This document discusses poliomyelitis (polio), including: 1. Polio is caused by an RNA virus that infects the human digestive tract and sometimes the central nervous system, potentially causing paralysis or death. 2. India has made great progress against polio through vaccination programs like the Universal Immunization Programme and National Immunization Days. 3. Surveillance of acute flaccid paralysis cases and environmental sampling are important to detect poliovirus transmission and ensure polio is truly eradicated.

1. Poliomyelitis
Dr.Tushar Bhabhor
(2nd year P.G student)
Community Medicine Department
NHLMMC Ahmedabad

2. Introduction
• Poliomyelitis is an acute viral infection
• Cause by an RNA virus
• It is primarily an infection of the human
alimentary tract but the virus may infect the
central nervous system.
• 1% cases resulting the paralysis and possibly
death

3. Problem statement in the world

4. Fore Regions Polio-free
1.America
2.Europe
3.Western pacific
4.SEAR

5. Problem statement in the world

8. Indian Scenario
• India biggest achievement against polio
• In India vaccination against polio started in
1978. it was successful in covering around
40%.
• Universal immunization programme (UIP) was
launched 1995
• Pulse polio immunization programme along
with UIP

9. Indian Scenario

10. Gujarat- Last Case in 2007
Source-polio_frequently_asked_statistics_02_apr2015

11. • On 27th March 2014 India was declared as
non-endemic country for polio.
• Polio achieved and implementing polio
endgame strategy

12. Polio Eradication and Endgame
Strategic plan 2013-2018
• 1. To detect and interrupt poliovirus
transmission
• 2. To strengthen immunization systems and
withdraw oral polio vaccine
• 3. To contain poliovirus and certify
interruption of transmission
• 4. To plan how to utilize the legacy of the fight
against polio

13. Polio Surveillance
• 1- Acute flaccid paralysis surveillance
• 2- Environmental surveillance

14. Acute flaccid paralysis surveillance
• 1. Finding and reporting children with acute
flaccid paralysis (AFP)
• 2. Transporting stool samples for analysis
• 3. Isolating poliovirus
• 4. Mapping the virus

15. AFP- 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.

16. Commonest causes of AFP
• Poliomyelitis
• Gullain Barre Syndrome
• Traumatic neuritis
• Transverse Myelitis

17. Case Notification
• from where ? - RUs, Clinics, Pvt.Practitioners
• who reports ? - nodal person/ informer
• when ? - immediately on coming
across an AFP case
• whom to report ? - DHO/SMO
• by what means ? - fastest mode of communication
phone, fax,
• what information ? - name, address, date of onset

18. Confirm AFP
• investigate the case - at hospital / at home
• use case definition

19. Stool sample
• Number -Two stool samples, with a gap of at
least 24 hours between two samples
• Time- First within 14 days of onset of
paralysis
• Quantity – Thumb sized, Sealed containers,
and stored immediately in cold box.

20. Stool sample
• Transport-Maintenance of cold chain from
collection to the time it reaches lab---- by
vaccine carrier-
REVERSE COLD CHAIN
• No leakage, proper labels & packing
• Vaccine carrier once used for transporting stool
sample is disposed off never used for any
purpose.

21. Environmental surveillance
• Environmental surveillance involves testing
sewage or other environmental samples for
the presence of poliovirus.

22. Overall indicators and targets
the "bottom line" on AFP surveillance
number AFP cases
reported yearly
% cases with 2
adequate stools

 >80%
>1/1,00,000 children
under 15 years of age
Indicator Target

23. Epidemiology of Poliomyelitis

24. Host
Agent Environment
Epidemiological

25. Agent factors
• Viral infection: caused by RNA virus
• Primarily an infection of human alimentary
tract, but may infect the central nervous system

26. Polio virus
• Classification-
-Wild Virus (WV)
-Vaccine Virus (VV)

27. Serotypes
• Serotypes:
Type 1, 2 and 3
All types cause paralysis
• Outbreaks of paralytic polio due to type-1
• Poliovirus can survive for long periods in the
external environment.
• In water 4 months
• In faeces 6 months

28. Epidemiological Characteristics of Polio
Serotypes
• All types cause paralysis
• Type 1- Most frequent paralysis,
Highest epidemic potential,
During polio free last serotype to disappear
• Type 2- Rarely paralytic,
during polio free first serotype to disappear
• Type 3- Paralysis less frequent
Less epidemic potential, scattered cases

29. During eradication first serotype
to disappear is 2 >> 3 >>> 1
• In India
• Type 2- last case 1999
• Type 1 -2008
• Type 3- 2011

30. Reservoir of infection
Man is the only reservoir
• Clinical & sub clinical cases
• Every clinical cases >1000 sub clinical cases
• No chronic or carrier stage

31. Communicability
• As long as 3-4 months
• Most infectious 7-10 days before & after the
onset of paralysis

32. Host factors
• Age- all age group
- 6 months – 3 years most vulnerable
-50% cases <1 year of age
-Can affect children up to 15 years
• Sex- ratio of 3 males to 1 female

33. Immunity
• Active
–through immunization / natural
infection
–Immunity believed to be lifelong
• Passive
–Maternal immunity- protection about 6
months

34. • Local- Intestine-
Prevent the entry of the agent
By Natural infection &
Oral Polio Vaccine
• Systemic- Humoral antibodies-
Prevent agent to reach target organ
By Natural Infection &
Injectable & Oral Polio Vaccine
Immunity

35. Environment factors
• Rainy season-Highest transmission
• June- Sept- 60% cases in India
• Half life of excreted virus in sewage in the
tropical climate- 48 hours
• Long survival in cold climate

36. Route of entry- oral cavity
Infectious material
• Oropharyngeal secretion-
• Feacal material

37. Mode of Transmission
Faeco-oral route
Directly through contaminated fingers
Droplet infection
Close contact personal with infected
droplet spread.

38. Incubation period
• Short incubation period - usually 7-14 days,
(range 3-35 days)

39. Clinical Spectrum

40. Clinical Spectrum
• 1- Inapparent (Subclinical) Infection
• 2- Abortive polio or Minor Illness
• 3- Non-paralytic polio
• 4- Paralytic polio

41. Clinical Outcome of Poliovirus Infections
Paralytic poliomyelitis
Abortive-Clinical illness, no paralysis
Asymptomatic infection
90-95%4-8%
0.1-1%

42. Time course of events in infection with
poliovirus

43. Paralytic Polio
• Phases of symptoms
–Non paralytic
–Paralytic

44. Clinical aspects
–Non paralytic
• Symptoms similar to minor illness
• Headache nausea vomiting more intense
• Stiffness and soreness of muscles in neck,
trunk & limbs

45. Clinical aspects
• Major phase
– muscle pain, spasms
– return of fever
– rapid onset of flaccid paralysis
– progression usually complete within 72
hours
– asymmetric paralysis (legs>arms)
– residual flaccid paralysis within 60 days

46. Lab. Investigation
• Serum sample
• Stool Sample
• Culture

47. Differential diagnosis
• Paralytic poliomyelitis
• Guillain-Barre syndrome
• Transverse myelitis
• Traumatic neuritis

48. Prevention

49. Prevention
Primary Secondary Tertiary
A--Care of exposed
person
B—Immunization
C- Polio eradication
Strategies
-Symptomatic -Rehabilitation

50. Primary Prevention
• Health Education
• Improving Sanitation & Hygiene
• Vaccination

51. Polio Vaccine
• Inactivated Polio Vaccine(IPV) by Salk
– Killed
– Systemic immunity only
• Oral Polio Vaccine(OPV) by Sabine
– Live virus
– Both local & systemic immunity
• Both Vaccines contain trivalent antigen

52. OPV
• Bivalent, OR trivalent
• 2-3 drops
• Useful during epidemic
• Replace wild virus into vaccine virus in guts

53. OPV- Draw back
• Heat sensitive->8o C rapidly reduce potency
• After 3 dosed seroconversion rate is 73%,90%,
70% for type 1,2 & 3 respectively.
• Reasons for low seroconversion
– High level of maternal antibodies & competing
entero viruses & diarrhoea.

54. IPV
• Route of administration- IM (right thigh)
• Doses- 0.5 ml during 14 week
• 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

55. • 120 countries add the inactivated polio vaccine to
their routine immunization programmes.
In India IPV will be introduced during oct-nov 2015
and removal of oral polio vaccines in early 2016,
a critical element of the plan to achieve a polio-free
world.
IPV

56. Vaccine Derived Poliovirus (VDPV)
• OPV is a safe vaccine on rare occasions
adverse events
• OPV adverse events may occur Vaccine-
associated paralytic poliomyelitis (VAPP)
• VAPP occurs in both OPV recipients and their
unimmunized child contacts. It is most
frequently associated with type 3(sabin) (60%
of cases) followed by type 2 and type 1

57. VDPV are divided into three
categories
(circulating VDPV) cVDPV.
(Immunodeficiency-related VDPV) iVDPV.
(Ambiguous VDPV) aVDPV.

58. TREATMENT AND CONTROL
• THERE IS NO CURE FOR POLIO BUT
THERE ARE WAYS TO CONTROL THE
PROGRESS OF THIS DISEASE.

59. Rehabilitation
• Healthy muscles can be trained to take over
some of the functions of nearby muscles that
are weakened by polio.

60. Differences between IPV & OPV
IPV (Salk type)
• Killed vaccine
• IM, SC
• Circulating antibody but no
local
• Not useful in epidemics
• Costlier
OPV (Sabin type)
• Live vaccine
• Orally
• Immunity is both humoral
and intestinal
• Effectively used in
controlling epidemics
• cheaper

61. Strategies For Polio
Eradication

62. Strategies For Polio Eradication
1. Conduct pulse polio immunization days
every year until poliomyelitis is eradication.
2. Sustain high levels of routine immunization
coverage.
3. Monitor surveillance capable of detecting all
cases of AFP due to polio and non-polio
aetiology

63. 4. Ensure rapid case investigation, including the
collection of stool samples for virus isolation.
5. Follow-up of all cases of AFP at 60 days
6. Conduct outbreak control for cases
confirmed or suspected to be poliomyelitis to
stop transmission

64. Pulse Polio Immunization
• Started from 1995
• AIM-
To breaks the chain of transmission of wild
polio virus existing in the community by
replacing it with the vaccine virus in the guts.

65. Mass Immunization campaign
(Pulse Polio Immunization)
• Pulse- Sudden, mass administration of OPV
on a single days to all children 0-5 years of age
irrespective of their previous polio vaccination
status
• It is additional to routine immunization
• Also known as NIDs (National
Immunization Days)

66. • Kept during winter---(Nov. to Feb.)
• Minimum 2 rounds with not less than 4 weeks
& more than 3 months gap.
• Additional rounds are kept depending on
incidence of polio cases in a state.

67. Why during Winter
• Low transmission
• Better cold chain maintenance
• Better Immunization rate-Less prevalence of
other intestinal organism
• Better compliance of field staff for H-H
activities

68. IPPI
• Sunday-Booths round
• Successive Monday, Tuesday & Wednesday
house to house search to vaccinate children who
have not received vaccine on Sunday.

69. Mobile team- IPPI round

70. Mopping Up
After the detection of case in an
area, Immunization to all children
under 5 years of age in the block /
district

71. Mopping up
Unimmunized Population
Polio cases
Immune Population

72. 73
Polio laboratories
National labs
Reference labs
Global
specialized lab
for polio

73. • National Lab– BJMC- Identify presence of
polio virus in sample
• Reference Lab.- Confirms the vaccine or wild
virus
• Global Specialized lab. For polio—
Identify not only polio strain but its genetic
derive

74. Do Boond Zindagi ki ……….