Epidemiologic Notes and Reports Vaccine-Associated
Poliomyelitis -- United States, 1981
A 27-year-old resident of King County, Washington, was recently
reported to have vaccine-associated poliomyelitis. On June 3,
1981,
the man developed mild rhinorrhea, and over the next 2 days he
experienced pain in his left leg, a sensation of pressure in his
lower
back, and fever and headache. He also complained of difficulty in
urinating. He was hospitalized on June 6. On examination, nasal
phonation was noted, and the gag reflex was diminished. There was
marked weakness of muscle groups in the left leg, including foot
drop,
and the deep-tendon reflexes were absent in that leg.
Cerebrospinal
fluid contained 9 red blood cells/uL and 335 white blood cells/uL,
with 5% polymorphonucleocytes, 80% lymphocytes, and 15% monocytes.
The glucose level was 81 mg/dL, and the protein, 38 mg/dL.
Poliomyelitis was immediately considered by attending
physicians,
and poliovirus type II was cultured from a stool specimen obtained
the
day of admission. This isolate was determined to be vaccine-like
by
the oligonucleotide-mapping technique at CDC. Serologic studies of
acute- and convalescent-phase serum specimens showed a neutralizing
antibody titer of 160 to poliovirus type II in both specimens.
Neither specimen contained detectable antibodies to poliovirus
types I
or III. No further neurologic deficits developed, and the patient
was
discharged after 1 week. Sixty days later, he still had a
left-foot
drop and marked weakness of muscles in his left leg, necessitating
crutches and a foot brace.
The patient had no chronic health problems, no history of
travel
to any area with endemic poliomyelitis, and no exposure to known
cases. Because of his family's religious convictions, he had not
been
vaccinated for poliomyelitis. Eleven days before onset of
symptoms,
he had spent a day with relatives, including an 8-week-old infant
who
had received her first oral poliovirus vaccine 8 days before the
visit. Active surveillance did not detect any other cases.
Reported by CM Nolan, MD, Seattle-King County Health Dept, RM
Laughery, MD, HB Miller, MD, P Tretheway, PA, Renton, DM Perry, MD,
Seattle, HL Cahn, MD, Benton-Franklin Health District, Richland, J
Mills, J Allard, PhD, State Epidemiologist, Washington State Dept
of
Health and Social Svcs; Immunization Div, Center for Prevention
Svcs,
Viral Diseases Div, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: This case satisfies the definition of endemic,
vaccine-associated, household-contact paralytic poliomyelitis
according to epidemiologic criteria used by CDC (1). The
characteristics of the infecting virus as vaccine-like in the
laboratory confirms the epidemiologic classification.
Although inactivated polio vaccine (IPV) and oral polio vaccine
(OPV) are both effective in preventing poliomyelitis, the
Immunization
Practices Advisory Committee (ACIP) of the Public Health Service
(2)
and other advisory groups (3,4) have considered the benefits and
risks
of each vaccine to the entire population and have recommended OPV
as
the vaccine of choice for primary vaccination of children in the
United States.
Vaccine-associated poliomyelitis is a predictable complication
of
the widespread use of OPV. In the period 1969-1980, 291.4 million
doses of OPV were distributed in the United States, and 93 cases of
vaccine-associated poliomyelitis were reported. Of the 93 cases,
36
occurred among vaccine recipients (1 case/8.1 million doses of
vaccine
distributed) and 57 among household or community contacts of
vaccinees
(1 case/5.1 million doses distributed). Most vaccinees (92%) who
acquired poliomyelitis were less than or equal to 4 years of age,
whereas most persons (73%) who acquired poliomyelitis after contact
with vaccinees were greater than or equal to 20 years of age.
Vaccine-related poliomyelitis is most frequently associated with
poliovirus types II or III.
Ideally, poliomyelitis among contacts of vaccinees could be
prevented if all persons were immune to all 3 poliovirus types
before
having contact with a vaccinee. Most adults in the United States
do
possess such immunity, even with no record of having been
vaccinated
against poliomyelitis; however, some do not possess such immunity
and
are therefore at risk of acquiring vaccine-associated
poliomyelitis.
Because of the overriding importance of ensuring prompt and
complete
immunity of children and because of the rarity of OPV-associated
disease, the ACIP recommends that responsible adults be informed of
the small risk of vaccine-associated poliomyelitis and that OPV be
administered to a child regardless of the vaccination status of
immunocompetent adult household contacts (2). Alternatively,
unvaccinated adult contacts can be vaccinated with IPV first, if
strong assurance is obtained that immediately following the
vaccination of the adult contacts, the child will begin and
complete
an OPV series.
American Academy of Pediatrics. Report of the Committee on
Infectious Diseases, 18th ed. Evanston, Illinois, AAP, 1977.
Nightingale E. Recommendations for a national policy on
poliomyelitis vaccination. N Engl J Med 1977;297:249-53.
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