This document provides information about poliomyelitis (polio) including its history, epidemiology, clinical features, diagnosis, treatment, vaccination, and global eradication efforts. It notes that polio cases have declined globally from over 350,000 cases in more than 125 endemic countries in 1985 to just 22 cases in Afghanistan and Pakistan in 2019. India was declared polio-free in 2014 and key milestones in India's polio eradication program are highlighted. Oral polio vaccine and inactivated polio vaccine are discussed.

1. POLIOMYELITIS
Dr. Dhruvendra Pandey
Associate Professor,
Department of Community Medicine

2. From 125 Polio Endemic
countries
to 3 endemic countries
0
100
200
300
400
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Polio
cases
(thousands)
Wild Poliovirus (WPV) Eradication, 1985–2019*
Last type 2 polio in
the world
Last Polio
Case in
India
Last type 3
polio
In the world
Eradication
of WPV 2
11/26/2022

3. Wild Poliovirus 1988

4. Wild Poliovirus 2008

5. Global WPV1 & cVDPV Cases1, Previous 6 Months
Endemic country (WPV1)
11/26/2022
WPV1 cases (latest onset)
Afghanistan: 10 (10 Nov 2019)
Pakistan: 61 (16 Nov 2019)
cVDPV1 cases (latest onset)
Myanmar: 4 (09 Aug 2019)
Philippines: 1 (28 Oct 2019)
Malaysia: 1 (30 Oct 2019)
cVDPV2 cases (latest onset)
Angola: 64 (21 Oct 2019)
Benin: 6 (15 Oct 2019)
CAR: 14 (06 Oct 2019)
Chad: 1 (09 Sep 2019)
DRC: 39 (21 Oct 2019)
Ethiopia: 4 (09 Sep 2019)
Ghana: 9 (23 Oct 2019)
Nigeria: 7 (09 Oct 2019)
Pakistan: 11 (03 Nov 2019)
Philippines: 9 (25 Oct 2019)
Togo: 3 (16 Oct 2019)
Zambia: 1 (16 Jul 2019)
1Excludes viruses detected from environmental surveillance ; 2Onset of paralysis: 11 Jun 2019 – 10 Dec 2019

6. WPV1 cases (latest onset)
Afghanistan: 22 (10 Nov
2019)
Pakistan: 98 (16 Nov 2019)
cVDPV1 cases (latest onset)
Philippines: 1 (28 Oct 2019)
Malaysia: 1 (30 Oct 2019)
Myanmar: 6 (09 Aug 2019)
cVDPV2 cases (latest onset)
Angola: 71 (21 Oct 2019)
Benin: 6 (15 Oct 2019)
CAR: 16 (06 Oct 2019)
Chad: 1 (09 Sep 2019)
China: 1 (25 Apr 2019)
DRC: 53 (21 Oct 2019)
Ethiopia: 5 (09 Sep 2019)
Ghana: 9 (23 Oct 2019)
Niger: 1 (03 Apr 2019)
Nigeria: 18 (09 Oct 2019)
Pakistan: 11 (03 Nov 2019)
Philippines: 9 (25 Oct 2019)
Somalia: 3 (08 May 2019)
Togo: 3 (16 Oct 2019)
Zambia: 1 (16 Jul 2019)
Global WPV1 & cVDPV Cases1, Previous 12 Months2
Endemic country (WPV1)
1Excludes viruses detected from environmental surveillance; 2Onset of paralysis 11 Dec 2018 – 10 Dec 2019
11/26/2022
Public Health Emergency
of International Concern
First declared under the International
Health Regulations in May 2014
Confirmed on 16 September 2019

7. 28
306
6
20
54
0
13 20
4
14 8 0
21 12
0
22
94
0
0
50
100
150
200
250
300
350
Afghanistan Pakistan Nigeria
2014 2015 2016
Endemic Countries, 2014-19*
cases
11/26/2022

8. Pakistan/Afghanistan: Main Risks
• Ongoing transmission in the Southern & Northern corridors
• Accessing all children in highly mobile populations
• Impact of elections and sustaining government commitment at all levels
• Systemic weaknesses in EPI throughout many parts of both countries
• Resistance to vaccination (both overt and covert)
• In Afghanistan
Bans on house to house campaigns in Southern Province
Increasing inaccessibility in Eastern region
Deteriorating security situation creating environment of fear
Challenges in getting female front line workers particularly in high risk areas

9. Situation of Polio Eradication in India

10. 0
0
0
0
0
0
0
0
1
42
741
559
874
676
66
134
225
268
265
1126
0
300
600
900
1200
1500
1800
2100
Wild Poliovirus Cases, India
P1 wild P3 wild
No WPV case since January 2011
* data as on 7 December 2019
P2 wild
1600
1934

11. India - Major Milestones Achieved
2011 : Last polio case due to
WPV
(13 January, 2011)
2012 : Removed from list of
polio endemic countries
2014 : Received polio-free
certification on 27
March
2015: Introduction of IPV in RI
2016: tOPV - bOPV switch, 25
April 2016
Rukhsar, the last polio
case due to wild
poliovirus (WPV) in India
!

12. 27 March 2014:
South-East Asia Region of WHO certified polio-free

13. * data as on 7 December 2019
Year
a i a c i
2009 1 1 4 15
2010 1 3 1
2011 4 2
2012 1
2013 2 3
2014 3
2015 1 1
2016 1
2017
2018
2019
Total 1 1 15 18 9
1
1
type 1 type 2 type 3
i
Figure 7: Vaccine-derived Poliovirus inAFPcases,, India, 2009 - 2019
a-VDPV
c-VDPV
i-VDPV
Vaccine-derived Poliovirus in AFP Cases, India, 2009 – 19*

14. 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

15. 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

16. 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

17. 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 )

18. 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

19. 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

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

21. 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

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

23. 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

24. 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

25. 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

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

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

28. 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)

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

31. INDIA
27-03-2014

32. 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 )

33. 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.

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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)

42. DIFF. BETWEEN IPV & OPV
• IPV ( Salk )
– Killed ,
– IM, strict 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, strict 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

43. 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

44. 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

45. VACCINE VIAL MONITOR

46. 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

47. 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

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

49. 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

50. 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

51. 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

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

53. EVENTS AFTER DETECTING AFP CASE
(60 days Follow Up)
AFPcase–
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

54. 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

55. 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

56. 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

57. 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 )

58. 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

59. 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

60. Unprecedented Progress but the
Risks Remain….

61. International
importation
Gaps in AFP
surveillance or
delays in detection
of WPV
Delayed and/or
inadequate
response to
importation
Areas with low
population
immunity
Risks to Polio Eradication in India
Emergence of
VDPVs
Complacency/
Lack of focus
Risks

62. Polio Eradication & Endgame Strategic Plan 2013-18
• Objective 1
–Polio virus detection and interruption
• Objective 2
–Immunization systems strengthening, IPV
introduction & OPV withdrawal
• Objective 3
–Containment and certification
• Objective 4
–Transition planning
“…ensure that the investments made to eradicate poliomyelitis contribute
to future health goals, through a programme of work to systematically
document and transition the knowledge, lessons learned and assets of
the Global Polio Eradication Initiative….”

63. GPEI Strategy 2019-2023: Why a Revised Strategy?
The Polio Eradication & Endgame Strategic Plan (PEESP) 2013-2018 was developed
to guide the program to the anticipated goal of polio eradication
Though progress continues, transmission still not interrupted in Pakistan and
Afghanistan
The polio program is being extended to achieve eradication
‒A new budget for the period 2019-2023 was approved by the Polio Oversight Board in September
2018 to support program’s work

64. Endgame strategy

65. Endgame strategy
• Eventual cessation of all OPV use globally at some point in the
future (e.g. 2017-2018 period).
• A tOPV-bOPV switch globally, potentially as early as April
2014
• Use of IPV in conjunction with OPV
• Support research activities to generate evidence to guide
decision making
- tOPV-bOPV switch and introduction of IPV in routine
immunization
- bOPV assessment study to understand the efficacy of
additional bOPV products from different manufacturers

66. Towards a polio-free
India
Rukhsar. Let's
ensure she is
the last polio
case in India!