POLIOMYELITIS AFP Surveillance Gamal Eldin Mohamed Osman بسم الله الرحمن الرحيم WHO.POLIO PROGRAMME. SAAN`A, YEMEN

The poliovirus … Brunhilde Lansingh Leon

Poliomyelitis

Outcome of Poliovirus Infection Unapparent or sub-clinical infection (90 – 95%) Non-paralytic poliomyelitis (10 %) Paralytic poliomyelitis (0.1 – 1%) Abortive poliomyelitis (4 – 5%)

Any age Any age Ascending, symmetric (9% with asymmetry) Ascending, symmetric (9% with asymmetry) 7% children with relapse 7% children with relapse Guillain-Barr é syndrome: is an acute inflammatory demyelinating polyneuropathy characterized by progressive muscle weakness and areflexia 5

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Transverse Myelitis 8

Polio virus  Genus: Enterovirus  Family: Picornaviridae  Three major antigenic sites (surface proteins (VP1- 3) Three serotypes (1, 2, and 3)

What is Poliomyelitis?  Polio= gray matter  Myelitis= inflammation of the spinal cord  This disease result in the destruction of motor neurons caused by the poliovirus.

Infectivity  Poliovirus has been isolated from stool more than two weeks before paralysis and 3-6 wks after the onset of paralysis  Excretion in some patients may occur for up to 2 months

Duration of Fecal Excretion of Wild Polioviruses P O L I O 20 Viral excretion drops significantly after 14 days, but poliovirus may still be detected up to 60 days after onset. Early Detection Late Detection

13 Reservoir Poliovirus infects only human beings and there is no animal reservoir. The virus does not survive long in the environment outside the human body. There is no long-term carrier state. Environment Time for virus infectivity to fall by 90% 1. Soil Summer1.5 days Winter20 days 2. Sewage At 23 o C26 days At 2 o C180 days 3.Surface water Fresh5.5 days Sea2.5 days

Receptors Wild Poliovirus A child with no intestinal Immunity has free Receptors for WPV and help replicating Wild Poliovirus

Age group distribution for poliomyelitis

16 DISTINGUISHING FEATURES OF POLIO 1. Asymmetric flaccid paralysis (usually affecting proximally) 2. Fever at onset (high, always present at onset, gone the following day) 3.Rapid progression of paralysis 4.Residual weakness after 60 days 5.Preservation of sensory nerve function

The disease of poliomyelitis has a long history. The first example may even have been more than 3000 years ago. An Egyptian stele dating from the 18th Egyptian dynasty ( BCE) shows a priest with a deformity of his leg characteristic of the flaccid paralysis typical of poliomyelitis..

Polio Eradication WHO strategies: - routine immunization -national immunization days -surveillance of acute flaccid paralysis -mopping up of immunization

Global situation  At the time of adoption of polio eradication target (1988)  350,000 polio cases every year  125 countries endemic for polio.  In 2011  650 cases (i.e.> 99% reduction)  Only 4 endemic countries (Nigeria, India, Pakistan & Afghanistan)  10 re-infected countries  In 2012  222 cases (i.e.> 99.5% reduction)  Only 3 endemic countries (Nigeria, Pakistan & Afghanistan).  In 2013 up to date  2 cases from Pakistan  Only 3 endemic countries (Nigeria, Pakistan & Afghanistan)

Polio situation in Yemen  Last case of WPV in Yemen was in April 2006 from Ibb Governorate, Hubish district. 20

cases / 125 countries Poliomyelitis in 1988

Wild Poliovirus 2011

Wild Poliovirus 2012

Polio Cases * CountryP1P3P1P3 Pakistan Afghanistan *EMRO- Polio- Data as of 08 January 2013 Polio – EMRO in 2012*

2011 Regional Risk Assessment Map* Eastern Mediterranean Region *Data through end of Q Risk Interpretation (Score) ( ≤50) (51–74) ( ≥75)

AFP and Poliomyelitis EMR 2012

Americas Peru 1991 Europe Tajikistan 2010 Western Pacific Cambodia 1997 ? Polio: Last Cases Polio Eradication

28 Rapid progression of paralysis, <2-3 days (from onset to maximum paralysis) Loss of muscle tone, “floppy” (as opposed to spastic or rigid) WEAKNESS, LOSS OF FUNCTION/MOTION

AFP- Case Definition Any case of AFP in a child <15 years of age or Any case of paralytic illness (regardless of age) in which a clinician suspects polio.

Differential Diagnosis of AFP 1. Poliomyelitis 2. Gullian Barrie Syndrome 3. Transverse Myelitis 4. Traumatic Neuritis 5. Cerebral Malaria 6. Meningitis Complications 7. Hypokalaemia 9. Pott”s Disease 10. Diphtheria

Stool Collection  2 Stool specimens hrs. apart  Within 14 days of onset of paralysis  Can be done up to 2 months from onset  At least 8 gm. Each  Special container must be used  Side of the container to be labeled with Name & EPID No.  “ Reverse Cold Chain ” to be maintained

60th Day FU Examination  Done on 60 th day from onset  Must be done < 70 days from onset  Type of paralysis is verified (Flaccid or Spastic)  Presence or absence of Residual weakness

MESSAGE AFP SURVEILLANCE

If the diagnosis has been settled, Why to notify about AFP case?  Please, do not hesitate to notify about any AFP case whatever the diagnosis is. AFP case investigation does not interfere with your line of management for the case.

Hot Cases AFP Cases with symptoms typical of polio Fever at onset, short progression, Asymmetric paralysis, sensation intact… and any of the following: Under 3 years + Incomplete immunization Belonging to High risk group History of travel or contact with persons from polio-endemic countries

Virological AFP Case Classification Scheme (non-polio AFP rate > 2/ , >= 80% with adequate specimens) : discard polio- compatible expert review Wild poliovirus No wild poliovirus inadequate specimens no residual weakness discard two adequate specimens discard confirm residual weakness, died or lost to follow- up AFP case

Case investigation & specimen collection < 14 days of onset The Process of AFP surveillance Onset of Paralysis Case classification (< 90 days of paralysis onset) Detection & notification < 7 days of onset Follow up examination > 60 days of onset Specimens arrive at National laboratory < 3 days of being sent < 28 days of receipt Primary culture results reported to EPI  Isolates sent to regional lab results reported to EPI < 28 days of receipt