Poliomyelitis is an acute viral infection that mainly affects children and can cause paralysis. It is caused by three serotypes of the poliovirus. While most infections are mild or asymptomatic, the virus can infect the central nervous system in rare cases and cause paralysis. Global efforts aim to eradicate polio through high routine immunization coverage, supplemental immunization activities like pulse polio campaigns, acute flaccid paralysis surveillance to detect cases, and mop-up immunization in high-risk areas. Combined, these strategies have helped eliminate wild poliovirus from many countries.

1. POLIOMYELITIS
Dr. Sushrit A. Neelopant
Assistant Professor,
Department of Community Medicine
RIMS, Raichur

2. INTRODUCTION
• Polio – Grey, Muellos – marrow ( Greek )
• Acute viral infection, occurs mainly in children
• Caused by RNA virus
• Primarily infection of GIT
• It may infect CNS in < 1 %
– May cause varying degree of paralysis
• First described - Michael Underwood -1789
• First outbreak described in U.S. -1843
• 21,000 paralytic cases reported- U. S. - 1952
• Global eradication in near future

3. HISTORY
• Heine - described Polio in 1840
• Medin - in 1890
• Hence called as Heine-Medin disease
• Landsteiner & Popper – Identified the virus in 1909
• Enders, Robbibs, Waller– Cultivated the virus - Nobel
• Salk vaccine – Killed vaccine 1955
• Sabin vaccine – Live attenuated vaccine in 1959

4. PROBLEM STATEMENT- WORLD
• Pre vaccination - found all countries
• Since extensive use from 1955 – eliminated from developed
countries
• Still endemic in
– Pakistan, Afghanistan

5. INDIA
27-03-2014

6. CONTD…..
• 2002- 1600 cases in 159 Districts
• 2003 – 225 cases in 87 Districts
• 2004 – 136 cases in 44 Districts
• 2005 – 66 cases in 35 Districts
• 2006 – 383 cases – Western UP , Bihar

7. EPIDEMIOLOGY - TREND
• It can occur sporadically, Endemically & Epidemically
• Earlier it was a sporadic disease
• Evolved as epidemic disease
• Earlier it was disease of infants, later started affecting
older age group
• Earlier seen in temperate climate now in tropical
climate also

8. AGENT
• Poliovirus – 3 serotypes 1, 2 & 3
– Type 1– Brunhilde, 2 – Lansing, 3 - Loen
• Most outbreaks - type 1 virus
• It can survive outside the human body for 4 months
in cold season, 6 months – faeces
• Rapidly destroyed by pasteurization, chemical,
physical agents, drying (not available in freeze dried
form )

9. RESERVOIR OF INFECTION
• Man is the only source of infection
• Most cases – Mild, sub clinical – Play an imp. role in
spread of the infection
• For every clinical case of Polio – 1000 sub clinical
cases in children & 75 in adults
• Period of communicability – 7–10 days before & after
the onset of symptoms

10. HOST
• Age – Infants & children
• Most vulnerable age – 6 months–3 years
• Sex – 3 males to 1 female
• Maternal antibody– Protect 6 months after birth
• Infection– Confers long lasting immunity, but no
protection against another strain

11. FACTORS– PROVOCATE LATENT
INFECTION
• Injection
– DPT (Vascularisation part spinal cord)
• Fatigue
– Trauma, Excercise
• Surgery
– Head & Neck region

12. ENVIRONMENT
• Likely to occur rainy season
• In India – 60 % cases – June–September
• Environmental sources – Contaminated water, food,
through flies
• Over crowding, poor sanitation – Opportunity for
infection

13. MODE OF TRANSMISSION
• Transmitted – Droplet infection, faeco–oral route
Acute phase
• Faeco oral route – Later phase
– Fluids
– Foods
– Fruits & Vegetables
– Fomites
– Fingers
– Flies

14. PATHOGENESIS
• Portal of entry- Oral route. Adheres to the epithelial
cells and replicates. Passes to the submucosa and
replicates in Peyer`s patches & tonsils
• Travels to regional L.N. and gives rise to initial
viraemia.
• Localization and replication occurs in R.E.Cells
• A second viraemia occurs with localization in
different organs

15. PATHOGENESIS
• CNS infection- most likely to occur during viraemia
either through muscle end plate or blood stream
• Virus detectable in oro-pharynx up to 3 weeks and in
stool up to 12 weeks and up to 1 year in immuno-
deficient patients
• In GIT, during replication, the oral polio virus can
undergo mutation and convert into more neuro
virulent phenotype

16. SUMMARY - PATHOGENESIS
• Entry into mouth
• Replication in pharynx, GI tract,
local lymphatics
• Hematologic spread to lymphatics and central
nervous system
• Viral spread along nerve fibers
• Destruction of motor neurons

17. CLINICAL SPECTRUM
Infection with Polio virus
Sub clinical
infection
95 %
Abortive
infection 4 %
Aseptic menin
1 %
Paralytic
< 1 %

18. ASEPTIC MENINGITIS
• 1% cases
• CSF findings - raised proteins, normal sugar,
pleocytosis (<1000 cells, Polymorphonuclear
predominance)
• Lasting for 2-10 days.
• Non paralytic polio

19. PARALYTIC POLIO
• <1% of cases.
• Occurring one or more days after symptoms of
aseptic meningitis
• Sudden onset fever, vomiting, anorexia
• Back & neck muscle pain
• Followed by lower motor neuron paralysis (Flaccid)

20. CONTD…..
• Mild cases- Few muscles paralysed
• More proximal than distal
• Severe cases entire limb paralysed
• No sensory loss ( DD- GBS )
• DTR – Diminished
• 2-3 days full paralysis (Asymmetrical)
• Residual paralysis

22. BULBAR POLIOMYELITIS
• Fever, weakness swallowing, coughing
• Paralysis of pharynx
• Collection of secretion in the throat
• Inability to swallow threatens life
• Recovery good but slow ( If they survive )

23. POST POLIO SYNDROME
• New occurence of weakness, fatigue, fasciculations
and pain with atrophy of groups of muscles involved
in initial episode of paralysis
• May occur after 20-40 years
• May extend over 1-10 years
• Due to dysfunction and exhaustion of motor neurons
that compensated for the neurons lost and not due
to re-infection or reactivation

24. DIAGNOSIS
• Isolation of the virus- Stool
• Virus cannot be grown in culture- from throat swab,
CSF or Blood
• Rise in antibody titer – Confirmatory
• Aseptic meningitis- 1%.
– With CSF revealing raised proteins, normal sugar,
pleocytosis (<1000 cells, PMN predominance)
Lasting for 2-10 days

25. POLIO VIRUS – ELECTRON
MICROSCOPE

26. MANAGEMENT
• General supportive care
– Isolation
– Concurrent disinfection – Stool – 10 % Cresol
– Bed rest – avoid stress on affected muscles
– Paracetamol – Fever, Pain
– Prophylactic oral antibiotics
– Splints – to prevent deformity
– Fluid & electrolyte balance ( Oral )
– Physiotherapy – After acute phase of illness – 6
weeks

27. DIFFERENTIAL DIAGNOSIS FOR POLIO
• Transverse myelitis
– No fever, symmetrical paralysis lower extremity,
marked sensory loss, in children > 4 yrs., CSF – N
• Traumatic neuritis
– H/O IM injection, paralysis of limb with pain, Limb
affected below knee, foot drop, slow recovery, any
age group

28. DIFFERENCE – POLIO & GB SYNDROME
POLIO MYELITIS
• Caused – virus
• Common – Infants, < 5 yrs
• Acute onset
• Fever present
• Flaccid, asymmetrical
• Descending
• No sensory deficit
• No cranial nerve involvement
GB SYNDROME
• Demyelinating dis.
• Rare – Infants, 1-4 yrs
• Chronic
• Fever- 2-3 weeks prior
• Flaccid, symmetrical
• Ascending
• Sensory deficit present
• Cranial nerves involved – 7,9

29. PREVENTION
• Immunization is the only way to protect children
against polio
• All children by the age of 6 months– Fully immunized
• Both Killed & Live vaccines are available

30. POLIO VACCINE
• 1955 Inactivated vaccine
• 1959 Live attenuated vaccine
• 1987 Enhanced-potency IPV (IPV)
– It can be given with DPT, sero-conversion is better
compared to OPV after 3 doses
– It can also prevent the multiplication of virus in
the pharynx

31. INACTIVATED KILLED VACCINE
• Also known as Salk Vaccine
• Contains all 3 types – Polio virus
• 4 doses required – 1st 3 when child 6 weeks old with
1-2 months interval
• 4th dose – 6- 12 months after the 3rd dose
• Additional doses every 5 years till the age of 18 years

32. CONTD…..
• Sabin 1957
• Contains live attenuated virus ( all 3 types )
• Ideal to give each type as monovalent vaccine
• Administrative purpose trivalent vaccine given
• Vaccine contains – 3 lakh TCID 50 of type 1, 1 lakh
TCID 50 of type 2 & 3 lakh TCID 50 of type 3 (TCID –
Tissue culture infective dose)

33. DIFF. BETWEEN IPV & OPV
• IPV ( Salk )
– Killed ,
– IM, Cold chain not req
– Systemic immunity
– Doesn’t protect gut – Re-
inf. With wild virus
– Not useful – to control
epidemics / Eradication
– Trained person req.
– Imm. Shorter – 5 years
– No vaccine associated
paralysis
• OPV ( Sabin )
– Live attenuated
– Oral, Cold chain req.
– Local & Systemic imm.
– Protects gut from re inf.
With wild virus
– Useful – Control
epidemics / Eradication
– Trained person not req
– Immunity – Lifelong
– Vaccine associated
paralysis can occur

34. NATIONAL IMMUNIZATION SCHEDULE
• Soon after birth – Zero dose polio
• 1st dose – 6 weeks
• 2nd dose 10 weeks
• 3rd dose 14 weeks
• 1st booster 18 months
• 2nd booster – 4 years 6 months - 5 years
• Dose – 2 drops
• Vaccine associated paralytic polio esp with type 3
virus due to mutation

35. REASON FOR VACCINE FAILURE
• Incomplete schedule
• Use of date expired vaccine
• Instability of vaccine
• Lack of cold chain maintenance
– Vaccine vial monitor -
• Vaccine associated paralytic polio

36. VACCINE VIAL MONITOR

37. ERADICATION OF POLIOMYELITIS
• A country is said to be free from polio – Zero
incidence for continuous 3 years
• Why eradicate polio ?
– Humans – only reservoir
– No chronic carrier state
– Half life – excreted wild polio virus in sewage – 48
hours
– Potent vaccine is available
– Lifelong immunity if schedule is completed
correctly

38. CONTD…..
• Last case in United States in 1979
• Western Hemisphere certified polio free in 1994
• Last isolate of type 2 poliovirus in India in October
1999
• Global eradication goal

39. Wild Poliovirus 1988

40. Wild Poliovirus 2008

41. PULSE POLIO IMMUNIZATION
• GOI – introduced 1995
• Supplementary programme – Routine imm.
• PPI started - in-spite of good routine immunization
coverage, because 10 % remained unimmunized
• For 100 % Immunization coverage < 3 yrs
• Later on it was extended to < 5 yrs children
• PPI on NID on 2 occasions with 4-6 weeks gap

42. HOW PPI HELPS TO ERADICATE POLIO
• Wild polio virus requires un immunized gut for its
multiplication within 1-2 days of its excretion
• Immunized children’s gut doesn’t allow
multiplication of wild polio virus
• Hence if all children < 5years get immunized against
polio, on PPI day, wild polio virus can’t survive

43. STRATEGIES OF POLIO ERADICATION
• High level routine immunization coverage
• Pulse polio immunization
• Acute flaccid paralysis surveillance
• Mop up immunization

45. AFP SURVEILLANCE
• Introduced– 1997 in India
• To detect final reservoir of wild polio virus
• AFP– Sudden onset of paralysis of the limb <4 weeks
duration in child <15 years
• AFP surveillance– Detecting all cases of acute
paralysis not only polio cases, it ensures that polio
cases are not missed
• Hence AFP surveillance is tool to detect suspected
polio cases

46. OBJECTIVES OF AFP SURVEILLANCE
• To detect high risk areas– to plan immunization
• To monitor progress of AFP surveillance
• To certify country polio free
• It is an indicator of sensitivity of surveillance
system

47. EVENTS AFTER DETECTING AFP CASE
(60 days FU)
AFP case–
2 stool
samples
Wild Polio
virus
Confirmed
case
No wild
polio virus
Discard
Inadequate
sample
Residual
weakness
Died, Lost - FU
Confirm
No residual
weakness
Discard

48. REPORTING OF AFP CASES
• All AFP cases reported to District immunization
officer – DIO, as early as possible
• In case no AFP cases- Zero reporting is must
– Initial phase AFP required – detecting polio virus
– Later stages – to prove the absence of polio virus
• AFP – Public health emergency

49. LINE LISTING OF CASES
• Reporting of every case of AFP in a prescribed
proforma
• It includes
– Name, age, sex, address, imm. Status, date of
onset of paralysis, clinical findings etc
• Helps in avoiding duplication of case
• Follow up of the case
• Identify high risk areas
• Implement control measures

50. MOP UP IMMUNIZATION
• Last stage in polio eradication
• Door to door immunization of all children in high risk
area – circulation of wild polio virus is reported or
suspected
• All children within 5 km area immunized
• About 2000- 3000 children are immunized
• Started within 48 hrs of reporting a case of AFP and
to complete within 7 days

51. INTENSIVE PULSE POLIO IMMUNIZATION- IPPI
• In- spite of PPI, AFP cases do occur
• GOI – 1999 intensified PPI
• 3 days programme
• 1st day – Children immunized in Booth
• 2nd day – House to house survey
– X mark if child not immunized, non co-operation,
locked houses
– P mark if child is immunized ( GV mark on the
finger of the child indicate immunization )

52. CONTD…..
• 3rd day – Only X marked houses are visited
– Children are immunized with OPV
– X mark is wiped
– P mark is put on the door
• Purpose of IPPI – not to miss even single child

53. SUPPLEMENTARY IMMUNIZATION ACTIVITIES-
SNID
• In some states – UP , Bihar
• To supplement PPI, 2 more round of OPV from
October - January
• Better coverage of children
• Consistency in vaccine coverage
• To maintain high level of AFP surveillance

54. SUMMARY
• Poliomyelitis is an acute, highly infectious disease of
children
• One of the diseases to be eradicated
• High routine immunization, Pulse polio
immunization, AFP surveillance, Mop up
immunization – Help in the eradication of the disease

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