although poliomyelitis caused by wild - type poliovirus has been almost eradicated , especially in developed countries , vaccine - associated paralytic poliomyelitis ( vapp ) cases still continue to occur in most of developed and developing countries . in korea , the last indigenously acquired cases of poliomyelitis caused by wild poliovirus were reported in 1983 , and the eradication of wild poliomyelitis in korea was certified in october 2000 . live attenuated oral polio vaccine ( opv ) has been successfully used to control wide - type poliomyelitis over the past 30 yr . although it has several advantages such as low cost , ease of use , and high efficacy rate with herd immunity ( 1 ) , opv has a drawback of causing a rare but serious complication of vaccine associated paralysis . furthermore , vapp cases can not be distinguished clinically from the wide - type poliomyelitis ( 1 ) . in india a report described 181 vapp cases among 125 million children less than 5 yr of age in one year , of 1.45 per million children per year , or seven cases per million birth cohorts ( 2 , 3 ) . assuming an annual average of 45 cases in latin america , the total in latin america and india experienced 226 cases a year . the annual incidence of vapp in european countries , according to the who , is 0.4 - 3.0 per million vaccinated children ( 1 ) . in the u.s.a . , an estimated risk for vapp ranged from 1 case per 2.5 million doses of opv distributed in 1980 - 89 ( 4 ) to 1 case per 3.2 million doses distributed in 1973 - 84 ( 5 ) . in korea , opv was introduced in 1962 , about 4 yr after the first implementation of ipv , and has been used alone since 1975 for the prevention of poliomyelitis . as the statistics from the who show , it is apparent that as long as opv is in use , there is always the risk of vapp to occur regardless of where it is used . the over all risk for vapp is approximately one case in 2.4 million doses of opv vaccine with a first dose risk of one in 750,000 . when considering the birth cohort and the amount of opv distributed in korea , an occurrence of 0.5 - 2 cases of vapp a year can be expected . unfortunately , however , since the day of opv administration started in korea , there has not been any vapp case reported so far . this is the first case of a recipient vapp confirmed in december 2003 by the ( korean ) national committee on certification of poliomyelitis . we hope this report will be an initiative in finding more cases of vapp and also facilitate the epidemiological surveillance system in handling cases of acute flaccid paralysis in korea . a 4 month - old - male patient presenting weakness and decreased movement of the left lower extremity was transferred to our institute . he was in good health until 1 month before the visit when his parents noticed weakness of left lower extremity . he received opv with dtap at local health center 1 month before presenting those symptoms . making the diagnosis in this case was somewhat delayed because his parents hesitated to seek a proper medical help initially and took him to an orthopedics clinic where he was evaluated and treated under a misdiagnosis . his body weight was 8.1 kg , length 66 cm , and head circumference 41.2 cm and those growth indexes measurements continued to be in the 50 - 90th percentile at the time of this report ( 2 yr old ) . the physical examination revealed alert mental status , and cranial nerve function tests were all normal . neurologic examination revealed markedly decreased spontaneous movement and flaccid paralysis on the left lower extremity ( gi / v ) with knee jerk ( + /- ) , biceps tendon reflex ( + /+ ) , and ankle clonus ( -/- ) . the response to painful stimuli on the left lower extremity was markedly reduced , but there was normal in other part of his body . he had no history of intramuscular injection or trauma on the left side buttock area . laboratory evaluation , simple skeletal radiography , hip joint sonogram , and 3-phase bone scan were all within normal ranges . electrodiagnostic evaluations showed normal sensory nerve action potentials and low amplitudes in left tibial and deep peroneal nerve . up to the time of this presentation , he was able to sit alone at 10 months old and walk unaided ( left side heel walking ) at 16 months of age . his development quotients ( by korean developmental screening test ) of gross motor , fine motor , personal - social , language , and cognitive - adaptation were all 100 in each category . his upper limb diameters ( mid - arm ) were 7.5/7.5 cm , diameters of lower extremities were 30.5/28 cm at the mid - thigh and 22/20 cm at the mid - calf level . at the time of presentation , he had muscle weakness ( giv / v ) , hypotonia , and atrophy on the left lower extremity with ipsilateral claw foot ( fig . vapp is a very rare , but well - known serious complication following the administration of opv . it can occur among otherwise healthy opv recipients , or healthy person who had close contact with vaccine recipients , or community contacts as well although there is no standard case definition for vapp , a case of recipient vapp is generally accepted if acute flaccid paralysis occurred 4 to 40 days after receiving opv and residual weakness lasted for more than 60 days after the onset of paralysis . isolation of vaccine - related poliovirus in any stool samples and no isolation of wild poliovirus from any stool samples are also generally required to confirm the vapp cases ( 6 ) . however , the isolation of vaccine - related virus is not required in making the diagnosis in some countries such as u.s.a .. vapp cases are also be categorized as either : 1 ) a recipient case : the patient must have received opv 4 to 40 days prior to the onset of illness , or 2 ) a contact case : the patient must have had a contact with recent opv recipients who received immunization 4 to 75 days before the onset of illness . however , receiving opv more than 40 days or had a contact more than 75 days prior to the onset of symptoms does not preclude classification in these categories ( 7 ) . electrophysiologic studies usually show normal sensory nerve conduction velocity , normal or reduced amplitude in compound motor action potentials , and no slowing of nerve conduction velocities . intramuscular injection may induce peripheral nerve damage . differentiating vapp from peripheral nerve injuries is difficult because of the similarities in their clinical findings . therefore , recognizing an injection trauma or traumatic neuritis must be accurate to reduce the danger of vapp cases go unnoticed ( 10 ) . west nile virus and enterovirus 71 are also implicated in polio - like paralytic syndrome ( 7 , 8) . in 1997 , american academy of pediatrics ( aap ) recommended a polio vaccination schedule consisting of two initial doses of ipv followed by two additional doses of opv to prevent the vapp . , aap figured vapp would not be eliminated unless the use of opv was stopped . in 2000 , aap changed their policy to provide " all - ipv schedule " for routine childhood immunization ( 11 ) . recently , some countries including the u.s.a . and germany have changed their national policies to recommend vaccination with ipv alone instead of opv ( 12 ) . in korea , advisory committee on immunization practices recommended using ipv either alone or together with opv in 2002 , and all ipv schedule was implemented in 2005 . in conclusion , we report a case of vapp , which we followed for a relatively long period of time . despite massive physical therapy provided , the patient is left with permanent hypotonic monoparesis ( giv / v ) with atrophy on the left lower extremity and left side claw foot . since we failed to isolate the causative strain in this case , we report this patient as the first clinically confirmed case of vapp in korea . a good afp surveillance system as were as physicians ' appropriate concerns are important in detecting poliomyelitis in the future , either wild or vaccine - related , so that we can reach the common goal of eradicating poliomyelitis .
this report describes a case of acute flaccid paralysis after administration of oral polio vaccine ( opv ) . 
 a 4 month - old male patient with the decreased movement of left lower extremity for 1 month was transferred to the department of pediatrics . 
 he received opv with dtap at 2 months of age . 
 flaccid paralysis was detected 4 weeks after opv immunization . 
 attempts to isolate sabin - like viruses in the two stool and csf samples failed because those specimens were collected more than 2 month after the onset of paralysis . 
 hypotonic monoparesis ( giv / v ) , hypotonia and atrophy on the left lower extremity , and ipsilateral claw foot persisted for more than 18 months , while we followed him with rehabilitation therapy . 
 this is the first case of officially approved , recipient vaccine - associated paralytic poliomyelitis in korea .