Using Acute Flaccid Paralysis Surveillance as a Platform for Vaccine-Preventable Disease Surveillance.

Surveillance for acute flaccid paralysis (AFP) is a fundamental cornerstone of the global polio eradication initiative (GPEI). Active surveillance (with visits to health facilities) is a critical strategy of AFP surveillance systems for highly sensitive and timely detection of cases. Because of the extensive resources devoted to AFP surveillance, multiple opportunities exist for additional diseases to be added using GPEI assets, particularly because there is generally 1 district officer responsible for all disease surveillance. For this reason, integrated surveillance has become a standard practice in many countries, ranging from adding surveillance for measles and rubella to integrated disease surveillance for outbreak-prone diseases (integrated disease surveillance and response). This report outlines the current level of disease surveillance integration in 3 countries (Nepal, India, and Nigeria) and proposes that resources continue for long-term maintenance in resource-poor countries of AFP surveillance as a platform for surveillance of vaccine-preventable diseases and other outbreak-prone diseases.

Perceived consequences of ageing with late effects of polio and strategies for managing daily life: a qualitative study.

BACKGROUND: New or increased impairments may develop several decades after an acute poliomyelitis infection. These new symptoms, commonly referred to as late effects of polio (LEoP), are characterised by muscular weakness and fatigue, generalised fatigue, pain at rest or during activities and cold intolerance. Growing older with LEoP may lead to increased activity limitations and participation restrictions, but there is limited knowledge of how these persons perceive the practical and psychological consequences of ageing with LEoP and what strategies they use in daily life. The aim of this qualitative study was therefore to explore how ageing people with LEoP perceive the their situation and what strategies they use for managing daily life. METHODS: Seven women and seven men (mean age 70 years) were interviewed. They all had a confirmed history of acute poliomyelitis and new impairments after a stable period of at least 15 years. Data were transcribed verbatim and analysed using systematic text condensation. RESULTS: The latent analysis resulted in three categories 'Various consequences of ageing with LEoP', 'Limitations in everyday activities and participation restrictions', and 'Strategies for managing daily life when ageing with LEoP' and 12 subcategories. The new impairments led to decreased physical and mental health. The participants perceived difficulties in performing everyday activities such as managing work, doing chores, partaking in recreational activities and participating in social events, thereby experiencing emotional and psychological distress. They managed to find strategies that mitigated their worries and upheld their self-confidence, for example finding practical solutions, making social comparisons, minimising, and avoidance. CONCLUSION: Ageing with LEoP affected daily life to a great extent. The participants experienced considerable impact of the new and increased impairments on their life situation. Consequently, their ability to participate in various social activities also became restricted. Social comparisons and practical solutions are strategies that facilitate adaptation and acceptance of the new situation due to LEoP. This emphasises the need to design rehabilitation interventions that focus on coping, empowerment and self-management for people ageing with LEoP.

The effects of a home-based arm ergometry exercise programme on physical fitness, fatigue and activity in Polio survivors: a randomised controlled trial.

OBJECTIVE: To investigate the effect of an eight-week home-based arm ergometry aerobic exercise programme on physical fitness, fatigue, activity and quality of life in Polio Survivors. DESIGN: An assessor blinded randomised controlled trial. SETTING: Home-based exercise. SUBJECTS: Fifty-five Polio survivors randomised to exercise or control groups. INTERVENTION: Home-based arm ergometry at an intensity of 50%-70% maximum heart rate, compared with usual physiotherapy care. MAIN MEASURES: The Six-minute Arm Test, Fatigue Severity Scale, Physical Activity Scale for Individuals with Physical Disabilities and SF-36. Assessments were completed at baseline and at eight weeks. RESULTS: There was no significant difference in the primary outcome, exercising heart rate during the Six-minute Arm Test, between the groups at follow-up [97.6 (SD10.1) compared to 102.4 (SD13.7) beats per minute ( P=0.20)]. Blood pressure was significantly lower in the intervention group at follow-up [systolic blood pressure 132(18.6)mmHg compared to 144.1(14.6)mmHg ( P=0.002)]. There were no between group differences in the Fatigue Severity Scale ( P=0.25) or Physical Activity Scale for Individuals with Physical Disabilities ( P=0.49), with a small difference in SF-36 physical component score ( P=0.04). CONCLUSIONS: This home-based arm ergometry programme successfully facilitated aerobic exercise in Polio Survivors, but did not result in a significant change in physical fitness, measured by the Six-minute Arm Test.

Faster Detection of Poliomyelitis Outbreaks to Support Polio Eradication.

As the global eradication of poliomyelitis approaches the final stages, prompt detection of new outbreaks is critical to enable a fast and effective outbreak response. Surveillance relies on reporting of acute flaccid paralysis (AFP) cases and laboratory confirmation through isolation of poliovirus from stool. However, delayed sample collection and testing can delay outbreak detection. We investigated whether weekly testing for clusters of AFP by location and time, using the Kulldorff scan statistic, could provide an early warning for outbreaks in 20 countries. A mixed-effects regression model was used to predict background rates of nonpolio AFP at the district level. In Tajikistan and Congo, testing for AFP clusters would have resulted in an outbreak warning 39 and 11 days, respectively, before official confirmation of large outbreaks. This method has relatively high specificity and could be integrated into the current polio information system to support rapid outbreak response activities.

Nucleotide variation in Sabin type 3 poliovirus from an Albanian infant with agammaglobulinemia and vaccine associated poliomyelitis.

BACKGROUND: Vaccine-associated paralytic poliomyelitis (VAPP) and immunodeficient long-term polio excretors constitute a significant public health burden and are a major concern for the WHO global polio eradication endgame. CASE PRESENTATION: Poliovirus type 3 characterized as Sabin-like was isolated from a 5-month-old Albanian child with X-linked agammaglobulinemia and VAPP after oral polio vaccine administration. Diagnostic workup and treatment were performed in Italy. Poliovirus replicated in the gut for 7 months. The 5' non coding region (NCR), VP1, VP3 capsid proteins and the 3D polymerase genomic regions of sequential isolates were sequenced. Increasing accumulation of nucleotide mutations in the VP1 region was detected over time, reaching 1.0 % of genome variation with respect to the Sabin reference strain, which is the threshold that defines a vaccine-derived poliovirus (VDPV). We identified mutations in the 5'NCR and VP3 regions that are associated with reversion to neurovirulence. Despite this, all isolates were characterized as Sabin-like. Several amino acid mutations were identified in the VP1 region, probably involved in growth adaptation and viral persistence in the human gut. Intertypic recombination with Sabin type 2 polio in the 3D polymerase region, possibly associated with increased virus transmissibility, was found in all isolates. Gamma-globulin replacement therapy led to viral clearance and neurological improvement, preventing the occurrence of persistent immunodeficiency-related VDPV. CONCLUSIONS: This is the first case of VAPP in an immunodeficient child detected in Albania through the Acute Flaccid Paralysis surveillance system and the first investigated case of vaccine associated poliomyelitis in Italy since the introduction of an all-Salk schedule in 2002. We discuss over the biological and clinical implications in the context of the Global Polio Eradication Program and emphasize on the importance of the Acute Flaccid Paralysis surveillance.

Repeater F-waves are signs of motor unit pathology in polio survivors.

INTRODUCTION: The purpose of this study was to determine whether F-waves reveal electrophysiological features of anterior horn cells in polio survivors. METHODS: Forty-three polio survivors and 20 healthy controls underwent motor nerve conduction studies of the median and tibial nerves bilaterally, including sampling of F-waves elicited by 100 stimuli and the determination of motor unit number estimation (MUNE). RESULTS: A significant increase in abnormally stereotyped ("repeater") F-waves and a reduction of F-wave persistence were observed in both nerves in the polio group as compared with the control group. Repeater F-waves had a negative correlation with MUNE. CONCLUSIONS: These trends in F-wave persistence and repeater F-waves after motor unit loss are characteristic findings in polio survivors. Repeater F-waves are a sign of motor unit pathology.

Pulsed Radiofrequency of Dorsal Root Ganglia for the Treatment of Complex Regional Pain Syndrome in an Adolescent with Poliomyelitis Sequel: A Case Report.

OBJECTIVE: Complex regional pain syndrome (CRPS) is a painful and disabling syndrome in which the patient presents with neuropathic pain, edema, or vasomotor or pseudomotor abnormalities that are often refractory to treatment. Polio paralysis is caused by the damage or destruction of motor neurons in the spine, which lead to corresponding muscle paralysis. This report is a case report on the application of a pulsed radiofrequency (PRF) current to dorsal root ganglia (DRG) for the treatment of CRPS type 1 in an adolescent patient. DESIGN: Single case report. SETTING: Selcuk University Hospital. PATIENT: A 16-year-old girl who suffered from CRPS type 1 secondary to surgeries for the sequelae of poliomyelitis. INTERVENTIONS: PRF current application to the lumbar 4 and lumbar 5 DRG. OUTCOME MEASURES: Pain reduction. RESULTS: The patient had complete resolution of her symptoms, which was maintained at a 6-month follow-up. CONCLUSIONS: This case illustrates that PRF applied to lumbar 4 and lumbar 5 DRG may play a significant role in CRPS type 1 management after the surgical treatment of poliomyelitis sequelae in adolescent patients. Further randomized, controlled studies are needed to support this argument.

Measuring gender satisfaction among women aging with paralytic polio.

In this study we tested the Gendered Outcome Scale as a measure of gender satisfaction among 295 women aging with the disabling effects of paralytic polio. Principal components analysis, reliability analyses, and content validity were analyzed on the scale. The scale had a Cronbach's alpha of.90. Younger women had more gender satisfaction (r =.181, p <.01), and women who had greater disability had greater gender satisfaction. (r = -.127, p <.05). The results support that the scale is a valid and reliable measure for determing gender satisfaction. Further work is needed to test the scale in diversified samples.

Poliovirus infection transiently increases COPII vesicle budding.

Poliovirus (PV) requires membranes of the host cell's secretory pathway to generate replication complexes (RCs) for viral RNA synthesis. Recent work identified the intermediate compartment and the Golgi apparatus as the precursors of the replication "organelles" of PV (N. Y. Hsu et al., Cell 141:799-811, 2010). In this study, we examined the effect of PV on COPII vesicles, the secretory cargo carriers that bud from the endoplasmic reticulum and homotypically fuse to form the intermediate compartment that matures into the Golgi apparatus. We found that infection by PV results in a biphasic change in functional COPII vesicle biogenesis in cells, with an early enhancement and subsequent inhibition. Concomitant with the early increase in COPII vesicle formation, we found an increase in the membrane fraction of Sec16A, a key regulator of COPII vesicle formation. We suggest that the early burst in COPII vesicle formation detected benefits PV by increasing the precursor pool required for the formation of its RCs.

Living with polio and postpolio syndrome in the United Kingdom.

The term Postpolio Syndrome (PPS) is used to describe new and late manifestations of poliomyelitis that occur later in life in polio survivors. Polio had been eradicated in the United Kingdom (UK) and most of Europe, although this is not the case in all countries. Research in this area has tended to focus upon the impact of polio and PPS on health status and functional health rather than its overall effect on people's lives. This study's two main aims were to explore the ways in which polio and PPS in the UK has affected the respondents' lives and to ascertain their views about how the quality of life could be improved. The two questions were as follows: (1) How has the health of people with polio and PPS affected their quality of life? (2) What would people with polio and PPS change to improve their quality of life? Deductive content analysis using existing qualitative data from a cross-sectional survey of 336 returned questionnaires from persons with polio and PPS was carried out. The average age of the participants was 54 years. Our research found that polio survivors valued social occupations and participation in family life. Our research has also shown that healthcare professionals still do not understand polio and PPS and this lack of understanding influences their clients' quality of life. Finances and accessibility of environments also influence participation in chosen occupations. Rehabilitation programmes for people with polio and PPS need to be targeted towards maintaining and improving accessible environments and participation in chosen occupations, and healthcare professionals need to ensure that persons with polio and PPS are referred to persons with specific expertise in this area.

Examination of knee joint moments on the function of knee-ankle-foot orthoses during walking.

The goal of this study was to investigate clinically relevant biomechanical conditions relating to the setup and alignment of knee-ankle-foot orthoses and the influence of these conditions on knee extension moments and orthotic stance control during gait. Knee moments were collected using an instrumented gait laboratory and concurrently a load transducer embedded at the knee-ankle-foot orthosis knee joint of four individuals with poliomyelitis. We found that knee extension moments were not typically produced in late stance-phase of gait. Adding a dorsiflexion stop at the orthotic ankle significantly decreased the knee flexion moments in late stance-phase, while slightly flexing the knee in stance-phase had a variable effect. The findings suggest that where users of orthoses have problems initiating swing-phase flexion with stance control orthoses, an ankle dorsiflexion stop may be used to enhance function. Furthermore, the use of stance control knee joints that lock while under flexion may contribute to more inconsistent unlocking of the stance control orthosis during gait.

Limited trafficking of a neurotropic virus through inefficient retrograde axonal transport and the type I interferon response.

Poliovirus is an enteric virus that rarely invades the human central nervous system (CNS). To identify barriers limiting poliovirus spread from the periphery to CNS, we monitored trafficking of 10 marked viruses. After oral inoculation of susceptible mice, poliovirus was present in peripheral neurons, including vagus and sciatic nerves. To model viral trafficking in peripheral neurons, we intramuscularly injected mice with poliovirus, which follows a muscle-sciatic nerve-spinal cord-brain route. Only 20% of the poliovirus population successfully moved from muscle to brain, and three barriers limiting viral trafficking were identified. First, using light-sensitive viruses, we found limited viral replication in peripheral neurons. Second, retrograde axonal transport of poliovirus in peripheral neurons was inefficient; however, the efficiency was increased upon muscle damage, which also increased the transport efficiency of a non-viral neural tracer, wheat germ agglutinin. Third, using susceptible interferon (IFN) alpha/beta receptor knockout mice, we demonstrated that the IFN response limited viral movement from the periphery to the brain. Surprisingly, the retrograde axonal transport barrier was equivalent in strength to the IFN barrier. Illustrating the importance of barriers created by the IFN response and inefficient axonal transport, IFN alpha/beta receptor knockout mice with muscle damage permitted 80% of the viral population to access the brain, and succumbed to disease three times faster than mice with intact barriers. These results suggest that multiple separate barriers limit poliovirus trafficking from peripheral neurons to the CNS, possibly explaining the rare incidence of paralytic poliomyelitis. This study identifies inefficient axonal transport as a substantial barrier to poliovirus trafficking in peripheral neurons, which may limit CNS access for other viruses.

The effects of a home-based arm ergometry exercise programme on physical fitness, fatigue and activity in polio survivors: protocol for a randomised controlled trial.

BACKGROUND: Many Polio survivors have reduced mobility, pain and fatigue, which make access to conventional forms of aerobic exercise difficult. Inactivity leads to increased risk of health problems, many of which are prevalent among Polio survivors. Aerobic exercise programmes in Polio survivors should utilise stable muscle groups and should be designed to minimise exacerbation of pain and fatigue. A home-based arm ergometry aerobic exercise programme may represent an affordable and accessible exercise modality, incorporating exercise prescription principles in this group. METHODS/DESIGN: This is a prospective, single blinded, randomised controlled trial. There are two arms; exercise intervention using arm ergometers and control. Polio survivors meeting eligibility criteria will be recruited and randomly allocated to intervention or control groups. Participants allocated to the intervention group will receive a small arm ergometer and a polar heart rate monitor. They will carry out a home-based moderate intensity (50-70% HRMax) aerobic exercise programme for eight weeks, following instruction by the treating physiotherapist. Assessments will occur at baseline and after eight weeks and will include tests of physical fitness, activity, energy cost of walking, fatigue and quality of life. Clinically feasible assessment tools including the Six Minute Arm Test, the Physical Activity Scale for People with Physical Disabilities questionnaire, the Physiological Cost Index, Fatigue Severity Scale and the SF-36v2 will be utilised. DISCUSSION: The efficacy of a home-based arm ergometry programme in Polio survivors will be examined. No previous trial has examined such a programme using a wide range of outcome measures pertinent to Polio survivors. This study will provide new information on the impact of arm ergometry on physical fitness, activity, body composition, fatigue, pain, muscle strength, and health related quality of life. Also, the study will provide information, which at present is lacking, on safety of aerobic exercise in Polio, as potential negative outcomes of activity including loss of muscle strength, increased pain and fatigue will be closely monitored.

Functional and environmental factors affecting work status in individuals with longstanding poliomyelitis.

INTRODUCTION: Remunerative employment is a major concern of individuals with chronic disabilities, among them, those with longstanding poliomyelitis (LSP). Although LSP is not rare there are almost no data related to work participation. PURPOSE: The aims of the current study were to determine the effects of a number of social and functional variables as barriers or facilitators to work participation in persons with LSP. PATIENTS AND METHODS: Charts of 123 LSP patients of working age that were seen in the post-polio outpatient clinic, between the years 2000 and 2005 were reviewed for the study. Data on age, gender, family status, level of function in activities of daily living, basic, and extended (B-ADL and E-ADL), and mobility were then analyzed for correlation to the vocational status. RESULTS: Seventy-two people (58.5%) were employed at the time of the survey. Gender and marital status were not found to significantly differ as regard to employment. Using assistive devices for mobility or being dependent for basic ADL were associated with lower levels of employment. Driving was positively associated with the employment status of the LSP individuals. CONCLUSION: Persons with LSP encounter important barriers to work participation, particularly on the International Classification of Functioning, Disability, and Health (ICF) components of activity and environment.

Femoral neck bone mineral density in ambulatory men with poliomyelitis.

UNLABELLED: We evaluated bilateral femoral neck bone mineral densities (FNBMDs) in 32 men with poliomyelitis and their matched controls. Men with poliomyelitis had significantly lower FNBMD in both legs, and FNBMD was lowest in their shorter legs. Knee extensor strength and regular exercise were important predictive factors associated with decreased FNBMD. INTRODUCTION: People with poliomyelitis (polio) are prone to leg fractures after mild trauma. The flaccid paralysis, asymmetric involvement, and underdeveloped growth of afflicted legs may lead to osteoporosis of either leg, characterized by different patterns. This study aimed to measure their femoral FNBMD and to explore the factors associated with changes in FNBMD in either leg. METHODS: We did a prospective study to evaluate bilateral FNBMD with dual-energy X-ray absorptiometry in 32 men with polio (age range, 41-57 years; mean, 47 years) and 32 age- and body mass index-matched controls. Measuring the difference in leg length, we classified the legs of each polio subject as "longer" or "shorter." In addition, we chose the right leg of each control as a reference leg. We then used the Mann-Whitney U test to compare FNBMD of these three groups of legs and searched for the factors associated with FNBMD using stepwise multiple regression analyses. RESULTS: Compared to the reference leg, men with polio had significantly lower FNBMD in both their longer and shorter legs, by 13% and 23%, respectively. The difference in FNBMD between the two legs of polio subjects was significant. Knee extensor strength and regular exercise were two important factors associated with bilateral FNBMD in men with polio. CONCLUSIONS: Men with polio had lower bilateral FNBMD. FNBMD of the shorter leg should be the choice for predicting the risk of hip fracture in men with polio because on average, the shorter leg has lower BMD.

Macro electromyography and motor unit number index in the tibialis anterior muscle: differences and similarities in characterizing motor unit properties in prior polio.

Our objective was to establish the usefulness of the noninvasive method of the motor unit number index (MUNIX) in a large muscle and to study how macro electromyography (EMG) and MUNIX complement each other in describing the motor units (MUs) in prior polio. MUNIX and macro EMG were performed in 48 tibialis anterior muscles in 33 prior polio patients. In addition, the reproducibility of MUNIX was investigated. It is shown that MUNIX can be used to characterize MUs with high reproducibility, even in a large muscle. As judged by MUNIX values, the patients had a 25% reduction of motor neurons, whereas the macro EMG indicated a loss of 60% of the neurons. Macro EMG showed more pronounced changes compared with control material than the MUNIX. One of the reasons for this finding may be the difference in MU populations studied with the two methods.

Persistent infection with Theiler's virus leads to CNS autoimmunity via epitope spreading.

Multiple sclerosis (MS) is a T cell-mediated autoimmune demyelinating disease, which may be initiated by a virus infection. Theiler's murine encephalomyelitis virus (TMEV), a natural mouse pathogen, is a picornavirus that induces a chronic, CD4+ T cell-mediated demyelinating disease with a clinical course and histopathology similar to that of chronic progressive MS (ref. 3). Demyelination in TMEV-infected mice is initiated by a mononuclear inflammatory response mediated by virus-specific CD4+ T cells targeting virus, which chronically persists in the CNS (ref. 4-6). We show that beginning 3-4 weeks after disease onset, T-cell responses to multiple myelin autoepitopes arise in an ordered progression and may play a pathologic role in chronic disease. Kinetic and functional studies show that T-cell responses to the immunodominant myelin proteolipid protein epitope (PLP139-151) did not arise because of cross-reactivity between TMEV and self epitopes (that is, molecular mimicry), but because of de novo priming of self-reactive T cells to sequestered autoantigens released secondary to virus-specific T cell-mediated demyelination (that is, epitope spreading). Epitope spreading is an important alternate mechanism to explain the etiology of virus-induced organ-specific autoimmune diseases.

Body composition assessment in Taiwanese individuals with poliomyelitis.

OBJECTIVES: To measure the changes in the total and regional body fat mass, and assess the clinical usefulness of the body mass index (BMI) in detecting overweight subjects with sequelae of poliomyelitis. DESIGN: Prospective, cross-sectional study. SETTING: General community. PARTICIPANTS: Subjects with poliomyelitis (n=17; age range, 42-57y; mean, 47y; 12 men, 5 women) and able-bodied people (n=17) matched by sex, age, body weight, and body height participated in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total and regional body composition was measured with dual-energy x-ray absorptiometry. Clinical characteristics such as blood pressure, serum biochemical studies, and habitual behaviors (daily cigarette smoking, alcohol consumption, and exercise regimen) of all participants were evaluated. RESULTS: Compared with able-bodied controls, subjects with poliomyelitis had a 50% greater total body fat mass, significant increases in the regional fat mass in every part of the body, and had the greatest increase of fat mass in the thorax. Nearly all the subjects (94%) with poliomyelitis were obese according to standards of body composition. However, one third of them had a BMI value of less than 25.0kg/m(2). CONCLUSIONS: People with poliomyelitis have a higher prevalence of obesity and a significant increase in total and regional fat mass. Current BMI underestimates the total body fat mass percentage compared with the control; therefore, a population-specific BMI should be used to address the prevalence of obesity in postpolio survivors.

The meaning of gender while aging with paralytic polio.

The purpose of this article is to report the influence of gender on aging with childhood onset paralytic polio. The hermeneutic phenomenological exploration of gender was done using multiple qualitative interviews with 25 women, age 55 to 75 years of age, who had polio since before 14 years of age. We noted three themes: (a) the movement of her body, (b) integrating body and gender, and (c) gender discrepancies. Findings are discussed in the context of gendered expectations and the women's bodies.