The document discusses acute flaccid paralysis (AFP) and polio eradication efforts. It defines AFP and lists potential causes. It then outlines the components of AFP surveillance, including case notification, investigation, follow up, and data management. Specifics of case investigation, stool sample collection and transport are provided. Details are given on poliovirus transmission and pathogenesis. The global polio eradication strategy involves high routine immunization, national immunization days, active surveillance of AFP cases, and mop-up activities in areas of transmission. Milestones for achieving eradication by 2012 are proposed.

1. Dr. Anita Lamichhane

2. Acute Flaccid Paralysis
 Rapid onset of weakness, including weakness of
the muscles of respiration and swallowing,
progressing to maximum severity within several
days to weeks

3. Acute Flaccid Paralysis
 WHO:
 Poliomyelitis
 Gullain Barrie syndrome
 Transverse myelitis
 Traumatic Neuritis

4. Components of AFP Surveillance
 The AFP surveillance network and case
notification
 Case & laboratory investigation
 Outbreak response & active case search in the
community
 60 day follow up, cross notification & tracking of
cases

5.  Data management & case classification
 Virologic classification scheme
 Surveillance performance indications

6. Case and laboratory investigation
 Immediate investigation into the case within 48 hrs
of notification
 Stool specimen collection & transportation
 2 stool specimen collected as soon as possible
after the onset of paralysis (ideally within 14 days
of onset of paralysis & at least 24 hrs apart)
 Each specimen should be 8 gms- each about the
size of the adult thumb

7. Stool container

8.  Collected in a clean, dry, screwed capped container
 No preservative or transport media should be used
 The specimens collected, labeled ,transported in the
cold chain-on frozen ice packs/ ice, in a stool
specimen carrier or a vaccine carrier
 In Pakistan, the specimen is sent to NIHL( National
Institute 0f Health Laboratories ) at Islamabad

9. Poliomyelitis
 Two Greek words: polios (gray) & myelios (spinal
cord..anterior horn cells )
 In 1908, the polio virus was discovered by Karl
Landsteiner

10.  An enterovirus
 3 serotypes-P1,P2,P3
 P1 - causes outbreaks—is the most likely virus to
cause paralysis.
 P2 - the easiest to eradicate followed by P3
 Human are the only hosts without which the virus
cannot survive

11.  The Virus is excreted in the stools for three to six
weeks.
 It is more stable than most viruses ,can stay alive
for several weeks in contaminated food or water.
 It is one of the most contagious viruses.
 If one family member is infected, nearly all the rest
of the family becomes infected.

12. Portal of entry multiplies in the cells of the mucous
is the mouth membranes in the pharynx and
intestines
Hematological Invades local lymphoid
spread tissue
• virus becomes neurotropic
• produces destruction of the motor neurons in the
anterior horn and brainstem

14.  Cold chain- Maintenance of temperature from
vaccines synthesis to delivery to child.
 Reverse cold chain- Maintenance of cold chain
from stool collection to delivery to the laboratories

15. Yearly report
Year-to-date Year-to-date
Total cases 2010 2009 Total in 2009
Globally 39 110 1606
in endemic
countries 32 80 1256
in non-endemic
countries: 7 30 350

16. Yearly report …of Pakistan
 In Pakistan, one new WPV3 case was reported on
the 17th February 2010, from Quetta, Baluchistan.
 Bivalent OPV was used for the first time in
Pakistan in NIDs held from 15-17 Feb 2010
 The next round will be held from 15-17 March
2010 in targeted high and medium risk districts,
using bOPV

17. Number of confirmed cases of
poliomyelitis in Pakistan, 1997–
2008

18. Number of districts with confirmed
poliomyelitis cases in Pakistan,
1997–2008

19.  Pakistan has recorded 76 cases in 2009 to date:
 52 type 1
 23 type 3
 one type 1/3 mixture.

20. SNIDs in Afghanistan
 the Provincial Government of Nangarhar, UN
agencies jointly launched sub-national
immunization days (SNID) in Jalalabad on
Sunday, 14 February 2010.

21. Disease Surveillance
 The ongoing systematic collection & analysis of
data & the provision of information which leads to
action being taken to prevent & control a disease,
usually one of an infectious nature

22. Herd immunity
 Immunity of a sufficient number of individuals in a
population such that infection of one individual will
not result in an epidemic.

23. Wild polioviruses
 Isolates known or believed to have circulated
persistently in the community & reference strains
derived from these isolates.
 May be present in a variety of clinical materials
faeces & throat specimens
less commonly in blood
rarely in CSF in non-paralytic & paralytic infections.
.

24.  In fatal infections, wild poliovirus may be present in
 faeces
 intestinal contents
 lymph nodes
 brain tissue
 spinal cord tissue

25. Vaccination
 1955 - Mr. Salk discovered IPV
 1957 - Mr. Sabin discovered OPV
 EPI- globally launched in 1974
 In Pakistan in 1978 training was started and
became apparent in 1979

26. Polio Eradication
 In 1988 , World Health Assembly, in its resolution
41.28 – set goals of A global polio eradication
program
 OPV was recommended.
 In Pakistan started in 1993-94
 Led by the World Health Organization, UNICEF,
and The Rotary Foundation

27.  Global Eradication of polio program was
established in 1989.
 Today only 4 countries are endemic to polio
 Pakistan,
 Nigeria,
 India,
 Afghanistan

28. What is Eradication ???
 The World Health Organization (WHO) defines
polio eradication essentially as ‘zero incidence of
wild poliovirus transmission anywhere in the
world’.

29. Polio eradication requires
+
Finding and Finding and
controlling wild controlling wild
poliovirus in human poliovirus in
populations laboratories

30. Why was it launched ???
 Humans are thought to be poliovirus's only host
 Virus survival in the environment is limited.
 Immunization with vaccines interrupts virus
transmission

31. Objectives of the Global polio Eradication
initiative
 To interrupt transmission of the wild poliovirus as
soon as possible
 To achieve certification of global polio eradication
 To contribute to health system ,development &
strengthening routine immunization & surveillance
for communicable disease in a synergistic way

32. Strategies of achieving the goal
 High routine infant immunization
 Supplementary doses of OPV to all children under 5 yrs
of age during SIAS( Supplementary immunization
activities)
 Active AFP Surveillance for wild poliovirus through
reporting & lab testing of all AFP cases among children
under 15 yrs of age
 Targeted “Mop-up" campaigns once wild poliovirus
transmission is limited to a specific focal area.

33. High routine infant immunization
 All countries aim to immunize at least 90% of
infants with four OPV doses
 These doses are part of the basic (EPI)
 High routine immunization coverage decreases the
incidence of polio & sets the stage for eradication

34. National Immunization Days
(NIDs)
 It is the 2nd part of the four-pronged strategy and is also
known as mass immunization campaign.
 Important activity for interrupting wild poliovirus
circulation in endemic countries
 A supplementary immunization
 Intended to complement - not replace - routine
immunization.

35.  The aim of mass campaigns is to interrupt
circulation of poliovirus by immunizing every child
under 5 years of age with two doses of OPV,
regardless of previous immunization status.
 Three to five years of NIDs are usually required to
eradicate polio
 NIDs are needed for at least 3 consecutive years
to interrupt transmission

36.  NIDs are normally conducted during the cool, dry
season
( immunological response to OPV is improved and
the potential damage to heat-sensitive OPV is
reduced.)
 SNIDs) target children for polio vaccination in
specific high-risk regions of countries rather than
the entire country.

37. Surveillance of new cases of polio
 Countries to ensure that all cases of poliomyelitis
are detected
 The goal of AFP surveillance is to report and
investigate “any case of acute flaccid (floppy)
paralysis

38.  surveillance systems should be capable of
 detecting at least one case of AFP per 100 000
population < 15 years;
 collecting adequate stool specimens from at least
80% of AFP cases
 testing all specimens at a WHO-accredited
laboratory.

39. Mop-up Activities
 AFP surveillance data are used to identify the final
chains of wild poliovirus transmission in each
geographical area
 In these areas, two doses of OPV are
administered to all children < 5 years, regardless
of their prior immunization status, by immunization
teams that go house-to-house.

40.  Improve coverage & ensure that the most difficult-to-
reach children are immunized, thereby interrupting the
last chains of wild poliovirus transmission
 In addition to delivering supplemental OPV doses,
mop-up activities often include an active search for AFP
cases

41. Summary of Proposed Milestones
Milestones for future Target year
1. Establish comprehensive policy for future 2003
 management.
2. Eliminate wild poliovirus transmission. 2003
3. Certification of ‘eradication’ of wild viruses. 2006
4. Introduction of IPV in routine immunization. 2006
5. Complete withdrawal of OPV. 2009
6. Certification of ‘true eradication’ of 2012
polioviruses.
7. Discontinue polio immunization. 2015

42. Polio Eradication in Pakistan
 In Jan 2010, meeting covered the tribal leaders
and religious scholars
 In South Waziristan, Mufti Maulana Abdul
Qayuum issued a fatwa supporting polio efforts, 15
mosques were made after the ceremony
 Women also played an important role in increasing
the coverage

43.  Special teams of women were mobilized & trained
to go house-to-house and address the recent rise
in refusal rates
 The delivery teams equipped with appropriate
messages, were able to cover 61% of all the
refusal families in Larana.

44. Recent advances of polio virus
 Researches use crippled Polio Virus to attack
Brain Cancer
 Polio virus has a natural affinity to invade the
brain, by binding to the CD155 receptor on the
surface of the motor neurons
 Brain tumors overproduce the CD155 receptors
which makes the cell in the tumors more
susceptible to poliovirus infection

45.  The genetically engineered altered poliovirus
when introduced in the body
 Enters the normal motor neurons (it shares the
same CD155 receptors as brain tumour cells )but
cannot grow in normal neurons
 Kills the brain tumor cells

46. no cure for polio
it can be
prevented