Pediatricians should ensure children who recently entered the U.S. are vaccinated against all three types of poliovirus

January 12, 2017

Melissa Jenco, News Content Editor

Pediatricians should ensure children who recently entered the U.S. are vaccinated against all three types of poliovirus, health officials said Thursday.
Physicians will have to verify immunization status through documentation instead of antibody testing, according to the Centers for Disease Control and Prevention (CDC)guidance.
“Given the large number of refugees coming from different countries who may have different schedules, they (the CDC) wanted to clarify what would be considered an up-to-date vaccination in the U.S.,” said Yvonne A. Maldonado, M.D., FAAP, vice chair of the AAP Committee on Infectious Diseases who provided input on the guidance.
The Academy and the CDC’s Advisory Committee on Immunization Practices recommend children in the U.S. receive four doses of inactivated polio vaccine (IPV), which protects against all three virus types. The immunization schedule calls for doses to be given at ages 2 months, 4 months, 6 through 18 months, and 4 through 6 years and lays out additional guidance on timing and catch-up vaccination.
While wild poliovirus type 2 has been declared eradicated, people in countries using live attenuated vaccines could contract a vaccine-derived type 2 virus, according to the CDC. That led 155 countries last year to switch from a live attenuated trivalent oral poliovirus vaccine (tOPV) to a bivalent vaccine that contains types 1 and 3.
The CDC’s updated guidance published Thursday in the Morbidity and Mortality Weekly Report calls for children living in the U.S. but vaccinated abroad to be vaccinated against all three types. Doctors must rely on documentation alone to determine a child’s status.
“Right now there are few laboratories that have the type 2 virus because we don’t want it reintroduced, so serologic testing for all three types is generally not available,” said Walter A. Orenstein, M.D., FAAP, lead author of the 2015 AAP clinical report on polio eradicationwho also provided input on the CDC guidance.
Vaccination in other countries may be accepted if tOPV or IPV was used on a similar or accelerated schedule to that of the U.S. The guidance details acceptable intervals. If both were used, the total doses to complete the series should mirror U.S. recommendations. If a child only received tOPV and the doses were given before age 4 years, he or she should receive one dose of IPV at 4 years or older, at least six months after the tOPV vaccination.
Children under age 18 who do not have documented evidence of tOPV or IPV should be revaccinated with IPV using the U.S. schedule, according to the CDC.
“If you’re not certain that a child received a trivalent vaccine, you should not accept those doses as adequate and (should) revaccinate that child,” Dr. Orenstein said.

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno




A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left


What is that nature of the acute illness in infancy?
What is the nature of the subsequent deterioration?
What investigations should be performed?
What is the differential diagnosis of the cause of the progressive calf hypertrophy?



An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.


A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3


Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition


The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies



  • tumours

  • amyloidosis

  • cysticercosis

    Link here