Poliomyelitis

Dr. Sanjeev Gupta

 Introduction
Poliomyelitis is an acute viral infection
Cause by an RNA virus
It is primarily an infection of the human
alimentary tract but the virus may infect the
central nervous system.
1% cases resulting the paralysis and possibly
death
Problem statement in the world
Fore Regions Polio-free

1.America
2.Europe
3.Western pacific
4.SEAR
Problem statement in the world
 Indian Scenario
India biggest achievement against polio
In India vaccination against polio started in
1978. it was successful in covering around
40%.
Universal immunization programme (UIP) was
launched 1995
Pulse polio immunization programme along
with UIP
Indian Scenario
 On 27th March 2014 India was declared as
non-endemic country for polio.
Polio achieved and implementing polio
endgame strategy
 Polio Eradication and Endgame
Strategic plan 2013-2018
1. To detect and interrupt poliovirus
transmission
2. To strengthen immunization systems and
withdraw oral polio vaccine
3. To contain poliovirus and certify
interruption of transmission
4. To plan how to utilize the legacy of the fight
against polio
 Polio Surveillance
1- Acute flaccid paralysis surveillance

2- Environmental surveillance
Acute flaccid paralysis surveillance
1. Finding and reporting children with acute
flaccid paralysis (AFP)
2. Transporting stool samples for analysis
3. Isolating poliovirus
4. Mapping the virus
 AFP- Case Definition
Any child < 15 years who has acute onset of
flaccid paralysis for which no obvious cause
(such as severe trauma or electrolyte
imbalance) is found, or paralytic illness in a
person of any age in which polio is suspected.
 Commonest causes of AFP

Poliomyelitis
Gullain Barre Syndrome
Traumatic neuritis
Transverse Myelitis
 Case Notification
from where ? - RUs, Clinics, Pvt.Practitioners

who reports ? - nodal person/ informer

when ? - immediately on coming
across an AFP case
whom to report ? - DHO/SMO
by what means ? - fastest mode of communication
phone, fax,
what information ? - name, address, date of onset
 Confirm AFP
investigate the case - at hospital / at home
use case definition
 Stool sample
Number -Two stool samples, with a gap of at
least 24 hours between two samples

Time- First within 14 days of onset of

paralysis

Quantity Thumb sized, Sealed containers,

and stored immediately in cold box.
 Stool sample
Transport-Maintenance of cold chain from
collection to the time it reaches lab---- by
vaccine carrier-
REVERSE COLD CHAIN
No leakage, proper labels & packing
Vaccine carrier once used for transporting stool
sample is disposed off never used for any
purpose.
 Environmental surveillance
Environmental surveillance involves testing
sewage or other environmental samples for
the presence of poliovirus.
Overall indicators and targets
the "bottom line" on AFP surveillance
Indicator Target
number AFP cases >1/1,00,000 children
reported yearly under 15 years of age

% cases with 2 >80%

adequate stools
Epidemiology of Poliomyelitis
 Epidemiological

Agent Environment

Host
 Agent factors
Viral infection: caused by RNA virus

Primarily an infection of human alimentary

tract, but may infect the central nervous system
 Polio virus

Classification-
-Wild Virus (WV)
-Vaccine Virus (VV)
 Serotypes
Serotypes:
Type 1, 2 and 3
All types cause paralysis

Outbreaks of paralytic polio due to type-1

Poliovirus can survive for long periods in the
external environment.
In water 4 months
In faeces 6 months
 Epidemiological Characteristics of Polio
Serotypes
All types cause paralysis
Type 1- Most frequent paralysis,
Highest epidemic potential,
During polio free last serotype to disappear
Type 2- Rarely paralytic,
during polio free first serotype to disappear
Type 3- Paralysis less frequent
Less epidemic potential, scattered cases
 During eradication first serotype
to disappear is 2 >> 3 >>> 1
In India
Type 2- last case 1999

Type 1 -2008

Type 3- 2011
 Reservoir of infection

Man is the only reservoir

Clinical & sub clinical cases

Every clinical cases >1000 sub clinical cases
No chronic or carrier stage
 Communicability
As long as 3-4 months

Most infectious 7-10 days before & after the

onset of paralysis
 Host factors
Age- all age group
- 6 months 3 years most vulnerable
-50% cases <1 year of age
-Can affect children up to 15 years

Sex- ratio of 3 males to 1 female

 Immunity
Active
through immunization / natural
infection
Immunity believed to be lifelong

Passive
Maternal immunity- protection about 6
months
 Immunity
Local- Intestine-
Prevent the entry of the agent
By Natural infection &
Oral Polio Vaccine
Systemic- Humoral antibodies-
Prevent agent to reach target organ
By Natural Infection &
Injectable & Oral Polio Vaccine
 Environment factors
Rainy season-Highest transmission
June- Sept- 60% cases in India
Half life of excreted virus in sewage in the
tropical climate- 48 hours
Long survival in cold climate
Route of entry- oral cavity

Infectious material
Oropharyngeal secretion-
Feacal material
 Mode of Transmission
Faeco-oral route
Directly through contaminated fingers

Droplet infection
Close contact personal with infected
droplet spread.
 Incubation period

Short incubation period - usually 7-14 days,

(range 3-35 days)
Clinical Spectrum
 Clinical Spectrum

1- Inapparent (Subclinical) Infection

2- Abortive polio or Minor Illness
3- Non-paralytic polio
4- Paralytic polio
Clinical Outcome of Poliovirus Infections

Paralytic poliomyelitis

Abortive-Clinical illness, no paralysis

Asymptomatic infection

4-8% 90-95%

0.1-1%
Time course of events in infection
with poliovirus
 Paralytic Polio
Phases of symptoms
Non paralytic
Paralytic
 Clinical aspects

Non paralytic
Symptoms similar to minor illness
Headache nausea vomiting more intense
Stiffness and soreness of muscles in neck,
trunk & limbs
 Clinical aspects
Major phase
muscle pain, spasms
return of fever
rapid onset of flaccid paralysis
progression usually complete within 72
hours
asymmetric paralysis (legs>arms)
residual flaccid paralysis within 60 days
 Lab. Investigation

Serum sample

Stool Sample

Culture
 Differential diagnosis

Paralytic poliomyelitis
Guillain-Barre syndrome
Transverse myelitis
Traumatic neuritis
Prevention
 Prevention

Primary Secondary Tertiary

A--Care of exposed
person -Symptomatic -Rehabilitation
BImmunization
C- Polio eradication
Strategies
 Primary Prevention

Health Education
Improving Sanitation & Hygiene
Vaccination
 Polio Vaccine
Inactivated Polio Vaccine(IPV) by Salk
Killed
Systemic immunity only

Oral Polio Vaccine(OPV) by Sabine

Live virus
Both local & systemic immunity

Both Vaccines contain trivalent antigen

 OPV
Bivalent, OR trivalent
2-3 drops
Useful during epidemic
Replace wild virus into vaccine virus in guts
 OPV- Draw back
Heat sensitive->8o C rapidly reduce potency
After 3 dosed seroconversion rate is 73%,90%,
70% for type 1,2 & 3 respectively.
Reasons for low seroconversion
High level of maternal antibodies & competing
entero viruses & diarrhoea.
 IPV
Route of administration- IM (right thigh)
Doses- 0.5 ml during 14 week
Heat stable
Can be used in immuno-compromised patient
Used in the country where polio is eliminated
Can not be used during epidemic of polio
 120 countries add the inactivated polio vaccine to
their routine immunization programmes.

IPV

In India IPV will be introduced during oct-nov 2015

and removal of oral polio vaccines in early 2016,
a critical element of the plan to achieve a polio-free
world.
Vaccine Derived Poliovirus (VDPV)
OPV is a safe vaccine on rare occasions
adverse events
OPV adverse events may occur Vaccine-
associated paralytic poliomyelitis (VAPP)

VAPP occurs in both OPV recipients and their

unimmunized child contacts. It is most
frequently associated with type 3(sabin) (60%
of cases) followed by type 2 and type 1
 VDPV are divided into three
categories
(circulating VDPV) cVDPV.

(Immunodeficiency-related VDPV) iVDPV.

(Ambiguous VDPV) aVDPV.

 TREATMENT AND CONTROL

THERE IS NO CURE FOR POLIO BUT

THERE ARE WAYS TO CONTROL THE
PROGRESS OF THIS DISEASE.
 Healthy muscles can be trained to take over
Rehabilitation
some of the functions of nearby muscles that
are weakened by polio.
 Differences between IPV & OPV
IPV (Salk type) OPV (Sabin type)
Killed vaccine Live vaccine
IM, SC Orally
Circulating antibody but no Immunity is both humoral
local and intestinal
Not useful in epidemics Effectively used in
controlling epidemics
Costlier cheaper
Strategies For Polio
Eradication
Strategies For Polio Eradication

1. Conduct pulse polio immunization days

every year until poliomyelitis is eradication.
2. Sustain high levels of routine immunization
coverage.
3. Monitor surveillance capable of detecting all
cases of AFP due to polio and non-polio
aetiology
4.Ensure rapid case investigation, including the
collection of stool samples for virus isolation.
5. Follow-up of all cases of AFP at 60 days
6.Conduct outbreak control for cases
confirmed or suspected to be poliomyelitis to
stop transmission
 Pulse Polio Immunization
Started from 1995
AIM-
To breaks the chain of transmission of wild
polio virus existing in the community by
replacing it with the vaccine virus in the guts.
 Mass Immunization
campaign (Pulse Polio
Immunization)

Pulse- Sudden, mass administration of OPV

on a single days to all children 0-5 years of age
irrespective of their previous polio vaccination
status

It is additional to routine immunization

Also known as NIDs (National
Immunization Days)
 Kept during winter---(Nov. to Feb.)

Minimum 2 rounds with not less than 4 weeks

& more than 3 months gap.

Additional rounds are kept depending on

incidence of polio cases in a state.
 Why during Winter
Low transmission
Better cold chain maintenance
Better Immunization rate-Less prevalence of
other intestinal organism
Better compliance of field staff for H-H
activities
 IPPI
Sunday-Booths round

Successive Monday, Tuesday & Wednesday

house to house search to vaccinate children who
have not received vaccine on Sunday.
Mobile team- IPPI
round
 Mopping Up

After the detection of case in an

area, Immunization to all children
under 5 years of age in the block /
district
 Mopping up

Immune Population
Polio cases
Unimmunized Population
Polio laboratories

National labs
Reference labs
Global
specialized lab
for polio
7
3
 National Lab BJMC- Identify presence of
polio virus in sample

Reference Lab.- Confirms the vaccine or wild

virus
Global Specialized lab. For polio
Identify not only polio strain but its genetic
derive
Do Boond Zindagi ki
.