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Vaccine-derived polioviruses (VDPV)

Vaccine-derived polioviruses (VDPVs) are rare strains of poliovirus that have genetically mutated from the strain contained in the oral polio vaccine.

The oral polio vaccine contains a live, attenuated (weakened) vaccine-virus. When a child is vaccinated, the weakened vaccine-virus replicates in the intestine and enters into the bloodstream, triggering a protective immune response in the child. Like wild poliovirus, the child excretes the vaccine-virus for a period of six to eight weeks. Importantly, as it is excreted, some of the vaccine-virus may no longer be the same as the original vaccine-virus as it has genetically altered during replication. This is called a vaccine-derived poliovirus.

Very rarely, vaccine-derived poliovirus can cause paralysis. Vaccine-associated paralytic poliomyelitis (VAPP) occurs in an estimated 1 in 2.7 million children receiving their first dose of oral polio vaccine.

Child receiving OPV in Nigeria
In 2009, Nigeria conducted nationwide polio supplementary immunization activities
in response to a cVDPV outbreak
WHO/T. Moran

Types of vaccine-derived poliovirus

There are three types of vaccine-derived poliovirus:
   1. circulating vaccine-derived poliovirus (cVDPV)
   2. immunodeficiency-related vaccine-derived   poliovirus (iVDPV)
   3. ambiguous vaccine-derived poliovirus (aVDPV).

1. Circulating vaccine-derived poliovirus (cVDPV)

On very rare occasions, if a population is seriously under-immunized, there are enough susceptible children for the excreted vaccine-derived polioviruses to begin circulating in the community. These viruses are called circulating vaccine-derived polioviruses (cVDPV).

The lower the population immunity, the longer these viruses survive. The longer they survive, the more they replicate, change, and exchange genetic material with other enteroviruses as they spread through a community.

If a population is fully immunized against polio, it will be protected against the spread of both wild and vaccine strains of poliovirus.

Episodes of circulating vaccine-derived poliovirus are rare. Between 2000 and 2011 – a period in which more than 10 billion doses of oral polio vaccine were given worldwide – 20 cVDPV outbreaks occurred, resulting in 580 polio cases. In the same period, wild poliovirus paralysed over 15 500 children.

2. Immunodeficiency-related vaccine-derived poliovirus (iVDPV)

Prolonged replication of vaccine-derived viruses has been observed in a small number of people with rare immune deficiency disorders. Because they are not able to mount an immune response, these people are not able to clear the intestinal vaccine virus infection, which is usually cleared within six to eight weeks. They therefore excrete immunodeficiency-related vaccine-derived polioviruses (iVDPVs) for prolonged periods.

The occurrence of iVDPVs is very rare. Only 33 cases have been documented worldwide. Of these, most stopped excretion within six months or died.

3. Ambiguous vaccine-derived poliovirus (aVDPV)

Ambiguous vaccine-derived polioviruses (aVDPVs) are vaccine-derived polioviruses that are either isolated from people with no known immunodeficiency, or isolated from sewage whose ultimate source is unknown. Very little is known about them.

Testing for vaccines-derived polioviruses

All cases of acute flaccid paralysis (AFP) among children under fifteen years of age are reported and tested for wild poliovirus or vaccine-derived polioviruses within 48 hours of onset.

In 2009, the Global Polio Laboratory Network started using a new method to routinely screen for vaccine-derived polioviruses. The method is based on real-time reverse transcription-polymerase chain reaction (rRT-PCR), which targets nucleotide substitutions that occur early in the emergence of the virus.

A scientist working in a containment hood
A new method is being used to routinely test for vaccine-derived polioviruses

Implications and management of vaccine-derived polioviruses

Circulating vaccine-derived polioviruses must be managed in the same way as wild poliovirus outbreaks. The solution is the same for all polio outbreaks: immunize every child several times with the oral vaccine to stop polio transmission, regardless of whether the virus is wild or vaccine-derived.

Vaccine-derived polioviruses appear to be less transmissible than wild poliovirus. Outbreaks are usually self-limiting or rapidly stopped with 2–3 rounds of high-quality supplementary immunization activities.

Once wild poliovirus transmission has been stopped globally, the vaccine-viruses will be the only source of live polioviruses in the community and could potentially lead to the re-emergence of polio. Use of the oral polio vaccine in routine immunization programmes will therefore be phased out to eliminate the rare risks posed by vaccine-derived polioviruses.