Poliomyelitis

POLIOMYELITIS
Dr. Animesh Gupta
M.B.B.S., M.D., F.D.M.,
F.A.G.E.
Associate Professor
Dept. of Community
Medicine
Narayan Medical College &
Hospital, Jamuhar, Bihar
Monday, August 8, 2022 2

SLO
At the end of this class, the student must be able to
o Describe the epidemiology of Poliomyelitis in children
o Classify clinical spectrum of poliomyelitis
o Enumerate clinical features/presentation of poliomyelitis in children
o Describe the treatment of Poliomyelitis in children
o Describe the Prevention of Poliomyelitis in children
oDescribe the eradication strategy of Poliomyelitis in children

INTRODUCTION
oPolio – grey matter, myelitis – inflammation
of the spinal cord
oIt is an acute viral infection caused by an
RNA virus belonging to Picornaviridae
family under enterovirus genera.
oIt primarily infects human alimentary tract
but may infect the CNS resulting in varying
degrees of paralysis & possibly death

HISTORY
o1580-1350 BC an Egyptian tablet
portrays a priest with a withered leg,
indicating that the disease dates backs to
ancient times.
o1789 – First recognized by Dr Micheal
Underwood.
o1835 – Badam described acute paralysis
in 4 children suggestive of paralysis
o1875 – Erb introduced the term acute
anterior poliomyelitis.
o1909 – Causative virus was recognised by
Karl Landsteiner and Erwin Popper.

PROBLEM
STATEMENT

India has not
reported any polio
cases since
January 2011.
India was declared
Polio free since
27th March 2014.

15 June 2016 – Global
emergency after an active
strain of wild polio virus
was detected in a water
sample collected from a
drain.
Vaccine derived polio
virus was detected in this
water sample after 5 years
of polio free status in
India.
3.5 lakh children aged
between 6 weeks to 3
years from Hyderabad and
Ranga Reddy district were
vaccinated.

EPIDEMIOLOGY
AGENT FACTOR
oAgent – Poliovirus
o Serotype
oType 1 - (Brunhilde/Mahoney): mostly causes outbreaks
oType 2 - (Lansing): easiest to eradicate
oType 3 - (Leon): often last to be eradicated
VAPP (Vaccine Associated Paralytic Polio)- Type- 2 & 3
Virus remain alive in water for 4 months & in faeces for 6
months
Pasteurization, physical and chemical agents – inactivation of
the virus
Group
:
Group IV
((+)ssRNA)
Family
:
Picornaviridae
Genus
:
Enterovirus
Specie
s:
Poliovirus

AGENT FACTOR….
oReservoir of infection-
Man is only reservoir
No chronic carrier
Most infectious are sub-clinical & mild cases
oSource of infection
Faeces & Oropharyngeal secretions of infected persons
oIncubation period: 7 to 14 days( 3- 35 days)
oCommunicability
Cases are most infectious 7-10 days before & after onset of symptoms

HOST FACTOR
oAge – 6 months to 3 yrs.
oSex – M:F is 3:1
oRisk factors – Trauma, operative procedures such as
tonsillectomy, administration of immunizing agents such as
alum-containing DPT
oImmunity-
oMaternal Ab disappears during first 6 months
oReinfection can occur since infection with one type does not
protect completely against the other two types of viruses.
oNo cross immunity

ENVIRONMENTAL FACTOR
oRainy season i.e. June to September - 60% cases occur
oContaminated water, food & flies
oOvercrowding & poor sanitation

CLINICAL
SPECTRUM

CLINICAL
PRESENTAT
ION
Inapparent infection:
- No presenting symptoms
- Recognised by virus isolation or raise in
antibody titre
Abortive polio or Minor Illness:
- Mild or self-limiting illness due to
viraemia
- Recognised by viral isolation or raise in
antibody titre
Non paralytic polio:
- Presenting with stiffness and pain in
the neck
- Synonymous with aseptic meningitis
16
Monday, August 8, 2022

CLINICAL
PRESENTAT
ION
Paralytic Polio
•Predominant sign is asymmetrical
flaccid paralysis
• History of fever at the onset of
paralysis is suggestive of polio
•Associated symptoms – malaise,
anorexia, nausea vomiting, headache,
sore throat, constipation, abdominal
pain, stiffness of neck and back muscles
• Tripod signs is present

TRIPOD SIGN
18

CHARACTERISTICS OF PARALYSIS
oSudden paralysis, temporary or permanent
oProgression of paralysis reaches its maximum in less than 4
days ( 4 - 7 days)
oDescending in character i.e. starting at the hip and moving
down to the distal parts of the extremity.
oAs it is patchy paralysis muscle strength varies in different
muscles group of different limbs.
oProximal muscle group are more involved as compared to the
distal ones.
oDeep tendon reflexes are diminished before the onset of
paralysis. No sensory loss.

PARALYTIC
POLIO…
oCranial nerve involvement is seen in
bulbar and bulbospinal forms of
paralytic poliomyelitis.
oThere may be facial asymmetry,
difficulty in swallowing, weakness or
loss of voice.
oRespiratory insufficiency may be life
threatening and is usual cause of
death.
oAfter the acute phase, atrophy of the
affected muscles lead to a life with
residual paralysis
21

LABORATORY INVESTIGATION
oStool examination
oDemonstration of Virus –
oThroat secretions
oBlood sample

TREATMENT
oNo specific treatment
oOnly symptomatic treatment – Analgesic, anti-spasmodic
oPhysiotherapy
oGood Nursing care

Despite the progress achieved since 1988, as long as a single child
remain infected with virus, children in all countries are at risk of
contracting the disease.
The polio virus can easily be imported to a polio free country and can
be spread rapidly.
Failure to eradicate could result in as many as 2,00,000 every year.
Polio vaccine given multiple times, can protect a child for life.
24
There is no cure for polio; it can only be prevented

ENDEMIC & OUTBREAK COUNTRIES

PREVENTION, CONTROL &
ERADICATION STRATEGY

PREVENTION & CONTROL
Primary
Health education
Improving sanitation & Personal hygiene
 Immunization (OPV & IPV)
Secondary
Symptomatic treatment
Physiotherapy
Tertiary – Rehabilitation
DR. ANIMESH GUPTA 29

OPV
(LIVE ATTENUATED
VACCINE)
oDescribed by Albert Sabin in
1957
o Live attenuated virus (3
types) grown in primarily
monkey kidney or human
diploid cell cultures
o Schedule
oAt birth- Zero dose of polio
o6, 10 & 14 weeks –1st, 2nd & 3rd
doses
o12 to 18 months – one booster
dose
oDose & route of
administration -
o2 drops given orally
oInduces both humoral &

OPV…
Heat sensitive – 80 C rapidly reduce potency
Not used in immunocompromised person and
corticosteroid therapy

IPV
(INACTIVATED POLIO
VACCINE)
oDescribed by Jonas Salk in 1955
oContains all 3 types of poliovirus
inactivated by formalin
oSchedule- 4 doses
o1st dose – 6 weeks
o 2nd & 3rd doses at an interval of
1-2 months and 4th dose 6-12
months after 3rd dose
oAdditional doses at school entry
& every 5 years until the age of
18 years
oDose & route of administration –
0.5ml IM/SC
o Immunity- Induces humoral
antibodies but not intestinal or
local immunity

IPV…
• 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

VVM (VACCINE VIAL MONITOR)

INDIA TO INTRODUCE
INJECTABLE INACTIVATED
POLIOVIRUS VACCINE (IPV)
In May 2012, the World Health Assembly endorsed
the Polio Eradication & Endgame Strategic Plan 2013-
2018
India joins 125 other countries to introduce
Inactivated Poliovirus Vaccine (IPV) into routine
immunization as part of Polio Eradication and
Endgame Strategic plan in 2015.
IPV would be given along with third dose of oral polio
vaccine (OPV) at 14 weeks of age for children under
one year of age.

POLIO
ERADICATIO
N

STRATEGY FOR ERADICATION
oSustain high level of routine immunization
oConduct Pulse polio immunization
oMonitor Polio Surveillance (AFP)
oEmergency Preparedness & Response Plan (EPRP) –
Polio case detection
oInternational polio certification for travelers

PULSE POLIO
IMMUNIZATION (PPI)
oLaunched in India in 1995.
oTarget to Children in the age group
of 0-5 years
o Administered polio drops during
National immunization days every
year.
o2 doses of OPV vaccines are given
at an interval of 4 to 6 weeks during
National immunization day (Nov. to
Feb.)
oThe dose of OPV during PPI are
extra doses which supplement & do
not replace the doses received
during routine immunization.
Pulse- Sudden, mass
administration of OPV on a single
days to all children 0-5 years of age
irrespective of their previous polio

INTENSIFIED PULSE POLIO
IMMUNIZATION (IPPI)
oBooth activity – on Sunday
oSuccessive Monday, Tuesday & Wednesday – house to
house search to vaccinate children who have not received
vaccine on Sunday.
MOPPING UP
oAfter the detection of case in an area, Immunization to all
children under 5 years of age in the block /district

POLIO
SURVEILLANCE
oAFP Surveillance
Finding and reporting
children with acute flaccid
paralysis (AFP)
Transporting stool
samples for analysis
Isolating poliovirus
Mapping the virus
oEnvironmental
Surveillance

AFP SURVEILLANCE….
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.

STOOL SAMPLE
oNumber -Two stool samples, with a gap of at least 24 - 48
hours between two samples
oTime- First within 14 days of onset of paralysis
oQuantity – Thumb sized
Storage – sealed in container and stored immediately inside
a refrigerator or packed between ice packs at 4-8°C in a cold
box
Transport – National Laboratory* within 72 hours of
collection with Maintenance of cold chain
*BJMC Ahmedabad, NIV Bangalore, ERC Mumbai, IoS Kolkata,
NCDC Delhi, CRI Kasauli, KIPM Chennai, SGPGI Lucknow

 Isolating polio virus
Isolation of polio virus from stool sample
Distinguishing between wild polio virus and vaccine related
polio virus
Mapping the virus
Once wild poliovirus has been identified, further tests are
carried out to determine where the strain may have originated.
By determining the exact genetic make-up of the virus, wild
viruses can be compared to others and classified into genetic
families, which cluster in defined geographical areas.

ENVIRONMENTAL
SURVEILLANCE
Environmental
surveillance
involves testing
sewage or other
environmental
samples for the
presence of
poliovirus.

Onset of paralysis
Investigation of suspected
case (≤48 hours of report)
2 stool specimens
collected 24 hours
apart
Outbreak response
immunization,
additional case finding
60-day follow-up exam
Specime
ns arrive
at
national
laborator
y
Results
reported
from
national
laboratory
Poliovirus isolates send
to regional reference
laboratory for intratypic
differentiation
Final classification of the case by the
expert committee (≤ 12 weeks since
onset of paralysis)
Flow diagram of case
investigation,
stool specimen collection and
outbreak response immunization
≤ 3
Days
≤ 24
Days
≤ 7 Days

INTERNATIONAL
CERTIFICATE OF
VACCINATION
oYellow card or Carte Jaune is
an international certificate of
vaccination (ICV), issued by
WHO
oPakistan, Afghanistan, Nigeria,
Democratic Republic of the
Congo, Papua New Guinea,
Kenya, Somalia and Syria.
oTravelers must take bivalent
OPV or IPV at least a month
before departure or arrival
oThe certificate is valid for one
year

48
As long as a single child remains infected,
children in all countries are at risk of contracting
polio.
“END POLIO NOW: COUNTDOWN TO
HISTORY”
DR. ANIMESH GUPTA

Thank

Poliomyelitis

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