A developing country perspective on vaccine-associated paralytic poliomyelitis

When the Expanded Programme on Immunization was established and oral poliovirus vaccine (OPV) was introduced for developing countries to use exclusively, national leaders of public health had no opportunity to make an informed choice between OPV and the inactivated poliovirus vaccine (IPV). Today, as progress is made towards the goal of global eradication of poliomyelitis attributable to wild polioviruses, all developing countries where OPV is used face the risk of vaccine-associated paralytic poliomyelitis (VAPP). Until recently, awareness of VAPP has been poor and quantitative risk analysis scanty but it is now well known that the continued use of OPV perpetuates the risk of VAPP. Discontinuation or declining immunization coverage of OPV will increase the risk of emergence of circulating vaccine-derived polioviruses (cVDPV) that re-acquire wild virus-like properties and may cause outbreaks of polio. To eliminate the risk of cVDPV, either very high immunization coverage must be maintained as long as OPV is in use, or IPV should replace OPV. Stopping OPV without first achieving high immunization coverage with IPV is unwise on account of the possibility of emergence of cVDPV. Increasing numbers of developed nations prefer IPV, and manufacturing capacities have not been scaled up, so its price remains prohibitively high and unaffordable by developing countries, where, in addition, large-scale field experience with IPV is lacking. Under these circumstances, a policy shift to increase the use of IPV in national immunization programmes in developing countries is a necessary first step; once IPV coverage reaches high levels (over 85%), the withdrawal of OPV may begin.     

The occurrence of vaccine-associated paralytic poliomyelitis in Brazil, 1995 to 2001]

OBJECTIVE: To describe the occurrence of vaccine-associated paralytic poliomyelitis (VAPP) in Brazil between 1995 and 2001 and to determine the level of risk for this adverse event. METHODS: This retrospective study utilized data from acute flaccid paralysis investigation and notification records from the Ministry of Health in Brazil. Cases were defined as individuals with a diagnosis of acute flaccid paralysis and a positive stool culture or sequelae compatible with poliomyelitis appearing up to 60 days after the beginning of motor impairment. Also included were individuals in any age range who had contact with vaccinated persons between the 4th and 40th day before the onset of the disease and who developed motor impairment between 4 and 85 days after this contact. Risk was calculated as the ratio between the number of cases and the respective number of doses given in a year, according to the National Immunization Program. RESULTS: Ten cases of VAPP were recorded in the period. The mean age of the cases was 4.7 months. Four cases were associated with the first dose, four with the second dose, and two cases were attributed to contact. In two cases type 1 virus was identified; in one case, type 2; and in three cases, type 3. More than one serotype was isolated in four cases. In all 10 cases the serotype was determined. The observed risk for VAPP during the period studied was 1:5.11 million when considering only the first dose and 1:10.67 million for all the doses. CONCLUSION: The main technical and ethical dilemma of the post-poliomyelitis elimination stage is the occurrence of paralytic cases that result from the vaccine policy itself, whose objective is the eradication of polio.     

Imported melioidosis--South Florida, 2005

In 2005, two cases of melioidosis (one in August, one in October) were reported to the Florida Department of Health, the first cases since reporting the disease became mandatory in Florida in 2003. In one case, Burkholderia pseudomallei was not recognized as the bacterium that causes the disease melioidosis, which led to a delay in reporting the case to the local health department. In both cases, delayed recognition and unsafe laboratory practices resulted in laboratory workers being exposed to B. pseudomallei. This report summarizes the clinical and laboratory aspects of the cases and the epidemiologic study conducted by the Florida Department of Health. The findings emphasize the need for improved laboratory recognition and reporting of B. pseudomallei, safe laboratory handling of B. pseudomallei, and close adherence to antibiotic regimens for treating and preventing recurrence of melioidosis.     

Risk of vaccine-associated paralytic poliomyelitis in Latin America, 1989-91.

A major factor influencing the success of poliomyelitis eradication in the Americas was the reliance on mass immunization campaigns with oral poliovirus vaccine (OPV). As global poliomyelitis eradication activities accelerate and campaign vaccine delivery strategies are applied elsewhere, it is critical to determine whether the risk of vaccine-associated paralytic poliomyelitis (VAPP) is altered when routine delivery strategies are supplemented with mass immunization campaigns. We analysed all 6043 cases of acute flaccid paralysis (AFP) reported in Latin America over the period 1989-91 in order to estimate the risk of VAPP. The overall risk was estimated to be one case per 1.5-2.2 million doses of OPV administered, compared with one case per 1.4 million doses administered in England and Wales (1985-91) and with one case per 2.5 million net doses distributed in the USA (1980-89). These data suggest that to eradicate poliomyelitis globally, strategies that rely on mass immunization campaigns to supplement routine delivery services, as recommended by WHO, do not appear to alter significantly the risk of VAPP.     

小月龄儿疑似脊髓灰质炎疫苗相关麻痹2例流行病学调查

目的：分析2007年及2008年杭州市二例小月龄儿脊髓灰质炎疫苗相关麻痹病例的传播及其影响因素。方法：对报告的2例急性弛缓性麻痹（AFP）患儿进行流行病学调查。结果：1例脊灰病毒分离与定型为Ⅱ＋Ⅲ型,诊断小组认定为脊灰疫苗相关麻痹型脊灰（VAPP）病例。1例实验室检测为阴性,专家诊断小组诊断为可能是VAPP病例,建议按VAPP病例有关规定处理。结论：在实现无脊灰目标后,将面临苗相关麻痹型脊灰病例的发生等问题。应采取的措施主要是：保持高水平的免疫接种率和高质量的急性弛缓性麻痹病例监测工作。     

荆门市一例疫苗相关麻痹型脊髓灰质炎病例调查分析

2007年7月16日湖北省荆门市第一人民医院报告了1例脊髓灰质炎（AFP）病例,同年12月26日由湖北省预防接种异常反应诊断小组确诊为疫苗相关麻痹型脊髓灰质炎病例,现将病例调查结果分析如下。     

2004-2013年河南省脊髓灰质炎疫苗 相关麻痹型病例分析

摘要:目的　了解河南省疫苗相关麻痹型脊髓灰质炎（Vaccine-Associated Paralytic Poliomyelitis,VAPP）病例发生情况,为其防控策略制定提供科学依据。方法　对河南省2004-2013年的VAPP病例进行描述性分析。结果　河南省2004-2013年共发生VAPP病例19例,VAPP发生率为0.14/100万,首剂服苗VAPP发生率为0.93/100万。VAPP病例男女性别比为8.5∶1,2～6月龄儿童占73.68%。73.68%的病例为首次服苗,服苗至麻痹平均时间间隔为23 d,随访均有残留麻痹。病例便标本病毒分型以Ⅱ型为主。结论　VAPP病例以低月龄、首次服苗儿童为主。应加强接种前预检工作,严格掌握禁忌症。同时适时调整脊灰疫苗免疫策略,减少或避免VAPP的发生。     

Imported Haycocknema perplexum Infection,United States

We report an imported case of myositis caused by a rare parasite, Haycocknema perplexum, in Australia in a 37-year-old man who had progressive facial, axial, and limb weakness, dysphagia, dysphonia, increased levels of creatine kinase and hepatic aminotransferases, and peripheral eosinophilia for 8 years. He was given extended, high-dose albendazole.     

Imported dengue--United States, 1997 and 1998

Dengue is a mosquito-transmitted acute viral disease caused by one of four dengue virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4). Dengue is endemic in most tropical areas of the world and has occurred in U.S. residents returning from travel to such areas. CDC maintains a laboratory-based passive surveillance system for imported dengue among U.S. residents. The system relies principally on reports by clinicians to state health departments, which forward patient specimens to CDC for diagnostic testing. This report summarizes information about imported dengue cases among U.S. residents for 1997 and 1998, which indicates that most persons with a known travel history probably acquired infection in the Caribbean islands or Asia.     

Imported dengue--United States, 1999 and 2000

Dengue is a mosquito-transmitted acute viral illness caused by any of the four dengue virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4). Dengue is endemic in most tropical and subtropical areas of the world and has occurred among U.S. residents returning from travel to such areas. CDC maintains a laboratory-based passive surveillance system for imported dengue among U.S. residents (laboratory-diagnosed dengue in a U.S. resident living in an area without known authochthonous dengue transmission, with travel history outside the United States in the 14 days before symptom onset). The system relies on reports by clinicians to state health departments, which forward patient specimens to CDC for diagnostic testing. This report summarizes information about imported dengue cases among U.S. residents during 1999-2000. The findings indicate that dengue continues to cause disease in U.S. travelers abroad. Travelers to tropical areas should protect themselves from mosquito bites, and health-care providers should consider dengue in the differential diagnosis of illness for patients who have returned recently from such areas.     

Measles--United States, 2005

Measles is a highly infectious, acute viral illness that can be complicated by severe pneumonia, diarrhea, and encephalitis and can result in death. In the prevaccine era, approximately 500,000 cases of measles occurred annually in the United States. During 2005, local and state health departments reported to CDC 66 confirmed cases of measles (incidence rate: less than one case per 1 million population), 34 of which were from a single outbreak in Indiana associated with infection in a traveler returning to the United States. This report describes the epidemiology of U.S. measles cases in 2005 and documents the absence of endemic measles and the continued risk for imported measles infections that can result in transmission within the United States. The findings underscore the need to maintain the highest possible measles vaccination coverage in the United States and to adhere to recommendations regarding measles vaccination.     

Travel-associated dengue--United States, 2005

Dengue is a mosquito-transmitted, acute viral disease caused by any of four dengue virus serotypes (DEN-1, DEN-2, DEN-3, or DEN-4). Dengue is endemic in most tropical and subtropical areas of the world and has occurred among U.S. residents returning from travel to such areas. In collaboration with state health departments, CDC maintains a passive surveillance system for travel-associated dengue among U.S. residents. Suspected dengue in travelers is reported to state health departments, which forward specimens to CDC for diagnostic testing. A case of travel-associated dengue is defined as laboratory-diagnosed dengue in a resident of one of the 50 states or the District of Columbia (DC) who traveled to a dengue-endemic area outside the United States or DC any time during the 14 days before symptom onset. This report summarizes information regarding 96 travel-associated dengue cases, including one fatality, among U.S. residents during 2005. Travelers to tropical areas can reduce their risk for dengue by using mosquito repellent and avoiding exposure to mosquitoes. Health-care providers should consider dengue in the differential diagnosis of febrile illness in patients who have returned recently from dengue-endemic areas.     

福建省2008-2011年疫苗相关麻痹型脊髓灰质炎发生率及其影响因素研究

儿童服用脊髓灰质炎(脊灰)疫苗(OPV)后有可能发生疫苗相关麻痹型脊灰(VAPP)病例,虽然发生率极低,但随着OPV大量使用,在无脊灰国家和地区,VAPP的重要性日渐凸显,因此对VAPP的发生及其影响因素研究日益重要[1].本研究通过免疫规划监测信息管理系统福建省2008-2011年OPV常规免疫以及历年强化免疫/查漏补种OPV数据估算VAPP发生率,并对2004-2011年急性弛缓性麻痹(AFP)病例监测系统病例资料进行分析,探讨VAPP发生的影响因素.     

Fatal occupational injuries--United States, 2005

Data from the annual Census of Fatal Occupational Injuries (CFOI), collected by the Bureau of Labor Statistics (BLS), provide information on fatal occupational injuries that occur in the United States. CDC's National Institute for Occupational Safety and Health (NIOSH) uses CFOI data to support research and evaluation activities related to the National Occupational Research Agenda (NORA), a partnership between the public and private sectors to encourage workplace safety and health research. Since 1992, when BLS first introduced CFOI, BLS has annually reported data on fatal occupational injuries from all 50 states and the District of Columbia. For 2005, BLS reported a total of 5,702 work-related fatal injuries and a rate of 4.0 deaths per 100,000 workers; compared with 1992, this represents an 8% decline in the number of deaths (from 6,217 in 1992) and a 23% decline in the fatality rate (from 5.2 in 1992). This report summarizes the 2005 data, which indicated that the highest percentages of fatal workplace injuries were attributed to highway incidents, followed by falls, being struck by an object, and homicides. Since 1992, the number of deaths resulting from highway incidents, falls, and being struck by an object has increased, and the number of homicides has decreased. To reduce the number of workplace deaths, transportation measures targeting workers (e.g., truck safety and highway work-zone safety) should be enhanced by state and local transportation agencies and coordinated with highway-safety measures for the general public.     

Syringe exchange programs--United States, 2005

Syringe exchange programs (SEPs) provide free sterile syringes in exchange for used syringes to reduce transmission of bloodborne pathogens among injection-drug users (IDUs). SEPs in the United States began as a way to prevent the spread of human immunodeficiency virus (HIV) and other bloodborne infections such as hepatitis B and hepatitis C. The National Institute on Drug Abuse recommends that persons who continue to inject drugs use a new, sterile syringe for each injection. Monitoring syringe exchange activity is an important part of assessing HIV prevention measures in the United States. As of November 2007, a total of 185 SEPs were operating in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2007). This report summarizes a survey of SEP activities in the United States during 2005 and compares the findings with previous SEP surveys (Beth Israel Medical Center [BIMC], unpublished data, 2000 and 2004). The findings indicated an increase in overall funding for SEPs, including an increase in public funding, and a stabilization in both the number of SEPs operating and the number of syringes exchanged since 2004. This report also documents an expansion of services offered by SEPs, a trend that resulted from an increase in state and local funding. These expanded services are helping protect IDUs and their communities from the spread of bloodborne pathogens and are providing access to health services for a population at high risk. Monitoring of syringe exchange activity should continue.     

Trends in tuberculosis--United States, 2005

For 2005, a total of 14,093 tuberculosis (TB) cases (4.8 cases per 100,000 population) were reported in the United States, representing a 3.8% decline in the rate from 2004. This report summarizes provisional 2005 data from the national TB surveillance system and describes trends since 1993. The findings indicate that although the 2005 TB rate was the lowest recorded since national reporting began in 1953, the decline has slowed from an average of 7.1% per year (1993-2000) to an average of 3.8% per year (2001-2005). In 2005, the TB rate in foreign-born persons in the United States was 8.7 times that of U.S.-born persons. In addition, Hispanics, blacks, and Asians had TB rates 7.3, 8.3, and 19.6 times higher than whites, respectively. Moreover, the number of multidrug-resistant (MDR) TB cases in the United States increased 13.3%, with 128 cases (up from 113 in 2003) of MDR TB in 2004, the most recent year for which complete drug-susceptibility data are available. The deceleration of the decline in the overall national TB rate, the persistent disparities in TB rates between U.S.-born and foreign-born persons and between whites and racial/ethnic minorities, and the increase in MDR TB cases all threaten progress toward the goal of TB elimination in the United States. Effective TB control and prevention in the United States require sufficient resources, continued collaborative measures with other countries to reduce TB globally, and interventions targeted to U.S. populations with the highest TB rates.     

Prevalence of stroke--United States, 2005

Stroke is the third most common cause of death in the United States. Stroke also results in substantial health-care expenditures; the mean lifetime cost resulting from an ischemic stroke is estimated at $140,000 per patient. Nationwide, costs related to stroke are expected to reach an estimated $62.7 billion in 2007. Stroke death rates are higher in the southeastern United States, compared with other regions of the country; blacks, American Indians/Alaska Natives (AI/ANs), Asians/Pacific Islanders, and Hispanics die from stroke at younger ages than whites. Regional and national data on self-reported stroke prevalence have been published previously; however, state-specific prevalence data for persons with a history of stroke have not. To provide national-level stroke prevalence estimates by age group, sex, race/ethnicity, and education level and overall prevalence estimates for each of the 50 states, the U.S. Virgin Islands (USVI), the District of Columbia (DC), and Puerto Rico, CDC analyzed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of that analysis and provides the first state-based prevalence estimates of stroke. The results indicated that, in 2005, substantial differences existed in the prevalence of stroke by state/territory, race/ethnicity, age group, and education level. To lower the incidence of stroke and meet the Healthy People 2010 objective to reduce stroke deaths (objective no. 12-7) and the overall goal to eliminate health disparities, public health programs should augment stroke risk-factor prevention and educational measures in disproportionately affected regions and populations.     

Drowning--United States, 2005-2009

Drowning is a leading cause of unintentional injury death worldwide, and the highest rates are among children. Overall, drowning death rates in the United States have declined in the last decade; however, drowning is the leading cause of injury death among children aged 1-4 years. In 2001, approximately 3,300 persons died from unintentional drowning in recreational water settings, and an estimated 5,600 were treated in emergency departments (EDs). To update information on the incidence and characteristics of fatal and nonfatal unintentional drowning in the United States, CDC analyzed death certificate data from the National Vital Statistics System and injury data from the National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) for 2005-2009. The results indicated that each year an average of 3,880 persons were victims of fatal drowning and an estimated 5,789 persons were treated in U.S. hospital EDs for nonfatal drowning. Death rates and nonfatal injury rates were highest among children aged ≤4 years; these children most commonly drowned in swimming pools. The drowning death rate among males (2.07 per 100,000 population) was approximately four times that for females (0.54). To prevent drowning, all parents and children should learn survival swimming skills. In addition, 1) environmental protections (e.g., isolation pool fences and lifeguards) should be in place; 2) alcohol use should be avoided while swimming, boating, water skiing, or supervising children; 3) lifejackets should be used by all boaters and weaker swimmers; and 4) all caregivers and supervisors should have training in cardiopulmonary resuscitation.     

Reporting vaccine-associated paralytic poliomyelitis: concordance between the CDC and the National Vaccine Injury Compensation Program.

This paper compares cases of paralytic poliomyelitis reported to the systems operated by the National Vaccine Injury Compensation Program and the Centers for Disease Control and Prevention (CDC) for reporting of adverse events associated with vaccination. Of the 118 cases of vaccine-associated paralytic poliomyelitis determined by either system, 18 were reported initially only to the compensation program, 50 only to the CDC, and 50 to both. The annual incidence of vaccine-associated paralytic poliomyelitis determined from data from both systems varied from 6 to 13 cases (mean = 9.1) a year, with an increase of 1.4 cases a year when initial reports only to the compensation program are included. Thus, the compensation program provides important supplemental incidence data.