‫بسم هللا الرحمن الرحيم‬
POLIOMYELITIS
AFP Surveillance
Gamal Eldin Mohamed Osman
WHO.POLIO PROGRAMME. SAAN`A, YEMEN
The poliovirus …
Leon
Lansingh
Brunhilde
Poliomyelitis
Outcome of Poliovirus Infection
Paralytic poliomyelitis (0.1 – 1%)
Non-paralytic poliomyelitis (10 %)
Abortive poliomyelitis (4 – 5%)
Unapparent or sub-clinical infection
(90 – 95%)
Guillain-Barré syndrome:
is an acute inflammatory demyelinating
polyneuropathy characterized by progressive muscle
weakness and areflexia

Any age

Ascending, symmetric (9% with asymmetry)

7% children with relapse
5
6
7
Transverse Myelitis
8
Polio virus



Genus: Enterovirus
Family: Picornaviridae
Three major antigenic sites (surface proteins (VP13) 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
Viral excretion drops
significantly after 14 days,
but poliovirus may still be
detected up to 60 days
after onset.
Early Detection
Late Detection
POLIO
20
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
1. Soil
2. Sewage
3.Surface
water
13
Time for virus infectivity to fall by 90%
Summer
1.5 days
Winter
20 days
At 23 o C
26 days
At 2 o C
180 days
Fresh
5.5 days
Sea
2.5 days
A child with no intestinal
Immunity has free
Receptors for WPV
and help replicating
Wild Poliovirus
Receptors
Wild Poliovirus
Age group distribution for
poliomyelitis
% distribution of polio cases by age, Sudan (N)
Jan-Nov 2004
50
45
40
35
30
% 25
20
15
10
5
0
1 years
2 years
3 years
4 years
5 years
> 5 years
DISTINGUISHING FEATURES OF POLIO
16
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
(1580 - 1350 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
20

Last case of WPV in Yemen was in April 2006 from
Ibb Governorate, Hubish district.
Poliomyelitis in 1988
350 000 cases / 125 countries
Wild Poliovirus 2011
Wild Poliovirus 2012
Polio – EMRO in 2012*
Polio Cases
*EMRO- Polio- Data as of 08 January 2013
2011
2012*
Country
P1
P3
P1
P3
Pakistan
190
2
58
0
Afghanistan
76
0
37
0
2011 Regional Risk Assessment Map*
Risk Interpretation (Score)
( ≤50)
High
(51–74)
Medium
( ≥75)
Low
Not Included
Non EMR countries
Eastern Mediterranean Region
*Data through end of Q3 2011
AFP and Poliomyelitis EMR 2012
Polio: Last Cases
Americas
Peru 1991
Western Pacific
Cambodia 1997 ?
Europe
Tajikistan 2010
Polio Eradication
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
28
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 24-48 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 60th day from onset
Must be done < 70 days from onset
Type of paralysis is verified
(Flaccid or Spastic)
Presence or absence of Residual
weakness
AFP SURVEILLANCE
MESSAGE
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:
Virological AFP Case Classification
Scheme
(non-polio AFP rate > 2/100.000, >= 80% with adequate specimens):
confirm
Wild poliovirus
AFP
case
inadequate
specimens
No wild
poliovirus
residual
weakness,
died or lost
to followup
no
residual
weakness
two
adequate
specimens
expert
review
poliocompatible
discard
discard
discard
Onset of Paralysis
< 7 days of onset
Detection & notification
The Process of AFP
surveillance
< 14 days of onset
< 3 days of
being sent
Case investigation
& specimen
collection > 60 days
of onset
< 28 days of Primary culture
receipt
Specimens
arrive at
National
laboratory
results reported to
EPI
Isolates sent to
regional lab

Case classification
(< 90 days of paralysis onset)
Follow up examination
results reported
to EPI