Poliomyelitis ppt by dr.Mumtaz wazir

Poliomyelitis : 

Poliomyelitis Dr.Mumtaz TMO PAEDS B UNIT Lady Reading Hospital

What is Poliomyelitis?: 

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.

History: 

History Associated with man since ancient times Egyptian hieroglyph indicates presence since 1400 BC

History cont…..: 

History cont….. First described by Michael Underwood in 1789 First outbreak described in U.S. in 1843 Global eradication in near future

About poliovirus: 

About poliovirus RNA virus Family---- picarnoviridae Genus------ enterovirus Highly contagious – usually infects 100% of susceptible Occurs more commonly in hot, humid months.

Structure: 

Structure

Serotypes: 

Serotypes Three serotypes with no cross immunity Type 1 polio : wild type,natural infection Type 2 polio: Eradicated Type 3 polio : Greater temperature stability Requires trivalent polio vaccine

Epidemialogy: 

Epidemialogy Inapparent----- 90-95% induce protective immunity Apparent but non paralytic---5% Paralytic Infants----1/1000 Adolescents----1/100

How is polio transmitted?: 

How is polio transmitted? Reservoir ---- Human Poliovirus is transmitted through fecal-oral route with implantation and replication occurring in the intestinal mucosa.

Infectivity: 

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

Slide 11: 

11 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 Summer 1.5 days Winter 20 days 2. Sewage At 23 o C 26 days At 2 o C 180 days 3.Surface water Fresh 5.5 days Sea 2.5 days

Pathogenesis: 

Pathogenesis Incubation period --- 8-10 days (5-38 days) Both types ----------- host entry via GI tract Infect M-cells ( intestine) Replication ---- inside the cell

Slide 13: 

Local lymphnodes infected ---- viremia occurs --- CNS infected --- primary target motor neurons --- Paralysis ……when more than 52% of neurons are affected -----medulla less extensive lesions leads to paralysis/vital centers impairment.

Slide 14: 

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

Cell Binding and Entry: 

Cell Binding and Entry

Slide 16: 

16 Clinical Outcome of Poliovirus Infections asymptomatic infection clinical illness, no paralysis paralytic poliomyelitis 90-95% 4-8% 0.1%

Slide 17: 

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

Clinical Manifestations: 

Clinical Manifestations 1 . Inapperant infections: 90-95%,no disease/sequel 2 . Abortive PM: 5%, short lived, influenza like syndrome, complete recovery 3 . Non paralytic PM: 1%,more severe signs/symptoms, temporary weakness no sensory deficit, complete recovery

Cont…..: 

Cont….. 4 . Paralytic PM: 0.1%, may be spinal PM, bulbar PM, polio encephalitis a . Spinal paralytic PM: Influenza like syndrome,2-3 days symptoms free interval, fever, headache, myalgia, hyperesthesia, fasciculation, spasm, flaccid paralysis.

Contin….: 

Contin…. b . Bulbar PM: Involves cranial nerve and medullary centers. nasal tang to voice, dysphagia, ineffective cough, nasal regurge, hoarse voice, deviation of palate and tongue. respiratory irregularities and CVS alterations.

Conti…: 

Conti… C . Polioencephalitis: Rare form, involve higher brain centers. Irritability, disorientation, fits, exaggerated reflexes, coarse termors, spastic paralysis.

When does paralysis occur?: 

When does paralysis occur? The paralytic phase of PM is variable , some pts progress from paresis to paralysis while other recover which may be slow/rapid. The extent of paresis is directly related to the neuronal involvement , paralysis occurs when more than 52% neurons supplying the muscle are affected

Is there any chance of recovery?: 

Is there any chance of recovery? Progression of paralysis stops ,once temp is normal. Little recovery noted in first few day/wks but if it is to occur , is usually evident within 6m.the regain of power and reflexes is slow and may continue to improves as long as 18m. Lack of improvement from paralysis within the first several wks is usually evidence of permanent paralysis

Polio and its impacts on life: 

Polio and its impacts on life

Post-Polio Syndrome- The new Challenge of an Old disease : 

Post-Polio Syndrome- The new Challenge of an Old disease Onset 10-40 years after initial attack(25-50% polio survivors) New weakness in the affected and seemingly unaffected muscles Progressive weakness , fatigue(generalized and muscular),muscle atrophy , pain from joint degeneration and skeletal deformities

PPS CONT……: 

PPS CONT…… causes Exact cause unknown Continued degeneration of motor neurons & nerve terminals have been postulated Diagnostic criteria prior PM period of partial / complete recovery Symptoms(at least for a year) No other medical,muscular or orthopaedic cause

PPS CONT….: 

PPS CONT…. TREATMENT No specific treatment Non fatiguing exercise I/v immunoglobulin may reduce pain, improve life quality and improve muscle strength

Diagnosis of polio: 

Diagnosis of polio Should be suspected in incomplete/unimmunized child with paralysis or if occurs 7-14 days following OPV. Fever, headache, neck, and back pain, asymmetric flaccid paralysis without sensory deficit are rare in other illness. Stool culture is confirmative of PM and with the current techniques available serotyping can be done. Poliovirus can also be confirmed thru ELIZA and PCR done on the stool specimen

Diagnosis cont…..: 

Diagnosis cont….. CSF may be normal or may show pleocytosis with normal/slightly raised protein Serology, 4 fold increase in Ab titre

D/D OF AFP: 

34 ACUTE FLACCID PARALYSIS POLIOMYELITIS GUILLAN-BARRE SYNDROME TRANSVERSE MYELITIS OTHER ENTEROVIRUSES DISEASES OF MUSCLES METABOLIC DISORDERS D/D OF AFP Meningitis, Encephalitis(TBM, Aseptic) Injection Trauma (Injection Neuritis) CVA

Slide 35: 

35 Differential diagnosis of poliomyelitis Polio Guillain-Barré syndrome Traumatic neuritis Transverse myelitis Installation of paralysis 24 to 48 hours onset to full paralysis from hours to ten days from hours to four days from hours to four days Fever at onset high, always present at onset of flaccid paralysis, gone the following day not common commonly present before, during and after flaccid paralysis rarely present Flaccid paralysis Acute,usually asymmetrical, principally proximal Generally acute, symmetrical and distal asymmetrical, acute and affecting only one limb acute, lower limbs, symmetrical Muscle tone reduced or absent in affected limb Global hypotonia reduced or absent in affected limb hypotonia in lower limbs Deep-tendon reflexes decreased to absent Globally absent decreased to absent absent in lower limbs early, hyper- reflexia later Sensation severe myalgia, backache, no sensory changes cramps, tingling, hypoanaesthesia of palms and soles pain in gluteus, hypothermia anesthesia of lower limbs with sensory level Cranial nerve involvement only when bulbar involvement is present often present, affecting nerves VII, IX, X, XI, XII absent Absent Respiratory insufficiency only when bulbar involvement is present in severe cases, enhanced by bacterial pneumonia absent Sometimes

DISTINGUISHING FEATURES OF POLIO: 

36 DISTINGUISHING FEATURES OF POLIO Asymmetric flaccid paralysis (usually affecting proximally) 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

Treatment: 

Treatment No specific antiviral treatment Supportive Management with aims to limit progression to prevent deformity to prepare the family for lifelong disability Avoid IM inj. And surgical procedures Bed rest, avoid exertion Analgesic, sedatives, hot packs Proper body alignments

Slide 38: 

Attractive diet and care of hydration May need Air way maintenance Frequent suction Tracheotomy Monitoring of the vitals Physiotherapy after infection has subsided Corrective surgery and orthotic support

Complication: 

Complication Gastric dilatation Melena Hypertension Acute pulmonary edema Hypercalcaemia Life long disability

Prognosis: 

Prognosis Good with death rare in Inapparent illness Abortive poliomyelitis 60% mortality in severe bulbar PM, 5-10% for spinal PM or less severe bulbar PM.

What makes paralysis more likely??: 

What makes paralysis more likely?? Male child but female adult PM at puberty Pregnancy Increased physical activities or exercise in early illness Immunodeficiency IM injection Trauma

PREVENTION & ERADICATION: 

PREVENTION & ERADICATION Hygienic measure--- limit the spread Vaccination Is only effective tool to prevent PM

WHAT MAKES IT POSSIBLE : 

43 NO ANIMAL RESERVOIR EFFECTIVE TOOL (ORAL POLIO VACC) SURVIVES POORLY IN ENVIROMENT WHAT MAKES IT POSSIBLE

Vaccine types: 

Vaccine types IPV: Given i/m Formalin killed Available in developed countries Only for self protection Elicits higher serum IgG 4 doses at 2 m, 4 m, 6-18 m and 4-6 yrs

Vaccine types cont….: 

Vaccine types cont…. 2 . OPV: Live attenuated Induce mucosal IgA 0,6,10,14 wks,18m and 5 yrs May revert to neurovirulent strain Only vaccine approved by WHO to eradicate POLIO

OPV CONT…..: 

OPV CONT…..

Polio Vaccine Adverse Reactions: 

Polio Vaccine Adverse Reactions Rare local reactions (IPV) No serious reactions to IPV have been documented Paralytic poliomyelitis (OPV only)

Polio Vaccine Contraindications and Precautions: 

Polio Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose of vaccine Moderate or severe acute illness

Polio Eradication: 

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

Global situation: 

Global situation At the time of adoption of polio eradication target (1988) 350,000 polio cases every year 125 countries endemic for polio. In 2009 1604 cases (i.e. 99% reduction) Only 4 endemic countries (Nigeria, India, Pakistan & Afghanistan) 10 re-infected countries

POLIO AFFECTED CHILDREN 1988: 

53 POLIO AFFECTED CHILDREN 1988 350000 cases 125 countries

POLIO AFFECTED CHILDREN 2009: 

54 POLIO AFFECTED CHILDREN 2009 1604 children 17 countries 741 cases 388cases 89 Cases 38 Cases 66 cases 45 Cases

Slide 55: 

Wild Poliovirus 2010

POLIOMYEILTIS: 

POLIOMYEILTIS and PAKISTAN

2010: 

2010 The Target Year, For Polio Free Pakistan . (Ministry Of Health ,Govt of Pakistan)

JANUARY18,2010 : 

JANUARY18,2010 Bushra,9 year old child , from Bara Khyber Agency Confirmed as the first POLIO case of the year ,2010. Health Authority , Reported . So the Dream of POLIO FREE PAKISTAN could not be fulfilled

Polio Cases in Pakistan, 1997- 2010 : 

Polio Cases in Pakistan, 1997- 2010 Cases (n)

Polio status in PAKISTAN(2010): 

Polio status in PAKISTAN(2010) TOTAL CASES 43 TYPE 1 25 TYPE 3 18 60 VIRUS TYPE KPK FATA PUNJAB SINDH BALOCHISTAN TYPE 1 07 16 01 00 01 TYPE 3 04 06 01 01 00

REASONS FOR FAILURE TO ERADICATE POLIO: 

REASONS FOR FAILURE TO ERADICATE POLIO over crowding and poor sanitation Inaccessibility in NWFP/FATA Extensive population movement.(Crisis in Swat and other FATA agencies) Sub-optimal campaign quality in some districts and towns Low routine immunization coverage Pockets of refusal Significant changes in health manpower Sharing free border with Afghanistan

How can pediatricians and other doctors help?: 

How can pediatricians and other doctors help? Free, liberal reporting of all acute flaccid paralysis & other vaccine preventable diseases especially suspected measles and NNT cases Create community demand for vaccination – making parents responsible for ensuring their children are vaccinated Highlighting the need for supplementary doses of OPV Establish polio desks at clinics during campaigns Assure parents about safety of vaccines & multiple do

Personal and community protection: 

Personal and community protection Vaccinated and has serum immunity but no Intestinal immunity Protected herself but able to replicate wild poliovirus Personal and community protection Personal protection but no community protection Vaccinated and has serum immunity and Intestinal immunity Protected himself and not able to replicate wild poliovirus NO Personal protection and no community protection Not Vaccinated and no serum and intestinal immunity Not Protected himself and able to replicate wild poliovirus

CONCLUSION: 

CONCLUSION “We are on the last kilometer of a marathon; surely it is worth crossing the finish line”