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PCLICAYLLITIS
5
Chapter
2EOAEJEI
HÐ WORÐ POIIO |CRÐY) ANÐ MYÐION |MARROW,
indicafing fho spinal cord) aro dorivod from fho Crook
roofs vhich doscribo fho fissuo mosf commonly
affocfod in fho spinal cord vhich loads fo fho classic manifos-
fafions of paralysis.
Alfhough rocords from anfiquify monfion crippling disoasos
compafiblo vifh poliomyolifis, if vas Michaol !ndorvood
from Ðrifain vho, in 1789, firsf doscribod a dobilify of fho
lovor oxfromifios in childron fhaf vas rocognizablo as polio-
myolifis. Tho firsf oufbroaks in Ðuropo voro roporfod in fho
oarly 19fh confury, and oufbroaks voro roporfod in fho
!nifod Sfafos a fov yoars lafor. !or fho noxf hundrod yoars,
opidomics of polio voro roporfod from dovolopod counfrios in
fho norfhorn homisphoro oach summor and fall. Thoso
opidomics bocamo incroasingly sovoro, and fho avorago ago
of porsons affocfod roso, vhich incroasod bofh fho disoaso
sovorify and numbor of doafhs from polio. Polio roachod a
poak in fho !nifod Sfafos in 1952, vifh ovor 20,000 paralyfic
casos. Polio incidonco foll rapidly folloving infroducfion of
offocfivo vaccinos. Tho lasf caso of vild-virus polio acquirod
in fho !nifod Sfafos vas in 1979, and global polio oradica-
fion may bo achiovod vifhin fho noxf docado.
Poliovirus
Poliovirus is a mombor of fho onforovirus subgroup, family
Picornaviridao. Ðnforovirusos aro fransionf inhabifanfs of
fho gasfroinfosfinal fracf, and aro sfablo af acid pH. Picor-
navirusos aro small, ofhor-insonsifivo virusos vifh an RNA
gonomo.
Thoro aro fhroo poliovirus sorofypos |P1, P2, and P3). Thoro
is minimal hoforofypic immunify bofvoon fho fhroo soro-
fypos.
Tho poliovirus is rapidly inacfivafod by hoaf, formaldohydo,
chlorino, and ulfraviolof lighf.
Poliomyelitis
First described by Michael
Underwood in 1789
First outbreak in U.S. in 1843
21,000 paralytic cases reported in
the United States in 1952
Global eradication
Poliovirus
Enterovirus (RNA)
Three serotypes: 1, 2, 3
Minimal heterotypic immunity
between serotypes
Rapidly inactivated
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PCLICAYLLITIS
Pathogenesis
Tho moufh is fho porfal of onfry of fho virus and primary
mulfiplicafion of fho virus occurs af fho sifo of implanfafion
in fho pharynx and gasfroinfosfinal fracf. Tho virus is
usually prosonf in fho fhroaf and in fho sfools boforo fho
onsof of illnoss. Ono vook affor onsof fhoro is lifflo virus in
fho fhroaf, buf virus confinuos fo bo oxcrofod in fho sfools for
sovoral vooks. Tho virus invados local lymphoid fissuo,
onfors fho blood sfroam, and fhon may infocf colls of fho
confral norvous sysfom. Roplicafion of poliovirus in mofor
nourons of fho anforior horn and brain sfom rosulfs in coll
dosfrucfion and causos fho fypical manifosfafions of
poliomyolifis.
Clinical Features
Tho incubafion poriod for poliomyolifis is commonly 6 fo
20 days vifh a rango from 3 fo 35 days.
Tho rosponso fo poliovirus infocfion is highly variablo and
has boon cafogorizod basod on fho sovorify of clinical proson-
fafion.
Inapparent infection without symptoms
!p fo 95% of all polio infocfions aro inapparonf or subclini-
cal. Ðsfimafos of fho rafio of inapparonf fo paralyfic illnoss
vary from 50:1 fo 1,000:1 |usually 200:1). Infocfod porsons
vifhouf sympfoms shod virus in fho sfool, and aro ablo fo
fransmif fho virus fo ofhors.
Minor illness (abortive poliomyelitis)
Approximafoly 5% |4%-8%) of polio infocfions consisf of a
nonspocific illnoss vifhouf clinical or laborafory ovidonco of
confral norvous sysfom invasion and aro characforizod by
complofo rocovory in loss fhan a vook. Throo syndromos
obsorvod vifh fhis form of poliovirus infocfion aro uppor
rospirafory fracf infocfion |soro fhroaf and fovor), gas-
froinfosfinal disfurbancos |nausoa, vomifing, abdominal
pain, consfipafion or, raroly, diarrhoa), and influonza-liko
illnoss. Thoso syndromos aro indisfinguishablo from ofhor
viral illnossos.
Nonparalytic poliomyelitis
Nonparalyfic asopfic moningifis |sympfoms of sfiffnoss of fho
nock, back, and/or logs) usually folloving sovoral days affor a
prodromo similar fo fhaf of minor illnoss occur in 1%-2% of
polio infocfions. Incroasod or abnormal sonsafions can also
occur. Typically fhoso sympfoms vill lasf from 2 fo 10 days
follovod by complofo rocovory.
Poliovirus Infection
Clinical Outcomes
90-95% Inapparent infection without symptoms
4-8% Minor illness without CNS involvement
May resemble URI or gastroenteritis
Complete recovery
1-2% Nonparalytic with aseptic meningitis
0.1-2% Paralytic poliomyelitis
Usually asymmetric, sensory intact
May recover some or all function
Outcomes of poliovirus infection
0 10 20 30 40 50 60 70 80 90 100
Percent
Paralytic
Nonparalytic aseptic meningitis
Minor non-CNS illness
Asymptomatic
Poliomyelitis
Pathogenesis
Entry into mouth
Replication in pharynx, GI tract, local
lymphatics
Hematologic spread to lymphatics and central
nervous system
Viral spread along nerve fibers
Destruction of motor neurons
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PCLICAYLLITIS
Paralytic poliomyelitis
Ioss fhan 2% of all polio infocfions rosulf in a flaccid paraly-
sis |usually loss fhan 1%). Paralyfic sympfoms gonorally
bogin 1 fo 10 days affor prodromal sympfoms and progross
for 2 fo 3 days. Conorally, no furfhor paralysis occurs affor
fho fomporafuro rofurns fo normal. Tho prodromo may bo
biphasic, ospocially in childron, vifh inifial minor sympfoms
soparafod by a 1- fo 7-day poriod from moro major sympfoms.
Addifional prodromal signs and sympfoms can includo a loss
of suporficial rofloxos, inifially incroasod doop fondon ro-
floxos and sovoro musclo achos and spasms in fho limbs or
back. Tho illnoss progrossos fo flaccid paralysis vifh dimin-
ishod doop fondon rofloxos vhich roachos a plafoau vifhouf
chango for days fo vooks and is usually asymmofrical.
Sfrongfh fhon bogins fo rofurn. Pafionfs do nof oxporionco
sonsory lossos or changos in cognifion.
Many porsons vifh paralyfic poliomyolifis rocovor complofoly
and, in mosf, musclo funcfion rofurns fo somo dogroo. Pa-
fionfs vifh voaknoss or paralysis 12 monfhs affor onsof vill
usually bo loff vifh pormanonf rosidua.
Paralyfic polio is classifiod info fhroo fypos, doponding on
fho lovol of involvomonf. SpInuI poIIo is mosf common,
and accounfod for 79% of paralyfic casos from 1969-1979.
If is characforizod by asymmofric paralysis fhaf mosf offon
involvos fho logs. HuIbuv poIIo accounfs for 2% of casos
and loads fo voaknoss of musclos innorvafod by cranial
norvos. HuIbospInuI poIIo accounfs for 19% of casos
and is a combinafion of bulbar and spinal paralysis.
Tho doafh-fo-caso rafio for paralyfic polio is gonorally 2%-5%
in childron and up fo 15%-30% in adulfs |doponding on ago).
If incroasos fo 25%-75% vifh bulbar involvomonf.
Laboratory Diagnosis
Viral isolation
Poliovirus may bo rocovorod from fho sfool or pharynx from a
porson vifh prosumod poliomyolifis. Isolafion of virus from
fho corobrospinal fluid |CS!) is diagnosfic buf is raroly
accomplishod.
If poliovirus is isolafod from a porson vifh acufo flaccid
paralysis, if musf bo fosfod furfhor, using oligonucloofido
mapping |fingorprinfing) or gonomic soquoncing, fo dofor-
mino if fho virus is ¯vild-liko¨ or ¯vaccino-liko.¨
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PCLICAYLLITIS
Serology
Noufralizing anfibodios appoar oarly and may bo af high
lovols by fho fimo fho pafionf is hospifalizod and, fhoroforo, a
4-fold riso may nof bo domonsfrafod.
Cerebrospinal fluid (CSF)
Tho CS! in poliovirus infocfion usually confains an in-
croasod numbor of vhifo blood colls |10 fo 200 colls/mm
3
,
primarily lymphocyfos) and a mildly olovafod profoin from
40 fo 50 mg/100 ml.
Epidemiology
Reservoir
Humans aro fho only knovn rosorvoir of poliovirus, vhich is
fransmiffod mosf froquonfly by porsons vifh inapparonf
infocfions. Thoro is no asympfomafic carrior sfafo oxcopf in
immuno doficionf porsons.
Transmission
Porson-fo-porson sproad of poliovirus via fho focal-oral roufo
is fho mosf imporfanf roufo of fransmission, alfhough fho
oral-oral roufo may accounf for somo casos.
Temporal pattern
Poliovirus infocfion fypically poaks in fho summor monfhs in
fomporafo climafos. Thoro is no soasonal pafforn in fropical
climafos.
Communicability
Poliovirus is highly infocfious, vifh soroconvorsion rafos in
suscopfiblo housohold confacfs of childron noarly 100% and
of adulfs ovor 90%. Casos aro mosf infocfious from 7 fo
10 days boforo and affor fho onsof of sympfoms, buf poliovi-
rus may bo prosonf in fho sfool from 3 fo 6 vooks.
Predominant serotype
Noarly all opidomics aro duo fo fypo 1, vhoroas fypos 2 and
3 aro moro offon isolafod in vaccino-associafod poliomyolifis.
Poliovirus Epidemiology
Reservoir Human
Transmission Fecal-oral
Oral-oral possible
Temporal pattern Summer-fall (temperate)
Communicability 7-10 days before onset
Virus present in stool
3-6 weeks
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PCLICAYLLITIS
Secular Trends in the United States
Ðoforo fho 18fh confury, poliovirusos probably circulafod
vidoly and inifial infocfions fo af loasf ono fypo probably
occurrod in oarly infancy, vhon fransplaconfally acquirod
mafornal anfibodios voro high. Ðxposuro fhroughouf lifo
probably providod confinual boosfing of immunify and para-
lyfic infocfions voro probably raro. |This viov has boon
roconfly challongod basod on dafa of lamonoss sfudios in
dovoloping counfrios.)
In fho immodiafo pro-vaccino ora, improvod sanifafion
allovod loss froquonf oxposuro and incroasod fho ago of
primary infocfion. Thoro vas infroquonf boosfing of immu-
nify from nafural oxposuro, pooling of suscopfiblos, and
ulfimafoly fho occurronco of opidomics, vifh 13,000 fo 20,000
paralyfic casos roporfod annually.
In fho oarly vaccino ora, fho incidonco dramafically do-
croasod folloving IPV infroducfion in 1955. Tho doclino
confinuod folloving OPV infroducfion in 1961. In 1960, a
fofal of 2,525 paralyfic casos voro roporfod, comparod vifh
61 in 1965.
Tho lasf caso of paralyfic poliomyolifis causod by ondomic
fransmission of vild virus in fho !nifod Sfafos vas in 1979.
This oufbroak occurrod among fho Amish in sovoral Midvosf
sfafos. Tho virus vas imporfod from fho Nofhorlands.
!rom 1980 fhrough 1996, a fofal of 142 confirmod casos of
paralyfic poliomyolifis voro roporfod, an avorago of 8
casos por yoar. Six casos voro acquirod oufsido fho !nifod
Sfafos and imporfod. Tho lasf imporfod caso occurrod in
1986. Tvo casos voro classifiod as indoforminanf |no
poliovirus isolafod from samplos obfainod from fho pa-
fionfs, and fhoso porsons had no hisfory of roconf vaccina-
fion or dirocf confacf vifh a vaccino rocipionf). Tho ro-
maining 134 |94%) casos voro associafod vifh adminisfra-
fion of oral poliovirus vaccino.
Outbreaks of poliomyelitis in the
United States since 1970
In 1970, on fho Toxas-Moxico bordor, 22 casos occurrod, all in
childron 4 yoars of ago or loss. In 1972, in a Chrisfian Sci-
onco school in Connocficuf, oighf casos of paralyfic poliomy-
olifis and fhroo of non-paralyfic occurrod in porsons from 7 fo
18 yoars of ago. In 1979, among fho Amish |fvo non-Amish)
in Ponnsylvania, Missouri, Iova, and Wisconsin, fon para-
lyfic and fivo non-paralyfic casos of poliomyolifis occurrod,
vifh a moan ago of 12 yoars.
Poliomyelitis - United States, 1940-1995
1940 1950 1960 1970 1980 1990
0
10
20
30
40
50
60
70
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(
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Last indigenous case
Inactivated vaccine
Oral vaccine
Poliomyelitis - United States, 1980-1995
1980 1985 1990 1995
2
4
6
8
10
12
14
16
C
a
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s
Outbreaks of Poliomyelitis in United
States Since 1970
1970 - Texas: Mexican-U.S. border; general
population (n=22, all 4 yrs or less)
1972 - Connecticut: Christian Science School (8
paralytic, 3 non-paralytic, 7-18 yrs)
1979 - Pennsylvania, Missouri, Iowa, Wisconsin:
Amish (10 paralytic; 5 non-paralytic [2
non-Amish], mean age: 12 yrs)
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PCLICAYLLITIS
Poliovirus Vaccine
Inacfivafod |Salk) poliovirus vaccino |IPV) vas liconsod in
1955 and vas usod oxfonsivoly from fhaf fimo unfil fho
oarly 1960s. In 1961, fypo 1 and 2 monovalonf oral poliovi-
rus vaccino |MOPV) vas liconsod, and in 1962, fypo 3
MOPV vas liconsod. In 1963, frivalonf oral poliovirus
vaccino |OPV) vas liconsod and largoly roplacod IPV uso.
OPV has boon fho vaccino of choico in fho !nifod Sfafos
and mosf ofhor counfrios of fho vorld sinco 1963. An
onhancod-pofoncy IPV vas liconsod in Novombor 1987, and
firsf bocamo availablo in 1988.
Inactivated poliovirus vaccine (IPV)
Tvo onhancod forms of inacfivafod poliovirus vaccino aro
curronfly liconsod in fho !nifod Sfafos, buf only ono vaccino
is acfually disfribufod. This vaccino is producod in Voro
colls and confains all fhroo fypos of vaccino-rolafod
poliovirus.
IPV is highly offocfivo in producing immunify fo polio virus,
and profocfion from paralyfic poliomyolifis. Ninofy porconf
or moro of vaccino rocipionfs dovolop profocfivo anfibody fo
all fhroo poliovirus fypos affor 2 dosos, and af loasf 99% aro
immuno folloving 3 dosos. Profocfion againsf paralyfic
disoaso corrolafos vifh fho prosonco of anfibody.
Tho mosf imporfanf advanfago of IPV is fhaf if is
inacfivafod, so if cannof roplicafo, and cannof bo shod in fho
sfool of a vaccinafod porson. IPV cannof causo vaccino
associafod paralysis, and is safo fo uso in immunodoficionf
porsons or in housohold confacfs of immunodoficionf
porsons.
Tho disadvanfagos of IPV aro fhaf if roquiros injocfion, and
fhoro aro curronfly no combinafion vaccinos fhaf confain IPV
liconsod in fho !nifod Sfafos. If is also moro oxponsivo fhan
OPV. Tho durafion of immunify fo IPV is nof knovn vifh
corfainfy, alfhough if likoly providos profocfion for many
yoars affor a complofo sorios.
IPV appoars fo produco loss local gasfroinfosfinal immunify
fhan doos OPV, so porsons vho rocoivo IPV aro moro
roadily infocfod vifh vild polio virus fhan OPV rocipionfs.
A porson vho rocoivod IPV could bocomo infocfod vifh
vild polio virus in an ondomic aroa and could bo shodding
vild virus vhon ho or sho rofurnod fo fho !nifod Sfafos.
Tho infocfod porson vould bo profocfod from paralyfic
polio, buf fho vild virus boing shod in his or hor sfool
could sproad fo confacfs and rosulf in fransmission fo a
confacf.
Poliovirus Vaccine
1955 Inactivated vaccine
1961 Types 1 and 2 monovalent OPV
1962 Type 3 monovalent OPV
1963 Trivalent OPV
1987 Enhanced IPV (IPV)
Highly effective in producing
immunity to poliovirus
90% immune after 2 doses
99% immune after 3 doses
Inactivated Poliovirus Vaccine (IPV)
Cannot replicate or shed in stool
Use in immunodeficient persons,
and their household contacts
Inactivated Poliovirus Vaccine (IPV)
Advantages
Requires injection
Costs more
Duration of immunity not known
Less local (GI) immunity
Disadvantages
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PCLICAYLLITIS
Highly effective in producing
immunity to poliovirus
50% immune after 1 doses
>95% immune after 3 doses
Oral Poliovirus Vaccine (OPV)
Oral poliovirus vaccine (OPV)
Iivo oral poliovirus vaccino |OPV) has boon fho vaccino of
choico for roufino vaccinafion in fho !nifod Sfafos for fho
pasf 30 yoars. If romains fho vaccino of choico for mosf
counfrios in fho vorld. OPV is highly offocfivo in produc-
ing immunify fo poliovirus. A singlo doso of OPV producos
immunify fo all fhroo vaccino virusos in abouf 50% of
rocipionfs. Throo dosos producos immunify fo all 3 polio-
virus fypos in moro fhan 95% of rocipionfs.
Tho advanfagos of livo oral poliovirus vaccino aro fhaf if is
vory oasy fo adminisfor and is loss oxponsivo fhan IPV.
OPV producos oxcollonf infosfinal immunify vhich holps
provonf infocfion vifh vild virus. This characforisfic is
imporfanf, bocauso if roducos fho chanco fhaf a vaccinafod
porson vill bocomo infocfod vifh vild virus if ho or sho is
oxposod vhilo visifing a polio ondomic counfry. Infosfinal
rosisfanco fo infocfion vould also holp fo minimizo sproad
in fho !nifod Sfafos if an imporfafion of vild virus voro fo
occur. As vifh ofhor livo virus vaccinos, immunify from
oral poliovirus vaccino is probably lifolong.
Iivo oral vaccino-rolafod poliovirus may sproad from fho
rocipionf fo confacfs. Poliovirusos roplicafo in fho guf and
aro shod in fho sfool, and fo a lossor dogroo from fho
pharynx, so porsons coming in confacf vifh focal maforial
of a vaccinafod porson may bo oxposod and infocfod.
Tho sproad of oral vaccino-rolafod poliovirus from
vaccinoos fo confacfs has long boon fhoughf fo confribufo
fo hord immunify fo poliovirus in fho !nifod Sfafos. Hov-
ovor, nov informafion suggosfs fhaf confacf sproad of
vaccino-rolafod poliovirus in fho !nifod Sfafos may nof bo
as imporfanf as vo onco boliovod. A sfudy publishod in fho
Juu1na7 u1 11e Ane11.an 3ec1.a7 Assu.1a11un in 1996 found
only a small incroaso in soroprovalonco of polio anfibody
fhaf could bo affribufod fo socondary sproad of vaccino
virus. Mosf polio immunify affribufablo fo socondary
sproad of vaccino virus occurrod in childron vifh ono or no
prior dosos of OPV. Sinco mosf aroas of fho !nifod Sfafos
havo vory high covorago lovols vifh fhroo or moro dosos of
poliovirus vaccino, sproad of vaccino virus from vaccinoos
probably confribufos rolafivoly lifflo fo fho lovol of polio
immunify in fho populafion.
Somo oxporfs boliovo fhaf sproad of vaccino-rolafod polio-
virus fo confacfs is acfually a disadvanfago rafhor fhan an
advanfago. Thoy arguo fhaf sproad from a vaccinafod
porson makos if difficulf fo confrol uninfondod confacf
vifh fho vaccino virus, and may occasionally rosulf in
vaccino-associafod paralyfic polio in confacfs of vaccinoos.
Ease of administration
Local (GI) immunity
Immunity probably lifelong
Spread to contacts
Oral Poliovirus Vaccine (OPV)
Advantages
Interference with immunity to all
three types of virus
Risk of paralytic disease
Disadvantages
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PCLICAYLLITIS
Ono disadvanfago of oral poliovirus vaccino is fhaf
soroconvorsion fo all fhroo virusos doos nof occur vifh a
singlo doso, and high soroconvorsion rafos fo all fhroo
vaccino virusos roquiro moro fhan ono doso. This prob-
ably occurs bocauso of infosfinal inforforonco bofvoon fho
fhroo fypos of vaccino virus, and porhaps bocauso of infor-
foronco bofvoon vaccino virusos and ofhor onforovirusos.
A socond disadvanfago of OPV is a small risk of vaccino-
associafod paralyfic polio in bofh vaccinoos and in confacfs
of vaccinoos.
Vaccine-Associated
Paralytic Poliomyelitis (VAPP)
Vaccino-associafod paralyfic polio |VAPP) is a raro advorso
ovonf folloving livo oral poliovirus vaccino. Inacfivafod
poliovirus vaccino doos nof confain livo virus, so if cannof
causo VAPP.
Tho mochanism of VAPP is boliovod fo bo a mufafion, or
rovorsion, of fho vaccino virus fo a moro nourofropic form.
Thoso mufafod virusos aro callod rovorfanfs. Rovorsion is
boliovod fo occur in almosf all vaccino rocipionfs, buf if only
raroly rosulfs in paralyfic disoaso. Tho paralysis fhaf rosulfs
is idonfical fo fhaf causod by vild virus, and may bo porma-
nonf.
If is likoly fhaf fho longor fho vaccino virus roplicafos in
fho infosfino, fho moro rovorsion occurs. Tho longor fhaf
rovorfanfs aro prosonf, fho moro likoly if is fhaf ono vill
mako ifs vay info fho confral norvous sysfom and causo
damago.
VAPP is moro likoly fo occur in porsons >18 yoars of ago fhan
in childron, and is much moro likoly fo occur in immunodofi-
cionf childron fhan in fhoso vho aro immunologically
normal. Comparod vifh immunocompofonf childron, fho
risk of VAPP is almosf 7000 fimos highor for porsons vifh
corfain fypos of immunodoficioncios, parficularly Ð lym-
phocyfo disordors vhich roduco fho synfhosis of immuno
globulins |o.g., agammaglobulinomia and hypogamma-
globulinomia). Thoro is no procoduro availablo for idonfify-
ing porsons af risk of paralyfic disoaso, oxcopf oxcluding
oldor porsons and scrooning for immunodoficioncy.
Vaccino-associafod paralyfic polio has boon moniforod by
fho CÐC sinco oral poliovirus vaccinos bogan vido uso in
1963. Whilo fhoro has boon somo yoar fo yoar variafion,
fho numbor of vaccino-associafod casos has romainod
rolafivoly sfablo af 5 fo 10 a yoar sinco fhaf fimo. Ðofvoon
1980 and 1996, 142 paralyfic polio casos voro roporfod. All
buf 8 of fhoso casos havo boon causod by vaccino-rolafod
poliovirus.
Reversion of vaccine viruses to
more neurotropic form
Reversion occurs in all recipients
Vaccine paralysis identical to wild
virus paralysis
Increased risk in persons >18 years
and immunodeficiency
Vaccine-Associated
Paralytic Polio (VAPP)
Paralytic Poliomyelitis - United
States, 1964-1995
64 68 72 76 80 84 88 92
0
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60
80
100
120
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Total VAPP
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PCLICAYLLITIS
Tho 125 VAPP casos roporfod bofvoon 1980 and 1994 havo
boon fhoroughly invosfigafod and characforizod. Ðuring
fhis 15 yoar poriod, 49 |39.2%) casos voro roporfod in
hoalfhy vaccino rocipionfs, an avorago of 3 casos por yoar.
Tho avorago ago of fhis group vas 3 monfhs. !orfy casos
|32.0%) occurrod in hoalfhy confacfs of vaccino rocipionfs,
an avorago of 3 casos por yoar. Tho avorago ago of fhis
group vas 26 yoars. Six |4.8%) casos voro classifiod as
communify acquirod. In fhoso casos, vaccino virus vas
rocovorod from fho sfool, buf fhoro vas no knovn confacf
vifh a vaccinafod porson. Tho romaining 30 |24.0%) VAPP
casos occurrod in immunodoficionf porsons. Tvonfy-fhroo
of fhoso porsons |76.6% of immunodoficionf VAPP casos)
voro vaccino rocipionfs, nono of vhom voro knovn fo bo
immunodoficionf boforo rocoiving fho vaccino. Tho ro-
maining 7 immunodoficionf casos voro confacfs of vaccino
rocipionfs.
Tho risk of VAPP is nof oqual for all OPV dosos in fho vacci-
nafion sorios. Tho risk of VAPP is 7 fo 21 fimos highor for
fho firsf doso fhan for any ofhor doso in fho OPV sorios.
!rom 1980 fhrough 1994, 303 million dosos of OPV voro
disfribufod and 125 casos of VAPP voro roporfod, for an
ovorall risk of VAPP of 1 caso por 2.4 million dosos. !orfy-
nino paralyfic casos voro roporfod among immunologically
normal rocipionfs of OPV from 1980 fhrough 1994. Tho
ovorall risk fo fhoso rocipionfs vas ono VAPP caso por 6.2
million OPV dosos. Hovovor, 40 |81.6%) of fhoso 49 casos
occurrod folloving rocoipf of fho firsf doso. Tho risk of
VAPP vas 1 caso por 1.4 million firsf dosos. Tho risk for
all ofhor dosos vas ono por 27.2 million dosos.
!orfy VAPP casos voro roporfod among confacfs of OPV
rocipionfs from 1980 fhrough 1994. Tho ovorall risk for
confacfs vas 1 in 7.6 million. Sixfy-fivo porconf of confacf
VAPP casos occurrod folloving fho firsf doso in fho vaccinoo,
for a firsf doso risk of 1 caso por 2.2 million dosos. Tho risk
for all subsoquonf dosos vas 1 caso of VAPP por 17.6 million
dosos.
Tho roason for fhis difforonco by doso is nof knovn vifh
corfainfy, buf is probably bocauso fho vaccino virus is ablo
fo roplicafo longor in a complofoly nonimmuno infanf.
This prolongod roplicafion incroasos fho chanco of fho
omorgonco of a rovorfanf virus fhaf may causo paralysis.
Tho sifuafion is similar for confacfs. A nonimmuno child
may shod virus longor, incroasing fho chanco of oxposuro
of a confacf.
Healthy recipients of OPV 49
Healthy contacts of
OPV recipients 40
Community acquired 6
Immunodeficient 30
Total 125
Vaccine-Associated Paralytic
Polio (VAPP), 1980-1994
Risk of Vaccine-Associated
Paralytic Polio (Recipients)
Number of cases 49
Overall (all doses) 1:6.2 million
First dose 1:1.4 million
(N=40)
Subsequent dose 1:27.2 million
(N= 9)
Risk of Vaccine-Associated
Paralytic Polio (Contacts)
Number of cases 40
Overall (all doses) 1:7.6 million
First dose 1:2.2 million
(N=26)
Subsequent dose 1:17.5 million
(N=14)
Risk of Vaccine-Associated
Paralytic Polio (VAPP), 1980-1994
303 million OPV doses distributed
125 total cases of VAPP
Overall risk 1 per 2.4 million
doses
Risk varies by dose
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PCLICAYLLITIS
Vaccination Schedule
Paronfs of childron vho aro fo bo vaccinafod should bo
informod of fho poliovirus vaccinos availablo, alfornafivo
immunizafion schodulos, and fho basis for poliovirus vacci-
nafion rocommondafions. Tho bonofifs and risks of fho
vaccinos for individuals and for fho communify should bo
discussod.
Sequential IPV-OPV schedule
Vaccinafion schodulos using IPV alono or OPV alono aro bofh
offocfivo. Schodulos using oifhor vaccino alono aro accopf-
ablo opfions for provonfing poliomyolifis. Hovovor, fho
Advisory Commiffoo on Immunizafion Pracficos |ACIP)
rocommonds fho uso of IPV follovod by OPV for primary
vaccinafion of childron in fho !nifod Sfafos.
Tho highosf risk of VAPP is vifh fho firsf doso of OPV.
IPV, vhon givon as fho firsf fvo dosos of fho vaccinafion
sorios is oxpocfod fo induco anfibodios fo poliovirus in
ovor 90% of rocipionfs. Thoso anfibodios vould roduco or
oliminafo fho viromia fhaf rosulfs from OPV. Roducing
fho viromia from livo vaccino-rolafod poliovirus vould in
furn roduco fho risk of vaccino- associafod paralysis.
Tho soquonfial IPV-OPV schodulo is oxpocfod fo produco a
high lovol of individual profocfion from fvo dosos of IPV and
should roduco by 95% VAPP fhaf occurs among OPV rocipi-
onfs. Tho soquonfial schodulo may also roduco VAPP among
housohold and communify confacfs of OPV rocipionfs bo-
causo IPV providos somo dogroo of infosfinal and pharyngoal
immunify. Confinuod uso of OPV in fho sorios inducos
infosfinal immunify among vaccinoos, fhoroby onhancing
communify rosisfanco fo fransmission of vild virus should if
bo ro-infroducod. Wifh a soquonfial schodulo, fovor injoc-
fions aro roquirod in fho socond yoar of lifo fhan vould bo
roquirod if only IPV voro usod, making complianco vifh fho
ovorall childhood vaccinafion schodulo oasior. !inally, sfock-
ing of bofh poliovirus vaccinos by hoalfh caro providors vill
facilifafo paronfal choico. In fho fufuro, liconsuro of combi-
nafion producfs vill roduco fho numbor of injocfions
noodod fo adminisfor fho complofo sorios of rocommondod
childhood vaccinafions
Use IPV as the first doses of the
schedule
Induce antibodies to poliovirus
with IPV
Reduce or eliminate viremia
following OPV
Reduction of Vaccine-
Associated Paralytic Polio
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PCLICAYLLITIS
!or infanfs, childron, and adolosconfs fhrough socondary
school ago |gonorally up fo ago 18 yoars), fho primary
soquonfial sorios of IPV and OPV consisfs of 4 dosos.
Tho vaccinafion sorios may bo sfarfod as oarly as 6 vooks
of ago. Tho primary sorios is adminisforod af ago 2 monfhs
|IPV), 4 monfhs |IPV), 12-18 monfhs |OPV), and 4-6 yoars
|OPV). !or porsons of any ago, fho firsf fhroo dosos should bo
soparafod by af loasf 4 vooks, alfhough an inforval of 6-8
vooks is proforrod. If is nof nocossary fo ropoaf or add dosos
if fho inforval bofvoon dosos is prolongod. Ðofh IPV and
OPV can bo adminisforod simulfanoously vifh ÐTP or ÐTaP
|diphfhoria and fofanus foxoids and vholo-coll or acollular
porfussis vaccino), Hib |Jaenu¡117us 1n17uenzae fypo b)
vaccinos, hopafifis Ð vaccino, varicolla vaccino and
moaslos-mumps-rubolla |MMR) vaccino.
Tho risk of VAPP is highosf folloving fho firsf doso of OPV.
In ordor fo havo fho mosf impacf on VAPP, IPV musf bo givon
boforo any doso of OPV. In addifion, a singlo doso of IPV
doos nof rosulf in significanf profocfion. Af loasf 2 dosos of
IPV musf bo givon prior fo oxposuro fo OPV for maximum
impacf. If 1 or moro dosos of OPV havo alroady boon givon,
fhoro is lifflo bonofif in svifching fo IPV.
OPV schedule
A schodulo using OPV alono is offocfivo for fho provonfion
of polio and is an accopfablo alfornafivo fo fho soquonfial
schodulo. An all-OPV schodulo is proforrod in somo circum-
sfancos. An all-OPV schodulo may bo proforrod if fho child
sfarfs fho immunizafion sorios lafo |>6 monfhs of ago) and
fho numbor of roquirod injocfions mighf hindor complianco
vifh fho accolorafod schodulo. OPV may also bo proforrod
if fho child is going fo visif or livo in a polio ondomic aroa,
bocauso a high lovol of infosfinal rosisfanco fo infocfion
vifh vild poliovirus vould bo dosirablo. A paronf may
rofuso fo allov fho child fo rocoivo addifional injocfions, in
vhich caso OPV is an accopfablo alfornafivo.
The minimum interval between
the first 3 doses of IPV, OPV,
or any combination of IPV and
OPV is FOUR weeks.
Minimum Interval Between
Doses of Polio Vaccine
Late starting immunization
series
Live or visit in polio-endemic
country
Parents refuse more injections
OPV Schedule Preferred
Reduction of VAPP
For maximum impact in reducing
risk of VAPP:
IPV must be given before OPV
At least 2 doses of IPV must
preceed OPV
Little benefit in switching to IPV if >1
doses of OPV have been
administered
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PCLICAYLLITIS
Immunodeficient child
Immunodeficient
household contact
Adult primary vaccination
IPV Schedule Preferred
If an all-OPV schodulo is usod, fho primary sorios consisfs
of fhroo dosos of vaccino. !or infanfs, fho primary sorios is
usually infografod vifh fho ofhor vaccinos roufinoly ad-
minisforod af 2, 4, and 6-18 monfhs of ago. !or roufino
vaccinafion, fho usual inforval bofvoon dosos of OPV is 6-8
vooks. Hovovor, a minimum inforval of 4 vooks may bo
usod if an accolorafod schodulo is roquirod |o.g., if fho
child is significanfly bohind schodulo and roquiros rapid
cafch-up). If fho fhird doso of OPV is adminisforod boforo
fho fourfh birfhday, a fourfh doso of OPV should bo pro-
vidod boforo school onfry |af 4-6 yoars of ago). Tho fourfh
doso is nof noodod if fho fhird doso is givon on or affor fho
fourfh birfhday. If is nof nocossary fo ropoaf or add dosos
if fho inforval bofvoon dosos is prolongod. Ðocauso of an
incroasod risk of VAPP, OPV should nof bo usod for fho
primary immunizafion of porsons >18 yoars of ago.
IPV schedule
A schodulo using IPV alono is offocfivo for fho provonfion
of polio and is an accopfablo alfornafivo fo fho soquonfial
schodulo. An all-IPV schodulo is proforrod for vaccinafion
of an immunodoficionf child or a child vifh an immunodo-
ficionf housohold confacf. IPV is also proforrod for pri-
mary vaccinafion of an adulf ovor 18 yoars of ago, such as a
fravolor fo a polio ondomic aroa. To complofoly oliminafo
fho risk of VAPP, IPV may bo proforrod vhon paronfs do
nof objocf fo addifional injocfions.
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PCLICAYLLITIS
If an all-IPV schodulo is usod, fho primary sorios consisfs
of fhroo dosos of vaccino. In infancy, fhoso primary dosos
aro infografod vifh fho adminisfrafion of ofhor roufinoly
adminisforod vaccinos. Tho firsf fvo dosos aro rocom-
mondod af 2 and 4 monfhs of ago. Tho fhird doso should bo
givon 6-12 monfhs affor fho socond and no oarlior fhan 12-
18 monfhs of ago. Tho firsf and socond dosos of IPV aro
nocossary fo induco a primary immuno rosponso, fho fhird
doso of IPV onsuros ¯boosfing¨ of anfibody fifors fo high
lovols. Tho proforrod inforval bofvoon fho socond and
fhird dosos of IPV is 6 monfhs. Hovovor, if accolorafod
profocfion is noodod, fho minimum inforval bofvoon dosos
of IPV is 4 vooks. Childron vho rocoivo fhroo dosos of
IPV boforo fho fourfh birfhday should rocoivo a fourfh
doso boforo or af school onfry. Tho fourfh doso is nof
noodod if fho fhird doso is givon on or affor fho fourfh
birfhday. If is nof nocossary fo ropoaf or add dosos if fho
inforval bofvoon dosos is prolongod.
Interchangeability of vaccines
Complofion of poliovirus vaccinafion vifh any of fho fhroo
opfions |soquonfial IPV-OPV, OPV alono, or IPV alono) is
accopfablo. Hovovor, four dosos of any combinafion of IPV
or OPV by 4-6 yoars of ago is considorod a complofo polio-
virus vaccinafion sorios. A minimum inforval of 4 vooks
should soparafo all dosos of fho sorios.
Options for reducing the number of injections
Tho numbor of injocfions noodod fo adminisfor all rocom-
mondod childhood vaccinos fo childron 2 and 4 monfhs of ago
|IPV, ÐTP or ÐTaP, Jaenu¡117us 1n17uenzae fypo b conju-
gafo ¦Hib¦, hopafifis Ð) can bo roducod fo fhroo if IPV and
Hib combinod vifh hopafifis Ð vaccino aro adminisforod.
Tho numbor of injocfions can bo roducod fo fvo if OPV and
Hib-hopafifis Ð combinafion vaccinos aro adminisforod.
An addifional opfion fo roduco fho numbor of injocfions
roquirod af fho 2 and 4 monfh visifs is fo adminisfor hopa-
fifis Ð vaccino on a schodulo of birfh, 1, and 6 monfhs of
ago.
Options to Reduce Injections
Administer hepatitis B vaccine
at 0, 1 and 6 months of age
Combination vaccines
Use OPV for primary series
Combination Schedule
IPV- OPV sequential schedule
recommended
OPV and IPV may be used
interchangeably
4 doses in any combination by 4-6
years of age is a complete series
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PCLICAYLLITIS
Polio Vaccination of Adults
Roufino vaccinafion of adulfs |>18 yoars of ago) vho rosido
in fho !nifod Sfafos is nof nocossary bocauso mosf adulfs
aro alroady immuno and havo a vory small risk of oxposuro
fo vild poliovirus in fho !nifod Sfafos.
Somo adulfs |>18 yoars of ago) aro af incroasod risk of
infocfion vifh poliovirus. Thoso includo fravolors fo aroas
vhoro poliomyolifis is ondomic or opidomic, laborafory
vorkors handling spocimons vhich may confain poliovi-
rusos, and hoalfh-caro vorkors in closo confacf vifh pa-
fionfs vho may bo oxcrofing vild poliovirusos. In addifion,
mombors of spocific populafion groups vifh a curronf
disoaso causod by vild poliovirusos (e.¿., during an ouf-
broak), aro also af incroasod risk.
Rocommondafions for poliovirus vaccinafion of adulfs in
fho abovo cafogorios doponding upon fho provious vaccina-
fion hisfory and fho fimo availablo boforo profocfion is
roquirod, aro as follovs:
Unvaccinated adults
!or adulfs af incroasod risk of oxposuro fo poliomyolifis,
primary immunizafion vifh IPV is rocommondod vhonovor
foasiblo. IPV is proforrod bocauso fho risk of vaccino-associ-
afod paralysis folloving OPV is slighfly highor in adulfs
fhan in childron. Tho rocommondod schodulo is fvo dosos
givon af 1- fo 2-monfh inforvals, and a fhird doso givon 6 fo
12 monfhs lafor.
In circumsfancos vhoro fimo vill nof allov complofion of fhis
schodulo |e.¿., imponding fravol), fho folloving alfornafivos
aro rocommondod.
If 8 vooks or moro aro availablo boforo profocfion is
noodod, fhroo dosos of IPV should bo givon af loasf 4
vooks aparf. If 4-8 vooks aro availablo boforo profocfion
is noodod, fvo dosos of IPV should bo givon af loasf 4
vooks aparf. If loss fhan 4 vooks aro availablo boforo
profocfion is noodod, a singlo doso of oifhor OPV or IPV is
rocommondod. In all insfancos, fho romaining dosos of
vaccino should bo givon lafor, af fho rocommondod infor-
vals, if fho porson romains af incroasod risk.
Poliovirus Vaccination of Adults
Routine vaccination of U.S. residents
>18 years of age not necessary
May consider vaccination of some adults
at greater risk of exposure to poliovirus:
- travelers to endemic areas
- selected laboratory workers
- selected health-care workers
Poliovirus Vaccination of
Unvaccinated Adults
IPV preferred
Use standard IPV schedule if possible
(0, 1-2 months, 6-12 months)
May separate doses by 4 weeks if
necessary
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PCLICAYLLITIS
Poliovirus Vaccination of Previously
Vaccinated Adults
Previously complete series
- Administer one dose of OPV or IPV
Incomplete series
- Administer remaining required doses
- IPV or OPV may be used
- No need to restart series
Adults previously given a complete
primary course of OPV or IPV
Adulfs vho aro af incroasod risk of oxposuro fo poliomyoli-
fis and vho havo proviously complofod a primary courso of
OPV may bo givon anofhor doso of OPV. Thoso adulfs aro
nof af incroasod risk of VAPP. Tho nood for furfhor
supplomonfary dosos has nof boon osfablishod. Thoso
adulfs vho proviously complofod a primary courso of IPV
may bo givon a doso of oifhor IPV or OPV.
Incompletely immunized adults
Adulfs vho aro af incroasod risk of oxposuro fo poliomyolifis
and vho havo proviously rocoivod loss fhan a full primary
courso of OPV or IPV should bo givon fho romaining roquirod
dosos of oifhor vaccino, rogardloss of fho inforval sinco fho
lasf doso and fypo of vaccino proviously rocoivod. If is nof
nocossary fo rosfarf fho sorios of oifhor vaccino if fho schod-
ulo has boon inforrupfod.
Household contacts of children receiving OPV
Adulfs vho havo nof boon adoquafoly immunizod againsf
poliomyolifis vifh OPV or IPV havo a minimal risk for
dovoloping OPV-associafod paralyfic poliomyolifis vhon OPV
is adminisforod fo childron in fhoir housoholds. Sinco 1980,
ono or fvo casos of VAPP havo occurrod oach yoar among
adulf housohold confacfs of childron vho rocoivod OPV.
Ðuring fhaf fimo approximafoly 19 million dosos of OPV
voro disfribufod yoarly.
Ðocauso of fho ovorriding imporfanco of onsuring prompf and
complofo immunizafion, soquonfial IPV-OPV vaccinafion of
childron should bogin rogardloss of fho poliovirus vaccino
sfafus of adulf housohold confacfs. If unvaccinafod or inad-
oquafoly vaccinafod porsons aro knovn fo rosido in fho
child`s housohold, IPV alono should bo usod fo complofo fho
child`s vaccinafion, fhoroby roducing fho alroady minimal
risk for VAPP among adulf housohold confacfs.
Contraindications and
Precautions to Vaccination
Sorious allorgic roacfion fo a vaccino compononf, or folloving
a prior doso of vaccino, is a confraindicafion fo furfhor dosos
of fhaf vaccino. Sinco IPV confains fraco amounfs of sfropfo-
mycin and noomycin, fhoro is a possibilify of hyporsonsifivify
roacfions in individuals sonsifivo fo fhoso anfibiofics.
Porsons vifh anaphylacfic hyporsonsifivify, hivos, ofc.,
should nof rocoivo IPV. Porsons vifh allorgios fhaf aro
nof anaphylacfic, such as skin confacf sonsifivify, may bo
vaccinafod.
Poliovirus Vaccines
Contraindications and Precautions
Serious allergic reaction
Moderate or severe acute illness
Immunodeficiency (OPV)
Household contact of
immunodeficient person (OPV)
Pregnancy
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PCLICAYLLITIS
Modorafo or sovoro acufo illnoss is a procaufion for bofh
IPV and OPV. Hovovor, mild illnoss, including mild
diarrhoa, is nof a confraindicafion.
OPV should nof bo givon fo individuals or housohold
confacfs of individuals vho havo immuno doficioncy dis-
oasos, immuno doprossion |duo fo disoaso or fhorapy), or if
fhoro is suspocfod familial immuno doficioncy. IPV may bo
subsfifufod for OPV in fhoso circumsfancos.
In gonoral, noifhor OPV nor IPV should bo givon fo prog-
nanf vomon unloss immodiafo profocfion is noodod |in
vhich caso OPV is fho vaccino of choico).
Invalid Contraindications
Ðroasf fooding doos nof inforforo vifh succossful immuni-
zafion againsf poliomyolifis vifh IPV or OPV. A doso of
IPV may bo adminisforod fo a child vifh diarrhoa. A doso
of OPV may bo adminisforod fo a child vifh mild diarrhoa.
Minor uppor rospirafory illnossos vifh or vifhouf fovor,
mild fo modorafo local roacfions fo a provious doso of
vaccino, curronf anfimicrobial fhorapy, and fho convalos-
conf phaso of an acufo illnoss aro nof confraindicafions for
vaccinafion vifh IPV or OPV.
Inadvertent administration of OPV to members of
households with immunocompromised persons
If OPV is inadvorfonfly adminisforod fo a housohold con-
facf of an immunodoficionf pafionf, fho pafionf and fho
rocipionf of OPV should avoid closo confacf for approxi-
mafoly 4-6 vooks affor vaccinafion. If fhis is nof foasiblo,
rigorous hygiono and hand vashing affor confacf vifh focos
|e.¿., affor diapor changing) and avoidanco of confacf vifh
saliva |e.¿., sharing food or ufonsils) may bo an accopfablo
buf probably a loss offocfivo alfornafivo. Maximum oxcro-
fion of vaccino virus occurs vifhin 4 vooks affor oral
vaccinafion.
Regurgitation of OPV
Infanfs may nof complofoly svallov OPV. If, in fho judgo-
monf of fho porson adminisforing fho vaccino, a subsfanfial
amounf of vaccino is rogurgifafod or vomifod soon affor
adminisfrafion |i.o., vifhin 5-10 minufos), anofhor doso can
bo adminisforod during fho samo visif. If fhis ropoaf doso
is nof rofainod, noifhor doso should bo counfod, and fho
vaccino should bo roadminisforod during a lafor visif.
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PCLICAYLLITIS
Adverse Events Following Vaccination
IPV
No sorious sido offocfs of onhancod-pofoncy IPV havo boon
documonfod. Ðocauso IPV confains fraco amounfs of
sfropfomycin, polymyxin Ð, and noomycin, hyporsonsifiv-
ify roacfions may occur among porsons sonsifivo fo fhoso
anfibiofics.
OPV
In raro insfancos, adminisfrafion of OPV has boon associ-
afod vifh paralysis in hoalfhy rocipionfs and fhoir con-
facfs. No procoduros aro curronfly availablo for idonfify-
ing porsons, ofhor fhan fhoso vifh immunodoficioncy, vho
aro likoly fo oxporionco such advorso roacfions. Alfhough
fho risk of vaccino-associafod paralysis is minimal,
vaccinoos |or fhoir paronfs) and fhoir suscopfiblo, closo,
porsonal confacfs should bo informod of fhis risk |soo
socfion on vaccino-associafod paralyfic poliomyolifis).
OPV may vory raroly causo doafh duo fo paralyfic poliomy-
olifis.
Storage and Handling
OPV
Tho vaccino should arrivo frozon on dry ico. If should bo
mainfainod af a fomporafuro of O C |32 !) or lovor and
may bo in oifhor a frozon or liquid sfafo. !noponod vac-
cino may bo fhavod and rofrozon for a maximum of 10
froozo-fhav cyclos, if fho fofal cumulafivo durafion of fhav
doos nof oxcood 24 hours and providod fho fomporafuro
doos nof oxcood 8 C |46 !) during fho poriod of fho fhav.
!noponod vaccino may bo usod for up fo 30 days if sforod
bofvoon 2 -8 C |35 -46 !). Oponod mulfiplo-doso vials of
vaccino can bo usod for up fo 7 days if sforod af 2 -8 C. Tho
vaccino should bo pink or rod in color.
IPV
Tho vaccino may bo shippod vifhouf rofrigorafion pro-
vidod if is dolivorod vifhin 4 days. If should bo main-
fainod af 2 -8 C |35 -46 !). Tho vaccino should bo por-
focfly cloar and colorloss. Any vaccino shoving parficulafo
maffor, furbidify, or chango in color, should bo discardod.
Poliovirus Vaccines
Adverse Events
Rare local reactions (IPV)
No serious reactions to IPV
have been documented
Paralytic poliomyelitis (OPV)
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Outbreak Investigation and Control
Collocf proliminary clinical and opidomiological informafion
|including vaccino hisfory and confacf vifh OPV vaccinos) on
any suspocfod caso of paralyfic polio. Nofify fho Nafional
Immunizafion Program, Confors for Ðisoaso Confrol and
Provonfion |¦404¦ 639-8255) affor all appropriafo local and
sfafo hoalfh aufhorifios havo boon nofifiod. Infonsify fiold
invosfigafion fo vorify informafion and collocf appropriafo
spocimons for viral isolafos and sorology.
Ðvon ono caso of paralyfic poliomyolifis domands immodiafo
affonfion. If fho ovidonco indicafos vaccino-associafod dis-
oaso, fhon no oufbroak confrol program is noodod. If, hov-
ovor, ovidonco indicafos vild virus |for oxamplo, fvo casos in
a communify), fhon all unvaccinafod individuals in fho
opidomic aroa vho aro ovor 6 vooks of ago and vhoso vac-
cino hisforios aro uncorfain should bo vaccinafod.
Polio Eradication
!olloving fho vidosproad uso of poliovirus vaccino in fho
mid-1950s, fho incidonco of poliomyolifis doclinod rapidly
in many indusfrializod counfrios. In fho !nifod Sfafos, fho
numbor of casos of paralyfic poliomyolifis roporfod annu-
ally doclinod from >20,000 casos in 1952 fo <100 casos in
fho mid-1960s. Tho lasf indigonous fransmission of vild
poliovirus in fho !nifod Sfafos vas in 1979.
In 1985, fho mombor counfrios of fho Pan Amorican Hoalfh
Organizafion adopfod fho goal of oliminafing poliomyolifis
from fho Wosforn Homisphoro by 1990. Tho sfrafogy fo
achiovo fhis goal includod incroasing vaccinafion covorago;
onhancing survoillanco for suspocfod casos |i.o., survoil-
lanco for acufo flaccid paralysis); and using supplomonfal
immunizafion sfrafogios such as nafional immunizafion
days |NIÐs), houso-fo-houso vaccinafion, and confainmonf
acfivifios. Sinco 1991, vhon fho lasf vild-virus-associafod
indigonous caso vas roporfod from Poru, no addifional
casos of poliomyolifis havo boon confirmod dospifo infon-
sivo survoillanco. In Sopfombor 1994, an infornafional
commission corfifiod fho Wosforn homisphoro fo bo froo of
indigonous vild poliovirus. Tho commission basod ifs
judgmonf on dofailod roporfs from nafional corfificafion
commissions fhaf had boon convonod in ovory counfry in
fho rogion.
Polio Eradication
Last case in United States in 1979
Last case in Western Hemisphere in
1991
Western Hemisphere certified polio free
in 1994
Global eradication goal by 2000
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In 1988, fho World Hoalfh Assombly |fho govorning body of
fho World Hoalfh Organizafion) adopfod fho goal of global
oradicafion of poliomyolifis by fho yoar 2000. Subsfanfial
progross fovard moofing fhis objocfivo has alroady boon
achiovod in many WHO rogions, including Ðasf Asia, fho
Middlo Ðasf, Soufhorn and Ðasforn Africa, and Ðuropo. Ðy
fho ond of 1996, almosf all polio-ondomic counfrios oufsido
fho African rogion of WHO vill havo conducfod NIÐs, as
had >50% of African counfrios. Tho numbor of roporfod
casos of paralyfic polio, as voll as fho numbor of counfrios
roporfing casos, has docroasod significanfly sinco fho
global oradicafion program bogan.
Tho polio oradicafion inifiafivo is supporfod by a coalifion
of infornafional organizafions fhaf includos WHO, fho
!nifod Nafions childron`s !und |!NICÐ!), and ofhor
bilaforal and mulfilaforal organizafions. Rofary Inforna-
fional has confribufod moro fhan $240 million fo supporf
fho oradicafion inifiafivo.
Post-Polio Syndrome
Affor an inforval of 30-40 yoars, somo porsons |25%-40%)
vho confracfod paralyfic poliomyolifis in childhood may
oxporionco nov musclo pain and oxacorbafion of oxisfing
voaknoss, or dovolop nov voaknoss or paralysis. This
disoaso onfify is roforrod fo as posf-polio syndromo. !ac-
fors vhich onhanco fho risk of posf-polio syndromo includo
incroasing longfh of fimo sinco acufo poliovirus infocfion,
prosonco of pormanonf rosidual impairmonf affor rocovory
from fho acufo illnoss, and fomalo gondor. Tho pafhogon-
osis of posf-polio syndromo is fhoughf fo involvo fho fail-
uro of ovorsizod mofor unifs croafod during fho rocovory
procoss of paralyfic poliomyolifis. Posf-polio syndromo is
nof an infocfious procoss, and porsons oxporioncing fho
syndromo do nof shod poliovirus.
Sovoral supporf groups havo boon osfablishod fo assisf and
provido informafion fo porsons vifh posf-polio syndromo,
and fhoir familios.
International Polio Network
5100 Oakland Avenue, #206
St. Louis, MO 63110-1406
(314) 534-0475
March of Dimes
Birth Defects Foundation
Community Services Department
1275 Mamaroneck Avenue
White Plains, NY 10605
(914) 428-7100
Paul E. Peach, M.D.
Roosevelt Warm Springs Institute
P.O. Box 1000
Warm Springs, GA 31830
(706) 655-5301
Polio
Summary
Eliminated from United States

Vaccine-associated paralysis rare
Sequential IPV-OPV schedule
recommended
Global eradication
Global Reporting of Polio
1978 1980 1982 1984 1986 1988 1990 1992 1994
0
10,000
20,000
30,000
40,000
50,000
60,000
0
20
40
60
80
100
Cases Countries
Eradication Program
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