The battle to eradicate polio from the globe received another serious setback yesterday with news that the disease has spread to Indonesia as well as Yemen, both of which had been polio-free for nearly 10 years.
The World Health Organisation yesterday confirmed that an 18-month-old child had been paralysed by polio in a village in west Java, Indonesia. The case was declared the first since 1995. Seven other suspected cases are being investigated.
Teams of WHO staff flew to Indonesia to help the government limit the outbreak. Four thousand children in four villages have already been immunised.
That news followed hard on the heels of revelations that there had been 22 confirmed polio cases in the past fortnight in Yemen, which had been free of polio since 1996.
The strain of polio virus in all the cases has been identified as the one that caused a large outbreak of the disease in Nigeria last year.
Immunisation against polio had to be stopped in the Nigerian state of Kano in August 2003 because of local suspicions and rumours that the vaccine had been designed to make Muslim children infertile.
After intense negotiations and a supply of the vaccine made in an Islamic country - Indonesia - the immunisation programme began again last August.
But the virus, which was responsible for 814 cases of polio in Niger and Nigeria up to March this year, was carried out of Nigeria into neighbouring countries including Sudan, and now has travelled as far as Indonesia. WHO staff said yesterday they did not know whether the virus had gone straight from Sudan to Indonesia, or whether it had first been conveyed to Saudi Arabia, the site of two cases.
David Heymann, the WHO director general's representative for polio, and an expert in communicable diseases, said yesterday that nobody yet knew how widespread the outbreak might be in Indonesia.
"We don't know how the virus got to this west Java area," he said. "Did it go into the capital, Jakarta?"
The virus may have been carried to west Java during a pilgrimage to a shrine there in February, he said.
Fortunately, however, Indonesia's child immunisation rate is 90% (although some parts of the country have higher rates than others), and at present it is the low season for polio transmission - infection rates rise in the summer months.
Yemen, he said, was a different story. Immunisation coverage was not high, but a national campaign took place last month because of the country's proximity to Sudan. The first four confirmed cases were in the south-west, on the Red Sea coast. Ten days later it was reported that 18 other cases had been identified, spread across the country.
The virus can be carried by adults or children, whether immune or not, and once people have it they will excrete it for six to eight weeks.
The high point of the polio eradication campaign was in 2003, when the disease had disappeared from all but six countries. Since the Kano episode, however, polio has spread to 12 countries.
Dr Heymann admitted the spread was causing problems. "This is a setback, but these countries did it before. The hope is that they will be able to do it again." But money was now a pressing issue. "We have spent all our $25m [£13m] emergency resources for the coming two years," he said. "We are now having a cash flow problem."
The immunisation effort in Yemen will cost $4.5m. The Indonesians will pay for their own vaccine, but there will be other costs to the campaign amounting to up to $1.5m. The eradication effort has already spent $4bn, but now needs at least $50m more.
Despite the spread of the infection and the costs, Dr Heymann said giving up was not an option. "We can't turn back now. This is a resolution that the world made in 1988 and we are obliged to finish this programme and we will finish it," he said.
