title: Individual-based modeling of potential poliovirus transmission in connected religious communities in North America with low uptake of vaccination.
abstract: BACKGROUND
  Pockets of undervaccinated individuals continue to raise concerns about their potential to sustain epidemic transmission of vaccine-preventable diseases. Prior importations of live polioviruses (LPVs) into Amish communities in North America led to their recognition as a potential and identifiable linked network of undervaccinated individuals.
  
  
  METHODS
  We developed an individual-based model to explore the potential transmission of a LPV throughout the North American Amish population.
  
  
  RESULTS
  Our model demonstrates the expected limited impact associated with the historical importations, which occurred in isolated communities during the low season for poliovirus transmission. We show that some conditions could potentially lead to wider circulation of LPVs and cases of paralytic polio in Amish communities if an importation occurred during or after 2013. The impact will depend on the uncertain historical immunity to poliovirus infection among members of the community.
  
  
  CONCLUSIONS
  Heterogeneity in immunization coverage represents a risk factor for potential outbreaks of polio if introduction of a LPV occurs, although overall high population immunity in North America suggests that transmission would remain relatively limited. Efforts to prevent spread between Amish church districts with any feasible measures may offer the best opportunity to contain an outbreak and limit its size.
authors.affiliation: Kid Risk, Inc. Delft University of Technology, Delft, The Netherlands.
authors.forename: Kasper H
authors.initials: KH
authors.lastname: Kisjes
authors.affiliation: Kid Risk, Inc.
authors.forename: Radboud J
authors.initials: RJ
authors.lastname: Duintjer Tebbens
authors.affiliation: Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Wallace
authors.affiliation: Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Pallansch
authors.affiliation: Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Cochi
authors.affiliation: Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Steven G F
authors.initials: SG
authors.lastname: Wassilak
authors.affiliation: Kid Risk, Inc. College of Medicine, University of Central Florida, Orlando, Florida.
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Thompson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D061365:Amish; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009656:North America / Q000453:epidemiology; D011051:Poliomyelitis / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission*; D017955:Poliovirus / Q000302:isolation & purification*; D023321:Poliovirus Vaccines / Q000008:administration & dosage*; D012111:Residence Characteristics; D018570:Risk Assessment; D014611:Vaccination / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D023321:Poliovirus Vaccines
keywords: disease outbreaks; heterogeneity; immunization; individual-based model; polio