Dr. Anita Lamichhane

Acute Flaccid Paralysis

Rapid onset of weakness, including weakness of

the muscles of respiration and swallowing,

progressing to maximum severity within several

days to weeks

Acute Flaccid Paralysis

WHO:

Poliomyelitis

Gullain Barrie syndrome

Transverse myelitis

Traumatic Neuritis

Components of AFP Surveillance

The AFP surveillance network and case

notification

Case & laboratory investigation

Outbreak response & active case search in the

community

60 day follow up, cross notification & tracking of

cases

Data management & case classification

Virologic classification scheme

Surveillance performance indications

Case and laboratory investigation

Immediate investigation into the case within 48 hrs

of notification

Stool specimen collection & transportation

2 stool specimen collected as soon as possible

after the onset of paralysis (ideally within 14 days

of onset of paralysis & at least 24 hrs apart)

Each specimen should be 8 gms- each about the

size of the adult thumb

Stool container

Collected in a clean, dry, screwed capped container

No preservative or transport media should be used

The specimens collected, labeled ,transported in the

cold chain-on frozen ice packs/ ice, in a stool

specimen carrier or a vaccine carrier

In Pakistan, the specimen is sent to NIHL( National

Institute 0f Health Laboratories ) at Islamabad

Poliomyelitis

Two Greek words: polios (gray) & myelios (spinal

cord..anterior horn cells )

In 1908, the polio virus was discovered by Karl

Landsteiner

An enterovirus

3 serotypes-P1,P2,P3

P1 - causes outbreaks—is the most likely virus to

cause paralysis.

P2 - the easiest to eradicate followed by P3

Human are the only hosts without which the virus

cannot survive

The Virus is excreted in the stools for three to six

weeks.

It is more stable than most viruses ,can stay alive

for several weeks in contaminated food or water.

It is one of the most contagious viruses.

If one family member is infected, nearly all the rest

of the family becomes infected.

multiplies in the cells of the mucous membranes in the pharynx and intestines

Invades local lymphoid tissue

Hematological spread

• virus becomes neurotropic • produces destruction of the motor neurons in the anterior horn and brainstem

Portal of entry is the mouth

Cold chain- Maintenance of temperature from

vaccines synthesis to delivery to child.

Reverse cold chain- Maintenance of cold chain

from stool collection to delivery to the laboratories

Yearly report

Total casesYear-to-date

2010Year-to-date

2009 Total in 2009

Globally 39 110 1606

in endemic countries 32 80 1256

in non-endemic countries: 7 30 350

Yearly report …of Pakistan

In Pakistan, one new WPV3 case was reported on

the 17th February 2010, from Quetta, Baluchistan.

Bivalent OPV was used for the first time in

Pakistan in NIDs held from 15-17 Feb 2010

The next round will be held from 15-17 March

2010 in targeted high and medium risk districts,

using bOPV

Number of confirmed cases of poliomyelitis in Pakistan, 1997–2008

Number of districts with confirmed poliomyelitis cases in Pakistan, 1997–2008

Pakistan has recorded 76 cases in 2009 to date:

52 type 1

23 type 3

one type 1/3 mixture.

SNIDs in Afghanistan

the Provincial Government of Nangarhar, UN

agencies jointly launched sub-national

immunization days (SNID) in Jalalabad on

Sunday, 14 February 2010.

Disease Surveillance

The ongoing systematic collection & analysis of

data & the provision of information which leads to

action being taken to prevent & control a disease,

usually one of an infectious nature

Herd immunity

Immunity of a sufficient number of individuals in a

population such that infection of one individual will

not result in an epidemic.

Wild polioviruses

Isolates known or believed to have circulated

persistently in the community & reference strains

derived from these isolates.

May be present in a variety of clinical materials

faeces & throat specimens

less commonly in blood

rarely in CSF in non-paralytic & paralytic infections.

.

In fatal infections, wild poliovirus may be present in

faeces

intestinal contents

lymph nodes

brain tissue

spinal cord tissue

Vaccination

1955 - Mr. Salk discovered IPV

1957 - Mr. Sabin discovered OPV

EPI- globally launched in 1974

In Pakistan in 1978 training was started and

became apparent in 1979

Polio Eradication

In 1988 , World Health Assembly, in its resolution

41.28 – set goals of A global polio eradication

program

OPV was recommended.

In Pakistan started in 1993-94

Led by the World Health Organization, UNICEF,

and The Rotary Foundation

Global Eradication of polio program was established in

1989.

Today only 4 countries are endemic to polio

Pakistan,

Nigeria,

India,

Afghanistan

What is Eradication ???

The World Health Organization (WHO) defines

polio eradication essentially as ‘zero incidence of

wild poliovirus transmission anywhere in the

world’.

Polio eradication requires

Finding and controlling wild

poliovirus in human populations

+

Finding and controlling wild

poliovirus in laboratories

Why was it launched ???

Humans are thought to be poliovirus's only host

Virus survival in the environment is limited.

Immunization with vaccines interrupts virus

transmission

Objectives of the Global polio Eradication initiative

To interrupt transmission of the wild poliovirus as

soon as possible

To achieve certification of global polio eradication

To contribute to health system ,development &

strengthening routine immunization & surveillance

for communicable disease in a synergistic way

Strategies of achieving the goal

High routine infant immunization

Supplementary doses of OPV to all children under 5 yrs of

age during SIAS( Supplementary immunization activities)

Active AFP Surveillance for wild poliovirus through

reporting & lab testing of all AFP cases among children

under 15 yrs of age

Targeted “Mop-up" campaigns once wild poliovirus

transmission is limited to a specific focal area.

High routine infant immunization

All countries aim to immunize at least 90% of

infants with four OPV doses

These doses are part of the basic (EPI)

High routine immunization coverage decreases the

incidence of polio & sets the stage for eradication

National Immunization Days (NIDs)

It is the 2nd part of the four-pronged strategy and is also

known as mass immunization campaign.

Important activity for interrupting wild poliovirus

circulation in endemic countries

A supplementary immunization

Intended to complement - not replace - routine

immunization.

The aim of mass campaigns is to interrupt

circulation of poliovirus by immunizing every child

under 5 years of age with two doses of OPV,

regardless of previous immunization status.

Three to five years of NIDs are usually required to

eradicate polio

NIDs are needed for at least 3 consecutive years

to interrupt transmission

NIDs are normally conducted during the cool, dry

season

( immunological response to OPV is improved and

the potential damage to heat-sensitive OPV is

reduced.)

SNIDs) target children for polio vaccination in

specific high-risk regions of countries rather than

the entire country.

Surveillance of new cases of polio

Countries to ensure that all cases of poliomyelitis

are detected

The goal of AFP surveillance is to report and

investigate “any case of acute flaccid (floppy)

paralysis

surveillance systems should be capable of

detecting at least one case of AFP per 100 000

population < 15 years;

collecting adequate stool specimens from at least

80% of AFP cases

testing all specimens at a WHO-accredited

laboratory.

Mop-up Activities

AFP surveillance data are used to identify the final

chains of wild poliovirus transmission in each

geographical area

In these areas, two doses of OPV are

administered to all children < 5 years, regardless

of their prior immunization status, by immunization

teams that go house-to-house.

Improve coverage & ensure that the most difficult-to-

reach children are immunized, thereby interrupting the

last chains of wild poliovirus transmission

In addition to delivering supplemental OPV doses,

mop-up activities often include an active search for AFP

cases

Summary of Proposed Milestones

Milestones for future Target year

1. Establish comprehensive policy for future management.

2003

2. Eliminate wild poliovirus transmission. 2003

3. Certification of ‘eradication’ of wild viruses. 2006

4. Introduction of IPV in routine immunization. 2006

5. Complete withdrawal of OPV. 2009

6. Certification of ‘true eradication’ of polioviruses.

2012

7. Discontinue polio immunization. 2015

Polio Eradication in Pakistan

In Jan 2010, meeting covered the tribal leaders

and religious scholars

In South Waziristan, Mufti Maulana Abdul

Qayuum issued a fatwa supporting polio efforts, 15

mosques were made after the ceremony

Women also played an important role in increasing

the coverage

Special teams of women were mobilized & trained

to go house-to-house and address the recent rise

in refusal rates

The delivery teams equipped with appropriate

messages, were able to cover 61% of all the

refusal families in Larana.

Recent advances of polio virus

Researches use crippled Polio Virus to attack

Brain Cancer

Polio virus has a natural affinity to invade the

brain, by binding to the CD155 receptor on the

surface of the motor neurons

Brain tumors overproduce the CD155 receptors

which makes the cell in the tumors more

susceptible to poliovirus infection

The genetically engineered altered poliovirus

when introduced in the body

Enters the normal motor neurons (it shares the

same CD155 receptors as brain tumour cells )but

cannot grow in normal neurons

Kills the brain tumor cells

no cure for polio

it can be prevented