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Acute poliomyelitis

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PAEDIATRICS

PAEDIATRICS

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  • 1. ACUTE POLIOMYELITIS DR. NATARAJ PL
  • 2.
  • 3. Clinical Diagnosis (WHO case definition)
    “ A case of poliomyelitis is defined as any child under fifteen years of age with acute flaccid paralysis or any person with paralytic illness at any age when polio is suspected”
  • 4. Cycle of infection
    Agent
    • Poliovirus : three serotypes (P1, P2, P3) with different antigenicity
    • 5. The virus can live in water for three months and in the faeces for six months.
    • 6. The poliovirus is rapidly inactivated by heat, formaldehyde, chlorine and ultraviolet light.
    Reservoir
    Cases : clinical & subclinical plays a role in the spread of infection
    Carriers: faecal temporary. There is no chronic carrier.
    Source of infection:
    Faeces and pharyngeal secretions of the infected person
  • 7. Person
    Age and sex:
    In developing countries Poliomyelitis is a disease of young children and adolescents
    In developed countries adults were affected more commonly than children with increased both the disease severity and deaths.
    Sex difference have been noticed in the ratio of three male to one female
  • 8. Time
    Poliovirus infection typically peaks in the summer months.
    Man is the only reservoir
  • 9. Time course of poliovirus infection
  • 10. Mode of transmission
    1-Feaces (feco-oral): in areas with lack of personal hygiene
    especially in young children in developing countries. It results in
    infection not paralysis.
    2-Droplet:in developed countries with high standard of
    sanitation, droplet is common mode of transmission during the
    acute phase of the disease when the virus is in the throat.
    3-Direct contact with respiratory discharge
    4- Common vehicle: ingestion of food or drink contaminated with faeces
    5- Indirect contact with articles contaminated with pharyngeal discharge of infected person.
    Inlet
    The mouth and nose
  • 11. Pathogenesis of Polio Virus Infection
  • 12. Immunity in Polio
    Transplacentally acquired passive immunity
    After natural infection
    After immunisation
    Local immunity
  • 13. Immunity to Poliovirus Infection
    Exposure to poliovirus initiates a complex process that eventually results in both humoral (systemic) and mucosal (local) immunity.
    Poliovirus infection provides lifelong immunity against the disease, but this protection is limited to the particular type of poliovirus involved (Type 1, 2, or 3)
    Thus, infection with one type does not protect an individual against infection of the other two types. IgMand IgG antibodies are detected in the serum as early as 1-3 days following natural infection but disappears after 2-3 months.
  • 14. Poliomyelitis: Risk Factors
    Immune deficiency
    Pregnancy
    Poor sanitation and hygiene
     Poverty
     Unimmunized status, especially if <5 years
    Tonsillectomy: a risk factor for bulbar paralysis.
    Intramuscular injections or truama
    Genetics:
    No genetic susceptibility has been identified.
  • 15. Response to Infection
  • 16. Abortive poliomyelitis
    5% cases
    Influenza like symptoms 1-2 weeks later
    Lasts only for 2-3 days
    Clinical examination unremarkable
    Complete recovery
  • 17. Non paralytic poliomyelitis
    1% cases
    Initial minor illness-headache, nausea, vomiting, soreness and stiffness of neck muscles, fleeting paralysis of bladder and constipation
    Short symptom free interlude
    Major illness
  • 18. Non paralytic poliomyelitis
    Nuchal and spinal rigidity are hallmark
    Tripod sign, Kiss the knee
    Neck rigidity, Kernigs sign
    Head drop
    Reflexes usually normal
    Changes in reflex indicate impending paralysis
  • 19. Paralytic poliomyelitis-spinal
    2nd phase of the illness
    Spotty paralysis
    Asymmetric flaccid paralysis
    One leg most common followed by one arm
    Absent DTRs
  • 20. Paralytic poliomyelitis-spinal
    Absent DTRs
    No sensory deficits
    Full picture by 3 days. Usually no further progression
    Bowel and bladder dysfunction
    Older age and provocation paralysis the biphasic illness is not seen
  • 21. Paralytic poliomyelitis-spinal
    Recovery is slow starting after several weeks of the disease, but usually within 6 months
    If not then residual paralysis
    Recovery may continue for as long as 18 months
    Atrophy, deformity and failure to grow
  • 22. Paralytic poliomyelitis-Bulbar
    Nasal twang to voice and nasal regurgitation of food
    Inability to swallow and pooling of oral secretions
    Palatal and tongue involvement
    Vocal cord palsy
  • 23. Paralytic poliomyelitis-Bulbar
    Vital centers in medulla being involved
    Ascending paralysis
    Autonomic disturbances
    Recovery is variable
  • 24. Paralytic poliomyelitis-Encephalitis
    Involvement of higher centers
    Seizures,coma,spastic paralysis
    Peripheral & cranial nerve palsies
    Respiratory paralysis-due to variety of possibilities
  • 25.
  • 26. Clinical Evolution
  • 27. Poliomyelitis: Complications
    Urinary tract infection
    Skin ulcers
    Traumatic injuries to affected limb(s)
    Atelectasis & Pneumonia
    Myocarditis
    Postpoliomyelitis progressive muscular atrophy.
    Postpoliomyelitis motor neuron disease.
    Respiratory muscle involvement and death
  • 28. Poliomyelitis: Diagnosis 
    Based on the clinical presentation.
    Cerebrospinal Fluid:
    Leukocytosis, Increased protein, Normal glucose.
    Virus recovery from stool, throat washing, blood.
    • Virus recovery from stool is essential to diagnosis.
    • 29. Obtain stool, blood and throat samples for viral serology, demonstrating a four fold rise in IgG is helpful but not always easy.
    • 30. Positive IgM is diagnostic.
    Polymerase chain reaction amplification of poliovirus RNA from CSF or serologically, by comparing viral titers in acute and convalescent sera.
  • 31. Diagnosis…cont 
    Electrodiagnostic investigations reveal normal sensory nerve studies.
    Motor nerve studies:
    show normal to mildly slowed conduction velocities and low to normal amplitudes.
    MRI may be helpful to evaluate involvement of anterior horn of the spinal cord or other findings.
  • 32. Differential diagnosis
    Guillain-Barre syndrome
    Diphtheric paralysis
    Botulism
    Myasthenia Gravis
    Polymyositis & Viral myositis
    Transverse Myelitis
    Spinal cord compression
    Hypokalemic periodic paralysis
  • 33.
  • 34. Treatment-Abortive
    Analgesics & sedatives
    Bed rest
    Nutrition
    Avoid exertion & IM injections
  • 35. Treatment-non paralytic
    Above mentioned methods
    Hot packs & hot tub baths
    Firm bed
    Foot board or splint
    Gentle physical therapy
  • 36. Treatment-Paralytic
    Care of bowel & bladder
    Increased fluid intake
    Care of airway & secretions
    Monitor vital signs
    Ventilation
    Tracheostomy
  • 37.
  • 38. Outcome
    Complete recovery in abortive & non paralytic polio
    60% mortality in bulbar polio & 5% in spinal polio
    Recovery beyond 6 months is unlikely
  • 39. Four different oral polio vaccines are available to stop polio transmission. From left to right: mOPV3, mOPV1, bOPV and OPV
  • 40. Oral polio vaccine
    Contains 3 serotypes of vaccine virus
    Grown on monkey kidney (Vero) cells
    Contains magnesium sulfate, phenolphthalein
    Heat sensitive – to be stored at –200 c
    Stored at 2-80 c during administration
    VVM on the vial
  • 41. Oral polio vaccine
    Shed in stool for up to 6 weeks following vaccination – Herd immunity
    Seroconversion rates of 73%, 90% and 70% for 1, 2, 3 serotypes after 3 doses
    4 doses in the first year of life and boosters-IAP recommendation
    Type 2 serotype disappears first with immunisation
    Used in pulse polio programme
  • 42. Oral polio vaccine-Adverse reactions
    Vaccine associated paralytic poliomyelitis(VAPP)-250 to 800 cases annually-1/5 million doses
    Most common by type2 (type 3 as per Nelson and Park)
    Circulating vaccine derived polio viruses (cVDPV)-out breaks of paralytic polio
  • 43.
  • 44.
  • 45.
  • 46. VACCINE VIAL MONITOR
    X
    3 = bad:Don’t Utilize
    1 = good:Utilize
    X
    2 = good:Utilize
    4 = bad:Don’t Utilize
    The central square is equal to, or darker than the surrounding circle
    The central square is lighter than the surrounding circle
  • 47. Polio is suitable to be eradicated for the following reasons
    Polio only affects humans, there are no known animal reservoirs
    An effective, inexpensive vaccine is available: Oral Polio Vaccine (OPV)
    Immunity is life long
    There are no chronic carriers
    Half life of excreted virus in the sewage is 48hrs ( spread occurs only during this period)
  • 48. AFP surveillance
    AFP is defined as sudden onset of weakness and floppiness in any part of body in a child <15 years or paralysis in a person of any age in whom polio is suspected
    Background rate of AFP 1/1,00,000 children is minimum
  • 49. AFP surveillance
    Case notification and investigation –within 48 hours
    2 stool samples 24 hours apart within 2 weeks (upto 60 days)
    Outbreak response immunization
    Active case searching
    Hot cases identification
  • 50. AFP surveillance
    Collection of stool samples
    Transportation
    Eight national laboratories
    60 day follow up
  • 51. AFP surveillance – strategies
    High coverage of routine immunization
    Supplemental doses of OPV
    Surveillance of AFP cases
    Conducting mop-up vaccination campaigns
  • 52. AFP surveillance – virological classification
  • 53. Before a WHO region can be certified polio-free, three conditions must be satisfied:
    There are at least three years of zero polio cases due to wild poliovirus;
    Disease surveillance efforts in countries meet international standards; and
    Each country must illustrate the capacity to detect, report and respond to “imported” polio cases
  • 54. What is Post Polio Syndrome ?
    It is the late manifestation of acute paralytic polio.
    25-40% of people who had paralytic polio15-40yr previously.
    They show symptoms of muscle and joint pain, general fatigue and weakness.
    Three indications of PPS:
    A. Previous diagnoses of polio
    B. Long interval following recovery: people usually live long
    but effect can occur during 30-35 years after the diagnoses.
    C. Gradual onset: weakness that tends to be perceptible until it
    interferes with daily activities.
  • 55. Criteria For Diagnosis of Post Polio Syndrome
    A prior episode of paralytic poliomyelitis.
    EMG evidence of longstanding denervation.
    A period of neurologic recovery and functional stability preceding the onset of new problems (Usually >20 years).
  • 56. Strategies of polio eradication
    There are four core strategies to stop transmission of the wild poliovirus
    A-Routine immunization of infants
    B-Supplementary immunization
    National immunization days ( EPI)
    Mopping up immunization ( EPI)
    C- Surveillance Acute flaccid paralysis and mop-up vaccination campaigns.
    D-An effective virological laboratory
  • 57. REVERSE COLD CHAIN
    Sister kennys treatment
    Why PPI during nov-feb
    Brunhilde, lansing and lean
    WPV2 is not reported since 1999
    Mc -1,VAPP-3
  • 58. Thank you