Centers for Disease Control and Prevention

National Center for Immunization and Respiratory DiseasesPhotographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or any use by othAdult Polio VaccinationSarah Kidd, MD, MPHACIP MeetingFebruary 23, 2023
 Briefly summarize work group deliberations on adult polio v

 Present proposed language for adult polio vaccination (anti

vote in June)

 Solicit feedback and identify areas where more data are ne

an ACIP vote

Objectives for Today’s Presentation 
 Vaccination is recommended for certain adults who are at greater ri

to polioviruses than the general population

 Unvaccinated adults who are at increased risk should receive a prim

series with IPV

 Adults who have had a primary series of OPV or IPV and who are at 

can receive another dose of IPV

2000 Recommendations for Inactivated Polio VacVaccination of AdultsPoliomyelitis Prevention in the United States (cdc.gov)
 2000 statement focused on adults at increased risk of poliovirus exp

 Unclear how to define increased risk in setting of circulating vaccine-

poliovirus (cVDPV) in US

 Unclear recommendation for unvaccinated adults who were not con

increased risk of exposure

 Unclear recommendation for vaccinated adults and when/if a booste2000 Statement on IPV Vaccination for AdulQuestions and problems that came up in 20Poliomyelitis Prevention in the United States (cdc.gov)
 Should completion of a primary polio vaccination series with IPV be 

for unvaccinated and incompletely vaccinated adults in the US? – Population: Unvaccinated and incompletely vaccinated (with OPV or IPV) US adu– 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
An adult is considered fully vaccinated if they received:

– A primary series of ≥3 doses of trivalent OPV (tOPV) or IPV in any co

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 d

Current Definition of Fully VaccinatedPoliomyelitis 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 a

introduction of polio vaccine

0

5000

10000150002000025000

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

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 on

1997: Sequential 

IPV followe
Global Paralytic WPV1 and cVDPV Cases

1, Previous 

Polio Now – GPEI (polioeradication.org)

WPV1 cases (latest onset)Pakistan 20 15-Sep-22Afghanistan 1 29-Aug-22Mozambique 8 10-Aug-22cVDPV1 cases (latest onset)DR Congo 92 16-Dec-22Malawi 4 01-Dec-22Mozambique 19 20-Nov-22Madagascar 11 25-Sep-22cVDPV2 cases (latest onset)Indonesia 2 03-Jan-23CAR 5 26-Dec-22Algeria 3 13-Dec-22DR Congo 260 10-Dec-22Yemen 121 02-Dec-22Chad 36 11-Nov-22Sudan 1 31-Oct-22Cameroon 2 30-Oct-22Niger 13 27-Oct-22Nigeria 29 27-Oct-22Mali 1 26-Oct-22Benin 10 09-Oct-22Togo 1 30-Sep-22Ghana 3 14-Sep-22Somalia 4 23-Aug-22USA 1 20-Jun-22Ethiopia 1 01-Apr-22Mozambique 4 26-Mar-22Eritrea 1 02-Mar-22cVPDV3 case (latest onset)Israel 1 12-Feb-22
Paralytic Polio Case in New York State, July 2

• A case of paralytic polio caused by vaccine-derived poliovirus type 2 

confirmed in an unvaccinated young adult from Rockland County, NeJuly 21, 2022

• Genetic sequencing has indicated a linkage to polioviruses collected 

wastewater in Israel, United Kingdom, and Canada

• Rockland County has reported overall low vaccine coverage for over 

• In summer 2022, 60% of children under 2 yrs of age had received 

recommended 3 doses of IPV (zip code level as low as 37%)

• No additional paralytic cases have been identified
 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

 Most recent positive sample was collected on 

December 15, 2022; no detections in samples collected in last 7 weeks

 No additional paralytic polio cases identifiedWastewater Testing for Poliovirus
Percent positive (95% Confidenc

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

1998–2004 6–11 years 97.2 (94.7–98.8) 98.0 (96.4–99.0) 1990–1998 12–19 years 94.7 (92.0–96.6) 98.2 (96.6–99.2) 1970–1990 20–39 years 92.7 (90.0–94.2) 96.9 (95.2–98.2) 1960–1970 40–49 years 93.9 (91.6–95.7) 95.8 (93.8–97.3) Seroprevalence of Poliovirus Antibodies by Age, United States NHANES Serosurvey, 2009–2010Source: Wallace et al, BMC Public Health 2016.
 Presence of detectable neutralizing antibody is a correlate of protect

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

 Serologic immunogenicity among infants and children1 – 70%–100% seropositive after 2 doses – 88%–100% seropositive after 3 doses Estimates of vaccine effectiveness against paralytic polio2 – 36%–89% for 1 dose – 89%– 98% for 2 doses Paucity of data on adults receiving a primary seriesEffectiveness of Enhanced-Potency IPV1. Vidor et al review, PIDJ 1997.2. Stoeckel et al, Rev Infect Dis 1984. CDC, MMWR 1988. John, Rev Med Virol 1993.
 Intestinal immunity1 – No significant difference between IPV and unvaccinated individuals in the odds o

– IPV vaccination appears to reduce the mean quantity of shed poliovirus by 63%–– Some data to suggest that IPV vaccination reduces duration of shedding; recent 

indicated no impact of IPV

 Nasopharyngeal (NP) immunity2 – Evidence to suggest similar, low rates of NP shedding (0%–4%) among OPV and IIPV and Mucosal ImmunitySources: 1. Hird and Grassly meta-analysis, PLoS Pathogens 2012. 2. 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 fr

severity of reported adverse reactions compared with the other vacc

 No severe adverse events have been causally associated with use of t

formulation of IPV

Safety: IPV is well-tolerated.Sources: Sanofi Pasteur Package Insert - IPOL (fda.gov) . Vidor et al, PIDJ 1997. Murdin et al, Vaccine 1996. Wattigney et al, Pediatrics 2001. IO
 >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 va Standalone IPV accounted for just 0.5% of reports VAERS is passive reporting system, cannot assess causal associations Reported adverse events were similar and proportional to other vaccVaccine Adverse Event Reporting System (VAERS) 2000–2012Source: Iqbal et al, Lancet ID 2015. 
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 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 Unvaccinated Adults

• Indi• Opp

antivaccpote
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 Unvaccinated Adults

• Po• Gr

inctimrec

• Po

opvaex
Pros:

 Allows unvaccinated adults and their health care providers to take ad

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

 Brings adult polio vaccination policy closer in line with other routine c

vaccines, e.g., MMR and varicella vaccines

 Is less complicated policy to communicate and understand (i.e., recom

doesn’t change based on latest wastewater data)

Pros and Cons of a Uniform Recommendation for Unvaccinated and Incompletely Vaccinated Adult
Cons:

 Most adults in the United States have a low risk of poliovirus exposur

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

 Demand for IPV could potentially exceed supply, particularly if a large 

adults without documentation of polio vaccination status assume thevaccinated – However, this issue can be mitigated by providing guidance for this group in the 

considerations

Pros and Cons of a Uniform Recommendation for Unvaccinated and Incompletely Vaccinated Adult
 Majority of work group believe pros of uniform recommendation out

approximately 1/3 favor maintaining the current risk-based recomme

Majority Recommendation:Adults who are known or suspected to be unvaccinated or incompletely against polio should complete a primary vaccination series with IPV.Clinical Considerations:In general, unless there are specific reasons to believe they were not vaadults who were born and raised in the United States can assume they against polio as children.Proposed Language for Unvaccinated and IncompVaccinated Adults
 Should a booster IPV dose be recommended for adults in the US wh

previously completed a primary polio vaccination series? – Population: US adults aged >18 years who have completed a primary polio vacci

trivalent OPV, IPV, or a combination of both) – Intervention: Booster dose of IPV – Comparison: Adults who completed a primary series but did not receive a boost

– 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 IP

at increased risk can receive another dose of IPV. Available data do need for more than a single lifetime booster dose with IPV for adult

 Rationale – Longstanding recommendation since tOPV was used in routine immunization – Actual need for supplementary dose not established, but “there is value in assur

against infection with wild polioviruses when exposure can reasonably be expectStatement) – At least 2 reported cases of paralytic polio in adult travelers who had completed vaccination series with Salk IPV and/or tOPV

Boosters: 2000 Statement and RationaleCDC MMWR 1977; CDC MMWR 1986.
Percent positive (95% Confidenc

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

1998–2004 6–11 years 97.2 (94.7–98.8) 98.0 (96.4–99.0) 1990–1998 12–19 years 94.7 (92.0–96.6) 98.2 (96.6–99.2) 1970–1990 20–39 years 92.7 (90.0–94.2) 96.9 (95.2–98.2) 1960–1970 40–49 years 93.9 (91.6–95.7) 95.8 (93.8–97.3) Unclear Need for IPV Booster in Vaccinated AdultSeroprevalence of Poliovirus Antibodies by Age, UniNHANES Serosurvey, 2009–2010Source: Wallace et al, BMC Public Health 2016.NOTE: Presence of detectable neutralizing antibody is a correlate of protection against paralytiImmunity 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 BoosterSources: Broderick et al, Vaccine 2015; Domenicus et al, Vaccine 2014; Fukushima et al, Vaccines 2022; Grimprel et al, Vaccine 2005; Kovac et Human Vaccines 2010; Zimmermann et al, Vaccine 2013.

Data from GrimpreSeropositivity befocontaining booster poliovirus serotype
 Risk-based

 Shared clinical decision-makingProposed Language: Adults who have received a primary series of tOPV or IPV in any com

who are at increased risk of poliovirus exposure may receive anotheAvailable data do not indicate the need for more than a single lifetimdose with IPV for adults.

Strong Majority of Work Group Agree with CurreRecommendation for Adult IPV Booster
Thank you to the ACIP Polio Work Group Me

 ACIP voting members

– Oliver Brooks (Chair)– Lynn Bahta

 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 Societ

y

– Joseline Zafack, Public Health Agency of Canada– Oliver Baclic, Public Health Agency of Canada

 Ex Officio

– Robin Levis, FDA– Robin Wisch, FDA

 Consultants

– Edwin Asturias– Doug E Campos-– Emily Lutterloh– Walt Orenstein– Jennifer Rosen– Eli Rosenberg

 CDC

– Achal Bhatt– Stephanie Bialek– Thomas Clark– Kathleen Dooling– Brian Edlin– Concepcion Estiv– Halle Getachew– Sarah Kidd– Janelle King– Elisabeth Krow-L– 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.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for DisPhotographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or 

any use by other CDC CIOs or any external audiences.