Feb 25, 2010

Without official recognition PPS in Mexico Press Realease

With your support or comments thanks in advance

A.C Litaff, Post Polio Association (APPLAC) founded by Liliana Marasco Garrido, has 9 years of struggle in Mexico to recognize the existence of post-polio syndrome and especially to be responsive to the people who, if any, have this disorder neuromuscular degeneration, causing a high degree of motor impairment and serious effects on health.

But time and again received in response to the health authorities are only promises that the intention of taking action to create diagnostic services, adequate care and technical and technological aids.
Therefore, Marasco says that this year we have nothing to celebrate "World Day of Disabled Persons" as an important sector of people with polio have been discriminated against and excluded. The authorities know they have promised and not fulfilled. "It further claims that were denied the right to health, which is in the Mexican Constitution, but also in the Convention on the Rights of Persons with Disabilities. A relevant fact of this exclusion is that those affected are adults of working age and those with motor impairments, in the logic of social programs, "we are seen as going out already," says Liliana, and are not considered in public programs, rather they are targeted to children with disabilities and welfare to the elderly.
Without official recognition 

The problem begins when the health authorities do not recognize the existence of post-polio syndrome, despite scientific evidence that is in the U.S. and several European countries. On the Internet there is a whole network of blogs created by people with the condition. It is estimated that Mexico may have more than six thousand people. Through the efforts of Liliana Marasco, the health secretary of the Salinas presidency, Dr. Julio Frenk, facilitated the creation of the first post-polio clinic in the National Rehabilitation Institute (RNI), but few know it exists, it is not in the directory Institute, there is no information on the website. Why?, Said in an interview with Dr. Alvaro Lomeli Rivas, deputy director of rehabilitation medicine, is that"we want to ensure that the syndrome exists," and while the medical committee created in INR to investigate this issue not find what call scientific evidence, will not recognize the condition.

In 2008 the clinic saw 13 patients, but none was diagnosed with post polio syndrome, but with aftermath of polio and joint disease. Dr. Lomeli explained: "We realized that people have polio sequelae of the disease itself, but in the long term, a person can loose the strength in his limbs from the virus, is prone to muscle and bone deformity, and I submit knee, hip, and deformity of the hands. And strong dislocations can occur when they break some of the limbs. But this is post-polio syndrome, a worsening of symptoms and it is as if again they had the virus. " In this battle to achieve recognition that the syndrome does exist, the Post Polio Litaff Association is dedicated to gathering evidence, beyond the actual case of Liliana, diagnosed at a clinic in Houston and found the support and solidarity specialists such as Dr. Carlos Vallbona, director of the Clinic Herman Hesse which deals with problems of the spine and post-polio syndrome, the Medical Center Houston. It was there where he obtained an accurate diagnosis in 2000 after six years of searching for an answer to his suffering.

Without going any further, the World Health Organization in 2010 to include this syndrome in the world rankings, within the G14 codecorresponding to the central nervous system diseases. WHO states that the SPP is "an evolution of the clinical condition is irreversible and incurable, with regard to the progressive dysfunction of motor units, which can not be classified as polio sequelae.

Broken promises 
However, Liliana Marasco recognizes that in these nine years there was a breakthrough in 2006. In an interview, says of what was discussed and what the current situation in the attention to the SPP in Mexico.
What has gotten the Post Polio Association in these nine years? 
I think the first symposium on post-polio syndrome was made in 2006 with the support of the Ministry of Health. He brought the most qualified medical specialist, from Bailor College, the Medical Center in Houston. On that occasion the prevalent vaccine was introduced which is the IPO, we were immediately covered with it to tell children with double coverage to no longer be exposed to wild polio.

That thought we would go to the following in our project and other ongoing sub clinical. But since there has not been more progress, despite the work and we continue asking the authorities to listen carefully to this exists, that is scientific. It is a syndrome of primary disease called polio. That's what I do not understand.
Do people who may have post-polio syndrome today are those who had polio in the sixties? 
Not long before, from 49 onwards there was brutal outbreaks, the largest outbreak was in 52. Covered the entire United States and Mexico, thus many children were affected. The syndrome refers to the traditional side effects that are attacking you after 30 or 40 years have had the disease. It is a progressive neuromuscular disease.
Where can I meet people who have post-polio syndrome in Mexico?
With much prodding to Dr. Julio Frenk, in the past six years, and with Deputy Secretary Dr. Roberto Tapia, and Dr. Romeo Rodriguez Suarez agreed to be done to begin with a clinic at the National Institute of Rehabilitation. Currently there but it seems that until right now has not been a single person who can diagnose differentially with PPS.
In the INR told us they are confident that SPP exists in Mexico becausethey have no scientific evidence.
Yes, there is a lack of interest, not to be due, to deny what is obvious, that there is a wealth of information on all countries to support the existence of this syndrome, there's the World Health and the Pan American Health Organization, they have it classified.
What do you think they should?
There are many factors, but let's be clear, we all know that disability is an expense to the government. And people with post-polio need orthotics, physical therapy, occupational therapy, and much they cost. And if there is a program that has a budget to meet the disability of adults, since the post-polio syndrome, less.

In other countries, for example, in America does there are clinics specializing in this syndrome occurs, what attention there? 

Well, we're talking about two totally opposite worlds parameters. That the person who has post-polio is respected, first, second, the clinic has served and may one day get a diagnosis. If I had major complications were too advanced or side effects, are another highlight, Medicare, health insurance service will meet your needs, from his wheelchair or electric, medications and doctor visits, surgeries and all that required. The truth, they have a very different treatment that we have people with disabilities in Mexico.
What are the symptoms of PPS?
The symptoms are numerous and the most common is extreme tiredness that may be increasing, which decreases the physical strength to reach the chronic fatigue. Then comes the cold intolerance, you may notice that when everyone else is talking about there's a pleasant climate, and you are freezing. Another is insomnia. It is a progressive neuromuscular problem, then the entire central nervous system is compromised. There are mood swings, because the pain greatly affects the person. In many breathing problems because there were more affected lung throughout the respiratory system.
To arrive at a doctor's diagnosis was a doctor pilgrimage 

It took six years in which, from the moment I stopped walking, because I walked, attended my house, worked without problems, I was seeing all kinds of specialists and no one knew what I had. Meanwhile health was deteriorating, which is the worst. There came a very complicated moment where the whole family did not know what to do, because (the disease) increased at a rate barbaric. And the worst is not knowing what you have, the uncertainty. 
The syndrome occurs in adults of working age 

Even to have a differential diagnosis must be 10 years of stability that has not been any change. So you do not only present at 40 or 50 years old. If someone had 10 years without any change, but at 10 or 12 years you begin to notice gradual changes, loss of muscle, or strength or fatigue, and you're talking about there is a problem. But the institutions do not take into account that these people are the ones who head a household with children in school or university and have to move forward.
You will attend with conventional and complementary medicine 
Yes, since I was told the U.S. that there is nothing to offer in conventional medicine for people with PPS, I said I would use the options in Mexico that gives the herb, naturism, the ozone therapy and pharmaceuticals that help what my brain and my body does not and does not produce. We need minerals magnesium, amino acids, serotonin because we no longer produce them or its production is very low.
What is your complaint about what happens in Mexico? 
After much struggle, so much evidence of them and bring all documentation they ask us, all have in their hand, the existence of post-polio syndrome, I see that we live in discrimination and exclusion very large and we have no right to health. I wonder why we have the General Law on People with Disabilities if you really do not have rights.
Where do you come to demand these rights? 
Since the Health Ministry, Undersecretary Dr. Mauricio Hernandez has been very welcoming and friendly, but there has been no follow-up indicated that he would.
There are few doctors who knew the polio epidemics and were in "the new generations learn about the disease?
In fact in the textbooks of medical students no longer speak because polio was eradicated in Mexico. But as long as polio exists in the face of the earth can not say that ceased to exist. The one that is already eradicated is smallpox. But while there are epidemics in Afghanistan or in India, is giving us indications that the disease exists. And at any moment, unfortunately, the virus can mutate, even more so with climate change.
It should raise awareness among medical students about what is polio, so that later can understand what are the side effects in Post-poliomyelitis. Health should take this into account to have any idea how many we are, where we are, how to diagnose, INEGI statistics that do not have.
Now, you regularly need technical assistance orthodics or prosthesis type and see that next year's budget to make these technical aids decreased. Furthermore we see that in the absence of budget gives priority to the care of children with motor impairment and not the adults, especially in the productive age.What do you think of this? 
What can I say if I asked CONADIS through there these technical aids for motor impairment. I submitted to the DIF projects on the urgent need for banks exist prostheses, orthopedics, wheelchairs, supplementary aid. People of working age adults treat us like people who go out and not worth the trouble. We saw that for this government is nothing more disability in children and the elderly.
So people with PPS are excluded and discriminated against. If you go to a hospital can not respond because you do not even know what you have. The most marginalized, who have less access to health, are suffering the most.
Within the Secretariat, spoke of the prevention of health, because here's an opportunity to implement prevention. To prevent polio who had come to suffer more severe post-polio.
Liliana, what follows in this fight? 
It opens an opportunity that could be favorable for us, with the choice of master Carlos Rios as the candidate of Mexico to the UN Committee on the Convention on the Rights of Persons with Disabilities, he as a person with sequelae of polio could push the government Mexico recognizes the SPP and end this discrimination that affects us. He was going to ask.

Feb 24, 2010

Testimony Of The Vaccine Changed Year 2007


Dear Post Polio Organizations,

Tuesday May 30th I met with Dr. Roberto Tapia Conyer, the Health Secretary of the United Mexican State (Mexico).  It is with great honor I tell you the Secretary of Health approved the use of polio IPV vaccine in Mexico! I cannot tell you how I feel after all work I have done, it is a great satisfaction for Post Polio LITAFF Association A.C to achieve this goal.  I went to this meeting with the idea of telling the Secretary it is time they must change the polio vaccine they use to vaccinate our children and it in must be one of his priorities.  They accepted my request!  However, they need social organization to give them support so they can start working on this change.  January 2007 they will make the official announcement to the world.

Since Litaff is a civil organization, they asked me to get letters from as many International Post Polio Sequale (PPS) organizations as I could.  We need your help.  Mexico’s government needs all PPS organizations around the world to support the motion that we need, to stop using the live vaccine in our country!  Mexican national politics, are like that of any other country, a letter from our affiliate organization, IPPSO and all other organizations worldwide, telling the Mexico government of the importance of this vaccine change is very valuable.  We want to make the same changes that were made in the United States in 2000:  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4905a1.htm

The more letters, signatures, and testimonies we receive, the more it will help our Secretary of Health in the work he has to do.  He has to deal with several international procedures; your support will help when he explains to OPMS (Mundial – World Panamerican of Health) to the OMS, etc. about the importance of not using live vaccine in our country!   

Please forward this letter to other PPS Organization, I appreciate very much.  He knows all ready about our affiliation with the International Post Polio Support Organization (IPPSO) and he is so pleased, I told him how we work together.

Thank you in advance for giving this support to Litaff and the Mexican Secretary of Health.  You may send all of your letters or emails to Dr. Roberto Tapia Conyer, Secretary of Health, to me, Liliana Marasco Garrido at litaffac@prodigy.net.mx   and I will personally give them to him.

My heart is full of joy, and gratitude to God who helped me to make this part of my dream come true.  Many of you know I have worked with all my enthusiasm and unconditional love, for this personal mission I decided to take on 6 years ago.
My kinds regards and love to all,

 Liliana Marasco Garrido
 President     & Founder
  Post Polio LITAFF Association A.C
  Web Site    www.pospoliolitaff.org
   Tel/Fax 001 (52) 55742926 

Poliomyelitis Prevention in the United States

Skip Navigation LinksSkip Navigation Links
Centers for Disease Control and Prevention

CDC HomeSearchHealth Topics A-Z
Recommendations and Reports
May 19, 2000 / 49(RR05);1-22

Poliomyelitis Prevention in the United States

Updated Recommendations of the Advisory Committee on 

Immunization Practices (ACIP)

Advisory Committee on Immunization Practices Membership List, June 1999

John F. Modlin, M.D.
Professor of Pediatrics and Medicine
Dartmouth Medical School
Lebanon, New Hampshire
Dixie E. Snider, Jr., M.D., M.P.H.
Associate Director for Science
Atlanta, Georgia
Richard D. Clover, M.D.
University of Louisville School of Medicine
Louisville, Kentucky
David W. Fleming, M.D.
Oregon Health Division
Portland, Oregon
Mary P. Glode, M.D.
The Children's Hospital
Denver, Colorado
Marie R. Griffin, M.D.
Vanderbilt University Medical Center
Nashville, Tennessee
Fernando A. Guerra, M.D., M.P.H.
San Antonio Metropolitan Health District
San Antonio, Texas
Charles M. Helms, M.D., Ph.D.
University of Iowa Hospital and Clinics
Iowa City, Iowa
David R. Johnson, M.D., M.P.H.
Michigan Department of Community Health
Lansing, Michigan
Chinh T. Le, M.D.
Kaiser Permanente Medical Center
Santa Rosa, California
Paul A. Offit, M.D.
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Jessie L. Sherrod, M.D.
Charles R. Drew University School of Medicine and Science
Los Angeles, California
Bonnie M. Word, M.D.
State University of New York
Stony Brook, New York
Robert F. Breiman, M.D.
National Vaccine Program Office
Atlanta, Georgia
William Egan, Ph.D.
Food and Drug Administration
Rockville, Maryland
Geoffrey S. Evans, M.D.
Health Resources and Services Administration
Rockville, Maryland
T. Randolph Graydon
Health Care Financing Administration
Baltimore, Maryland
Kristin Lee Nichol, M.D., M.P.H.
VA Medical Center
Minneapolis, Minnesota
Regina Rabinovich, M.D.
National Institute of Allergy and Infectious Diseases/National Institutes of Health
Bethesda, Maryland
David H. Trump, M.D., M.P.H.
Office of the Assistant Secretary of Defense (Health Affairs)
Falls Church, Virginia
American Academy of Family Physicians
Richard Zimmerman, M.D.
Pittsburg, Pennsylvania
American Academy of Pediatrics
Larry Pickering, M.D.
Norfolk, Virginia
Jon Abramson, M.D.
Winston-Salem, North Carolina
American Association of Health Plans
Erik K. France, M.D.
Denver, Colorado
American College of Obstetricians and Gynecologists
Stanley A. Gall, M.D.
Louisville, Kentucky
American College of Physicians
Pierce Gardner, M.D.
Stony Brook, New York
American Hospital Association
William Schaffner, M.D.
Nashville, Tennessee
American Medical Association
H. David Wilson, M.D.
Grand Forks, North Dakota
Association of Teachers of Preventive Medicine
W. Paul McKinney, M.D.
Louisville, Kentucky
Biotechnology Industry Organization
Yvonne E. McHugh, Ph.D.
Emeryville, California
Canadian National Advisory Committee on Immunization
Victor Marchessault, M.D.
Cumberland, Ontario
Healthcare Infection Control Practices Advisory Committee
Jane D. Siegel, M.D.
Dallas, Texas
Infectious Diseases Society of America
Samuel L. Katz, M.D.
Durham, North Carolina
National Immunization Council and Child Health Program, Mexico
Jose Ignacio Santos, M.D.
Mexico City, Mexico

National Medical Association
Rudolph E. Jackson, M.D.
Atlanta, Georgia
National Vaccine Advisory Committee
Georges Peter, M.D.
Providence, Rhode Island
Pharmaceutical Research and Manufacturers of America
Barbara J. Howe, M.D.
Collegeville, Pennsylvania
The following CDC staff members prepared this report:
D. Rebecca Prevots, Ph.D., M.P.H.
Roger K. Burr, M.D., M.P.H.
Epidemiology and Surveillance Division

Roland W. Sutter, M.D., M.P.H.&T.M.
Vaccine-Preventable Disease Eradication Division
Trudy V. Murphy, M.D.
Epidemiology and Surveillance Division National Immunization Program

Poliomyelitis Prevention in the United States

Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP)


These recommendations of the Advisory Committee on Immunization Practices (ACIP) for poliomyelitis prevention replace those issued in 1997. As of January 1, 2000, ACIP recommends exclusive use of inactivated poliovirus vaccine (IPV) for routine childhood polio vaccination in the United States. All children should receive four doses of IPV at ages 2, 4, and 6--18 months and 4--6 years. Oral poliovirus vaccine (OPV) should be used only in certain circumstances, which are detailed in these recommendations. Since 1979, the only indigenous cases of polio reported in the United States have been associated with the use of the live OPV. Until recently, the benefits of OPV use (i.e., intestinal immunity, secondary spread) outweighed the risk for vaccine-associated paralytic poliomyelitis (VAPP) (i.e., one case among 2.4 million vaccine doses distributed). In 1997, to decrease the risk for VAPP but maintain the benefits of OPV, ACIP recommended replacing the all-OPV schedule with a sequential schedule of IPV followed by OPV. Since 1997, the global polio eradication initiative has progressed rapidly, and the likelihood of poliovirus importation into the United States has decreased substantially. In addition, the sequential schedule has been well accepted. No declines in childhood immunization coverage were observed, despite the need for additional injections. On the basis of these data, ACIP recommended on June 17, 1999, an all-IPV schedule for routine childhood polio vaccination in the United States to eliminate the risk for VAPP. ACIP reaffirms its support for the global polio eradication initiative and the use of OPV as the only vaccine recommended to eradicate polio from the remaining countries where polio is endemic.


As a result of the introduction of inactivated poliovirus vaccine (IPV) in the 1950s, followed by oral poliovirus vaccine (OPV) in the 1960s, poliomyelitis control has been achieved in numerous countries worldwide, including the entire Western Hemisphere (1,2). In the United States, the last indigenously acquired cases of polio caused by wild poliovirus were detected in 1979 (3). In 1985, the countries of the Americas* established a goal of regional elimination of wild poliovirus by 1990 (4). In 1988, the World Health Assembly (WHA), which is the directing council of the World Health Organization (WHO), adopted the goal of global polio eradication by the end of 2000 (5). In the Americas, the last case of polio associated with isolation of wild poliovirus was detected in Peru in 1991 (6). The Western Hemisphere was certified as free from indigenous wild poliovirus in 1994, an accomplishment achieved by the exclusive use of OPV (7). The global polio eradication initiative has reduced the number of reported polio cases worldwide by >80% since the mid-1980s, and worldwide eradication of the disease by the end of 2000 or soon after appears feasible (8).

Summary of Recent Polio Vaccination Policy in the United States

Based on the continued occurrence of vaccine-associated paralytic poliomyelitis (VAPP) in the United States, the absence of indigenous disease, and the sharply decreased risk for wild poliovirus importation into the United States, the Advisory Committee on Immunization Practices (ACIP) recommended in June 1996 a change from an all-OPV schedule for routine childhood poliovirus vaccination to a sequential IPV-OPV vaccination schedule (i.e., two doses of IPV at ages 2 and 4 months, followed by two doses of OPV at ages 12--18 months and 4--6 years). These recommendations were officially accepted by CDC and published in January 1997 (9). The sequential schedule was intended to be a transition policy in place for 3--5 years until eventual adoption of an all-IPV schedule. At the same time that ACIP recommended a sequential schedule, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommended expanded use of IPV, with all-OPV, all-IPV, and sequential IPV-OPV as equally acceptable options (10,11).
After the successful implementation of expanded IPV use without any observed declines in childhood immunization coverage (12,13), AAP and AAFP joined ACIP in January 1999 in recommending that the first two doses of polio vaccine for routine vaccination be IPV in most circumstances (14,15). However, an all-IPV schedule was still needed to eliminate the risk for VAPP while maintaining population immunity. Thus, ACIP recommended in June 1999 that the all-IPV schedule begin January 1, 2000 (16). Although AAFP concurred with this recommendation, AAP recommended only that the all-IPV schedule begin during the first 6 months of 2000 (17,18).
The United States can remain free of polio only by maintaining high levels of population immunity and reducing or eliminating the risk for poliovirus importation. ACIP strongly reaffirms its support for the global polio eradication initiative, which relies on OPV in countries where the disease has recently been endemic. This report provides the scientific and programmatic background for transition to an all-IPV schedule, presents the current recommendations for polio prevention in the United States, and summarizes recommendations for OPV use if the U.S. vaccine stockpile is needed for out break control.


Characteristics of Poliomyelitis

Acute Poliomyelitis
Poliomyelitis is a highly contagious infectious disease caused by poliovirus, an enterovirus. Most poliovirus infections are asymptomatic. Symptomatic cases are typically characterized by two phases --- the first, a nonspecific febrile illness, is followed (in a small percentage of cases) by aseptic meningitis or paralytic disease. The ratio of cases of inapparent infection to paralytic disease ranges from 100:1 to 1,000:1.
After a person is exposed to poliovirus, the virus replicates in the oropharynx and the intestinal tract. Viremia follows, which can result in infection of the central nervous system. Replication of poliovirus in motor neurons of the anterior horn and brain stem results in cell destruction and causes the typical clinical manifestations of paralytic polio. Depending on the sites of paralysis, polio can be classified as spinal, bulbar, or spino-bulbar disease. Progression to maximum paralysis is rapid (2-4 days), is usually associated with fever and muscle pain, and rarely continues after the patient's temperature has returned to normal. Spinal paralysis is typically asymmetric and more severe proximally than distally. Deep tendon reflexes are absent or diminished. Bulbar paralysis can compromise respiration and swallowing. Paralytic polio is fatal in 2%--10% of cases. After the acute episode, many patients recover at least some muscle function and prognosis for recovery can usually be established within 6 months after onset of paralytic manifestations.
Post-Polio Syndrome
After 30--40 years, 25%--40% of persons who contracted paralytic polio during childhood can experience muscle pain and exacerbation of existing weakness or develop new weakness or paralysis. This disease entity, called post-polio syndrome, has been reported only in persons infected during the era of wild poliovirus circulation. Risk factors for post-polio syndrome include a) the passage of more time since acute poliovirus infection, b) the presence of permanent residual impairment after recovery from the acute illness, and c) being female (19).


Polio is caused by three serotypes of poliovirus --- types 1, 2, and 3. In countries where poliovirus is still endemic, paralytic disease is most often caused by poliovirus type 1, less frequently by poliovirus type 3, and least frequently by poliovirus type 2. The virus is transmitted from person to person primarily by direct fecal-oral contact. However, the virus also can be transmitted by indirect contact with infectious saliva or feces, or by contaminated sewage or water.
The first paralytic manifestations of polio usually occur 7--21 days from the time of initial infection (range: 4-30 days). The period of communicability begins after the virus replicates and is excreted in the oral secretions and feces. This period ends with the termination of viral replication and excretion, usually 4--6 weeks after infection. After household exposure to wild poliovirus, >90% of susceptible contacts become infected. Poliovirus infection results in lifelong immunity specific to the infecting viral serotype.
Humans are the only reservoir for poliovirus. Long-term carrier states (i.e., excretion of virus by asymptomatic persons >6 months after infection) are rare and have been reported only in immunodeficient persons (20,21). Risk factors for paralytic disease include larger inocula of poliovirus, increasing age, pregnancy, strenuous exercise, tonsillectomy, and intramuscular injections administered while the patient is infected with poliovirus (22--24).
Secular Trends in Disease and Vaccination Coverage in the United States
In the United States, poliovirus vaccines have eliminated polio caused by wild poliovirus. The annual number of reported cases of paralytic disease declined from >20,000 in 1952 to an average of 8--9 cases annually during 1980--1994 (Figure) (3,25,26). During 1980--1998, a total of 152 cases of paralytic polio were reported, including 144 cases of VAPP, six imported cases, and two indeterminate cases (16). Until worldwide polio eradication is achieved, epidemics caused by importation of wild virus to the United States remain a possibility unless population immunity is maintained by vaccinating children early in their first year of life. In the United States, outbreaks of polio occurred in 1970, 1972, and 1979 after wild poliovirus was introduced into susceptible populations that had low levels of vaccination coverage. Vaccination coverage among children in the United States is at the highest level in history because of ongoing immunization initiatives. Assessments of the vaccination status of children entering kindergarten and first grade indicated that 95% had completed primary vaccination against polio during the 1980--81 school year, and rates continue to be above that level.
Coverage levels among preschool-aged children are lower than the levels at school entry, but have increased substantially in recent years. Nationally, representative vaccination coverage rates among children aged 19--35 months are derived from the National Immunization Survey (NIS). Vaccination coverage with at least three doses of poliovirus vaccine among children in this age group increased from 88% in 1995 to 91% in 1996 and remained >90% in 1997 and 1998 (13).
Serosurveys have identified high levels of population immunity consistent with these high coverage rates. Based on data from selected surveys, >90% of children, adolescents, and young adults had detectable antibodies to poliovirus types 1 and 2, and >85% had antibody to type 3 (27,28). Data from seroprevalence surveys conducted in two inner-city areas of the United States during 1990--1991 documented that >80% of all children aged 12--47 months had antibodies to all three poliovirus serotypes. Of the children who had received at least three doses of OPV, 90% had antibodies to all three serotypes (29). A serosurvey conducted during 1997--1998 among low-income children aged 19--35 months living in four U.S. cities reported that 96.8%, 99.8%, and 94.5% were seropositive to poliovirus types 1, 2, and 3, respectively (30).
Both laboratory surveillance for enteroviruses and surveillance for polio cases suggest that endemic circulation of indigenous wild polioviruses ceased in the United States in the 1960s. During the 1970s, genotypic testing (e.g., molecular sequencing or oligonucleotide fingerprinting) of poliovirus isolates obtained from indigenous cases (both sporadically occurring and outbreak-associated) in the United States indicated that these viruses were imported (31). During the 1980s, five cases of polio were classified as imported. The last imported case, reported in 1993, occurred in a child aged 2 years who was a resident of Nigeria; the child had been brought to New York for treatment of paralytic disease acquired in her home country. Laboratory investigations failed to isolate poliovirus among samples taken from this child after she arrived in the United States.
Recent experience in Canada illustrates the continuing potential for importation of wild poliovirus into the United States until global eradication is achieved. In 1993 and 1996, health officials in Canada isolated wild poliovirus in stool samples from residents of Alberta and Ontario. No cases of paralytic polio occurred as a result of these wild virus importations. The strain isolated in 1993 was linked epidemiologically and by genomic sequencing to a 1992 polio outbreak in the Netherlands (32). The isolate obtained in 1996 was from a child who had recently visited India (33).
Inapparent infection with wild poliovirus no longer contributes to either the establishment or maintenance of poliovirus immunity in the United States because these viruses no longer circulate in the population. Thus, universal vaccination of infants and children is the only way to establish and maintain population immunity against polio.

Polio Eradication

After the widespread use of poliovirus vaccine in the mid-1950s, the incidence of polio declined rapidly in many industrialized countries. In the United States, the number of cases of paralytic polio reported each year declined from >20,000 cases in 1952 to <100 cases in the mid-1960s (3). In 1988, the WHA resolved to eradicate polio globally by 2000 (5). This global resolution followed the regional goal to eliminate polio by 1990, set in 1985 by the countries of the Western Hemisphere. The last case of polio associated with wild poliovirus isolation was reported from Peru in 1991, and the entire Western Hemisphere was certified as free from indigenous wild poliovirus by an International Certification Commission in 1994 (7). The following polio eradication strategies, which were developed for the Americas, were adopted for worldwide implementation in all polio-endemic countries (34):
  • Achieve and maintain high vaccination coverage with at least three doses of OPV among infants aged <1 year.
  • Develop sensitive systems of epidemiologic and laboratory surveillance, including acute flaccid paralysis (AFP) surveillance.
  • Administer supplemental doses of OPV to all young children (usually those aged <5 years) during National Immunization Days (NIDs) to rapidly decrease widespread poliovirus circulation.
  • Conduct mopping-up vaccination campaigns (i.e., localized campaigns that include home-to-home [or boat-to-boat] administration of OPV) in areas at high risk to eliminate the last remaining chains of poliovirus transmission.
In 1998, global coverage with at least three doses of OPV among infants aged <1 year was 80%. All WHO regions** reported coverage rates of >80%, except the African Region (AFR), where coverage improved from 32% in 1988 to 53% in 1998 (8). Also in 1998, a total of 90 countries conducted either NIDs (74 countries) or Sub-National Immunization Days (16 countries). These 90 countries provided supplemental doses of OPV to approximately 470 million children aged <5 years (i.e., approximately three quarters of the world's children aged <5 years) (8). In 1999, NIDs were conducted in all 50 polio-endemic countries. NIDs in the AFR targeted approximately 88 million children aged <5 years (35). Synchronized NIDs were conducted in 18 countries of the European Region (EUR) and Eastern Mediterranean Region (EMR), vaccinating 58 million children aged <5 years. Another 257 million children aged <5 years were vaccinated in December 1998 and January 1999 in countries of the EMR (Pakistan), South East Asia Region (SEAR) (Bangladesh, Bhutan, India, Myanmar, Nepal, and Thailand), and Western Pacific Region (WPR) (China and Vietnam) (36--40). NIDs in India reached 134 million children, representing the largest mass campaigns conducted to date. Each round of NIDs in India was conducted in only one day (41). Mopping-up campaigns have been conducted widely in the countries of the Americas (including Brazil, Colombia, Mexico, Peru, and several countries in Central America) and more recently in the Mekong delta area encompassing Cambodia, Laos, and Vietnam in 1997 and 1998, and in Turkey in 1998 (37,38).
These supplemental immunization activities have been successful in decreasing the number of reported polio cases globally from 35,251 in 1988 (when the polio eradication target was adopted) to 6,227 in 1998, a decrease of 82% (8). This decrease in incidence is even more remarkable considering the progress in implementing sensitive systems for AFP surveillance, which substantially increased the completeness of reporting of suspected or confirmed polio cases. To conduct virological surveillance, a global laboratory network has been established that processes stool specimens in WHO-accredited laboratories, with both quality and performance monitored closely (42).
Concurrent with the decline in polio incidence, the number of polio-endemic countries has decreased from >120 in 1988 to approximately 50 in 1998. Approximately 50% of the world's population resides in areas now considered polio-free, including the Western Hemisphere, WPR (which encompasses China), and EUR. Two large endemic areas of continued poliovirus transmission exist in South Asia and Sub-Saharan Africa. Priority countries targeted for accelerated implementation of polio eradication strategies include seven reservoir countries (Bangladesh, Democratic Republic of the Congo, Ethiopia, India, Nepal, Nigeria, and Pakistan) and eight countries in conflict (Afghanistan, Angola, Democratic Republic of the Congo, Liberia, Sierra Leone, Somalia, Sudan, and Tajikistan) (8). Progress in these countries will be essential to achieve the goal of global polio eradication by the end of 2000.

Vaccine-Associated Paralytic Poliomyelitis (VAPP)

Cases of VAPP were observed almost immediately after the introduction of live, attenuated poliovirus vaccines (43,44). Before the sequential IPV-OPV schedule was introduced, 132 cases of VAPP were reported during 1980--1995 (Figure) (26; CDC, unpublished data, 2000). Fifty-two cases of paralysis occurred among otherwise healthy vaccine recipients, 41 cases occurred among healthy close contacts of vaccine recipients, and 7 cases occurred among persons classified as community contacts (i.e., persons from whom vaccine-related poliovirus was isolated but who had not been vaccinated recently or been in direct contact with vaccine recipients). An additional 32 cases occurred among persons with immune system abnormalities who received OPV or who had direct contact with an OPV recipient (Table).
The overall risk for VAPP is approximately one case in 2.4 million doses of OPV vaccine distributed, with a first-dose risk of one case in 750,000 first doses distributed (Table). Among immunocompetent persons, 83% of cases among vaccine recipients and 63% of cases among contacts occurred after administration of the first dose (Table) (3,25,36). Among persons who are not immunodeficient, the risk for VAPP associated with the first dose of OPV is sevenfold to 21-fold higher than the risk associated with subsequent doses (25). Immunodeficient persons, particularly those who have B-lymphocyte disorders that inhibit synthesis of immune globulins (i.e., agammaglobulinemia and hypogammaglobulinemia), are at greatest risk for VAPP (i.e., 3,200-fold to 6,800-fold greater risk than immunocompetent OPV recipients) (45).
Since implementation of the sequential IPV-OPV schedule in 1997, five cases of VAPP with onset in 1997 and two cases with onset in 1998 were confirmed. Three of these cases were associated with administration of the first or second dose of OPV to children who had not previously received IPV, and one of the 1998 cases was associated with administration of the third dose. Although these data suggest a decline in VAPP after introduction of the sequential schedule, continued monitoring with additional observation time is required to confirm these preliminary findings because of potential delays in reporting (25,46).

Transition to an All-IPV Schedule

Adopting an all-IPV schedule for routine childhood polio vaccination in the United States is intended to eliminate the risk for VAPP. However, this schedule requires two additional injections at ages 6--18 months and 4--6 years because no combination vaccine that includes IPV as a component is licensed in the United States. Because of concerns regarding potential declines in childhood immunization coverage after introduction of the sequential IPV-OPV schedule (which required two additional injections at ages 2 and 4 months), several evaluations were conducted during this transition period. No evidence exists that childhood vaccination coverage declined because of these additional injections. In two West Coast health maintenance organizations (HMOs) with automated recording and tracking systems for vaccination, researchers assessed the up-to-date vaccination status of infants at age 12 months (i.e., two doses of poliovirus vaccine, three doses of diphtheria and tetanus toxoids and acellular pertussis vaccine [DTaP], two doses of Haemophilus influenzae type b vaccine [Hib], and two doses of hepatitis B vaccine [HepB]). The proportion of children who started the routine vaccination schedule with IPV ranged from 36%--98% across the HMOs by the third quarter of 1997. Infants starting with IPV were as likely to be up-to-date as were infants starting with OPV (12).
Available data from other public-sector clinics showed similar results. In one inner-city clinic in Philadelphia, 152 children due for their first dose of polio vaccine received IPV. Of the 145 children who returned to the clinic, 144 received a second dose of IPV. More than 99% of children due for their third and fourth injections (including IPV) during a single visit received them as indicated (47). An evaluation conducted at six public health clinics in one Georgia county also concluded that, of 567 infants who received their first dose of polio vaccine by age 3 months, 534 (94%) received IPV. Among these infants, 99.6% were also up-to-date for their first doses of diphtheria and tetanus toxoids vaccine (DTP), DTaP, Hib, and HepB (48). More detailed data on compliance with the recommended vaccination schedules is available from state immunization registries.
Another study reviewed immunization data from children born in Oklahoma during January 1, 1996--June 30, 1997 (i.e., 36,391 children seen at one of 290 facilities). The percentage of children who received IPV as their first dose of polio vaccine increased from <2% of children born in 1996 to 15% of children born in the first quarter of 1997 and to 30% of children born in the second quarter of 1997. However, receipt of IPV did not impact overall vaccination coverage; 80% of children receiving IPV for their first dose were up-to-date, as were 80% of children receiving OPV (49).
In 1995, a total of 448,030 doses of IPV were distributed (i.e., approximately 2% of total poliovirus vaccine doses) in the United States. IPV use increased from 6% of all polio doses distributed in 1996 to 29% in 1997 and 34% in 1998. Through August 31, 1999, a total of 69% of doses purchased were IPV, indicating increased acceptance of IPV (18).


Case Investigation

Each suspected case of polio should prompt an immediate epidemiologic investigation with collection of laboratory specimens as appropriate (see Laboratory Methods). If evidence suggests the transmission of wild poliovirus, an active search for other cases that could have been misdiagnosed initially (e.g., as Guillain-Barré syndrome [GBS], polyneuritis, or transverse myelitis) should be conducted. Control measures (including an OPV vaccination campaign to contain further transmission) should be instituted immediately. If evidence suggests vaccine-related poliovirus, no vaccination plan should be developed because no outbreaks associated with live, attenuated vaccine-related poliovirus strains have been documented.
The two most recent outbreaks of polio reported in the United States affected members of religious groups who object to vaccination (i.e., outbreaks occurred in 1972 among Christian Scientists and in 1979 among members of an Amish community). Polio should be suspected in any case of acute flaccid paralysis that affects an unvaccinated member of such a religious group. All such cases should be investigated promptly (see Surveillance).


CDC conducts national surveillance for polio in collaboration with state and local health departments. Suspected cases of polio must be reported immediately to local or state health departments. CDC compiles and summarizes clinical, epidemiologic, and laboratory data concerning suspected cases. Three independent experts review the data and determine whether a suspected case meets the clinical case definition of paralytic polio (i.e., a paralytic illness clinically and epidemiologically compatible with polio in which a neurologic deficit is present 60 days after onset of symptoms [unless death has occurred or follow-up status is unknown]). CDC classifies confirmed cases of paralytic polio as a) associated with either vaccine administration or wild virus exposure, based on epidemiologic and laboratory criteria, and b) occurring in either a vaccine recipient or the contact of a recipient, based on OPV exposure data (25). For the recommended control measures to be undertaken quickly, a preliminary assessment must ascertain as soon as possible whether a suspected case is likely vaccine-associated or caused by wild virus (see Case Investigation and Laboratory Methods).

Laboratory Methods

Specimens for virus isolation (e.g, stool, throat swab, and cerebrospinal fluid [CSF]) and serologic testing must be obtained in a timely manner. The greatest yield for poliovirus is from stool culture, and timely collection of stool specimens increases the likelihood of case confirmation. At least two stool specimens and two throat swab specimens should be obtained from patients who are suspected to have polio. Specimens should be obtained at least 24 hours apart as early in the course of illness as possible, ideally within 14 days of onset. Stool specimens collected >2 months after the onset of paralytic manifestations are unlikely to yield poliovirus. Throat swabs are less often positive than stool samples, and virus is rarely detected in CSF. In addition, an acute-phase serologic specimen should be obtained as early in the course of illness as possible, and a convalescent-phase specimen should be obtained at least 3 weeks later.
The following tests should be performed on appropriate specimens collected from persons who have suspected cases of polio: a) isolation of poliovirus in tissue culture; b) serotyping of a poliovirus isolate as serotype 1, 2, or 3; and c) intratypic differentiation using DNA/RNA probe hybridization or polymerase chain reaction to determine whether a poliovirus isolate is associated with a vaccine or wild virus.
Acute-phase and convalescent-phase serum specimens should be tested for neutralizing antibody to each of the three poliovirus serotypes. A fourfold rise in antibody titer between appropriately timed acute-phase and convalescent-phase serum specimens is diagnostic for poliovirus infection. The recently revised standard protocol for poliovirus serology should be used (50). Commercial laboratories usually perform complement fixation and other tests. However, assays other than neutralization are difficult to interpret because of inadequate standardization and relative insensitivity. The CDC Enterovirus Laboratory is available for consultation and will test specimens from patients who have suspected polio (i.e., patients with acute paralytic manifestations). The telephone number for this lab is (404) 639-2749.



IPV was introduced in the United States in 1955 and was used widely until OPV became available in the early 1960s. Thereafter, the use of IPV rapidly declined to <2% of all poliovirus vaccine distributed annually in the United States. A method of producing a more potent IPV with greater antigenic content was developed in 1978 and is the only type of IPV in use today (51). The first of these more immunogenic vaccines was licensed in the United States in 1987. Results of studies from several countries have indicated that the enhanced-potency IPV is more immunogenic for both children and adults than previous formulations of IPV (52).

Vaccine Composition

Two IPV vaccine products are licensed in the United States,*** although only one (IPOL®) is both licensed and distributed in the United States. These products and their descriptions are as follows:
  •  IPOL®. One dose (0.5 mL administered subcutaneously) consists of the sterile suspension of three types of poliovirus: type 1 (Mahoney), type 2 (MEF-1), and type 3 (Saukett). The viruses are grown on Vero cells, a continuous line of monkey kidney cells, by the microcarrier method. After concentration, purification, and formaldehyde inactivation, each dose of vaccine contains 40 D  antigen units of type 1 poliovirus, 8 D antigen units of type 2, and 32 D antigen units of type 3. Each dose also contains 0.5% of 2-phenoxyethanol and up to 200 ppm of formaldehyde as preservatives, as well as trace amounts of neomycin, streptomycin, and polymyxin B used in vaccine production. This vaccine does not contain thimerosal.
  • POLIOVAX®. One dose (0.5 mL administered subcutaneously) consists of the sterile suspension of three types of poliovirus: type 1 (Mahoney), type 2 (MEF-1), and type 3 (Saukett). The viruses are grown on human diploid (MRC-5) cell cultures, concentrated, purified, and formaldehyde inactivated. Each dose of vaccine contains 40 D antigen units of type 1 poliovirus, 8 D antigen units of type 2, and 32 D antigen units of type 3, as well as 27 ppm formaldehyde, 0.5% of 2-phenoxyethanol, 0.5% of albumin (human), 20 ppm of Tween 80™, and <1 ppm of bovine serum. Trace amounts of neomycin and streptomycin can be present as a result of the production process. This vaccine does not contain thimerosal.


A clinical trial of two preparations of enhanced-potency IPV was completed in the United States in 1984 (53). Among children who received three doses of one of the enhanced-potency IPVs at ages 2, 4, and 18 months, 99%--100% had developed serum antibodies to all three poliovirus types at age 6 months, which was 2 months after administration of the second dose. The percentage of children who had antibodies to all three poliovirus serotypes did not increase or decrease during the 14-month period after the second dose, confirming that seroconversion had occurred in most of the children. Furthermore, geometric mean antibody titers increased fivefold to tenfold after both the second and third doses.
Data from subsequent studies have confirmed that 90%--100% of children develop protective antibodies to all three types of poliovirus after administration of two doses of the currently available IPV, and 99%--100% develop protective antibodies after three doses (53--55). Results of studies showing long-term antibody persistence after three doses of enhanced-potency IPV are not yet available in the United States. However, data from one study indicated that antibody persisted throughout a 4-year follow-up period (56). In Sweden, studies of persons who received four doses of an IPV with lower antigen content than the IPVs licensed in the United States indicated that >90% of vaccinated persons had serum antibodies to poliovirus 25 years after the fourth dose (57). One dose of IPV administered to persons during an outbreak of poliovirus type 1 in Senegal during 1986--1987 was 36% effective; the effectiveness of two doses was 89% (58).
Several European countries (e.g., Finland, Netherlands, Sweden, and Iceland) have relied exclusively on enhanced-potency IPV for routine poliovirus vaccination to eliminate the disease. More recently, all Canadian provinces have adopted vaccination schedules relying exclusively on IPV (i.e., five doses at ages 2, 4, 6, and 18 months and 4--6 years), and Ontario has used an all-IPV schedule since 1988 (59). In addition, France has used only IPV since 1983 (60).


In countries relying on all-IPV schedules, no increased risk for serious adverse events has been observed. An extensive review by the Institute of Medicine (IOM) of adverse events associated with vaccination suggested that no serious adverse events have been associated with the use of IPV in these countries (61). Since expanded use of IPV in the United States in 1996, no serious adverse events have been linked to use of IPV (CDC, unpublished data, 1999).


Recommendations for IPV Vaccination of Children

Routine Vaccination
All children should receive four doses of IPV at ages 2, 4, and 6--18 months and 4--6 years. The first and second doses of IPV are necessary to induce a primary immune response, and the third and fourth doses ensure "boosting" of antibody titers to high levels. If accelerated protection is needed, the minimum interval between doses is 4 weeks, although the preferred interval between the second and third doses is 2 months (see Recommendations for IPV Vaccination of Adults). All children who have received three doses of IPV before age 4 years should receive a fourth dose before or at school entry. The fourth dose is not needed if the third dose is administered on or after the fourth birthday.
Incompletely Vaccinated Children
The poliovirus vaccination status of children should be evaluated periodically. Those who are inadequately protected should complete the recommended vaccination series. No additional doses are needed if more time than recommended elapses between doses (e.g., more than 4--8 weeks between the first two doses or more than 2--14 months between the second and third doses).
Scheduling IPV Administration
Until appropriate combination vaccines are available, the administration of IPV will require additional injections at ages 2 and 4 months. When scheduling IPV administration, the following options should be considered to decrease the number of injections at the 2- and 4-month patient visits:
  • Administer HepB at birth and ages 1 and 6 months.
  • Schedule additional visits if there is reasonable certainty that the child will be brought back for subsequent vaccination at the recommended ages.
  • Use available combination vaccines.
Interchangeability of Vaccines
Children who have initiated the poliovirus vaccination series with one or more doses of OPV should receive IPV to complete the series. If the vaccines are administered ac cording to their licensed indications for minimum ages and intervals between doses, four doses of OPV or IPV in any combination by age 4--6 years is considered a complete series, regardless of age at the time of the third dose. A minimum interval of 4 weeks should elapse if IPV is administered after OPV. Available evidence indicates that persons primed with OPV exhibit a strong mucosal immunogloblulin A response after boosting with IPV (62).
Administration with Other Vaccines
IPV can be administered simultaneously with other routinely recommended childhood vaccines. These include DTP, DTaP, Hib, HepB, varicella (chickenpox) vaccine, and measles-mumps-rubella vaccine.

Recommendations for IPV Vaccination of Adults

Routine poliovirus vaccination of adults (i.e., persons aged >18 years) residing in the United States is not necessary. Most adults have a minimal risk for exposure to polioviruses in the United States and most are immune as a result of vaccination during childhood. Vaccination is recommended for certain adults who are at greater risk for exposure to polioviruses than the general population, including the following persons:
  • Travelers to areas or countries where polio is epidemic or endemic.
  • Members of communities or specific population groups with disease caused by wild polioviruses.
  • Laboratory workers who handle specimens that might contain polioviruses.
  • Health-care workers who have close contact with patients who might be excreting wild polioviruses.
  • Unvaccinated adults whose children will be receiving oral poliovirus vaccine.
Unvaccinated adults who are at increased risk should receive a primary vaccination series with IPV. Adults without documentation of vaccination status should be considered unvaccinated. Two doses of IPV should be administered at intervals of 4--8 weeks; a third dose should be administered 6--12 months after the second. If three doses of IPV cannot be administered within the recommended intervals before protection is needed, the following alternatives are recommended:
  • If more than 8 weeks are available before protection is needed, three doses of IPV should be administered at least 4 weeks apart.
  • If fewer than 8 weeks but more than 4 weeks are available before protection is needed, two doses of IPV should be administered at least 4 weeks apart.
  • If fewer than 4 weeks are available before protection is needed, a single dose of IPV is recommended.
The remaining doses of vaccine should be administered later, at the recommended intervals, if the person remains at increased risk for exposure to poliovirus. Adults who have had a primary series of OPV or IPV and who are at increased risk can receive another dose of IPV. Available data do not indicate the need for more than a single lifetime booster dose with IPV for adults.

Precautions and Contraindications

Hypersensitivity or Anaphylactic Reactions to IPV or Antibiotics Contained in IPV
IPV should not be administered to persons who have experienced a severe allergic (anaphylactic) reaction after a previous dose of IPV or to streptomycin, polymyxin B, or neomycin. Because IPV contains trace amounts of streptomycin, polymyxin B, and neomycin, hypersensitivity reactions can occur among persons sensitive to these antibiotics. No serious adverse events related to use of enhanced-potency IPV have been documented.
Although no adverse effects of IPV have been documented among pregnant women or their fetuses, vaccination of pregnant women should be avoided on theoretical grounds. However, if a pregnant woman is at increased risk for infection and requires immediate protection against polio, IPV can be administered in accordance with the recommended schedules for adults (see Recommendations for IPV Vaccination of Adults).
IPV is the only vaccine recommended for vaccination of immunodeficient persons and their household contacts. Many immunodeficient persons are immune to polioviruses as a result of previous vaccination or exposure to wild virus when they were immunocompetent. Administration of IPV to immunodeficient persons is safe. Although a protective immune response in these persons cannot be ensured, IPV might confer some protection.
False Contraindications
Breastfeeding does not interfere with successful immunization against polio. A dose of IPV can be administered to a child who has diarrhea. Minor upper respiratory illnesses with or without fever, mild to moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and the convalescent phase of an acute illness are not contraindications for vaccination (63).



Routine production of OPV in the United States has been discontinued. However, an emergency stockpile of OPV for polio outbreak control is maintained. Because OPV is the only vaccine recommended to control outbreaks of polio, this section describes OPV and indications for its use.

Vaccine Composition

Trivalent OPV contains live attenuated strains of all three poliovirus serotypes. The viruses are propagated in monkey kidney cell culture. Until introduction of the sequential IPV-OPV schedule in 1997, OPV was the nation's primary poliovirus vaccine, after its licensing in the United States in 1963. One dose of OPV (0.5 mL administered orally from a single dose dispenser) is required to contain a minimum of 106 TCID50 (tissue culture infectious dose) Sabin strain of poliovirus type 1 (LSc 2ab), 105.1 TCID50Sabin strain of poliovirus type 2 (P712 Ch 2ab), and 105.8 TCID50 Sabin strain of poliovirus type 3 (Leon 12a1b), balanced in a formulation of 10:1:3, respectively. The OPV formerly manufactured in the United States**** contained approximately threefold to tenfold the minimum dose of virus necessary to meet these requirements consistently (64). Each dose of 0.5 mL also contained <25 µG each of streptomycin and neomycin.


After complete primary vaccination with three doses of OPV, >95% of recipients develop long-lasting (probably lifelong) immunity to all three poliovirus types. Approximately 50% of vaccine recipients develop antibodies to all three serotypes after a single dose of OPV (53). OPV consistently induces immunity of the gastrointestinal tract that provides a substantial degree of resistance to reinfection with poliovirus. OPV interferes with subsequent infection by wild poliovirus, a property that is important in vaccination campaigns to control polio epidemics. Both IPV and OPV induce immunity of the mucosa of the gastrointestinal tract, but the mucosal immunity induced by OPV is superior (65,66). Both IPV and OPV are effective in reducing pharyngeal replication and subsequent transmission of poliovirus by the oral-oral route.


Recommendations for OPV Vaccination for Outbreak Control

As affirmed by ACIP, OPV remains the vaccine of choice for mass vaccination to control polio outbreaks (16). Data from clinical trials and empirical evidence support the effectiveness of OPV for outbreak control. The preference for OPV in an outbreak setting is supported by a) higher seroconversion rates after a single dose of OPV compared with a single dose of IPV; b) a greater degree of intestinal immunity, which limits community spread of wild poliovirus; and c) beneficial secondary spread (intestinal shedding) of vaccine virus, which improves overall protection in the community.
As a live attenuated virus, OPV replicates in the intestinal tract and induces antibodies in more recipients after a single dose. Thus, OPV can protect more persons who are susceptible in a population, making it the preferred vaccine for rapid intervention during an outbreak (53,67). Among persons previously vaccinated with three doses of IPV or OPV, excretion of poliovirus from the pharynx and the intestine appears most closely correlated with titers of homologous humoral antibody (68). Three doses of either IPV or OPV induce protective antibody levels (neutralizing antibody titers >1:8) to all three serotypes of poliovirus in >95% of infant recipients (9). Therefore, boosting of immunity with a single dose of OPV or IPV is likely to reduce both pharyngeal and intestinal excretion of poliovirus, effectively stopping epidemic transmission of wild poliovirus.
Use of OPV for Outbreak Control
OPV has been the vaccine of choice for polio outbreak control. During a polio outbreak in Albania in 1996, the number of cases decreased 90% within 2 weeks after administration of a single dose of OPV to >80% of the population aged 0--50 years. Two weeks after a second round of vaccination with OPV, no additional cases were observed (69). Rapidly implemented mass vaccination campaigns resulting in high coverage appears to have been similarly effective in interrupting wild poliovirus outbreaks in other countries (70).
European countries that rely solely on IPV for routine poliovirus vaccination (e.g., the Netherlands and Finland) have also used OPV for primary control of outbreaks. During the 1992--93 polio outbreak in the Netherlands, OPV was offered to members of a religious community affected by the outbreak (who were largely unvaccinated before the outbreak) and other persons living in areas affected by the outbreak. IPV was given to immunized persons outside the outbreak areas to ensure protection in this population (71). During a 1984--85 polio outbreak in Finland, 1.5 million doses of IPV initially were administered to children <18 years for immediate boosting of protection (72). Later, approximately 4.8 million doses of OPV were administered to 95% of the population. In contrast, mass vaccination with IPV exclusively has had little impact on outbreaks and has rarely been used since OPV became available (70,73).

Recommendations for Other Uses of OPV

For the remaining nonemergency supplies of OPV, only the following indications are acceptable for OPV administration:
  • Unvaccinated children who will be traveling in fewer than 4 weeks to areas where polio is endemic. If OPV is not available, IPV should be administered.
  • Children of parents who do not accept the recommended number of vaccine injections. These children can receive OPV only for the third or fourth dose or both. In this situation, health-care providers should administer OPV only after discussing the risk for VAPP with parents or caregivers.

Precautions and Contraindications

Hypersensitivity or Anaphylactic Reactions to OPV
OPV should not be administered to persons who have experienced an anaphylactic reaction to a previous dose of OPV. Because OPV also contains trace amounts of neomycin and streptomycin, hypersensitivity reactions can occur in persons sensitive to these antibiotics.
Although no adverse effects of OPV have been documented among pregnant women or their fetuses, vaccination of pregnant women should be avoided. However, if a pregnant woman requires immediate protection against polio, she can receive OPV in accordance with the recommended schedules for adults (see Use of OPV for Outbreak Control).
OPV should not be administered to persons who have immunodeficiency disorders (e.g., severe combined immunodeficiency syndrome, agammaglobulinemia, or hypogammaglobulinemia) (74--76) because these persons are at substantially increased risk for VAPP. Similarly, OPV should not be administered to persons with altered immune systems resulting from malignant disease (e.g., leukemia, lymphoma, or generalized malignancy) or to persons whose immune systems have been compromised (e.g., by therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation or by infection with human immunodeficiency virus [HIV]). OPV should not be used to vaccinate household contacts of immunodeficient patients; IPV is recommended. Many immunodeficient persons are immune to polioviruses as a result of previous vaccination or exposure to wild virus when they were immunocompetent. Although their risk for paralytic disease could be lower than for persons with congenital or acquired immunodeficiency disorders, these persons should not receive OPV.
Inadvertent Administration of OPV to Household Contacts of Immunodeficient Persons
If OPV is inadvertently administered to a household contact of an immunodeficient person, the OPV recipient should avoid close contact with the immunodeficient person for approximately 4--6 weeks after vaccination. If this is not feasible, rigorous hygiene and hand washing after contact with feces (e.g., after diaper changing) and avoidance of contact with saliva (e.g., sharing food or utensils) can be an acceptable but probably less effective alternative. Maximum excretion of vaccine virus occurs within 4 weeks after oral vaccination.
False Contraindications
Breastfeeding does not interfere with successful immunization against polio. A dose of OPV can be administered to a child who has mild diarrhea. Minor upper respiratory illnesses with or without fever, mild to moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and the convalescent phase of an acute illness are not contraindications for vaccination (63).

Adverse Reactions

Vaccine-Associated Paralytic Poliomyelitis (VAPP)
In rare instances, administration of OPV has been associated with paralysis in healthy recipients and their contacts. No procedures are available for identifying persons (other than those with immunodeficiency) who are at risk for such adverse reactions. Although the risk for VAPP is minimal, vaccinees (or their parents) and their susceptible, close, personal contacts should be informed of this risk (Table). Administration of OPV can cause VAPP that results in death, although this is rare (3,45).
Guillain-Barré Syndrome (GBS)
Available evidence indicates that administration of OPV does not measurably increase the risk for GBS, a type of ascending inflammatory polyneuritis. Preliminary findings from two studies in Finland led to a contrary conclusion in a review conducted by IOM in 1993 (77,78). Investigators in Finland reported an apparent increase in GBS incidence that was temporally associated with a mass vaccination campaign during which OPV was administered to children and adults who had previously been vaccinated with IPV. However, after the IOM review, these data were reanalyzed, and an observational study was completed in the United States. Neither the reanalysis nor the new study provided evidence of a causal relationship between OPV administration and GBS (79).


The National Childhood Vaccine Injury Act of 1986 requires health-care providers to report serious adverse events after poliovirus vaccination (80). Events that must be reported are detailed in the Reportable Events Table of this act and include paralytic polio and any acute complications or sequelae of paralytic polio. Adverse events should be reported to the Vaccine Adverse Events Reporting System (VAERS). VAERS reporting forms and information are available 24 hours a day by calling (800) 822-7967.

Vaccine Injury Compensation Program

The National Vaccine Injury Compensation Program, established by the National Childhood Vaccine Injury Act of 1986, provides a mechanism through which compensation can be paid on behalf of a person who died or was injured as a result of receiving vaccine. A Vaccine Injury Table lists the vaccines covered by this program and the injuries, disabilities, illnesses, and conditions (including death) for which compensation can be paid (81). This program provides potential compensation after development or onset of VAPP in a) an OPV recipient (within 30 days), b) a person in contact with an OPV vaccinee (no time frame specified), or c) an immunodeficient person (within 6 months). Additional information is available from the National Vaccine Injury Compensation Program ([800] 338-2382) or CDC's National Immunization Program Internet site at the following address: <http://www.cdc.gov/nip/vaers.htm>.


In 1997, ACIP recommended using a sequential schedule of IPV followed by OPV for routine childhood polio vaccination in the United States, replacing the previous all-OPV vaccination schedule. This change was intended to reduce the risk for VAPP. Since 1997, the global polio eradication initiative has progressed rapidly, and the likelihood of poliovirus importation into the United States has decreased substantially. The sequential schedule has been well accepted, and no declines in childhood immunization coverage have been observed. On the basis of these data, ACIP recommended on June 17, 1999, an all-IPV schedule for routine childhood polio vaccination in the United States to elimi nate the risk for VAPP. ACIP also reaffirms its support for the global polio eradication initiative and the use of OPV as the only vaccine recommended to eradicate polio from the remaining countries where polio is endemic.


  1. Kim-Farley RJ, Bart KJ, Schonberger LB, et al. Poliomyelitis in the USA: virtual elimination of disease caused by wild virus. Lancet 1984;2:1315--7.
  2. Nathanson N, Martin JR. The epidemiology of poliomyelitis: enigmas surrounding its appearance, epidemicity, and disappearance. Am J Epidemiol 1979;110:672--92.
  3. Strebel PM, Sutter RW, Cochi SL, et al. Epidemiology of poliomyelitis in the United States one decade after the last reported case of indigenous wild virus-associated disease. Clin Infect Dis 1992;14:568--79.
  4. Pan American Health Organization. PAHO director announces campaign to eradicate poliomyelitis from the Americas by 1990. Bull Pan Am Health Organ 1985;19:213--5.
  5. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva: World Health Organization, 1988 (Resolution WHA 41.28).
  6. CDC. Update: eradication of paralytic poliomyelitis in the Americas. MMWR 1992;41:681--3.
  7. CDC. Certification of poliomyelitis elimination---the Americas, 1994. MMWR 1994;43:720--2.
  8. CDC. Progress toward global poliomyelitis eradication, 1997--1998. MMWR 1999;48:416--21.
  9. CDC. Poliomyelitis prevention in the United States: introduction of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine. Recommendations of the Advisory Committee on Immunization Practices. MMWR 1997;46(No. RR-3).
  10. American Academy of Pediatrics Committee on Infectious Diseases. Poliomyelitis prevention: recommendations for use of inactivated and live oral poliovirus vaccines. Pediatrics 1997;99:300--5.
  11. Prevots DR, Strebel PM. Poliomyelitis prevention in the United States: new recommendations for routine childhood vaccination place greater reliance on inactivated poliovirus vaccine. Pediatric Annals 1997;26:378--83.
  12. CDC. Impact of the sequential IPV/OPV schedule on vaccination coverage levels---United States, 1997. MMWR 1998;47:1017--9.
  13. CDC. National vaccination coverage levels among children aged 19--35 months---United States,1998. MMWR 1999;48:829--30.
  14. American Academy of Pediatrics Committee on Infectious Diseases. Poliomyelitis prevention: revised recommendations for use of inactivated and live oral poliovirus vaccines. Pediatrics 1999;103:171--2.
  15. CDC. Recommended childhood immunization schedule---United States, 1999. MMWR 1999;48:12--6.
  16. CDC. Notice to readers. Recommendations of the Advisory Committee on Immunization Practices: revised recommendations for routine poliomyelitis vaccination. MMWR 1999;48:590.
  17. CDC. Recommended childhood immunization schedule---United States, 2000. MMWR 2000;49:35--8, 47.
  18. American Academy of Pediatrics Committee on Infectious Diseases. Prevention of poliomyelitis: recommendations for use of only inactivated poliovirus vaccine for routine immunization. Pediatrics 1999;104:1404--6.
  19. Ramlow J, Alexander M, LaPorte R, Kaufman NC, Kuller L. Epidemiology of the post-polio syndrome. Am J Epidemiol 1992;136:769--86.
  20. CDC. Prolonged poliovirus excretion in an immunodeficient person with vaccine-associated paralytic poliomyelitis. MMWR 1997;46:641--3.
  21. Khetsuriani N, Prevots DR, Pallansch M, Kew O. Vaccine-derived poliovirus (VDPV) persistence among immunodeficient persons with vaccine-associated paralytic poliomyelitis (VAPP) [Abstract no. 675]. Presented at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 26--29, 1999.
  22. Sutter RW, Patriarca P, Suleiman AJM, et al. Attributable risk of DTP (diphtheria and tetanus toxoids and pertussis vaccine) injection in provoking paralytic poliomyelitis during a large outbreak in Oman. J Infect Dis 1992;165:444--9.
  23. Strebel PM, Ion-Nedelcu N, Baughman AL, et al. Intramuscular injections within 30 days of immunization with oral poliovirus vaccine---a risk factor for vaccine-associated paralytic poliomyelitis. N Engl J Med 1995:332:500--6.
  24. Gromeier M, Wimmer E. Mechanism of injury-provoked poliomyelitis. J Virology 1998;72:5056--60.
  25. Prevots DR, Sutter RW, Strebel PM, Weibel RE, Cochi SL. Completeness of reporting for paralytic poliomyelitis, United States, 1980 through 1991. Arch Pediatr Adolesc Med 1994;148:479--85.
  26. CDC. Paralytic poliomyelitisUnited States, 19801994. MMWR 1997;46:79--83.
  27. Kelley PW, Petruccelli BP, Stehr-Green P, Erickson RL, Mason CJ. The susceptibility of young adult Americans to vaccine-preventable infections: a national serosurvey of US army recruits. JAMA 1991;266:2724--9.
  28. Orenstein WA, Wassilak SGF, Deforest A, Rovira EZ, White J, Etkind P. Seroprevalence of polio virus antibodies among Massachusetts schoolchildren [Abstract no. 512]. In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1988.
  29. Chen RT, Hausinger S, Dajani AS, et al. Seroprevalence of antibody against poliovirus in inner-city preschool children: implications for vaccination policy in the United States. JAMA 1996:275:1639--45
  30. Prevots R, Pallansch MW, Angellili M, et al. Seroprevalence of poliovirus antibodies among low SES children aged 19--35 months in 4 cities, United States, 1997--1998 [Abstract no.158]. Presented at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 26--29, 1999.
  31. Rico-Hesse R, Pallansch MA, Nottay BK, Kew OM. Geographic distribution of wild poliovirus type 1 genotypes. Virology 1987;160:311--22.
  32. CDC. Isolation of wild poliovirus type 3 among members of a religious community objecting to vaccination---Alberta, Canada, 1993. MMWR 1993;42:337--9.
  33. Ministry of Health Ontario. Wild type poliovirus isolated in Hamilton. Public Health and Epidemiology Report Ontario 1996;7:1-2.
  34. Hull HF, Ward NA, Hull BP, Milstien JB, de Quadros C. Paralytic poliomyelitis: seasoned strategies, disappearing disease. Lancet 1994;343:1331-7.
  35. CDC. Progress toward poliomyelitis eradication---African Region, 1998--April 1999. MMWR 1999;48:513--8.
  36. CDC. Progress toward poliomyelitis eradication in Europe and Central Asian Republics, 1997--May 1998. MMWR 1998;47:504--8.
  37. CDC. Wild poliovirus transmission in bordering areas of Iran, Iraq, Syria, and Turkey, 1997--June 1998. MMWR 1998;47:588--92.
  38. CDC. Final stages of poliomyelitis eradication---Western Pacific Region, 1997--1998. MMWR 1999;48:29--33.
  39. CDC. Progress toward poliomyelitis eradication---Pakistan, 1994--1998. MMWR 1999;48:121--6.
  40. CDC. Progress toward poliomyelitis eradication---South East Asia Region, 1997--1998. MMWR 1999;48:230--2, 39.
  41. CDC. Progress toward poliomyelitis eradication---India, 1998. MMWR 1998;47:778--81.
  42. CDC. Status of the Global Laboratory Network for poliomyelitis eradication, 1994--1996. MMWR 1997;46:692--4.
  43. Terry LL. The association of cases of poliomyelitis: with the use of type III oral poliomyelitis vaccines---a technical report. Washington, DC: US Department of Health, Education and Welfare, 1962.
  44. Henderson DA, Witte JJ, Morris L, Langmuir AD. Paralytic disease associated with oral polio vaccines. JAMA 1964;190:41--8.
  45. Sutter RW, Prevots DR. Vaccine-associated paralytic poliomyelitis among immunodeficient persons. Infect Med 1994;11:426, 429--30, 435--8.
  46. Prevots DR, Khetsuriani N, Wharton M. Evidence for a decline in the number of vaccine-associated paralytic poliomyelitis cases in the United States following implementation of a sequential poliovirus vaccination schedule, 1997--1998. Presented at the 36th annual meeting of the Infectious Disease Society of America, Denver, Colorado, November 12--15, 1998.
  47. Melman ST, Ehrlich ES, Klugman D, Nguyen TT, Anbar RD. Parental compliance with initiation of sequential schedule for infant immunization [Abstract no. 104]. In: Abstracts of the 1998 Pediatric Academic Societies' Annual Meeting. The Woodlands, Texas: American Pediatric Society/Society for Pediatric Research, 1998.
  48. Kolasa MS, Desai SN, Bisgard KM, Dibling K, Prevots DR. Impact of the sequential poliovirus vaccination schedule: a demonstration project. Am J Prev Med 2000;18:1--6.
  49. Stevenson JM, Chen W, Brown P, Maley M. Implementation and impact of the ACIP recommended sequential schedule for IPV/OPV [Abstract no. 363]. In: Abstracts of the 1998 Pediatric Academic Societies' Annual Meeting. The Woodlands, Texas: American Pediatric Society/Society for Pediatric Research, 1998.
  50. World Health Organization. Report of a WHO informal consultation on polio neutralizing antibody assays. Geneva: World Health Organization, 1991; publication no. WHO/EPI/RD/91.3.
  51. van Wezel AL, van der Velden-de-Groot CAM, van Herwaarden JAM. The production of inactivated poliovaccine on serially cultivated kidney cells from captive-bred monkeys. 3rd General Meeting of ESACT, Oxford, 1979. Dev Biol Stand 1980;46 (special issue):151--8.
  52. International Association of Biological Standardization. International Symposium on Reassessment of Inactivated Poliomyelitis Vaccine. Dev Biol Stand 1981;47(special issue).
  53. McBean AM, Thoms ML, Albrecht P, Cuthie JC, Bernier R. Serologic response to oral polio vaccine and enhanced-potency inactivated polio vaccines. Am J Epidemiol 1988;128:615--28.
  54. Faden H, Modlin JF, Thoms ML, McBean AM, Ferdon MB, Ogra PL. Comparative evaluation of immunization with live attenuated and enhanced-potency inactivated trivalent poliovirus vaccines in childhood: systemic and local immune responses. J Infect Dis 1990;162:1291--7.
  55. Modlin JF, Halsey NA, Thoms ML, et al. Humoral and mucosal immunity in infants induced by three sequential inactivated poliovirus vaccine-live attenuated poliovirus vaccine immunization schedules. J Infect Dis 1997;175(suppl 1):S228--S234.
  56. Faden H, Duffy L, Sun M, Shuff C. Long-term immunity to poliovirus in children immunized with live attenuated and enhanced-potency inactivated trivalent poliovirus vaccine. J Infect Dis 1993;168:452--4.
  57. Bottiger M. A study of the sero-immunity that has protected the Swedish population against poliomyelitis for 25 years. Scand J Infect Dis 1987;19:595--601.
  58. Robertson SE, Traverso HP, Drucker JA, et al. Clinical efficacy of a new, enhanced-potency, inactivated poliovirus vaccine. Lancet 1988;1:897--9.
  59. Varughese P, Carter A, Acres S, Furesz J. Eradication of indigenous poliomyelitis in Canada: impact of immunization strategies. Can J Public Health 1989;80:363--8.
  60. Malvy D, Drucker J. Elimination of poliomyelitis in France: epidemiology and vaccine status. Public Health Rev 1993--94;21:41--9.
  61. Institute of Medicine. Polio vaccines. In: Stratton KR, Howe CJ, eds. Adverse events associated with childhood vaccines. Evidence bearing on causality. Washington, DC: National Academy Press 1994:187210.
  62. Herremans MPT Tineke, Reimerink JHJ, Buisman AM, Kimman TG, Koopmans MPG. Induction of mucosal immunity by inactivated poliovirus vaccine is dependent on previous mucosal contact with live virus. J Immunol 1999;162:5011--8.
  63. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994;43(No. RR-1).
  64. Patriarca PA, Wright PF, John TJ. Factors affecting the immunogenicity of oral poliovirus vaccine in developing countries [Review]. Rev Infect Dis 1991;13:926--39.
  65. Onorato IM, Modlin JF, McBean AM, Thomas ML, Losonsky GA, Bernier RH. Mucosal immunity induced by enhanced-potency inactivated and oral polio vaccines. J Infect Dis 1991;163:1--6.
  66. Henry JL, Jaikaran ES, Davies JR, et al. A study of poliovaccination in infancy: excretion following challenge with live virus by children given killed or living poliovaccine. J Hyg (Cambridge) 1966;64:105--20.
  67. Ion-Nedelcu N, Strebel PM, Toma F, et al. Sequential and combined use of inactivated and oral poliovirus vaccines: Dolj District, Romania, 1992--1994. J Infect Dis 1997;175(suppl 1):S241--S246.
  68. Nishio O, Ishihara Y, Sakae K, et al. The trend of acquired immunity with live poliovirus vaccine and the effect of revaccination: follow-up of vaccinees for ten years. J Biol Stand 1984;12:1--10.
  69. Prevots DR, Ciofe M, Sallabanda A, et al. Outbreak of paralytic poliomyelitis in Albania, 1996: high attack rate among adults and apparent interruption of transmission following a nationwide mass vaccination. Clin Infect Dis 1998;26;419--25.
  70. Patriarca PA, Sutter RW, Oostvogel PM. Outbreaks of paralytic poliomyelitis, 1976--1995. J Infect Dis 1997;175(suppl 1):S165--S172.
  71. Oostvogel PM, van Wijngaarden JK, van der Avoort HGAM, et al. Poliomyelitis outbreak in an unvaccinated community in the Netherlands, 1992--1993. Lancet 1994;344:665--70.
  72. Hovi T, Cantell K, Huovilainen A, et al. Outbreak of paralytic poliomyelitis in Finland: widespread circulation of antigenically altered poliovirus type 3 in a vaccinated population. Lancet 1986;1:1427--32.
  73. Poos RS, Nathanson N. Use of poliomyelitis vaccine under epidemic conditions. Report of outbreak of poliomyelitis among naval personnel and dependents in Hawaii. JAMA 1956;162:85--92.
  74. Nightingale EO. Recommendations for a national policy on poliomyelitis vaccination. N Engl J Med 1977;297:249--53.
  75. CDC. Poliomyelitis prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1982;31:22--6, 31--4.
  76. CDC. Recommendations of the Immunization Practices Advisory Committee (ACIP). Poliomyelitis prevention: enhanced-potency inactivated poliomyelitis vaccine---supplementary statement. MMWR 1987;36:795--8.
  77. Uhari M, Rantala M. Cluster of childhood Guillain-Barré cases after an oral polio vaccine campaign. Lancet 1989;2:440--1.
  78. Kinnunen E, Farkkila M, Hovi T, Juntunen J, Weckstrom P. Incidence of Guillain-Barré syndrome during a nationwide oral poliovirus vaccine campaign. Neurology 1989;39:1034--6.
  79. Rantala H, Cherry JD, Shields WD, Uhari M. Epidemiology of Guillain-Barré syndrome in children: relationship of oral polio vaccine administration to occurrence. J Pediatr 1994;124:220--3.
  80. Chen RT, Rastogi SC, Mullen JR, et al. The Vaccine Adverse Event Reporting System (VAERS). Vaccine 1994;6:542--50.
  81. Kitch EW, Evans G, Gopin R. U.S. law. In: Plotkin SA, Orenstein WA, eds. Vaccines. Third edition. Philadelphia, PA: W.B. Saunders Company, 1998:1165--86.
* Anguilla, Antigua and Barbuda, Argentina, Aruba, Bahamas, Barbados, Belize, Bermuda, Bolivia, Brazil, Canada, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, French Guiana, Grenada, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Jamaica, Martinique, Mexico, Montserrat, Netherlands Antilles, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, United States of America, Uruguay, Venezuela, United Kingdom Virgin Islands, and United States Virgin Islands.
** African Region (AFR), Region of the Americas (AMR), Eastern Mediterranean Region (EMR), European Region (EUR), South East Asia Region (SEAR), and Western Pacific Region (WPR).*** Official names: IPOL® (enhanced-inactivated poliomyelitis vaccine), manufactured and distributed by Aventis-Pasteur, Swiftwater, Pennsylvania; and POLIOVAX,®manufactured by Aventis-Pasteur, Ontario, Canada (licensed but not distributed in the United States).
**** Official name: Orimune® (poliovirus vaccine, live, oral, trivalent types 1,2,3 [Sabin]), manufactured by Lederle Laboratories, Division of American Cyanamid Company, Pearl River, New York.


Return to top.

Return to top.


Polio Film


Entradas populares



México Post Polio Una Vida Un Camino Una Experiencia

Post Polio LITAFF A.C.

Postpoliolitaff.- Asociación Post Polio Litaff A.C Primera Organización oficial sobre Síndrome de Post Poliomielitis En México.

Polio y Efectos Secundarios SPP
- See more at: http://polioamigossinfronteras.blogspot.mx/#sthash.6PkHAkfM.dpuf


Salk Institute

Polio Video

Polio Lungs


Polio Reinders

March Of Dimes Polio History

Erradicación de La poliomielitis

Blog Archive

Search This Blog

No more Polio

Dr. Bruno