Polio Vaccine


Article Author:
Meghan O'Grady


Article Editor:
Paul Bruner


Editors In Chief:
Venkat Minnaganti
John Brusch
Janak Koirala


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
1/17/2019 8:25:19 AM

Indications

Poliomyelitis is a vaccine-preventable disease caused by the poliovirus.

This virus is highly infectious, spreading from person to person mainly through the fecal-oral route. Children under the age of 5 are most commonly infected. Seventy-two percent of infected children will remain asymptomatic but continue to shed the virus that may infect others. Once ingested, the virus multiplies in the gastrointestinal (GI) tract and can ultimately lead to an acute nonspecific illness including symptoms such as:

  • Sore throat
  • Vomiting
  • Fever
  • Fatigue
  • Headache
  • Neck stiffness
  • Extremity stiffness/pain

Most notably, the virus’s invasion of the central nervous system (CNS) can lead to significant morbidity, including paralysis of the extremities or the diaphragm, which occurs in approximately 1 in 200 persons infected. Those with CNS manifestations of poliomyelitis are at particularly high risk of mortality, with 5% to 10% ultimately dying due to diaphragm paralysis.[1]There is no cure for polio, thus prevention is key.

An injectable polio vaccine has been available in the United States since 1955, ultimately leading to the eradication of the disease in the United States by 1979. Today the CDC recommends the polio vaccine series among the list of routine childhood vaccinations.[2]

Specific recommendations regarding vaccine administration in the United States are made by the Centers for Disease Control and Prevention (CDC) and, more specifically, the Advisory Committee on Immunization Practices (ACIP). Recommendations regarding routine childhood immunization against polio include a four-dose vaccine series of inactivated polio vaccine (IPV) given at 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age. 

The third and fourth doses must be separated by at least 6 months. Due to the use of combination vaccines during childhood, some children may receive five doses of IPV, which is considered a safe practice.[3]

Alternate recommendations are provided for catch-up immunization schedules for children or accelerated vaccine series for adults or children who are traveling to areas of the world where transmission is a higher risk.

There are no routine recommendations made for adults regarding the IPV series, largely because most adults in the United States have been vaccinated as children. Those adults who are at higher risk of exposure are encouraged to consider the vaccination series. Risk of exposure may be increased by travel to endemic areas, occupational exposure, or contact with known unvaccinated persons. 

The IPV series is intended to provide protection against all known wildtype strains of the poliovirus, which includes types 1, 2, and 3.[4]

In some areas of the world, routine vaccination practice includes the oral polio virus (OPV) rather than IPV. Both series are comprised of four doses. A key difference is that the OPV is a live attenuated virus. A series begun with one formulation may be completed with the other, so long as the individual receives a total of four doses, the last dose being given as a booster between the ages of 4 and 6 years.

Mechanism of Action

Though multiple formulations of polio vaccines exist, only the trivalent inactivated polio vaccine is currently used in the United States. This single-disease immunization is called poliovirus vaccine inactivated. The virus for this formulation is grown on monkey kidney tissue culture and is inactivated by formaldehyde before its incorporation into the vaccine. The vaccine does contain a preservative as well as trace amounts of polymyxin B, streptomycin, and neomycin. It is also available in its inactivated form in the combination vaccines DTaP/IPV/Hib, DTaP/Hep B/IPV, and DTaP/IPV.

Inactivated vaccines provide immunity by supplying the body’s immune system with a dose of inactivated antigen. Because this antigen is not alive, it cannot replicate in the host. Inactivated vaccines cannot cause disease, thus they may be administered to an immunocompromised host. However, their inability to replicate also confers a lesser amount of immunity, necessitating multiple doses of the vaccine. The IPV, like all other inactivated vaccines, is administered in series.

In contrast, the OPV used in other regions of the world is a live attenuated virus. The three strains of the wildtype virus are weakened in a laboratory setting prior to their incorporation into the oral vaccine. This allows the body's immune system to encounter the virus in a less threatening manner, but also to mount a humoral immune response to protect the recipient from harm with potential future exposures. 

Administration

Immunity to polio may be conferred by the use of a single antigen IPV or as part of a combination vaccine. The volume of solution injected for each is 0.5 mL, but the route of delivery differs. While single antigen IPV may be administered intramuscularly or subcutaneously, all three of the combination vaccines should be administered only intramuscularly. Site of administration depends on the patient age and size, with preference given to the anterolateral thigh in infants and the deltoid in children and adults.

In the case of the OPV, single vials contain 0.5 mL of vaccine solution, which is administered with a pipette into the mouth and swallowed by the recipient. 

Adverse Effects

Serious reactions following routine immunizations are rare. The rate of allergic reaction to routine vaccines is 1 per million doses administered. More commonly the recipient may experience a local vaccine reaction, including erythema or soreness at the injection site.

Vaccine-derived poliovirus (VDPV) presents a small risk in regions where immunization rates are low, and the oral polio vaccine (OPV) is administered. The live attenuated virus may acquire virulence, thus posing an infectious threat. It is not known to be a complication of the IPV, the only polio vaccine used in the United States for routine childhood vaccinations since 2000.

Contraindications

The IPV is contraindicated in individuals who have had anaphylaxis following either a previous dose of the vaccine or after taking streptomycin, polymyxin B, or neomycin, as the vaccine does contain trace amounts of these substances.

Injectable polio vaccine is both safe and recommended for administration to immunodeficient individuals and members of their household, as it is not a live vaccine. Note that the oral polio vaccine is live and should not be administered to immunocompromised persons.[5]

IPV is also safe to administer during pregnancy or to a breastfeeding mother.[6]

Adverse reactions following the receipt of the IPV are reportable to the Vaccine Adverse Event Reporting System (VAERS) per protocol. 

Monitoring

A completed polio vaccine series confers high levels of immunity. After three doses of the standard four-dose series of IPV, efficacy stands at 99% to 100%. The fourth and completing dose is given as a booster between the ages of 4 and 6 years of age. No long-term monitoring of immunity is recommended.

Duration of protection is unknown but is suspected to last years after completion of the primary vaccine series.[7]

In regions of the world where polio morbidity is high and immunity is conferred mainly through the OPV series, booster doses in addition to the four dose series may be warranted.

Toxicity

There is no antidote to the polio vaccine, nor have longterm negative effects of the inactivated polio vaccine been recorded.

Toxicity related to the oral polio vaccine is not specific to the formulation, but rather as would be expected with any live vaccine. As previously stated, live vaccines are to be avoided in immunocompromised persons.

Enhancing Healthcare Team Outcomes

Polio vaccine prevents the potentially life-altering effects of polio. The healthcare team must be aware that some parents may be reluctant to provide this vaccination for their children. It is important that all members of the team work together to educate patients and their families that no longterm negative effects of the inactivated polio vaccine been recorded. Furthermore, the complications of acquiring polio can be serious and long-lasting. By working as a team, health professionals can educate the public about the risks and benefits of polio vaccination. Ultimately, by increasing compliance, all members of the community will be protected from this devasting disease.(Level 1)


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Polio Vaccine - Questions

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Which of the following vaccines is inactivated, and thus may be used to vaccinate an immunocompromised patient?



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The mother of an infant asks about the safety of poliovirus vaccine. What is the best response?



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Which of the following vaccines are never given via an intramuscular injection?



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Which of the following intervals is incorrect for the administration of the inactivated poliovirus vaccine?



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Which of the following is an example of a vaccine containing inactivated virus?



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A 28-year-old G1P0 female with past medical history of hypothyroidism, currently at eight weeks gestation, is preparing for travel to Pakistan in 8 weeks. Her hypothyroidism has been controlled throughout an uncomplicated pregnancy. She did not receive routine childhood vaccinations. Which of the following recommendations should be made to this patient regarding her immunization status against poliomyelitis?



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A 4-month-old male presents to his primary care provider for a well child check. He is due for immunizations today. He has had all routinely recommended vaccinations up to this point. His mother is concerned that he may be allergic to a vaccine he received at his previous well child check, specifically the inactivated polio vaccine (IPV). Following administration, he developed redness immediately surrounding the injection site, which also felt warm to the touch. The mother noted no fever or signs of distress at home. How should she be counseled regarding her child’s reaction to the IPV?



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A 30-year-old male presents to the clinic in anticipation of a business trip. On review of his medical record, you note that his immunizations are not up to date. He cannot recall a particular reason for this but would like to update all of his vaccines today. Past medical history is significant only for asthma, for which he takes a daily inhaled corticosteroid. On his paperwork, he has noted allergies to soy and an antibiotic, of which he cannot remember the name. On further questioning, he states this antibiotic was prescribed for an infection he experienced after being bit by a deer fly. He developed hives and shortness of breath within ten minutes of ingestion and made a trip to the emergency room. Which of the following recommendations should be made today regarding the administration of the inactivated polio vaccine (IPV)?



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A 5-year-old female presents to her primary care office for a well child check. She was recently adopted from Nigeria by a family in the United States. During her time in Nigeria, she received three doses of the oral polio vaccine (OPV). She received her most recent dose at age 18 months. What should be recommended to this family today regarding polio vaccines?



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Polio Vaccine - References

References

Bitnun A,Yeh EA, Acute Flaccid Paralysis and Enteroviral Infections. Current infectious disease reports. 2018 Jun 29     [PubMed]
Global progress toward laboratory containment of wild polioviruses, June 2001. MMWR. Morbidity and mortality weekly report. 2001 Jul 27     [PubMed]
Tzeng SY,McHugh KJ,Behrens AM,Rose S,Sugarman JL,Ferber S,Langer R,Jaklenec A, Stabilized single-injection inactivated polio vaccine elicits a strong neutralizing immune response. Proceedings of the National Academy of Sciences of the United States of America. 2018 Jun 5     [PubMed]
Feldstein LR,Mariat S,Gacic-Dobo M,Diallo MS,Conklin LM,Wallace AS, Global Routine Vaccination Coverage, 2016. MMWR. Morbidity and mortality weekly report. 2017 Nov 17     [PubMed]
Zhao D,Ma R,Zhou T,Yang F,Wu J,Sun H,Liu F,Lu L,Li X,Zuo S,Yao W,Yin J, Introduction of Inactivated Poliovirus Vaccine and Impact on Vaccine-Associated Paralytic Poliomyelitis - Beijing, China, 2014-2016. MMWR. Morbidity and mortality weekly report. 2017 Dec 15     [PubMed]
Polio vaccines: WHO position paper, January 2014. Releve epidemiologique hebdomadaire. 2014 Feb 28     [PubMed]
Anselem O,Parat S,Théau A,Floret D,Tsatsaris V,Goffinet F,Launay O, [Vaccination and pregnancy]. Presse medicale (Paris, France : 1983). 2014 Jun     [PubMed]

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