Wolfgang Preiser Handout 22 June 2006

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1 Polio(myelitis) an old disease Public Health Forum: Polio in Namibia Faculty of Health Sciences, Tygerberg Hospital 22 nd June 2006 Poliomyelitis: Viruses, Vaccines, and Eradication Wolfgang Preiser Discipline of Medical Virology University of Stellenbosch / NHLS Tygerberg Departement Gesondheidswetenskappe Faculty of Health Sciences 2 Milestones in polio virology 1909: Landsteiner and Popper transmit disease to nonhuman primates 1949: Enders, Weller and Robbins propagate virus in vitro using cell culture 100 nm The Polioviruses 3 serotypes: 1, 2, and 3 genus Enterovirus, family Picornaviridae (pico Italian = small; containing RNA genome) Ø 25 nm non-enveloped resistant against many detergents and disinfectants stable for weeks at +4ºC and for days at room temperature 3 4 Poliovirus infection Time course of poliovirus infection Virus replicates in gastro-intestinal tract Large quantities shed in stool for several weeks Faeco-oral transmission route: person-to-person (e.g. within households) if hygiene and sanitation poor Incubation period days (to onset of paralysis) Shift in epidemiology: endemic epidemic (21,000 cases of paralytic polio in USA in 1952) vaccine era 5 6 1

2 Hygiene made it worse... Polio vaccine development: Salk (IPV) 1954: Jonas Salk produces first successful poliovirus vaccine formalin-inactivated whole polioviruses 1, 2, and 3 (trivalent) Salk vaccine = inactivated poliovirus vaccine (IPV) 7 8 Polio vaccine development: Sabin (OPV) 1961: live attenuated poliovirus vaccine developed by Albert Sabin licensed cell-culture derived polioviruses 1, 2, and 3 (trivalent) Sabin vaccine = oral poliovirus vaccine (OPV) monovalent OPV also available (mopv) 9 2

3 Polio vaccines: which is best? Oral (live attenuated) polio vaccine (OPV) temperature-sensitive (cold chain required) no injection reproduces in vaccinee induces mucosal immunity in the gut almost 100 percent effective provides contact immunity: ~ 25 % of close contacts will be immunised rare but significant side effect: vaccine-associated paralytic polio (VAPP) Polio vaccines: which is best? Inactivated (injectable) polio vaccine (IPV) more stable requires injection does not reproduce in vaccinee unproblematic in immunocompromised and pregnant individuals does not induce mucosal immunity in the gut booster doses needed does not provide contact immunity no risk of VAPP Vaccination schedule in South Africa Oral polio vaccine (OPV) given routinely to all children at: birth 6 weeks 10 weeks 14 weeks 18 months 5 years of age Polio vaccination works! Polio global annual reported incidence and POL3 coverage, WHO vaccine-preventable diseases: monitoring system global summary Rationale for polio eradication The following conditions make it feasible to eradicate polio: Affects only humans no animal reservoir Effective, safe and inexpensive vaccine available Immunity following either immunisation or natural infection is life-long No long term carrier state Poliovirus does not survive very long in the environment

4 1. high routine infant immunisation coverage; 2. national immunization days (NIDs) targeting all children <5 years; 3. acute flaccid paralysis (AFP) surveillance; and 4. mop-up immunization campaigns to interrupt final chains of transmission high routine infant immunisation coverage: at least three doses of OPV plus a dose at birth in polio-endemic countries The World Health Organisation (WHO) target is >80% of OPV3 South Africa set a target of 90% 2. national immunization days (NIDs) targeting all children <5 years: mass polio immunisation campaigns aim: to rapidly interrupt possible chains of polio transmission immunise all children younger than 5 years, irrespective of their immunisation history with two doses of OPV during two rounds Clinical manifestations 3. acute flaccid paralysis (AFP) surveillance: 23 purpose: to detect possible cases of polio to show that if cases of wild polioviruses were to be imported, they would be detected notification of 1 case of AFP per 100,000 children 15 years per year laboratory investigations of 80 % of AFP cases: 2 stool samples within 2 weeks tested for poliovirus (quality criteria) follow-up after 60 days: residual paralysis? if fulfilled no polio cases occur, and imports would be detected! 24 "typical" paralytic disease ~ 1 % non-specific symptoms ~ 5 10 % asymptomatic ~ % 4

5 4. mop-up immunization campaigns to interrupt final chains of transmission house-to-house vaccination of all children younger than 5 years of age within a high-risk geographic area or population with two doses of OPV regardless of previous immunisation history Progress in South Africa last laboratory-confirmed case of polio in 1989 AFP notifiable since 1994 case-based surveillance instituted in 1995 several national polio immunisation campaigns conducted: 1995, 1996, 1997, and 2000 (Western Cape 2002) currently working on being certified free of wild poliovirus Polio eradication: progress 28 Wild poliovirus, 07 Jun 2005 to 06 Jun 2006 Last cases of polio Americas: Luis Fermin Tenorio Peru 1991 Wild virus type 1 Wild virus type 3 Wild virus type 1 & 3 European Region: Melik Minas Turkey 1998 Endemic countries: Nigeria, India, Pakistan, Afghanistan; as of 01 January 2006, Egypt and Niger were reclassified as non-endemic countries. Case or outbreak following importation (last 6 months) Case or outbreak following importation (6-12 months) Western Pacific Region: Mum Chanty Cambodia

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