1. Poliomyelitis

2. Instructional Objectives: At the end of the lecture the student would be able to: 1-Demonstrate the main clinical characteristics of poliomyelitis. 2-Point out the occurrence of the disease. 3-List the causative agent, mode of transmission, incubation period, and period of communicability of poliomyelitis. 4-List the main preventive measures of poliomyelitis. 5-Describe the control measures of poliomyelitis. 6-Define the WHO strategies of polio eradication.

3. Polio virus infection occur in GI tract with spread to regional LN and in minority of cases to CNS

4. Flaccid paralysis occurs in <1 % of polio virus infection >90% of infections are either in apparent or non specific fever Aseptic meningitis occurs in about 1% of infections Clinical responses are extremely varied

5.  In apparent: Paralytic polio=200:1  Minor illness: Manifested as low grade fever, malaise, headache, nausea & vomiting (10%)

6. major illness: Manifested as Sever muscle spasm, followed by Neck & back stiffness, it ends with flaccid paralysis:  Asymmetrical  Maximized within 3-4 days  Site is depend on the location of nerve cell destruction in the spinal cord or brain stem  Legs are affected more than arms  Proximal parts more often than distal parts

7.  Affected muscles are floppy, reflexes are diminished,sense of pain & touch remain normal  Residual paralysis is usually present after 60 days  Severe cases : quadriplegia, abdomen & thoracic muscles, bulbar polio

8. Differential diagnosis of Acute flaccid paralysis (AFP):  Paralytic polio  Guillian Barre syndrome  Transverse myelititis  Traumatic neuritis  Acute motor axonal neuropathy  Encephalitis  Meningitis  Tumors

9. Distinguishing characteristics:  Asymmetrical flaccid paralysis  Fever at onset  Rapid progression of paralysis  Residual paralysis after 60 days  Preservation of sensory nerve function

10. Causative agent : Entero virus : Type 1 2 & 3  Paralytogenic less commonly  Most frequent frequent cause  Cause of outbreak of vaccine associated.

11. Occurrence : Prior to immunization it had a world wide distribution. It is eradicated from the western Hemispheres & industrialized countries The greatest risk of polio now occurs on the Indian sub continent,&to lesser extent, in the countries of west &central Africa If cases appeared in industrialized countries they are either imported or vaccine associated

12. High risk groups:  Groups that refused immunization  Minority population  Migrants  Unregistered children  Refuges & poor urban Age of distribution: Remains primarily a disease of infants & young children,in many polio endemic regions 70-80% of cases are <3 years of age & 80-90% are <5 years of age

13. Seasonality :  hot, rainy,season tropical  Late summer & autumn temperate Reservoir : Human most frequently persons with in apparent infections. Long term carriers have not been found.

14. Mode of transmission:  Direct person to person principally through fecal –oral transmission - bad standard of sanitation - young children  Pharyngeal droplets - good sanitation - older age groups  Food, milk, & other materials contaminated with feces rare  Insects no reliable evidence exists  Water,sewage, rarely implicated.

15. Incubation period:  7- 14 days for paralytic cases  Reported range of 3-35 days Period of communicability:  Not precisely defined  Transmission is possible as long as the virus is excreted  Virus appeared in throat secretion as early as 36 hrs & in feces 72 hrs after exposure to infection  Virus persists in the throat for (1) week &in the feces for 3-6 weeks

16. Prevention: Education of public on the advantages of immunization in early childhood Vaccination trivalent (OPV) inactivated (IPV)

17. OPV: Advantages: Recommended by WHO for polio eradication &EPI 3 doses will protect at least 80-85 % of immunized children Induces both circulating antibody &intestinal resistance. Immunize some susceptible contacts through secondary spread Low cost, (however)

18. OPV: Disadvantages: Low rates of seroconversion in developing countries It is contra indicated in all immune deficient persons Vaccine associated paralysis (VAPP) 1:2.5,000,000 doses (1:800000 in 1 st dose) Lower level of serum antibodies (break down in the cold chain, acute diarrhea, or local intestinal immunity)

20. Reading the vaccine vial monitor ((VVM))

21. IPV:  Prevents paralytic polio by producing sufficient Antibodies In the serum  It has no risk of vaccine associated paralysis  Lower level of intestinal immunity  More expensive.

22. Vaccine Schedule Birth zero dose 6 wks 1 st dose 10 wks 2 nd dose 4 basic doses 14 wks 3 rd dose of OPV 9 months for children not immunized at birth If OPV is given to child with diarrhea the dose should be repeated

23. The recommended schedule of immunization in Iraq rootvaccinesage ID+ORAL+IMB.C.G+POLIO(0)+HB11 week IM+ORAL+IMD.P.T(1)+POLIO(1)+HB22 Months IM+ORALD.P.T(2)+POLIO(2)4 Months IM+ORAL+IMD.P.T(3)+POLIO(3)+HB36 Months SC+ORALMEASLES+VIT A9 Months SCM.M.R15Months ORAL+IMFIRST.B00STER POLIO+D.P.T 18-24 Months ORAL+IM2 nd..B00STER POLIO+D.P.T 4-6 Years

24. Control: Reporting is obligatory any case of AFP under 15 y should be fully investigated (clinical, epidemiological, and stool culture) Isolation Concurrent disinfection Protection of contacts Inv of source No Sp Rx

25. Polio Eradication : Polio is one of only a limited number of diseases they can be eradicated  Polio only affects human  An effective vaccine is available  Immunity is life long  No long term carriers  No animal or insect reservoir  Virus can only survive for a very short period in the environment

26. Strategy of Eradication:  High routine immunization coverage with OPV i.e giving the 4 basic doses during the 1 st year of life  Supplementary immunization in the form of mass campaigns or NIDs  Effective surveillance.  Final stage when Very few or no cases are occurring,door-to-door immunization campaigns (mopping up) in areas where the virus persists.

27. Number of confirmed Polio cases in the EMRO Region 2009-2010-2011 Date of last case201120102009Country 20/04/20113814489Pakistan 11/01/2010 1 2538Afghanistan 40South Sudan 5North Sudan 20/04/201139169172Total