Polio

Definition

Poliomyelitis, also called polio or infantile paralysis, is a highly infectious viral disease that may attack the central nervous system and is characterized by symptoms that range from a mild nonparalytic infection to total paralysis in a matter of hours.

Description

There are three known types of polioviruses (called 1, 2, and 3), each causing a different strain of the disease and all being members of the viral family of enteroviruses (viruses that infect the gastrointestinal tract). Type 1 is the cause of epidemics, and many cases of paralysis, which is the most severe manifestation of the infection. The virus is usually a harmless parasite of human beings. Some statistics quote one in 200 infections as leading to paralysis, while others state that one in 1,000 cases reach the central nervous system (CNS). When it does reach the CNS, inflammation and destruction of the spinal cord motor cells (anterior horn cells) occurs, which prevents them from sending out impulses to muscles. This causes the muscles to become limp or soft, and they cannot contract, a condition called flaccid paralysis and is the type found in polio. The extent of the paralysis depends on where the virus strikes and the number of cells that it destroys. Usually, some of the limb muscles are paralyzed; the abdominal muscles or muscles of the back may be paralyzed, affecting posture. The neck muscles may become too weak for the head to be lifted. Paralysis of the face muscles may cause the mouth to twist or the eyelids to droop. Life may be threatened if paralysis of the throat or of the breathing muscles occurs.

Humans are the only natural host for polioviruses, and it most commonly infects younger children, although older children and adults can be infected. Crowded living conditions and poor hygiene encourage the spread of poliovirus. Risk factors for this paralytic illness include older age, pregnancy, abnormalities of the immune system, and a recent episode of excessively strenuous exercise concurrent with the onset of the CNS phase. As of 2004, the last naturally occurring polio case in the United States was diagnosed in 1979.

Causes and symptoms

Poliovirus can be spread by direct exposure to an infected individual, and more rarely, by eating foods contaminated with waste products from the intestines (feces) and/or droplets of moisture (saliva) from an infected person. Thus, the major route of transmission is fecal-oral, which occurs primarily with poor sanitary conditions. The virus is believed to enter the body through the mouth with primary multiplication occurring in the lymphoid tissues in the throat, where it can persist for about one week. During this time, it is absorbed into the blood and lymphatics from the gastrointestinal tract where it can reside and multiply, sometimes for as long as 17 weeks. Once absorbed, it is widely distributed throughout the body until it ultimately reaches the CNS (the brain and spinal cord). The infection is passed on to others when poor hand washing allows the virus to remain on the hands after eating or using the bathroom. Transmission remains possible while the virus is being excreted and it can be transmitted for as long as the virus remains in the throat or feces. The incubation period ranges from three to 21 days, but cases are most infectious from seven to ten days before and after the onset of symptoms.

There are two basic patterns to the virus: the minor illness (abortive type) and the major illness (which may be paralytic or nonparalytic). The minor illness accounts for 80 to 90 percent of clinical infections and is found mostly in young children. It is mild and does not involve the CNS. Symptoms include a slight fever , fatigue, headache , sore throat , and vomiting , which generally develop three to five days after exposure. Recovery from the minor illness occurs within 24 to 72 hours. Symptoms of the major illness usually appear without a previous minor illness and generally affect older children and adults.

About 10 percent of people infected with poliovirus develop severe headache and pain and stiffness of the neck and back. This is due to an inflammation of the meninges (tissues which cover the spinal cord and brain). This syndrome is called aseptic meningitis . The term aseptic is used to differentiate this type of meningitis from those caused by bacteria. The patient usually recovers completely from this illness within several days.

About 1 percent of people infected with poliovirus develop the most severe form. Some of these patients may have two to three symptom-free days between the minor illness and the major illness, but the symptoms often appear without any previous minor illness. Symptoms again include headache and back and neck pain. The major symptoms, however, are due to invasion of the motor nerves, which are responsible for movement of the muscles. This viral invasion causes inflammation and then destruction of these nerves. The muscles, therefore, no longer receive any messages from the brain or spinal cord. The muscles become weak, floppy, and then totally paralyzed. All muscle tone is lost in the affected limb and the muscle becomes soft (flaccid). Within a few days, the muscle begins to decrease in size (atrophy). The affected muscles may be on both sides of the body (symmetric paralysis) but are often on unbalanced parts of the body (asymmetric paralysis). Sensation or the ability to feel is not affected in these paralyzed limbs.

When poliovirus invades the brainstem (the stalk of brain which connects the two cerebral hemispheres with the spinal cord, called bulbar polio), a person may begin to have trouble breathing and swallowing. If the brainstem is severely affected, the brain's control of such vital functions as heart rate and blood pressure may be disturbed, a condition that can lead to death.

The maximum state of paralysis is usually reached within just a few days. The remaining, unaffected nerves then begin the process of attempting to grow branches, which can compensate for the destroyed nerves. Fortunately, the nerve cells are not always completely destroyed. By the end of a month, the nerve impulses start to return to the apparently paralyzed muscle and by the end of six months, recovery is almost complete. If the nerve cells are completely destroyed; however, paralysis is permanent.

Diagnosis

Fever and asymmetric flaccid paralysis without sensory loss in a child or young adult almost always indicate poliomyelitis. Using a long, thin needle inserted into the lower back to withdraw spinal fluid (lumbar puncture) will reveal increased white blood cells and no bacteria (aseptic meningitis). Nonparalytic poliomyelitis cannot be distinguished clinically from aseptic meningitis due to other agents. Virus isolated from a throat swab and/or feces or blood tests demonstrating the rise in a specific antibody is required to confirm the diagnosis.

Treatment

There is no specific treatment for polio except symptomatic. Therapy is designed to make the patient more comfortable (pain medications and hot packs to soothe the muscles), and intervention if the muscles responsible for breathing fail (for instance, a ventilator to take over the work of breathing). During active infection, rest on a firm bed is indicated. Physical therapy is the most important part of management of paralytic polio during recovery.

Prognosis

When poliovirus causes only the minor illness or simple aseptic meningitis, the patient can be expected to recover completely. Among patients with the major illness, about 50 percent recover completely. About 25 percent of such patients have slight disability, and about 25 percent have permanent and serious disability. Approximately 1 percent of all patients with major illness die. The greatest return of muscle function occurs in the first six months, but improvements may continue for two years.

Post-polio syndrome (PPS) is a condition that can strike polio survivors anywhere from 10 to 40 years after their recovery from polio. It is caused by the death of individual nerve terminals in the motor units that remain after the initial polio attack. Symptoms include fatigue, slowly progressive muscle weakness, muscle and joint pain, and muscular atrophy. The severity of PPS depends upon how seriously the survivors were affected by the first polio attack.

Prevention

There are two types of polio immunizations available in the United States, but since the year 2000, one is rarely used. A vaccine takes advantage of the fact that infection with polio leads to an immune reaction, which will give the person permanent, lifelong immunity from reinfection with the form of poliovirus for which the person was vaccinated.

The Salk vaccine (also called the killed polio vaccine or inactivated polio vaccine, IPV) consists of a series of three shots that are given just under the skin to children at the ages of two months, four months, and any time between six and 18 months. A fourth injection is given between the ages of four to six years as a booster. This immunization contains no live virus, just the components of the virus that provoke the recipient's immune system to react as if the recipient were actually infected with the poliovirus. The recipient thus becomes immune to infection with the poliovirus.

Since the year 2000, the Sabin vaccine (also called the oral polio vaccine or OPV) has been discontinued in the United States, although it is still being used in other countries. It contains the live, but weakened, poliovirus and because OPV uses the live virus, it has the potential to cause infection in individuals with weak immune defenses (both in the person who receives the vaccine and in close contacts). Approximately nine cases a year of vaccine related polio was associated with OPV in the United States. Although this is a rare complication, occurring in only one in 6.8 million doses administered and one in every 6.4 million doses from having close contact with someone who received the vaccine, the risk of having polio from OPV was greater than it was of naturally acquiring it.

Following the launching of the Global Polio Eradication Initiative, the number of cases fell 99 percent from an estimated 350,000 cases to less than 3,500 cases worldwide in 2000. At the end of 2000, the number of polio-infected countries was approximately 20, down from 125. The goal of the World Health Organization (WHO) is to have polio eliminated from the planet by the year 2005. The virus has still been identified in Africa and parts of Asia, so travelers to those areas may want to check with their physicians concerning booster vaccinations.

Resources

BOOKS

Oshinsky, David. Polio: An American Story. Oxford, UK: Oxford University Press, 2004.

PERIODICALS

Alexander, L. N., et al. "Vaccine Policy Changes and Epidemiology of Poliomyelitis in the United States" Journal of the American Medical Association 292 (2004): 1696–1701.

ORGANIZATION

International Polio Network. 4207 Lindell Blvd., Suite 110, St. Louis, MO 63108–2915. Web site: http://www.postpolio.org.

March of Dimes Birth Defects Foundation. National Office, 1275 Mamaroneck Avenue, White Plains, NY 10605. Web site: http://www.modimes.org/.

WEB SITES

World Health Organization. Global Polio Eradication Progress 2004. Available online at http://www.polioeradication.org/.

Linda K. Bennington, MSN,CNS