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  1. 1. Poliomyelitis Dr.T.V.Rao MD
  2. 2. What is Poliomyelitis <ul><li>Poliomyelitis (polio) is a highly infectious viral disease, which mainly affects young children. The virus is transmitted through contaminated food and water, and multiplies in the intestine, from where it can invade the nervous system. </li></ul>
  3. 3. How Polio presents <ul><li>Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. In a small proportion of cases, the disease causes paralysis, which is often permanent. Polio can only be prevented by immunization. </li></ul>
  4. 4. Where is Polio present TODAY <ul><li>In 2008, only four countries in the world remain with polio-endemic, down from more than 125 in 1988. The remaining countries are Afghanistan, India, Nigeria and Pakistan. </li></ul>
  5. 5. POLIOMYLETIS. <ul><li>Involves CNS, produces serious Illness. </li></ul><ul><li>Causes Destruction of Motor Neurons in Spinal cord. </li></ul><ul><li>Produces FLACID PARALYSIS. </li></ul><ul><li>India has still has many cases of Poliomyelitis. </li></ul>
  6. 6. Polio An Enterovirus <ul><li>Poliovirus , the causative agent of poliomyelitis , is a human enterovirus and member of the family of Picornaviridae .Poliovirus is composed of a RNA genome and a protein capsid. The genome is single-stranded positive-sense RNA genome that is about 7500 nucleotides long. The viral particle is about 300 Ångström in diameter with icosahedral symmetry. </li></ul>
  7. 7. Pioneers who Discovered Vaccine
  8. 8. Poliomyelitis <ul><li>First described by Michael Underwood in 1789 </li></ul><ul><li>First outbreak described in U.S. in 1843 </li></ul><ul><li>21,000 paralytic cases reported in the U. S. in 1952 </li></ul><ul><li>Global eradication in near future </li></ul>
  9. 9. Classification of Polio virus . <ul><li>Type 1 - Brunhilde and Mahoney. </li></ul><ul><li>Type 2- Lansing and Mefi. </li></ul><ul><li>Type 3- Leon and Salkett. </li></ul>
  10. 10. Properties of Polio virus, <ul><li>Size is 27 nm </li></ul><ul><li>Contains 4 viral protein VP1 to VP 4 </li></ul><ul><li>VP1 Carries the major antigenic site, and combines with type specific neutralizing antibodies </li></ul>
  11. 11. Properties of Polio virus. <ul><li>Typical Entero virus. </li></ul><ul><li>Inactivated at 55 0 c for 30 mt. </li></ul><ul><li>Chlorine at 0.1 ppm </li></ul><ul><li>Ether is not effective. </li></ul><ul><li>Animal susceptibility. </li></ul><ul><li>Monkey brain </li></ul><ul><li>Requires Primate specific membranes. </li></ul><ul><li>Contains 3 Antigenic types 1,2,3 </li></ul><ul><li>Can be differentiated by ELISA and CF methods. </li></ul>
  12. 12. Polio Infection . <ul><li>Incubation 3 – 21 days </li></ul><ul><li>On average 14 days </li></ul><ul><li>Predisposing factors. </li></ul><ul><li>Severe muscular acitivity can lead to paralysis, as it increases the blood flow </li></ul><ul><li>May produce paralysis in the limb or bulbar region </li></ul><ul><li>Injecting vaccines with adjuvant can predispose to paralysis </li></ul><ul><li>Patients who underwent tonsillectomy have higher incidence as Ig G secretion is reduced </li></ul><ul><li>Rarely oral Polio vaccine produces poliomyelitis. </li></ul>
  13. 13. Pathogenesis and pathology . <ul><li>Enter through Mouth, </li></ul><ul><li>Multiplies in Oropharynx tonsils and Intestines, </li></ul><ul><li>Excreted in Stool. </li></ul><ul><li>Enters the CNS from Blood. </li></ul><ul><li>Spread along the Axons of peripheral nerves to CNS. </li></ul><ul><li>Progress along the fibers of the lower motor neurons spinal cord or brain. </li></ul>
  14. 14. Pathology and Pathogenesis. <ul><li>Destroy the Anterior horn cells of the Spinal Cord </li></ul><ul><li>Do not Multiply in Muscles only muscles manifest with weakness and flaccid paralysis result is secondary. </li></ul><ul><li>Occasionally produce </li></ul><ul><li>Myocarditis, </li></ul><ul><li>Lymphatic hyperplasia. </li></ul>
  15. 15. Clinical Manifestations. <ul><li>In apparent, Only 1% manifest with clinical features. </li></ul><ul><li>Can lead to permanent paralysis. </li></ul><ul><li>Incubation 7-14 days, ( 3-35 ) </li></ul><ul><li>May be abortive Poliomyelitis, </li></ul><ul><li>Only Fever, Malaise, Drowsiness, </li></ul><ul><li>Non paralytic Poliomyelitis, </li></ul><ul><li>Aseptic Meningitis. </li></ul>
  16. 16. <ul><li>Outcomes of Poliovirus Infection </li></ul>
  17. 17. Paralytic Poliomyelitis . <ul><li>Manifest as Flaccid Paralysis.( Caused due to damage to Lower Motor Neurons.) </li></ul><ul><li>Partial recovery within 6 months. </li></ul><ul><li>Patient may continue with life time disability </li></ul><ul><li>Can involve Spinal cord, and Bulbo spinal region </li></ul><ul><li>Bulb spinal involvement can paralyze respiratory muscle and lead to Respiratory failure </li></ul><ul><li>. </li></ul>
  18. 18. Cripples a Grwoing Child
  19. 19. Clinical presentation of typical Polio
  20. 21. Aseptic Meingitis <ul><li>Present with Non paralytic form with stiffness and pain in the back and neck region </li></ul><ul><li>Lasts for 2 -10 days </li></ul><ul><li>Recovery rapid and complete </li></ul><ul><li>On rare occasions advance to paralysis </li></ul>
  21. 22. Laboratory Diagnosis . <ul><li>Viral isolation from </li></ul><ul><li>Throat swabs, </li></ul><ul><li>Rectal swabs. </li></ul><ul><li>Stool specimens, </li></ul><ul><li>Transported in frozen containers. </li></ul><ul><li>Produce cytopathic effect on </li></ul><ul><li>Human and Monkey cells </li></ul><ul><li>Produce cytopathic effects. </li></ul>
  22. 23. Viral Isolation <ul><li>From feces - present in 80% of cases in 1 st week </li></ul><ul><li>In 50 % till 3 rd week </li></ul><ul><li>In 25 % till several weeks </li></ul><ul><li>Collect the fecal sample at the earliest. </li></ul><ul><li>Primary monkey kidney is the ideal cell line for isolation of virus </li></ul><ul><li>Viral isolation must be interpreted with caution and clinical presentation </li></ul>
  23. 24. Laboratory Diagnosis (Serology ) <ul><li>Estimation of Antibodies Ig M </li></ul><ul><li>A paired sample is essential. </li></ul>
  24. 25. Immunity . <ul><li>Permanent type specific. </li></ul><ul><li>1 and 2 types have Heterotypic resistance. </li></ul><ul><li>Mother to Off spring immunity lasts for less than 6 months. </li></ul>
  25. 26. Epidemiology <ul><li>Endemic </li></ul><ul><li>Epidemic </li></ul><ul><li>Hygiene plays in spread of diseases. </li></ul><ul><li>Children < 5 in Developing countries. </li></ul>
  26. 27. Prevention and Control. (Vaccines) <ul><li>Sabin’s Live attenuated vaccine </li></ul><ul><li>Grown in Monkey kidney cells, Human Diploid cells. Preserved at 4 c </li></ul><ul><li>Multiple doses are given </li></ul><ul><li>Given as oral Drops </li></ul><ul><li>At present only vaccine given in our National Programme of Immunization </li></ul><ul><li>Boosts Immunity with Production Ig G ,Ig M </li></ul><ul><li>And also Ig A Participate as participant in Prevention. </li></ul>
  27. 28. Vaccination Sabin's- Oral Administration <ul><li>Sabin’s vaccine is administered orally. </li></ul><ul><li>Contains </li></ul><ul><li>Type 1 – 10 lakhs, </li></ul><ul><li>Type 2- 2 lakhs </li></ul><ul><li>Type 3- 3 Lakhs. </li></ul><ul><li>The virus are stable with Mg cl. </li></ul>
  28. 29. Oral Polio Vaccine <ul><li>Highly effective in producing immunity to poliovirus </li></ul><ul><li>50% immune after 1 dose </li></ul><ul><li>>95% immune after 3 doses </li></ul><ul><li>Immunity probably lifelong </li></ul>
  29. 30. Sabin's Vaccine
  30. 31. Live Polio vaccines –Protects Society too <ul><li>The Live Polio vaccine infects multiples in the Intestines and thus Immunizes the Individual </li></ul><ul><li>Vaccines not only produces IgM and IgG in the blood but also IgA antibodies in the Intestines. </li></ul><ul><li>Which help the gut immunity </li></ul>
  31. 32. Live Vaccine Associated Polio <ul><li>On few occasions type 2 and type 3 virus may mutate in the course of multiplication </li></ul><ul><li>May lead to Vaccine associated Polio </li></ul><ul><li>But very negligible </li></ul>
  32. 33. Role Of Immunoglobulins in Prevention <ul><li>Immunoglubulins can provide protection for a few weeks against the paralytic polio </li></ul><ul><li>But does not prevent subclinical infection </li></ul><ul><li>Effective if given shortly before infection </li></ul><ul><li>No value once the clinical symptoms develop </li></ul>
  33. 34. Salk Vaccines <ul><li>Salk Vaccine - A Killed Vaccine. </li></ul><ul><li>Four Injections are administered in a period of two years, </li></ul><ul><li>Administration of periodic booster recommended. </li></ul><ul><li>Most of the Western Nations do use it. </li></ul>
  34. 35. Salk Vaccine ( Killed-Inject able)
  35. 36. Vaccination in Immunodeficient <ul><li>Only Killed viral vaccines used in Immunodeficient persons </li></ul><ul><li>( SALK ) </li></ul>
  36. 37. Present prevalence of Polio attacks
  37. 38. Wild Poliovirus 2006
  38. 39. Global Eradication <ul><li>WHO target date - year 2000 </li></ul><ul><li>Yet in 2008 we have Polio cases </li></ul>
  39. 40. Pulse Polio Immunization
  40. 41. Global Eradication. <ul><li>The Indian Programme of PULSE POLIO Immunization is a part of it to eradicate Polio </li></ul><ul><li>Recent resurgence in UP and Bihar is a threat to the desired Goal. </li></ul><ul><li>In spite of best efforts thousands occur globally in Africa and Indian subcontinent. </li></ul>
  41. 42. Let us be partners in Eradication of Polio
  42. 43. Created for Undergraduate Teaching Programme Dr.T.V.Rao,MD Email [email_address]