Current Trends Paralytic Poliomyelitis -- United States, 1982 and 1983

As of June 1984, 21 patients with paralytic poliomyelitis had been reported to CDC with onset of illness in 1982 and 1983.* Nine of the patients had onset in 1982, and 12, in 1983. All 21 cases were classified as vaccine-associated, using both epidemiologic and laboratory classifications (1,2Št) (Tables 1 and 2). One case occurred in a 22-year-old unimmunized individual with no history of contact with a trivalent oral poliomyelitis vaccine (OPV) recipient before onset of his illness. Although his case was classified epidemiologically as endemic, not vaccine-associated, a vaccine-like poliovirus type 2 was isolated from his stool.

Eight cases occurred among OPV recipients. All were associated with the first OPV dose, and seven were 2 months to 4 months of age, the recommended age for the first OPV dose. Vaccine-like polioviruses were isolated from the stools of all eight patients; five had polio- virus 3; one, poliovirus 2; one, both polioviruses 2 and 3; and one, polioviruses 1 and 3.

Six cases occurred among household contacts of OPV recipients; five were parents of first-dose recipients of OPV; one was a 4H-month-old unimmunized sibling (Table 3). One of the six household-contact patients had another child in the same household who was a second-dose recipient of OPV. Two of the ill parents had no histories of immunization against poliomyelitis; the remaining three were all partially immunized** against poliomyelitis. Vaccine-like poliovirus isolates were obtained from four of the six contact cases; of the remaining two, one was serologically confirmed.

Three cases occurred among nonhousehold contacts of OPV recipients. The two with onset reported in 1982 were both children; one had contact with a playmate who had received his third OPV dose; and the other had contact with a babysitter's child who had received her second OPV dose. The nonhousehold contact patient reported in 1983 was a 31-year-old unimmunized man who had contact with a nephew who had received his first OPV dose. Overall, seven (78%) of the OPV-contact patients were associated with the vaccinees' first doses of OPV (Table 3).

Three cases were classified as occurring in immune-deficient individuals. Two developed paralysis after receiving their first OPV doses, and the third developed paralysis after the fourth dose. The immunodeficiency in each case was diagnosed in retrospect after the onset of paralytic poliomyelitis. None of the cases were immunosuppressed because of drug therapy. Reported by Respiratory and Enterovirus Br, Div of Viral Diseases, Center for Infectious Diseases, Surveillance, Investigations, and Research Br, Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Before widespread use of vaccine in the 1950s, the number of paralytic poliomyelitis cases reached over 20,000 per year. However, fewer than 25 cases have been reported annually for the last 10 years. With the reduction of naturally occurring poliovirus circulation in the United States, the epidemiology of paralytic poliomyelitis has changed to include a substantial proportion of vaccine-associated cases. Better classification of cases is aided by new laboratory methods that provide more accurate characterization of poliovirus isolates (1,2). Since 1978, these methods have been systematically applied to isolates obtained from patients with endemic disease. The first years that all reported cases of paralytic poliomyelitis appeared vaccine-associated, either epidemiologically or by laboratory characterization of poliovirus isolates, were 1982 and 1983.

Vaccine-associated poliomyelitis has been rare but predictable with widespread use of OPV. During 1972-1983, 278.8 million OPV doses were distributed in the United States. During this same period, 87 vaccine-associated cases in apparently immunologically normal individuals were reported. Thirty-two occurred among vaccine recipients (one case per 8.7 million OPV doses distributed), and 55 cases occurred among household and nonhousehold contacts of vaccinees (1 case per 5.1 million doses distributed).

Because the number of susceptible vaccine recipients or contacts of recipients is not known, the true risk of vaccine-associated poliomyelitis is impossible to determine precisely. The ratio of cases to the number of OPV doses distributed roughly measures the overall risk of vaccine-associated poliomyelitis and demonstrates to a prospective OPV recipient or a contact the overall rarity of OPV-associated disease.

The Immunization Practices Advisory Committee continues to recommend OPV as the vaccine of choice for primary immunization of children in the United States when the benefits and risks for the entire population are considered (3). The choice of OPV as the preferred polio vaccine has also been made by the Committee on Infectious Diseases of the American Academy of Pediatrics (4) and a special expert committee of the Institute of Medicine, National Academy of Sciences (5).

References

1. van Wezel AL, Hazendonk AG. Intratypic serodifferentiation of poliomyelitis virus strains by strain-specific antisera. Intervirology 1979;11:2-8.

2. Nottay BK, Kew OM, Hatch MH, Heyward JT, Obijeski JF. Molecular variation of type 1 vaccine-related and wild polioviruses during replication in humans. Virology 1981;108:405-23.

3. ACIP. Poliomyelitis prevention. MMWR 1982;31:22-6, 31-4.

4. American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 19th ed. Evanston, Illinois: American Academy of Pediatrics, 1982.

5. Nightingale EO. Recommendations for a national policy on poliomyelitis vaccination. N Engl J Med 1977;297:249-53. *These reported cases comprise the "Best Available Paralytic Poliomyelitis Case Count," i.e., they are clinically and epidemiologically compatible with poliomyelitis with residual neurologic deficit 60 days after onset of initial symptoms (or death). **All had received less than the full primary course of three OPV doses or four doses of inactivated poliomyelitis vaccine (IPV). One had received one dose of monovalent poliomyelitis vaccine (MOPV); one had received three doses of MOPV; and the third had received three doses of IPV and one dose of MOPV.

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