Poliomyelitis in children -- Classification, Epidemiology, Etiology, Clinical Features, Complications, Management, Prognosis and Prevention

1. Poliomyelitis in children
Classification, Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
Allah gives wisdom to whom He wills, and whoever has been given
wisdom is given much good; and only the wise take the guidance
Quran surah Al-Baqara 2:269
Al- Quran

3. Case scenario
• An 3 year old girl presents with inability to walk for the
last three days
• On examination, her temperature of 100 F.
• Child is unable to walk. She is able to stand
• Her right leg appears painful
• Which system is affected ?
• What further examination is needed ?

4. Differential Diagnosis of Child
who is unable to walk
• Neurological / muscular weakness / paralysis
• Locomotor (bone / joint) problems
• Trauma

5. Further evaluation of child with a Limp
• Locomotor examination (bones and joint)
• Neurological examination of limbs
• SOMI
• Cranial nerves
• Autonomic functions (bowel / bladder / vasomotor)
• Respiration / Power of respiratory muscles

6. Case scenario (continues)
• On neurological examination, tone in right leg is
decreased. Power of hip flexors, knee flexors and ankle
extensors is 2/5. Deep tendon reflexes in right leg are
absent.
• Left leg is normal. Cranial nerves are intact. SOMI are
negative.
• Respiratory rate is 30. Chest indrawing is not present
• Examination of joints is normal. Passive joint movements
are not painful
• What is the most likely diagnosis ?

7. Differential Diagnosis of Acute Flaccid Paralysis (AFP) –
(weakness with hypotonia)
• Poliomyelitis – (mostly unilateral lower limb)
• Guillain-Barre syndrome (GBS) – often bilateral,
ascending paralysis of lower and upper limbs
• Traumatic neuritis – (after misplaced intramuscular
injection damaging a nerve)
• Transverse myelitis – (focal inflammation in spinal cord)

8. Poliomyelitis
An infectious disease caused by polio virus and
characterized by muscular weakness due to
damage to anterior horn cells of LMN
(lower motor neurons)

9. ETIOLOGY
Polio virus
Types 1 , 2 , 3
RNA virus
an entero virus

10. Polio – Epidemiology and Transmission
• Usual age = less than 5 years
• Source of virus – Stools of infected persons
• Transmission – Feco – Oral route
(contaminated water / milk / food)
• Virus has short survival outside human body
• INCUBATION PERIOD – 7 – 21 days
• Infectivity Period: 4 to 6 weeks

11. Pathogenesis of Poliomyelitis
• Oral entry
• Gut lymphoid tissue
• (3rd day) Minor viremia
• Reticulo-endothelial system
• (7th day) Major viremia
• anterior horn cells
• Neuronal death

12. Clinical Features
Poliomyelitis is an ancient disease

13. Clinical types of Poliomyelitis
• Asymptomatic / subclinical infection (90 – 95 %)
• Abortive / non-specific minor illness (5 %)
• Non-paralytic / CNS symptoms ( 1%)
• Paralytic Poliomyelitis ( 0.1%)

14. Viremia in Clinical types of Poliomyelitis

15. Asymptomatic / subclinical infection
(90 – 95 %)
• Child gets infected with Polio virus
• Child does not develop any symptoms
• Develops antibodies against poliovirus (type specific
antibodies)

16. Abortive / non-specific minor illness
(5 %)
• Child develops non-specific symptoms
• Fever, malaise, sore throat, nausea, pain abdomen,
headache, muscle pains
• There are no specific CNS symptoms
• Child recovers in 2-3 days

17. Non-paralytic disease / CNS symptoms
( 1%)
• Fever, malaise, nausea, muscle pains
• CNS symptoms – headache, vomiting, neck stiffness
• SOMI are positive
• No Paralysis
• Recovers in 5 – 10 days

18. Paralytic Poliomyelitis
( 0.1%)
• Fever, headache, muscular pains
• Paralysis of skeletal muscles in an irregular distribution
• Usually a single lower limb is affected
• Hypotonia
• Tendon reflexes absent

19. Factors predisposing to Paralytic Poliomyelitis
• Presence of these factors during the polio virus infection
may predispose to development of paralytic disease
• Exercise, fatigue,
• Intramuscular injections
• Use of steroids

20. Types of Paralytic Poliomyelitis
• Spinal Poliomyelitis (common) – limbs, trunk, diaphragm
• Bulbar Poliomyelitis (rare) – dysphagia, dysphonia,
(cranial nerves and vital cardiorespiratory centers
affected)
• Encephalitic Poliomyelitis (very rare) – disorientation,
convulsions

21. Common Clinical Presentations
of Poliomyelitis

22. Clinical Study of Paralytic Poliomyelitis at Nishtar Hospital Multan
1988 (when POLIO was a common illness)
T I Bhutta, Imran Iqbal: Paralytic poliomyelitis in southern Punjab: a perspective on the EPI program.
Pakistan Paediatric Journal 1988; XII (4): 227 – 243

23. Clinical Study of Paralytic Poliomyelitis at Nishtar Hospital Multan
1988 (when POLIO was a common illness)
T I Bhutta, Imran Iqbal: Paralytic poliomyelitis in southern Punjab: a perspective on the EPI program.
Pakistan Paediatric Journal 1988; XII (4): 227 – 243

24. Diagnosis

25. Diagnosis of Poliomyelitis
• Systemic symptoms (fever, malaise, loss of appetite)
• Acute flaccid paralysis (AFP) – weakness with hypotonia
• Neurological weakness – Lower Motor Neuron (LMN)
• Polio virus culture is positive (stool specimen culture)

26. Differential Diagnosis of Acute Flaccid Paralysis (AFP)
(weakness with hypotonia)
• Poliomyelitis – (mostly unilateral lower limb weakness)
• Guillain-Barre syndrome (GBS) – often bilateral,
ascending paralysis of lower and upper limbs
• Traumatic neuritis – (after misplaced intramuscular
injection damaging a nerve)
• Transverse myelitis – (focal inflammation in spinal cord)

27. Differential Diagnosis of Acute Flaccid Paralysis (AFP)

28. Investigations in of cases of
Acute Flaccid Paralysis (AFP)
• CBC, CRP, Serum electrolytes
• Nerve conduction studies of affected limbs
- Acute Poliomyelitis – Normal
- GBS – acute demyelination of motor nerves
• Polio virus culture (stool specimen culture)
• Method: Stool samples (two samples, 24 hours apart, within two weeks of
paralysis onset) are sent in ice-box to Viral culture laboratory (National
Institute of Health) for virus culture studies

29. Complications of Poliomyelitis
• Respiratory insufficiency (acute stage)
• Residual paralysis (chronic disability)

30. MANAGEMENT
• Acute phase
• Convalescent phase (acute symptoms subside)
• Chronic phase (residual paralysis)

31. Management of Acute Paralysis
• Rest
• Positioning of limbs (neutral position)
• Analgesics for pain
• Hydration & nutrition
• Care of bed-ridden patient

32. Management of Convalescent Phase
• Analgesia
• Neutral position of limbs (with splints)
• Massage of limbs
• Passive & active exercises
• Care of bed-ridden patient

33. Rehabilitation for Residual Paralysis
• Exercises (active and passive)
• Splints (prevent deformity and contractures)
• Braces (walking support)
• Surgery (tendon lengthening and transplant)

34. Prevention of
Poliomyelitis

35. PREVENTION
• Polio vaccine
• IPV (Injectable Polio Vaccine) – systemic immunity
• OPV (Oral Polio Vaccine) – herd immunity
• EPI Schedule
Poliomyelitis
Vaccine
OPV 4 doses OPV0: soon after birth
OPV1: 6 weeks
OPV2: 10 weeks
OPV3: 14 weeks
IPV 1 dose IPV-I: 14 weeks

36. Global Polio Eradication Program
Started in 1988

37. Poliomyelitis can be eradicated because –
• Only human beings are source of transmission
• No chronic carrier state
• No animal vector involved
• Virus does not survive long in environment
• Effective vaccines available
• Methodology: Produce immunity against polio virus in all
human beings so that chain of transmission of virus is
interrupted and polio virus cannot survive anywhere

39. Strategy for Polio Eradication (4 components)
• Routine Polio vaccination of all infants – IPV and / or
OPV
• National Immunization Days (NIDs) – (a dose of OPV for
every child at the same day)
• AFP surveillance (identify every case of poliomyelitis in
the community)
• Mopping up (Repeated vaccination to eradicate the
remaining focus of infection)

40. Poliomyelitis cases in Pakistan
• 1988 – 40000
• 1994 – National Immunization Days started
• 2000 – 200
• 2010 – 140
• 2015 – IPV started
• 2020 – 84