para>Extremely rare; primary vaccination not recommended (except if a patient is traveling to endemic areas) ‚
Pediatric Considerations
Most common in children, between 3 months and 16 years of age. Infection extremely rare in the United States since the introduction of routine vaccination (1).
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Pregnancy Considerations
A risk factor for developing polio (incidence and severity of polio are increased in pregnant women)
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EPIDEMIOLOGY
Incidence
- Eliminated in the United States. Incidence worldwide has dropped more than 99% with global polio eradication efforts since 1988.
- Small outbreaks after importation in areas where polio elimination has occurred; rarely as vaccine-associated paralytic polio (VAPP), and in outbreaks occasionally caused by circulating vaccine-derived poliovirus where OPV used.
Prevalence
- In 2015, two countries remain polio-endemic: Afghanistan and Pakistan; Nigeria, the last endemic African country, became polio-free in 2014.
- Worldwide: 359 cases of paralytic polio were reported in 2014. Previous worldwide reports were 416 in 2013, down from 1,595 cases in 2009 (2,3).
- In March 2014, India was certified polio-free after 3 years of intensive surveillance following the last reported case.
- No wild-virus cases of polio in the United States. In 2014, cases of polio-like illnesses were reported in California. Patients presented with acute paralysis and anterior horn abnormalities. No polio virus was isolated, and the specific etiology remains unknown.
ETIOLOGY AND PATHOPHYSIOLOGY
- Poliovirus is spread by fecal " “oral contact and initially infects the GI tract. Viral replication takes place within the GI epithelium, tonsillar, intestinal, and mesenteric lymph nodes. Hematogenous spread to CNS is rare, and results in paralytic polio due to destruction of neuronal tissue.
- Pharyngeal spread is less common, but it is the prevalent mode of transmission in areas of good hygiene.
- Person-to-person spread is most common, followed by contaminated water and sewage.
- Three serotypes of poliovirus (genus Enterovirus):
- Type 1 most frequently associated with epidemics
- Types 2 and 3, sometimes associated with VAPP
RISK FACTORS
- Poor sanitation, hygiene, and public health infrastructure
- Poverty
- Unimmunized status, especially if <5 years of age
GENERAL PREVENTION
- Vaccination using inactivated poliovirus vaccine (IPV) in industrialized countries
- Vaccination using oral polio vaccine (OPV) in endemic or at-risk countries
- No causal link between the polio vaccine and Guillain-Barre syndrome
- In developing countries, treat water sources to prevent spread.
COMMONLY ASSOCIATED CONDITIONS
- IM injections or trauma during the prodrome of paralytic polio are thought to precipitate paralysis.
- Tonsillectomy is a risk factor for bulbar paralysis.
DIAGNOSIS
HISTORY
- If the affected person is from a nonendemic country, then travel history is important (4).
- Most patients are asymptomatic.
- ~10% will show symptoms of a minor GI illness:
- Fever, headache, malaise, nausea and vomiting
- A minority of these patients progress to a major illness, which includes asymmetric flaccid paralysis of the extremities (usually lower).
- Aseptic meningitis occurs in a minority of patients with major illness.
PHYSICAL EXAM
- Fever
- Significant motor loss (flaccid paralysis)
- Meningeal signs may be present in the minor illness or early phases of paralytic polio.
- Decreased deep tendon reflexes
- Muscle atrophy in affected areas
DIFFERENTIAL DIAGNOSIS
- For acute flaccid paralysis and paralytic polio:
- Guillain-Barre syndrome
- Transverse myelitis
- Acute motor axonal neuropathy (China paralytic syndrome)
- Traumatic neuritis
- Myasthenia gravis
- Polymyositis
- Periodic paralysis
- Trichinosis
- Aseptic, bacterial, and tuberculous meningitis/encephalitis
- Toxic encephalopathies
- Tick paralysis
- For nonparalytic acute polio infection:
- Enteroviruses, echoviruses, and coxsackieviruses
DIAGNOSTIC TESTS & INTERPRETATION
- Viral culture from stool, pharynx, or CSF is diagnostic.
- CSF and pharynx virus isolation (early in disease) and/or feces (early and late in disease)
- Increased CSF protein
- Lymphocytosis, especially of CSF
- Normal CSF glucose
- Serology
- Virus culture from stool or pharynx
- MRI may help evaluate the anterior horn of the spinal cord or other neurologic findings.
- An antibody response (if negative) helps rule out (rather than rule in) polio, because immunization also provokes such a response (5).
Diagnostic Procedures/Other
Electromyogram (EMG) can help assess the progress of paralysis and of PPS. ‚
Test Interpretation
Spinal cord: perivascular cuffing, abnormal motor nuclei, chromatolysis of motor neurons, intermediate and posterior column inflammation ‚
TREATMENT
There is no curative treatment. Primary therapy is supportive. The European Federation of Neurological Societies guidelines on PPS emphasize muscular training, targeted physical therapy, and assistive devices. ‚
GENERAL MEASURES
- Mechanical ventilation, if required for bulbar polio
- Rehabilitation to preserve or improve functional status of paralyzed limbs
- Report all suspected polio cases immediately to public health authorities.
- Any case of polio is considered an international public health concern.
MEDICATION
- Do not use aspirin in children (Reye syndrome risk).
- Antibiotics, only if concurrent infection develops
- Parasympathomimetic pharmacotherapy for urinary retention may be required (e.g., bethanechol, starting at 10 mg 3 times daily).
- Evidence is insufficient to support or refute the use of intravenous immunoglobulin (IVIG) in the routine treatment of PPS (6)[B]. Small studies on lamotrigine and modafinil suggest some benefit, but no conclusive evidence is available to recommend routine use (6)[C].
- Amantadine and pyridostigmine did not reduce fatigue in randomized trials (7)[B],(8).
ISSUES FOR REFERRAL
- Multidisciplinary team involvement for cases of major polio including infectious disease, neurology, respiratory, occupational and physical therapy, behavioral health, and public health authorities (9).
- After discharge, referral to physical therapy (PT), neurology, and/or physical medicine for ongoing rehabilitation
ADDITIONAL THERAPIES
- Early PT in acute flaccid paralytic polio may help a child to regain function and develop adaptations.
- With flaccid paralysis (acute or postpolio), extended PT may be required.
SURGERY/OTHER PROCEDURES
- Tracheostomy for respiratory (bulbar) paralysis
- Surgery may be required in patients with muscle contractures or to relieve severe deformity resulting from muscle atrophy and paralysis.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- New-onset neurologic symptoms, such as stiff neck, seizures, and paralysis
- Once diagnosed, patients with paralytic polio may need admission to observe for bulbar paralysis.
- Dehydration
- Inpatient admission for acute phase if concern for respiratory/bulbar paralysis exists; outpatient or rehabilitation facility for therapy
Nursing
- Mobilize to prevent stasis ulcers and to help regain function. Pain control in case of contractures
- Provide a bed that has a firm mattress, footboard, foam-rubber pads, or sandbags. Change the patient 's positions frequently. Ensure good skin care.
- Manage fecal impaction and urinary retention; catheterization may be necessary.
Discharge Criteria
- The minor form of the illness is typically self-limited.
- In cases of the major form of the illness, develop a comprehensive multidisciplinary plan for long-term follow-up involving physical/occupational therapy, respiratory therapy, behavioral health, and relevant subspecialty consultants.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- PT is essential for patients with paralytic polio.
- Counseling for the patient, caregivers, and family is useful in managing lifetime sequelae.
- Bed rest is often necessary during the active phase, PT and nonfatiguing exercises may help preserve function.
DIET
Determined by patient 's ability to swallow; may require tube feedings if paralyzed ‚
PATIENT EDUCATION
- For patient education materials, contact: International Polio Network: 4502 Maryland Avenue, St. Louis, MO 63108, 314-361-0475
- Educational presentation on polio from the CDC: www.cdc.gov/vaccines/pubs/pinkbook/downloads/Slides/Polio10.ppt
- PPS patient materials via Post-Polio Health International: www.post-polio.org/
- The Global Polio Eradication Initiative, coordinated by the WHO: www.polioeradication.org
- Brain Resources and Information Network (BRAIN), National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, Bethesda, MD: www.ninds.nih.gov
PROGNOSIS
- Often irreversible paralysis; <5% mortality during acute phase of disease
- Increased mortality in patients age >40 years
- Poor recovery for totally paralyzed muscle groups; good recovery for partially paralyzed muscle groups
- Variable recovery for PPS ; facilitated by sound PT
COMPLICATIONS
- UTI
- Skin ulcers
- Traumatic injuries to affected limb(s)
- Atelectasis; pneumonia
- Myocarditis
- Postpoliomyelitis progressive muscular atrophy: progressive weakness ≥30 years after an attack of poliomyelitis. Adult survivors of childhood polio may suffer late complications.
- Postpoliomyelitis motor neuron disease: occurs years after acute poliomyelitis; less common than postpoliomyelitis progressive muscular atrophy
- VAPP is a rare complication of the oral poliovirus vaccine.
- Vaccine derived polio viruses (VDPV) can circulate and cause outbreaks, or remain a chronic infection in those with primary immunosuppression.
REFERENCES
11 American Academy of Pediatrics Committee on Infectious Diseases. Poliovirus. Pediatrics. 2011;128(4):805 " “808.22 Centers for Disease Control and Prevention. Polio. www.cdc.gov/polio/.33 Global Polio Eradication Initiative: www.polioeradication.org/. Accessed 2014.44 Hird ‚ TR, Grassly ‚ NC. Systematic review of mucosal immunity induced by oral and inactivated poliovirus vaccines against virus shedding following oral poliovirus challenge. PLoS Pathog. 2012;8(4):e1002599.55 Mayer ‚ CA, Neilson ‚ AA. Poliomyelitis " ”prevention in travellers. Aust Fam Physician. 2010;39(3):122 " “125.66 Koopman ‚ FS, Uegaki ‚ K, Gilhus ‚ NE, et al. Treatment for postpolio syndrome. Cochrane Database Syst Rev. 2011;(2):CD007818.77 Stein ‚ DP, Dambrosia ‚ JM, Dalakas ‚ MC. A double-blind, placebo-controlled trial of amantadine for the treatment of fatigue in patients with the post-polio syndrome. Ann N Y Acad Sci. 1995;753:296 " “302.88 Horemans ‚ HL, Nollet ‚ F, Beelen ‚ A, et al. Pyridostigmine in postpolio syndrome: no decline in fatigue and limited functional improvement. J Neurol Neurosurg Psychiatry. 2003;74(12):1655 " “1661.99 Gonzalez ‚ H, Olsson ‚ T, Borg ‚ K, et al. Management of postpolio syndrome. Lancet Neurol. 2010;9(6):634 " “642.
CODES
ICD10
- A80.9 Acute poliomyelitis, unspecified
- A80.4 Acute nonparalytic poliomyelitis
- A80.30 Acute paralytic poliomyelitis, unspecified
- A80.39 Other acute paralytic poliomyelitis
- A80.2 Acute paralytic poliomyelitis, wild virus, indigenous
- A80.1 Acute paralytic poliomyelitis, wild virus, imported
- A80.0 Acute paralytic poliomyelitis, vaccine-associated
- G14 Postpolio syndrome
ICD9
- 045.90 Acute poliomyelitis, unspecified, poliovirus, unspecified type
- 045.20 Acute nonparalytic poliomyelitis, poliovirus, unspecified type
- 045.10 Acute poliomyelitis with other paralysis, poliovirus, unspecified type
- 045.00 Acute paralytic poliomyelitis specified as bulbar, poliovirus, unspecified type
- 138 Late effects of acute poliomyelitis
- 045.93 Acute poliomyelitis, unspecified, poliovirus type III
- 045.92 Acute poliomyelitis, unspecified, poliovirus type II
- 045.91 Acute poliomyelitis, unspecified, poliovirus type I
- 045.23 Acute nonparalytic poliomyelitis, poliovirus type III
- 045.22 Acute nonparalytic poliomyelitis, poliovirus type II
- 045.21 Acute nonparalytic poliomyelitis, poliovirus type I
- 045.12 Acute poliomyelitis with other paralysis, poliovirus type II
- 045.11 Acute poliomyelitis with other paralysis, poliovirus type I
- 045.13 Acute poliomyelitis with other paralysis, poliovirus type III
SNOMED
- Acute poliomyelitis (disorder)
- Acute nonparalytic poliomyelitis
- Acute paralytic poliomyelitis
- anterior acute poliomyelitis (disorder)
- post poliomyelitis syndrome (disorder)
CLINICAL PEARLS
- About 95% of wild-virus polio cases are asymptomatic, and <1% will develop paralysis. Wild-type polio eradicated in the United States.
- VAPP occurred with 1 of 2.9 million doses of OPV, but has been eliminated from the United States since the implementation of the IPV-only vaccine in 2000.
- Report all cases of polio to public health authorities immediately.