Centers for Disease Control and Prevention

National Center for Immunization and Respiratory Diseases

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Adult Polio Vaccination

Sarah Kidd, MD, MPH

ACIP Meeting

June 21, 2023
▪ Summarize work group deliberations on adult polio vaccination

– Recommendations for unvaccinated and incompletely vaccinated adults

– Recommendations for booster doses of IPV

▪ Present work group’s proposed language for an ACIP vote

Objectives for Today’s Presentation 
▪ Problem

– Is the problem of public health importance?

▪ Benefits & Harms

– How substantial are the desirable anticipated effects?

– How substantial are the undesirable anticipated effects?

– Do the desirable effects outweigh the undesirable effects?

– What is the overall certainty of this evidence for the critical outcomes?

▪ Values

– Does the target population feel that the desirable effects are large relative to the undesirable effects?

– Is there important uncertainty about or variability in how much people value the main outcome?

▪ Acceptability

– Is the intervention acceptable to key stakeholders?

▪ Resource Use

– Is the intervention a reasonable and efficient allocation of resources?

▪ Equity

– What would be the impact on health equity?

▪ Feasibility

– Is the intervention feasible to implement?

ACIP Evidence to Recommendations (EtR) Framework
▪ Vaccination is recommended for certain adults who are at greater risk for exposure 

to polioviruses than the general population

▪ Unvaccinated adults who are at increased risk of exposure should receive a primary 

vaccination series with IPV

▪ Adults who have had a primary series of oral polio vaccine (OPV) or IPV and who 

are at increased risk of exposure can receive another dose of IPV

2000 Recommendations for Inactivated Polio Vaccine (IPV) 

Vaccination of Adults

Poliomyelitis Prevention in the United States (cdc.gov)
▪ 2000 statement focused on adults at increased risk of poliovirus exposure

▪ Uncertainty about how to define increased risk in setting of circulating vaccinederived poliovirus (cVDPV) in US

▪ Unclear guidance for unvaccinated adults who were not known to be at increased 

risk of exposure

▪ Uncertainty about vaccinated adults and when/if a booster was advised

2000 Statement on IPV Vaccination for Adults

Questions that arose in 2022

Poliomyelitis Prevention in the United States (cdc.gov)
IPV = inactivated polio vaccine

tOPV = trivalent oral polio vaccine

▪ Should completion of a primary polio vaccination series with IPV be recommended 

for unvaccinated and incompletely vaccinated adults in the US?

– Population: Unvaccinated and incompletely vaccinated (with tOPV or IPV) US adults aged ≥18 years

– Intervention: Completion of a primary vaccination series with IPV

– Comparison: No vaccination or partial series completion

– Outcomes: 

• Prevention of paralytic poliomyelitis

• Serologic immunity to poliovirus types 1, 2, and 3

• Serious adverse events following vaccination

• Indirect effects, e.g., community transmission, impact on health systems

Policy Question #1 for Work Group
▪ A primary series of ≥3 doses of tOPV or IPV in any combination administered ≥4 

weeks apart

AND

▪ The last dose in the series was given on or after the 4th birthday

AND

▪ The last dose in the series was given ≥6 months after the previous dose

Current Definition of Fully Vaccinated

Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP) Regarding Routine Poliovirus Vaccination 

(cdc.gov); Poliomyelitis Prevention in the United States (cdc.gov)
▪ Poliovirus infection can cause 

poliomyelitis and lifelong paralysis

– Paralytic disease occurs in <1% of 

infections (varies by serotype)

– Non-paralytic clinical illness occurs in 

~25%, including 1%–5% with aseptic 

meningitis

– Approximately 75% of infections are 

asymptomatic

Public Health Problem
Paralytic polio decreased rapidly in the US after 

introduction of polio vaccine

0

5000

10000

15000

20000

25000

195019521954195619581960196219641966196819701972197419761978198019821984198619881990199219941996199820002002200420062008201020122014201620182020

1994: Americas 

certified polio-free

Year

Number of poliomyelitis cases

1955: Salk IPV

1961: Sabin OPV

1979: Last indigenous 

Wild-type case in US

2000: IPV only

1997: Sequential enhanced-potency

IPV followed by OPV
Global Paralytic WPV1 and cVDPV Cases1

, Previous 12 Months2

Polio Now – GPEI (polioeradication.org) WPV1 = wild poliovirus type 1; cVDPV = circulating vaccine-derived poliovirus
Paralytic Polio Case in New York State, July 2022

• A case of paralytic polio caused by vaccine-derived poliovirus type 2 (VDPV2) was 

confirmed in an unvaccinated young adult from Rockland County, New York, on 

July 21, 2022

• Genetic sequencing has indicated a linkage to polioviruses collected in 

wastewater in Israel, United Kingdom, and Canada

• Rockland County has reported overall low vaccine coverage for over 20 years

• In summer 2022, 60% of children under 2 years of age had received 3 doses of 

IPV (zip code level as low as 37%)

• No additional paralytic cases have been identified
WWS Report (ny.gov)

▪ Poliovirus type 2 genetically linked to the case detected 

in wastewater samples in New York (Rockland, Orange, 

Sullivan, and Nassau counties and New York City)

▪ Retrospective testing detected poliovirus as early as 

April 2022

▪ Only 2 positive samples since November 1st (December 

15th in Orange; February 22nd in Rockland)

▪ No detections in samples collected in last 15 weeks

Wastewater Testing for Poliovirus in New York
Poliovirus in New York, 2022

Source: Polio WWS Report (ny.gov)

▪ One paralytic polio 

case in unvaccinated 

young adult in 

Rockland County, NY 

in 2022

▪ Likely indicative of 

≥1–2 thousand 

mostly asymptomatic 

infections
National Salk Vaccination Coverage by September 1961 by Age and Race, 

Household US Immunization Survey (USIS)

Source: Morris, Public Health Reports 1964.

Number of doses (%)

Birth year Age in 1961 0 1–2 ≥3

1957–1960 1–4 years

White 11% 11% 78%

Non-white 26% 21% 53%

1952–1956 5–9 years

White 6% 5% 89%

Non-white 13% 16% 72%

1947–1951 10–14 years

White 6% 5% 89%

Non-white 12% 12% 77%

1942–1946 15–19 years

White 14% 7% 78%

Non-white 25% 11% 64%
National Salk Vaccination Coverage by September 1961 by Age and Race, 

Household US Immunization Survey (USIS)

Source: Morris, Public Health Reports 1964.

Number of doses (%)

Birth year Age in 1961 0 1–2 ≥3

1932–1941 20–29 years

White 34% 11% 55%

Non-white 55% 12% 33%

1922–1931 30–39 years

White 43% 10% 48%

Non-white 65% 11% 24%

1912–1921 40–49 years

White 70% 6% 24%

Non-white 83% 6% 11%

1902–1911 50–59 years

White 90% 3% 8%

Non-white 92% 4% 4%
0

10

20

30

40

50

60

70

80

90

100

Polio3 Coverage (%)

Year of Survey

National Surveys of 3-dose Polio (Polio3) Vaccination 

Coverage among Children, United States, 1959–2017 

Sources: Simpson et al, AJPM 2001 Forty years and four surveys: How does our measuring measure up? – ScienceDirect. CDC, MMWR 2001 National, State, and Urban Area Vaccination Coverage Levels Among 

Children Aged 19--35 Months --- United States, 2000 (cdc.gov). CDC, MMWR 2006 National, State, and Urban Area Vaccination Coverage Among Children Aged 19--35 Months --- United States, 2005 (cdc.gov). 

CDC, MMWR 2011 National and State Vaccination Coverage Among Children Aged 19--35 Months --- United States, 2010 (cdc.gov). Hill et al, MMWR 2016 Vaccination Coverage Among Children Aged 19–35 

Months — United States, 2015 | MMWR (cdc.gov). Hill et al, MMWR 2018 Vaccination Coverage Among Children Aged 19–35 Months — United States, 2017 | MMWR (cdc.gov).

USIS-reported Polio3 coverage among 

children aged 1–4 years

NHIS-reported Polio3 coverage among 

children aged 24–35 months

NIS-reported Polio3 coverage among 

children aged 19–35 months
Percent positive (95% Confidence Interval)

Birth years Age in 2009–2010 Poliovirus Type 1 Poliovirus Type 2 Poliovirus Type 3

1998–2004 6–11 years 97.2 (94.7–98.8) 98.0 (96.4–99.0) 93.8 (91.8–95.4)

1990–1998 12–19 years 94.7 (92.0–96.6) 98.2 (96.6–99.2) 84.3 (81.0–87.2)

1970–1990 20–39 years 92.7 (90.0–94.2) 96.9 (95.2–98.2) 78.6 (74.6–82.2)

1960–1970 40–49 years 93.9 (91.6–95.7) 95.8 (93.8–97.3) 85.8 (82.3–88.8)

Seroprevalence of Poliovirus Antibodies by Age, 

United States NHANES Serosurvey, 2009–2010

Source: Wallace et al, BMC Public Health 2016.
Percent positive (95% Confidence Interval)

Birth years Age & Race/Ethnicity Poliovirus Type 1 Poliovirus Type 2 Poliovirus Type 3

1998–2004 6–11 years

Mexican-American 98.5 (96.4–99.5) 98.2 (96.0–99.4) 97.7 (94.7–99.3)

Other Hispanic 98.8 (93.5–100.0) 99.2 (94.7–100.0) 93.8 (87.0–97.7)

Non-Hispanic White 96.9 (93.1–98.9) 97.6 (94.9–99.1) 92.3 (88.5–95.2)

Non-Hispanic Black 99.1 (96.0–99.9) 99.1 (96.3–99.9) 96.1 (90.6–98.8)

Non-Hispanic Other 92.8 (83.1–97.9) 97.6 (87.6–99.9) 91.1 (81.0–96.9)

1990–1998 12–19 years

Mexican-American 93.7 (90.5–96.1) 98.4 (96.3–99.4) 80.4 (74.5–85.4)

Other Hispanic 96.1 (90.2–98.9) 99.1 (94.7–100.0) 88.5 (81.0–93.8)

Non-Hispanic White 94.7 (89.5–97.8) 97.7 (95.1–99.2) 84.3 (79.3–88.5)

Non-Hispanic Black 93.8 (89.4–96.7) 99.6 (97.7–100.0) 84.6 (79.3– 89.0)

Non-Hispanic Other 97.1 (90.7–99.6) 98.6 (93.0–100.0) 88.5 (79.3–94.6)

Seroprevalence of Poliovirus Antibodies by Age & Race/Ethnicity, 

United States NHANES Serosurvey, 2009–2010

Source: Wallace et al, BMC Public Health 2016.
Birth years Age & Race/Ethnicity

Percent positive (95% Confidence Interval)

Poliovirus Type 1 Poliovirus Type 2 Poliovirus Type 3

1970–1990 20–39 years

Mexican-American 91.2 (86.1–94.9) 93.7 (90.2–96.2) 76.2 (71.5–80.4)

Other Hispanic 86.7 (78.5–92.6) 94.2 (89.8–97.1) 78.4 (70.5–84.9)

Non-Hispanic White 93.6 (91.2–95.5) 97.2 (95.3–98.5) 79.2 (75.1–82.9)

Non-Hispanic Black 94.7 (91.5–96.9) 98.4 (96.4–99.5) 81.6 (75.8–86.6)

Non-Hispanic Other 90.5 (82.4–95.8) 98.9 (92.4–100.0) 74.3 (54.9–88.6)

1960–1970 40–49 years

Mexican-American 89.1 (83.9–93.1) 88.7 (80.9–94.1) 75.8 (69.5–81.3)

Other Hispanic 89.4 (81.6–94.7) 91.3 (82.4–96.7) 85.4 (72.5–93.8)

Non-Hispanic White 94.9 (91.7–97.1) 97.0 (94.3–98.6) 87.0 (82.1–91.0)

Non-Hispanic Black 94.7 (90.0–97.6) 96.9 (92.1–99.2) 87.3 (78.7– 93.8)

Non-Hispanic Other 92.9 (75.0–99.2) 96.1 (87.2–99.5) 86.2 (68.9–95.9)

Seroprevalence of Poliovirus Antibodies by Age & Race/Ethnicity, 

United States NHANES Serosurvey, 2009–2010

Source: Wallace et al, BMC Public Health 2016.
▪ US remains at risk of poliovirus importations as long as there is ongoing transmission 

of poliovirus globally

▪ Data indicate that most US adults have serologic immunity to poliovirus types 1–3

▪ However, unvaccinated and incompletely vaccinated adults remain susceptible to 

paralytic polio if exposed to poliovirus

Summary of Problem
Work group interpretation

Is paralytic poliomyelitis a problem of public health importance?

EtR Domain: Public Health Problem

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
▪ Presence of detectable neutralizing antibody is a correlate of protection against 

paralytic disease.

– Immunity against paralytic disease may be present even in absence of detectable antibodies.

▪ Serologic immunogenicity among infants and children

– 70%–100% seropositive after 2 doses

– 88%–100% seropositive after 3 doses

▪ Estimates of vaccine effectiveness against paralytic polio

– 36%–89% for 1 dose

– 89%–98% for 2 doses

▪ Paucity of data on adults receiving a primary series

Effectiveness of Enhanced-Potency IPV

Sources: Vidor et al review, PIDJ 1997. Stoeckel et al, Rev Infect Dis 1984. CDC, MMWR 1988. John, Rev Med Virol 1993.
▪ Intestinal immunity

– No significant difference between IPV and unvaccinated individuals in the odds of shedding 

– IPV vaccination appears to reduce the mean quantity of shed poliovirus by 63%–91%

– Some data to suggest that IPV vaccination reduces duration of shedding; recent modeling study 

indicated no impact of IPV

▪ Nasopharyngeal (NP) immunity

– Evidence to suggest similar, low rates of NP shedding (0%–4%) among OPV and IPV vaccinees

IPV and Mucosal Immunity

Sources: Hird and Grassly meta-analysis, PLoS Pathogens 2012. Kok et al, Bulletin of WHO 1992. Onorato et al, JID 1991. Brouwer et al, J R Soc Interface 2022.
▪ Local reactions at injection site reported in trials

– Tenderness in 14%–29%

– Induration in 3%–11%

– Erythema in 0.5%–1.4%

▪ Combining IPV with other vaccines is not associated with increased frequency or 

severity of reported adverse reactions compared with the other vaccines alone

▪ No severe adverse events have been causally associated with use of the current 

formulation of IPV

Safety

Sources: Sanofi Pasteur Package Insert - IPOL (fda.gov) . Vidor et al, PIDJ 1997. Murdin et al, Vaccine 1996. Wattigney et al, Pediatrics 2001. IOM 1994. 
▪ >250 million IPV-containing vaccine doses distributed 2000–2012

▪ 41,792 adverse event reports submitted for IPV-containing vaccines

– 34,880 (88%) were for non-serious events 

– 95% were among persons <7 years of age

▪ Most events were associated with IPV co-administered with other vaccines

▪ Standalone IPV accounted for just 0.5% of reports

▪ VAERS is passive reporting system, cannot assess causal associations

Vaccine Adverse Event Reporting System (VAERS) Data, 

2000–2012

Source: Iqbal et al, Lancet ID 2015. 
Work group interpretation

How substantial are the desirable anticipated effects of completing a 

primary polio vaccination series in unvaccinated adults?

EtR Domain: Benefits & Harms

Minimal Small Moderate Large Varies Don’t 

know
Work group interpretation

How substantial are the undesirable anticipated effects of completing a 

primary polio vaccination series in unvaccinated adults?

EtR Domain: Benefits & Harms

Minimal Small Moderate Large Varies Don’t 

know
Work group interpretation

Do the desirable effects of completing a primary polio vaccination series 

outweigh the undesirable effects in unvaccinated adults?

EtR Domain: Benefits & Harms

Anticipated 

benefits 

outweigh 

anticipated 

harms

Anticipated 

harms outweigh 

anticipated 

benefits

Varies Don’t know
Public Knowledge and Beliefs about Poliovirus

Annenberg Science Knowledge (ASK) Survey*, October 2022

*Nationally representative panel of 1,572 US adults surveyed by SSRS for the Annenberg Public Policy Center of the University of Pennsylvania from October 11-18, 2022; this 

was 9th wave of the ASK survey whose respondents were first empaneled in April 2021.

What U.S. Adults Know and Believe About Polio and the Bivalent Covid Booster | The Annenberg Public Policy Center of the University of Pennsylvania

▪ 85% said they were likely 

to recommend that an 

eligible person in their 

household get 

vaccinated with the polio 

vaccine 
▪ Values of unvaccinated adults might differ from those of general population

▪ Unvaccinated adults are likely a heterogeneous group

– Persons whose families chose for them to not be vaccinated as children

– Persons who missed opportunities to be vaccinated as children

▪ Lack of data on how these populations perceive their risk of polio and perceive the 

potential positive vs. negative effects of polio vaccination 

Considerations for Values of Population in Question 

(Unvaccinated or Incompletely Vaccinated Adults)
Pros

▪ Context of global polio eradication efforts

▪ Prevention of paralytic polio has been a public health priority for decades

Cons

▪ Competing priorities for clinicians and local public health departments

▪ Uncertainty about eligibility for vaccination and true level of risk to adults in the US 

outside of outbreak setting

Additional Considerations for Acceptability to Key 

Stakeholders
Work group interpretation

Does the target population (unvaccinated or incompletely vaccinated 

adults) feel that the desirable effects of vaccination are large relative to 

undesirable effects?

EtR Domain: Values of Target Population 

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
Work group interpretation

Is there important uncertainty or variability in how much people value 

the main outcome (prevention of paralytic poliomyelitis)?

EtR Domain: Values of Target Population 

Important 

uncertainty 

or variability

Probably 

important 

uncertainty 

or variability

Probably not 

important 

uncertainty 

or variability

No 

important 

uncertainty 

or variability

No known 

undesirable 

outcomes
Work group interpretation

Is the intervention (vaccination of adults known or suspected to be 

unvaccinated or incompletely vaccinated) acceptable to key 

stakeholders?

EtR Domain: Acceptability to Key Stakeholders

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
Potential supply:

▪ Currently just one US-licensed manufacturer of stand-alone IPV (Sanofi)

▪ Three US-licensed manufacturers of combination vaccines that include IPV (Sanofi, 

Merck, GSK)

Potential demand: 

▪ Difficult to quantify: Uncertain number of adults who know they are unvaccinated or 

undervaccinated

Resource Use and Feasibility: Potential Supply and Demand
▪ Paralytic polio case identified in July 2022

▪ Persistent wastewater detections in area during summer to early fall 2022

▪ National and local media attention

▪ Calls for unvaccinated to get vaccinated

▪ Concerted health department efforts to reach unvaccinated persons

▪ No significant supply issues

Resource Use and Feasibility: New York Experience 
▪ Access to vaccination sites that stock IPV

▪ Potential effects on health system screening and recall algorithms

– Will need clear guidance for who is eligible for vaccination

▪ Feasibility of implementing risk-based recommendations, particularly if risk of 

exposure in the population changes over time

Additional Resource and Feasibility Considerations
Work group interpretation

Is the intervention (vaccination of adults known or suspected to be 

unvaccinated or incompletely vaccinated) a reasonable and efficient 

allocation of resources?

EtR Domain: Resource Use 

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
Work group interpretation

Is the intervention (vaccination of adults known or suspected to be 

unvaccinated or incompletely vaccinated) feasible to implement?

EtR Domain: Feasibility

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
▪ Different rates of childhood vaccination and poliovirus immunity

▪ Opportunity to receive catch-up polio vaccination as an adult likely increases equity

▪ No known differences in vaccine effectiveness among immunocompetent persons in 

the US setting

▪ Assuring equitable access to vaccination sites with IPV will be an important 

consideration for implementation 

Equity Considerations
Work group interpretation

What would be the impact (of vaccinating adults known or suspected to 

be unvaccinated or incompletely vaccinated) on health equity?

EtR Domain: Equity

Reduced 

equity

Probably 

reduced

equity

Probably 

no impact

Probably 

increased 

equity

Increased 

equity Varies Don’t know
For unvaccinated/incompletely vaccinated adults known to be at increased risk of 

poliovirus exposure:

Work Group Judgement: Balance of Consequences

Completing a Primary Polio Vaccination Series

Undesirable

consequences 

clearly

outweigh 

desirable 

consequences 

in most settings

Undesirable

consequences 

probably 

outweigh

desirable 

consequences 

in most settings

The balance 

between 

desirable and 

undesirable 

consequences 

is closely 

balanced or 

uncertain

Desirable

consequences 

probably

outweigh 

undesirable 

consequences 

in most settings

Desirable 

consequences 

clearly 

outweigh 

undesirable 

consequences 

in most 

settings

There is 

insufficient 

evidence to 

determine the 

balance of 

consequences
For unvaccinated/incompletely vaccinated adults NOT specifically known to be at 

increased risk of poliovirus exposure:

Work Group Judgement: Balance of Consequences

Completing a Primary Polio Vaccination Series

Undesirable

consequences 

clearly

outweigh 

desirable 

consequences 

in most settings

Undesirable

consequences 

probably 

outweigh

desirable 

consequences 

in most settings

The balance 

between 

desirable and 

undesirable 

consequences 

is closely 

balanced or 

uncertain

Desirable 

consequences 

probably 

outweigh 

undesirable 

consequences 

in most 

settings

Desirable

consequences 

clearly

outweigh 

undesirable 

consequences 

in most settings

There is 

insufficient 

evidence to 

determine the 

balance of 

consequences
Situations that put adults at increased risk of exposure 

to poliovirus include:

▪ Travelers who are going to countries where polio is epidemic or 

endemic (For additional information, see Polio: For Travelers).

▪ Laboratory and healthcare workers who handle specimens that 

might contain polioviruses.

▪ Healthcare workers or other caregivers who have close contact 

with a person who could be infected with poliovirus.

▪ Unvaccinated or incompletely vaccinated adults whose children 

will be receiving oral poliovirus vaccine (for example, international 

adoptees or refugees).

▪ Unvaccinated or incompletely vaccinated adults living or working 

in a community where poliovirus is circulating.

Considerations for a Risk-Based vs. Uniform 

Recommendation for All Unvaccinated Adults
Situations that put adults at increased risk of exposure 

to poliovirus include:

▪ Travelers who are going to countries where polio is epidemic or 

endemic (For additional information, see Polio: For Travelers).

▪ Laboratory and healthcare workers who handle specimens that 

might contain polioviruses.

▪ Healthcare workers or other caregivers who have close contact 

with a person who could be infected with poliovirus.

▪ Unvaccinated or incompletely vaccinated adults whose children 

will be receiving oral poliovirus vaccine (for example, international 

adoptees or refugees).

▪ Unvaccinated or incompletely vaccinated adults living or working 

in a community where poliovirus is circulating.

Considerations for a Risk-Based vs. Uniform 

Recommendation for All Unvaccinated Adults

• Individual-level;

• Opportunity to 

anticipate risk and 

vaccinate prior to 

potential exposure 
Situations that put adults at increased risk of exposure 

to poliovirus include:

▪ Travelers who are going to countries where polio is epidemic or 

endemic (For additional information, see Polio: For Travelers).

▪ Laboratory and healthcare workers who handle specimens that 

might contain polioviruses.

▪ Healthcare workers or other caregivers who have close contact 

with a person who could be infected with poliovirus.

▪ Unvaccinated or incompletely vaccinated adults whose children 

will be receiving oral poliovirus vaccine (for example, international 

adoptees or refugees).

▪ Unvaccinated or incompletely vaccinated adults living or working 

in a community where poliovirus is circulating.

Considerations for a Risk-Based vs. Uniform 

Recommendation for All Unvaccinated Adults

• Population-level;

• Group already at 

increased risk at 

time risk is 

recognized;

• Potential missed 

opportunities for 

vaccination prior to 

exposure
Challenges in 2022: • In which of these 

counties are 

unvaccinated adults 

considered at increased 

risk of exposure?

• When are unvaccinated 

adults in these counties 

no longer at increased 

risk of exposure?

• Are unvaccinated adults 

traveling to these 

counties at increased 

risk of exposure?

WWS Report_6_19_23 (ny.gov)
Pros:

▪ Allows unvaccinated adults and their health care providers to take advantage of 

opportunities to get vaccinated before they are at increased risk of exposure

▪ Brings adult polio vaccination policy closer in line with other routine childhood 

vaccines, e.g., MMR and varicella vaccines

▪ Is less complicated policy to communicate and understand (i.e., recommendation 

doesn’t change based on latest wastewater data)

Pros and Cons of a Uniform Recommendation for 

Unvaccinated and Incompletely Vaccinated Adults
Cons:

▪ Most adults in the United States have a low risk of poliovirus exposure and paralytic 

polio, and most adults received primary polio vaccination series as children

▪ Demand for IPV could potentially exceed supply, particularly if a large number of 

adults without documentation of polio vaccination status assume they were not 

vaccinated

– However, this issue can be mitigated by providing guidance for this group in the clinical 

considerations

Pros and Cons of a Uniform Recommendation for 

Unvaccinated and Incompletely Vaccinated Adults
▪ Majority of work group believe pros of uniform recommendation outweigh cons; 

approximately 1/3 favor current risk-based recommendation (and adding language 

for those not known to be at increased risk of exposure)

Proposed Language:

Adults who are known or suspected to be unvaccinated or incompletely vaccinated 

against polio should complete a primary vaccination series with IPV.

Proposed Language for Unvaccinated and Incompletely 

Vaccinated Adults
▪ In general, unless there are specific reasons to believe they were not vaccinated, 

most adults who were born and raised in the United States can assume they were 

vaccinated against polio as children. Polio vaccination has been part of the routine 

childhood immunization schedule for decades and is still part of the routine 

childhood immunization schedule. Adults who received any childhood vaccines 

almost certainly were vaccinated for polio.

Important Context to Be Included in Clinical Considerations
2

nd Policy Question: Adult IPV Boosters
▪ Should a booster IPV dose be recommended for adults at increased risk of 

poliovirus exposure who have previously completed a primary polio vaccination 

series?

– Population: US adults aged ≥18 years at increased risk of poliovirus exposure who have completed 

a primary polio vaccination series (with tOPV, IPV, or a combination of both)

– Intervention: Booster dose of IPV

– Comparison: Adults who completed a primary series but did not receive a booster dose

– Outcomes: 

• Prevention of paralytic poliomyelitis

• Serologic immunity to poliovirus types 1, 2, and 3

• Serious adverse events following vaccination

• Indirect effects, e.g., community transmission, impact on health systems

Policy Question #2 for Work Group
▪ 2000 Statement: “Adults who have had a primary series of OPV or IPV and who are 

at increased risk [of exposure to poliovirus] 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.”

▪ Rationale

– Longstanding recommendation since tOPV was used in routine immunization

– Actual need for supplementary dose not established, but “there is value in assuring protection 

against infection with wild polioviruses when exposure can reasonably be expected.” (1977 ACIP 

Statement)

– At least 2 reported cases of paralytic polio in adult travelers who had completed a primary 

vaccination series with Salk IPV and/or tOPV

Boosters: 2000 Statement and Rationale

CDC MMWR 1977; CDC MMWR 1986.
▪ IHR Emergency Committee recommendation for travelers DEPARTING countries with 

poliovirus circulation, to prevent exportation

– Applies to residents and travelers staying >4 weeks

– If implemented by a country, proof of polio vaccination (IPV or tOPV) within the last 12 months could be 

required prior to leaving the country

– Still included in most recent Polio IHR Statement

▪ 2014 MMWR: 

“Adults who have completed a routine series of polio vaccine are considered to have lifelong 

immunity to poliovirus but data are lacking. As a precaution, persons aged ≥18 years who are 

traveling to areas where there has been WPV circulation in the last 12 months and who have 

received a routine series with either IPV or OPV in childhood should receive another dose of IPV 

before departure. For adults, available data do not indicate the need for more than a single lifetime 

booster dose with IPV.”

2014 Interim Guidance

In Response to WHO Polio International Health Regulations (IHR) Emergency Committee Temporary 

Recommendations

Wallace MMWR 2014; Statement of the thirty-fifth Polio IHR Emergency Committee (who.int)
Percent positive (95% Confidence Interval)

Birth years Age in 2009–2010 Poliovirus Type 1 Poliovirus Type 2 Poliovirus Type 3

1998–2004 6–11 years 97.2 (94.7–98.8) 98.0 (96.4–99.0) 93.8 (91.8–95.4)

1990–1998 12–19 years 94.7 (92.0–96.6) 98.2 (96.6–99.2) 84.3 (81.0–87.2)

1970–1990 20–39 years 92.7 (90.0–94.2) 96.9 (95.2–98.2) 78.6 (74.6–82.2)

1960–1970 40–49 years 93.9 (91.6–95.7) 95.8 (93.8–97.3) 85.8 (82.3–88.8)

Unclear Need for IPV Booster in Vaccinated Adults:

Seroprevalence of Poliovirus Antibodies by Age, United States 

NHANES Serosurvey, 2009–2010

Source: Wallace et al, BMC Public Health 2016.

NOTE: Presence of detectable neutralizing antibody is a correlate of protection against paralytic disease.

Immunity against paralytic disease may be present even in absence of detectable antibodies.
▪ No data on vaccine effectiveness of primary 

series + booster vs. primary series only

▪ Serologic studies in adults with heterogeneous 

pre-booster vaccination 

histories/seropositivity: 98%–100% were 

seropositive 1 month after an IPV-containing 

booster

▪ One study followed up trial participants 10 

years post-booster: 98%–100% still seropositive

Benefits of IPV Booster

Sources: Broderick et al, Vaccine 2015; Domenicus et al, Vaccine 2014; Fukushima et al, Vaccines 2022; Grimprel et al, Vaccine 2005; Kovac et al, Vaccine 2015; Larnaudie et al, 

Human Vaccines 2010; Zimmermann et al, Vaccine 2013.

Data from Grimprel et al, Vaccine 2005: 

Seropositivity before and 1 month after IPVcontaining booster by study group and 

poliovirus serotype
▪ Local reactions at injection site reported in trials

– Tenderness in 14%–29%

– Induration in 3%–11%

– Erythema in 0.5%–1.4%

▪ Combining IPV with other vaccines is not associated with increased frequency or 

severity of reported adverse reactions compared with the other vaccines alone

▪ No severe adverse events have been causally associated with use of the current 

formulation of IPV

Safety of IPV

Sources: Sanofi Pasteur Package Insert - IPOL (fda.gov) . Vidor et al, PIDJ 1997. Murdin et al, Vaccine 1996. Wattigney et al, Pediatrics 2001. IOM 1994. 
Work group interpretation

For adults at increased risk of poliovirus exposure who were previously 

vaccinated, how substantial are the desirable anticipated effects of 

receiving a booster dose of IPV?

EtR Domain: Benefits & Harms

Minimal Small Moderate Large Varies Don’t 

know
Work group interpretation

For adults at increased risk of poliovirus exposure who were previously 

vaccinated, how substantial are the undesirable anticipated effects of 

receiving a booster dose of IPV?

EtR Domain: Benefits & Harms

Minimal Small Moderate Large Varies Don’t 

know
Work group interpretation

For adults at increased risk of poliovirus exposure who were previously 

vaccinated, do the desirable effects of receiving a booster dose of IPV 

outweigh the undesirable effects?

EtR Domain: Benefits & Harms

Anticipated 

benefits 

outweigh 

anticipated 

harms

Anticipated 

harms outweigh 

anticipated 

benefits

Varies Don’t know
Public Knowledge and Beliefs about Poliovirus

Annenberg Science Knowledge (ASK) Survey*, October 2022

*Nationally representative panel of 1,572 US adults surveyed by SSRS for the Annenberg Public Policy Center of the University of Pennsylvania from October 11-18, 2022; this 

was 9th wave of the ASK survey whose respondents were first empaneled in April 2021.

What U.S. Adults Know and Believe About Polio and the Bivalent Covid Booster | The Annenberg Public Policy Center of the University of Pennsylvania

▪ 85% said they were likely 

to recommend that an 

eligible person in their 

household get 

vaccinated with the polio 

vaccine 
Work group interpretation

Does the target population (adults at increased risk of poliovirus 

exposure who were previously vaccinated) feel that the desirable effects 

of a booster dose are large relative to undesirable effects?

EtR Domain: Values of Target Population

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
Work group interpretation

Is there important uncertainty or variability in how much people value 

the main outcome (prevention of paralytic poliomyelitis)?

EtR Domain: Values of Target Population

Important 

uncertainty 

or variability

Probably 

important 

uncertainty 

or variability

Probably not 

important 

uncertainty 

or variability

No 

important 

uncertainty 

or variability

No known 

undesirable 

outcomes
▪ Current recommendation (“Adults who have had a primary series of OPV or IPV and 

who are at increased risk [of exposure to poliovirus] can receive another dose of 

IPV.”) is long-standing and is generally accepted and feasible

▪ If “at increased risk of exposure” group is expanded (e.g., to include previously 

vaccinated adults in certain US areas with poliovirus circulation), feasibility might be 

affected

▪ New York State and New York City experience in 2022

– No significant IPV supply issues

Considerations for Acceptability, Feasibility, and Resources
Work group interpretation

Is the intervention (providing a booster IPV dose to adults at increased 

risk of poliovirus exposure who previously completed a primary polio 

vaccination series) acceptable to key stakeholders?

EtR Domain: Acceptability to Key Stakeholders

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
Work group interpretation

Is the intervention (providing a booster IPV dose to adults at increased 

risk of poliovirus exposure who previously completed a primary polio 

vaccination series) a reasonable and efficient allocation of resources?

EtR Domain: Resource Use

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
Work group interpretation

Is the intervention (providing a booster IPV dose to adults at increased 

risk of poliovirus exposure who previously completed a primary polio 

vaccination series) feasible to implement?

EtR Domain: Feasibility

No Probably 

no

Probably 

yes

Yes Varies Don’t 

know
▪ No known differences in response to primary series by socioeconomic group in US 

setting

▪ No groups or settings known to be disadvantaged by current recommendation

▪ Potential increased equity by boosting immunity in those at increased risk of 

exposure, especially persons with potential occupational exposures to poliovirus

Equity Considerations from Work Group
Work group interpretation

What would be the impact (of providing a booster IPV dose to adults at 

increased risk of poliovirus exposure who previously completed a 

primary polio vaccination series) on health equity?

EtR Domain: Equity

Reduced 

equity

Probably 

reduced

equity

Probably 

no impact

Probably 

increased 

equity

Increased 

equity Varies Don’t know
IPV booster for adults at increased risk of poliovirus exposure who have 

previously completed a primary polio vaccination series

Work Group Judgement: Balance of Consequences

Undesirable

consequences 

clearly

outweigh 

desirable 

consequences 

in most settings

Undesirable

consequences 

probably 

outweigh

desirable 

consequences 

in most settings

The balance 

between 

desirable and 

undesirable 

consequences 

is closely 

balanced or 

uncertain

Desirable

consequences 

probably

outweigh 

undesirable 

consequences 

in most settings

Desirable

consequences 

clearly

outweigh 

undesirable 

consequences 

in most settings

There is 

insufficient 

evidence to 

determine the 

balance of 

consequences
▪ Risk-based

▪ Shared clinical decision-making

Proposed Language:

▪ Adults who have received a primary series of tOPV or IPV in any combination and 

who are at increased risk of poliovirus exposure may receive another dose of IPV. 

Available data do not indicate the need for more than a single lifetime booster 

dose with IPV for adults.

Majority of Work Group Agree with Current 

Recommendation for Adult IPV Booster
Situations that put adults at increased risk of exposure to poliovirus include:

▪ Travelers who are going to countries where polio is epidemic or endemic (For additional information, 

see Polio: For Travelers).

▪ Laboratory and healthcare workers who handle specimens that might contain polioviruses.

▪ Healthcare workers or other caregivers who have close contact with a person who could be infected 

with poliovirus.

Clinical Considerations
▪ ACIP voting members

– Oliver Brooks (Chair)

– Lynn Bahta

– Sybil Cineas

▪ Liaisons

– Lynn Fisher, American Academy of Family Physicians

– Chandy C John, American Academy of Pediatrics 

– Sandra Fryhofer, American Medical Association

– Kathy Kudish, Association of Immunization Managers

– Marcus Plescia, Association of State and Territorial Health Officials

– Paul R Cieslak, Council of State and Territorial Epidemiologists

– Christine Hahn, Council of State and Territorial Epidemiologists

– Tina Q. Tan, Infectious Diseases Society of America

– Adenike Shoyinka, Infectious Diseases Society of America

– Mary Wilson, International Society of Travel Medicine

– Jaqueline Lawler, National Association of County and City Health Officials

– Kathy Edwards, Pediatric Infectious Diseases Society

– Joseline Zafack, Public Health Agency of Canada*

– Oliver Baclic, Public Health Agency of Canada*

Polio Work Group Members

*In the event of a Work Group poll, CDC, FDA, and Public Health Agency of Canada members are not included.

▪ Consultants

– Edwin Asturias

– Doug E Campos-Outcalt*

– Emily Lutterloh

– Walt Orenstein

– Jennifer Rosen

– Eli Rosenberg

▪ Ex Officio

– Robin Levis, FDA*

– Robin Wisch, FDA*

▪ CDC*

– Achal Bhatt

– Stephanie Bialek

– Thomas Clark

– Brian Edlin

– Concepcion Estivariz

– Halle Getachew

– Sarah Kidd

– Janelle King

– M. Steve Oberste

– Janell Routh

– Eileen Yee
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Questions and Discussion