DEPARTMENT OF MICROBIOLOGY

FACULTY OF MEDICAL SCIENCES

UNIVERSITY OF SRI JAYEWARDENEPURA

ACUTE FLACCID PARALYSIS

Learning Outcomes:
⮚ Be able to describe, the microbial aetiology, microbiological and
immunological basis of pathogenesis, treatment and prevention of polio

⮚ Appraise the value of specimens, microbiological investigations and

communication with the microbiology laboratory in patient management

Introduction
Acute flaccid paralysis (AFP) is a clinical syndrome characterized by new onset of
hypotonic muscle weakness, including (less frequently) weakness of the muscles of
respiration and swallowing, progressing to maximum severity within several days to
weeks.

Possible causes of AFP include,

1. Polio
2. Other infectious causes
● Non - Polio enteroviruses
(Coxsackie viruses, Echoviruses, Enterovirus 70 and 71)
3. Neurological disorders
● Guillain Barre Syndrome
● Transverse myelitis
● Ryes syndrome
4. Toxic substances
● Clostridium botulinum toxin
● Snake venom
5. Poisons
● Curare
6. Trauma
● Spinal injury

● AFP is the most common sign of acute polio, and used for surveillance of polio
cases.
● The world now stands on the brink of global eradication of poliomyelitis.

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Department of Microbiology, Faculty of Medical Sciences, USJP
Updated at the handout consensus meeting, June 2020
● In the early stages of the disease polio may be difficult to differentiate from other
forms of AFP. Therefore, to insure that no case of polio goes undetected
surveillance targets a symptom (AFP) rather than a specific disease (e.g. polio).
● Highly sensitive surveillance for acute flaccid paralysis (AFP), including immediate
case investigation, and specimen collection are critical for the detection of wild
poliovirus circulation with the ultimate objective of polio eradication. AFP
surveillance is also critical for documenting the absence of poliovirus circulation for
polio-free certification.
● In Sri Lanka poliomyelitis was made a notifiable disease in 1944. There was a major
outbreak of poliomyelitis in 1962. In 1966 the immunization campaign was started
to vaccinate all children less than 15 years with OPV.
● But every 6 years epidemics continued to occur, as the maintenance of the cold
chain was not good. As effective cold chain maintenance was introduced from
Medical Supplies Division to peripheral units, a rapid decline in the number of cases
was seen.
● In Sri Lanka surveillance for AFP commenced in 1990 and the last case of
poliomyelitis was detected in 1993 (weekly epidemiological report 2000 July).

Causative organism of poliomyelitis

Poliovirus - 3 types (1, 2, 3)

Family - Picornaviridae (Pico = small + RNA)
Genus - Enterovirus

Virology of Polio Virus

● Small, non-enveloped virus
● Stable at acidic pH (in contrast to the rhinoviruses - the other members of the
picorna virus group)
● Grow in cell culture with cytopathic effect (CPE)

Microbiological basis of pathogenesis

Source: Man is the only natural host. Therefore, prevention of human to human
transmission will result in elimination.

Transmission:
Major route is faeco - oral, especially where overcrowding and poor hygiene is
prevalent.
(Droplet infection may occur)

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Department of Microbiology, Faculty of Medical Sciences, USJP
Updated at the handout consensus meeting, June 2020
 Human faecal matter

Hand Sewage Solid waste Land fills

Water supply

Shellfish

Human

● Stable at acid pH. Therefore, the virus can overcome gastric acidity.
● Primary site of multiplication is the lymphoid tissue of alimentary tract
including the pharynx.
● Spread from the gut is in two direction
1. Outwards into blood (viraemia) and then to other tissues and organs
2. Inwards into the lumen of the gut and to excretion in faeces

Poliovirus enters the body by ingestion and infects the pharynx and intestinal mucosa
Overcome IgA

Replicates in the lymphoid tissue (tonsils, the intestinal lymphoid tissue - Peyer's
patches, cervical and mesenteric lymph nodes)

Released from lymph nodes, enters the blood stream (viraemia)

Flu like symptoms (~5%) [~95% asymptomatic]

~1% invades the central nervous system (nonparalytic aseptic meningitis)
~ 0.1% - 0.5% spreads along certain nerve fiber pathways, destroying motor neurons
(paralytic poliomyelitis)
Risk factors for increased transmission and developing paralysis
● Immune deficiency
● Malnutrition
● Tonsillectomy
● Physical activity immediately following the onset of paralysis
● Skeletal muscle injury or IM injection of vaccines or therapeutic agents
● Pregnancy
Infection with each serotype generates type-specific, lifelong immunity but little or no
immunity to infection caused by heterologous serotypes

Clinical feature
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Department of Microbiology, Faculty of Medical Sciences, USJP
Updated at the handout consensus meeting, June 2020
● Incubation period ranges from 5 to 35 days
● 95% of the infections – asymptomatic
● 5% (4% - 8%) - Minor flu like illness
● Non paralytic poliomyelitis (~1%)
● 0.1% - 0.5% - Paralytic poliomyelitis - Paralysis is usually asymmetrical
● Polio encephalitis

Lab Diagnosis
1. Isolation of the polio virus in stools

● Collection of stool sample

As the excretion of virus in stools is intermittent at least 2 stool samples are needed.
Samples should be collected 24 - 48 hours apart. Initial sample should be collected as
early as possible following admission, ideally within 2 weeks of onset of paralysis as
virus excretion is maximum during (the 1st week following onset of paralysis) that
period. It is advisable to defecate into a clean bowl and then collect the sample into a
screw capped bottle.

● Transportation
Samples are transported in ice to Medical Research Institute. If there is any delay in
transport it should be kept at 4º C till the time of transport. Sample should reach the
lab within 3 days of collection.

Minimum of two stools specimens collected 24-48

hours apart
Quantity of stool required: 8-10g
Container: clean, dry, screw capped, wide mouthed,
leak proof
With detailed request form

● Isolation in cell culture

Inoculate into cell culture where polio virus will produce CPE (cytopathic effect)
Note: If a polio virus is isolated PCR is used to differentiate wild virus from vaccine
derived virus and to determine the three serotypes.

Treatment

● No specific treatment.
● Symptomatic treatment during the acute illness.

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Department of Microbiology, Faculty of Medical Sciences, USJP
Updated at the handout consensus meeting, June 2020
 ● Bed rest is important during the acute illness and intramuscular injections
should be avoided.
● Rehabilitation (especially physical, psychological and social) after the acute
illness - may take weeks or months.

Prevention
1. Routine vaccination
There are two types of vaccines
a) Killed polio vaccine (IPV – Injectable Polio Vaccine) - Salk
It contains three strains
b) Oral Polio vaccine (OPV) - Sabin
Trivalent (composed of strains of the 3 types of polio viruses -1, 2, 3)-
(discontinued) and bivalent (containing types 1 and 3 only) OPV are available.
The virus strains are live and attenuated.

● Trivalent OPV was the main vaccine used for poliomyelitis immunization and
the only polio vaccine used in the expanded programme of immunization in
Sri Lanka until May 2016
● In May 2016, the EPI schedule was changed. Now the bivalent OPV is used. It
is given on completion of 2, 4, 6 months of age and booster doses on
completion of 18 months and 5 years (schools entry) as 2 drops of OPV at
each time.
● An additional doses of IPV (trivalent) fractionated (0.1ml intradermal) is given
at 2 and 4 months only

Reasons for the change

It was shown that serotype 2 of polio vaccine was responsible for most cases of
vaccine induced polio.
Therefore bivalent oral vaccine (Sabin vaccine) with serotype 1 and 3 was used.
However to compensate for the lack of serotype 2 the trivalent killed vaccine
preparation (Salk vaccine) is given in 2nd and 4th month. Also the inactivated vaccine
is given at a lower dose as an intra-dermal vaccine, as good immunity is then induced
as opposed to IM

Hexavalent vaccine (containing DPT,hepB, HIB and IPV) is available outside the NPI
schedule.

Advantages of OPV
- Ease of administration (oral)
- Low cost
- Herd immunity
- Gives excellent intestinal immunity
- 3 doses produce immunity to all 3 polio virus types in more than 95% people
- Can be given during an epidemic

Disadvantages of OPV
- Sensitive to inactivation by heat, so strict cold chain should be maintained.
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Department of Microbiology, Faculty of Medical Sciences, USJP
Updated at the handout consensus meeting, June 2020
 - Rare possibility of developing paralysis (VAPP) due to vaccine virus. This risk
is increased in persons with immuno-deficiency.

● Vaccine Associated Paralytic Poliomyelitis (VAPP)

The vaccine virus carries a small risk of causing paralytic poliomyelitis in
the vaccine recipient and unimmunized close contacts

● Vaccine Derived Polio Virus (VDPV)

In very rare instances, the vaccine virus can change genetically.
These mutated viruses may be excreted and could cause paralysis or
outbreaks, if a population is under-immunized

2. Conduct National immunization days

3. AFP surveillance
Case definition - Any child under 15 years of age with AFP or any person of any
age with paralytic illness if polio is suspected
● Two stool specimens should be collected from the patient 24-48 hours
apart and within 14 days of the onset of paralysis for virus isolation
● One stool specimen from 3-5close contacts under 15 years of age.

Significance of AFP surveillance

Sri Lanka has been polio free from 1993 and south east-asia was declared polio free
from 2014. The world is on the verge of eradicating polio. If a case of polio is found it
is significant. Therefore the ministry of health has a national AFP surveillance
programme according to WHO guidelines to exclude polio in all AFP cases. Notify
all AFP cases to the Ministry of Health, which has a national AFP surveillance
programme.

4. Notification of cases
All AFP cases should be immediately notified over the telephone/fax/email to
the epidemiologist. Notification should also be done to the M.O.H.

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Department of Microbiology, Faculty of Medical Sciences, USJP
Updated at the handout consensus meeting, June 2020