CHOOSING SIDES IN POLIO WAR\Many claim oral vaccine's safe and effective, but CDC may call\for mix with injections.

Byline: Elizabeth Cosin Daily News Staff Writer

Polio - the once-dreaded disease that put young victims in iron lungs, wheelchairs and worse - is practically gone.

And now that the United States is approaching what might be the final drive to eradicate the virus, health agencies are bickering over just how to grind it out so it never comes back to cripple again.

There have been no reported cases of polio occurring on their own in the U.S. since 1979 and in the entire Western Hemisphere since 1991. In fact, the World Health Organization expects to completely eradicate the disease worldwide by 2005.

But a controversy has developed over a proposal by the federal Centers for Disease Control and Prevention that would recommend changes in the way doctors immunize children against polio.

At the heart of the controversy is the oral polio vaccine, which has been the preferred method of immunization since it was first developed by Albert B. Sabin and approved for use in the U.S. in 1961. Because it is a live attenuated virus - in other words, a weakened version of the polio virus - it can cause polio in people who have significantly compromised immune systems.

And while the incidences of vaccine-caused polio are extremely rare - one in 7.5 to 9 million doses, or six to 10 cases a year in the U.S. - public health officials were concerned that even those few cases were too many, considering the availability of a safer, injectable vaccine.

The CDC proposal, as it stands now, would give doctors a choice of how to administer the vaccine. But its Advisory Committee on Immunization Practices contends that the number of vaccine-related polio cases could be halved if doctors used injections to administer the first two of four recommended doses of the polio vaccine.

The injections, which carry a dead or inactivated form of the virus, would help boost the immune system of children more susceptible to contracting polio, the panel argued, making it less likely that the subsequent "live" doses will infect them.

"The only cases of polio reported in this country in years are caused by the oral vaccine," said Dr. Joel Ward of the Harbor-UCLA Medical Center, who serves on the CDC advisory committee that has been developing the recommendations. "We thought that was unacceptable considering there were other, safer vaccines now available."

The CDC is expected to vote on a proposal this summer, after which various medical associations, including the Academy of Pediatrics, will decide whether to follow the CDC's lead. Doctors and government health organizations are not required to follow CDC recommendations, but they generally do.

But the proposed recommendation is triggering an uproar, even now.

The changes, say pediatricians, public health officials and consumer health advocates, would be more costly, less effective and might add to the obstacles they face in ensuring that children are fully immunized.

So controversial is the proposal that the Los Angeles County Public Health official in charge of immunization says she will refuse to endorse the CDC plan, even if it is approved as expected this June.

"My opinion is that it would be a giant mistake and I see no logic or reason to change the way we administer the polio vaccine," said Shirley Fannin, who serves as the county's director of disease control. "Frankly, I see it as spending a whole lot of money for a theoretical problem."

Many in the health-care community see little reason to alter or make more complex a program that has worked so well for so long - a far cry from the days when epidemics of polio were common and were greatly feared because the disease left many of its victims paralyzed for life.

"The oral vaccine has been an extraordinary success," said Dr. George Carlo, a physician who heads a nonprofit research institute in Washington, D.C., that has been a leading critic of the CDC's proposal. "Do nothing and we will likely see polio eradicated within 10 years. There just doesn't seem to be enough evidence that this method will work any better than the current program. The consequences are that we could have a reversal."

Carlo echoed the fears of several other physicians and public and private health officials that a number of factors - in particular that the dead virus is not as effective as the live version - will lead to fewer children being properly immunized.

In California, public health policy dictates that children cannot enroll in kindergarten unless they can show they have been immunized against nine childhood diseases, including polio - with the vaccine typically administered at the ages of 2 months, 4 months, 18 months and before beginning school, at 4 to 6 years of age.

But it has been difficult for health officials to convince parents, particularly poor and new immigrant populations, to get their children immunized on time. Many argue that adding more immunizations - there are currently 13 required during the first 24 months - would give parents another reason to skip or put off their children's immunizations.

"We know that by the time kids get to kindergarten, most have been immunized. What we don't know is how many of them are being immunized on time," said Franco Reyna, project coordinator of the nonprofit Multicultural Area Health Education Center of Los Angeles, which helps educate people - mostly Latinos - about a variety of important health issues from prenatal care to immunization and AIDS.

Said Reyna: "The younger children are the ones most susceptible."

And proposing extra shots, as the CDC plan recommends, is never popular with doctors and other care-givers who must actually administer the injections to children who are likely to scream and cry during the procedure. Doctors acknowledge that needles bring out a real fear in children that should be taken seriously.

"We always want to minimize the number of shots children get," said Dr. Brian Greenberg, a pediatrician who practices in Agoura and Tarzana. "Every pediatrician is sensitive to that. But the trauma of getting a shot is incomparable to actually getting the disease."

Shots aside, however,Fannin and other officials worry that the dead vaccine won't give the same blanket protection as the live vaccine, which can "cross-vaccinate": In the same way the weakened virus can cause polio in people with significant immunity deficiencies, it can also spread its effectiveness from a child who has recently been immunized with the live vaccine to one who has not. Because the great majority of people have sufficient immune systems to handle the weakened virus, this means extra insurance that more kids will be covered - even if they don't get all their shots.

This particular quality of the oral vaccine has been largely responsible in helping fight the spread of polio over the years because it helped immunize children who did not take the vaccine.

"I can say without hesitation that if we had been using the injections, we would not have had nearly the success against polio in this country that we have had," said Fannin. "The oral virus is so much more effective because its immunity can be spread so easily. And to do this just because of the theoretical possibility that someone will get infected is silly. No one in L.A. has been infected that way by the virus; the possibility is extremely rare."

Yet, one other issue is the potential cost of the injectable vaccine, which is much more expensive - and not as widely available - as the oral polio vaccine. Fannin predicts implementing the recommendations would cost the county millions of dollars.

The federal government provides childhood vaccinations to the county, which are given to the public free of charge. But the county still has to pay for syringes and employees to dispense the vaccine - not to mention the cost of disposing of the biohazardous material, Fannin said.

What's more, it takes longer to administer an injection than to give the oral polio vaccine, Fannin said. Last year, the county gave 209,000 children the live polio vaccine.

Yet, proponents of combining the vaccines dismiss the effectiveness argument, as well as contentions that adding two more shots to the litany children must receive will cause reluctance among parents to have their children vaccinated. They argue the polio shots will someday be combined in the same syringe with other vaccines, thus actually cutting the number of shots needed.

"We know there is concern among health-care providers," said Barbara Reynolds, a CDC health education specialist in Georgia. "Our proposal does give them a choice, it's flexible. Right now there are basically two options: four shots or four oral doses. We wanted to strike a balance between the two."

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Photo (1--Cover--color) THE NEW POLIO BATTLE Health officials debate whether vaccine regimen should include injections. (2) Omri Peled, 2 months, gets a DTP/HIB immunization from Dr. Brian Greenberg and comfort from mom Galit. Some experts advocate replacing two of four doses of oral polio vaccine with two doses of injectable vaccine in the array of immunizations all children must get during their first two years. David Sprague/Daily News