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Descriptions of polio-like illnesses have been around since 

antiquity, including a funerary stele depicting a man with 

a withered leg leaning on a staff. Michael Underwood first 

described a debility of the lower extremities in children that was 

recognizable as poliomyelitis in England in 1789, but the disease 

was not observed in epidemics until the late 19th century. 

During the first half of the 20th century, developed countries in 

the Northern Hemisphere suffered epidemics each summer and 

fall that became increasingly severe. Polio infections peaked in 

the United States in 1952, with more than 21,000 paralytic cases. 

Following introduction of effective vaccines in 1955 (inactivated 

polio vaccine, IPV) and 1961 (oral poliovirus vaccine, OPV), 

polio incidence declined rapidly. The last case of wild poliovirus 

acquired in the United States was in 1979.

Poliovirus

Poliovirus is a member of the enterovirus subgroup, family 

Picornaviridae. Picornaviruses are small, ether-insensitive viruses 

with an RNA genome. 

There are three poliovirus serotypes (type1, type 2, and type 

3); immunity to one serotype does not produce significant 

immunity to the other serotypes.

Poliovirus is rapidly inactivated by heat, formaldehyde, chlorine, 

and ultraviolet light.

Pathogenesis

The virus enters through the mouth and multiplies in the 

oropharynx and gastrointestinal tract. The virus is usually 

present in nasopharyngeal secretions for 1 to 2 weeks and 

can be shed in stools for several weeks after infection, even 

in individuals with minor symptoms or no illness. During 

intestinal replication, the virus invades local lymphoid tissue 

and may enter the bloodstream, and then infect cells of the 

central nervous system. Poliovirus-induced destruction of motor 

neurons of the anterior horn of the spinal cord and brain stem 

cells results in distinctive paralysis.

Clinical Features

The incubation period for nonparalytic poliomyelitis is 3 to 6 

days. For the onset of paralysis in paralytic poliomyelitis, the 

incubation period is usually 7 to 21 days. The risk of severe 

disease and death following primary infection with poliovirus 

increases with increasing age.

Approximately 70% of all polio infections in children are 

asymptomatic. Infected individuals without symptoms shed the 

Poliomyelitis

● First described by Michael

Underwood in 1789

● Developed countries in

Northern Hemisphere

suffered increasingly severe

epidemics in the first half

of the 20th century

● More than 21,000 paralytic

cases reported in the U.S.

in 1952

● Last case of wild poliovirus

acquired in the U.S. was 1979

Poliovirus

● Enterovirus (RNA)

● Three serotypes: type 1, type 2,

type 3

● Immunity to one serotype

does not produce significant

immunity to other serotypes

● Rapidly inactivated by heat,

formaldehyde, chlorine,

ultraviolet light

Poliomyelitis Pathogenesis

● Entry through mouth

● Replication in oropharynx,

gastrointestinal tract

● Invades local lymphoid tissue

and may enter the bloodstream,

and then infect cells of the

central nervous system

● Destruction of motor neurons

result in distinctive paralysis

Concepcion F. Estivariz, MD; Ruth Link-Gelles, PhD, MPH; and Tom Shimabukuro, MD, MPH, MBA

https://www.cdc.gov/vaccines/pubs/pinkbook/polio.html Aug 2021
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virus in nasopharyngeal secretions and stool for several days or 

weeks and are able to transmit the virus to others.

Approximately 24% of polio infections in children consist of a 

minor, nonspecific illness without clinical or laboratory evidence 

of central nervous system invasion. This clinical presentation is 

known as abortive poliomyelitis, and is characterized by a low 

fever, sore throat, and complete recovery in less than a week. 

Nonparalytic aseptic meningitis occurs in 1% to 5% of polio 

infections in children. The clinical presentation includes stiffness 

of the neck, back, or legs, usually following several days of a 

prodrome similar to that of minor illness. Increased or abnormal 

sensations (e.g., pain in the limbs, back, or neck), headache, and 

vomiting can also occur. Typically, symptoms last 2 to 10 days 

and are followed by complete recovery.

Less than 1% of all polio infections in children result in flaccid 

paralysis. The course may be biphasic in children, with initial 

minor illness that lasts several days, a symptom-free period 

of 1 to 3 days, followed by the major illness with paralysis, 

fever and muscle pain. Paralysis usually progresses within 2 

to 3 days. Among adolescents and adults, the minor illness is 

often absent and they suffer more severe pain and paralysis. 

Paralysis is typically asymmetrical, more severe proximally, 

and associated with absent or reduced deep tendon reflexes 

and intact sensation. Patients usually do not experience 

changes in cognition.

Paralysis is often permanent, although total or partial 

recovery can occur through compensation by muscles not 

affected. Weakness or paralysis present 12 months after 

onset, which occurs in two-thirds of patients with paralysis, is 

usually permanent.

Paralytic polio is classified into three types, depending on 

the level of involvement. Spinal polio is most common, and 

during 1969–1979 accounted for 79% of paralytic cases. It 

is characterized by asymmetric paralysis that most often 

involves the legs. Bulbar polio presents with weakness of facial, 

oropharyngeal, and respiratory muscles innervated by cranial 

nerves and accounted for 2% of cases during this period. 

Bulbospinal polio, a combination of bulbar and spinal paralysis, 

accounted for 19% of cases.

The case fatality ratio for paralytic polio is generally 2% to 5% 

among children and up to 15% to 30% among adolescents and 

adults. It increases to 25% to 75% with bulbar involvement.

Paralytic disease with similar clinical manifestations may be 

caused by naturally occurring wild-type polioviruses, by the 

attenuated polioviruses contained in the oral poliovirus vaccine 

(Sabin strains) in extremely rare occasions, or by vaccine-derived 

Poliomyelitis Clinical Features

● Incubation period

■ 3 to 6 days for nonparalytic

poliomyelitis

■ 7 to 21 days for onset

of paralysis in paralytic

poliomyelitis

● Paralysis is often permanent

● Paralytic disease may be caused

by wild-type polioviruses,

attenuated polioviruses in oral

vaccine, or by vaccine-derived

polioviruses
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polioviruses (VDPVs), which are Sabin vaccine strains that have 

reverted and re-acquired the virulence and transmissibility of 

wild polioviruses. 

After an interval of 15 to 40 years, 25% to 40% of persons who 

contracted paralytic poliomyelitis in childhood experience new 

muscle pain and exacerbation of existing weakness or develop 

new weakness or paralysis. This disease entity is referred to as 

post-polio syndrome. Post-polio syndrome is not an infectious 

process, and persons experiencing this syndrome do not shed 

poliovirus.

Laboratory Testing

The greatest yield for poliovirus is from viral culture of stool 

specimen; it is less likely to be recovered from the pharynx, 

and only rarely recovered from cerebrospinal fluid (CSF) or 

blood. If poliovirus is isolated, reverse transcriptase polymerase 

chain reaction (RT-PCR) and genomic sequencing are used to 

determine the serotype (i.e., 1, 2, or 3), and whether the virus is 

a wild, vaccine (Sabin), or VDPV strain. 

Because viral shedding may be intermittent and the amount of 

virus declines after paralysis onset, it is recommended to collect 

two stool specimens at least 24 hours apart and within 14 

days of onset of symptoms. Poliovirus may be detected during 

the first 3 to 10 days after paralysis onset in oropharyngeal 

specimens, but stool specimens are preferred.

Serology

Serology for all three types of poliovirus is currently not 

available in most laboratories because of new regulations for 

poliovirus containment. Furthermore, serology has several 

limitations. Two specimens are needed, one early in the course 

of the illness and another three weeks later. A four-fold rise in 

the titer of the second specimen suggests poliovirus infection, 

and two negative specimens may rule out poliovirus infection. 

However, immunocompromised patients may have two titers 

with no antibody detected and still be infected with poliovirus. 

Among immunocompetent patients, the four-fold increase may 

not be observed because neutralizing antibodies appear early 

and may exist at the time of hospitalization, or the patient may 

have antibodies from prior vaccination. 

Epidemiology

Occurrence

At one time, poliovirus infection occurred throughout the 

world. Vaccination resulted in reduced circulation of wild 

poliovirus and its elimination from the United States in 1979. 

A polio eradication program conducted by the Pan American 

Health Organization led to elimination of polio in the Western 

Hemisphere in 1991. The Global Polio Eradication Program has 

Poliovirus Epidemiology

● Reservoir

■ Human

● Transmission

■ Fecal-oral or oral-oral

● Temporal pattern

■ Peaks in the summer in 

temperate climates; no 

season pattern in 

tropical climates

● Communicability

■ Highly infectious

days before and after 

onset of symptoms

■ Most infectious in the days 

immediately before and 

after onset of symptoms
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dramatically reduced wild poliovirus transmission throughout 

the world. Type 2 and 3 wild poliovirus have been eradicated 

worldwide and endemic circulation of type 1 wild poliovirus 

persists only in two countries. 

Reservoir

Humans are the only known reservoir of poliovirus, which 

is transmitted most frequently by persons with inapparent 

infections. There is no asymptomatic carrier state except in 

immunocompromised persons.

Transmission

Person-to-person spread of poliovirus occurs via the fecal-oral 

or oral-oral routes. The fecal-oral route is the most important 

transmission pathway in settings with suboptimal hygiene and 

sanitation. 

Temporal Pattern

Poliovirus infection typically peaks in the summer months in 

temperate climates. There is no seasonal pattern in tropical 

climates.

Communicability

Poliovirus is highly infectious, with seroconversion rates among 

susceptible household contacts of children nearly 100%, and 

greater than 90% among susceptible household contacts of 

adults. Persons infected with poliovirus are most infectious in 

the days immediately before and after the onset of symptoms, 

but poliovirus may remain present in the stool for up to 6 weeks.

Secular Trends in the United States

Before the 18th century, polioviruses probably circulated widely. 

Initial infections with at least one type probably occurred 

in early infancy, when transplacentally acquired maternal 

antibodies were high and protected infants from infectioncausing paralysis. 

In the immediate prevaccine era, during the first half of the 

20th century, improved sanitation resulted in less frequent 

exposure and increased the age of primary infection, resulting 

in large epidemics with high numbers of deaths. The incidence 

dramatically decreased after the introduction of inactivated 

polio vaccine (IPV) in 1955 and continued to decline following 

oral polio vaccine (OPV) introduction in 1961. From the more 

than 21,000 paralytic cases reported in 1952, only 2,525 cases 

were reported in 1960 and 61 cases in 1965. 

The last cases of locally-acquired paralytic poliomyelitis 

caused by wild poliovirus in the United States were reported 

in 1979, during an outbreak in Amish communities in several 

Poliovirus Secular Trends 

in the United Status

● Before the 18th century, 

polioviruses probably 

circulated widely

● In immediate prevaccine era, 

improved sanitation resulted 

in less frequent exposure 

and increased age of primary 

infection, resulting in large 

epidemics with high 

death count

● Incidence dramatically 

decreased following inactivated 

polio vaccine (IPV) introduction 

in 1955

● Last cases of locally-acquired 

paralytic poliomyelitis caused 

by wild poliovirus in the U.S. 

reported in 1979

● Last case of vaccine-associated 

paralytic polio (VAPP) acquired 

in the U.S. reported in 1999
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18

Midwestern states. Epidemiologic and virologic evidence 

indicated that this outbreak was seeded by an importation from 

the Netherlands.

From 1980–1999, 162 confirmed cases of paralytic poliomyelitis 

were reported in the United States, an average of 8 cases 

per year. Six cases were caused by wild poliovirus acquired 

outside the United States and two cases were classified as 

indeterminant (no poliovirus isolated from samples obtained 

from the patients, and patients had no history of recent 

vaccination or direct contact with a vaccine recipient). The 

remaining 154 (95%) cases were vaccine-associated paralytic 

polio (VAPP) caused by the Sabin poliovirus strains contained in 

OPV vaccine. 

In order to eliminate VAPP from the United States, the Advisory 

Committee on Immunization Practices (ACIP) recommended in 

2000 exclusive use of IPV vaccine. The last case of VAPP acquired 

in the United States was reported in 1999. Paralysis caused by 

VDPV was reported in an immunocompromised person in 2009, 

who was likely infected with vaccine poliovirus 12 years prior to 

the onset of paralysis. In 2005, asymptomatic infections with a 

circulating VDPV were detected in several unvaccinated children 

in Minnesota. The source of the virus was not determined, 

but it appeared to have been circulating undetected in an 

unidentified location, possibly another country, for at least 2 

years based on genetic changes in the virus. 

Among children born during 2015 or 2016, 92.7% had received 

at least 3 doses of poliovirus vaccine by age 24 months, 

compared to 91.7% for children born during 2013 or 2014. 

Eradication 

Following the widespread use of poliovirus vaccine in the 

mid-1950s, the incidence of poliomyelitis declined rapidly in 

many industrialized countries. 

In 1985, the member countries of the Pan American Health 

Organization adopted the goal of eliminating poliomyelitis 

from the Western Hemisphere by 1990. The strategy to achieve 

this goal included increasing vaccination coverage; enhancing 

surveillance for suspected cases (i.e., surveillance for acute 

flaccid paralysis); and using supplemental immunization 

strategies such as national immunization days, house-to-house 

vaccination, and containment activities. In 1994, an international 

commission certified the Western Hemisphere to be free of 

indigenous wild poliovirus. 

Following the success in the Americas, the World Health 

Assembly adopted the goal of global eradication of poliovirus 

in 1988. The polio eradication initiative is led by a coalition of 

Poliomyelitis Eradication

● Mid-1950s—Widespread use 

of poliovirus vaccine

● 1988—Polio paralyzed 

~350,000 individuals per year 

in more than 125 countries

● 1994—Western Hemisphere 

free of indigenous wild 

poliovirus

● 2015—Type 2 wild 

poliovirus eradicated

● 2019—Type 3 wild 

poliovirus eradicated

● 2019—Only 125 cases caused 

by wild poliovirus globally 

(99% reduction from 1988) 

and endemic in only 

two countries

● 2019—Low routine 

immunization and poor 

vaccination campaigns 

resulted in re-emergence of 

type 2 VDPV

Wild Poliovirus 1988

Countries that have eliminated polio Countries that have never eliminated polio

No available data

Wild Poliovirus 2018

Countries that have eliminated polio Countries that have never eliminated polio

No available data
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international organizations including WHO, the United Nations 

Children’s Fund (UNICEF), CDC, Rotary International, the Bill and 

Melinda Gates Foundation, and Gavi. 

Substantial progress has been made towards polio 

eradication. In 1988, polio paralyzed an estimated 350,000 

individuals per year in more than 125 countries. By 2019, 

only 125 cases caused by wild poliovirus were reported 

globally, a reduction of more than 99% from 1988, and 

polio remained endemic in only two countries. The Global 

Commission for the Certification of Poliomyelitis Eradication 

declared type 2 wild poliovirus eradicated in 2015 and type 

3 wild poliovirus eradicated in 2019. Unfortunately, low 

coverage with routine immunization and poor quality of 

vaccination campaigns conducted before the trivalent-tobivalent switch have resulted in re-emergence of type 2 

VDPV. In 2019, circulating type 2 VDPV caused outbreaks in 

20 countries in Africa and Asia and paralyzed 369 children.

Poliovirus Vaccines 

Inactivated poliovirus (IPV) vaccine was licensed for use in 1955 

and was used extensively from that time until the early 1960s.

In 1961, type 1 and 2 monovalent oral poliovirus (mOPV) 

vaccines were licensed, followed by type 3 mOPV vaccine 

in 1962, and trivalent OPV (tOPV) vaccine in 1963. Oral 

poliovirus (OPV) vaccine contains live poliovirus strains (Sabin) 

derived from wild polioviruses and attenuated by repeated 

passages through cells to induce mutations that reduce their 

neurovirulence and transmissibility. 

Upon ingestion of OPV vaccine, the live attenuated polioviruses 

replicate in the intestinal mucosa and lymphoid cells in 

the oropharynx and intestine, in a similar manner to wild 

poliovirus infection. Vaccine viruses are excreted in the stool 

of the vaccinated person for up to 6 weeks after a dose, with 

maximum shedding in the first 1 to 2 weeks after vaccination. 

Vaccine viruses may spread from the recipient to contacts. 

Persons in contact with fecal material of a vaccinated person 

may be exposed and infected with vaccine virus. Replication 

and shedding of vaccine virus in stools may occur upon intake 

of a new OPV vaccine dose, but the duration of shedding is 

usually short and virus concentration in stools is lower. 

Trivalent OPV vaccine largely replaced IPV vaccine as the vaccine 

of choice in the United States and most other countries of the 

world until the late 1990s. The nearly exclusive use of tOPV 

vaccine led to elimination of wild poliovirus from the United 

States in less than 20 years. However, one case of VAPP occurred 

for every 2 to 3 million doses of tOPV vaccine administered. 

The burden of VAPP in industrialized countries resulted in 

progressive discontinuation of OPV vaccine. 

Poliovirus Vaccines

● IPV (IPOL)

● Combination vaccines

■ DTaP-HepB-IPV (Pediarix)

■ DTaP-IPV/Hib (Pentacel)

■ DTaP-IPV (Kinrix)

■ DTaP-IPV (Quadracel) 

■ DTaP-IPV-Hib-HepB (Vaxelis) 

(licensed but not yet 

available for use)
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In 1996, the Advisory Committee on Immunization Practices 

(ACIP) recommended an increase in use of IPV through a 

sequential schedule of IPV followed by tOPV to reduce the 

occurrence of VAPP. The sequential schedule eliminated VAPP 

among vaccine recipients by producing humoral immunity to 

polio with inactivated polio vaccine prior to exposure to live 

vaccine virus. Since tOPV was still used for the third and fourth 

doses, a risk of VAPP would continue to exist among contacts of 

vaccine recipients, who were exposed to live vaccine virus in the 

stool of vaccine recipients.

The sequential IPV–OPV polio vaccination schedule was widely 

accepted by both providers and parents. Fewer cases of VAPP 

were reported in 1998–1999, suggesting an impact of the 

increased use of IPV vaccine. To further the goal of complete 

elimination of paralytic polio in the United States, in 1999 ACIP 

recommended that IPV vaccine be used exclusively. Exclusive 

use of IPV vaccine eliminated the shedding of live vaccine virus, 

eliminating any indigenous VAPP. 

Among the 3 wild poliovirus types, type 2 was declared 

eradicated in 2015. To remove the risk for infection with 

circulating type 2 VDPV (cVDPV2), in 2016 all OPV-using 

countries simultaneously switched from tOPV to bivalent OPV 

(bOPV) vaccine, which contains only types 1 and 3 polioviruses, 

following a directive from the World Health Organization. One 

or several doses of IPV vaccine is used in all countries, either 

exclusively or in combined schedules with bOPV. Use of mOPV2 

in response to cVDPV2 outbreaks must be approved by the 

Director General of the WHO; the mOPV2 Advisory Group makes 

recommendations for use. 

Two single-antigen inactivated poliovirus (IPV) products are 

currently licensed for use in the United States, but only one 

vaccine, IPOL, is currently distributed.

There are five combination vaccines that contain IPV vaccine. 

DTaP-HepB-IPV (Pediarix), DTaP-IPV/Hib (Pentacel), DTaP-IPV 

(Kinrix), DTaP-IPV (Quadracel), and DTaP-IPV-Hib-HepB (Vaxelis) 

are licensed and available for use in the United States.

Characteristics 

IPV contains wild poliovirus strains grown individually in Vero 

cells and inactivated with formaldehyde. The initial formula 

developed by Jonas Salk in the 1950s was replaced by an 

enhanced potency formula in the late 1980s, which contains 

40:8:32 units of serotypes 1, 2, and 3, respectively. IPV vaccine 

is administered by either subcutaneous or intramuscular 

injection. Each dose of IPV vaccine contains antibiotics 

neomycin, streptomycin, and polymyxin B, and the preservative 

2-phenoxyethanol. It contains no adjuvant. Specific ingredients 

to combination vaccines containing IPV vaccine differ.

Poliovirus Vaccine 

Characteristics (IPV)

● Grown in monkey kidney 

(Vero) cells

● Inactivated with formaldehyde

● Contains serotypes 1, 2, and 3

● Administered by either 

subcutaneous or intramuscular 

injection

● Contains neomycin, 

streptomycin, polymyxin B, 

2-phenoxyethanol
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Vaccination Schedule and Use

The first dose of IPV vaccine may be administered as early as 

age 6 weeks but is usually administered at age 2 months, with 

a second dose at age 4 months. The third dose should be given 

at age 6 through 18 months of age. The recommended interval 

between the doses in the primary series is 2 months. However, 

if accelerated protection is needed, the minimum interval 

between each of the first 3 doses of IPV vaccine is 4 weeks. The 

final dose in the IPV series should be administered at age 4 

through 6 years and at least 6 months after the previous dose. 

A dose of IPV vaccine on or after age 4 years is recommended 

regardless of the number of previous doses. 

Shorter intervals between doses or beginning the series 

at a younger age may lead to lower seroconversion rates. 

Consequently, the use of the minimum age (6 weeks) and 

minimum intervals between doses in the first 6 months of 

life is recommended only if the vaccine recipient is at risk for 

imminent exposure to circulating poliovirus (e.g., during an 

outbreak or because of travel to a polio-endemic region).

IPV vaccine should be given at the same visit as other 

recommended vaccines.

Combination Vaccines 

DTaP-HepB-IPV (Pediarix)

DTaP-HepB-IPV vaccine is approved for use as a 3-dose series 

for children age 6 weeks through 6 years. It is administered to 

infants at age 2, 4, and 6 months. The minimum intervals for 

DTaP-HepB-IPV vaccine are determined by the DTaP component. 

The 3 doses must be separated by at least 4 weeks between 

doses. Because the minimum age for the first dose of DTaPHepB-IPV vaccine is 6 weeks, this vaccine cannot be used for 

the birth dose of hepatitis B (HepB) vaccine. The final dose of 

DTaP-HepB-IPV vaccine should be administered at age 24 weeks 

or older, the minimum age for completion of the hepatitis B 

vaccine series. When DTaP-HepB-IPV vaccine is used to provide 

3 doses at age 2, 4, and 6 months (based on the DTaP and IPV 

schedules), this will result in a 4-dose HepB vaccine series, which 

is acceptable. 

DTaP-IPV/Hib (Pentacel)

DTaP-IPV/Hib vaccine is approved for use as a 4-dose series 

for children age 6 weeks through 4 years. It is administered to 

infants at age 2, 4, 6, and 15 through 18 months. The minimum 

intervals for DTaP-IPV/Hib vaccine are determined by the 

DTaP component. The first 3 doses must be separated by at 

least 4 weeks between doses. Dose 4 must be separated from 

dose 3 by at least 6 months, and should not be administered 

before age 12 months. When DTaP-IPV/Hib vaccine is used 

to provide 4 doses at age 2, 4, 6, and between 15 through 18 

months (based on the DTaP and Hib schedules), an additional 

Polio Vaccination Schedule (IPV) 

● Typically administered at age 2, 

4, 6 through 18 months, and 4 

through 6 years

● Recommended interval 

between each of the first 3 

doses is 2 months

● Recommended interval 

between dose 3 and dose 4 is 

at least 6 months

● Minimum interval between 

doses is 4 weeks*

● Minimum age for dose 1 is 6 

weeks*

● A dose on or after age 4 years 

is recommended regardless of 

number of previous doses

*Recommended only if vaccine recipient 

is at risk for imminent exposure to 

circulating poliovirus (e.g. outbreak or 

travel to endemic region)
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booster dose with IPV-stand alone or DTaP-IPV vaccine should 

be administered at age 4 through 6 years. This will result in a 

5-dose IPV vaccine series, which is acceptable. 

DTaP-IPV-Hib-HepB (Vaxelis)

DTaP-IPV-Hib-HepB is approved for use as a 3-dose series 

for children age 6 weeks through 4 years. It is administered 

to infants at age 2, 4, and 6 months. The minimum intervals 

for DTaP-IPV-Hib-HepB vaccine are determined by the DTaP 

component. The 3 doses must be separated by at least 4 weeks 

between doses. Because the minimum age for the first dose of 

DTaP-IPV-Hib-HepB vaccine is 6 weeks, this vaccine cannot be 

used for the birth dose of hepatitis B (HepB) vaccine. The final 

dose of DTaP-IPV-Hib-HepB vaccine should be administered at 

age 24 weeks or older, the minimum age for completion of the 

hepatitis B vaccine series. When DTaP-IPV-Hib-HepB vaccine is 

used to provide 3 doses at age 2, 4, and 6 months (based on 

the DTaP and IPV schedules), this will result in a 4-dose HepB 

vaccine series, which is acceptable. 

DTaP-IPV (Kinrix) 

DTaP-IPV (Kinrix) vaccine is approved only for dose 5 of DTaP 

vaccine and dose 4 of IPV vaccine in children age 4 through 

6 years whose previous DTaP vaccine doses have been with 

Infanrix and/or Pediarix for dose 1, 2, and 3 and Infanrix for 

dose 4. However, if DTaP-IPV (Kinrix) vaccine is administered to 

children who received another brand of DTaP vaccine for prior 

DTaP vaccine doses, or if administered as dose 1, 2, 3, or 4 of the 

DTaP vaccine series or dose 1, 2, or 3 of the IPV vaccine series, 

the dose of DTaP-IPV (Kinrix) does not need to be repeated.

DTaP-IPV (Quadracel)

DTaP-IPV (Quadracel) vaccine is approved only for dose 5 of 

DTaP vaccine and dose 4 or 5 of IPV vaccine in children age 4 

through 6 years who have received 4 doses of Pentacel and/or 

Daptacel vaccine. However, if DTaP-IPV (Quadracel) vaccine is 

administered to children who received another brand of DTaP 

vaccine for prior DTaP vaccines doses, or if administered as 

dose 1, 2, 3, or 4 of the DTaP vaccine series or dose 1, 2, or 3 of 

the IPV series, the dose of DTaP-IPV (Quadracel) does not need 

to be repeated.

Polio Vaccination of Adults

Routine vaccination of adults (age 18 years or older) who reside 

in the United States is not necessary or recommended because 

most adults are already immune due to childhood vaccination 

and have a very small risk of exposure to wild poliovirus in the 

United States. 

Some adults, however, are at increased risk of exposure 

to poliovirus. These include laboratory workers handling 

specimens that may contain polioviruses, healthcare personnel 

Poliovirus Vaccination of Adults

● Routine vaccination of adults 

age 18 or older in the U.S. is not 

necessary or recommended

● Laboratory workers handling 

poliovirus-containing 

specimens, healthcare 

personnel treating patients with 

possible polio, and travelers 

to areas where poliomyelitis is 

endemic or epidemic may need 

vaccination

■ Adults at risk without record 

of polio vaccination should 

receive primary immunization
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Poliomyelitis

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treating patients who could have polio or have close contact 

with a person who could be infected with poliovirus, and 

travelers to areas where poliomyelitis is endemic or epidemic. 

Recommendations for poliovirus vaccination of these adults 

depends upon previous vaccination history and time available 

before protection is required.

When an adult at increased risk of exposure to poliomyelitis 

has never received polio vaccine or does not have a written 

record of polio vaccination, primary immunization with IPV 

is recommended. The recommended schedule is 2 doses 

separated by 1 to 2 months, and a third dose administered 6 

to 12 months after the second dose. The minimum interval 

between dose 2 and dose 3 is 6 months.

In some circumstances time will not allow completion of this 

schedule. If 8 weeks or more are available before protection is 

needed, 3 doses of IPV vaccine should be given at least 4 weeks 

apart. If 4 to 8 weeks are available before protection is needed, 

2 doses of IPV vaccine should be given at least 4 weeks apart. 

If less than 4 weeks are available before protection is needed, 

a single dose of IPV vaccine is recommended. In all instances, 

the remaining doses of vaccine should be given later, at the 

recommended intervals, if the person remains at increased risk.

Immunogenicity and Vaccine Efficacy

IPV vaccine is highly effective in producing immunity to 

poliovirus and protection from paralytic poliomyelitis. Ninety 

percent or more of vaccine recipients develop protective 

antibody to all three poliovirus types after 2 doses, and at least 

99% are immune following 3 doses. 

IPV vaccine prevents wild poliovirus from reaching the central 

nervous system in recipients, thus preventing paralysis. 

Protection against paralytic disease correlates with the presence 

of antibody after vaccination. IPV vaccine appears to produce 

less local gastrointestinal immunity than does OPV vaccine. 

Individuals who receive IPV vaccine usually do not shed virus 

in nasopharynx but excrete virus in stools following exposure 

to wild or vaccine poliovirus. The duration of shedding and 

amount of virus in the stool of IPV-vaccinated individuals is 

similar to that of unvaccinated individuals, if they have never 

been exposed to live poliovirus (vaccine or wild). The duration 

of immunity with IPV is not known with certainty, although it 

probably provides lifelong immunity after a complete series. 

OPV vaccine is highly effective in producing immunity to 

poliovirus. Because of interference among serotypes during 

intestinal replication, a single dose of tOPV produces immunity 

to all three vaccine viruses in approximately 50% of recipients. 

OPV vaccine produces local intestinal immunity, which reduces 

Poliovirus Vaccine Efficacy (IPV)

● Highly effective in producing 

immunity to poliovirus

● 90% or more immune after 2 

doses

● At least 99% immune after 3 

doses

● Duration of immunity not 

known with certainty, although 

probably lifelong
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shedding of virus upon re-infection with poliovirus of the same 

serotype and reduces potential transmission. Subsequent 

doses cause less interference during intestinal replication and 

3 doses produce immunity to all three poliovirus types in more 

than 95% of recipients in industrialized countries. As with other 

live-virus vaccines, immunity from oral poliovirus vaccine is 

probably lifelong. 

Contraindications and Precautions 

to Vaccination

As with other vaccines, a history of a severe allergic reaction 

(anaphylaxis) to a vaccine component or following a prior 

dose is a contraindication to further doses. Moderate or severe 

acute illness (with or without fever) in a patient is considered a 

precaution to vaccination, although persons with minor illness 

may be vaccinated. 

Since IPV contains trace amounts of streptomycin, neomycin, 

and polymyxin B, there is a possibility of allergic reactions in 

persons sensitive to these antibiotics. Persons with allergies 

that are not anaphylactic, such as skin contact sensitivity, 

may be vaccinated. 

Contraindications to combination vaccines that contain IPV 

include the contraindications to the individual component 

vaccines (e.g., DTaP, hepatitis B), but specific ingredients 

might differ.

Pregnancy

Pregnancy is a precaution to IPV vaccination. Although no 

adverse effects of IPV vaccine 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 vaccine 

can be administered in accordance with the recommended 

schedule for adults.

Vaccine Safety

In pre-licensure trials of enhanced-potency IPV, local reactions 

were mild and transient. Participants reported induration 

(18%), pain (13%), and erythema (3.2%) within 48 hours after 

vaccination. Systemic reactions reported were fever (38% 

reported temperature ≥ 39°C), irritability, sleepiness, fussiness 

and crying. Study participants received DTP at the same time 

as IPV and therefore these systemic reactions could not be 

attributed to a specific vaccine. However, the frequency and 

severity of these reactions were comparable to that reported 

when DTP is given alone. 

Poliovirus Vaccine 

Contraindications and 

Precautions (IPV)

● Contraindication

■ Severe allergic reaction to 

a vaccine component or 

following a prior dose of 

vaccine

● Precaution

■ Moderate or severe 

acute illness

■ Pregnancy, unless at 

increased risk and requiring 

immediate protection 

against polio

Poliovirus Vaccine Safety

IPV

● Local reactions mild and 

transient

● Induration, pain, erythema

■ 3.2%-18%

● Fever (39°C)

■ 38%

OPV

● VAPP occurs very rarely
286

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No increased risks for serious adverse events have been 

observed in countries relying on all-IPV schedules. After the 

expanded use of IPV in the United States, a review of the 

Vaccine Adverse Events Reporting System from 1991 through 

1998 did not show an increase in the reporting rate for 

poliovirus vaccine-associated adverse events with the increased 

use of IPV. In addition, the distribution of symptoms grouping 

was comparable for IPV and OPV.

VAPP occurs very rarely after administration of OPV vaccine. The 

mechanism of VAPP is believed to be a mutation, or reversion, of 

the attenuated vaccine poliovirus to a more neurotropic form. 

Reversion is believed to occur in almost all vaccine recipients, 

but it only rarely results in paralytic disease. The paralysis that 

results is identical to that caused by wild poliovirus. IPV vaccine 

does not contain live virus, so it cannot cause VAPP.

The risk of VAPP is 7 to 21 times higher for the first dose than 

for any other dose in the series. VAPP is more likely to occur 

in persons age 18 years or older than in children, and it is 

almost 7,000 times higher for persons with certain types of 

immunodeficiencies, particularly B-lymphocyte disorders (e.g., 

agammaglobulinemia and hypogammaglobulinemia), which 

reduce the synthesis of immune globulins. 

VDPVs are genetically divergent forms of vaccine strains. 

VDPVs develop through prolonged replication of vaccine 

strains contained in OPV in an immunodeficient individual 

or in a community with poor vaccination coverage and have 

re-acquired the neurovirulence and transmissibility of wild 

poliovirus. The risks of paralysis and manifestations of paralysis 

caused by VDPVs are similar to those of wild poliovirus of the 

same serotype. Outbreaks of circulating VDPVs have been 

responsible for more than 1,200 cases of paralytic polio during 

2000–2019 and have exceeded the wild poliovirus case count 

since 2017.

Vaccine Storage and Handling

IPV vaccine should be maintained at refrigerator temperature 

between 2°C and 8°C (36°F and 46°F). Manufacturer package 

inserts contain additional information. For complete information 

on best practices and recommendations, please refer to CDC’s 

Vaccine Storage and Handling Toolkit, www.cdc.gov/vaccines/

hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. 

Surveillance and Reporting of Poliomyelitis 

For information on guidance for state and local health 

department staff who are involved in surveillance activities for 

vaccine-preventable diseases, please consult the Manual for 

the Surveillance of Vaccine-Preventable Diseases, www.cdc.gov/

vaccines/pubs/surv-manual/chapters.html. 
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Acknowledgements

The editors would like to acknowledge Valerie Morelli and Ginger 

Redmon for their contributions to this chapter.

Selected References

CDC. International notes certification of poliomyelitis 

elimination– the Americas, 1994. MMWR 1994;43(39):720 –2.

CDC. Immunization schedules. Atlanta: CDC; 2020. 

www.cdc.gov/vaccines/schedules/hcp/index.html. Accessed 

August 29, 2020. 

CDC. Poliomyelitis prevention in the United States: updated 

recommendations of the Advisory Committee on Immunization 

Practices (ACIP). MMWR 2000;49(RR-5):1–22.

CDC. Updated recommendations of the Advisory Committee 

on Immunization Practices (ACIP) regarding routine poliovirus 

vaccination. MMWR 2009;58(30):829–30.

Chard A, Datta S, Tallis G, et al. Progress toward polio eradication - 

worldwide, January 2018-March 2020. MMWR 2020;69(25)784–9. 

DeVries A, Harper J, Murray A, et al. Vaccine-derived 

poliomyelitis 12 years after infection in Minnesota. N Engl J Med

2011;364(24):2316–23.

Food and Drug Administration. Prescribing information (package 

insert). IPOL (poliovirus vaccine inactivated). Silver Spring, MD: 

U.S. Department of Health and Human Services, Food and 

Drug Administration; 2019. https://www.fda.gov/media/75695/

download. Accessed October 13, 2020.

Global Polio Eradication Initiative. Global wild and circulating 

vaccine-derived poliovirus cases, 2018-2019 (data as of 24 August 

2020). polioeradication.org/polio-today/polio-now/this-week. 

Accessed August 28, 2020.

Prevots D, Sutter R, Strebel P, et al. Completeness of 

reporting for paralytic polio, United States, 1980 through 1991. 

Arch Pediatr Adolesc Med 1994;148(5):479–85. 

Sutter R, Kew O, Cochi S, et al. Poliovirus vaccine—live. In Plotkin 

S, Orenstein W, Offit P, eds. Plotkin’s Vaccines. 7th ed. Philadelphia, 

PA: Elsevier;2018:866–917.

Vidor E. Poliovirus vaccine—inactivated. In Plotkin S, Orenstein 

W, Offit P, eds. Plotkin’s Vaccines. 7th ed. Philadelphia, PA: 

Elsevier;2018:841–865.

NOTES
288

Poliomyelitis

 18

Wallace G, Curns A, Weldon W, et al. Seroprevalence of 

poliovirus antibodies in the United States population, 

2009–2010. BMC Public Health 2016;16:721. 

Wattigney W, Mootrey G, Braun M, et al. Surveillances for 

poliovirus vaccine adverse events, 1991 to 1998: impact of 

a sequential vaccination schedule of inactivated poliovirus 

vaccine followed by oral poliovirus vaccine. Pediatrics

2001;107(5):E83.

World Health Organization. Polio vaccines: WHO position paper 

(March, 2016). Wkly Epidemiol Rec 2016;91(12):145–68.

NOTES