Polio or Poliomyelitis

Dr. Kamal Khadka

Department of Community
05/27/2024 Medicine 1
 What is poliomyelitis?
• Poliomyelitis is an acute viral infection caused by an RNA virus.

• It is primarily an infection of the human alimentary tract but the virus may
infect the central nervous system in a very small percentage( about 1% ) of
cases resulting in varying degrees of paralysis, and possibly death
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GLOBAL CASELOAD/PROBLEM STATEMENT

• Wild poliovirus cases have decreased by over 99% since 1988, from an
estimated 350 000 cases in more than 125 endemic countries then, to 175
reported cases in 2019, 6 reported cases in 2021.

• Of the 3 strains of wild poliovirus wild poliovirus type 2 was

eradicated in 1999 and no case of wild
polio virus type 3 has been found since the last
reported case in Nigeria in November 2012.

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• Both strains have officially been certified as globally eradicated, type 2 on
1999 and type 3 on 2020.

• WPV type 1 is probably the only wild poliovirus type that remains in
circulation

• The last case of polio in Nepal was in 2010, and along with countries of South
East Asia Region , Nepal was certified polio free in 2014.

• This status has been maintain since then.

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 ENDEMIC COUNTRIES

• Endemic countries are those countries where indigenous wild poliovirus

(WPV) circulation has never stopped.

• Polio remains endemic in three countries Afghanistan, Nigeria and

Pakistan.

• Until poliovirus transmission is interrupted in these

countries, all countries remain at risk of importation of polio, especially
vulnerable countries with weak public health and immunization services and
travel or trade links to endemic countries.
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EPIDEMIOLOGICAL DETERMINANTS

AGENT FACTOR
• The causative Agent is the poliovirus which has three serotypes 1,2 and 3.

• Poliovirus can survive for long periods in the external environment.

• In a cold environment, it can live in water for 4 months and in faeces for 6 months.

• It & therefore, well-adapted for the faecal-oral route of transmission.

• However, the virus may be rapidly inactivated by pasteurization, and a variety of

physical and chemical agents
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There are three types of polioviruses:

• Type 1 (P1): it is most common type and causes most epidemics. It is most
difficult to eradication.

• Type 2 (P2): it is most antigenic and most easily eradicable.

• Type 3 (P3): it is associated with vaccine associated paralytic polio (VAPP)

and05/27/2024
most commonly associated with paralysis caused by wild polio virus. 8
Reservoir of Infection:
• Man is the only known reservoir of infection.
• Most infections are subclinical.
• It is the mild and subclinical infections that play a dominant role in the
spread of infection; they constitute the submerged portion of the iceberg.
• It is estimated that for every clinical case, there may be 1000 subclinical
cases in children and 75 in adults.
• There are no chronic carriers.
• No animal source has yet been demonstrated.
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Infectious Material:

The virus is found in the faeces and oropharyngeal secretions of an infected

person.

Period of Communicability:

The cases are most infectious 7 to 10 days before and after onset of
symptoms.

In the faeces, the virus is excreted commonly for 2 to 3 weeks, sometimes as
long as 3 to 4 months.

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 HOST FACTORS
• Age: The disease occurs in all age groups, but children are usually more
susceptible than adults because of the acquired immunity of the adult population.

• Sex: Sex differences have been noted in the ratio of M: F is 3 : 1

• Risk Factors: Several provocative or risk factors have been found to precipitate
an attack of paralytic polio in individuals already infected with polio viruses.

• They include fatigue, trauma, intramuscular injections, operative procedures such

as tonsillectomy undertaken during epidemics of polio and administration of
immunizing
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Agents particularly alum-containing DPT . 11
Immunity:

• The maternal antibodies gradually disappear during the first 6 months of life.

• Immunity following infection is fairly solid although reinfection can occur

since infection with one type do not protect completely against the other two
types of viruses.

• Type-2 virus appears to be the effective antigen.

• Neutralizing antibody is widely recognized as an important index of

immunity polio after infection.

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Environmental factors
Polio is more likely to occur during the rainy season.

The environmental sources of infection a contaminated water, food and flies.

Polio virus survives for a long time in a cold environment

Overcrowding and poor sanitation provide opportunities for exposure to

infection.

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Mode of transmission

Faecal-Oral Route

Droplet Infection

Faecal-Oral Route:

• This is the main route of spread in developing countries.

• The infection may spread directly through contaminated fingers where hygiene
is poor, or indirectly through contaminated water, milk, foods, flies and articles
of daily use.

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Droplet Infection:

• This may occur in the acute phase of disease when the virus occurs in the
throat.

• Close personal contact with an infected person facilitates droplet spread.

• This mode of transmission may be relatively more important in developed

countries where faecal transmission is remote.
Incubation period

• Usually 7 to 14 days (range 3 to 35 days).

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Epidemiological basis of polio eradication

• Man is only known host

• A long term carrier state is not known to occur

• Half life of excreted virus in sewage is 48 hours and spread can occur only
during the period

• Availability of an effective intervention an delivery strategy

• Practical diagnostic tool.

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• CLINICAL SPECTRUM

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05/27/2024 18
LABORATORY DIAGNOSIS

Stool examination

• Isolation of wild poliovirus from stool is the recommended method for

laboratory confirmation of paralytic poliomyelitis.

• Recommended in every case of AFP

• Virus usually can be found in the faeces from onset to upto<8 weeks after
paralysis, with the highest probability of detection during the first 2 weeks after
paralysis onset.

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OTHER EXAMINATION

• CSF examination

• Throat examination

• Blood examination

• If probable case dies a definitive diagnosis of polio can be made or rejected by

autopsy examination of spinal cord.

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Adequate specimens for polio
2 specimens

At least 24 hours apart

Within 14 days of onset of AFP

Adequate volume (8-10 gm/adult thumb size

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Prevention
• Immunization is the sole effective means of preventing poliomyelitis.

• Both killed and live attenuated vaccines are available and both are safe and
effective when used correctly.

• It is essential to immunize all infants by 6 months of age to protect them against

polio.

• Two types of vaccines

Inactivated (Salk) polio vaccine (IPV) Or fIPV

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Protects from all type of polio type1,2,3
Oral (Sabin) polio vaccine (OPV)

• Trivalent oral polio vaccine (tOPV)

Protect against all type of polio virus 1,2,3-following the “OPV Switch” on
April 2016 trivalent is no longer in use.

Bivalent oral polio vaccine (bOPV)

Protect from polio virus 1 and 3

Monovalent oral polio vaccine (mOPV)

mOPV 1 for type 1, mOPV 2 for type 2, mOPV 3 for type 3

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Inactivated (Salk) polio vaccine (IPV). / fIPV

• IPV is usually made from selected wild polio virus (WPV) strains-namely,

• Mahoney (Salk type 1),

• MEF-1 (Salk type 2) and

• Saukett (Salk type 3)

• Grown in vero cell culture or human diploid cells.

• Vaccine contains all the three types of poliovirus, inactivated by formalin.

(killed vaccine)
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• The improved IPV contains 40, 8 and 32D antigen units of type-1, 2 and 3 virus

respective (previous vaccine had 20, 2 and 4 D antigen units).

• IPV is administered by intramuscular (preferred) or subcutaneous routes

As an alternative to the intramuscular injection of a full dose of IPV, countries

may consider using fractional doses fIPV (1/5 of the full IPV dose) via the

intradermal route.

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ADVANTAGE OF IPV
The major advantage of IPV is that being an inactivated vaccine, it can be given in

• pregnancy and immune-compromised persons (person with lympho-reticular

malignancies, on radiotherapy corticosteroid, >50 years of age).

• No risk of vaccine associated paralytic polio (VAPP) as virus is inactive.

• Vaccine does not require stringent conditions during storage and transportation, thus
having long shelf life.

• One or two doses of live vaccine (OPV) can be given safely as booster after an initial
course of immunization with IPV.

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Disadvantages
• It induces only humoral immunity (circulating antibodies) but no
local (intestinal) immunity, thus it provides protection against
paralysis but not against reinfection of intestine by wild virus

• It is not suitable for an epidemic as immunity not develops rapidly

and injection can precipitate paralytic polio

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Polio (Sabin) vaccine -Described by Sabin in 1957
• It contains live attenuated viruses (type 1, 2 and 3) grown in primary monkey
kidney or human diploid cell culture

• Dose 2 drops (0.1 ml)

• Development of immunity: OPV induces local intestinal immunity by production

of secretory IgA as well as humoral immunity by inducing production of serum
antibodies (IgG).

• So, it gives protection from paralysis and also prevents infection of the gut by
wild viruses.
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• OPV, the viruses multiply in the gut and the vaccine progeny is excreted in the
feces and secondary spread occurs to house hold contacts and susceptible
contacts in the community.

• Non-immunized person may therefore, be immunized. Thus widespread herd

immunity results, even if only approximately 66% of the community is
immunized (100% coverage is not required).

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Advantages of OPV

• Easy to administer

• Induces both humoral and intestinal immunity

• Antibody is quickly produced in a large proportion of vaccines, even a single

dose elicits substantial immunity

• The vaccine excretes the virus and so infects others who are also immunized
thereby

• Useful in controlling epidemics

• Relatively
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inexpensive 30
Disadvantages

• OPV is a thermo labile vaccine -----maintenance of cold chain is required and

vaccine is stored at-20°C in deep freeze.

• Stabilized vaccine -----recent oral polio vaccines are heat stabilized. They can

be kept without losing potency for at 4°C and for a month at room temperature.

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Complication

Being living viruses, the vaccine viruses, particularly type 3 do mutate

in the course of their multiplication in vaccinated children, and rare
cases of vaccine associated paralytic polio have occurred in

• Recipients of the vaccine

• Their contacts.

Risk is 1-4 cases per million vaccines

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Contraindications are:

• Immune-compromised people

• Patients suffering from leukemia and malignancy or AIDS

• Person receiving corticosteroids

• Pregnancy

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S IPV fIPV OPV
N
1 Type Inactivated/killed Inactivated/killed Live
attenuated
2 Volume 0.5ml 0.1ml 2 drops
3 Schedule 1dose-14 week 14week,9 month 6,10,14 weeks
4 Administratio IM/SC ID Oral
n

5 Site Thigh Upper arm Mouth

6 Immunity Induce circulating Induce circulating Humoral and
antibody no local antibody no local intestinal
immunity immunity immunity
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SN IPV fIPV OPV

7 Cost Costlier Costlier Cheaper

effectiveness
8 Epidemic Not helpful Not helpful Used in
control epidemic
control
9 Prevention Prevent Prevent paralysis Prevent not only
paralysis but not but not paralysis but
reinfection reinfection also intestinal
reinfection
10 Manufacture Difficult Difficult Easy

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Polio Eradication and Endgame Strategic Plan (2013-2018)

• The Polio Eradication and Endgame Strategic Plan 2013-2018 represents a

major milestone in polio eradication and describes specific steps to take to

successfully achieve eradication

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The plan has 4 objectives

• Detect and interrupt all polio virus transmission

• Strengthen the immunization system and withdraw the oral vaccine

• Contain polio virus and certify interruption of transmission

• Legacy planning

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• Under this endgame plan to achieve and sustain a polio- free world, the use of

oral polio vaccine (OPV) must eventually be stopped worldwide, starting with

OPV that contains type 2 poliovirus (OPV type 2).

• At least one dose of inactivated polio vaccine (IPV) must be introduced as a risk

mitigation measure. The steps involved are

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• By end 2015, introduce at least 1 dose of IPV into all routine immunization
systems, at least 6 months before the switch from trivalent oral polio vaccine
(tOPV) to bivalent oral polio vaccine (bOPV, containing types 1 and 3
poliovirus

• During 2016, switch from tOPV to bOPV, which does not contain type 2 virus,
in routine immunization and polio campaigns, as before that bOPV was only
licensed for use in SIAs.(supplementary immunization activities)

• Plan for the eventual withdrawal of all OPV.

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05/27/2024 40
Polio Eradication Strategy 2022–2026

A transformative new strategy to end polio for good

GOAL 1: Permanently interrupt all poliovirus transmission in the endemic

countries

GOAL 2: Stop cVDPV transmission and prevent outbreaks in polio-free regions

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Launch of the Global Polio Eradication Initiative

• In 1988, the 41st World Health Assembly adopted a resolution for the
worldwide eradication of polio.

• It marked the launch of the Global Polio Eradication Initiative (GPEI),

spearheaded by national governments, WHO, Rotary International, the US
Centers for Disease Control and Prevention (CDC), UNICEF, and supported by
key partners including the Bill & Melinda Gates Foundation.

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Strategic objectives
• Create urgency and accountability to generate greater political will.

• Generate vaccine acceptance through context-adapted community engagement.

• Expedite progress through expanded integration efforts with a broader range of

partners in immunization, essential health care and community services.

• Improve frontline success through changes to campaign operations and

outbreak response operations.

• Enhance detection and response through sensitive surveillance.

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A. Polio Surveillance

• Surveillance is the most important part of the whole polio

eradication initiative.

• Without surveillance, it would be impossible to pinpoint where and

how wild poliovirus is still circulating, verify that the virus has been
eradicated.

• Surveillance identifies new cases and detects importation of wild

poliovirus.
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• There are 4 steps of Acute flaccid paralysis (AFP) surveillance

1. Finding and reporting children with AFP

• Every case of AFP in any child under 15 years should be reported

• The number of AFP cases reported each year is used as an indicator of country's
ability to detect polio, even in countries where the disease no longer occurs.

• A country's surveillance system needs to be sensitive enough to detect at least

one case of AFP for every 50000 children under 15 years, even in the absence
of polio.

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2. Transporting stool sample for analysis

• All children (<15 years) with AFP should be reported and tested for wild

poliovirus within 48 hours of onset.

• Two stool specimens taken 24-48 hours apart are required.

• Specimens are transported in cold box at 4-8°C (reverse cold chain)

• Specimen should arrive at lab within 72hrs of collection

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3. Isolating Polio Virus

Polio virus should be isolated and should be distinguished between wild and

vaccine derived virus.

4. Mapping the virus

Tests are carried out to determine where the strain may have originated

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B. Environmental surveillance

• Environmental surveillance involves testing sewage or other environmental

samples for the presence of poliovirus.

Environmental Surveillance (ES) for poliovirus examine composite human fecal

samples from untreated wastewater collection systems typically located

downstream from high-risk populations in defined geographical areas.

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• ES supplement AFP surveillance and play an important role to document

absence of

• indigenous wild poliovirus;

• no importations of virus via international travelers,

• vaccination switch information and

• identify vaccine derived poliovirus in defined geographical areas

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• Since November 2017, National Public Health Laboratory (NPHL) has been
conducting ES for poliovirus from five sites of Kathmandu Valley.

The five permanent ES sites are:

• Sewer Inlet Chamber- Chabahil,

• Bagamati Manahara Confluence,

• Bagmati/Dhobikhola confluence,

• Tukucha and

• Shovabagawati.
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Future benefits of polio eradication
• Once polio is eradicated, the world can celebrate the delivery of a major global
public good that will benefit all people equally, no matter where they live.

• Economic modelling has found that the eradication of polio would save at least
US$ 40– 50 billion, mostly in low‐income countries.

• Most importantly, success will mean that no child will ever again suffer the
terrible effects of lifelong polio‐paralysis.

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• More than 16 million people are able to walk today, who would otherwise have

been paralyzed.

• An estimated 1.5 million childhood deaths have been prevented , through the

systematic administration of vitamin A during polio immunization activities.

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POLIOMYELITIS IN NEPAL
• Nepal has been no polio case since 2010 and certification of wild poliovirus
elimination on 2014

• switched to bivalent oral polio vaccine vaccine(bOPV) from trivalent oral polio
vaccine(tOPV)on 17April 2016(5 Baisakh2073).

• Nepal introduced the Inactivated Polio Vaccine (IPV) into its routine
immunization programme in 2014.

• Nepal is first country in South Asia region to launch IPV as part of the global
roll05/27/2024
out of the vaccine. 53
KEY STRATEGIES FOR POLIO ERADICATION IN NEPAL

Routine immunization ‐

Supplementary Immunization Activity (SIA)

Surveillance of acute flaccid paralysis (AFP)

Mop‐up campaigns

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