By: Rukhsar Jabbar. M.Sc. Physiotherapy. Freelance Health Writer. Medical review and editorial support provided by the DLHA Team.
Poliomyelitis: Image of some African children on crutches in residual paralytic stage of poliomyelitis.
Click on image to enlarge.
Highlights
Introduction
The African Region reached a remarkable milestone in August 2020 when it was certified to be free of native wild poliovirus (WPV). This incredible accomplishment was the result of years of devoted work, and the region has stayed unwavering in its resolve to eradicate all polio cases, protecting kids from the terrible consequences of paralysis and death. [1]
A coalition of national, local governments, civil society organizations, international health organizations, and community volunteers worked for decades to achieve this amazing accomplishment.
Despite this noteworthy achievement, there are still instances of the circulating vaccine-derived poliovirus (cVDPV), a non-wild version of the poliovirus, occurring in 25 countries throughout the African Region. Moreover, WPV importations were documented in 2022 in Malawi and Mozambique, two nations that had been unaffected by polio for more than thirty years. The transmission of this imported WPV in Southern Africa was recently declared over.
These cases demonstrate that the possibility of importation persists as a hazard until all cases of polio are eliminated worldwide. [2]
This article aims to briefly discuss poliomyelitis, its cause, method of infections, transmission, symptoms, complications and it is treated in the context of the African region.
Polio (poliomyelitis) is a crippling illness caused by the poliovirus. While it generally results in mild or no symptoms for most individuals, it can lead to paralysis or death in about 5% of cases. [3]
This infectious condition is contracted through contact with fluid and food materials that contain infected stool contents (fecal-oral contamination). The virus may then enter the lymph nodes of the body (lymphatic replication) and blood stream with invasion of the central nervous system.
Poor sanitary conditions in poorer nations are the main risk factors of the disease.
When a patient presents with early signs and symptoms of new-onset paralysis, poliomyelitis should be highly suspected by healthcare professionals in the locality and by those tending to patients who are unvaccinated or have recently traveled to polio endemic areas of the world. [4]
Poliovirus, a member of the Picornaviridae family and the Enterovirus C species, causes acute polio and the post-polio syndrome.
Pictorial image of the poliovirus. Credit: CDC
There are three varieties (serotypes) of wild poliovirus (WPV); types 1, 2, and 3. Before vaccines were widely used, wild poliovirus type 1 was the main cause of paralytic polio worldwide. Since 2015, wild poliovirus types 2 and 3 were declared extinct. [4]
Poliomyelitis: Infection pathway and effects. Click on image to enlarge.
Poliovirus primarily spreads through fecal-oral contamination, though oral-oral transmission can also occur.
Following primary infection, the virus reproduces (replicates) in the lymphatic tissues of the back of the mouth (oropharynx) and bowel (gastrointestinal tract).
Maximum passage of the virus in stool (viral excretion) starts two to three days before symptoms appear and lasts for about a week.
Most poliovirus infections (up to 95%) present with flu-like symptoms and are not paralytic. However, about 5% of cases can result in pure motor paralysis. The exact mechanism by which the virus enters the central nervous system is unclear.
When the virus spreads to the central nervous system, it attacks and kills special cells in the spinal cord called anterior horn cells (motorneurons or motorneurons). These cells provide electrical signals to muscles of the body to cause movement. The death of anterior horn motorneurons (motorneurons), leads to complete muscle weakness (paralysis) while leaving skin sensations intact. [4]
The initial symptoms of poliomyelitis are -
A permanent paralysis occurs in one of 200 infections (typically in the legs). 5–10% of paraplegic people (i.e., those with paralysis of both limbs) pass away from immobilized breathing muscles.
The majority of polio cases occur in children under five years old. But the disease can strike an unvaccinated person at any age.
Poliomyelitis presents in stages, as acute, recovery, and residual paralysis.
Symptoms like fever, stiff neck, severe muscle weakness in the limbs, and bladder and bowel dysfunctions (autonomic dysfunction) are indicative of the acute stage.
Paralyzed muscles start to heal during the convalescent or recovery period, when the acute symptoms go away
Up to two years may pass during this phase, with the greatest progress happening in six months. The patient is left with residual paralysis, an imbalance in muscle power, and bad posture in the last stage. Patients in this stage comprise 60% of those with remaining deficits of some kind. [4]
Paralytic polio has no known treatment and no cure.
When polio causes weakness in the arms or legs, physical treatment or occupational therapy can help. Additionally, physical therapy may enhance long-term results, particularly if it is started early in the course of the condition. [5]
In addition to other types of supportive care, patients with polio receive a course of exercise (regimens) that are specially designed to meet their demands and functional condition. The patient's functional level may decline if the exercises cause them undue weariness and pain. Activity reduction, pacing (intervals of rest between activities), cryotherapy, thermotherapy), stretches, use of assistive equipment, and lifestyle changes are all possible physiotherapy treatments for post-polio muscle pain. [6]
The following are some exercise that aids functional recovery in poliomyelitis:
In those whose respiratory muscles are affected, simple breathing exercises or a spirometer can be used to do respiratory muscle training at home. Over the course of 10–14 weeks, the patient completes 20 minutes of training, which consists of 10 repetitions of 1 minute of exercise, 1 minute of rest, and repeats.
Exercises involving joint movement are not advised when the muscles are extremely sore or in spasm. Simple exercises are performed on the hips, ankles, and other joints to maintain their complete range of motion without causing pain. It could be necessary to substitute passive movements for active ones while dealing with paralyzed joints. [6]
To avoid abnormalities, the patient maintains proper posture in bed. In addition to supporting the knee and ankle and keeping the knee straight, detachable supports such as above-knee calipers also aid in preventing hip flexion abnormalities. For patients with a flail spine, spinal supports aid in back support.
Progressive mobilization of the patient requires moving from bed supports to chair supports, sitting supports to standing supports, and walking supports.
To facilitate recovery from tiredness, a supervised progressive resistance training programme with voluntary contractions and rest intervals is provided. In order to reduce the potential risk of overuse, the initial training load is minimal and is progressively raised. [6]
To reach the highest possible degree of cardiovascular fitness without exacerbating chronic fatigue, the right amount of exercise must be prescribed.
Joint and muscle stretches aid in the prevention of contractures. Stretching joints in the opposite direction of the contracture is necessary, and it should be done at least three times a day.
Equinus is the most crucial deformity to address. [6]
Click on image to enlarge.
Vaccination is the most efficient way to prevent polio and there are two vaccination varieties that can shield individuals and populations against polio. [7]
Depending on the patient's age, an injection of the inactivated poliovirus vaccine (IPV) is administered in the arm or leg.
The oral poliovirus vaccine, or OPV, is still in use in most of the world. See Table 1 for the polio vaccination schedule in use in Nigeria for example under the National Programme on Immunisation (NPI). This same schedule or similar is in use in most African countries
Both oral and injectable polio vaccines are used in African countries during population level mass immunisation exercises.
Related: Immunisation schedules - Africa
Children are protected by the polio vaccine because it primes their bodies to fend against the poliovirus. When administered all recommended doses of the inactivated polio vaccine, nearly all children (more than 99%) will be protected.
African children receiving oral polio vaccine. Credit: World Health Organization (WHO)
Proper hand hygiene must be observed in addition to receiving the vaccination as protection. Regularly wash your hands with soap and water. Take note that poliovirus is not killed by alcohol-based hand sanitizers. [5]
Table 1: Summary of the current vaccination schedule for children in Nigeria under the National Programme on Immunisation [11].
The body's immune system must be aroused in order to detect the polio virus when it enters the body and stop it from producing the disease, even if cleanliness and hygiene are important in limiting the spread of poliomyelitis and averting outbreaks. [8]
No vaccination is 100% effective since not everyone who receives a vaccination develops immunity for personal reasons. 85% to 95% of children's routine vaccinations are successful. Nonetheless, an outbreak is less likely to happen if the majority of people are immunized since they outweigh those who are not. [8]
Vaccines are quite safe. The majority of vaccination side effects are modest and transient, such as an arm ache or a low-grade fever. The truth is, illnesses with the polio virus have a greater potential to do long-term harm to children than any vaccination they receive. One of the safest vaccines is the oral polio vaccine, which seldom ever causes minor side effects. [8]
Because of earlier large vaccination campaigns, illness rates are quite low in many countries. Some illnesses are still common because tourists inadvertently bring (i.e., import) illnesses into other nations, and if the population is not protected, the illness can spread fast among them. [8]
The poliovirus is highly contagious and has the ability to reach and attack the central nervous system, causing permanent paralysis. Polio cannot be cured, but it can be prevented by vaccination. Immunity is primarily acquired in countries with low or middle incomes through multiple rounds of scheduled vaccination with the routine oral polio vaccine (OPV) and at least one full dose of the inactivated polio vaccine, which is injected in muscles (intramuscularly) or in the skin (intradermally) in a fractional (one-fifth) dose.[9]
The last several years have seen an acceleration of the remarkable progress made in the eradication of polio. After it is eventually eliminated from the planet, the challenge will be to safely discontinue vaccinations or alter immunization process to prevent the recurrence of poliomyelitis. [10]
Staying informed about polio helps fight misinformation, understand the disease's dangers, and monitor eradication progress, especially in high-risk areas.
Vaccination is the best way to prevent polio, protecting people and communities through herd immunity. Africa being declared free of wild poliovirus in 2020 highlights the need for ongoing vaccination to prevent a comeback and support global eradication.
1. World Health Organization (WHO) Regional Office for Africa. Polio. [Internet. n.d.]. Cited 2024 May 23. Available from here.
2. United Nations Foundation. Leveraging Civil Society Contributions for Polio Efforts in Africa. [Internet. Last updated, 2023 Sept April 13]. Cited 2024 May 23. Available from here.
3. Cleveland Clinic. Polio: Causes, Symptoms & Vaccine Schedule. [Internet. Last updated 2022 Aug. 5]. Cited 2024 May 29. Available from here.
4. Wolbert JG, Rajnik M, Higginbotham K. Poliomyelitis. In: StatPearls [Internet. Last updated 2024 Jan 22]. Treasure Island (FL): StatPearls Publishing. Cited 2024 May 18] Available from here.
5. Centers for Disease Control and Prevention (CDC). Polio. About Polio in the United States. Polio [Internet. 2024 May 9]. Cited 2024 May 18. Available from here.
6. CB Physiotherapy Blog. Poliomyelitis; Treatment and Management of Muscle Weakness by Physiotherapy [Internet. 2022 May 3]. Cited 2024 May 28. Available from here.
7. World Health Organization (WHO). Poliomyelitis [Internet. 2023 Oct. 24]. Cited 2024 May 18]. Available from here.
8. Mustafa I. Misconceptions about Vaccines. UNICEF Sudan. [Internet. 2020 Nov 4]. Cited 27 May 2024. Available from here.
9. Stamidis KV, Bologna L, Bisrat F, Tadesse T, Tessema F, Kang E. Trust, Communication, and Community Networks: How the CORE Group Polio Project Community Volunteers Led the Fight against Polio in Ethiopia’s Most At-Risk Areas. The American Journal of Tropical Medicine and Hygiene. 2019;101(4_Suppl):59-67. doi:10.4269/ajtmh.19-0038. Available from here.
10. Minor P. The polio endgame. Human Vaccines & Immunotherapeutics, 3014. 10(7), i–iii. doi: 10.4161/21645515.2014.981115. Available from here.
11. World Health Organisation (WHO). Vaccination schedule for Poliomyelitis. [Internet, n.d.]. Accessed June 5, 3035. Available from here.
Published: June 6, 2024
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