Poliomyelitis

Introduction

 Poliomyelitis also known as infantile

paralysis is an infectious viral disease
that affects the spinal cord or a part of
the brain
 . Poliomyelitis infection is caused by an
enterovirus, which causes muscular
paralysis. In some cases respiratory
muscles are affected; in others limb
muscles.
 Poliomyelitis
 Poliomyelitis is an acute viral infection
caused by an RNA virus. It is primarily an
infection of the human alimentary tract but
the virus may infect the central nervous
system in a very small percentage (about
1 per cent) of cases resulting in varying
degrees of paralysis, and possibly death.
 Poliomyelitis eradication
 Epidemiological basis
 Poliomyelitis is eradicable because man is
the only host.
 A long-term carrier state is not known to
occur.
 The half-life of excreted virus in the
sewage is about 48 hours, and spread can
only occur during this period.
 Agent factors
 AGENT : The causative agent is the
poliovirus which has three serotypes 1,2
and 3. Most outbreaks of paralytic polio
are due to type-1 virus.
 In a cold environment, it can live in water
for 4 months and in faeces for 6 months ,
the virus may be rapidly inactivated by
pasteurization, and a variety of physical
and chemical agents.
 RESERVOIR OF INFECTION
 Man is the only known reservoir of
infection. Most infections are subclinical. It
is the mild and subclinical infections that
play a dominant role in the spread of
infection
 There are no chronic carriers. No animal
source has yet been demonstrated
 INFECTIOUS MATERIAL
 The virus is found in the faeces and
oropharyngeal secretions of an infected
person,
 PERIOD OF COMMUNICABILITY :
 The cases are most infectious 7 to 10
days before and after onset of symptoms.
In the faeces, the virus is excreted
commonly for 2 to 3 weeks, sometimes as
long as 3 to 4 months.
 Host factors
 AGE :, polio is essentially a disease of
infancy and childhood. About 50 per cent
of cases are reported in infancy. The most
vulnerable age is between 6 months and 3
years,
 SEX : Sex differences have been noted
in the ratio of 3 males to one female
 RISK FACTORS
 : They include ,
 fatigue, trauma, intramuscular injections,
operative procedures such as
tonsillectomy undertaken especially during
epidemics of polio and administration of
immunizing agents particularly alum-
containing DPT.
 IMMUNITY
 The maternal antibodies gradually disappear
during the first 6 months of life. Immunity
following infection is fairly solid although
 Re-infection can occur since infection with one
type does not protect completely against the
other two types of viruses. Type 2 virus appears
to be the most effective antigen. Neutralizing
antibody is widely recognized as an important
index of immunity to polio after infection .
 Environmental factors

 Polio is more likely to occur during the

rainy season.. The environmental sources
of infection are contaminated water, food
and flies. Polio virus survives for a long
time in a cold environment. Overcrowding
and poor sanitation provide opportunities
for exposure to infection.
 Mode of transmission

 (a) FAECAL-ORAL ROUTE :

 . The infection may spread directly through
contaminated fingers where hygiene is poor, or
indirectly through contaminated water, milk,
foods, flies and articles of daily use.
 (b) DROPLET INFECTION : This may occur in
the acute phase of disease when the virus
occurs in the throat.
 Incubation period
 Usually 7 to 14 days (range 3 to 35 days).
 Early symptoms of polio
 These are similar to those of other viral
infections, it includes; slight fever, headache
 , dizziness, nervous irritability, and vomiting.
 Skin can become tender and sore.
 Stiffness and pain in the back and neck, and
pain in the arms, legs, or abdomen.
 Muscles may be tender and spasmodic (subject
to involuntary contractions).
 Clinical spectrum
 (a) INAPPARENT (SUBCLINICAL)
INFECTION
 (b) ABORTIVE POLIO OR MINOR
ILLNESS
 (c) NON-PARALYTIC POLIO
 (d) PARALYTIC POLIO
 PARALYTIC POLIO
 Occurs in less than one per cent of infections.
The virus invades CNS and causes varying
degrees of paralysis.
 The predominant sign is asymmetrical flaccid
paralysis. A history of fever at the time of onset
of paralysis is suggestive of polio.
 The other associated symptoms are malaise,
anorexia, nausea, vomiting, headache, sore
throat, constipation and abdominal pain.
 There might be signs of meningeal irritation,
i.e., stiffness of neck and back muscles.
 Tripod sign
 The child finds difficulty in sitting and sits by
supporting hands at the back and by partially
flexing the hips and knees. Progression of the
paralysis to reach its maximum in the majority of
cases occurs in less than 4 days (may take 4-7
days).
 The paralysis is characterized as descending,
i.e. starting at the hip and then moving down to
the distal parts of the extremity.
 It is asymmetrical patchy paralysis, proximal
muscle groups are more involved as compared
to distal ones.
 CNS
 There is no sensory loss. Cranial nerve
involvement is seen in bulbar and
bulbospinal forms of paralytic
poliomyelitis.
 There might be facial asymmetry,
difficulty in swallowing, weakness or loss
of voice. Respiratory insufficiency can be
life-threatening and is usually the cause of
death.
 Chronic state
 After the acute phase, atrophy of the
affected muscles lead to a life with
residual paralysis which is typical and
relatively easy to identify as poliomyelitis .
 Progressive paralysis, coma or
convulsions usually indicate a cause other
than polio, as does a very high case
fatality rate .
 Treatment

 There is no specific treatment for polio. Good

nursing care from the beginning of illness can
minimise or even prevent crippling.
 Physiotherapy is of vital importance. It can be
initiated in the affected limb immediately. It helps
the weakened muscles to regain strength. Very
probably, the child may have to put on metal
callipers.
 PREVENTION

 Immunization is the sole effective means

of preventing poliomyelitis.
 Both killed (Salk) and live attenuated
(Sabin) vaccines are available and both
are safe and effective when used
correctly.
 It is essential to immunize all infants by 6
months of age to protect them against
polio.
 Types of Vaccines

 Two types of vaccines are used

throughout the world; they are :
 1. Inactivated (Salk) polio vaccine (IPV)
 2. Oral (Sabin) polio vaccine (OPV)
Dr Jonas
Salk, who
created the
first polio
vaccine in
1955
 Inactivated (Salk) polio vaccine
This vaccine contains all the three types of
poliovirus, inactivated by formalin.
IPV induces, humoral antibodies (IgM, IgG and IgA
serum antibodies) but does not induce intestinal
or local immunity.
 Inactivated polio vaccine, because it does not
contain living virus, is safe to administer
 to persons with immune deficiency diseases and
in pregnancy.
Oral (Sabin) polio vaccine (OPV)

 . Oral polio vaccine (OPV) was described

by Sabin in 1957 contains live attenuated
virus (types 1,2 and 3) grown primary
monkey kidney or human diploid cell
cultures. Each virus type can be given
separately as monovalent vaccine, but for
administrative convenience, rather the
efficacy, it is given as trivalent (TOPV)
vaccine.
 Advantages
: (i) since given orally, it is easy to administer and
does not require the use of highly trained
personnel (ii) induces both humoral and
intestinal immunity,
 (iii) antibody is quickly produced in a large
proportion of vaccinees, even a single dose
elicits (except in tropical countries) substantial
immunity
 (iv) the vaccinee excretes the virus and so
infects others who are also immunized thereby
 (v) useful in controlling epidemics (vi) relatively
inexpensive .
 Dose and Mode of administration

 The dose is 2 drops or as stated on the label.

WHO recommends that vaccinators use dropper
supplied with vial of oral polio vaccine. This is
the most direct and effective way to deliver the
correct drop size.
 Tilt the child's back, gently squeeze the cheeks
or pinch the nose to make the mouth open. Let
the drops fall from the dropper onto the tongue.
Repeat the process if the child spits out the
vaccine
National Immunization Schedule
:
 The WHO Programme on Immunization (EPI)
recommend primary course of 3 doses of OPV
at one-month interval commencing the first dose
when infant is 6 weeks and polio zero dose just
after
 It is very important to complete vaccination of all
infants before 6 months of age. This is because
most polio cases occur between the ages of 6
months and 3 years..
 Three doses of OPV
 Three doses of OPV are required because, as a
result of competitive inhibition, only one strain
will replicate reliably;
when the second dose is given, the immune
system will prevent the strain that replicated the
first time from doing so, leaving the field clear for
one of the others;
 and the third dose ensures that there is cover
against the third strain.
 Complications :

 Being living viruses, the vaccine viruses,

particularly type 3 do mutate in the course of
their multiplication in vaccinated children, and
rare cases of vaccine-associated paralytic polio
have occurred in
 (a) recipients of the vaccine, about 1 case per
million vaccinees, and
 (b) their contacts 1 case per 5 million doses of
vaccine .


 Contraindications :

 The contraindications for the

administration of OPV are acute infectious
diseases, fevers, diarrhoea and dysentery.
 Patients suffering from leukaemias and
malignancy and those receiving
corticosteroids may not be given OPV.
 OPV should be delayed until after
pregnancy unless immediate protection is
required, when IPV is indicated
 WPV Incidence
In Pakistan
 , the number of confirmed polio cases increased from 28
cases reported from 17 districts in 2005 to 40 cases
reported from 20 districts in 2006. Of the 40 polio cases,
20 were caused by WPV1 and 20 by WPV3. The
majority of WPV1 cases were reported from Sindh
Province or from security-compromised areas in North-
West Frontier Province
 The virus spread most rapidly in Sindh, and by February
2007, a total of 10 WPV3 cases had been reported from
eight districts. As of February 28, six cases (two WPV1
and four WPV3) had been confirmed.
 Pakistan

 Number of Confirmed Cases of

Poliomyelitis 2002-2009
(as of 19 February 2009)

 90 103 53 28 40 32 118 6
 Strategies for polio eradication

 Line listing of cases

 Mopping Up :
 Pulse Polio Immunization
 PPIs are when oral polio vaccine is given
to all children 0-5 years of age, in the
country on a single day, regardless to
previous immunizations. PPIs occur as
two rounds about 4 to 6 weeks apart
 Epidemiological Investigations

 The occurrence of a single case of polio

should prompt an immediate
epidemiological investigation, including an
active search for other cases.
 An epidemic is defined now as 2 or more
local cases caused by the same virus type
in any 4-week period .
 Samples
 Samples of faeces from all cases or suspected
cases of polio should be collected and
forwarded to the laboratory for virus isolation.
 In addition, where possible, paired sera should
be collected, the first specimen at the clinical
suspicion of paralytic polio and the second at the
period of convalescence.
 A rising titre of poliovirus neutralising antibody
provides useful confirmatory evidence.