Polio is the disease most people thought we had put behind us here in the United States. But earlier this summer, an individual in Rockland County, N.Y., contracted the virus likely from exposure in this country, and ended up paralyzed.

The last time there was community transmission of polio in the U.S. was 1979. The Americas were declared polio free in 1994. Though it's just one case of paralysis at the moment, public health officials — both locally and nationally — are taking the news very seriously.

Wastewater testing and genetic sequencing have shown the virus has been quietly circulating in a couple New York counties since at least May. And it recently was detected in New York City's wastewater. "Even a single case of paralytic polio represents a public health emergency in the United States," the Centers for Disease Control and Prevention declared in a recent report.

Low vaccination rates in Rockland county mean there's a risk of more paralytic cases in that community, the report said. The challenges that health officials are facing while managing the local response in New York may indicate where other spots in the country could soon be headed.

"Rockland County is basically New York City," says Perry Halkitis, dean of the School of Public Health at Rutgers University. "New York City is basically New Jersey. Rockland County is basically Connecticut." Because people travel so much, diseases like polio can spread quickly, he explains. "Are there probably dozens, if not hundreds, if not more cases of undetected polio in our population? Probably. Are we catching them? Probably not."

And health officials have to tackle this outbreak in a moment of rising wariness towards public health fueled by the COVID crisis.

A feeling of dread

The news about the paralytic case circulated amongst those in local government before it was announced to the public. Mona Montal — chief of staff for the town of Ramapo in Rockland county — remembers what went through her head: "Here we go again." She was, of course, thinking of the grueling last two plus years of combatting COVID. "Do I as an individual, and do we collectively, as a county and as a community, have the strength to go through this again?," she wondered.

And polio, with its possibility of paralysis, is an especially terrifying disease. "Polio cannot be cured," Montal explains. "And once it's paralytic polio, you're paralyzed. Plain and simple."

Before the vaccine was rolled out across the U.S., paralysis and children in braces and wheelchairs were among the haunting images of outbreaks from the 1940s and 50s. In fact, Montal was told stories of her own family members who died or were paralyzed by the disease.

During COVID, she worked on the county's COVID vaccine information campaign, alongside Rockland County resident Shoshana Bernstein, an independent health communicator. The news of paralytic polio had Bernstein in knots. "I'll check my phone about seven times a night," she says. "I wake up like, 'Oh my God, is there another case?'"

A very small percentage of people with polio become paralyzed. Most of the time, there are no symptoms at all. Which is why, in public health, just one case of paralytic polio constitutes an outbreak — the tip of the iceberg.

"It's very difficult to predict how many people, but it's definitely a number of individuals that would have to be actively transmitting," says Dr. Irina Gelman, Commissioner of Health, Orange County, which is next door to Rockland. "Clearly a confirmed case of polio in the United States is major news."

When Rockland and Orange Counties started testing the wastewater for polio, samples going back to May were positive for polio. Then, sequencing the virus' genetic material surfaced something else that was unsettling.

"There are multiple strains, so they are different," says Gelman, "meaning we do know that it's more than one individual" who is shedding polio virus. In other words, the outbreak isn't contained.

The risk of low vaccination rates

Falling vaccination rates are a big part of the problem, in the U.S. and abroad. During the pandemic, many children missed shots and vaccine services were disrupted, the CDC notes in its report on the Rockland polio case. Nationally, by age two, nearly 93% of infants born during 2017-2018 were vaccinated for polio. But according to the New York State Immunization Information System, vaccination coverage among infants and children less than 24 months living in Rockland County was 60.3% in August 2022. In some communities, coverage was as low as 37.3%.

"I mean, to put it bluntly, it's just disappointing at this point that we are still here," Gelman says. "This is a vaccine-preventable disease. And had everyone just been up-to-date on their vaccination, we would have continued to report it as being eradicated."

Here's how authorities think the virus got here:

A person came to New York State infected with a strain of polio which is connected to samples found in the wastewater of Israel and the UK. The person didn't realize they had polio: They didn't have symptoms, or they were mild or generic. Then, because vaccination levels are low in some communities in New York State, the virus started spreading, eventually causing paralysis in a person in Rockland. The virus then continued to fan out, since Rockland and Orange Counties have some of the lowest polio vaccination rates for young kids in the country.

"It's a multitude of reasons spread across a multitude of demographics," says Bernstein. "There's no one single group that is not vaccinated." This is true not just of these communities in and around New York City.

"We have a large number of...populations who are choosing not to vaccinate [their children]," says Halkitis. "And so it is a reality across our country. We know from territory to territory, from borough to borough, from neighborhood to neighborhood, there's wide variation right now."

That is, although polio has only been detected in these few places in New York State so far, Halkitis warns it's likely to spread to other places near and far with pockets of low vaccination.

Tackling vaccine hesitancy

If polio does show up in other places in the U.S., they are likely face some of the same challenges Rockland and Orange Counties have encountered in reaching communities that are under-vaccinated.

Bernstein explains that COVID and all the talk of vaccinations just made everyone tired and confused in Rockland County. She's a member of the large ultra-Orthodox Jewish population here, some of whom, she says, choose to live a more insular lifestyle.

"Social and secular media is not really something that's brought in," Bernstein says. "So it's a lot of word of mouth," which, she acknowledges, makes some within her community vulnerable to anti-vaccine messaging. "We always say it's extremely easy to instill fear and extremely difficult to undo it," says Bernstein.

The county is a mosaic of people where vaccination rates are also low, including members of the Haitian and Latino communities. "I think any press release from the CDC is just — no one's even reading it," Bernstein says.

So Bernstein and Montal have joined forces to become a vital conduit between all the official public health language and the hearts and minds of their neighbors. The duo helped initiate a large printed infographic, which is hot off the presses. There are four versions in English, Spanish, Haitian Creole, and Yiddish. Montal says it's carefully worded.

"People have had PTSD with the word vaccination," Montal explains. "So we're immunizing, we're not vaccinating. And that's the messaging."

The two women work with trusted community leaders, like rabbis and pastors, to get the word out. And they've asked the CDC for a letter they can show these leaders that supports them in that effort.

"My dream is that after this," says Bernstein, "the CDC will actually have like a game plan of, 'Okay, we're using Rockland County as our model. And now we're going to repeat that model across the country.'"

The Rockland County Department of Health has organized a variety of polio-only immunization clinics in different locations once or twice a week. Montal says, "We have to bring the immunizations to the people. We can't expect the people to come to us."

To that end, last Wednesday afternoon in Spring Valley, at a polio immunization clinic, a total of about 15 people stopped by over a couple hours. Brian Hastings drove two hours from Long Island for a shot. Dolores Thaxton, who's 89 years old, was never vaccinated for polio and decided to roll up her sleeve.

This kind of outreach is a long-term effort, that may slowly pay off. Abigail Guerrero, a young mother from Ecuador who speaks very little English, came to the clinic for something else but saw the large infographic in Spanish taped up — the one that Bernstein and Montal helped make. This sign was her first encounter with the polio outbreak in her community and after reading it and learning about the disease, she decided to get immunized.

Back in Orange County, Commissioner of Health Dr. Irina Gelman says she's a sound sleeper, because she doesn't get much of it. She's up at 3:30 every morning. The drumbeat of disease hasn't let up since she began her job four years ago.

"We started with the measles outbreak," she says. "And we've gradually progressed into COVID 19. And simultaneously, we are now dealing with monkeypox. And with now polio. It was officially eradicated, yes. It does pose a tremendous amount of concern."