Eradicating Polio: How the World’s Pediatricians Can Help Stop This Crippling Illness Forever

Abstract

The American Academy of Pediatrics strongly supports the Polio Eradication and Endgame Strategic Plan of the Global Polio Eradication Initiative. This plan was endorsed in November 2012 by the Strategic Advisory Group of Experts on Immunization of the World Health Organization and published by the World Health Organization in April 2013. As a key component of the plan, it will be necessary to stop oral polio vaccine (OPV) use globally to achieve eradication, because the attenuated viruses in the vaccine rarely can cause polio. The plan includes procedures for elimination of vaccine-associated paralytic polio and circulating vaccine-derived polioviruses (cVDPVs). cVDPVs can proliferate when vaccine viruses are transmitted among susceptible people, resulting in mutations conferring both the neurovirulence and transmissibility characteristics of wild polioviruses. Although there are 3 different types of wild poliovirus strains, the polio eradication effort has already resulted in the global elimination of type 2 poliovirus for more than a decade. Type 3 poliovirus may be eliminated because the wild type 3 poliovirus was last detected in 2012. Thus, of the 3 wild types, only wild type 1 poliovirus is still known to be circulating and causing disease. OPV remains the key vaccine for eradicating wild polioviruses in polio-infected countries because it induces high levels of systemic immunity to prevent paralysis and intestinal immunity to reduce transmission. However, OPV is a rare cause of paralysis and the substantial decrease in wild-type disease has resulted in estimates that the vaccine is causing more polio-related paralysis annually in recent years than the wild virus. The new endgame strategic plan calls for stepwise removal of the type 2 poliovirus component from trivalent oral vaccines, because type 2 wild poliovirus appears to have been eradicated (since 1999) and yet is the main cause of cVDPV outbreaks and approximately 40% of vaccine-associated paralytic polio cases. The Endgame and Strategic Plan will be accomplished by shifting from trivalent OPV to bivalent OPV (containing types 1 and 3 poliovirus only). It will be necessary to introduce trivalent inactivated poliovirus vaccine (IPV) into routine immunization programs in all countries using OPV to provide population immunity to type 2 before the switch from trivalent OPV to bivalent OPV. The Global Polio Eradication Initiative hopes to achieve global eradication of polio by 2018 with this strategy, after which all OPV use will be stopped. Challenges expected for adding IPV into routine immunization schedules include higher cost of IPV compared with OPV, cold-chain capacity limits, more complex administration of vaccine because IPV requires injections as opposed to oral administration, and inferior intestinal immunity conferred by IPV. The goal of this report is to help pediatricians understand the change in strategy and outline ways that pediatricians can help global polio eradication efforts, including advocating for the resources needed to accomplish polio eradication and for incorporation of IPV into routine immunization programs in all countries.