Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 16, Number 7—July 2010
Dispatch

Vaccine-associated Paralytic Poliomyelitis in Immunodeficient Children, Iran, 1995–2008

Author affiliations: Tehran University of Medical Sciences, Tehran, Iran (S. Shahmahmoodi, S. Mamishi, A. Aghamohammadi, N. Aghazadeh, H. Tabatabaie, M. Yousefi, K. Farrokhi, M. Mohammadpour, R. Nategh, N. Parvaneh); Ministry of Health Center for Disease Control and Management, Tehran (M.M. Gooya, S.M. Zahraei, T. Mousavi); Pediatrics Center of Excellence, Tehran (S. Mamishi, A. Aghamohammadi, M. Mohammadpour, M.R. Ashrafi, N. Parvaneh)

Cite This Article

Abstract

To determine the prevalence of vaccine-associated paralytic poliomyelitis (VAPP) in immunodeficient infants, we reviewed all documented cases caused by immunodeficiency-associated vaccine-derived polioviruses in Iran from 1995 through 2008. Changing to an inactivated polio vaccine vaccination schedule and introduction of screening of neonates for immunodeficiencies could reduce the risk for VAPP infection.

After establishment of the Global Polio Eradication Initiative in 1988, the incidence of polio worldwide decreased from ≈350,000 cases annually to 1,606 cases in 2009 (1). Oral polio vaccine (OPV) has been efficiently used for >40 years and is associated with few adverse events (2). Its most commonly recognized adverse event, vaccine-associated paralytic poliomyelitis (VAPP), is estimated by the World Health Organization to cause 1 case per million births and by Minor (3) to cause ≈1 case per 6.2 million doses of OPV distributed.

VAPP is clinically indistinguishable from paralytic poliomyelitis caused by wild-type polioviruses (2) and occurs among healthy OPV recipients and their contacts, with onset temporally linked (within 60 days) to OPV exposure. Persons with primary immunodeficiencies are at >3,000-fold higher risk for VAPP (2,4). Isolates from immunodeficient VAPP (iVAPP) patients and some asymptomatic carriers show evidence of prolonged replication as indicated by >1% nucleotide sequence divergence from the corresponding Sabin OPV strain; such vaccine-derived polioviruses (VDPVs) isolated from immunodeficient persons after exposure to OPV are called iVDPVs (6,7).

Although most mutations involved in reversion of the OPV to a wild-type strain are found in the 5′ untranslated region of the virus genome, mutations have also been found in viral protein (VP) 1, VP2, and VP3 nt sequences (5). The >1% demarcation arises from the average rate of VP1 nt divergence of ≈1% per year, suggestive of prolonged replication (6,7). However, poliovirus evolution rates are variable, especially in the early phases of OPV replication (2). Immunodeficient OPV vaccine recipients are potential reservoirs for neurovirulent polio virus reintroduction into the population (8). To date, >44 cases in patients with immunodeficiency have been confirmed worldwide that excreted iVDPV for long periods (9,10). Timely diagnosis and containment of VDPVs needs to be addressed in posteradication strategies in regions where OPV is still used routinely. We present all 6 documented cases of iVAPP caused by iVDPVs diagnosed in Iran during 1995–2008 (Tables 1 and 2).

The Study

Patient 1 was a 17-month-old girl. She had exhibited antibody deficiency and thus received inactivated polio vaccine (IPV). She was a household contact of a healthy OPV-vaccinated sibling. Limited data indicated that paralysis became evident in June 1995. All 3 fecal specimens collected 3–6 days after onset of paralysis yielded VDPV type 2. Recombination with the Sabin 1 strain was detected, with a crossover site at nt 5355 (3A). The girl died 8 days after onset of paralysis with obscured etiology.

Patient 2 was a boy born in January 2005. He received 4 doses of OPV, administered at birth and at 2, 4, and 6 months of age. In August 2005, he was hospitalized with irritability, drowsiness, hypotonia, and right paraparesis. Two collected fecal specimens tested were positive for VDPV type 2. Recombination with the Sabin 1 strain was also found at nt 5358. At baseline, he had mild anemia, hypogammaglobulinemia, and diminished CD4+ T-cell counts. A test result for HIV was negative. The expression of human leukocyte antigen DR on his lymphocytes was low, indicating major histocompatibility complex class II deficiency. His condition deteriorated during the next several months, with involvement of respiratory muscles and 3 episodes of aspiration pneumonia. He died of respiratory failure at 11 months of age. Follow-up fecal cultures during his illness showed persistent VDPV type 2 shedding (11).

Patient 3 was a boy born in January 2006. Beginning at 2 months of age, he had chronic diarrhea, malabsorption, and failure to thrive. Recurrent episodes of pneumonia also developed, beginning when the boy was 4 months of age. OPV was administered at birth and at 2, 4, and 6 months of age. In October 2006, he was referred to hospital showing symptoms of acute paralysis of the left leg of 2 weeks’ duration, followed by involvement of his right leg and upper arms, accompanied by drowsiness, fever, and hypotonia. Laboratory results showed lymphopenia; anemia; decreased levels of immunoglobulin (Ig) G, IgA, and IgM; and diminished CD3+, CD4+, and CD8+ T-cell counts (Table 2). VDPV type 2 was isolated from both of his collected fecal specimens. The final diagnosis was severe combined immunodeficiency (SCID) caused by RAG2 mutation (R229W) (N. Parvaneh, unpub. data). The boy died <3 months after onset of paralysis after gram-negative sepsis in January 2007.

Patient 4 was a 15-month-old boy who had fever and weakness of the lower limbs in December 2006. He received 4 doses of OPV, administered at birth and at 2, 4, and 6 months of age. At admission to the hospital, his right leg was completely flaccid, and the left was paretic. VDPV type 3 was isolated from his feces. Recombination with the Sabin 1 strain was detected at the 3Dpol region of the genome. Immunologic workup showed hypogammaglobulinemia and diminished CD19+ B lymphocytes. The final diagnosis was X-linked agammaglobulinemia. The patient was treated with intravenous Ig and physical therapy. Follow-up fecal cultures showed no virus. He died 11 months after onset of paralysis with chronic respiratory insufficiency (12,13).

Patient 5, a girl born in September 2006, was the third child of healthy parents. She received OPV at birth and in November 2006. In February 2007, she was hospitalized with severe pneumonia and paraparesis. Two fecal specimens collected on days 3 and 5 after onset of paralysis were positive for VDPV types 1 and 2. B cell–negative T cell–negative SCID was diagnosed (Table 2); the girl died of severe sepsis and multiple organ failure in April 2007, 1 month after onset of VAPP.

Patient 6, a boy 2 years of age, had weakness in his right leg. At 7 months of age, progressive paralysis of the extremity developed after a febrile illness. His first fecal specimen was positive for the Sabin 2 strain. He subsequently experienced several episodes of pneumonia and upper respiratory infections necessitating hospitalization. Immunologic workup favored a diagnosis of X-linked agammaglobulinemia (Table 2). Electrodiagnostic studies of the affected limb indicated femoral nerve mononeuropathy. One of 2 additional fecal specimens collected was positive for VDPV type 2. The boy began intravenous Ig substitution (600 mg/kg every 4 weeks, continuing to date). Follow-up fecal samples became negative for polioviruses. His immunodeficiency is under control, and he has only residual paralysis of the right leg.

Conclusions

Although the Sabin 3 strain is associated with the highest rates of VAPP, probably because of low genetic stability, it is rarely associated with formation of VDPV and rarely seen in iVAPP (2). Our findings were similar, with iVDPV type 2 being the most common serotype (detected in 5 patients).

In our series, the median interval between administration of the last OPV dose and iVAPP onset was 3.1 months. Khesturiani et al. found a median interval of 2.3 months (8). In addition, the median interval between last OPV and onset of VAPP in the 23 iVDPV excretors reported during 1962–2004 was 0.6 years (2). Immune deficiency was diagnosed after onset of iVAPP in 5 of our patients. The exception is notable because it illustrates one of the few iVAPP cases in which immunodeficiency was diagnosed before paralytic manifestations (14). OPV is routinely administered at birth, when most primary immunodeficiencies are hardly identifiable (12). Introduction of neonatal screening programs for some immunodeficiencies such as SCID could help prevent inadvertent exposure of such patients to OPV.

The median interval between last OPV dose and last positive sample among the patients in our series was 3.5 months (range 1.5–14 months). Khesturiani et al. described an interval of 8.8 months–7.8 years (8). All the contact samples obtained for our cases were negative, implying an acceptable coverage of OPV in Iran.

Poliovirus accumulates mutations in VP1 region at ≈1% per year (6,7). However, our experience shows a more rapid evolution (Table 1), assuming that the virus has replicated in the patients' gastrointestinal systems from birth. However, changes in VP1 synonymous third-base codons are more constant during virus evolution and are more reliable indicators of poliovirus replicative age (4).

Although the risk for further transmission of iVDPV is relatively low, potential risk for circulation of iVDPV strains always remains. One episode of iVDPV spread (in an Amish population with low coverage of OPV) has been documented (15). Because elimination of iVDPV before cessation of OPV use seems impossible, changing to an IPV schedule seems mandatory for global poliovirus eradication.

Dr Shahmahmoodi is an assistant professor in the Virology Division, School of Public Health, Tehran University of Medical Sciences; and technical supervisor/responsible officer of Iran’s National Polio Laboratory. His research interests include polio viruses and nonpolio enteroviruses.

Top

Acknowledgments

We thank Olen Kew, Cara Burns, and Qi Chen for assistance with molecular analysis. We also thank the World Health Organization Headquarters and Eastern Mediterranean Region Offices for kind support and assistance.

The work performed in the Iran National Polio Laboratory was financially supported by the World Health Organization and School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. This work was also supported in part by a grant from Tehran University of Medical Sciences to N.P.

Top

References

  1. Global Polio Eradication Initiative [cited 2010 Apr 13]. http://www.polioeradication.org
  2. Kew  OM, Sutter  RW, de Gourville  EM, Dowdle  WR, Pallansch  MA. Vaccine-derived polioviruses and the endgame strategy for global polio eradication. Annu Rev Microbiol. 2005;59:587635. DOIPubMedGoogle Scholar
  3. Minor  P. Vaccine-derived poliovirus (VDPV): impact on poliomyelitis eradication. Vaccine. 2009;27:264952. DOIPubMedGoogle Scholar
  4. Martin  J. Vaccine-derived poliovirus from long term excretors and the end game of polio eradication. Biologicals. 2006;34:11722. DOIPubMedGoogle Scholar
  5. Minor  PD. The molecular biology of polio vaccines. J Gen Virol. 1992;73:306577. DOIPubMedGoogle Scholar
  6. Alexander  JP Jr, Gary  HE Jr, Pallansch  MA. Duration of poliovirus excretion and its implications for acute flaccid paralysis surveillance: a review of the literature. J Infect Dis. 1997;175(Suppl 1):S17682.PubMedGoogle Scholar
  7. Martin  J, Dunn  G, Hull  R, Patel  V, Minor  PD. Evolution of the Sabin strain of type 3 poliovirus in an immunodeficient patient during the entire 637-day period of virus excretion. J Virol. 2000;74:300110. DOIPubMedGoogle Scholar
  8. Khetsuriani  N, Prevots  DR, Quick  L, Elder  ME, Pallansch  M, Kew  O, Persistence of vaccine-derived polioviruses among immunodeficient persons with vaccine-associated paralytic poliomyelitis. J Infect Dis. 2003;188:184552. DOIPubMedGoogle Scholar
  9. Centers for Disease Control and Prevention. Update on vaccine-derived polioviruses. MMWR Morb Mortal Wkly Rep. 2006;55:10937.PubMedGoogle Scholar
  10. Centers for Disease Control and Prevention. Laboratory surveillance for wild and vaccine-derived polioviruses—worldwide, January 2008–June 2009. MMWR Morb Mortal Wkly Rep. 2009;58:9504.PubMedGoogle Scholar
  11. Parvaneh  N, Shahmahmoudi  S, Tabatabai  H, Zahraei  M, Mousavi  T, Esteghamati  AR, Vaccine-associated paralytic poliomyelitis in a patient with MHC class II deficiency. J Clin Virol. 2007;39:1458. DOIPubMedGoogle Scholar
  12. Mamishi  S, Shahmahmoudi  S, Tabatabaie  H, Teimourian  S, Pourakbari  B, Gheisari  Y, Novel BTK mutation presenting with vaccine-associated paralytic poliomyelitis. Eur J Pediatr. 2008;167:13358. DOIPubMedGoogle Scholar
  13. Shahmahmoodi  S, Parvaneh  N, Burns  C, Asghar  H, Mamishi  S, Tabatabaie  H, Isolation of a type 3 vaccine-derived poliovirus (VDPV) from an Iranian child with X-linked agammaglobulinemia. Virus Res. 2008;137:16872. DOIPubMedGoogle Scholar
  14. Centers for Disease Control and Prevention. Prolonged poliovirus excretion in an immunodeficient person with vaccine-associated paralytic poliomyelitis. MMWR Morb Mortal Wkly Rep. 1997;46:6413.PubMedGoogle Scholar
  15. Centers for Disease Control and Prevention. Poliovirus infections in four unvaccinated children—Minnesota, August–October 2005. MMWR Morb Mortal Wkly Rep. 2005;54:10535.PubMedGoogle Scholar

Top

Tables

Top

Cite This Article

DOI: 10.3201/eid1607.091606

Table of Contents – Volume 16, Number 7—July 2010

EID Search Options
presentation_01 Advanced Article Search – Search articles by author and/or keyword.
presentation_01 Articles by Country Search – Search articles by the topic country.
presentation_01 Article Type Search – Search articles by article type and issue.

Top

Comments

Please use the form below to submit correspondence to the authors or contact them at the following address:

Nima Parvaneh, Department of Pediatrics, Tehran University of Medical Sciences, No. 62 Gharib St, 14194 Tehran, Iran

Send To

10000 character(s) remaining.

Top

Page created: March 02, 2011
Page updated: March 02, 2011
Page reviewed: March 02, 2011
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
file_external