Spread of vaccine-derived poliovirus from a paralytic case in an immunodeficient child: an insight into the natural evolution of oral polio vaccine

Sabin strains used in the manufacture of oral polio vaccine (OPV) replicate in the human organism and can give rise to vaccine-derived polioviruses. The increased neurovirulence of vaccine derivatives has been known since the beginning of OPV use, but their ability to establish circulation in communities has been recognized only recently during the latest stages of the polio eradication campaign. This important observation called for studies of their emergence and evolution as well as extensive surveillance to determine the scope of this phenomenon. Here, we present the results of a study of vaccine-derived isolates from an immunocompromised poliomyelitis patient, the contacts, and the local sewage. All isolates were identified as closely related and slightly evolved vaccine derivatives with a recombinant type 2/type 1 genome. The strains also shared several amino acid substitutions including a mutation in the VP1 protein that was previously shown to be associated with the loss of attenuation. Another mutation in the VP3 protein resulted in altered immunological properties of the isolates, possibly facilitating virus spread in immunized populations. The patterns and rates of the accumulation of synonymous mutations in isolates collected from the patient over the extended period of excretion suggest either a substantially nonuniform rate of mutagenesis throughout the genome, or, more likely, the strains may have been intratypic recombinants between coevolving derivatives with different degrees of divergence from the vaccine parent. This study provides insight into the early stages of the establishment of circulation by runaway vaccine strains.     

First decade (1950-1960) of studies and trials with the polio vaccine.

The chronology of the development of polio vaccines following the first human trials of attenuated poliovirus vaccine in 1950 is described by me as a witness to the first decade of trials and tribulations following my discovery of polio vaccine in 1950. Mass vaccination trials are considered to be the most important phase of the discovery of oral polio vaccine (OPV). These took place in the Belgian Congo, Poland, Croatia, Switzerland, and finally in the former Soviet Union. By 1960, approximately 13 million individuals had been vaccinated with the Koprowski oral polio vaccine and over 11 million with the Sabin vaccine.     

A vision of a world without polio: the OPV cessation strategy.

Once the eradication of wild poliovirus has been confirmed, the public health benefits of routine immunization with OPV will no longer outweigh the burden of disease either due to paralysis caused by OPV (vaccine associated paralytic polio), or by outbreaks caused by circulating vaccine-derived polioviruses. The eventual cessation of OPV use in routine immunization programmes worldwide will become necessary to assure a lasting eradication of polio. As the world moves towards polio eradication and its certification, preparations are therefore being intensified for OPV cessation, and the risk management framework for safe OPV cessation is being put in place. The framework includes bio-containment of all known poliovirus and potentially infected substances, development of an international stockpile of oral polio vaccine, ensuring a mechanism for continued global surveillance and response for polio after eradication has been certified, and national policies if countries decide to continue vaccinating with inactivated polio vaccine (IPV). It is ironic that the vaccine on which the world has depended for polio eradication will itself become a risk to eradication once the transmission of wild poliovirus has been interrupted. Final preparations for the eventual global and simultaneous cessation of OPV will require the same level of international cooperation and coordination that has brought the world to the verge of polio eradication.     

Hypotheses and facts

The book, The river, is based on assumptions and not facts. Oral polio vaccine was produced entirely in rhesus monkey kidney cell cultures. Allegations that it was produced in chimpanzee kidneys at the Wistar Institute in Philadelphia or, alternatively, that the vaccine was made in the then Belgian Congo in chimpanzee kidney has no basis in fact. As the only witness to the historical events leading to the development of oral polio vaccine, I have demonstrated in this paper the truthful facts excluding any link between oral polio vaccine and human immunodeficiency virus.     

Some ethical issues arising from polio eradication programmes in India

The World Health Organisation's programme for the eradication of poliomyelitis as currently practised in India raises many ethical issues. In this paper we concentrate on just two. The first is the balance to be struck between the risks and benefits generated by the eradication programme itself. The issue of risks and benefits arises in relation to the choice between two different vaccine types available for polio programmes: oral polio vaccine (OPV) and inactivated polio vaccine (IPV). OPV is the vaccine currently used in the eradication campaign in India. We argue that given the current risks/benefits profile of this vaccine, there is an urgent need to review the programme and take remedial action to address existing problems (at least in India). The second issue we discuss is the fact that there is little effort to gain the informed consent of the parents of vaccinated children, as they are not currently told about the potential limitations of OPV or the possibility of vaccine-induced harm. We suggest that such a policy might be justifiable, given the importance of polio eradication, but only if there is a system of compensation for vaccine-induced harm as part of the eradication programme itself. There is a real danger that if these issues are not addressed then public trust in the eradication programme and vaccination programmes as a whole will be lost.     

The long-term economic effects of polio: Evidence from the introduction of the polio vaccine to Sweden in 1957

This study explores the impact an exogenous improvement in childhood health has on later-life outcomes. Using extensive and detailed register data from the Swedish Interdisciplinary Panel covering up to 2011, we follow individuals exposed to the introduction of the first vaccine against polio in Sweden (birth cohorts 1937–1966) until adulthood in order to quantify the causal effect of polio vaccination on long-term economic outcomes. The results show that, contrary to what has been found in the literature for other health-related interventions, including other vaccines, exposure to the vaccine against polio did not seem to have any long-term effects on the studied adult economic outcomes. Upon closer inspection of how the disease affects children, this might be explained by the fact that no scarring effects from exposure to high incidence of polio were found on adult income, educational achievement, or hospitalizations, which seems to suggest that those who contracted the illness but suffered only the milder symptoms of the disease made a full recovery and had no lifelong sequels as a consequence of the condition. The absence of scarring effects is hypothesized to be related to the pathology and epidemiology of the disease itself, which infects many, but scars only those who suffer the most recognizable paralytic symptoms.     

消灭脊髓灰质炎行动现状分析及免疫策略建议

脊髓灰质炎曾在全球广泛流行和传播,严重危害儿童健康。自1988年世界卫生大会发起全球消灭脊髓灰质炎行动倡议以来,全球脊髓灰质炎防控工作取得显著进展,但消灭脊髓灰质炎工作仍面临重重挑战。在目前维持无脊髓灰质炎状态下,我国面临的主要问题是疫苗相关麻痹型脊髓灰质炎(vaccine associated paralytic poliomyelitis, VAPP)病例和脊髓灰质炎疫苗衍生病毒(vaccine-derived poliovirus,VDPV)病例的发生。为此,通过回顾消灭脊髓灰质炎工作取得的进展,总结不同国家或地区在消灭脊髓灰质炎过程中所采用的防控策略,尤其是不同国家或地区的脊髓灰质炎疫苗使用经验,分析消灭脊髓灰质炎最后阶段面临的挑战,进而提出应对策略和建议,即科学评价防控措施、适时调整脊髓灰质炎免疫策略、努力消除接种犹豫并提高疫苗接种率,这对早日实现根除脊髓灰质炎的目标是非常有必要的。     

Next Generation Inactivated Polio Vaccine Manufacturing to Support Post Polio-Eradication Biosafety Goals

Worldwide efforts to eradicate polio caused a tipping point in polio vaccination strategies. A switch from the oral polio vaccine, which can cause circulating and virulent vaccine derived polioviruses, to inactivated polio vaccines (IPV) is scheduled. Moreover, a manufacturing process, using attenuated virus strains instead of wild-type polioviruses, is demanded to enhance worldwide production of IPV, especially in low- and middle income countries. Therefore, development of an IPV from attenuated (Sabin) poliovirus strains (sIPV) was pursued. Starting from the current IPV production process based on wild type Salk strains, adaptations, such as lower virus cultivation temperature, were implemented. sIPV was produced at industrial scale followed by formulation of both plain and aluminium adjuvanted sIPV. The final products met the quality criteria, were immunogenic in rats, showed no toxicity in rabbits and could be released for testing in the clinic. Concluding, sIPV was developed to manufacturing scale. The technology can be transferred worldwide to support post polio-eradication biosafety goals.     

Family Practitioners' Immunization Consent Practice Washington State, 1986

Of 400 Washington State family practitioners surveyed in 1986, 46% of those who give routine immunizations reported that they require written parental consent before administering vaccine. In all, 57% of respondents said they discuss diphtheria-tetanus-pertussis, measles-mumps-rubella, and oral polio vaccine with their patients. Nearly half provide written information on these immunizations, except for inactivated polio vaccine, for which fewer than 20% of the physicians surveyed provide verbal or written information.     

The Jezierski papers: live polio vaccine development in colobus monkey cells but not chimpanzee cells in the Belgian Congo, 1952-1958

A reading of ten relevant papers by Alexandre Jezierski provides evidence for the only attempt in Central Africa to develop a live oral polio vaccine (OPV) from growing reference wild polio strains to 210 passages in colobus monkey tissue culture, and experimental administration to about 25 humans. Chimpanzees were used as a human model, but their tissues or kidneys were absent from the passage and production line of the proposed vaccine. Thus, the implication published by Hooper that Jezierski had produced a candidate OPV that might have contained chimpanzee viruses, possibly simian immunodeficiency virus cpz or the precursor of human immunodeficiency virus-1 group M, is incorrect.     

Manufacturing and supply of monovalent oral polio vaccines.

A new polio vaccine was developed, produced and licensed by sanofi pasteur at the request of the World Health Organization (WHO) for mass immunization campaigns in endemic countries such as Egypt. The new vaccine, monovalent oral polio vaccine 1 or mOPV1, is currently used in Egypt as a critical part of a new WHO strategy to end polio type 1 transmission by the end of the year 2005 (types 2 and 3 polioviruses have already been eliminated from Egypt). To answer this specific need, an urgent program was mounted by Sanofi pasteur to manufacture 50million doses for Egypt, in close collaboration with WHO and National Regulatory Agencies (France and Egypt). The joint efforts between manufacturer, regulators and the WHO resulted in the quickest ever vaccine development and licensure and WHO pre-qualification. The production of mOPV was based on existing tOPV but with appropriate "change control" procedures to assure the quality of the product, and to distinguish mOPV from tOPV. Key success factors included clear and careful definition of the project; close collaboration between manufacturer, regulators and WHO; and commitment and motivation of staff. As a result, development and production of mOPV1 vaccine were carried out in a drastically reduced time period, leading to the release and delivery of the first 15 million doses of mOPV1 in April 2005.     

Unraveling the Transmission Ecology of Polio

Sustained and coordinated vaccination efforts have brought polio eradication within reach. Anticipating the eradication of wild poliovirus (WPV) and the subsequent challenges in preventing its re-emergence, we look to the past to identify why polio rose to epidemic levels in the mid-20th century, and how WPV persisted over large geographic scales. We analyzed an extensive epidemiological dataset, spanning the 1930s to the 1950s and spatially replicated across each state in the United States, to glean insight into the drivers of polio’s historical expansion and the ecological mode of its persistence prior to vaccine introduction. We document a latitudinal gradient in polio’s seasonality. Additionally, we fitted and validated mechanistic transmission models to data from each US state independently. The fitted models revealed that: (1) polio persistence was the product of a dynamic mosaic of source and sink populations; (2) geographic heterogeneity of seasonal transmission conditions account for the latitudinal structure of polio epidemics; (3) contrary to the prevailing “disease of development” hypothesis, our analyses demonstrate that polio’s historical expansion was straightforwardly explained by demographic trends rather than improvements in sanitation and hygiene; and (4) the absence of clinical disease is not a reliable indicator of polio transmission, because widespread polio transmission was likely in the multiyear absence of clinical disease. As the world edges closer to global polio eradication and continues the strategic withdrawal of the Oral Polio Vaccine (OPV), the regular identification of, and rapid response to, these silent chains of transmission is of the utmost importance.     

Economic considerations for the eradication endgame

An infectious disease will be eradicated only if it is eliminated everywhere, including in the hardest-to-reach, most vaccine-wary communities. If eradication is successful, it promises a dividend in the form of avoided infections and vaccinations. However, success is never certain unless and until eradication is achieved, and claiming the dividend means bearing the possibly great risk of re-emergence. Economic analysis of eradication evaluates these risks and rewards relative to the alternative of ‘optimal control’, and also exposes the incentives for achieving and capitalizing on eradication. Eradication is a ‘game’, because some countries may be willing to eliminate the disease within their borders only if assured that all others will eliminate the disease within their borders. International financing is also a game, because each country would rather free ride than contribute. Finally, for diseases such as polio, capitalizing on eradication is a game, for should any country continue to vaccinate in the post-eradication era using the live-attenuated polio vaccine, the countries that stop vaccinating will be exposed to the risk of vaccine-derived polioviruses. In the framework developed in this paper, eradication is a seductive goal, its attainment fraught with peril.     

Scale‐down of the inactivated polio vaccine production process

The anticipated increase in the demand for inactivated polio vaccines resulting from the success in the polio eradication program requires an increase in production capacity and cost price reduction of the current inactivated polio vaccine production processes. Improvement of existing production processes is necessary as the initial process development has been done decades ago. An up‐to‐date lab‐scale version encompassing the legacy inactivated polio vaccine production process was set‐up. This lab‐scale version should be representative of the large scale, meaning a scale‐down model, to allow experiments for process optimization that can be readily applied. Initially the separate unit operations were scaled‐down at setpoint. Subsequently, the unit operations were applied successively in a comparative manner to large‐scale manufacturing. This allows the assessment of the effects of changes in one unit operation to the consecutive units at small‐scale. Challenges in translating large‐scale operations to lab‐scale are discussed, and the concessions that needed to be made are described. The current scale‐down model for cell and virus culture (2.3‐L) presents a feasible model with its production scale counterpart (750‐L) when operated at setpoint. Also, the current scale‐down models for the DSP unit operations clarification, concentration, size exclusion chromatography, ion exchange chromatography, and inactivation are in agreement with the manufacturing scale. The small‐scale units can be used separately, as well as sequentially, to study variations and critical product quality attributes in the production process. Finally, it is shown that the scale‐down unit operations can be used consecutively to prepare trivalent vaccine at lab‐scale with comparable characteristics to the product produced at manufacturing scale. Biotechnol. Bioeng. 2013; 110: 1354–1365. © 2012 Wiley Periodicals, Inc.     

Changes in three of the four coat proteins of oral polio vaccine strain derived from type 1 poliovirus.

Little is yet known about the nature, or extent, of the changes involved in attenuation of neurovirulent poliovirus. The tryptic comparison reported here, of coat proteins from the Sabin type 1 polio vaccine and parental Mahoney virus, provides a useful approach and affords some insight into this question. The main obstacle, separation of the labile proteins VP1 and VP2 in an intact state from the vaccine strain, was overcome by incorporating 3.5 M urea into an otherwise standard preparative gel electrophoresis system. Tryptic maps revealed six altered leucine-containing peaks: two in VP1, none in VP2, three in VP3, and one in VP4. It is estimated, after correcting for leucine-free peptides, that the coat protein sequences may have undergone some 10 to 13 amino acid replacements, roughly 1.5% of the total, in the course of attenuation leading to the vaccine strain.     

Excretion of wild-type and vaccine-derived poliovirus in the feces of poliovirus receptor-transgenic mice

The emergence of circulating vaccine-derived poliovirus (cVDPV) strains in suboptimally vaccinated populations is a serious threat to the global poliovirus eradication. The genetic determinants for the transmissibility phenotype of polioviruses, and in particularly of cVDPV strains, are currently unknown. Here we describe the fecal excretion of wild-type poliovirus, oral polio vaccine, and cVDPV (Hispaniola) strains after intraperitoneal injection in poliovirus receptor-transgenic mice. Both the pattern and the level of fecal excretion of the cVDPV strains resemble those of wild-type poliovirus type 1. In contrast, very little poliovirus was present in the feces after oral polio vaccine administration. This mouse model will be helpful in elucidating the genetic determinants for the high fecal-oral transmission phenotype of cVDPV strains.     

1989－1994年中国脊髓灰质炎病毒的分子流行病学

１９８９～１９９４年中国发生的脊髓灰质炎流行,疫情开始集中于华东、中南地区,后期趋于南部沿海一带。对近百份来自１８个省、市、自治区脊灰病毒流行期间标本的分子生物学特征分析,发现流行主要由脊灰病毒Ⅰ型野毒株引起,未发现Ⅱ型野毒株,但１９９３年在新疆分离到１株Ⅲ型野毒株。Ⅰ型野毒株中共存在４个基因型病毒,其中ＣＨＮＰ１－Ｒ９１型病毒为这几年流行中新产生的重组病毒,在ＶＰ１／２Ａ区含有一段疫苗株序列,另一段野毒株序列很可能来自ＣＨＮＰ１－ＪＸ８９型病毒。这两个基因型病毒分布在全国大部份地区。病毒核酸的亲缘关系研究还证明,９２～９４年流行在南方沿海一带的脊髓灰质炎,主要由９１年产生的重组病毒引起。此研究揭示了各地区、各基因型病毒与疫情之间的流行病学关系及传播模式。     

Cold chain monitoring of OPV at transit levels in India: correlation of VVM and potency status

We have conducted a study to analyze monitoring of the cold chain of 674 OPV field samples collected at four different levels of vaccine distribution viz., immunization clinics, district stores, hospitals and Primary Health Centers (PHC) from states of Uttar Pradesh, Madhya Pradesh, and Delhi. The study design included: collection and scoring of vaccine vial monitor (VVM) status of the samples and testing for total oral polio virus concentration (TOPV) by standard WHO protocol. Ten samples each were exposed to 25 degrees C and 37 degrees C, and 10 samples as controls were kept at -20 degrees C. VVM were scored daily till they attained grade 4 and each sample was subsequently subjected to potency testing for individual polio serotypes 1, 2 and 3, and TOPV.Of the 674 samples tested it was observed that: samples from immunization clinics and district stores had an acceptable VVM score of grade 1 and 2; however the probable risk that a sub potent vaccine could have been administered was 2.15%. In 2.5% samples received from district stores vaccine had a VVM score of grade 3 (i.e., discard point), although vaccine when tested was found to be potent (i.e., leading to the vaccine wastage). With exposure to higher temperatures, VVM changed score to grade 2 and 3 when the vaccine was kept at 25 degrees C/37 degrees C, and the titres of individual serotypes 1, 2 and 3 and TOPV were beyond the acceptable limits.Important observations at the different levels of vaccine distribution network and correlation of VVM and potency status of OPV are discussed in the paper which will be of help to the EPI program managers at different transit levels.