NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

Show details

16Poliomyelitis

In 1994, the Western Hemisphere was certified as being free of indigenous wild-type (not vaccine-related) poliovirus, the enterovirus that causes paralytic poliomyelitis. The last cases of wild, indigenously acquired poliomyelitis in the United States were reported in 1979. The current risk of exposure to wild poliovirus in the United States is very low and continues to diminish as global eradication continues. In comparison, the risk of vaccine-associated poliomyelitis (VAPP) from oral polio vaccine (OPV), for both vaccine recipients and their susceptible contacts, is greater than the risk of paralytic poliomyelitis from wild-type virus. The risk of VAPP is approximately one per 750,000 first doses of OPV administered

Between 1980 and 1994, only six imported cases and two indeterminate cases of polio occurred in the United States, while there were 125 cases of VAPP. Although the successful elimination of indigenous wild-type polio is primarily attributable to the wide use of OPV, these recent changes in the epidemiological patterns of poliomyelitis in the United States prompted a re-examination and subsequent change in many of the recommendations regarding the routine use of OPV and inactive polio vaccine (IPV) beginning in the 1997 calendar year.

Paralytic poliomyelitis is currently designated as an infectious disease notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases.

Recommendations of Major Authorities

  • In 1997, the Advisory Committee on Immunization Practices (ACIP), American Academy of Family Physicians (AAFP), and American Academy of Pediatrics (AAP)
  • changed their recommendations for routine poliovirus vaccination, and now recommend expanded use of IPV for routine poliovirus vaccination. The American College of Preventive Medicine and Bright Futures have also adopted these guidelines. The revised recommendations include three acceptable options (sequential IPV-OPV; all IPV; and all OPV), and parents and providers may choose among them. Parents and other care-givers should be informed of the poliovirus vaccines available, alternative immunization schedules, and the basis for poliovirus vaccination recommendations. The benefits and risks of the vaccines and the advantages and disadvantages of the three vaccination options, for individuals and the community, should be discussed.
  • Sequential: IPV at 2 and 4 months; OPV at 12 to 18 months and 4 to 6 years All-IPV: IPV at 2, 4, 12 to 18 months, and 4 to 6 years All-OPV: OPV at 2, 4, 6-18 months, and 4 to 6 years
  • Advisory Committee on Immunization Practices
  • recommends a sequential IPV-OPV schedule for greatest overall public health benefit by decreasing the incidence of VAPP while maintaining high levels of population immunity to poliovirus to prevent outbreaks should wild poliovirus be reintroduced in the United States.
  • American Academy of Pediatrics and American Academy of Family Physicians
  • recommend parent and provider choice in the selection of the vaccination schedule most suitable for the child.
  • Canadian Task Force on the Periodic Health Examination
  • recommends either IPV or OPV. The IPV vaccination schedule is at 2, 4, 6 and 18 months and 4 to 6 years. The OPV schedule is at 2, 4, and 18 months and 4 to 6 years.
  • US Preventive Services Task Force
  • acknowledged the potential benefits of incorporating IPV into the childhood immunization schedule, but has not updated its recommendations since the change in the ACIP guidelines.

Basics of Poliomyelitis Immunization

1. Vaccine Types

Two types of trivalent vaccine are available for use in the United States: live oral poliovirus vaccine (OPV) and enhanced-potency inactivated poliovirus vaccine (IPV). Both vaccines contain antigens to poliovirus types I, II, and III and are highly effective. OPV, through its induction of intestinal immunity against poliovirus, is effective in controlling circulation of the wild virus. IPV also induces mucosal immunity, but to a lesser extent.

2. Schedule

a. Primary

  • IPV at 2 and 4 months; OPV at 12 to 18 months and 4 to 6 years OR IPV at 2, 4, and 12 to 18 months and 4 to 6 years OR OPV at 2, 4, and 12 to 18 months and 4 to 6 years
  • Parents of children who are to be vaccinated should be informed of the poliovirus vaccines available, the three alternative vaccination schedules, and the basis for the vaccination recommendations. The benefits and risks of the vaccines as well as the advantages and disadvantages of the three vaccination options for individuals and for the community should be discussed (Table 16.1).
Table 16.1. Advantages and Disadvantages of Three Poliovirus Vaccination Options.

Table

Table 16.1. Advantages and Disadvantages of Three Poliovirus Vaccination Options.

b. Late or Accelerated Schedule for Children

  • An all-OPV schedule is preferred for infants and children starting vaccination late (ie, after 6 months of age) or when accelerated protection against poliomyelitis is required. Three doses of OPV constitute a primary series and are required to assure seroconversion to all three serotypes of poliovirus. Under such circumstances, the minimum time interval between doses of OPV is 4 weeks. Administer a supplemental dose of OPV between 4 and 6 years of age. For infants and children for whom IPV is indicated and accelerated protection is needed, the minimum interval between doses of IPV is 4 weeks, although the preferred interval between the second and third dose is six months. Administer an additional dose of IPV between ages 4 and 6 years.

c. Late or Accelerated Schedule for Adults

  • Routine poliovirus vaccination of adults (generally those aged 18 years and older) residing in the United States is not necessary. Immunization is recommended for certain adults who are at risk of exposure to poliovirus, including travelers, laboratory and health-care workers, and unvaccinated adults residing in households of children receiving OPV. For unvaccinated adults, primary vaccination with IPV is recommended because the risk for VAPP after receiving OPV is higher among adults than among children. Two doses of IPV should be administered at intervals of 4 to 8 weeks; a third dose should be administered 6 to 12 months after the second. If three doses of IPV cannot be administered within the recommended intervals before protection is needed, the following alternatives are recommended:
  • If 8 or more weeks are available, three doses of IPV should be administered at least 4 weeks apart.
  • If less than 8 but more than 4 weeks are available, two doses of IPV should be administered at least 4 weeks apart.
  • If less than 4 weeks are available, a single dose of OPV or IPV is recommended.
  • The remaining doses of vaccine should be administered later, at the recommended intervals, if the person remains at increased risk.
  • Adults who previously completed a primary series of either OPV or IPV who are at increased risk of exposure to poliovirus may be given another dose of either OPV or IPV. These adults are not at increased risk for VAPP.

3. Dose and Administration

OPV is supplied in a disposable pipette containing a single dose of 0.5 mL or in 10-dose vials. The vaccine should be dropped on the back of the tongue. If a substantial amount of OPV is regurgitated or spit out within 5 to 10 minutes of administration, it may be readministered. If the repeat dose is also lost, attempt readministration at the next visit.

The recommended dose of IPV is 0.5 mL, given subcutaneously or intramuscularly in the thigh of infants and in the deltoid area of older children and adults with a 5/8" to 3/4", 23- to 25-gauge needle.

4. Contraindications/Precautions

There are few, true contraindications to administering vaccinations. See Appendix B, Table B.3 for a listing of valid contraindications. See Table 16.2 for a list of contraindications specific to polio immunization.

Table 16.2. True Contraindications and Precautions * for OPV/IPV Vaccination.

Table

Table 16.2. True Contraindications and Precautions * for OPV/IPV Vaccination.

Because of the increased risk for VAPP, OPV should not be administered to persons with immunodeficiency disorders or malignant diseases or to persons whose immune systems have been compromised by therapy (corticosteroids, alkylating drugs, antimetabolites or radiation) (see Adverse Reactions). Use IPV for these patients and their household contacts. Do not administer OPV to hospitalized infants until after discharge, because of the theoretical risk of poliovirus transmission in the hospital.

5. Adverse Reactions

The risk of paralysis in recipients of OPV and their close contacts is extremely low. The rate of VAPP after the first dose of OPV is approximately one case per 750,000 doses. All adults who are not immunized or inadequately immunized against polio should be informed of the very low risk of developing paralytic poliomyelitis after a child with whom they have close contact has been immunized with the OPV vaccine. Advise them to wash their hands well after diaper changes and avoid contact with feces. Nonimmunized and partially immunized adults may be offered immunization with IPV. Because of the overriding importance of ensuring prompt and complete immunization, sequential IPV-OPV vaccination of children should begin regardless of the polio vaccination status of adult contacts.

IPV does not induce paralysis, and its side effects are minor (eg, local pain and swelling at the injection site).

Any adverse effects should be reported to the Vaccine Adverse Event Reporting System (VAERS). Refer to Table B.4 for a detailed listing of adverse events. VAERS forms and instructions are available in the FDA Drug Bulletin (Food and Drug Administration) and the Physician's Desk Reference or by calling the 24-hour VAERS information recording at (800)822-7967. Refer to Appendix B for details.

6. Patient Education

The National Childhood Vaccine Injury Act requires health care providers to provide the following information to patients prior to administering a polio vaccination: (1) a concise description of the benefits of the vaccine, (2) a concise description of the risks associated with the vaccine, and (3) notice of the availability of the National Vaccine Injury Compensation Program.

The US Department of Health and Human Services has developed a pamphlet for this purpose ( see Patient Resources). Other patient educational materials may be used if they provide the information required by the National Childhood Vaccine Injury Act. For additional information about this requirement, contact the Training Coordinator, National Immunization Program, Centers for Disease Control and Prevention; (404)639-8226.

7. Vaccine Storage and Handling

Store OPV at temperatures low enough to keep it solidly frozen. Temperatures below -14°C (+7°F) may be required. Completely thaw the vaccine before use. A container of vaccine may be subjected to a maximum of 10 cycles of thawing and refreezing as long as the temperature of the vaccine does not exceed 8°C (46°F) and the total cumulative time thawed is not more than 24 hours. If the vaccine is thawed for more than 24 hours, it should not be refrozen but should be stored at 2 to 8°C (36 to 46°F) and used within 30 days. Store IPV at 2 to 8°C (36 to 46°F); do not freeze it. Do not use IPV vaccine that has been frozen. Handle all vaccine preparations according to manufacturers' instructions.

Patient Resources

  • Childhood Vaccines: What They Are and Why Your Child Needs Them. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000; Internet address: http://www.aafp.org.
  • Vaccine Information Statement -- Polio Vaccines: What You Need to Know, #I1921. US Department of Health and Human Services. This material is available from the National Immunization Program, M/S E-34, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-8225, fax (404)639-8828; state and local health departments, or the American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org
  • Immunization Protects Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016.Internet address: http://www.aap.org
  • Parents Guide to Childhood Immunizations, #00-590. US Department of Health and Human Services. This material is available from the National Immunization Program, M/S E-34, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-8225; fax (404)639-8828.

Provider Resources

  • Poliomyelitis prevention: enhanced potency inactivated poliomyelitis vaccine-supplementary statement, #I1925; Recommended childhood immunization schedule, #I1743; Six common misconceptions about vaccination and how to respond to them, #00-6561; Guide to contraindications in childhood vaccines, #00-6562. These and other documents are available from the National Immunization Program, Centers for Disease Control and Prevention, M/S E-34, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-8225; fax (404)639-8828.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Academy of Pediatrics, Committee on Infectious Diseases. Poliomyelitis prevention: recommendations for use of inactivated poliovirus vaccine and live oral poliovirus vaccine. Pediatrics. . 1997; 99(2):300–305. [PubMed: 9024465]
  3. Canadian Task Force on the Periodic Health Examination. Childhood immunizations. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 33.
  4. Centers for Disease Control. Paralytic poliomyelitis — Senegal, 1986-1987: update on the N-IPV efficacy study. MMWR. . 1988; 37:257–259. [PubMed: 3128726]
  5. Centers for Disease Control. Vaccine Adverse Event Reporting System — United States. MMWR. . 1990; 39:730–733. [PubMed: 2120567]
  6. Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR. 1994;43 (RR-1): 24-25.
  7. Centers for Disease Control and Prevention. Poliomyelitis prevention in the United States: introduction of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral Poliovirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR. . 1997; 46(No. RR-3):1–25. [PubMed: 9026708]
  8. Centers for Disease Control and Prevention. Recommended childhood immunization schedule-United States. 1997. MMWR. . 1997; 46:35–40. [PubMed: 9011782]
  9. Kimpen JL, Ogra PL. Poliovirus vaccines: a continuing challenge. Pediatr Clin North Am. . 1990; 37(3):627–649. [PubMed: 2161507]
  10. LaForce FM. Poliomyelitis vaccines: success and controversy. Infect Dis Clin North Am. . 1990; 4:75–83. [PubMed: 2407779]
  11. National Center for Health Statistics. Health, United States, 1995. Hyattsville, Md: Public Health Service. 1996.
  12. Patel R, Kinsinger L. Childhood immunizations: American College of Preventive Medicine Practice Policy Statement. Am J Prev Med. . 1997; 13(2):74–77. [PubMed: 9088441]
  13. Physician's Desk Reference. 51st ed. Montvale, NJ: Medical Economics Co: 1997:3005-3007.
  14. Strebel PM, Sutter RW, Coohi SL, et al. Epidemiology of poliomyelitis in the United States one decade after the last reported case of indigenous wild virus-associated disease. Clin Infect Dis. . 1992; 14:568–579. [PubMed: 1554844]
  15. US Preventive Services Task Force. Childhood immunizations.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 65.

Views

  • PubReader
  • Print View
  • Cite this Page

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...