update Poliomyelitis

7/28/2019 update Poliomyelitis

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POLIOMYELITISAN UPDATE

Dr.T.V.Rao MD

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A tribute to Pioneers who Changed

the World from Disability

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What is Poliomyelitis

Poliomyelitis (polio) is a highly

infectious viral disease, which

mainly affects young children. Thevirus is transmitted through

contaminated food and water, and

multiplies in the intestine, from

where it can invade the nervous

system.


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POLIOMYLETIS. Involves CNS,produces seriousIllness.

Causes Destruction ofMotor Neurons inSpinal cord.

Produces FLACID

PARALYSIS. India has still hasmany cases ofPoliomyelitis.


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Polio An Enterovirus

Poliovirus, the causative agent ofpoliomyelitis, is a human enterovirus andmember of the family of

Picornaviridae.Poliovirus is composed of aRNA genome and a protein capsid. Thegenome is single-stranded positive-senseRNA genome that is about 7500 nucleotides

long. The viral particle is about 300ngstrm in diameter with icosahedralsymmetry.


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What are PicornavirusA very largefamily of viruses

One of theSmallest in size

A singleStranded RNA

group

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Entero virusesThe Nomenclature has given

Numbers,

1.Polio virus types 1 to 3.2.Coxsasackie virus Group A. 1- 24.

3.Coxsasackie virus Group B. 1-6.

4.Echo virus type 1-33.

Entero virus type 68-71.

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Picorna Viruses.

Entero Viruses

Present and

Isolated from

Alimentary tract

Throat, LowerIntestine.

Rhino

virusesPresent and

isolatedfrom

Nose Throat

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Picorna Viruses.

Entero viruses,

Can produce

Severe paralysis,

Aseptic meningitis,

Myocarditis,

Vesicular andExanthematous skin

lesions.Most serious is

Poliomyelitis.

Rhino virus

Mainly produces

Respiratory illness

Conjunctivitis,

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Properties of Picorna Virus.

Smallest in Size,

Icosahedral 28-30 nm in Diameter,Contains 80 subunits.

Single Stranded RNA virus

Contains 4 major polypeptides.

VP 1, 2, 3. and VP 4.

Produce important Diseases like

1. Poliomyletis,Aspetic meningitis, andCommon Cold.

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Rhino Virus and others.

Rhino viruses 100 Antigenic types

Common cold is produced

Others,Hepatitis A Virus

In Animals.

Foot and Mouth Diseases.

.

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Entero Virus Group.

POLIOMYLETIS.

Involves CNS, produces serious

Illness.

Causes Destruction of MotorNeurons in Spinal cord.

Produces FLACID PARALYSIS.India has still has many cases of

Poliomyelitis.

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Prehistory of Polio disease

The effects of polio

have been known

since prehistory;

Egyptian paintings andcarvings depict

otherwise healthy

people with withered

limbs, and childrenwalking with canes at a

young age.

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Wild Poliovirus 2006

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Properties of Polio virus,

Size is 27 nm

Contains 4 viral

protein

VP1 to VP 4

VP1 Carries the

major antigenic site,

and combines with

type specific

neutralizing

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Properties of Polio virus. Typical Entero virus.

Inactivated at 550 c in 30 mt.

Chlorine at 0.1 ppm

Ether is not effective.

Animal susceptibility.

Monkey brain

Requires Primate specific membranes.

Contains 3 Antigenic types 1,2,3

Can be differentiated by ELISA and CF methods.

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Structure

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Poliovirus Genome Single RNA molecule ~7500 nucleotides

3 sub-regions with 10 protein products

IRES important for virulence

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Serotypes Specificity to receptor restricts mutation rate; slow genetic

drift

Three serotypes with no cross immunity

Type 1 polio 90%

Weakest, only 1% causes neuroparalysis

Type 2 polio 9% (Eliminated)

Type 3 polio 1%

Greater temperature stability

Requires trivalent polio vaccine Polioviruses can also vary in phenotype of virulence, host

cell lysis, and ability to raise host defense triggers

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Polio Infection. Incubation 3 21 days

On average 14 days

Predisposing factors.

Severe muscular acitivity can lead toparalysis, as it increases the blood flow

May produce paralysis in the limb or bulbarregion

Injecting vaccines with adjuvant can predispose toparalysis

Patients who underwent tonsillectomy have higherincidence as Ig G secretion is reduced

Rarely oral Polio vaccine produces poliomyelitis.

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What is Poliomyelitis? polio= gray matter

Myelitis= inflammation of the spinal cord

This disease result in the destruction ofmotor neurons caused by the poliovirus.

Polio is causes by a virus that attacks the

nerve cells of the brain & spinal cordalthough not all infections result in sever

injuries and paralysis.

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When was it reported?

Early cases Poliomyelitis wasrecorded in the late

1700s with the first

epidemic in the late1800s.

The cases that were

reported in 1979 where

mild and self-limited

and do not result in

paralysis.

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Documented History of Polio Poliomyelitis was first recognized as a distinct condition

by Jakob Heine in 1840. Its causative agent, poliovirus,

was identified in 1908 by Karl Landsteiner.[Although major

polio epidemics were unknown before the late 19th

century, polio was one of the most dreaded childhooddiseases of the 20th century. Polio epidemics have

crippled thousands of people, mostly young children; the

disease has caused paralysis and death for much of

human history. Polio had existed for thousands of yearsquietly as an endemic pathogen until the 1880s, when

major epidemics began to occur in Europe; soon after,

widespread epidemics appeared in the United States.

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What is Poliomyelitis Poliomyelitis (polio) isa highly infectious viraldisease, which mainlyaffects young children.The virus istransmitted throughcontaminated food andwater, and multiplies inthe intestine, fromwhere it can invade thenervous system.

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It cause paralysis? Paralytic disease occurs 0.1% to 1% ofthose who become infected with the poliovirus.

Paralysis of the respiratory muscles or fromcardiac arrest if the neurons in the medullaoblongata are destroyed.

Patients have some or full recovery fromparalysis usually apparent with proximally 6months

Physical therapy is recommended for full

recovery.

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How is polio transmitted? Poliovirus is transmitted

through both oral and

fecal routes with

implantation andreplication occurring in

either the orapgaryngeal

and or in the intestine of

mucosa. Polio cases aremost infected for 7-10

days before and after

clinical symptoms begin.

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Pathogenesis and pathology.

Enter through Mouth,

Multiplies in Oropharynx tonsils andIntestines,

Excreted in Stool.

Enters the CNS from Blood.

Spread along the Axons of peripheral

nerves to CNS. Progress along the fibers of the lowermotor neurons spinal cord or brain.

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Cell Binding and Entry

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Pathology and Pathogenesis.

Destroy the Anterior horn cells of theSpinal Cord

Do not Multiply in Muscles onlymuscles manifest with weakness andflaccid paralysis result is secondary.

Occasionally produce

Myocarditis,

Lymphatic hyperplasia.

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Spinal polio Spinal polio is the mostcommon form ofparalytic poliomyelitis; itresults from viral

invasion of the motorneurons of the anteriorhorn cells, or the ventral(front) gray mattersection in the spinal

column, Virus invasioncauses inflammation ofthe nerve cells, leadingto damage or destructionof motor neuron ganglia.

31

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Bulbar polio

Making up about 2% ofcases of paralytic polio,bulbar polio occurs whenpoliovirus invades and

destroys nerves withinthe bulbar region of thebrain stem. nervesweakens the muscles

supplied by the cranialnerves, producingsymptoms ofencephalitis,

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What are the symptoms?

Many include fever, pharyngitis,

headache, anorexia, nausea, and

vomiting. Illness may progress toaseptic meningitis and

menigoencephalitis in 1% to 4% of

patients. These patients develop ahigher fever, myalgia and sever

headache with stiffness of the neck

and back.


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0 20 40 60 80 100

Percent

Asymptomatic Minor non-CNS illness

Aseptic menigitis Paralytic

Outcomes of Poliovirus Infection

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Paralytic Poliomyelitis. Manifest as Flaccid

Paralysis.( Caused

due to damage to

Lower Motor Neurons.) Partial recovery within

6 months.

Patient may continue

with life time disability

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Paralytic Poliomyelitis.

Can involve Spinal

cord, and Bulbo

spinal region

Bulb spinal

involvement can

paralyze respiratory

muscle and lead toRespiratory failure

.

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Clinical Manifestations. In apparent, Only 1% manifest with clinical

features.

Can lead to permanent paralysis.

Incubation 7-14 days, ( 3-35 )

May be abortive Poliomyelitis,

Only Fever, Malaise, Drowsiness,Non paralytic Poliomyelitis,

Aseptic Meningitis.

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Cripples a Grow ing Child

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Clinical presentation of typical

Polio

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Aseptic Meningitis

Present with Nonparalytic form with

stiffness and pain inthe back and neckregion

Lasts for 2 -10 days

Recovery rapid andcomplete

On rare occasionsadvance to paralysis

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Immunity. Permanent type

specific.

1 and 2 types have

Heterotypic

resistance.

Mother to Off spring

immunity lasts for

less than 6 months.

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Laboratory Diagnosis. Viral isolation from

Throat swabs,

Rectal swabs.

Stool specimens,

Transported in frozen containers.

Produce cytopathic effect on

Human and Monkeycells

Produce cytopathic effects.

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Viral Isolation From feces - present in 80% of cases in 1stweek

In 50 % till 3rd week

In 25 % till several weeks Collect the fecal sample at the earliest.

Primary monkey kidney is the ideal cell line

for isolation of virus Viral isolation must be interpreted withcaution and clinical presentation

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Laboratory Diagnosis (Serology)

Estimation ofAntibodies Ig M

A paired

sample isessential.

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Treating Polio cases There is no cure for polio. The focus of modern

treatment has been on providing relief of

symptoms, speeding recovery and preventing

complications. Supportive measures includeantibiotics to prevent infections in weakened

muscles, analgesics for pain, moderate exercise

and a nutritious diet. Treatment of polio often

requires long-term rehabilitation, includingphysical therapy, braces, corrective shoes and, in

some cases, orthopedic surgery

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Epidemiology

Endemic

Epidemic

Hygiene plays inspread ofdiseases.

Children < 5 inDevelopingcountries.

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Pioneers who DiscoveredVaccine

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Types of Vaccinations in Use Two types of vaccine areused throughout theworld to combat polio.Both types induceimmunity to polio,efficiently blockingperson-to-persontransmission of wildpoliovirus, therebyprotecting both individualvaccine recipients andthe wider community(so-called herdimmunity)

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Polio fact A dime makes theDifference

The march of dimes beganin 1938 a fund-raisingcampaign for polio. Peoplewere asked to send one

dime directly to the WhiteHouse to help fight thedisease. In the first 3 daysthe White House received230,000 dimes. President

Franklin D. Roosevelt,whose profile is now onthe dimes was himselfparalyzed by polio.

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Vaccine Polio vaccine first appeared to be licensed in the

United States in 1955.

Advantages:

Ease to administration Good local mucosal immunity

Disadvantage:

Strict cold shipping & storage requirements Multiple doses required to achieve high humeral

conservation rates against all virus types

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Prevention and Control. (Vaccines)

Sabins Live attenuated vaccine Grown in Monkey kidney cells, HumanDiploid cells. Preserved at 4 c

Multiple doses are given Given as oral Drops

At present only vaccine given in ourNational Programme of Immunization

Boosts Immunity with Production Ig G ,Ig MAnd also Ig A Participate as participant inPrevention.

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Vaccination Sabin's- OralAdministration

Sabins vaccine is administered

orally.

ContainsType 1 10 lakhs,

Type 2- 2 lakhsType 3- 3 Lakhs.

The virus are stable with Mg cl.

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Oral Polio Vaccine Highly effective inproducing immunityto poliovirus

50% immune after 1dose

>95% immune after 3doses

Immunity probablylifelong

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Live Polio vaccinesProtectsSociety too

The Live Polio vaccine infects

multiples in the Intestines and thus

Immunizes the Individual

Vaccines not only produces IgM and

IgG in the blood but also IgAantibodies in the Intestines.

Which help the gut immunity

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Salk Vaccines Salk Vaccine - A Killed

Vaccine.

Four Injections are

administered in aperiod of two years,

Administration of

periodic booster

recommended.

Most of the Western

Nations do use it.

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Salk Vaccine ( Killed-Inject able)

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Vaccination in Immunodeficient

Only Killed viral

vaccines usedin

Immunodeficient

persons

( SALK )

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Polio Vaccination ofUnvaccinated Adults

IPV

Use standard IPVschedule if

possible (0, 1-2months, 6-12months)

May separate

doses by 4 weeksif acceleratedschedule needed

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Vaccine-Associated Paralytic Polio

Increased risk in persons >18 years Increased risk in persons withimmunodeficiency

No procedure available for identifyingpersons at risk of paralytic disease

5-10 cases per year with exclusive use

of OPVMost cases in healthy children and theirhousehold contacts

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Pediarix A new approved Vaccine

Contains IPV, DTaP,and hepatitis Bvaccines

Minimum age 6weeks, maximumage 6 years

Approved by FDA forfirst 3 doses of theIPV and DTaP series

Not approved forbooster doses

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Present prevalence of Polioattacks

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Global Eradication

WHO target

date - year2000

Yet in 2008 we

have Polio cases

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The Global Polio Eradication Initiative

Launch

In 1988, the forty-first World Health Assembly, consistingthen of delegates from 166 Member States, adopted a

resolution for the worldwide eradication of polio. It marked

the launch of the Global Polio Eradication Initiative,

spearheaded by the World Health Organization (WHO),Rotary International, the US Centers for Disease Control

and Prevention (CDC) and UNICEF. This followed the

certification of the eradication of smallpox in 1980,

progress during the 1980s towards elimination of the

poliovirus in the Americas, and Rotary Internationals

commitment to raise funds to protect all children from the

disease.

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Pulse Polio Immunization

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One of the major steps in achieving the goal for zero Poliochildren in any state or region is the introduction of Pulse

Polio immunization program. This Pulse Polio

immunization programme is one of the most sophisticated

plans which also got a huge success in our countryregarding the targets. These introduced Pulse Polio

immunization programme are also proving the best

methods to eradicate this disease from its origin too.

Moreover according to the scales of years, in 2000 it was

measured by the general surveys as the largest effort

recorded with these camps and spreading awareness

through this Pulse Polio immunization program.

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Global Eradication.

The Indian Programme of PULSE

POLIO Immunization is a part of it to

eradicate Polio

Recent resurgence in UP and Bihar is

a threat to the desired Goal.

In spite of best efforts thousands occurglobally in Africa and Indian

subcontinent.

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Live Vaccine Associated Polio

On few occasions

type 2 and type 3

virus may mutate in

the course ofmultiplication

May lead to Vaccine

associated Polio But very negligible

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Role Of Immunoglobulin's in

Prevention

Immunoglobulin's canprovide protection for afew weeks against the

paralytic polio But does not preventsubclinical infection

Effective if given shortly

before infection No value once theclinical symptomsdevelop

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Update on IndiaAugust 2011*

India has not reported a single case in more than six months.The most recent case had onset of paralysis on 13 January inWest Bengal (WPV1).

SNIDs took place beginning 26 June in Uttar Pradesh, Bihar,

Delhi and parts of West Bengal and other high-risk areas. Thenext SIAs will be SNIDs using bivalent oral polio vaccine(bOPV) in August.

India has also gone eight months without detecting any wild

poliovirus from environmental sampling. The last positiveenvironmental sample was taken from Mumbai in November,2010.

*Global polio eradication Initiative

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Polio eradication helps in Progress of theWorld

Once polio is eradicated,the world can celebratethe delivery of a majorglobal public goodsomething that willequally benefit allpeople, no matter wherethey live. Economicmodeling hasestablished thatsignificant financialbenefits will also accruefrom eradication.

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Where is Polio presentTODAY

In 2008, only four

countries in the world

remain with polio-

endemic, down frommore than 125 in 1988.

The remaining

countries are

Afghanistan, India,Nigeria and Pakistan.

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Bivalent Oral Polio India launchedBivalent Oral PolioVaccine in January 2010in place of a monovalentone which protectsagainst a single strain. Arecent scientific analysisof the BOPV found that itinduced a significantlyhigher immune response 30% more than othertrivalent or monovalentvaccines.

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INDIA DECLARES A POLIO FREENATION

India, which was declared polio-free in

February 2012, is perhaps the best

example of how a fully funded program

driven by committed leaders and dedicatedworkers can achieve success. India was

long considered the most difficult place to

end polio due to its population density, highrates of migration, poor sanitation, high

birth rates, and low rates of routine

immunization.

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Bill & Melinda Gates FoundationSUPPORTS UNIVERSAL ERADICATION OF POLIO

Polio eradication is a top priority

of the Bill & Melinda Gates

Foundation. As a major

supporter of the GPEI, we

contribute technical and

financial resources to our GPEIpartners to accelerate efforts to

eradicate polio. Many of these

strategies are proven, such as

targeted vaccination campaigns,

community mobilization, andstronger routine immunization

efforts

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We have Responsibility to Eradicate Polio

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The Programme is Dedicated toMedical and Health Care workers

who Dedicated for the Eradicationthe Poliomyelitis

Email

[email protected]

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