Poliomyelitis


– Poliomyelitis is an acute viral infection due to a poliovirus (serotypes 1, 2 and 3). Human-tohuman transmission is direct (faecal-oral) or indirect (ingestion of food and water contaminated by stool). Humans are the only reservoir of the virus. In principle the disease can be eradicated by mass vaccination.

– In endemic areas, epidemics usually affect children under 5 years of age.
In non- endemic areas, where vaccination coverage is low, young adults are most commonly affected.

Clinical features

– In more than 90% of cases, infection is asymptomatic.

– Non-paralytic form: a non-specific febrile illness with muscle pain, headache, vomiting, backache; no neurological involvement.
As spontaneous recovery usually occurs within 10 days, diagnosis is rarely made outside epidemic contexts.

 Paralytic form: in less than 1% of cases, after the non-specific signs, the patient develops rapid onset (from the morning to the evening) asymmetrical acute flaccid paralysis, predominantly of the lower limbs, with ascending progression. The muscles become soft with diminished reflexes. Sensation is maintained. The disease is life threatening if paralysis involves the respiratory muscles or muscles of swallowing. Initial urinary retention is common. Gastrointestinal disturbances (nausea, vomiting, diarrhoea), muscle pain and meningeal symptoms may also occur.

Laboratory

Look for the polio virus in stool samples. The virus is excreted for one month after infection, but only intermittently; therefore, 2 samples must be collected with an interval of 48 hours.

Treatment

– Hospitalise patients with the paralytic form: rest, prevent bed sores in bedridden patients, give analgesics (do not give IM injections to patients in the febrile phase), ventilate patients with respiratory paralysis.
– Physiotherapy once the lesions are stable to prevent muscle atrophy and contractures.
– Care for sequelae: physiotherapy, surgery and prosthetics.

Patients with acute flaccid paralysis (AFP)

– Consider all patients with AFP as suspected cases of poliomyelitis.
– Confirm the diagnosis by isolating the virus: send the 2 stool samples to a reference laboratory, with a clinical description of the patient. The stool samples must be stored and transported between 0 °C and 8 °C.
– While waiting for laboratory confirmation, vaccinate all children under 5 years of age living in the area (from the same village or neighbouring villages), irrespective of their vaccination status.
– Once the case is confirmed, organize a mass vaccination campaign: the area and the age group are determined as a function of epidemiological data.
– Surveillance: for each case of AFP there are between 100 and 200 subclinical cases. Therefore, active surveillance to detect new cases is essential for epidemic control.

Prevention

– 2 types of vaccines exist:
• a trivalent injectable inactivated poliovirus vaccine (IPV),
• a bivalent oral live attenuated poliovirus vaccine (bOPV).

– Vaccination schedule: depends on the epidemiology of the virus.
Protocols vary according to the country, follow national recommendations. For information, the WHO recommends:


Schedule
Primary vaccination

Endemic or at risk zones*

Other zones

Birth

1 dose bOPV**

6 weeks

1 dose bOPV

1 dose bOPV

10 weeks

1 dose bOPV

1 dose bOPV

14 weeks

1 dose bOPV + 1 dose IVP

1 dose bOPV + 1 dose VPI

* Countries where poliomyelitis is endemic or zones at high risk of importation and subsequent spread of the virus.
** The 1st dose of bOPV is administered at birth, or as soon as possible, to optimise seroconversion rates after subsequent doses and induce mucosal protection.

In children who start routine vaccination late (after the age of 3 months), the dose of IPV is administered together with the 1st dose of bOPV, followed by 2 doses of bOPV alone administered 4 weeks apart.

There is also an ‘IPV only’ schedule: 3 doses administered 4 weeks apart (e.g. at 6, 10 and 14 weeks) and a booster dose at least 6 months later.
IPV should eventually completely replace bOPV.