Correspondence

More on Vaccine-Associated Paralytic Poliomyelitis

N Engl J Med 1993; 329:1968-1969December 23, 1993

Article

To the Editor:

The case of vaccine-associated paralytic poliomyelitis reported by Mermel et al. (Sept. 9 issue)1 raises important questions for public health policy. At current rates, some 80 cases of vaccine-associated paralytic poliomyelitis may be anticipated in the United States over the next 10 years2. The immunocompetent man described by Mermel et al. contracted poliomyelitis although he had received a primary series of three doses of oral poliovirus vaccine (OPV). He did not, however, receive the recommended supplementary dose at school age to prevent the waning of immunity. This may have been the reason for his susceptibility. The case reinforces the importance of ensuring that children are vaccinated according to recommended schedules, including the school-age vaccination with the OPV booster dose, and may indicate the need for a further booster dose during adolescence or adulthood.

This case and others also raise the issue of a schedule of combined, sequential poliovirus vaccinations, with the first dose or doses of enhanced inactivated poliovirus vaccine (IPV) followed by OPV2. In the United States, such a schedule would prevent most cases of vaccine-associated paralytic poliomyelitis, since 76 to 88 percent of these cases result from the first or second dose of OPV. Infants are less likely to shed OPV virus if they have first been vaccinated with enhanced IPV3. Although enhanced IPV is currently more expensive than OPV (currently $7.26 per dose, vs. $2.16 per dose under the contract with the Centers for Disease Control and Prevention), this differential could be reduced by combining IPV with the diphtheria-tetanus-pertussis (DTP) vaccine.

T.H. Tulchinsky, M.D., M.P.H.
Ministry of Health, Jerusalem 91010, Israel

G. Birkhead, M.D., M.P.H.
New York State Department of Health, Albany, NY 12237

3 References

1
Mermel L, Sanchez de Mora D, Sutter RW, Pallansch MA. Vaccine-associated paralytic poliomyelitis. N Engl J Med 1993;329:810-811
Full Text | Web of Science | Medline

2
Institute of Medicine. An evaluation of poliomyelitis vaccine policy options. Washington, D.C.: National Academy of Sciences, 1988. (Publication no. IOM 88-04.)

3
Strebel PM, Sutte RW, Cochi 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
CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The merits of each poliovirus vaccine have been intensely debated. Although many countries exclusively use OPV, some, including Sweden, Finland, and the Netherlands, use IPV. Denmark, Israel, and Egypt use a combination of both vaccines.

In the United States in 1988, the Institute of Medicine reaffirmed the policy of reliance on OPV for routine use, reserving IPV for unvaccinated adults and for immunodeficient people and their household contacts1. The institute recommended that a sequential schedule of IPV followed by OPV be considered when a combination vaccine containing DTP vaccine and IPV is available. No such combination product is currently licensed in the United States.

The Institute of Medicine's precondition for a combined vaccine appears less meaningful since Haemophilus influenzae type b conjugate vaccine combined with DTP vaccine has become available. The use of such a combined vaccine would not automatically result in fewer injections per visit. It is also noteworthy that excretion of poliovirus after OPV is administered is not markedly decreased in infants previously vaccinated with one dose of IPV2,3. In addition, only about half of the approximately eight cases of vaccine-associated paralytic poliomyelitis that occur annually in the United States may be prevented with a sequential schedule (Centers for Disease Control and Prevention: unpublished data). This is due in part to the fact that the average age at diagnosis in patients with X-linked agammaglobulinemia is 2 1/2 years4. This limits the proportion of such cases that can be prevented with a sequential schedule.

Available data suggest that a schedule requiring at least two doses of IPV followed by two or three doses of OPV would be necessary to achieve humoral and mucosal immunity comparable to that achieved with current schedules for administering OPV3,5. Sequential schedules of IPV followed by OPV deserve renewed discussion. These schedules will prevent most cases of vaccine-associated paralytic poliomyelitis among immunocompetent infants receiving OPV, but they may not prevent the majority of cases among immunocompetent contacts and people with undiagnosed immunodeficiency. Only the global eradication of poliomyelitis, a goal adopted by the World Health Organization to be accomplished by the year 2000, will ultimately lead to the suspension of poliovirus vaccination and eliminate the disease burden associated with OPV.

Roland W. Sutter, M.D., M.P.H.&T.M.
Stephen L. Cochi, M.D.
Stephen C. Hadler, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333

Leonard Mermel, D.O., Sc.M.
Brown University School of Medicine, Providence, RI 02903

5 References

1
Institute of Medicine. An evaluation of the poliomyelitis vaccine policy options. Washington, D.C.: National Academy of Sciences, 1988. (Publication no. IOM 88-04.)

2
Abraham R, Minor P, Dunn G, Modlin JF, Ogra PL. Shedding of virulent poliovirus revertants during immunization of oral poliovirus vaccine after prior immunization with inactivated polio vaccine. J Infect Dis 1993;168:1105-1109
CrossRef | Web of Science | Medline

3
Modlin JF, Halsey NA, Thoms ML, Meschievitz CK, Patriarca PA. Serum neutralizing antibody response to three experimental sequential IPV-OPV immunization schedules. In: Program and Abstracts of the 33rd Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, October 17-20, 1993. Washington, D.C.: American Society for Microbiology, 1993:346. abstract.

4
Lederman HM, Winkelstein JA. X-linked agammaglobulinemia: an analysis of 96 patients. Medicine (Baltimore) 1985;64:145-156
CrossRef | Web of Science | Medline

5
Faden HS, Modlin JF, Thoms ML, McBean AM, Ferdon MB, Ogra PL. Comparative evaluation of immunization with live attenuated and enhanced-potency inactivated trivalent poliovirus vaccines in childhood: systemic and local immune responses. J Infect Dis 1990;162:1291-1297
CrossRef | Web of Science | Medline

Citing Articles (1)