Prolonged Excretion of Poliovirus among Individuals with Primary Immunodeficiency Disorder: An Analysis of the World Health Organization Registry

Grace Macklin, Yi Liao, Marina Takane, Kathleen Dooling, Stuart Gilmour, Ondrej Mach, Olen M. Kew, Roland W. Sutter, The iVDPV Working Group, Ousmane Diop, Nicksy Gumede Moeletsi, Raffaella Williams, Mohamed Seghier, Francis Delpeyroux, Gloria Rey Benito, Maria Cecilia Freire, Cara Burns, Humayun Asghar, Salman Sharif, Jagadish Deshpande, Shohreh Shahmahmoodi, Henda Triki, Laila E Bassioni, Amina Al-Jardani, Eugene Merav Weil Gavrilin, Javier Martín, Sirima Pattamadilok, Sunethra Gunasena, Yan Zhang, Wenbo Xu

Individuals with primary immunodeficiency disorder may excrete poliovirus for extended periods and will constitute the only remaining reservoir of virus after eradication and withdrawal of oral poliovirus vaccine. Here, we analyzed the epidemiology of prolonged and chronic immunodeficiency-related vaccine-derived poliovirus cases in a registry maintained by the World Health Organization, to identify risk factors and determine the length of excretion. Between 1962 and 2016, there were 101 cases, with 94/101 (93%) prolonged excretors and 7/101 (7%) chronic excretors. We documented an increase in incidence in recent decades, with a shift toward middle-income countries, and a predominance of poliovirus type 2 in 73/101 (72%) cases. The median length of excretion was 1.3 years (95% confidence interval: 1.0, 1.4) and 90% of individuals stopped excreting after 3.7 years. Common variable immunodeficiency syndrome and residence in high-income countries were risk factors for long-term excretion. The changing epidemiology of cases, manifested by the greater incidence in recent decades and a shift to from high- to middle-income countries, highlights the expanding risk of poliovirus transmission after oral poliovirus vaccine cessation. To better quantify and reduce this risk, more sensitive surveillance and effective antiviral therapies are needed.