EPIDEMIOLOGY OF POLIO MYELITIS AND POLIO ERADICATION PROGRAMME IN INDIA

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EPIDEMIOLOGY OF POLIO MYELITIS AND POLIO
ERADICATION PROGRAMME IN INDIA
DR.I.SELVARAJ,
I.R.M.S B.Sc.,M.B.B.S.,(M.D COMMUNITY MEDICINE)
D.P.H., D.I.H.,P.G.C.HFW(NIHFW,NEW DELHI)
Sr.D.M.O (ON STUDY LEAVE)
INDIAN RAILWAY MEDICAL SERVICE
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• THE AMERICAS WERE CERTIFIED POLIO-FREE IN 1994.
  (36 COUNTRIES)
• THE WESTERN PACIFIC WAS CERTIFIED POLIO-FREE IN
  2000. (37 COUNTRIES AND AREAS INCLUDING CHINA)
• EUROPE, COMPOSED OF 51 COUNTRIES, WAS CERTIFIED
  POLIO-FREE IN JUNE 2002. (51 COUNTRIES)
•  WITH ONLY SIX POLIO ENDEMIC COUNTRIES LEFT IN
  THE WORLD, POLIO TRANSMISSION COULD BE STOPPED BY
  END 2005.  THE WORLD COULD THEN BE CERTIFIED
  POLIO-FREE BY END-2008.

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HISTORY 1789 - British physician Michael
Underwood provides the first clinical description
of polio, referring to it as "debility of the
lower extremities." 1840 - German physician Jacob
von Heine publishes a 78-page monograph in 1840
which not only describes the clinical features of
the disease, but also notes that its symptoms
suggest the involvement of the spinal cord. 1908-
Austrian physicians Karl Landsteiner and Erwin
Popper make the first hypothesis that polio may
be caused by a virus.
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In 1908, Karl Landsteiner Erwin Popper
discovered a filterable agent as the cause of
poliomyelitis. An extract of medula from a fatal
human case was injected intraperitoneally in
monkeys. He worked then at the Pasteur Institute,
because no monkeys were available in the
University of Vienna. The lesions that appeared
were indistinguishable from those found in
humans. They could not pass the disease monkey
to monkey, but Simon Flexner Paul Lewis managed
this and found antibodies. Arnold Netter
Constantin Levaditti found antibodies in human
convalescents in 1908. Levaditti Landsteiner
demonstrated neutralizing antibodies in monkey
serum against active virus. Frank Mcfarland
Burnet Jean MacNamara en 1931 demonstrated
serotypes.
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In 1936, Albert Sabin Peter Olitsky cultured
poliovirus in embryonic nervous cells. In 1949,
John Enders, Thomas Weller Frederick C. Robbins
grew the virus in muscle cells (fibroblasts)
human embryonic skin cells, connective tissue
cells, intestine and nervous cells, winning the
Nobel prize in 1954. The important production
point is that the virus grows in nonnervous
cells.
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Sabin, Albert (1906-93) Pioneering researcher on
viruses and viral diseases who developed the oral
live-virus vaccine against polio. Sabin's vaccine
came to be preferred over the alternative
killed-virus vaccine developed by his bitter
rival Dr. Jonas Salk. The Sabin vaccine contains
harmless attenuated polio virus. Dr. Sabin first
showed that polio virus could grow in human nerve
tissue outside the human body. Through research
on monkeys he discovered how the polio virus
entered the human body. It had been widely
thought that the virus entered through the
respiratory tract. Sabin proved that the virus
first invaded the digestive tract and later
attacked nerve tissue. Albert Bruce Sabin was
born in Bialystok, Poland. He immigrated with his
family to the US in 1921. He graduated from New
York University medical school. He trained in
pathology, surgery and internal medicine at
Bellevue Hospital in New York and spent a year in
research at the Lister Institute in London. In
1935 he returned to New York to join the
Rockefeller Institute and then in 1939 moved to
the University of Cincinnati and its Children's
Hospital Research Foundation.
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AGENT POLIO VIRUS
The virion consists of a single strand of RNA
containing genetic information and a protein
coat. Humans are its only natural host. - The
poliovirus is a member of a larger family known
as Picornaviruses, which also includes
rhinoviruses (such as influenza) and the
hepatitis A virus. - Polio belongs to the
enterovirus subgroup, made up of over 70 viruses
that infect the intestines. - It is one of the
smallest RNA viruses, measuring around 25 nm in
diameter.
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EPIDEMIOLOGY

• AGENT POLIOVIRUS
• TYPE THREE SERO TYPES(TYPE-1,TYPE-2,TYPE-3)
• RESERVOIR MAN
• INFECTIOUS MATERIAL FAECES, ORO-PHARYNGEAL
  SECRETIONS
• INCUBATION PERIOD 7 TO 14 DAYS( 3- 35 DAYS)
• PERIOD OF COMMUNICABILITY 7 TO 10 DAYS
• HOST AGE 6 MONTHS TO 3 YEARS
• ENVIRONMENT RAINY SEASON (JUNE TO SEPTEMBER)
• MODE OF TRANSMISSION FAECO ORAL ROUTE, DROPLET
  INFECTION

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Left Picture of poliovirus. The poliovirus is
extremely small, about 50 nm (nanometer
one-billionth of a meter) Courtesy of David
Belnap and James Hogle
Right Cross-section of the poliovirus showing
the RNA, capsid, and nerve cell receptors
Illustration courtesy of Link Studio
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• Inapperent(sub-clinical) Infection this occurs
  approximately in 95 per cent of poliovirus
  infection. There are no presenting symptoms.
  Recognition only by isolation.
• Abortive Polio Or Minor Illness occurs
  approximately in 4-8 per cent of the infection.
  It causes only a mild or self limiting illness
  due to viraemia. The patient recovers quickly.
• Non paralytic polio occurs approximately in one
  per cent of all infections. The presenting
  features are stiffness and pain in neck and back.
  The disease lasts for two to ten days. Recovery
  is rapid.
• Paralytic polio occurs in less then one per cent
  of infections. The virus enters the brain and
  causes varying degree of disability.

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Global Status 1988
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GLOBAL STATUS 2004
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GLOBAL POLIO VIRUS CASES
1988 3,50 000 April 1, 2003,
1,925 polio cases 1998 1,934 1999
1,186 2000
265 2001 211 2002
1919 2003 784 2004
1,556 20.12.2005 - 1831
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2005 1,831 cases of wild poliovirus (excludes
vaccine derived polio viruses 8). 727 Nigeria
(endemic) 478 Yemen (importation) 299 Indonesia
(importation) 154 Somalia (importation) 64 India
(endemic) 27 Pakistan (endemic) 27 Sudan
(re-established transmission) 20 Ethiopia
(importation) 9 Angola (importation) 9 Niger
(endemic) 7 Afghanistan (endemic) 4 Nepal
(importation) 3 Mali (importation) 1 Chad
(re-established transmission) 1 Eritrea
(importation) 1 Cameroun (importation) Source
Polio cases from 1 January 2005, as of 17 January
2006
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• 25 million children are born in India every year.
• There is interval of 11 months between two PPIs.
• Over emphasis and too-frequent IPPI rounds and
  other supplemental immunization activities left a
  grass root health worker completely exhausted and
  fatigued.
• High population densities, poor sanitation, and
  low routine immunization coverage.
• Resistance for OPV immunization amongst Muslim
  community. OPV is an anti-fertility vaccine and
  would lead to impotence in male children or
  infect them with AIDS.
• Children in western UP from Muslim community
  have consistently been missed both during SIAs
  and for routine immunization.
• Significantly almost 66 of polio cases have
  occurred among Muslim children.
• A dwindling public involvement, and lack of
  commitment of all sectors of local administration
  have hampered the progress of this mass-campaign
  in the most populous and political sensitive
  states of north India.

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In 1993, Kerala became the first state in India
to conduct statewide immunization day. In 1994
Tamil Nadu became the second state to conduct
statewide immunization day. Delhi became the
third state, conducting statewide immunization
day on 2nd October 1994 and 4th December
1994.First PPI held in 1995-96 all children below
3 years of age were targeted on 9th December 1995
and 20th January 1996.
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POLIO ERADICATION PROGRAMME

• Conduct pulse polio immunisation for two days
  every year for three to four years or until polio
  is eradicated.
• Sustain high level of routine immunisation.
• Monitor OPV coverage at district levels and
  below.
• Improve surveillence capable of detecting all
  cases of polio.
• Ensure rapid case investigation, including the
  collection of stool samples.
• Arrange follow-up of all cases of paralytic polio
  at 60 days to check for residual paralysis.
• Conduct outbreak control for cases confirmed or
  suspected to stop transmission.

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National Immunization Days

• 9.12.1995 - I st NID
• 20.01.1996
• 07.12.1996 2nd NID
• 18.01.1997
• 07.12.1997 3rd NID
• 18.01.1998
• 06.12.1998 4th NID
• 17.01.1999
• 24.10.1999 5th NID
• 21.11.1999
• 19.12.1999
• 23.01.2000
• 2004 - ( 5- NID, 3SID)
• 2005 ( 2-NID, 6 SID)

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GOAL To assist
governments in their efforts to immunize every
child against polio until polio transmission has
stopped, so that the world can be certified
polio-free.
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From 1996-97 to all children under the age of 5
years were covered. Till 1998-99, the PPI
Programme consisted of vaccination of children at
fixed booths on two National Immunization
Days(NID), separated by six weeks, during the
winter season. The strategy for 20002001 has
been firmed up after studying the epidemiological
pattern of the disease in different parts of the
country and in consultation with group of
national / international experts, specially
constituted by WHO at the countrys request.
their advice is to adopt a differential approach
in response to the varying levels of success
already achieved in the different States.

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The country has accordingly been divided into
three zones Low Burden Zone (LBZ), Middle
Burden Zone (MBZ) and High Burden Zone (HBZ).
Experts have suggested that there should be two
national immunization days in the months of
December 2000 and January 2001, preceded by one
Sub-National Immunization Day for 11 States in
the month of November 2000 and another SNID for
the 4 States of UP, Bihar, West Bengal and Delhi
in the month of September 2000, which are in the
HBZ zone. The experts also advised that the
house to house component need not be insisted on
the LBZ areas, while the MBZ and HBZ should
continue with the house to house search and
immunization programme, as some children in these
States are missing vaccination in the NIDs.
As regards the LBZ and MBZ areas, experts have
advised mop up vaccination around each case of
confirmed polio not only in the district in which
the case appears but also in the surrounding
districts.
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The Global Polio Eradication Initiative
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OBJECTIVES

• TO INTERRUPT TRANSMISSION OF THE WILD POLIOVIRUS
  AS SOON AS POSSIBLE AND CERTIFY ALL WHO REGIONS
  POLIO-FREE BY THE END OF 2005
• TO IMPLEMENT THE POLIO ENDGAME PROGRAMME OF WORK,
  INCLUDING CONTAINMENT OF WILD POLIOVIRUS, GLOBAL
  POLIO-FREE CERTIFICATION, AND THE DEVELOPMENT OF
  A POST-ERADICATION IMMUNIZATION POLICY
• TO CONTRIBUTE TO HEALTH SYSTEMS DEVELOPMENT BY
  STRENGTHENING ROUTINE IMMUNIZATION AND
  SURVEILLANCE FOR COMMUNICABLE DISEASES.

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Strategies

• HIGH INFANT IMMUNIZATION COVERAGE WITH FOUR DOSES
  OF ORAL POLIO VACCINE IN THE FIRST YEAR OF LIFE
• SUPPLEMENTARY DOSES OF ORAL POLIO VACCINE TO ALL
  CHILDREN UNDER FIVE YEARS OF AGE DURING NATIONAL
  IMMUNIZATION DAYS (NIDS)
• SURVEILLANCE FOR WILD POLIOVIRUS THROUGH
  REPORTING AND LABORATORY TESTING OF ALL CASES OF
  ACUTE FLACCID PARALYSIS (AFP) AMONG CHILDREN
  UNDER FIFTEEN YEARS OF AGE
• TARGETED MOP-UP CAMPAIGNS ONCE WILD POLIOVIRUS
  TRANSMISSION IS LIMITED TO A SPECIFIC FOCAL AREA.

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Before a WHO region can be certified polio-free,
three conditions must be satisfied (   A) AT
LEAST THREE YEARS OF ZERO POLIO CASES DUE TO WILD
POLIOVIRUS ( B)  EXCELLENT CERTIFICATION
STANDARD SURVEILLANCE ( C) EACH COUNTRY MUST
ILLUSTRATE THE CAPACITY TO DETECT, REPORT AND
RESPOND TO IMPORTED POLIO CASES. LABORATORY
STOCKS MUST BE CONTAINED AND SAFE MANAGEMENT OF
THE WILD VIRUS IN INACTIVATED POLIO VACCINE (IPV)
MANUFACTURING SITES MUST BE ASSURED BEFORE THE
WORLD CAN BE CERTIFIED POLIO-FREE.
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In THERE ARE FOUR GLOBAL PRIORITIES TO STOP
TRANSMISSION OF THE WILD POLIOVIRUS AND OPTIMIZE
THE BENEFITS OF POLIO ERADICATION 1.     1.
Substantial external financial resources are
required to support the efforts of developing
countries to eradicate polio. These financial
resources must be secured to purchase oral polio
vaccine (OPV), to plan and implement national
immunization days and mop-up campaigns, and to
cover surveillance and laboratory
costs. 2.     2. India is the highest priority
country, because it has the highest number of
cases in the world (83), and for the first time
in the Initiatives history, previously
polio-free areas were reinfected, as the epidemic
in the north Indian state of Uttar Pradesh spread
into such Indian states as Gujarat, Rajasthan and
West Bengal. 3.     3. As the world is nearing
polio-free status, effective surveillance becomes
even more important to quickly identify any
potential outbreaks and manage them effectively.
Achieving certification standard surveillance is
also a requirement for certifying the world
polio-free. 4.     4. In conjunction with
effective surveillance, it is essential that the
capacity is in place to rapidly mount massive
immunization response campaigns to manage any
wild poliovirus importations quickly and
efficiently in polio-free areas
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FUTURE BENEFITS OF POLIO ERADICATION ONCE POLIO
IS ERADICATED, THE WORLD CAN CELEBRATE NOT ONLY
THE ERADICATION OF A DISEASE BUT THE DELIVERY OF
A GLOBAL PUBLIC GOOD SOMETHING FROM WHICH EVERY
PERSON, REGARDLESS OF RACE, SEX, ETHNICITY,
ECONOMIC STATUS OR RELIGIOUS BELIEF, CAN BENEFIT
FOR ALL TIME, NO MATTER WHERE THEY LIVE. THE
HUMANITARIAN BENEFIT IS TREMENDOUS, AS BETWEEN
2002 AND 2040, OVER TEN MILLION NEW CASES OF
POLIO WORLDWIDE WOULD MANIFEST THEMSELVES.
ADDITIONALLY, THE SAVINGS OF POLIO ERADICATION
ARE POTENTIALLY AS HIGH AS US 1.5 BILLION PER
YEAR FUNDS THAT COULD BE USED TO ADDRESS OTHER
PUBLIC HEALTH PRIORITIES.
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VACCINE VIAL MONITOR
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THE MAGNESIUM CHLORIDE STABILISED VACCINE WILL
MAINTAIN ADEQUATE IMMUNOGENICITY FOR 18 MONTHS
WHEN KEPT IN A REFRIGERATOR AT 2C TO 8C, FOR
SIX WEEKS AT 25C AND FOR THREE DAYS AT
37C.AT -20C, ALL FORMULATIONS AND
PRESENTATIONS ARE VERY STABLE AND NO LOSS OF
POTENCY HAS BEEN OBSERVED OVER A PERIOD OF MORE
THAN FIVE YEARS.VACCINES SHOULD BE INSPECTED
VISUALLY FOR ANY PARTICULATE MATTER AND/OR OTHER
COLORATION PRIOR TO ADMINISTRATION.DUE TO MINOR
VARIATION OF ITS PH, POLIO SABIN (ORAL) MAY VARY
IN COLOUR FROM LIGHT YELLOW TO LIGHT RED. CHANGES
OF THE COLOUR OF THE VACCINE WITHIN THESE RANGES
DO NOT SIGNIFY DETERIORATION OF THE VACCINE.THE
VACCINE SHOULD BE STORED IN A REFRIGERATOR
BETWEEN 2C AND 8C OR IN A FREEZER AT -20C.
FREEZING AND THAWING DOES NOT AFFECT THE TITRE OF
THE VACCINE.IN ORDER TO PRESERVE OPTIMAL POTENCY
OF POLIO SABIN (ORAL), EXPOSURE OF THE VACCINE
TO AMBIENT (NON-REFRIGERATED) TEMPERATURES SHOULD
BE KEPT TO A MINIMUM AND EXPOSURE TO SUNLIGHT
SHOULD BE AVOIDED.
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The IEAG also made the following recommendations
regarding supplementary immunisation schedule and
vaccine Use of mOPV1 in Bihar, UP and
neighboring districts of Uttaranchal, Delhi, and
Mumbai/ Thane/Raigad during the May 2005 NID.
Given the high probability of ongoing low level
type 1 poliovirus transmission, and the risk of
further spread of this virus with the onset of
the rainy season in June, mOPV1 be used in a
further round in the full supplementary NID
(SNID) area (Bihar, UP and neighboring districts
of Uttaranchal, Delhi, and Mumbai/Thane/Raigad).
Any areas not covered with mOPV1 in the June SNID
should use mOPV1 in the August SNID. Trivalent
OPV should be used for the SNIDs during the three
remaining SNID rounds in 2005 (August, October
and November), except in areas where wild
poliovirus type 1 persists, in which case mOPV1
should be used in appropriate districts for two
sequential rounds. The geographic extent of the
four SNIDs should be expanded to include any
additional areas or state where a wild poliovirus
is isolated. If wild poliovirus type 1 is
isolated, mOPV1 should be used for at least two
rounds in these areas. Trivalent OPV should be
used for SIAs in 2006-2007 unless wild poliovirus
is isolated, in which case mOPV should be used in
at least two sequential rounds in an appropriate
area.
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Accurate surveillance for polio is essential for
eradication.Surveillance systems for polio have
been developed under the guidance of the global
polio eradication initiative and use a
combination of (1) identification of all
potential cases of acute flaccid paralysis (AFP),
the most obvious manifestation of polio infection
and (2) laboratory evaluation of stools from
these cases to confirm poliovirus as the
cause. Surveillance of cases of acute flaccid
paralysis among children less than 15 years of
age is a key component for a well functioning
polio surveillance system. The surveillance
system works through a network of surveillance
medical officers, the responsibility of them lies
in assisting the health services departments of
all states and maintaining a network of acute
flaccid paralysis reporting sites and rapidly
investigating the cases. AFP is defined as sudden
onset of weakness and floppiness in any part of
the body in a child less than 15 years of age. In
addition, paralysis in a person of any age in
whom polio is suspected is also reported. AFP
surveillance is used to detect cases of suspected
polio to initiate investigation and control
measures. Any case meeting the case definition
should be investigated and stool specimens
collected.
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Case Definition In the
Global Polio Eradication Initiative (PEI), acute
flaccid paralysis is defined as Any case of AFP
in a child aged lt15 years, or any case of
paralytic illness in a person of any age when
polio is suspected. Acute rapid progression of
paralysis from onset to maximum
paralysisFlaccid loss of muscle tone, floppy
as opposed to spastic or rigidParalysis
weakness, loss of voluntary movement Any case
meeting this definition undergoes a thorough
investigation to determine if the paralysis is
caused by polio.
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Components of AFP
Surveillance The objective of AFP surveillance
is to detect the exact geographic locations where
wild polioviruses are circulating in the human
population. All cases of acute flaccid paralysis
in children aged lt15 years are rigorously
investigated by a trained medical officer, with
collection of stool specimens to determine if
poliovirus is the cause of the paralysis.
Analysis of the location of polioviruses isolated
from AFP cases allows programme managers to plan
immunization campaigns (Pulse Polio Immunization)
to prevent continuing circulation of virus in
these areas.
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COMPONENTS OF AFP SURVEILANCE 1.The AFP
surveillance network and case notification 2.Case
and laboratory investigation 3.Outbreak response
and active case search in the community 4.60-day
follow-up, cross-notification and tracking
of cases  5.Data management and case
classification 6.Virologic case classification
scheme 7. Surveillance performance indicators
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Reference www.who.int www.mohfw.nic.in
www.polioeradication.org www.unicef.org/immunizat
ion Super course/ Pittsburgh university(www.pitt.e
du/super1) JIMA DECEMBER 2005 http//www.polionet
.org/vaccine.htm www.npspindia.org