POLIO MYELITIES

INTRODUCTION
Poliomyelitis is an enteroviral infection that can manifest in 4 different forms:
inapparent infection, abortive disease, nonparalytic poliomyelitis, and paralytic disease.
Before the 19th century, poliomyelitis occurred sporadically. During the 19th and 20th
centuries, epidemic poliomyelitis was more frequently observed, reaching its peak in the
mid 1950s. The worldwide prevalence of this infection has decreased significantly since
then because of aggressive immunization programs. Eradication of this disease during the
present decade is a top priority for the World Health Organization (WHO)
DEFINITION:
It is an acute infectious disease caused by any of the three types of Poliomyelitis
virus which affects chiefly the anterior horn cells of the Spinal cord and the medulla,
cerebellum and midbrain.
It is characterized by two febrile episodes, a minor and major illness separated by
a remission of one or two days followed by varying degrees of muscle weakness or
occasionally a progressive Paralysis that ends fatally.
OTHER NAME OF THE POLIO MYELITIES
Acute Anterior Poliomyelitis; Heine-Medin Disease: Infantile Paralysis.
ETIOLOGY AND EPIDEMIOLOGY:
causative virus is poliovirus (Legio Debilitants)
There are 3 distinct serelogic types of poliovirus (with no cross Immunity)

Type I is the most paralytogenic or the most frequent cause of Paralytic

poliomyelitis, both epidemic and endemic.
Type II the next most frequent.

Type III the least frequently associated with paralytic disease.

Types of Poliomyelitis
1) Spinal

Cervical
Thoracic

Lumbar

2) Bulbar
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Cranial nerves
Circular System

Respiratory System

3) Bulbo-spinal
4) Polioencephalitis
PERIOD OF COMMUNICABILITY:
Most contagious a few days before and after the onset of symptom when the virus is
found in the oropharynx for about a week, and in large quantities in the small bowel, and
continues to be in feces up to about 3 months.
Modes of Transmission:
- virus is harbored in GIT and is transmitted through saliva, vomitus and feces
1) Direct contact from one person to another person through healthy carriers via the
intestinal/oral pathways.
- it has been shown that poliovirus excretors are much more commonly found among
household or family contacts than among noncontact.
2) Indirect contact fecal-oral through food, water, utensils and objects contaminated
by human exreta.
- occasionally, the virus may be implanted through the oropharynx and in very rare
instances by parenteral.
INCUBATION PERIOD:
Usually 7-14 days, with a range of 5-35 days, for paralytic and non-paralytic
forms; 3-5 days for the minor illness.
PATHOGENESIS:

Polio virus reaches the intestinal tract through the mouth, enters the
intestinal mucosa and lodges and multiplies in undetermined sites,
possibly reticuloendothelial system. This is known as the Intestinal Phase.
The organism may then reach the blood (viremic phase) and then proceed
to CSN (neural phase)
In each of these stages the body defences respond and resist the invading
organisms.

The disease may stop in any of this sites, depending on the promptness
and effectiveness of the hosts antibody response at that particular phase.

Thus if the virus is inhibited or is stopped from increasing at the intestinal

phase, adequate immunity develops locally in the intestine as well as
systematically, with hardly any clinical manifestations. This is what
happens in the asymptomatic, silent or subclinical manifestations. This is
also the principle of oral vaccination.

If the virus proceeds unabated, it enters blood stream resulting in systemic

manifestations which, depending on the severity of infection may present
dregs of fever, headache, vomiting, and irritability.

The milder manifestations constitute the Abortive type of the disease and
the more severe manifestations; the Meningitic or preparalytic Type.

Unchecked, the organism proceed via nerve pathways to the CNS and
again depending on the site they invade, manifestations may
correspondingly be Spinal, Bulbospinal or Encephalitic.

CLINICAL MANIFESTATIONS:
4 Clinical forms are described:
1) Inapparent/Subclinical/Asymptomatic/Silent Type
Person who are expose to poliomyelitis ward like the nurses and other
members of the health team. But not all polio victim has small leg or both.
2) Abortive Type/Minor Illness of Poliomyelitis:
Starts with a mild to moderate upper respiratory infection or with symptoms of
mild influenza like slight fever, malaise, headache, sore throat, inflamed pharynx and
vomiting. This is follows by a remission of 1-2 days at which time the child may be
active and playful.
- This case may be unnoticed.
3) Preparalytic or Meningitic Type/Major Illness of Poliomyelitis:
Then the second febrile stage is observe, this time with higher temperature,
headache, vomiting, restlessness, anorexia, lethargy and pain in the neck and back, arms,
legs, and abdomen.
- It cause also muscle spasms and tenderness in the extension or extensora of neck and
back.
- Is usually lasts about a week with meningeal irritation persisting for about 2 weeks.
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4) Paralytic Type
Early manifestations are pain and some degree of stiffness followed by twitching and
diminished deep tendon reflexes.
-

There may be hyperesthesia and irritability.

Loss of tendon reflexes, positive Kernigs Sign and Brudzinskis Sign

In one or two days later, weakening of muscle plus paralysis.

Positive Hoynes Signs- his head will fall back when he is in supine and
his shoulders are elevated. He wont be able to raise his legs at full 90
degrees.

DIAGNOSIS
1) ISOLATION OF THE VIRUS

Blood- by the end of the 1st week, WBC count may be normal or slightly
increased.
Throat- by the end of the 1st week until the 2nd week

Fecal/stool- by the end of the 1st week until the 3rd or throughout the disease and
even up o 3 months.

CSF- is not a path gnomonic but may be help when considered with other
manifestations and the course of the disease.

2) SEROLOGIC DIAGNOSIS
It is of value when there is at least a 4 rise of antibody titer from the acute to the
acute to the convalescent stage, as determined by neutralization or complement fixation
tests.
3) WITH CNS INVOLVEMENT, CSF EXAMINATION:

Pleocytosis with early predominance of polymorph nuclear cells followed by a

shift to mononuclear cells.
Proteins- normal in the early stage of the disease and may be moderate elevated as
disease progresses
Glucose/sugar content is normal.

TREATMENT:
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1.Abortive Type/Minor Illness

Bed rest
Analgesic-to ease headache, back pains and muscle spasm

2. Preparalytic or Meningitic Type/Major Illness

Moist hot packs for 15-30 min every 2-4 hrs over the affected muscles
Anxiety and fear should be allayed

The limb should be in a position of comfort

3. Paralytic Type ( hospitalization required)

Suitable body alignment; feet at the right angle, knees slightly flexed, hips and
spine straight, with the use of board, sand bags, and occasionally light splint shells
Active and passive movements as soon as pain disappears

Avoid fecal impaction

Maintain good body alignment by using boards, sand bags, etc.

Make bed with cotton or woollen blanket both under and over the pt.

Change position frequently

Daily bath if necessary and change wet clothes

4. To avoid spread of microorganism

Secretions should be properly disposed

Avoid contact with person having known cases

Nasal and oral hygiene

PREVENTION:
1. Administration of polio vaccine

Salk Vaccine- solution of killed viruses that given intramuscularly

Sabin Vaccine- which is preparation attenuated living viruses that is administered
orally.

2. Effective Immunization-programs may be achieved carried out community wide to

include all infants over 2 months old, children and young adults with the preschool age
group as priority target.
COMPLICATION
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Respiratory paralysis- which includes the diaphragm and the inter costal muscle
Pneumonia

Myocarditis

Atelectasis

Pulmonary edema

Acute gastric dilatation, melena

Hypertension

8. Renal calculi

9. Late complication- skeletal and soft tissue deformity

PROGNOSIS
-

recovery from the nonparalytic form of poliomyelitis is usually complete.

In paralytic poliomyelitis, the degree of disability that results depends on
the extent of involvement and the management.

Recovery of muscle function usually occurs spontaneously within a few

weeks.

Muscles which are paralyzed in 1 month after the onset of illness recover
completely only in less than 2% of the cases.

Over all mortality for the paralytic form is about 4%

Prognosis is poorer in order children and adults.

Bulbar poliomyelitis is always serious particularly when the medulla and

respiratory muscles are involved.

PREVENTION
Administration of polio vaccine

Salk Vaccine- solution of killed viruses that given intramuscularly.

Sabin Vaccine- which is a preparation attenuated living viruses that is
administered orally:

Examples: Live Attenuated Trivalent Vaccine or Trivalent Oral Polio/Virus

Vaccine (TOPV).

immunity confers long lasting

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A booster dose after a year is recommended in low socioecomomic areas where

the high incidence of other enteroviruses may cause interference of immunity.

NURSING INTERVENTIONS:
1. Isolation of the patient

enteric precautions

2. To relieve pan and promote comfort

Apply moist hot packs to the affected muscle and to relieve muscle shortening.
Maintain good body alignment by using board, sandbags, etc.

Make bed with cotton or woolen blanket both under and over the patient

Change position frequently

Daily bath if necessary and change wet clothes.

3. To avoid spread of microorganisms

Isolation; secretions should be properly disposed

Avoid contact with person having known cases

Nasal and oral hygiene such as mouth and teeth must be clean, nose should be
cleansed for easily passage of air; moisten the mucus membrane with some
prescribed lubricant.

4. When a case of poliomyelitis or endemic occurs in a community, panic and tension

should be minimized
5. Childrens activities should be reduced to avoid physical exertion and fatigue and
chilling should not be overlooked.
6. Sanitation of the premises and proper food handling to avoid contamination by flies
should be overlooked.
7. Unvaccinated children and susceptible may be immunized.
8. Anyone who presents a minor febrile illness should be put to bed.
Medical and Nursing Management
a. medication and treatment

Analgesic- for relieving pain

Antipyretic- to relieve fever
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Surgical management
a. Muscle and tendon transplantation
Operation of Tendons

tenotomy- division of tendon

myotomy- division of muscle

fasciotomy- operation on deep fascia the most useful procedure in the surgical
treatment of poliomyelitis are operations that restore stability to failed joints.

b. Arthrodesis- fusion of bones across a joint space by surgical means, which

eliminates movement, usually performed to eliminate pain over a joint.

c. Osteotomy- cutting of bone into 2 parts followed by realignment of ends to

allow healing

d. Operation to equalized the leg length discrepancy After poliomyelitis, growth

affected leg is slowed down as much 6 to 7 cm by disuse, atrophy and diminished
blood flow to the limb. The degree of shortening depends of the severity of the
paralysis and the age at which paralysis begins.

CONCLUSION
Continue physical therapy on an outpatient basis to help muscle reeducation.
Specific exercise programs for strengthening lower extremities are helpful to avoid
contracture and muscle atrophy. Individuals with bowel and bladder problems need
ongoing follow-up as outpatients.