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.
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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