Poliomyelitis

What

Poliomyelitis or polio is an acute illness caused by gastrointestinal infection with 1 of the 3 types of poliovirus. The infection rate in households with susceptible young children can reach 100%.

Who

Inactivated poliovirus (IPV) vaccine or IPV-containing vaccine is recommended for:

• routine vaccination of infants
• routine booster vaccination in adults at higher risk of exposure to polio, such as healthcare workers and laboratory workers who may have contact with polio cases or poliovirus, and travellers to areas or countries where polio is epidemic or endemic
• vaccination of adults who have never received polio vaccine

How

IPV-containing vaccine is recommended for children at 2, 4 and 6 months and 4 years of age.

Vaccination is recommended every 10 years for adults at higher risk of exposure to polio.

Why

The Western Pacific region, including Australia, was declared polio-free in 2000. However, wild poliovirus from endemic countries can still be imported, and vaccination must continue until polio is eradicated around the world.

Polio vaccines available in Australia

The Therapeutic Goods Administration website provides product information for each vaccine.

See also Vaccine information and Variations from product information for more details.

Dose and route

The dose of IPOL is 0.5 mL given by subcutaneous injection. If IPOL is accidentally given intramuscularly, do not repeat the dose.

The dose of inactivated poliovirus (IPV)–containing combination vaccines is 0.5 mL given by intramuscular injection.

Co-administration with other vaccines

People can receive IPV-containing combination vaccines at any time before or after, or with, most other vaccines.

Interchangeability of oral and IPV vaccines

Oral polio vaccine (OPV) is no longer used in Australia.

OPV and IPV vaccine are interchangeable.

Children who started their polio vaccination schedule with OPV should finish it with IPV vaccine or an IPV-containing vaccine.³

Contraindications

The only absolute contraindications to inactivated poliovirus (IPV) vaccine or IPV-containing vaccine are:

• anaphylaxis after a previous dose of any IPV-containing vaccine
• anaphylaxis after any component of an IPV-containing vaccine

Precautions

IPV vaccine or IPV-containing vaccine are not routinely recommended for pregnant or breastfeeding women. However, pregnant or breastfeeding women can receive these vaccines if necessary.

See Vaccination for women who are planning pregnancy, pregnant or breastfeeding, and Table. Vaccines that are not routinely recommended in pregnancy: inactivated viral vaccines for more details.

Inactivated poliovirus (IPV) vaccine is a very well tolerated vaccine.

The most common adverse events in infants who receive IPV vaccine are:³

• erythema (in 0.5–1.5% of vaccine recipients)
• pain (in 14–29%)
• induration at the injection site (in 3–11%)

An extensive review of adverse events associated with polio vaccination suggested that no serious adverse events have been associated with the use of IPV vaccine in countries that use this vaccine.⁴

Repeat doses of IPV vaccine or IPV-containing vaccine are not associated with increased adverse events. Extra doses are safe, if needed.

Polioviruses are RNA enteroviruses from the family Picornaviridae.⁵ They can live transiently in the gastrointestinal tract.

There are 3 poliovirus serotypes: type 1, type 2 and type 3.

Polio is an acute illness caused by gastrointestinal infection with 1 of the 3 types of poliovirus. The virus enters through the mouth, multiplies in the pharynx and gut, and is excreted in faeces for several weeks. The virus invades local lymphoid tissue, enters the bloodstream, and may then infect and replicate in cells of the central nervous system.⁶

Polio has an incubation period of 3–21 days. People are most infectious from 7–10 days before symptoms start to 7–10 days after symptoms start.

Transmission is by the faecal–oral and, occasionally, the oral–oral route.⁷

Infection may:

• be asymptomatic
• result in a systemic illness
• cause paralytic polio

Symptoms of polio

If symptoms occur, they may include:

• headache
• gastrointestinal disturbance
• malaise
• stiffness of the neck and back (which suggests meningitis)
• paralysis (called paralytic polio), which is usually asymmetrical

The infection rate in households with susceptible young children can reach 100%.

Complications of polio

Paralytic polio is a complication of poliovirus meningitis, and may be:

• spinal (79%)
• bulbar (2%)
• bulbospinal (19%)

The ratio of asymptomatic infection to paralytic disease may be as high as 1000:1 in children and 75:1 in adults. The ratio depends on the poliovirus type, and on social and environmental conditions.⁸

The case-fatality rate for paralytic polio is 2–5% in children and 15–30% in adults. The case-fatality rate in bulbar polio is up to 75%.⁶

Post-polio syndrome is a complex of neuromuscular symptoms that occurs in 25–40% of people who survive paralytic polio. It typically occurs 15 years or more after the acute illness. Post-polio syndrome is diagnosed based on clinical signs and symptoms that include muscle weakness and muscle pain.⁹

Vaccine-associated paralytic polio from OPV

People given oral polio vaccine (OPV) can shed the oral vaccine virus in their faeces for up to 6 weeks after 1 dose,⁶ or for several years if they are immunocompromised.

Oral vaccine strains that are shed for many years or that infect people who are immunocompromised may mutate into neurovirulent strains.^10-15

OPV causes disease in approximately 1 in 2.9 million people who receive the vaccine.⁹ The clinical features of vaccine-associated paralytic polio are usually similar to those caused by wild-type (naturally occurring) poliovirus and can include paralytic polio.

Polio in Australia

Polio incidence fell dramatically from the early 1960s in Australia and worldwide.¹⁶

The most recent laboratory-confirmed case of polio caused by wild-type poliovirus in Australia was in 2007. This case was in an overseas-born student who acquired the disease during a visit to Pakistan.¹⁷ Before this, the last case of wild-type polio was in a person who arrived from Turkey in 1977.^18,19

IPV vaccine is used for all polio vaccinations in Australia. This is because of the rapid progress in global polio eradication and the diminished risk of wild-type polio.^1,20 The advantage of using IPV vaccine is that it cannot cause vaccine-associated paralytic polio.²¹

Polio in other countries

The World Health Organization’s intensified Global Polio Eradication Initiative has dramatically reduced the incidence of polio worldwide.²² Several regions have been certified free from polio:

• North America and South America in 1994²³
• the Western Pacific region (including Australia) in 2000²⁴
• the European region in 2002²⁵
• the Southeast Asian region in 2014²⁶

A few countries in Africa and Asia still have poliovirus transmission, but disease incidence is low. In these countries, polio cases are seen sporadically or as outbreaks among non-vaccinated people.

Vaccine-associated paralytic polio from OPV

Oral polio vaccine can be associated with:^27,28

• emergence of highly evolved vaccine-derived polioviruses (VDPVs) in people with primary immunodeficiency and long-term excretion
• polio outbreaks due to circulating VDPVs, particularly in areas with low vaccine coverage^27,28

Inactivated poliovirus (IPV) vaccine and IPV-containing combination vaccines contain polioviruses of types 1, 2 and 3 inactivated by formaldehyde.

Immunogenicity in children

In early clinical studies of infants who received 3 doses of IPV vaccine, nearly 100% of infants formed serum neutralising antibodies to all polio types.²⁹ Follow-up data for these children showed that 3 doses of IPV vaccine conferred immunity for at least 4 years and produced a strong immune response after challenge with oral polio vaccine.³⁰

A randomised multicentre trial compared the hexavalent and pentavalent IPV-containing vaccines. Infants who received either vaccine at 2, 4 and 6 months of age had seroprotective levels of antibody to poliovirus types 1, 2 and 3.³¹

Immunogenicity in adults

A randomised controlled trial among adolescents and adults ≥14 years of age compared immunogenicity of various vaccine formulations containing dTpa, dT and IPV. Almost all study participants (99–100%) showed seroprotection to all poliovirus types after receiving an IPV-containing vaccine, regardless of their vaccination history.³²

A follow-up study showed that 74% of participants had seroprotective antibody levels 10 years after the initial vaccination. After a booster dose, 98–100% of adults had seroprotective antibody levels for all poliovirus types.³³

Transport according to National Vaccine Storage Guidelines: Strive for 5.³⁴ Store at +2°C to +8°C. Do not freeze. Protect from light.

Infanrix hexa vaccine must be reconstituted. Add the entire contents of the syringe to the vial and shake until the pellet completely dissolves. Use the reconstituted vaccine as soon as practicable. If it needs to be stored, hold at room temperature for no more than 8 hours.

Polio is a notifiable disease in all states and territories in Australia.

State and territory public health authorities can provide advice about the public health management of polio, including management of cases and contacts.

Routine vaccination

Infanrix hexa

The product information for Infanrix hexa states that this vaccine is for:

• primary immunisation of infants from the age of 6 weeks
• booster dose for children 18 months of age if they need boosting for all antigens

The Australian Technical Advisory Group on Immunisation (ATAGI) recommends that Infanrix hexa may also be used for catch-up of the primary schedule or as a booster in children <10 years of age.

Infanrix IPV

The product information for Infanrix IPV states that this vaccine is for:

• use in a 3-dose primary schedule for immunisation of infants from the age of 6 weeks
• a single booster dose for children ≤6 years of age who have previously been vaccinated against diphtheria, tetanus, pertussis and polio

ATAGI recommends that Infanrix IPV may also be used for catch-up of the primary schedule or as a booster in children <10 years of age.

Quadracel

The product information for Quadracel states that this vaccine is for:

• use in a 3-dose primary schedule from the age of 2 months to 12 months
• a booster dose for children from 15 months to 6 years of age who have previously been vaccinated against diphtheria, tetanus, pertussis and polio

ATAGI recommends that Quadracel may also be used for catch-up of the primary schedule or as a booster in children <10 years of age. ATAGI also recommends that the primary schedule can start at 6 weeks of age.

Adacel Polio, Boostrix and Boostrix-IPV

The product information for Adacel Polio, Boostrix and Boostrix-IPV states that vaccine is for use in people aged ≥4 years for booster doses only.

ATAGI recommends that Adacel Polio, Boostrix and Boostrix-IPV should not be used in people aged <10 years, except in certain circumstances.

Vaccination after tetanus-containing vaccines

The product information for Boostrix-IPV states that people should not receive dTpa-containing vaccine within 5 years of a tetanus-containing vaccine.

ATAGI recommends that, if the person needs protection against pertussis, they can receive dTpa-containing vaccine at least 4 weeks after a dT-containing vaccine.

Contraindications

The product information for all polio-containing vaccines except IPOL states that these vaccines are contraindicated in children with either:

• encephalopathy of unknown aetiology, or
• neurologic complications occurring within 7 days after a vaccine dose

ATAGI recommends that the only contraindications are:

• history of anaphylaxis to a previous dose
• history of anaphylaxis to any of the vaccine components

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