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.H&FW(NIHFW,NEW DELHI)

Sr.D.M.O (ON STUDY LEAVE)

INDIAN RAILWAY MEDICAL SERVICE

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.

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.

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.

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.

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.

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.

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

Group:

Group IV ((+)ssRNA)

Family:

Picornaviridae

Genus:

Enterovirus

Species:

Poliovirus

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

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.

"Poliomyelitis" comes from the Greek word for gray,

polio, and myelo, meaning spinal cord. The Latin suffix
itis refers to inflammatory diseases.

Among children who are paralyzed by polio:

30% make a full recovery
30% are left with mild paralysis
30% have medium to severe paralysis
10% die

Global Status 1988

GLOBAL STATUS 2004

GLOBAL POLIO VIRUS CASES

1988
April 1, 2003,
1998
1999
2000
2001
2002
2003
2004
20.12.2005 -

3,50 000
1,925 polio cases
1,934
1,186
265
211
1919
784
1,556
1831

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 (reestablished transmission) 1 Eritrea (importation) 1 Cameroun
(importation)
Source: Polio cases from 1 January 2005, as of 17 January 2006

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.

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.

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.

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)

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.

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.

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.

The Global Polio

Eradication Initiative

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.

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.

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 POLIOFREE.

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

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.

VACCINE VIAL MONITOR

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.

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.

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.

Case Definition:
In the Global Polio Eradication Initiative (PEI), acute
flaccid paralysis is defined as:
Any case of AFP in a child aged <15 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 paralysis
Flaccid: loss of muscle tone, floppy as opposed to
spastic or rigid
Paralysis: weakness, loss of voluntary movement
Any case meeting this definition undergoes a thorough
investigation to determine if the paralysis is caused by
polio.

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 <15 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.

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

The most important aspect of this classification is

the collection of 2 adequate stool samples from all
cases. Samples are considered adequate if both the
specimens (1) are collected within 14 days of
paralysis onset and at least 24 hours apart; (2) are
of adequate volume (8-10g) and (3) arrives at a
WHO-accredited laboratory in good condition (ie,
no desiccation, no leakage), with adequate
documentation and evidence of cold-chain
maintenance.

THE GLOBAL POLIO LABORATORY NETWORK IS A 3-TIER

PYRAMIDAL NETWORK OF
A TOTAL OF 145 LABORATORIES CLASSIFIED AS NATIONAL,
REGIONAL REFERENCE AND GLOBAL SPECIALISED
LABORATORIES.
THE INDIAN NETWORK IS COMPRISED OF A TOTAL OF EIGHT
LABORATORIES WITH ONE GSL AND SEVEN NPL.
THESE ARE STRATEGICALLY LOCATED IN DIFFERENT PARTS OF
THE COUNTRY FOR QUICK, EASY ACCESS BY THE
SURVEILLANCE SYSTEM.
A SPECIFIC GEOGRAPHICAL AREA IS SERVED BY EACH
LABORATORY. ALL LABORATORIES IN THE GLOBAL POLIO
NETWORK FOLLOW STRICT BIO-SAFETY LEVEL 2 FACILITIES.
AND ALSO USE (A) IDENTICAL TESTING PROCEDURES AND HIGH
QUALITY EQUIPMENT AND REAGENTS, (B) HAVE INSTITUTED
QUALITY ASSURANCE PROGRAMMES AND (C) UNDERGO
ANNUAL PROFICIENCY TESTING AND ON-SITE EVALUATION BY
WHO FOR ACCREDITATION.

Reference:
www.who.int
www.mohfw.nic.in
www.polioeradication.org
www.unicef.org/immunization
Super course/ Pittsburgh university(
www.pitt.edu/~super1)
JIMA DECEMBER 2005
http://www.polionet.org/vaccine.htm
www.npspindia.org