Poliomyelitis

By:
Reema I. Dabbas
6th year medical student
Mutah university
Jordan
2010-2011
• Poliomyelitis, often called polio or
infantile paralysis, is an infectious
disease caused by a virus.
• This virus is a member of the
enterovirus subgroup of the
Picornaviridae family and has three
serotypes: PV1, PV2 and PV3.

• Immunity to one serotype of the virus

does not provide significant protection
against the other serotypes.
 Transmission is by faecal–oral

Multiplies in the oropharynx and the small intestine.

The virus invades the local lymphoid tissue in the GIT

The virus continues to be excreted in the stools for several

weeks after infection
• In a minority of cases, then enters the bloodstream
“causing viremia” and spreads to the central
nervous system.

• The virus may also spread to the central nervous

system along the peripheral nerves.

• The incubation period for polio infection is

usually between 7 and 14 days but may range
from 2 to 35 days.

• By 3–5 days after exposure, the virus can be

isolated in the blood, throat and faeces.
 Epidemiology
• As a result of vaccination, there has been a
dramatic reduction in the incidence of
poliomyelitis globally.
• However, the disease still remains endemic in
four countries – Nigeria, India, Pakistan and
Afghanistan.
• Other countries also have cases of wild-type
poliomyelitis from time to time, due to
importation
• The World Health Organization (WHO) aimed
to eradicate poliomyelitis by the year 2005.
• Although this was not successful, WHO is still
hopeful that polio eradication will be achieved
by 2010 or soon after, primarily through
‘national polio days’ where all children in a
certain region are given oral polio vaccine
(OPV)
 Clinical Picture
• Clinical manifestations of poliomyelitis can vary and
they are categorised according to severity.

• A large majority (up to 95%) of polio infections are

inapparent or asymptomatic.
• However, even those infected who don’t show any
symptoms shed the virus in their stools and, therefore,
are able to transmit the virus to others.

• In polio endemic areas, persons with inapparent

infections, particularly children, act as the main
reservoir of polio infection.
• Rarely “in less than 1% of polio infections”, the virus invades and
damages or completely destroys the motor neurons of anterior horn cells
of the spinal cord and brain stem.

• This form, known as paralytic polio, is the most severe and typical
manifestation of poliomyelitis.

• Depending on the extent of central nervous system damage, paralytic

polio is classified into:
o Spinal “80% of all paralytic polio cases”
o It is characterised by asymmetrical paralysis, commonly of the legs.
o Bulbar.
o Weakness of muscles innervated by cranial nerves
o Bulbospinal.
• About a tenth of patients who develop paralytic
polio can die without appropriate respiratory
support when their respiratory muscles are
paralysed.

• Most patients, even with paralytic polio, recover

completely and, in most others, muscle function
returns to some degree.

However, paralysis or weakness that persists 12

months after the onset is usually permanent.
 Signs & Symptoms
• In mild cases, the following nonspecific signs
and symptoms are observed and usually
resolve within a few days:
o Fever
o Headache
o Nausea Abortive polio
o Vomiting
o Abdominal pain
o Oropharyngeal hyperemia
• Nonparalytic poliomyelitis is characterized by the symptoms
described above in addition to the following:
o Nuchal rigidity
o More severe headache
o Back and lower extremity pain
o Meningitis with lymphocytic pleocytosis (usually)

• Paralytic poliomyelitis occurs in fewer than 5% of affected

patients and is characterized by the following:
o Compromise of the motor neurons may be localized or widespread.
o More frequently, asymmetric loss of muscle function is observed
with involvement of major muscle groups.
o Muscle atrophy is generally observed several weeks after the
beginning of symptoms.
o Recovery may be complete, partial, or absent
• Persons with residual impairment following paralytic poliomyelitis
can develop a condition called post polio syndrome (PPS), after a
period of prolonged stability (usually 30–40 years).

• It is characterised by:
– Exacerbation of existing muscle weakness.
– The development of weakness/paralysis in previously unaffected
muscles.

• PPS is believed to be caused by degeneration, with age, of over sized

motor units created during the recovery process of initial paralytic
polio.

• It is rarely life threatening but has a slow, step-wise, unpredictable

course.

• PPS is not an infectious process and persons who develop PPS do not
shed poliovirus.
 DDx
• Guillain-Barre Syndrome
• Botulism
• Rabies
• Enteroviral Infections
• Tetanus
• Myotonic dystrophy
• Aseptic meningitis
 Work-up
• Obtain specimens from the cerebrospinal fluid
(CSF), stool, and throat for viral cultures in
patients with suspected poliomyelitis infection.
• Obtain acute and convalescent serum for antibody
concentrations against the 3 polioviruses.
• A 4-fold increase in the immunoglobulin G (IgG)
antibody titers or a positive anti-immunoglobulin
M (IgM) titer during the acute stage is diagnostic.
 treatment
Medical Care
• No antivirals are effective against polioviruses.
• The treatment of poliomyelitis is mainly supportive.
• Analgesia is indicated in cases of myalgias or headache.
• Mechanical ventilation is often needed in patients with bulbar
paralysis.
• Tracheostomy care is often needed in patients who require long-term
ventilatory support.
• Physical therapy is indicated in cases of paralytic disease.
– In paralytic disease, provide frequent mobilization to avoid
development of chronic decubitus ulcerations.
– Active and passive motion exercises are indicated during the
convalescent stage.
• Fecal impaction is frequent in cases of paralytic disease and can be
treated with laxatives as soon as it develops.
Surgical Care
• Total hip arthroplasty is a surgical therapeutic
options for patients with paralytic sequelae of
poliomyelitis who develop of hip dysplasia
and degenerative disease.
• Consultations
o Physical therapist and rehabilitation therapist
o Pulmonologist
o Neurologist
o Immunologist
o Infectious diseases specialist
• Diet
o Because patients with poliomyelitis are prone to
develop constipation, a diet rich in fiber is usually
indicated.
Prevention
• Two types of vaccines used in the prevention
of poliomyelitis:
1. inactivated poliovirus vaccine “IPV”
administered parenterally
2.oral attenuated poliovirus vaccine “OPV”.
 Inactivated poliovirus vaccine
• IPV was the first polio vaccine available on the market, and
its widespread administration began in the 1950s.
• An enhanced inactivated poliovirus vaccine (eIPV)
formulation is now available.
• Nonenhanced early formulations had the disadvantages of
not being as immunogenic as OPV, not being able to induce
mucosal immunity, and having to be administered
parenterally, which increased costs and decreased
compliance.
• One of the major advantages of IPV is that it contains an
inactivated virus; for that reason, IPV is not associated with
the development of vaccine-associated poliomyelitis and
can be given to immunocompromised patients.
• Although they do not induce mucosal immunity, new
eIPV formulations have been proven to be as
immunogenic as OPV.

• For that reason, countries in which no cases of wild-

type disease have been reported during the last several
years (eg, the United States) have now adopted eIPV
immunization schedules. This new prophylactic
approach has the advantage of eliminating vaccine-
associated cases.

• This vaccine is administered when individuals are aged

2 months, 4 months, and 6-12 months and before
school entry, which is usually at age 4 years.
Oral attenuated poliovirus
vaccine

• Trivalent OPV has been used since the early 1960s.

• Immunization with this formulation was responsible
for the significant decrease in the prevalence of
disease throughout the world.
• This formulation has the advantages of inducing
mucosal immunity, providing appropriate herd
immunity, and increasing vaccine uptake because of
oral administration.
• Additionally, it is cost-effective, especially in
countries in the developing world.
• The major disadvantage of trivalent OPV is its
association with vaccine-associated paralytic
poliomyelitis (VAPP). Although the virus contained in
this formulation is attenuated, it may occasionally
become neurotropic and be able to produce disease
similar to wild-type virus.
• Trivalent OPV is being administered in developing
countries when individuals are aged 2 months, 4 months,
and 6 months and with a booster at age 4 years.

• VAPP occurs most frequently after the first dose of OPV

but may also occur after administration of the second or
third doses.
• A new high-potency monovalent oral poliovirus type 1 vaccine (mOPV1)
was introduced in India in April 2005.
• This vaccine is targeted to eliminate some of the last poliovirus reservoirs.

• This product constitutes part of an international effort to eradicate wild

poliovirus.

• Studies have revealed that mOPV1 is 3 times more effective against type 1
poliomyelitis than trivalent OPV.

• In addition, it has been demonstrated to be particularly efficacious in areas

in which the efficacy of trivalent OPV may be compromised by the high
prevalence of diarrhea and other infectious processes.
• Administration of OPV is contraindicated in
children who are immunocompromised and in
children whose caretakers are
immunocompromised.
• A risk for development of poliomyelitis is
present in those individuals who receive this
vaccine and are immunocompromised
 Who should be vaccinated
Children
• Children are recommended a primary course
of 3 doses of an IPV-containing vaccine at 2, 4
and 6 months of age and a booster dose at 4
years of age.

• The recommended interval between 2 doses is

2 months, but, for catch-up, the minimum
interval can be 1 month
Adults
• The schedule for unvaccinated adults is 3 doses administered
at intervals of 1–2 months.

Booster doses
• A booster dose is not required for fully vaccinated children
or adults unless they are at increased risk of infection, such
as

o Travelling to areas or countries where poliomyelitis is epidemic

or endemic.
o Healthcare workers, including laboratory workers, in possible
contact with poliomyelitis cases.

• For those exposed to a continuing risk of infection, booster

doses are desirable every 10 years.
 Vaccine efficacy/effectiveness

• IPV is highly effective in producing immunity to polio virus and

protection from paralytic poliomyelitis. After 2 doses of the vaccine,
over 90% of recipients develop protective antibodies to all three
types of the polio virus.

• After 3 doses, at least 99% of the recipients will have protection

against the disease. Protection against paralytic disease correlates
with the presence of antibodies against the polio virus.

• IPV appears to produce less local gastrointestinal immunity than

does OPV, so it is possible that persons who receive IPV are more
readily infected with wild-type polio virus than OPV recipients.
 Vaccine safety
• Inactivated poliomyelitis vaccines can be
safely administered to either persons with
impaired immunity or to persons living with
someone with impaired immunity.
• IPV vaccines may cause erythema, pain, and
induration at the injection site. Other
symptoms reported following administration
of IPV vaccines in young babies include fever,
crying and decreased appetite.
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