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Poliomyelitis
04/18/2024
Introduction
• Acute viral infection
• Caused by RNA virus (Picronaviruses)
• Human is natural reservoir of Infection
• Primary infection of alimentary tract
• May infect the CNS (Paralysis and possibly
death)
• Origin came from Greek word “Polio”
meaning “grey matter”
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Epidemiology
AGENT FACTORS:
• Agent: Poliovirus – picronavirus
• 3 serotypes: WPV1, WPV2 & WPV3
• WPV2 not detected since 1999 & declared
eradicated in September 2015
• WPV3 not detected since November 2012
• WPV1 is the sole serotype remaining in circulation
• Can Survive in cold environment in water for 4
months and in faeces for 6 months
• Inactivated by Pasteurization, heat, formaldehyde,
chlorine, UV light
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Left: Picture of
poliovirus. The
poliovirus is extremely Right: Cross-section of the
small, about 50 nm poliovirus showing the RNA,
(nanometer = one- capsid, and nerve cell
billionth of a meter) receptors Illustration courtesy
Courtesy of David of Link Studio
Belnap and James
04/18/2024
Reservoir of Infection:
• Man only known reservoir
• Most of infection are Subclinical
• It is estimated every clinical case there may be
1000 subclinical cases
• No chronic carriers
• No animal source of infection
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Infectious material:
• Faeces
• Oropharyngeal secretion
Period of communicability:
• 7-10 days before and after onset of symptom
• Virus excreted 2-3 weeks sometimes 3-4
months
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HOST FACTORS:
Age:
• All age
• Children are more susceptible
• Most cases (50%) reported in infancy (Vulnerable
age: 6 months to 3 years)
Sex:
• 3 male to 1 female
Risk factors:
• Fatigue, trauma, IM injection, operative procedure
like tonsillectomy during polio outbreaks and
immunization with DPT containing Alum
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Immunity
• Maternal antibodies disappear in first 6
months of life
• Immunity against one type doesn’t protect
against the other two types of virus (No cross
immunity)
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ENVIRONMENTAL FACTORS:
More likely to occur during rainy season
60 % cases recorded during June to September
Contaminated water, food and flies- Sanitation
barrier
Overcrowding and poor sanitation
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Mode of transmission
• Faecal-oral route:
Main route of spread in developing countries
Infection spreads either directly through contaminated
fingers or indirectly through contaminated water, milk,
foods and articles of daily use
• Droplet infection:
This may occur in the acute phase of disease when
virus occurs in throat
Close personal contact with infected person facilitates
droplet spread
More important in developed countries
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INCUBATION PERIOD:
• 7-14 days (Range 3-35 days)
CLINICAL SPECTRUM:
• When exposed to infection one of the
following response may occurs:
1. Inapparent (subclinical) infection
2. Abortive polio (minor illness)
3. Non-paralytic polio
4. Paralytic polio
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• Inapparent (Subclinical) Infection:
91-96 % of infection
No presenting symptoms
Virus isolation or rising antibody titer
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• Abortive polio or Minor illness:
4-8% of infection
Mild or self-limiting illness
Recover quickly
Virus isolation or rising antibody titer
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• Non-Paralytic Polio:
1 % of all infection
Stiffness and pain in neck and back
Last for 2-10 days – rapid recovery
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Outcome of polio virus infection
0 20 40 60 80 100
Percent
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Paralytic polio
In < 1 % of infection
Invade CNS - flaccid paralysis
Fever with onset of paralysis
Progression of paralysis reaches maximum in <4 days
Paralysis is descending i.e. starting at hip and then
moving down to distal parts of the extremities
Asymmetrical patchy paralysis- Muscle strength varies
in different groups of different limbs
Other associated symptom like malaise, anorexia, nausea,
vomiting, headache, sore throat, constipation and abdominal
pain
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Tripod sign may be present
Paralytic polio
Deep tendon reflexes are diminished
No sensory loss in the affected area
Cranial nerve involved in bulbar and bulbo-spinal
form of paralytic polio
Facial asymmetry, difficulty in swallowing,
weakness or loss of voice may be present
Respiratory insufficiency is usually the cause of
death
After acute phase – atrophy of affected muscle lead to
residual paralysis
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Treatment and Prevention
TREATMENT:
• No specific treatment
• Good nursing care can minimize crippling
• Physiotherapy is of vital importance
PREVENTION:
• Immunization is sole effective means of
prevention
• Two types of vaccines available:
Inactivated (Salk)polio vaccine
Oral (Sabin) polio vaccine
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Inactivated (Salk) polio vaccine
• IPV may contain trace amounts of formaldehyde,
streptomycin, neomycin or polymyxin B or
phenoxyethanol
• Available as a stand alone vaccine or in combination
with DPT, Hep B or H influenza B components
• Given intramuscular or intra-dermal as a fractional
dose
• Induces humoral antibodies (IgM,G and A) but
doesn’t induce local (intestinal) immunity
• Thus antibodies circulate in blood but cannot prevent
re-infection of the gut
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Merits:
Safe to administer
Can be given to individuals with immune deficiency
diseases
Can be given to individuals taking corticosteroid and
radiation therapy
Can be given to those aged >50 yrs
Can be given during pregnancy
No reported occurrence of VAPP or VDPV
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Dose schedule of IPV (stand-alone)
04/18/2024
• Currently a part of Universal Immunization
programme
• Given at 6 and 14 weeks
• Fractional IPV given intra-dermal
• Along with Bivalent OPV
04/18/2024
De merits:
Doesn’t provide Gut immunity
Cannot be administered during outbreaks
Needs expertise from the vaccinator
Associated Risks:
No serious AEFI reported
Minor erythema, induration and tenderness
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Oral (Sabin) polio vaccine
• OPV described by Sabin in 1957
• Contains Live attenuated virus grown in monkey
kidney or HDC
• Currently used as Bivalent OPV containing P1 and P3
Dose- schedule:
• According to UIP 2 drops by Oral route
• At Birth ( 0-polio)
• 3 doses 6, 10 and 14 weeks
• Booster at 1 and ½ year (along with DPT booster and
Measles 2nd dose)
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OPV and VACCINE VIAL MONITOR
(VVM)
04/18/2024
Development of Immunity
• Live vaccine strains infect intestinal epithelial cells
• After replication virus transported to Peyer’s patches
where secondary multiplication occurs
• The virus spreads now to other parts of the body
resulting in circulating antibodies
• Intestinal infection stimulates IgA antibodies which
prevent subsequent infection with wild strains
• Produces local and systemic immunity
• Vaccine virus gets transmitted to other close contacts
as it is shed off in faeces- Protects unimmunized
contacts leading to “Herd Immunity”
04/18/2024
Advantages:
• Easy to administered – not required highly trained
person
• Provide local and systemic immunity
• Quick antibody production
• Provide herd immunity
• Inexpensive and useful in control of epidemic
Complication:
• Free from complication
• VAPP about 1 per million vaccinees
• VDPV and rarely cVDPV outbreaks
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Contraindications:
• Immunocompromised individuals, those
suffering from leukemias, HIV positive and
malignancy shouldn’t receive live vaccine
04/18/2024
Differences between IPV & OPV
IPV OPV
ID or IM Orally