases were still being investigated. John Williams at Pittsburgh Children’s Hospital predicted the final 2018 total would be 250 to 300 cases. (Daly, Pittsburgh Post-Gazette, 16 Feb 2019) Annual totals from 2014 to 2017 were 120, 22, 149 and 35. Experts believe these numbers are a fraction of the real US totals because of underreporting.
Non-polio enteroviruses are “agents of interest” as causes of AFM, particularly EV-D68. (Burton, Lancet Neurology, March 2019) EV-D68-associated AFM cases have now been reported in several European countries (Knoester, Ped Inf Dis J, Jan 2019), in Argentina (Carballo, Emerg Inf Dis, March 2019), and by a UK Task Force (Euro Surveill, 7 Feb 2019).
Only a tiny minority of EV-D68-infected children develop AFM, which prompts experts to ask about risk factors that predispose to paralytic disease. In public they speak in generalities but avoid mentioning the possibility that injections of vaccines or antibiotics could be co-factors in 75% of AFM cases. That is the risk generally attributable to injections in AFM caused by polioviruses. (Cunningham, “Injections and acute flaccid myelitis: the dog that hasn’t barked” BMJ rr, 20 Dec 2018)
The foregoing has a bearing on the public health response to recent measles outbreaks. In the US there have been renewed calls for elimination of ALL non-medical exemptions from vaccine mandates—not just measles vaccine but from EVERY vaccine on the US immunization schedule. (NYT editorial, 20 Jan 2019. US News, 20 Feb 2019. et al.)
From the standpoint of severity, contagiousness, and impact on public health, measles is a bad disease; the same cannot be said for several other vaccine-targeted diseases. A mandate for measles vaccine can be scientifically and ethically justified; not so for most other vaccines. The emergence of AFM—a devastating paralytic disease—and the possibility that it could be triggered by vaccinations forces us to re-think some vaccine mandates.
One of the reasons for parental “vaccine hesitancy” and some measles cases is bullying by public health and pediatric officialdom. Parents who might have accepted measles vaccination for a child are put off by the extensive vaccine buffet they are pressured to accept. (Cunningham, “Vaccine mandates in the US are doing more harm than good.” BMJ 2015;351:h4576) They and many physicians know that manufacturers have been exempted from any liability for adverse effects. Furthermore, they are aware that our knowledge of long-term safety and effectiveness of many vaccines is quite limited, contrary to repeated assertions by the CDC and media outlets.
ALLAN S. CUNNINGHAM 24 February 2019
Competing interests: No competing interests
The editorial and review of the US outbreaks of acute flaccid myelitis/AFM is timely, but it fails to mention a potentially important co-factor in the cause of this “mystery illness”—intramuscular injections and provocation paralysis. (Stelzer-Braid, BMJ, 19 Dec 2018)
I venture to say that few clinicians today are aware that injections are strong risk factors for paralytic polio: recent injections (e.g. antibiotics, vaccinations) have accounted for 66% to 86% of attributable risk of paralysis when polioviruses are circulating. (Hill and Knowelden, BMJ, 1 July 1950. Strebel et al, NEJM 1995;332:500. Kohler et al, Int J Epidem, 2002;32:272) Even fewer clinicians are likely to know about poliovirus receptors, which are not expressed in normal human muscle fibers but are rapidly up-regulated in muscle damaged by injections. (Dalakas et al, NEJM 1995;333:62) This enables circulating polioviruses to bind to motor end plates from where they are transported along motor nerves to the spinal cord. (Gromeier and Wimmer, J Virol 1998;72:5056. Ren and Racaniello, J Infect Dis 1992;166:747) 99% of poliovirus infections are benign and self-limited, but of the 1% of paralytic cases a substantial proportion are provoked by injections. There is a dose-response effect: in Strebel’s report of vaccine-associated paralytic polio/VAPP in Romania, a single injection within 30 days of paralysis onset increased VAPP risk 8-fold; 2 to 9 injections increase VAPP risk 27-fold; and 10 or more injections increased VAPP risk 182-fold! For the contacts of OPV recipients the peak risk occurred when injections were given 8 to 21 days before onset of paralysis, similar to Hill’s observations from the 1949 polio epidemic in the UK.
It would seem that the foregoing observations should apply to recent AFM outbreaks. Gromeier, for example, showed experimentally how IM injections provoked paralytic polio, and suggested that the same thing could happen with non-polio enteroviruses. In spite of this, CDC investigations have included no questions about injections. This is surprising since the CDC was responsible for the Strebel study of provocation paralysis in Romania. They steadfastly publicize AFM as a “mystery disease.”
As of December 17, 2018 the CDC had confirmed 165 US cases of AFM so far in 2018; another 155 possible cases were under investigation. Since August 2014 there have been a total of 491 cases of AFM confirmed by the CDC, and some experts believe that the actual number is substantially larger because many cases go unreported…..This is a devastating disease: only 8% to 18% of children with AFM fully recover and 8% to 14% are left with severe disabilities. (Gill et al, CMAJ 2018 Dec 3;190:E1418)
Mere mention of injections in connection with AFM seems to be taboo, at least in US publicity about this mystery disease. I am aware of a single exception. On November 1, 2016 the Seattle Times reported the death of a 6 year-old boy from Bellingham, Washington from what was thought to be AFM. The case provoked some controversy because the family suspected vaccinations: 14 days before the onset of his illness he had received multiple vaccines for school admission, plus a flu shot. The Washington State Department of Health and hospital authorities publicly dismissed any role for vaccinations. Eventually, the CDC decided that his case was not AFM. The cause of his illness was never announced. (Seattle Times, Nov 5 and Nov 14, 2016)
Non-polio enteroviruses are at the top of the list of suspects, but I know from private correspondence that a number of pediatric experts believe we must also consider injections and provocation paralysis as possible co-factors. AFM epidemiology is consistent with the pattern of enterovirus circulation; it also follows the timing of back-to-school shots. Why is AFM so prominent in the US? Does it have anything to do with immunization policies and practices? Where do we go from here…..?
ALLAN S. CUNNINGHAM 20 December 2018
Competing interests: No competing interests
Re: US measles, vaccine mandates and totalitarian pharmocracy
Alan Cunningham [1] touches a little obliquely on an issue which has not yet been properly reported in this journal, the movement to clamp down on all vaccine exemptions in the United States [2] on the back of a few measles outbreaks which are neither particularly large, nor have had any fatalities. It should also be pointed out that unlike catching measles which gives lifetime immunity, immunity from vaccines fade. It is unlikely that more than a percentage of the vaccinated population any longer have immunity against measles, and achieving herd immunity via vaccination seems improbable.
Even if the vaccine was much more effective, any rational person might think that it was an extraordinary and epochal leap from dealing with a few extra cases of measles to exacting compulsion in the future for every vaccine the federal bureaucracy chooses to mandate. In all the rhetoric against "anti-vaxxers" [3] what is hidden is the absolute power that may be ceded to the US government over what might otherwise be considered a rather trivial medical episode, for which it will likely not be a remedy anyway.
[1] Allan S Cunningham, 'Acute flaccid myelitis, measles, and vaccine mandates', 24 February 2019 https://www.bmj.com/content/363/bmj.k5246/rr-0
[2] Elizabeth Cohen and John Bonifield, 'FDA chief: Federal government might step in if states don't change lax vaccine laws' CNN 20 February 2019, https://edition-m.cnn.com/2019/02/20/health/vaccine-exemptions-fda-gottl...
[3] Responses to Tanne, 'Measles: two US outbreaks are blamed on low vaccination rates', https://www.bmj.com/content/364/bmj.l312/rapid-responses
Competing interests: No competing interests