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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.

References

  1. CDC. Neurotropic Diseases Surveillance, Summary 1974-1976. Atlanta: CDC, 1977.

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

  3. American Academy of Pediatrics. Report of the Committee on Infectious Diseases, 18th ed. Evanston, Illinois, AAP, 1977.

  4. Nightingale E. Recommendations for a national policy on poliomyelitis vaccination. N Engl J Med 1977;297:249-53.

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