Utah may soon start monitoring wastewater for polio as federal authorities warn the nation’s first case in nearly a decade may only be the “tip of the iceberg.”

“We are definitely discussing that,” Dr. Leisha Nolen, the Utah Department of Health and Human Services’ state epidemiologist, told the Deseret News. “We have partners that we are working with to try to think of how to get that set up with our system.”

Nolen said she expects “in the near future” to be able to begin checking for evidence of polio in the sewage samples that are already routinely collected at wastewater treatment plants around the state to be screened for COVID-19.

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Response to the first case in the U.S. in nearly a decade

Just a few weeks ago, a 20-year-old man from an Orthodox Jewish community in a New York City suburb was identified as the nation’s first polio case since 2013. The man, who had not been vaccinated against polio, suffered weakness and paralysis. He is believed to have been infected by someone from outside the United States.

The New York State Department of Health responded by launching wastewater surveillance for polio in the region, and reported confirming the presence of the virus in a total of 11 samples collected in June and July that are genetically linked to the identified case.

On Friday, state and local public health officials announced polio had also been detected in New York City.

A team from the Centers for Disease Control and Preventions arrived last week in New York to further investigate, and a community health leader who requested anonymity told CNN earlier this week the federal experts are “quite nervous” that polio “could mushroom out of control very quickly and we could have a crisis on our hands.”

Dr. José Romero, director of the CDC’s National Center for Immunization and Respiratory Diseases, is also sounding the alarm.

Romero told CNN that detecting polio in the U.S. is “significant,” given the high levels of vaccination. The CDC had declared that polio had been eliminated, with no cases originating here since 1979, although travelers have brought the virus into the country.

“Remember, this is just the tip of the iceberg, right. The very tip of the iceberg. Because it’s the rare case that causes paralysis. So that means there must be several hundred other cases in the community circulating before you see this one case,” he said, given the region where the case occurred has low vaccination rates.

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In New York’s Rockland County, where the new case was identified, as well as neighboring Orange County, vaccination rates dip to around 60% compared to just under 80% statewide, according to the New York state health department. Nationwide, the vaccination rate for polio is more than 90%.

The Times of Israel reported the new polio case “comes amid fierce backlash against vaccination in some Orthodox communities fueled by the COVID-19 pandemic and following a measles outbreak in Rockland County in 2018 and 2019 that was centered in the area’s Haredi Orthodox population.”

A push is underway by public health authorities to vaccinate people against polio, the New York Jewish Week said, describing the new case as involving “a young adult, in a wheelchair” who recently married and reportedly is living at his parents home with his wife after being released from the hospital.

Are more Utahns susceptible to polio?

In Utah, public health officials are concerned there may be an increased vulnerability to polio.

“Our vaccinations are lower than we would like them to be, especially after the pandemic,” Nolen said, because many people delayed routine medical care, including polio shots for their young children. “Polio, unfortunately, can take advantage of when we have a susceptible population. And we do have that right now.”

In the New York case, the young man was exposed to polio while traveling and was vulnerable to the virus because he had not been vaccinated as a child due to what the Utah state epidemiologist termed “a wave in the past decade or two” where parents chose not to vaccinate their children.

She said the combination of more susceptibility and potential exposures makes it “useful to know if there’s polio in our community that could get into people and cause disease. So that is one where we could use the data from the wastewater to understand how much we need to be monitoring, how much we need to aggressively message.”

Utah has been relying on wastewater surveillance, along with emergency room visits, to track the spread of COVID-19 since the start of April, when Gov. Spencer Cox shifted the state’s pandemic response to treating the coronavirus more like the flu or other endemic disease.

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Polio may also need to be watched because it can cause severe disease, especially in children, Nolen said.

“Classically, polio really hits little kids hard. If we have a vulnerable little population, which we do in Utah, somebody traveling could certainly expose them here in the state and cause an outbreak,” she said, that could result in cases of long-lasting paralysis.

Still, Nolen said at this point, she doesn’t have “very high concerns. I do think it’s something to remember. Vaccines have changed our lives for the better and we want to have our children be able to have a life where they aren’t worried about polio” and other preventable diseases.

Reducing the chances of a polio outbreak

Children need four doses of polio vaccine to start kindergarten, said Rich Lakin, state immunization director with the Utah health and human services department. Usually, that means a first shot at 2 months old, followed by additional doses at 4 months, between 6 and 18 months and between 4 and 6 years old, he said.

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Older children and adults who didn’t get vaccinated according to that schedule — or who don’t have a record of previous shots — are only eligible for three doses, Lakin said. But as long as someone completes the required series, they should be protected for life against polio, he said.

While children 1 to 9 years old in London are being urged to get a booster dose of polio vaccine as further protection against the virus after it was detected in wastewater in the English capital, Lakin said there’s no talk of doing the same in the United States.

Utah’s vaccination rate was slightly higher than the national rate for 2-year-olds born in 2018, the most recent data available, reaching 94.2% compared to 93.9% for the U.S. Lakin said although that’s likely to have fallen during the COVID-19 pandemic, he believes the numbers may be on the rebound.

“I just hope we don’t have a polio outbreak. I don’t want to do this again. But I think it seems like infectious diseases are increasing,” he said, adding, “The more people you have vaccinated, then the less likely we are to have outbreaks. Plain and simple.”

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