PoliomyelitisPoliomyelitis

Dr.T.V.Rao MDDr.T.V.Rao MD

What is PoliomyelitisWhat is Poliomyelitis

Poliomyelitis (polio) is a highly infectious Poliomyelitis (polio) is a highly infectious viral disease, which mainly affects young viral disease, which mainly affects young children. The virus is transmitted through children. The virus is transmitted through contaminated food and water, and contaminated food and water, and multiplies in the intestine, from where it multiplies in the intestine, from where it can invade the nervous system. can invade the nervous system.

How Polio presentsHow Polio presents

Initial symptoms of polio include fever, Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. In a small the neck, and pain in the limbs. In a small proportion of cases, the disease causes proportion of cases, the disease causes paralysis, which is often permanent. Polio paralysis, which is often permanent. Polio can only be prevented by immunization. can only be prevented by immunization.

Where is Polio present Where is Polio present TODAYTODAY

In 2008, only four countries in the world In 2008, only four countries in the world remain with polio-endemic, down from remain with polio-endemic, down from more than 125 in 1988. The remaining more than 125 in 1988. The remaining countries are Afghanistan, India, Nigeria countries are Afghanistan, India, Nigeria and Pakistan. and Pakistan.

POLIOMYLETIS.POLIOMYLETIS. Involves CNS, produces serious Illness.Involves CNS, produces serious Illness. Causes Destruction of Motor Neurons in Causes Destruction of Motor Neurons in

Spinal cord.Spinal cord. Produces FLACID PARALYSIS.Produces FLACID PARALYSIS. India has still has many cases of India has still has many cases of

Poliomyelitis.Poliomyelitis.

Polio An EnterovirusPolio An Enterovirus

PoliovirusPoliovirus, the causative agent of , the causative agent of poliomyelitispoliomyelitis, is a human , is a human enterovirusenterovirus and and member of the family of member of the family of PicornaviridaePicornaviridae.Poliovirus is composed of a .Poliovirus is composed of a RNARNA genome genome and a protein capsid. The genome is and a protein capsid. The genome is single-stranded single-stranded positive-sensepositive-sense RNA RNA genomegenome that is about 7500 that is about 7500 nucleotidesnucleotides long. The viral particle is about 300 long. The viral particle is about 300 ÅngströmÅngström in diameter with in diameter with icosahedralicosahedral symmetry.symmetry.

Pioneers who Discovered Pioneers who Discovered VaccineVaccine

PoliomyelitisPoliomyelitis First described by Michael Underwood in First described by Michael Underwood in

17891789 First outbreak described in U.S. First outbreak described in U.S.

in 1843in 1843 21,000 paralytic cases reported in the U. S. 21,000 paralytic cases reported in the U. S.

in 1952in 1952 Global eradication in near futureGlobal eradication in near future

Classification of Polio virusClassification of Polio virus..

Type 1 - Brunhilde and Mahoney.Type 1 - Brunhilde and Mahoney. Type 2- Lansing and Mefi.Type 2- Lansing and Mefi. Type 3- Leon and Salkett. Type 3- Leon and Salkett.

Properties of Polio virus,Properties of Polio virus,

Size is 27 nmSize is 27 nm Contains 4 viral Contains 4 viral

protein protein VP1 to VP 4 VP1 to VP 4

VP1 Carries the major VP1 Carries the major antigenic site, and antigenic site, and combines with type combines with type specific neutralizing specific neutralizing antibodiesantibodies

Properties of Polio virus.Properties of Polio virus.

Typical Entero virus.Typical Entero virus. Inactivated at 55Inactivated at 5500 c for 30 mt. c for 30 mt. Chlorine at 0.1 ppmChlorine at 0.1 ppm Ether is not effective.Ether is not effective. Animal susceptibility.Animal susceptibility.

Monkey brainMonkey brain

Requires Primate specific membranes.Requires Primate specific membranes.

Contains 3 Antigenic types 1,2,3Contains 3 Antigenic types 1,2,3

Can be differentiated by ELISA and CF methods.Can be differentiated by ELISA and CF methods.

Polio InfectionPolio Infection.. Incubation 3 – 21 daysIncubation 3 – 21 days On average 14 daysOn average 14 days Predisposing factors.Predisposing factors. Severe muscular acitivity can lead to paralysis, as Severe muscular acitivity can lead to paralysis, as

it increases the blood flowit increases the blood flow May produce paralysis in the limb or bulbar regionMay produce paralysis in the limb or bulbar regionInjecting vaccines with adjuvant can predispose to paralysisInjecting vaccines with adjuvant can predispose to paralysisPatients who underwent tonsillectomy have higher Patients who underwent tonsillectomy have higher

incidence as Ig G secretion is reducedincidence as Ig G secretion is reducedRarely oral Polio vaccine produces poliomyelitis.Rarely oral Polio vaccine produces poliomyelitis.

Pathogenesis and pathologyPathogenesis and pathology..

Enter through Mouth,Enter through Mouth, Multiplies in Oropharynx tonsils and Intestines,Multiplies in Oropharynx tonsils and Intestines, Excreted in Stool.Excreted in Stool. Enters the CNS from Blood.Enters the CNS from Blood. Spread along the Axons of peripheral nerves to Spread along the Axons of peripheral nerves to

CNS.CNS. Progress along the fibers of the lower motor Progress along the fibers of the lower motor

neurons spinal cord or brain.neurons spinal cord or brain.

Pathology and Pathogenesis.Pathology and Pathogenesis.

Destroy the Anterior horn cells of the Destroy the Anterior horn cells of the Spinal CordSpinal Cord

Do not Multiply in Muscles only muscles Do not Multiply in Muscles only muscles manifest with weakness and flaccid manifest with weakness and flaccid paralysis result is secondary.paralysis result is secondary.

Occasionally produceOccasionally produce Myocarditis,Myocarditis, Lymphatic hyperplasia.Lymphatic hyperplasia.

Clinical Manifestations.Clinical Manifestations.

In apparent, Only 1% manifest with clinical In apparent, Only 1% manifest with clinical features.features.

Can lead to permanent paralysis.Can lead to permanent paralysis. Incubation 7-14 days, ( 3-35 )Incubation 7-14 days, ( 3-35 ) May be abortive Poliomyelitis,May be abortive Poliomyelitis,

Only Fever, Malaise, Drowsiness,Only Fever, Malaise, Drowsiness,

Non paralytic Poliomyelitis,Non paralytic Poliomyelitis,

Aseptic Meningitis.Aseptic Meningitis.

0 20 40 60 80 100

Percent

Asymptomatic Minor non-CNS illness

Aseptic menigitis Paralytic

Outcomes of Poliovirus InfectionOutcomes of Poliovirus Infection

Paralytic PoliomyelitisParalytic Poliomyelitis..

Manifest as Flaccid Paralysis.( Caused due to Manifest as Flaccid Paralysis.( Caused due to damage to Lower Motor Neurons.)damage to Lower Motor Neurons.)

Partial recovery within 6 months.Partial recovery within 6 months. Patient may continue with life time disabilityPatient may continue with life time disability Can involve Spinal cord, and Bulbo spinal regionCan involve Spinal cord, and Bulbo spinal region Bulb spinal involvement can paralyze respiratory Bulb spinal involvement can paralyze respiratory

muscle and lead to Respiratory failuremuscle and lead to Respiratory failure

..

Cripples a Grwoing ChildCripples a Grwoing Child

Clinical presentation of typical Clinical presentation of typical PolioPolio

Aseptic MeingitisAseptic Meingitis

Present with Non paralytic form with Present with Non paralytic form with stiffness and pain in the back and neck stiffness and pain in the back and neck regionregion

Lasts for 2 -10 daysLasts for 2 -10 days Recovery rapid and completeRecovery rapid and complete On rare occasions advance to paralysisOn rare occasions advance to paralysis

Laboratory DiagnosisLaboratory Diagnosis..

Viral isolation fromViral isolation from Throat swabs,Throat swabs, Rectal swabs.Rectal swabs. Stool specimens,Stool specimens, Transported in frozen containers.Transported in frozen containers. Produce cytopathic effect onProduce cytopathic effect on Human and Monkey Human and Monkey

cellscells Produce cytopathic effects.Produce cytopathic effects.

Viral IsolationViral Isolation

From feces - present in 80% of cases in From feces - present in 80% of cases in 11stst week week

In 50 % till 3In 50 % till 3rdrd week week In 25 % till several weeksIn 25 % till several weeks Collect the fecal sample at the earliest.Collect the fecal sample at the earliest. Primary monkey kidney is the ideal cell Primary monkey kidney is the ideal cell

line for isolation of virusline for isolation of virus Viral isolation must be interpreted with Viral isolation must be interpreted with

caution and clinical presentationcaution and clinical presentation

Laboratory Diagnosis Laboratory Diagnosis (Serology )(Serology )

Estimation of Antibodies Ig MEstimation of Antibodies Ig M A paired sample is essential.A paired sample is essential.

ImmunityImmunity..

Permanent type specific.Permanent type specific. 1 and 2 types have Heterotypic 1 and 2 types have Heterotypic

resistance.resistance. Mother to Off spring immunity lasts for less Mother to Off spring immunity lasts for less

than 6 months.than 6 months.

EpidemiologyEpidemiology

EndemicEndemic Epidemic Epidemic Hygiene plays in spread of diseases.Hygiene plays in spread of diseases. Children < 5 in Developing countries.Children < 5 in Developing countries.

Prevention and Control. Prevention and Control. (Vaccines)(Vaccines)

Sabin’s Live attenuated vaccineSabin’s Live attenuated vaccine Grown in Monkey kidney cells, Human Diploid Grown in Monkey kidney cells, Human Diploid

cells. Preserved at 4 c cells. Preserved at 4 c Multiple doses are given Multiple doses are given Given as oral DropsGiven as oral Drops At present only vaccine given in our National At present only vaccine given in our National

Programme of ImmunizationProgramme of Immunization Boosts Immunity with Production Ig G ,Ig MBoosts Immunity with Production Ig G ,Ig M And also Ig A Participate as participant in And also Ig A Participate as participant in

Prevention.Prevention.

Vaccination Sabin's- Oral Vaccination Sabin's- Oral AdministrationAdministration

Sabin’s vaccine is administered orally.Sabin’s vaccine is administered orally. Contains Contains

Type 1 – 10 lakhs,Type 1 – 10 lakhs,

Type 2- 2 lakhsType 2- 2 lakhs

Type 3- 3 Lakhs.Type 3- 3 Lakhs.

The virus are stable with Mg cl.The virus are stable with Mg cl.

Oral Polio VaccineOral Polio Vaccine

Highly effective in producing immunity to Highly effective in producing immunity to polioviruspoliovirus

50% immune after 1 dose50% immune after 1 dose >95% immune after 3 doses>95% immune after 3 doses Immunity probably lifelongImmunity probably lifelong

Sabin's VaccineSabin's Vaccine

Live Polio vaccines –Protects Live Polio vaccines –Protects Society tooSociety too

The Live Polio vaccine infects multiples in The Live Polio vaccine infects multiples in the Intestines and thus Immunizes the the Intestines and thus Immunizes the IndividualIndividual

Vaccines not only produces IgM and IgG Vaccines not only produces IgM and IgG in the blood but also IgA antibodies in the in the blood but also IgA antibodies in the Intestines.Intestines.

Which help the gut immunityWhich help the gut immunity

Live Vaccine Associated PolioLive Vaccine Associated Polio

On few occasions type 2 and type 3 virus On few occasions type 2 and type 3 virus may mutate in the course of multiplication may mutate in the course of multiplication

May lead to Vaccine associated PolioMay lead to Vaccine associated Polio But very negligibleBut very negligible

Role Of Immunoglobulins in Role Of Immunoglobulins in PreventionPrevention

Immunoglubulins can provide protection Immunoglubulins can provide protection for a few weeks against the paralytic poliofor a few weeks against the paralytic polio

But does not prevent subclinical infectionBut does not prevent subclinical infection Effective if given shortly before infectionEffective if given shortly before infection No value once the clinical symptoms No value once the clinical symptoms

developdevelop

Salk VaccinesSalk Vaccines

Salk Vaccine - A Killed Vaccine.Salk Vaccine - A Killed Vaccine. Four Injections are administered in a Four Injections are administered in a

period of two years,period of two years, Administration of periodic booster Administration of periodic booster

recommended.recommended. Most of the Western Nations do use it.Most of the Western Nations do use it.

Salk Vaccine ( Killed-Inject able)Salk Vaccine ( Killed-Inject able)

Vaccination in Vaccination in ImmunodeficientImmunodeficient

Only Killed viral vaccines used in Only Killed viral vaccines used in Immunodeficient personsImmunodeficient persons

( SALK )( SALK )

Present prevalence of Polio Present prevalence of Polio attacksattacks

Wild Poliovirus 2006

Global EradicationGlobal Eradication

WHO target date - year 2000WHO target date - year 2000 Yet in 2008 we have Polio casesYet in 2008 we have Polio cases

Pulse Polio ImmunizationPulse Polio Immunization

Global Eradication.Global Eradication.

The Indian Programme of PULSE POLIO The Indian Programme of PULSE POLIO Immunization is a part of it to eradicate Immunization is a part of it to eradicate PolioPolio

Recent resurgence in UP and Bihar is a Recent resurgence in UP and Bihar is a threat to the desired Goal.threat to the desired Goal.

In spite of best efforts thousands occur In spite of best efforts thousands occur globally in Africa and Indian subcontinent.globally in Africa and Indian subcontinent.

Let us be partners in Eradication of Let us be partners in Eradication of PolioPolio

Created for Created for Undergraduate Teaching Undergraduate Teaching

ProgrammeProgramme

Dr.T.V.Rao,MDDr.T.V.Rao,MD

EmailEmailtvraodoctor2000@yahoo.co.intvraodoctor2000@yahoo.co.in