Controlling Spread of Poliomyelitis

A. Minimum Period of Isolation of a Suspect or Confirmed Case

Place case on enteric precautions for six weeks after onset of symptoms or until poliovirus can no longer be recovered from feces (the number of negative specimens needed will be determined by the IDPH on a case-by-case basis).

B. Minimum Period of Quarantine of Contacts

None.

C. Protection of Contacts of a Case 

Implement control measures as described below while waiting for laboratory confirmation. While indigenous transmission of wild-type poliovirus in the United States (and the Western Hemisphere as a whole) has not occurred since 1991, the importation of poliovirus from polio-endemic regions may occur among under-immunized (1) tourists, (2) immigrants revisiting their countries of origin, or (3) members of religious groups who might refuse immunization, regardless of travel history. Polio-endemic regions include Afghanistan, Nigeria and Pakistan. An IDPH epidemiologist can help assess the likelihood of exposure to wild-type polio.

OPV is still being used outside of the U.S. Vaccine-associated paralytic poliomyelitis (VAPP) should also be considered as a cause of paralysis, especially if a patient has onset of paralysis after receipt of a first dose of OPV. No control measures are indicated if the case is determined to likely be VAPP. It is also possible that the case of paralysis is due to an infectious agent other than poliovirus, such as enterovirus, or due to some other noninfectious cause, and therefore not contagious. Therefore, it is crucial that laboratory testing be initiated to determine if the causative agent of paralysis is poliovirus and to differentiate wild-type from vaccine strain poliovirus.

Identify individuals or groups who may have been exposed to the case. Also, attempt to identify the route of introduction of poliovirus into the community. To identify these groups, think in terms of “zones of exposure” and consider members of the following groups:

• Household members
• School/ child care associates (students/attendees and staff)
• Staff and patients at medical facility where patient was cared for, especially if there was the potential for direct contact with feces or oral secretions
• Religious/social groups
• Sports teams and other extracurricular groups
• Bus mates
• Close friends
• Travelers from polio-endemic regions such as Afghanistan, Egypt, India, Niger, Nigeria, and Pakistan
• Any other persons who may have come in direct contact with the case’s feces or oral secretions

Identify high-risk susceptibles who had contact with the case during infectious period:

• Pregnant women should be referred to their obstetricians. (In child care or school settings remember to determine whether teachers, student-teachers, staff or students are pregnant.)
• Immunocompromised individuals should be referred to their healthcare providers.
• Infants < 6 weeks old (who are too young to have been vaccinated) should be referred to their pediatricians.

Identify and vaccinate all other susceptibles > 6 weeks old with IPV (if not contraindicated).  These are individuals without proof of immunity, including those with medical or religious exemptions to immunization.  Proof of immunity to poliovirus is defined as:

• For children (< 18 years of age): documentation of receipt of > 4 doses of polio vaccine with a minimum interval of 4 weeks between doses; only 3 doses are needed when the third dose is given on or after the fourth birthday. 

• For adults (> 18 years of age): documentation of receipt of > 3 doses of polio vaccine with a minimum interval of 4 weeks between doses with documentation of > 1 booster dose.

Remember, an individual who has received a primary series consisting of > 3 doses of vaccine AND has received > 1 booster dose does NOT need to receive another dose.

Note:

• Vaccinating an exposed individual who may be incubating poliovirus is not harmful.

Immune globulin (IG) has been found to be of no value as postexposure prophylaxis and is not recommended. (If the use of OPV for a mass vaccination campaign to control a polio outbreak in the U.S. is indicated, the CDC will advise the IDPH on how to obtain an emergency supply of OPV, who should receive OPV, and any other pertinent control measures.)

Apply precautions and isolate/exclude as follows:

• Case: Place on enteric precautions and exclude for 6 weeks after onset or until virus can no longer be recovered from feces (the number of negative specimens needed will be determined on a case-by-case basis).

• Contacts: Administer IPV; do not exclude.

Surveillance

Active surveillance for acute flaccid paralysis and other symptoms of polio infection should continue for at least 2 incubation periods (i.e., up to 70 days) beyond the onset of the last case in an area.

D. Preventive Measures

Vaccination, including routine childhood vaccination, catch-up vaccination of adolescents, and targeted vaccination of high-risk adult groups, is the best preventive measure against polio. Good personal hygiene (particularly proper handwashing) is also very important.

Routine Polio Childhood Immunization Recommendations

An all-IPV polio immunization schedule is now the recommended schedule. OPV is no longer recommended and is not available in the U.S. Four doses of IPV are usually needed to complete the primary series: doses are recommended at ages 2 months, 4 months, 6-18 months, and 4-6 years. At least 28 days are needed between doses, although a 6-8 week interval is preferred between doses 2 and 3 and a 6-month interval is preferred between doses 3 and 4. Only 3 doses are needed when the third dose is given on or after the fourth birthday. Polio vaccine is not routinely recommended for those > 18 years unless there is potential for exposure.

Polio Vaccine and Adults

Routine vaccination of persons >18 years of age residing in the U.S. is not necessary. However, polio vaccination is indicated for the following groups:

• Laboratory workers who handle poliovirus;
• Healthcare workers caring for polio patients;
• Persons traveling to regions of the world where polio is endemic or epidemic.

Polio Vaccination and Travel

In assessing the risk to a traveler for polio transmission, healthcare providers are urged to determine first if their patients will truly be traveling to a polio endemic or epidemic area, including Afghanistan, Cameroon, Nigeria, Pakistan and Somalia. Visit: www.cdc.gov/travel to obtain information on the risk of transmission of poliovirus in specific countries.

If travel to a polio-endemic or epidemic region is anticipated, please review the patient’s history of polio immunization. Ninety percent or more of vaccine recipients develop protective immunity to all three poliovirus types after two doses, and at least 99% are immune following three doses.

• If the patient has received a complete primary series of > 3 doses of polio vaccine, administer a booster dose of IPV. Remember, a single booster dose is all that is needed.

• If the patient is unimmunized or partially immunized, follow an accelerated schedule to complete as much of the series as possible before departure, as outlined in the table below:

Polio Vaccine Schedule

Weeks Available	Accelerated IPV Schedule*
> 8 weeks	3 doses, given 4 weeks apart
4-7 weeks	2 doses, given 4 weeks apart
< 4 weeks	1 dose

 * 1st dose may be given as early as 6 weeks of age