1. Imported Vaccine Associated Paralytic Poliomyelitis Arizona, 2005
Shoana Anderson
Arizona Dept of Health Services
March 7, 2006

2. Vaccine Associated Paralytic Poliomyelitis (VAPP)
Adverse reaction following live oral polio vaccination
Mutation of vaccine virus to a more neurotrophic form
Paralysis is rare and is clinically similar to WT polio
144 cases of VAPP in US 1980 – 1998
Last case in 1999

3. VAPP Increased risk for adults (>18 yrs)
Immunocompromised at increased risk
Higher risk associated with first dose
VAPP in US (1980 – 1998)*
41% Healthy OPV recipients
31% Healthy contacts
24% Immunodeficient
5% Community acquired
* Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 2004

4. Suspect Polio??
3/18/2005: ADHS notified of a suspect polio case in a 22 year old female
Bilateral lower extremity weakness
Previous difficulty breathing
High serologic titers to all 3 poliovirus types

5. Patient History
Case had been residing in Costa Rica since early January with host family
Philosophically opposed to vaccination
Previously healthy
Travel to several locations in Central and South America
No insect bites
No ill contacts

6. Clinical History
3/2/05: Patient reported fever, sore throat, and myalgia
3/3/05: Developed headache and neck and back pain
Urinary retention, bilateral LE weakness
3/6/05: Hospitalized in Costa Rica
3/8/05: Air-evacuated to Phoenix hospital

7. Clinical History
Case developed SOB, difficulty speaking, and respiratory failure requiring intubation
Demonstrated ascending flaccid paralysis
Reflexes absent
No sensory dysfunction
Differentials: transverse myelitis, GBS, viral meningitis

8. Clinical Findings and Diagnostic Studies
CSF/blood: pleocytosis, elevated protein
Negative for: HIV, WNV, SLE, CMV, Dengue virus
MRI: T2 signal hyperintensity
EMG: axonal polyneuropathy

9. Poliovirus Testing at CDC
Serology: collected 3/9 & 4/7
Types 1, 2, and 3 – 1:1442 (3/9)
Type 1 – 1:1442 (4/7)
Types 2 and 3 – 1:1152 (4/7)
Stools:
3/20: Positive for Sabin types 2 & 3
3/21: Negative
4/7: Negative
4/8: Negative
No other Enteroviruses identified

10. Clinical Course 60 Day Follow-up (May 2005)
Significant residual paralysis of both lower extremities
Primarily quads
Patient could ambulate with assistance
Areflexia
No remaining respiratory complications or upper extremity weakness
Classified as VAPP by committee: September , 2005

11. Exposure to OPV Case resided with host family (no young children)
Son lived next door – frequent visits
2 month old
3 year old
2 month old received first dose of OPV on 1/19/2005

12. Challenges Inexperience with poliovirus Delays in testing
Inappropriate treatment
Investigation protocols and specimen collection
International investigation and coordination
Vaccination of household members
2 younger siblings of the case only received 1 dose of IPV

13. Missed Opportunities
Case received HAV & HBV vaccination prior to travel
Unaware of the risk of travel to OPV-using country

14. Adult Polio Vaccination
Recommended only for those at increased risk
Travel to polio endemic/epidemic countries
Unvaccinated/Incomplete Vaccination
Standard IPV schedule
weeks between first 2 doses
3rd dose 6-12 months after the 2nd dose
Minimum interval: 4 weeks

15. Conclusions First case of paralytic polio in the US since 1999
First documented imported VAPP case
Exposed to OPV through vaccination of grandchild in host family
Consider vaccination of travelers to both polio endemic and OPV-using countries

16. Arizona Dept of Health Services
Laura Erhart
Susan Goodykoontz
Karen Lewis
Immunization Program
David Engelthaler, State Epi
Yavapai County Health Department
Stephen Everett
Sue Robyn
St Joseph’s Hospital and Flagstaff Medical Center
Kathy Howard
Dr. Russell Walker
Dr. Mark Lacy
Dr. Vincent Stack
CDC
Jim Alexander
Kristin Kenyan
Lorraine Alexander
Mark Pallansch

17. Arizona Department of Health Services
Questions
Shoana Anderson
Arizona Department of Health Services