18. Poliomyelitis

In the pre-vaccination era, cases of poliomyelitis occurred sporadically with epidemics in high-income countries in temperate zones. In tropical countries, where the virus still circulates, there is no seasonal pattern.

Classically, poliomyelitis is a disease of young children and adolescents. In countries where polio was endemic, most children acquired antibodies to all three subtypes by age 5 years and most paralytic disease occurred in children aged under 3 years. However, with improvements in living standards a greater number of cases have occurred at an older age, particularly in early adult life, with an associated higher frequency of paralytic disease.

In the 30 years since the Global Polio Eradication Initiative began, an estimated 18 million cases of paralytic poliomyelitis have been prevented, and out of 125 countries, two have ongoing transmission of wild-type 1 disease (Afghanistan and Pakistan).[1] No wild-type disease has been detected in Nigeria since 2016, and the WHO hopes to declare Africa wild poliovirus free in 2020. [2] Although wild-type 2 and 3 polio have been eradicated, there was a dramatic increase in polio cases during 2019, primarily due to outbreaks in Pakistan which spread across its borders to Afghanistan and Iran. [1] Disruption of immunisation programmes and poor sanitary conditions has enabled polio to spread, and in some countries, there are pockets of children unable to be accessed for vaccination due to conflict.

The risk of international spread of poliovirus was declared as a Public Health Emergency of International Concern in May 2014. Further to wild-type 1 disease, the incidence of circulating vaccine-derived poliovirus types (cVDPV) within under-vaccinated populations is of significant international concern, particularly in Africa and South-East Asia (China, Malaysia, Philippines and Indonesia).[3] For up-to-date surveillance information and countries at risk of potential international spread of polioviruses, see the ‘Polio Now’ section of the Global Polio Eradication Initiative website.

There was a synchronised global switch to bivalent oral polio vaccine (bOPV) in 2016 in countries with circulating polio once the wild-type 2 disease was declared eradicated. In these countries, OPV is used together with inactivated poliovirus vaccine (IPV). Many countries without circulating virus have discontinued OPV and provide only IPV to eliminate the risk vaccine-associated paralytic poliomyelitis (VAPP). However, shortages of IPV supply led to delays in this switch and mixed schedules have continued. A revised Polio Eradication & Endgame Strategic Plan 2019–2023 has been developed by the Global Polio Eradication Initiative.[4] Its goal is ‘the complete eradication and containment of all polioviruses’. Vaccination will continue worldwide until all polio has been eradicated.[1]

Since 1962 only six polio cases have been reported. Four of these cases were laboratory confirmed as VAPP and two were classified as probable VAPP.[5] The last case of VAPP was reported in 1999.[6] No cases have been reported since IPV replaced OPV in 2002.

The New Zealand Paediatric Surveillance Unit carries out active surveillance of acute flaccid paralysis (AFP). In 2019 there were nine notifications: all were reviewed by the New Zealand National Certification Committee for the Eradication of Polio and all were classified as non-polio (ESR, 8 June 2020).

The risk of importing wild-type or neurovirulent oral vaccine-derived (cVDPV) strains means that maintaining high IPV coverage in New Zealand is essential.

For further details, refer to the ESR annual notifiable disease reports.

Funded polio vaccines

See also section 16.4.2 for information about DTaP-IPV-HepB/Hib vaccine.

Immunogenicity and efficacy

IPV induces good systemic immune responses to protect against paralytic polio, but does not induce adequate intestinal neutralising antibody to interrupt faecal-oral transmission in regions with circulating polioviruses and with poor sanitation.[7]

Virtually all infants (99–100 percent) will seroconvert against all three strains after three doses of IPV vaccine, and more than 95 percent will seroconvert after two doses. [8] The efficacy of IPV is greater than 90 percent and immunity is expected to be long lasting. [9] Although antibody may decline over time in some individuals, there is no evidence that this leads to increased susceptibility to poliomyelitis.[10]

The combined IPV-containing vaccines induce immune responses against polioviruses superior to IPV stand-alone vaccines. This is due to the effect of the aluminium adjuvant present in these combination vaccines.[9]

Although immunocompetent adults previously immunised with OPV are expected to have lifelong protection against paralytic disease,[10] a study in Australia found that adolescents and young adults who were primed only with OPV had lower levels of serum neutralising antibody than the younger cohorts who had received OPV and at least one dose of IPV.[11] This data suggests that immunity provided by OPV primary schedule can be boosted by IPV to maintain individual immunity.

Transport according to the National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

Store at +2°C to +8°C. Do not freeze. DTaP-IPV-HepB/Hib vaccine should be stored in the dark.

The dose of DTaP-IPV-HepB/Hib (Infanrix-hexa) and DTaP-IPV (Infanrix-IPV) is 0.5 mL, administered by intramuscular injection (see section 2.2.3).

The dose of IPV (IPOL) is 0.5 mL, administered by subcutaneous injection.

Co-administration with other vaccines

DTaP-IPV-HepB/Hib, DTaP-IPV and IPV may be given at the same time as inactivated or live attenuated vaccines, at separate sites and in separate syringes.

A primary course of poliomyelitis vaccine is given as DTaP‑IPV‑HepB/Hib at ages 6 weeks, 3 months and 5 months, followed by a booster dose given as DTaP-IPV at age 4 years (see Table 18.1).

For partially immunised or previously unimmunised individuals, a primary immunisation course consists of three doses of IPV-containing vaccine (funded). The recommended interval is eight weeks between doses, but the minimum interval can be as short as four weeks for catch-up of children or adults (see Appendix 2).[12]

If a course of vaccine is interrupted, it may be resumed without repeating prior doses. A booster may be given if 10 years have elapsed since the last dose and exposure is possible (eg, in the case of a traveller to an area where the virus circulates; this is not funded).

If a child who began a course of OPV in another country moves to New Zealand, they can switch to IPV to complete the final doses. A further dose of IPV should be administered even if they have completed a full OPV (OPV or bOPV) course.

Note: All immunocompromised individuals and their household members may receive IPV. OPV was contraindicated in the immunocompromised because of the risk of VAPP. There is no risk of VAPP with IPV.

No adverse effects on the fetus have been reported following administration of IPV during pregnancy, but immunisation should not be carried out during the first or second trimester unless there are compelling reasons to do so, such as planned travel to an endemic area. However, bear in mind that pregnant women are particularly susceptible to paralytic polio.

If a previously unvaccinated pregnant woman is travelling to a country where polio is occurring, two doses should be administered four weeks apart prior to departure. If departure cannot be delayed allowing a four-week gap, give two doses at the maximum possible interval, though protection cannot be guaranteed. If the available interval is less than two weeks, a single dose is recommended, with further doses given on arrival where possible.

IPV may be given to breastfeeding women.

Polio-containing vaccines are funded for (re)vaccination of eligible patients, as follows. See also sections 4.2 and 4.2.5.

DTaP-IPV-HepB/Hib (Infanrix-hexa) and DTaP-IPV (Infanrix-IPV)

An additional four doses (as appropriate) of DTaP-IPV-HepB/Hib (for children aged under 10 years) or DTaP-IPV are funded for (re)vaccination of patients:

• post-HSCT or chemotherapy
• pre- or post-splenectomy
• pre- or post-solid organ transplant
• undergoing renal dialysis
• prior to planned or following other severely immunosuppressive regimens.

Up to an additional four doses (as appropriate) of DTaP-IPV-HepB/Hib are funded for children aged 10 years to under 18 years for (re)vaccination of patients post HSCT. This is an off-label use of this vaccine which requires a prescription from an authorised prescriber or the patient’s specialist. In this group, all prior immunity will have been lost and revaccination is equivalent to a primary immunisation schedule. DTaP-IPV-HepB/Hib not recommended for other severely immunocompromised individuals aged 10-18 years that require revaccination as they may have residual immune memory.

IPV (IPOL)

IPV is funded for patients following immunosuppression.

Booster doses of IPV are recommended (but not funded) for:

• all travellers to areas or countries where poliomyelitis remains endemic or with cVDPV (see section 18.3.1), who should receive a pre-travel polio booster
  • Under the Public Health Emergency of International Concern (PHEIC) regarding polio, proof of polio vaccination is required on departure from certain countries. See Global Polio Eradication Initiative website for the current country list.
  • Evidence of polio vaccination (a booster dose of IPV given 4 weeks to 12 months prior to exit from these countries) must be recorded on an International Certificate of Vaccination and Prophylaxis (ICVP).
  • An adult polio booster is recommended also for those travelling to countries that have cVDPV-2 only.[1]
• health care workers in direct contact with a case of poliomyelitis
• individuals at particular risk of exposure (eg, laboratory workers routinely handling faecal specimens from persons recently arriving from high-risk countries, which may contain wild or vaccine-derived polioviruses); a booster dose of IPV is recommended every 10 years.

All the above should have completed a primary course of polio vaccines. See Table ‎4.9 for those for whom IPV is particularly recommended. Where there is uncertainty about previous immunisation, a full course of IPV is recommended (see Appendix 2). There is no evidence for the need for routine boosters, but they are recommended to reduce any possible risk from waning immunity in situations of increased risk of exposure.

IPV‑containing vaccines are contraindicated if there is a history of an anaphylactic reaction to a previous dose or to any of the vaccine components.

See also section 16.6 for information about DTaP-IPV-HepB/Hib vaccine.

Pregnancy is a precaution for IPV-containing vaccination, but may be given to women who clearly need it. See section 18.5.3.

A small proportion of individuals experience mild local symptoms following IPV. Injection-site erythema is seen in 1–2 percent of infants, induration in 3–11 percent and pain in 14–29 percent. Similar local reactions are seen with combination vaccines. [9] There is no poliovirus excretion following IPV.

Serious adverse events are very rare following administration of the IPV currently manufactured. [8] See section 16.6 for information about DTaP-IPV-HepB/Hib vaccine.

1. World Health Organization. Progress towards poliovirus containment worldwide, 2018–2019. Weekly Epidemiological Record,, 2019. 94(39): p. 441-448.
2. World Health Organization. 2019 Polio: Statement of the Twenty-Third IHR Emergency Committee Regarding the International Spread of Poliovirus (Press release). World Health Organization: Geneva. 7 January 2020URL: https://www.who.int/news-room/detail/20-12-2019-statement-o-the-twenty-third-ihr-emergency-committee-regarding-the-international-spread-of-poliovirus. (accessed 3 July 2020)
3. Global Polio Eradication Initiative. 2020 Public Health Emergency Status. World Health Organization; 2020; URL: https://polioeradication.org/polio-today/polio-now/public-health-emergency-status/. (accessed 10 May 2022)
4. Global Polio Eradication Initiative. 2019 Polio Endgame Strategy 2019–2023. World Health Organization; 2019; URL: https://polioeradication.org/who-we-are/polio-endgame-strategy-2019-2023/. (accessed 10 May 2022)
5. Institute of Environmental Science and Research Ltd. 2019 Notifiable Diseases in New Zealand: Annual Report 2017. Porirua, New Zealand. URL: https://surv.esr.cri.nz/PDF_surveillance/AnnualRpt/AnnualSurv/2017/2017AnnualNDReport_FINAL.pdf. (accessed 3 July 2020)
6. Edwards EA, Grant CC, Huang QS, et al. A case of vaccine-associated paralytic poliomyelitis. Journal of Paediatrics and Child Health, 2000. 36(4): p. 408-11.
7. Macklin GR, Grassly NC, Sutter RW, et al. Vaccine schedules and the effect on humoral and intestinal immunity against poliovirus: a systematic review and network meta-analysis. Lancet Infectious Diseases, 2019. 19(10): p. 1121-1128.
8. American Academy of Pediatrics. 2018. Poliovirus Infections. in Red Book: 2018 Report of the Committee on Infectious Diseases, Kimberlin D, Brady M, Jackson M, and Long S (eds). URL: https://redbook.solutions.aap.org/redbook.aspx. (accessed 3 July 2020)
9. Vidor E. 2018. Poliovirus Vaccine - Inactivated, in Plotkin's Vaccines (7th edition), Plotkin S, Orenstein W, Offit P, and Edwards K (eds). Elsevier: Philadelphia, US.
10. World Health Organization. 2016. Polio vaccines: WHO position paper – March 2016. Weekly Epidemiological Record. 91(12): p. 145–68. URL: http://www.who.int/wer/2016/wer9112.pdf?ua=1 (accessed 29 March 2020)
11. Hendry AJ, Beard FH, Dey A, et al. Lower immunity to poliomyelitis viruses in Australian young adults not eligible for inactivated polio vaccine. Vaccine, 2020. 38(11): p. 2572-2577.
12. Australian Technical Advisory Group on Immunisation. 2018. Australian Immunisation Handbook (ed.), Canberra: Australian Government Department of Health. URL: https://immunisationhandbook.health.gov.au/ (accessed October 2019)
13. Sanofi-aventis New Zealand, NZ Datasheet: IPOL. 2019, Medsafe.