Poliomyelitis
Definition
Poliomyelitis (polio) is a highly infectious
disease caused by a virus. It invades the
nervous system and can cause varying
degrees of paralysis, and possibly death.
The virus enters the body through the
mouth and multiplies in the intestine.
PROBLEM STATEMENT :
In pre vaccination era polio was found
in all countries .
Since 1954 ,there was an extensive use
of polio vaccine . so,developed
countries eliminated it .
In 1988,the WHA assembly resolved to
eradicate polio globally.
Contd..
Acute flaccid paralysis surveillance is
conducted to identify all remaining
infected areas .
epidemiological situation in India
Wild poliovirus type 1 (WPV1): No WPV1 has been
reported in India from any source since January
2011.
No WPV1 has been detected in UP since
November2009, and in Bihar since September
2010.
The last isolations of WPV1 were two cases in
West Bengal.
Wild poliovirus type 3 (WPV3): The last WPV3 case
reported had onset in October 2010 in district Pakur in
Jharkhand and the last environmental isolate
reported was from Delhi in July 2010.
No case of WPV3 has been reported in Bihar since
January 2010 and in Uttar Pradesh since April 2010.
Current position in India:
India today has touched a milestone of being polio
free for one whole year.
On 25 February, 2012, India was officially struck off
the list of polio-endemic countries by the World
Health Organization (WHO), having gone more than
one year without reporting any cases of wild
poliovirus
Epidemiology - Agent factors
Agent :
- Poliovirus - 3 serotypes 1,2 and 3
- survives for long periods
- water 4 months , faeces 6 months
Reservoir - only man
Infectious material –
nasopharyngeal secretions , faeces
TYPES :
TYPE 1 - responsible for most epidemics
of paralytic polio.
TYPE 2 - responsible for in apparent
infections in the western countries.
TYPE 3.
Agent factors
Period of communicability :
- 7 to 10 days before and after onset of
symptoms.
- excreted in faeces for 2 to 3 weeks max
4 months.
HOST FACTORS
AGE :
it is a disease of infants and childhood.
SEX :
3 males to 1 female.
RISK FACTORS:
risk factors such as fatigue ,trauma ,IM injection ,operative
procedures such as tonsillectomy and aluminum containing DPT .
IMMUNITY :
- Maternal antibodies disappears during
first 6 months .
- Immunity following infection is fairly solid.
- Type 2 is the most effective antigen.
ENVIRONMENTAL FACTORS
Rainy season
Contaminated water , food, flies
Overcrowding, poor sanitation
MODE OF TRANSMISSION
FAECAL – ORAL ROUTE :
DROPLET INFECTION :
*INCUBATION PERIOD : 7-14 days
(range 3-35 days)
Clinical Features
Inapparent / Subclinical infection:
- it occurs in 95% of infection
- no symptoms .
Abortive polio or minor illness:
- occurs in 4-8 %
- mild or self limiting illness .
NON PARALYTIC POLIO:
- Occurs in 1% of infections .
- Features are stiffness in the neck
and the back .
PARALYTIC POLIO:
- Occurs in less than 1% of
infections .
- Predominant sign is flaccid
paralysis
- Associated symptoms are malaise, anorexia,
nausea, vomiting, headache, sore throat,
constipation and abd pain.
- Tripod sign may be present i.e the child
finds difficulty in sitting and sits by
supporting hands at the back and by partial
flexing the hips and the knees.
- Paralysis is characterized as descending i.e
starting at the hip and then moving down
to the distal parts of the extremities.
- It is an asymmetrical patchy paralysis.
- There is also difficulty in swallowing,
weakness, or loss of voice.
- Respiratory insufficiency is life
threatening
Prevention – Immunization
Two types of vaccines are used :-
Inactivated (Salk) polio vaccine (IPV)
Oral (Sabin) polio vaccine (OPV)
Inactivated (Salk) polio vaccine
- contains 3 types
- 4 inoculations, first 3 dose at interval of
1 to 2 month and fourth dose 6-12 months after 3 rd dose.
- 1st dose is given to 6 week old infant.
Disadvantage
- it induces humoral antibodies but
does not induce intestinal or local
immunities.
- it protects the individual from paralysis
and not the community.
- it not suitable in case of epidemic.
Advantages
- Can be administered to immune
deficiency pts
- Persons on radiation therapy
- Over 50 yrs
- During pregnancy
Oral (Sabin) polio vaccine
- described by Sabin in 1957
- contains live attenuated virus (types 1,2&3)
National Immunization Schedule :-
- 3 doses of OPV at 1 month interval
commencing the first dose when infant is 6
weeks.
- booster dose at 12-18 months later
- it is important to complete vaccination of all
infants before 6 months of age
Dose and Mode of Administration :-
- 3 drops
- WHO recommends the vaccinators to use
the dropper supplied with vial of OPV.
- tilt the child’s back, and gently squeeze the
cheeks or pinch the nose to make the
mouth open, let the drops fall onto the
child’s tongue.
Development of Immunity :-
- it infects intestinal epithelial cells and
transported to Peyers patches then to
circulation.
- it produces both local and systemic
immunity.
Advantages
- Oral administration
- Humoral and intestinal immunity
- Quick antibody production
- Vaccinee excretes virus
- Useful to control epidemics
- Cheap
Complications
- there is no complication except the case of
vaccine-associated paralytic polio.
Contraindication
- Acute infectious diseases, fevers, diarrhea
and dysentery.
- Patients suffering from leukemia,
malignancy.
Cold Chain
- Stabilised: by adding magnesium
chloride. Can be stored at 4 degree C
for a year
- Non stabilised
- stored at -20
Strategies for Polio eradication in India
- Conduct PPI every year until polio is eradicated.
- Sustain high level of routine investigation
coverage.
- Monitor OPV in district level and below.
- Improve surveillance capable of detecting all
cases of AFP.
- Ensure rapid case investigation.
- Arrange follow up of all cases of AFP at 60 days
to check for residual paralysis.
- Conduct outbreak control
Line listing of cases
- This started in the year 1989 to check for
duplication, year of onset of illness, detection
of high risk pockets and documentation of
high risk age groups.
- All cases of acute flaccid paralysis must be
reported to chief medical officer or District
immunization officer with following details .
Name, age, sex of the patients.
Fathers name & address
Vaccination status
Date of onset of paralysis & date of
reporting
Clinical diagnosis
Doctor’s name
Mopping Up
- it is the last stage in polio eradication.
- strategy involve door to door
immunization in high risk districts.
Pulse Polio Immunization
- PPIs is when OPV is given to all children 0-5 yrs of
age in a country on a single day regardless to
previous immunization.
- It has 2 rounds of about 4-6 weeks apart
- In India peak transmission is from June to Sept.
- this is only a extra dose
- Govt of India conducted the 1st round of PPI on
9th Dec 1995 & 20th Jan 1996.
Vaccine vial monitor:
It is a small square made of heat sensitive material &
placed on the outer coloured circle printed on the
label on the OPV vial.
Combined effect of time & temperature cause the
vaccine vial monitor to change colour gradually from
light at starting point & become darker with exposure
to heat.
The darkening process is irreversible.
Outer coloured circle is used as reference to
compare the colour of vaccine vial monitor.
Global Polio Eradication
Initiative
There are four core strategies to stop
transmission of the wild poliovirus :-
- High infant immunization coverage with four
doses of oral polio vaccine in the first year of
life;
- Supplementary doses of oral polio vaccine
to all children under five years of age during
national immunization days (NIDs)
- Surveillance for wild poliovirus
through reporting and laboratory
testing of all cases of acute flaccid
paralysis (AFP) among children under
fifteen years of age;
- Targeted “mop-up” campaigns
once wild poliovirus transmission is
limited to a specific focal area
