POLIOMYELITIS

AHMED SULTAN
 DEFINITION
• Poliomyelitis is an acute, highly infectious,
disabling and life-threatening disease of
children, caused by polio virus.
• Basically it is an infection of the intestine
transmitted by feco-oral route, but in about one
percent of the cases, it affects the central
nervous system also (mainly spinal cord).
• Clinically it is characterized by sudden onset of
fever, associated with constitutional signs and
symptoms, followed by the rapid onset of lower
motor neuron type of paralysis (flaccidity) either
of a group of muscles or of a limb.
 Magnitude of the Problem
• Before the introduction of the vaccine,
poliomyelitis was a global problem. After
the introduction of the vaccine and
effective immunization program
associated with the improvement of
sanitation, more than 125 countries have
virtually eradicated the disease.
 Agent Factors
• Causative Agent : It is a RNA virus, belonging
to the group Picarnovirus and the family
Enterovirus. It is 25 nm in size. Antigenically,
there are three types of polio-virus, namely
Type 1, Type 2 and Type 3, namedrespectively
after Brunhilde, Lansing and Leon.
• Type I is responsible to the extent of 80 to 90
percent.
• Type III causes paralysis less frequently and
• Type II causes rarely. Thus these strains differ
in their invasiveness.
• They can survive outside the human body for
fairly long periods (4 months in water and 6
months in life).
• The half life of the excreted virus in the
sewage is only 48 hours and spread of
infection through sewage can occur only
during this period.
• Even though it can survive outside the human
host, it multiplies only in the unimmunized
human gut. There is no development of cross-
immunity.
• They are readily destroyed by heat at 50°C,
and inactivated by U-V radiation, formalin,
chlorine and drying. Therefore freeze-
dried vaccine cannot be prepared. They
survive for years at sub-zero temperature.
• Reservoir of Infection: Human reservoir is the
only host. Therefore, poliomyelitis is a disease
of human beings only. There are no animal
reservoir. Such a human reservoir may be an
active clinical case or a carrier.
• The carrier of poliomyelitis is a temporary,
healthy carrier or incubatory carrier and there
is no chronic carrier state. It is estimated that
for every clinical case of polio, there are about
1000 subclinical cases among children, some
of whom may become carriers and about 75
subclinical cases among adults.
• Infective Materials: Infective materials are
the throat secretions and feces of a
diseased individual in the early stage and
only feces in the later stages.
• Period of Infectivity: The cases are
infectious one week before and about
three weeks after the onset of disease.
• Immunity :Maternal antibodies protects the
child during the first six months of infancy.
- Immunity is often developed following the
subclinical infection.
- The immunity developed after the clinical
infection is fairly good and it is type specific.
- There is no cross immunity (i.e. the immunity
developed with one type of virus does not
protect the child against the other).
• Environmental Factors: majority of the
cases occur during June to September.
- Lowest transmission season is November
to March.
- Overcrowding, poor sanitation and
contamination of food and water are the
main favorable factors for the
transmission of the virus
• Modes of Transmission: In the acute
stage of illness, the disease is transmitted
by both droplet infection as well as by
feco-oral route.
- After the acute stage, poliomyelitis is
transmitted by feco-oral route only, i.e.
through 6 F’s, i.e. through fecal
contamination of fluids (water, milk),
foods, fruits and vegetables, fomites (like
utensils), fingers (due to lack of personal
hygiene) and flies act as mechanical
carriers
 Clinical Spectrum
• The different outcomes of the infection is as follows:
- In 95 percent infections, it is only subclinical
infections and therefore, they are all asymptomatic
or inapparent cases. Recognition is only by rising
antibody titer.
- In about 4 percent, there will be mild, self-limiting,
non-specific febrile illness. Disease does not
progress. It is called minor-illness or abortive
poliomyelitis.
- In about 1 percent, there is development of
meningitis but no paralysis. It is called ‘Non-
paralytic poliomyelitis’. The patient will have all
features of meningitis, followed by recovery.
• In about less than 1 percent of infection,
the condition progresses to ‘major illness’,
wherein the virus invades CNS, specially
spinal cord resulting in varied type of
paralysis, i.e. called ‘paralytic
poliomyelitis’.
• Clinically paralytic poliomyelitis is
characterized by sudden onset of fever
and associated symptoms such as
headache, vomiting, malaise and anorexia.
• Next day, fever is associated with severe
myalgia (muscular pain) in the limbs,
followed by asymmetrically distributed,
lower motor neuron type of flaccid
paralysis.
• In mild cases few muscles are paralysed
and in severe case, the entire limb is
paralysed.
• Usually one leg is paralyzed. Paralysis
continues until the temperature returns to
normal. There is no sensory loss.
 Diagnosis
• Isolation of wild polio-virus from the stool
is the best way to confirm the diagnosis
of paralytic poliomyelitis.
• Virus is not likely to be cultured from
throat swab, CSF or blood. A rise in titer of
complement fixing antibodies is
confirmative.
 Management
• Since there is no treatment, polio cases require
general supportive care and skilled management as
follows:
- Isolation–in the isolation ward, because it is
infectious.
- Concurrent disinfection of saliva and excreta in 10
percent cresol.
- Absolute bed-rest is essential during the acute
phase.
- There should not be any stress on the affected
muscles.
- Expert nursing care with frequent change of
postures every 2 to 3 hours.
- Symptomatic treatment with paracetamol
to relieve pain and fever.
- Prophylactic oral antibiotics to prevent
secondary infection.
- Massage and injections during the acute
phase is absolutely contraindicated (i.e. for
about 6 weeks).
- Supportive treatment with splints is
provided to the limbs to prevent deformity
resulting from the action of antagonistic
muscles.
- Maintenance of fluids and electrolyte
balance done orally and not by infusion.
- Physiotherapy is recommended not in the
early stage but only after the acute phase
of about 6 weeks, because stress and
strain in the acute phase worsens the
disease and also wherever the damage is
reversible in the spinal cord, the paralyzed
muscles recover within about 4 weeks.
 Prevention and Control
• Since there is no treatment, elimination of
reservoir is not possible.
• Different modes of transmission can be
broken by construction of sanitation barrier.
• However, protection of susceptibles by
immunization is the only sole and most
effective method of preventing poliomyelitis.
• Since it is a disease of mainly children and the
susceptibility being universal all children must
be immunized during their infancy period itself,
preferably before 6 months of age.
 Active Immunization
• Inactivated polio vaccine (IPV): It is named after the
discoverer Salk, as Salk vaccine. It is a liquid killed
vaccine. It contains all the three types of polio-
viruses, killed by formalin, to be administered
intramuscularly (IMly).
• Primary course consists of 4 doses, first three
doses are given with an interval of 4 to 6 weeks,
starting from as early as 6 weeks of infancy and the
fourth dose is given about 6 to 12 months after 3rd
dose.
• Immunity lasts for few years. Additional dose is
given at the time of school entry and then booster
dose is given once in 5 years, till the age of 18 years.
• Oral polio vaccine: Oral polio vaccine (OPV)
is named after the discoverer Sabin as Sabin
vaccine. It is a live, liquid vaccine, containing
attenuated all the three types of polio viruses.
So it is also called as ‘Trivalent-vaccine’.
• Thus the child is protected against all the
three types of viruses, simultaneously, which
is of great administrative convenience
• OPV is given orally in the form of 2 drops per
dose.
• Schedule Under the National Universal
Immunization Programme, 4 doses of OPV,
are recommended as follows.
- Zero dose—at birth, along with BCG
- First dose—at 6 weeks
- Second dose—at 10 weeks
- Third dose—at 14 weeks; all three along
with DPT
 Advantages of Oral Polio Vaccine
• There is development of both local and
systemic immunity
• When the immunized child drinks
contaminated water containing wild polio
-virus, it is acted upon by the IgA of the
gut and is converted into attenuated, non-
pathogenic, vaccine progeny virus, which
when enters the mouth of the susceptible
child, induces immunity indirectly, thus
helps in the development of herd
immunity in the community.
• If all the children are immunized
simultaneously, and not even a single child is
left, the vaccine virus completely replaces the
wild polio virus from the entire nature, thus
OPV helps in eradication of the poliomyelitis
(Unimmunized gut is a must for the wild virus
to multiply).
• It is the vaccine of choice during the epidemics
• Administration is simple, easy, given orally and
not painful and not expensive
• Does not require the services of a trained
personnel.