POLIOMYELITIS

1. بسم الله الرحمن الرحيم POLIOMYELITIS AFP Surveillance GamalEldin Mohamed Osman WHO.POLIO PROGRAMME. SAAN`A, YEMEN

2. The poliovirus … BrunhildeLansingh Leon

3. Poliomyelitis

4. Outcome of Poliovirus Infection Paralytic poliomyelitis (0.1 – 1%) Non-paralytic poliomyelitis (10 %) Abortive poliomyelitis (4 – 5%) Unapparent or sub-clinical infection (90 – 95%)

5. 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

8. Transverse Myelitis

9. Polio virus • Genus:Enterovirus • Family: Picornaviridae • Three major antigenic sites (surface proteins (VP1-3) Three serotypes (1, 2, and 3)

10. 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.

11. 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

12. Viral excretion drops significantly after 14 days, but poliovirus may still be detected up to60 days after onset. Duration of Fecal Excretionof Wild Polioviruses Early Detection Late Detection P O L I O 20

13. 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.

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

15. Age group distribution for poliomyelitis

16. DISTINGUISHINGFEATURES 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

17. 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. .

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

19. 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)

20. Polio situation in Yemen • Last case of WPV in Yemen was in April 2006 from Ibb Governorate, Hubish district.

21. Poliomyelitis in 1988 350 000 cases/ 125countries

22. Wild Poliovirus 2011

23. Wild Poliovirus 2012

24. Polio – EMRO in 2012* *EMRO- Polio- Data as of 08 January 2013

25. 2011 Regional Risk Assessment Map* Risk Interpretation (Score) ( ≤50) (51–74) ( ≥75) Eastern Mediterranean Region *Data through end of Q3 2011

26. AFP and Poliomyelitis EMR 2012

27. Western Pacific Cambodia 1997 ? Europe Tajikistan 2010 Polio: Last Cases Americas Peru 1991 Polio Eradication

28. 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

29. 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 .

30. 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

31. 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

32. 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

33. AFP SURVEILLANCE Message

34. 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.

35. AFP surveillance Hot Cases AFP Cases with symptoms typical of polio Fever at onset, short progression, Asymmetric paralysis, sensation intact… and any of the following: History of travel or contact with persons from polio-endemic countries Belonging to High risk group Under 3 years + Incomplete immunization

36. confirm Wild poliovirus residual weakness, died or lost to follow-up polio-compatible expert review AFP case inadequate specimens discard No wild poliovirus no residual weakness discard two adequate specimens discard Virological AFP Case Classification Scheme (non-polio AFP rate > 2/100.000, >= 80% with adequate specimens):

37. Onset of Paralysis < 7 days of onset Detection & notification < 14 days of onset <28 days of receipt Primary culture results reported to EPI < 3 days of being sent Specimens arrive at National laboratory Case investigation & specimen collection Isolates sent to regional lab  > 60 days of onset < 28 days of receipt Case classification (< 90 days of paralysis onset) Follow up examination results reported to EPI The Process of AFP surveillance

38. Thank you