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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Vaccination is the main form of prevention for poliomyelitis. Two types of the vaccine are available: an inactivated form (IPV), and a live-attenuated form (OPV). IPV is the current vaccine in the United States, contains all 3 serotypes of poliovirus and should be administered in 4 doses. The immune response to the vaccine produces antibodies against the 3 serotypes, which are present in 100% of the cases after the 3rd dose. The live-attenuated form may contain all serotypes of the virus or be given in the bivalent or monovalent forms. OPV immunization leads to maintenance of antibodies in circulation for up to 5 years. The monovalent form of OPV is useful to strengthen the immune response towards a specific serotype, or in cases of single serotype outbreak.

Prevention

Vaccination

As a result of the introduction of inactivated poliovirus vaccine (IPV) in the 1950s, followed by oral poliovirus vaccine (OPV) in the 1960s, poliomyelitis control has been achieved in numerous countries worldwide, including the entire Western Hemisphere.[1][2][3] Two forms of the vaccine are available, the Inactivated Poliovirus Vaccine (IPV) and the Live-Attenuated Poliovirus Vaccine (OPV). In 1955 the Salk IPV was introduced, leading to an important reduction of endemic and epidemic poliomyelitis. However, this form of the vaccine showed low potency, since 17% of the infants who had received the vaccine, developed paralytic poliomyelitis.[4] The OPV vaccine was introduced in 1962, as a monovalent vaccine, and the trivalent form was made available in 1964. This form of the vaccine was rapidly adopted as the main vaccine against poliomyelitis, due to:[5][6]

However, because of the risk of developing Vaccine-associated paralytic poliomyelitis (VAPP) and circulating Vaccine-derived polioviruses (cVDPVs) with the OPV, countries with high polio immunization coverage (> 90%) and at low risk of wild poliovirus importation and spread including most developed countries currently only use the IPV form of the vaccine.[1][6]

Inactivated Poliovirus Vaccine

Vaccine containing the inactivated and more potent forms of the virus. IPV vaccine contains all 3 serotypes of the polivirus, and may be administered concomitantly with other routine vaccines or simply as trivalent IPV. IPV should be administered in 4 doses, at the 2nd, 4th, and between the 6th and the 18th month of life, and than between the 4th and 6th year of life.[1][7]

The vaccine leads to the formation antibodies against the 3 serotypes of virus, after the 2nd dose in 99% of cases, and after the 3rd dose in 100% of cases.[8][9] After the 3rd dose of the vaccine, antibody titers for serotypes 1 and 3 are higher in IPV, when compared to OPV, and similar for serotype 2.[10] Antibody titers may persist in circulation in some cases during 5 years.[11] However the efficacy of the first two doses of IPV is thought to be inferior to the same two doses of OPV.[12]

Children immunized with the IPV, when exposed to the live poliovirus, were more prone to shed greater amount of the virus in feces, and for a more extended period, when compared to children immunized with OPV. This indicated a greater tendency to asymptomatic poliomyelitis and to transmission of the virus in these individuals.[13][14]

Oral Poliovirus Vaccine (OPV)

Live-Attenuated Poliovirus Vaccine

The live-attenuated poliovirus vaccine (OPV) is no longer available in the United States, however it is still used in other countries. The intestinal immunity induced by the virus in the vaccine is thought to be identical to the one caused by the natural virus.[15] Commonly, after the first dose of OPV, children show the following seroconversion rates:[16]

  • Serotype 1 - 50%
  • Serotype 2 - 85%
  • Serotype 3 - 30%

On the second month after the third dose of OPV, the antibody prevalence to serotypes 1, 2 and 3 is > 96%.[9][17] Vaccine immunization leads to maintenance of antibodies in circulation for up to 5 years. Environmental re-exposure to the vaccine virus is thought to contribute to the persistence of antibodies in the population.[18][19] Following immunization with OPV, immunoglobulin A against the virus may be found in pharyngeal and duodenal secretions, between the 1st and 3rd weeks after administration, and may persist for more that 5 years.[20][21]

After receiving the vaccine, nonimmune individuals shed the virus through pharyngeal secretions during 1 to 3 weeks, and through feces during 1 to 6 weeks. This shedding of the virus is considered positive, particularly in areas of poor vaccination, since it may contribute to the immunization of the community.[22]

Monovalent

The monovalent vaccine, the Sabin oral vaccine, introduced in 1961 consisted of 3 monovalent vaccines. These were later replaced by the trivalent OPV.[23]

In 2005, in order to enhance the global efforts for the eradication of poliovirus in certain settings, the monovalent polivirus vaccine was re-introduced. The monovalent vaccine has higher immunogenicity for a certain serotype, when compared to the polyvalent kind, due to the absence of interference with other serotypes. Additionally, the monovalent vaccine also provides a more focused approach in settings of single serotype outbreak.[24][25]

Currently available OPVs

The currently available OPVs include:[6]

(i)Trivalent OPV (tOPV) against types 1, 2 and 3 (ii)Bivalent OPV against types 1 and 3 (bOPV) and (iii)Monovalent OPV against either type 1 (mOPV1) or type 3 (mOPV3).

  • WHO currently recommends co-ordinated withdrawal of the type 2 component of OPV due to the eradication of type 2 poliovirus since 1999. Trivalent OPV (tOPV) is to be replaced worldwide with bivalent OPV, this switch will occur by April 2016. The monovalent OPV against type 2 will remain available only for use whenever there is type 2 poliovirus outbreak.

Safety of Oral Polio Vaccine (OPV)

OPV is safe, however very rarely serious adverse events may occur. This include:[6][26]

  • Vaccine-associated paralytic poliomyelitis (VAPP) and circulating vaccine-derived polioviruses (cVDPVs) may occur.
  • The incidence of VAPP is 1 case per 2.4 million doses administered
  • Outbreaks of polio due to cVDPVs occasionally occur, mainly in areas of low polio immunization coverage.

Vaccination Guidelines

The current recommended guideline for poliomyelitis immunization include:[6]

Guidelines in Endemic and High-Risk Regions

Vaccine Type Serotypes covered Number of Doses Vaccination Schedule in Endemic and High Risk Countries†
Birth 6 weeks 10 weeks 14 weeks
OPV *Monovalent (Either Serotypes 1 or 2 or 3)
*Bivalent (Serotypes 1 & 3)‡
*Trivalent (Serotypes 1, 2, & 3) 		3 to 4 doses ✔ ✔ ✔ ✔
IPV *Serotype 1
*Serotype 2
*Serotype 3 		1 dose ✔
†Countries at high risk for importation and subsequent spread
‡Countries at high risk for importation and subsequent spread

Guidelines in Polio-eradicated Regions

Vaccine Type Serotypes covered Number of Doses Vaccination Schedule in Low Risk Countries†
2 months 4months 6 to 18 months ± Booster dose‡
IPV *Serotype 1
*Serotype 2
*Serotype 3 		3 or 4 doses ✔ ✔ ✔ ✔
†Countries with high immunization coverage (> 90%) and at low risk of wild poliovirus importation and spread
‡4th dose (booster) is given 6months after 3rd dose of the primary series, if the 1st dose of the primary series was given before 2months of life
‡‡In the USA however, 4 doses are given at 2months, 4months, 6 to 18 months, and a booster dose at 4 to 6 years[27]

References

  1. ↑ 1.0 1.1 1.2 "Poliomyelitis Prevention in the United States".
  2. ↑ Kim-Farley RJ, Bart KJ, Schonberger LB, Orenstein WA, Nkowane BM, Hinman AR; et al. (1984). "Poliomyelitis in the USA: virtual elimination of disease caused by wild virus". Lancet. 2 (8415): 1315–7. PMID 6150330.
  3. ↑ Nathanson N, Martin JR (1979). "The epidemiology of poliomyelitis: enigmas surrounding its appearance, epidemicity, and disappearance". Am J Epidemiol. 110 (6): 672–92. PMID 400274.
  4. ↑ Melnick JL (1978). "Advantages and disadvantages of killed and live poliomyelitis vaccines". Bull World Health Organ. 56 (1): 21–38. PMC 2395534. PMID 307445.
  5. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 "Polio vaccines: WHO position paper, January 2014". Wkly Epidemiol Rec. 89 (9): 73–92. 2014. PMID 24707513.
  7. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  8. ↑ Simoes EA, John TJ (1986). "The antibody response of seronegative infants to inactivated poliovirus vaccine of enhanced potency". J Biol Stand. 14 (2): 127–31. PMID 3020057.
  9. ↑ 9.0 9.1 McBean AM, Thoms ML, Albrecht P, Cuthie JC, Bernier R (1988). "Serologic response to oral polio vaccine and enhanced-potency inactivated polio vaccines". Am J Epidemiol. 128 (3): 615–28. PMID 2843039.
  10. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  11. ↑ Swartz TA, Roumiantzeff M, Peyron L, Stopler T, Drucker J, Epstein I; et al. (1986). "Use of a combined DTP-polio vaccine in a reduced schedule". Dev Biol Stand. 65: 159–66. PMID 2881820.
  12. ↑ Robertson SE, Traverso HP, Drucker JA, Rovira EZ, Fabre-Teste B, Sow A; et al. (1988). "Clinical efficacy of a new, enhanced-potency, inactivated poliovirus vaccine". Lancet. 1 (8591): 897–9. PMID 2895828.
  13. ↑ Onorato IM, Modlin JF, McBean AM, Thoms ML, Losonsky GA, Bernier RH (1991). "Mucosal immunity induced by enhance-potency inactivated and oral polio vaccines". J Infect Dis. 163 (1): 1–6. PMID 1845806.
  14. ↑ Modlin JF, Halsey NA, Thoms ML, Meschievitz CK, Patriarca PA (1997). "Humoral and mucosal immunity in infants induced by three sequential inactivated poliovirus vaccine-live attenuated oral poliovirus vaccine immunization schedules. Baltimore Area Polio Vaccine Study Group". J Infect Dis. 175 Suppl 1: S228–34. PMID 9203721.
  15. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  16. ↑ Cohen-Abbo A, Culley BS, Reed GW, Sannella EC, Mace RL, Robertson SE; et al. (1995). "Seroresponse to trivalent oral poliovirus vaccine as a function of dosage interval". Pediatr Infect Dis J. 14 (2): 100–6. PMID 7746690.
  17. ↑ Hardy GE, Hopkins CC, Linnemann CC, Hatch MH, Witte JJ, Chambers JC (1970). "Trivalent oral poliovirus vaccine: a comparison of two infant immunization schedules". Pediatrics. 45 (3): 444–8. PMID 5442915.
  18. ↑ Bass JW, Halstead SB, Fischer GW, Podgore JK, Wiebe RA (1978). "Oral polio vaccine. Effect of booster vaccination one to 14 years after primary series". JAMA. 239 (21): 2252–5. PMID 206735.
  19. ↑ Nishio O, Ishihara Y, Sakae K, Nonomura Y, Kuno A, Yasukawa S; et al. (1984). "The trend of acquired immunity with live poliovirus vaccine and the effect of revaccination: follow-up of vaccinees for ten years". J Biol Stand. 12 (1): 1–10. PMID 6699021.
  20. ↑ Ogra PL, Karzon DT, Righthand F, MacGillivray M (1968). "Immunoglobulin response in serum and secretions after immunization with live and inactivated poliovaccine and natural infection". N Engl J Med. 279 (17): 893–900. doi:10.1056/NEJM196810242791701. PMID 20617594.
  21. ↑ Ogra PL (1984). "Mucosal immune response to poliovirus vaccines in childhood". Rev Infect Dis. 6 Suppl 2: S361–8. PMID 6740074.
  22. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  23. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  24. ↑ Cáceres VM, Sutter RW (2001). "Sabin monovalent oral polio vaccines: review of past experiences and their potential use after polio eradication". Clin Infect Dis. 33 (4): 531–41. doi:10.1086/321905. PMID 11462191.
  25. ↑ el-Sayed N, el-Gamal Y, Abbassy AA, Seoud I, Salama M, Kandeel A; et al. (2008). "Monovalent type 1 oral poliovirus vaccine in newborns". N Engl J Med. 359 (16): 1655–65. doi:10.1056/NEJMoa0800390. PMID 18923170.
  26. ↑ "Safety of oral polio vaccine" (PDF).
  27. ↑ "Polio vaccination in the United States".

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