Prevalence of neutralizing antibodies against poliovirus 1, 2, and 3 in healthcare professionals aged 20-50 years / Prevalência de anticorpos neutralizantes contra poliovírus 1, 2 e 3 em profissionais de saúde de 20 a 50 anos de idade

ABSTRACT Objective: To describe the prevalence of neutralizing antibodies against poliovirus (PV1, PV2, and PV3) in blood samples of healthcare professionals aged 20 to 50 years. Methods: Health professionals who serve children at Darcy Vargas Children's Hospital and the Department of Pediatrics of Irmandade da Santa Casa de São Paulo. The sample size was calculated at 323 participants. The Mantel-Haenszel chi-square was used to verify differences between groups. The neutralization reaction detected human poliovirus antibodies. For susceptible individuals, vaccination with the inactivated+triple acellular polio vaccine was performed, and neutralizing antibodies were re-dosed after one week. Results: 333 professionals were studied - 92.8% were immune to poliovirus 1, 86.5% to poliovirus 2, and 63.3% to poliovirus 3; 37% had titers less than 1:8 for any serotype, 5;1% had titers below 1:8 for all three. Vaccination with inactivated polio vaccine was performed for susceptible participants, and neutralizing antibodies were dosed after one week, showing increased titers for all polioviruses. Conclusions: Despite the detection of a significant percentage of individuals with low poliovirus antibody titer, the challenge with vaccination demonstrated immune response compatible with poliovirus immunity.

RESUMO Objetivo: Descrever a prevalência de anticorpos neutralizantes contra poliovírus (tipos 1, 2 e 3) em amostra de sangue de profissionais de saúde com idade de 20 a 50 anos. Métodos: Profissionais de saúde que atendem crianças do Hospital Infantil Darcy Vargas e do Departamento de Pediatria da Irmandade da Santa Casa de São Paulo. O tamanho da amostra foi de 323 participantes. Os anticorpos contra poliovírus humanos foram detectados pela reação de neutralização. Para os indivíduos suscetíveis, foram administradas vacina para poliomielite inativada+tríplice e nova dosagem de anticorpos neutralizantes após uma semana. Utilizou-se o teste do qui-quadrado de Mantel-Haenszel para verificar as diferenças entre os grupos. Resultados: Foram estudados 333 profissionais - 92,8% eram imunes ao poliovírus 1; 86,5%, ao poliovírus 2; 63,57%, ao poliovírus 3; 37% apresentaram títulos inferiores a 1:8 para qualquer sorotipo; 5,1% tinham títulos abaixo de 1:8 para os três. Após a vacinação dos suscetíveis, houve elevação dos títulos para todos os poliovírus. Conclusões: Apesar da detecção de percentual significativo de indivíduos com baixo título de anticorpos para poliovírus, o desafio da vacinação demonstrou resposta imune robusta compatível.

Remarks on the possibility of introducing the fractionated dose of the inactivated poliomyelitis vaccine in the Latin American Child Immunization Schedule

Abstract Given that the last notified case of poliomyelitis due to wild poliovirus type 2 was in 1999, in 2012, the Strategic Advisory Group of Experts on Immunization (SAGE) of the World Health Organization (WHO) recommended the withdrawal of the type 2 component of oral polio vaccine (OPV) and the introduction of a bivalent OPV (bOPV) in all countries by 2016. WHO recommended also that the withdrawal should be preceded by the introduction of at least one dose of inactivated poliovirus vaccine (IPV) in routine immunization schedules. The introduction of IPV prior to the change of the bOPV in 2016 to trivalent OPV (tOPV) was based on the concept of ensuring that a substantial proportion of the population would be protected against type 2 polio after the removal of the type 2 OPV. However, the world's two producers of IPV (Bilthoven Biologicals and Sanofi) have faced problems in the production of this vaccine and therefore reported a reduction of the global supply of IPV. In response to the potential shortage of IPV, at a meeting held on March 10 2017, the SAGE and Technical Advisory Group (TAG) of the Pan American Health Organization (PAHO) urged the countries in the Latin American region to replace the routine administration of the full doses of inactivated polio vaccine (IPV-C) in the immunization schedule (administered by intramuscular route), administering a fraction of the full dose in two intradermal shots (IPV-f). The possibility of this strategy was analyzed by opinion leaders convened by the Paraguayan Society of Pediatrics with the support of the Latin American Society of Pediatric Infectious Diseases (SLIPE) and Latin American Association of Pediatrics (ALAPE). This document presents the results of the discussion.

Consideraciones referente a la posibilidad de introducir la dosis fraccionada de la vacuna antipoliomielitis inactivada en el calendario de Inmunizaciones del Niño Latinoamericano / Remarks on the possibility of the introduction of fractionated dose of the inactivated poliomyelitis vaccine in the Latin American Child Immunization Schedule

As last notified case of poliomyelitis due to wild poliovirus type 2 was 1999, in 2012, the Strategic Advisory Group of Experts on Immunization (SAGE) of the World Health Organization (WHO) recommended the withdrawal of the type 2 component of oral polio vaccine (OPV) and the introduction of bivalent OPV (bOPV) in all countries by 2016. WHO recommended also that the withdrawal should be preceded by the introduction of at least one dose of inactivated poliovirus vaccine (IPV) in routine immunization schedules. The introduction of IPV prior to the change of the bOPV in 2016 to trivalent OPV (tOPV) was based on the concept of ensuring that a substantial proportion of the population would be protected against type 2 polio after the removal of the type 2 OPV. However, the world's two producers of IPV (Bilthoven Biologicals and Sanofi) have faced problems in the production of this vaccine and therefore reported reduction in IPV global supply. In response to the possible shortage of IPV, the SAGE and Technical Adviser Group (TAG) of the Pan American Health Organization (PAHO), in the meeting of March 10, 2017, has urged that countries in the Latinamerican region should replace the routine administration of the full doses of polio inactivated vaccine (IPV-C) in the immunization schedule (administered by intramuscular route) by the administration of a fraction of the full dose in two shots by intradermal route (IPV-f). The possibility of this strategy was analyzed by leaders of opinions gathered by the call of the Paraguayan Pediatric Society with the support of the Latin American Society of Pediatric Infectious Diseases (SLIPE) and Latin American Association of Pediatrics (ALAPE). The results of the discussion are presented in this document.

Síndrome de Nicolau por la administración de la vacuna séxtuple intramuscular en un lactante de 6 meses / Nicolau syndrome induced by intramuscular injection of a hexavalent vaccine in a 6-month-old girl

El síndrome de Nicolau, también conocido como embolia cutis medicamentosa o dermatitis livedoide, es una reacción cutánea infrecuente, caracterizada por una necrosis de la piel y los tejidos blandos de aparición súbita luego de la aplicación intramuscular de algunas drogas. Presentamos a un bebé de 6 meses de edad que, al recibir la tercera dosis de la vacuna séxtuple intramuscular, desarrolló una lesión necrótica con reticulado violáceo periférico en el sitio de aplicación. Se destaca la importancia del diagnóstico precoz a fin de instaurar un adecuado tratamiento y seguimiento para evitar complicaciones secundarias a la isquemia.

Nicolau syndrome, also known as embolia cutis medicamentosa or livedo-like dermatitis, is a sudden tissue necrosis, a rare complication of intramuscular injection of some drugs. We report a case of a 6-month-old girl who received intramuscularly the third dose of hexavalent vaccine (DTaP-HVB-IPV/HIb), and immediately presented a livedoid lesion around the injection site, progressing to necrosis. We reinforce the importance of early diagnosis to perform a suitable treatment and clinical follow-up to avoid ischemic secondary complications.

Internações sensíveis à atenção primária específicas de mulheres / Sensitive female-specific hospitalization in primary care

Objetivou-se analisar as internações por condições sensíveis à atenção primária (ICSAP) específicas em mulheres e os fatores que determinam ou influenciam a ocorrência dessas internações (fatores socioeconômicos, sociodemográficos e controle de saúde) por meio de um inquérito de morbidade hospitalar realizado com amostra de 429 mulheres internadas em hospitais conveniados ao Sistema Único de Saúde. O percentual de ICSAP foi 49,42% (n = 212), com destaque para as internações específicas do sexo feminino 19,35% (n = 83). Associaram ao risco de internar por CSAP: idade superior a 60 anos, baixa escolaridade, internação prévia, realização de controle regular de saúde, falta de vínculo com a Estratégia Saúde da Família (ESF) e ser gestante. As causas evidentes foram as condições relacionadas à gravidez, ao parto e ao puerpério e às inflamações nos órgãos pélvicos femininos. Os resultados sugerem falhas no atendimento ambulatorial que deveria ser oportuno e resolutivo no contexto da saúde da mulher.

The scope of this paper was to analyze female-specific sensitive hospitalization occurring in primary care conditions and factors that determine or affect the occurrence of such hospitalizations (social, economic and demographic factors; health control). Analysis was performed by surveys on hospital morbidity with a sample of 429 females attended in Unified Health System (SUS) contracted hospitals. The sensitive hospitalizations percentage in primary care reached 49.42% (n = 212), highlighting female-specific hospitalization at 19.35% (n = 83). Hospitalization risks comprised elderly people over sixty, low schooling, previous hospitalizations, normal health control, lack of association with the Family Health Strategy and pregnancy. Evident causes were related to conditions of pregnancy, childbirth, post-partum and inflammations of the female pelvic organs. Results suggested flaws in outpatient attendance that should be adequate and provide solutions in women’s health.

Reactogenicidad asociada a la administración intradérmica de la vacuna de polio inactivada con un inyector sin aguja / Reactogenicity associated to the intradermally administered inactivated poliovirus vaccine with a needle-free injector

INTRODUCCIÓN: en la medida en que la meta de la erradicación de la poliomielitis llega a su concreción, la necesidad de contar con una vacuna de polio inactivada asequible y apropiada para el uso en países en vías de desarrollo se ha convertido en una meta para la Organización Mundial de la Salud. OBJETIVO: la evaluación de la reactogenicidad de la vacuna de polio inactivada. MÉTODOS: se realizó un estudio multicéntrico con diseño experimental, correspondiente a Fase I-II de un ensayo clínico controlado, aleatorio y a simple ciegas, en 471 lactantes sanos de ambos sexos nacidos entre los meses de julio y agosto de 2006 en Camagüey, cuyos padres brindaron su consentimiento por escrito y que cumplieron con los criterios de inclusión establecidos. Los niños recibieron a las 6, 10 y 14 semanas del nacimiento, tres dosis de vacuna de polio inactivada del Instituto de Sueros de Dinamarca, autorizada para su uso en esta investigación por las autoridades regulatorias nacionales. Al grupo de estudio A, se le administró por la vía intradérmica la dosis reducida de 0,1 mL de vacuna de polio inactivada en la cara anterolateral del muslo izquierdo utilizando el inyector sin aguja Biojector® 2000. El grupo control B recibió la dosis usual de 0,5 mL por la vía intramuscular profunda, administrada en el mismo sitio descrito antes con una jeringuilla prellenada. Se observaron los eventos adversos durante la primera hora, 24, 48, y 72 h subsiguientes, así como a los 7 y 30 d de administrada la vacuna. La reactogenicidad se evaluó inicialmente por el pediatra del área y luego por el médico de familia mediante la observación de los eventos adversos. RESULTADOS: 79,6 por ciento del total de niños asignados al grupo A y 75 por ciento del grupo B finalizaron el protocolo de investigación. No se detectaron eventos adversos moderados o serios. Predominaron las reacciones adversas locales menores, sobre todo induración, dolor y enrojecimiento en el sitio de la inyección. CONCLUSIÓN: el ensayo demostró la seguridad de la vacuna de polio inactivada para su uso por vía intramuscular y reconoció la seguridad del uso de la vía intradérmica y del inyector sin agujas.

INTRODUCTION: as the goal of poliomyelitis eradication is about to be accomplished, the need for an affordable and appropriate inactivated poliovirus vaccine (IPV) for use in developing countries has become a target for WHO. OBJECTIVE: to evaluate the reactogenicity of the inactivated poliovirus vaccine. METHOD: an experimental-type multicenter study was conducted, as part of a Phase I-II controlled clinical randomized and blinded assay, in 471 healthy infants of both sexes born in July and August 2006 in Camagüey province. The parents of the children who met the inclusion criteria gave their consent in writing. The children received three doses of the inactivated poliovirus vaccine at 6, 10 and 14 weeks after birth. This vaccine came form the Institute of Sera in Denmark and had been approved for use in this assay by the Cuban regularoty authorities, Low 0.1 ml inactivated poliovirus vaccine dose was intradermally administered to the study group A in the anterolateral side of the left thigh using the needle-free injector called Biojector ® 2000. The usual 0.5 mL dose was intramuscularly administered on the same site using a pre-filled syringe. The adverse events were observed during the first hour, 24, 48, and 72 hours after the immunization, as well as 7 and 30 days afterwards. The pediatrician in charge of the health area evaluated the reactogenicity at first and then the family physician was in charge of observing the adverse events in the remaining period. RESULTS: the 79.6 percent of children in group A and 75 percent in group B completed the research protocol. Mild local adverse reactions prevailed, mainly induration, pain and redness at the injection site. CONCLUSION: the clinical trial proved the safety of the inactivated poliovirus vaccine for intramuscular administration, and also showed the safety of the intradermal route of administration and of the needle-free injector.

Impacto económico de la introducción de la vacuna inactivada inyectable contra la poliomielitis en Colombia / Economic impact of introducing the injectable inactivated polio vaccine in Colombia

OBJETIVOS: Evaluar la relación costo-efectividad de la introducción de la vacuna inyectable contra la poliomielitis (VIP) en Colombia con respecto al sistema actual basado en el empleo de la vacuna oral (VOP). MÉTODOS: Se diseñó un modelo de Markov basado en una cohorte hipotética de recién nacidos que recibiría la VIP o la VOP con un seguimiento de dos años y estimaciones mensuales del número de casos de poliomielitis paralítica asociada con la vacuna (PPAV). El análisis del costo se realizó desde la perspectiva del asegurador (costos a lo largo de la vida) y la sociedad (casos de PPAV evitados y años de vida ajustados por discapacidad [AVAD] evitados). RESULTADOS: Entre 1988 y 1998 se aplicaron en Colombia 22,5 millones de dosis de la VOP y se detectaron nueve casos de PPAV, para una tasa de 4,0 ¥ 10-7 por dosis. Según el modelo, se podrían esperar entre 2 y 4 casos de PPAV en los dos años de seguimiento. El costo de tratar los casos de PPAV sería de US$ 302 008, con costos de vacunación con la VOP de US$ 737 037 y de US$ 5 527 777 con la VIP. La vacunación con la VIP permitiría evitar 64 AVAD con un costo de US$ 71 062 por AVAD evitado; evitar un caso de PPAV mediante la sustitución de la VOP por la VIP costaría entre US$ 1,8 millones y US$ 2,2 millones. CONCLUSIONES: La sustitución de la VOP por la VIP no es una medida efectiva en función del costo en Colombia, incluso si se sustituyera la vacuna celular contra la tos ferina, actualmente en uso, por una vacuna acelular combinada con una VIP.

OBJECTIVE: Evaluate the cost-effectiveness of introducing the injectable inactivated polio vaccine (IPV) in Colombia versus the current system based on the use of the oral vaccine (OPV). METHODS: A Markov model was designed, based on a hypothetical cohort of newborns that would receive the IPV or the OPV vaccine, with a two-year follow-up and monthly estimates of the number of cases of vaccine-associated paralytic poliomyelitis (VAPP) that would emerge. The cost was analyzed from the perspective of the insurer (costs throughout life) and society (cases of VAPP and disability-adjusted life years [DALYs] prevented). RESULTS: From 1988 to 1998, some 22.5 million doses of OVP were administered in Colombia and nine cases of VAPP were detected, for a rate of 4.0 ¥ 10-7 dose. According to the model, 2 to 4 cases of VAPP could be anticipated in the following two years. The cost of treating the VAPP cases would total US$302 008, with the cost of vaccination with OPV coming to US$737 037 and with IPV, US$5 527 777. Vaccination with IPV would prevent 64 DALYs, at a cost of US$71 062 per DALY prevented; preventing one case of VAPP by substituting OPV with IPV would cost between US$1.8 and US$2.2 million. CONCLUSIONS: Substituting OPV with IPV is not a cost-effective measure in Colombia, even if the cellular vaccine against whooping cough currently in use were replaced with an acellular vaccine combined with an IPV.

Vacunación antipoliomielítica en niños de la Ciudad de Buenos Aires / Antipoliomyelitic vaccination in children living in Buenos Aires City

A raíz de la presentación de un caso confirmado de poliomielitis paralítica por virus Sabin derivado (VSD) en niños de 15 meses se analizó la cobertura de vacunación antipoliomielítica en niños residentes en la Ciudad de Buenos Aires, durante el trienio 2006/2008. Se observó una mejora a lo largo del período analizado, pero sólo hubo valores superiores al 95 por ciento para la primera dosis. Aumentó la proporción de vacuna inactivada (IPV) en desmedro de la vacuna oral viva (OPV); en 2008, la cobertura con IPV primera dosis fue del 37,64 por ciento y del 19,48 por ciento para el ingreso escolar. La falta de inmunidad intestinal que se presenta en los niños vacunados con IPV, asociada a coberturas insatisfactorias condiciona un terreno propicio para la circulación de virus salvaje o VSD, lo cual favorece la aparición de casos de poliomielitis paralítica en niños no vacunados o inmunodeficientes.

Immunogenicity and safety of a pentavalent diphtheria, tetanus, acellular pertussis, inactivated poliovirus, haemophilus influenzae type b conjugate combination vaccine (pentaxim™) with hepatitis B vaccine.

Objective: To obtain immunogenicity and safety data for a pentavalent combination vaccine (diphtheria, tetanus, acellular pertussis, inactivated poliovirus, Hib polysaccharide-conjugate). Design: Multicenter, open, Phase III clinical study. A DTaP-IPV//PRP~T vaccine (PentaximTM) was given at 6,10,14 weeks of age; and Hepatitis B vaccine at 0,6,14 or at 6,10,14 weeks of age. Immunogenicity assessed 1 month post-3rd dose; safety assessed for 30 minutes by the investigator, then by parents and investigators to 8 days and 30 days post-vaccination. Setting: Tertiary-care hospitals. Participants/patients: 226 healthy Indian infants (6 weeks of age). Main outcome measures: Immunogenicity and safety. Results: Immunogenicity was high for each vaccine antigen, and similar to a historical control study (France) following a 2,3,4 month of age administration schedule. Post-3rd dose, 98.6% of subjects had anti-PRP ³0.15 mg/mL and 90.0% had titers ³1.0 mg/mL; the anti-PRP GMT was 4.1 µg/mL. Seroprotection rates for diphtheria and tetanus (³0.01 IU/mL) were 99.1% and 100%; and 100%,99.1% and 100%, for polio types 1,2 and 3 (³8 [1/dil]) respectively. Anti-polio GMTs were 440.5,458.9, and 1510.7 (1/dil) for types 1,2 and 3 respectively. The vaccine response rates to pertussis antigens (4-fold increase in antibody concentration) were 93.7% for PT and 85.7% for FHA; the 2-fold increase was 97.1% and 92.4%. Vaccine reactogenicity was low with adverse reaction incidence not increasing with subsequent doses. Conclusion: The DTaP-IPV//PRP~T vaccine, given concomitantly with monovalent hepatitis B vaccine, was highly immunogenic at 6, 10 and 14 weeks of age in infants in India. The vaccine was well tolerated.

Uso universal da vacina inativada contra poliomielite / Universal use of inactivated polio vaccine

OBJETIVOS: Apresentar uma atualização da situação da poliomielite no mundo, número de casos anuais, regiões mais atingidas pela doença, vacinas disponíveis na atualidade, seus riscos e benefícios, utilização da vacina monovalente, riscos da disseminação de um vírus mutante na comunidade, progressos que têm sido realizados em termos de erradicação mundial e as propostas da Organização Mundial da Saúde (OMS) nesse período de transição entre a erradicação global e o período pós-erradicação. FONTE DE DADOS: Foram consultadas bases de dados no período de 1955 a 2005 em MEDLINE, LILACS, The Web, Doctor's Guide; site da OMS e Organização Pan-Americana da Saúde (OPAS) e livro-texto. SíNTESE DOS DADOS: Em 1988, a OMS estabeleceu como meta a erradicação da doença e a interrupção da transmissão do vírus selvagem globalmente. Desde então, houve um dramático impacto no declínio da doença, embora em 2005 ainda existam alguns países considerados endêmicos e outros onde a pólio retornou, por conta de vírus importados. As vacinas utilizadas no mundo são as clássicas tOPV e IPV e, dentro desse processo de erradicação, o uso de vacinas mOPV tem sido estimulado nos locais em que circula apenas um tipo de poliovírus. Entretanto, as vacinas OPV, além de disseminarem o vírus na comunidade, podem causar paralisias por reversão do processo de neurovirulência. CONCLUSÕES:Para um mundo livre da doença poliomielite, será preciso retirar o vírus de circulação, o que só será possível se a vacina OPV for descontinuada, conforme propostas da OMS para esse período de transição e para a era pós-erradicação.

Immunogenicity and reactogenicity of two regimens of diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated polio and Haemophilus influenzae type b vaccines administered to infants primed at birth with hepatitis B vaccine.

An open, randomized study evaluated the immune response and safety of two different regimens of diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus-Haemophilus influenzae type b (DTPa-HBV-IPV-Hib) immunization in infants primed at birth with hepatitis B vaccine. One-half of the 150 healthy, full-term infants received a DTPa HBV-IPV-Hib vaccine at 1 1/2, 3 and 5 months of age; the other received a DTPa-IPV-Hib vaccine at 1 1/2, 3 and 5 months of age with separate HBV vaccine at 1 and 5 months of age. Immune response was similar following the two regimens with 100% of the vaccinees seroprotected for HBV, diphtheria, tetanus, Hib and poliovirus types 2 and 3 diseases after the full vaccination course. One vaccinee in the DTPa HBV-HPV- Hib group failed to respond to the poliovirus type 1 antigen. Response to the three pertussis antigens ranged from 92-97% in the DTPa-IPV-Hib plus separate HBV group and 100% in the DTPa HBV-IPV-Hib group. The most frequently reported post-vaccination symptoms were irritability in the DTPa-IPV-Hib plus separate HBV group (49% of vaccinees) and fever, defined as axillary temperature > or =37.5 degrees C, in the DTPa HBV- IPV-Hib group (50% of vaccinees).

Controversies in polio immunization.

Vaccines against poliomyelitis have been in use for nearly five decades now and have played a major role in progress towards global eradication of the disease. Both the vaccines, (oral polio vaccine and inactivated polio vaccine) and their uses are still debated with particular reference to their selective advantages vs. disadvantages, choice for individual vs. community protection and their administration strategies. Further occurrence of vaccine associated paralytic poliomyelitis with oral vaccine assumes importance in the face of disappearing disease. Further availability of inactivated polio vaccine in India and its various schedules such as sequential and combination schedules show some promise for polio eradication.

Manpower utilization in pulse polio immunization.

The present study was conducted in Union Territory of Chandigarh to find out the utilization pattern of manpower engaged in the implementation of Pulse Polio Campaign (PPI) on 7th December, 1997 with the objective to achieve a coverage close to 100% and thereby, eradicating poliomyelitis. Over 100,000 under-five children were expected to participate on PPI day. Out of 240 polio centres established in the Union Territory, 16 were selected by stratified random sampling covering 14,858 children. The observing teams recorded the information about the children and presence of staff members throughout the day between 8.00 a.m. and 5.00 p.m. It was observed that nearly half of the children received the polio drops within the first three hours while only a little over 5% visited polio centres in the last two hours. The average number of manpower varied between 5 and 6 throughout the day (more than the recommended four). The staff posted at urban, rural and slum centres did not visit the houses except for the few volunteers in slums. Unimmunized children should be identified by the staff in last two hours when the load at polio centres is extremely low. Adequate utilization of the full potential of the manpower will help in enhancing the PPI coverage close to 100%.

Imunização para o clínico geral / Immunization for the general clinic

O autor apresenta o panorama atual dos recursos de imunização disponíveis, enfocando o antígeno de cada produto e as indicações para as diferentes faixas etárias e grupos de risco

Poliomielitis paralítica asociada a vacuna: presentación de dos casos / Vaccine associated paralytic poliomyelitis: report of 2 cases

Ante la erradicación de la poliomielitis y de la circulación del virus polio salvaje en América y su importante disminución en el mundo los casos de polio paralítica asociada a vacuna (PPAV), aunque poco frecuentes, adquieren gran relevancia. Se presenta dos casos diagnosticados en el Hospital Dr. E. González Cortés, en los años 1992 y 1997. Los grupos de mayor riesgo de PPAV son los receptores de vacuna polio oral, especialmente lactantes después de la primera dosis, en adultos en contacto con receptores de vacuna y personas immunodeficientes. Esto ha llevado a muchos países a modificar su esquema de vacunación, incorporando la vacuna polio inactivada (VPI), que tiene igual efectividad y no encierra el riesgo de PPAV. Se destaca la necesidad de disponer en nuestro país de vacuna VPI para los pacientes inmunodeficientes y sus contactos