Oct 5, 2012

Remembering The first outbreak of polio in the United States in 26




Polio Outbreak Occurs Among Amish Families In Minnesota

By David Brown
Washington Post Staff Writer
Friday, October 14, 2005

The first outbreak of polio in the United States in 26 years occurred earlier this fall in an Amish community in central Minnesota, state and federal health officials reported yesterday.
Four children have been infected with the virus, although none has become paralyzed. The Amish typically decline to vaccinate their children. The last large outbreak of polio occurred in numerous Amish communities in several states in 1979.
The outbreak poses little threat to children outside the Amish community. About 98 percent of Minnesota's children are vaccinated against polio, said Harry Hull, the state epidemiologist.
The outbreak was discovered by chance on Sept. 29 after the first child -- a 7-month-old infant with a severe immune deficiency disease -- was tested for another problem in August. Yesterday's announcement reveals the microbe is circulating among healthy children in the isolated community, which has about 200 people in 24 families.
Polio causes paralysis in about one in every 200 infections.
The virus that all four children are carrying is derived from the oral polio vaccine. That vaccine has not been used in the United States since 2000, in part because it causes paralysis in about one of every 13 million doses administered. American children now get an injected vaccine, which also prevents infection.
The oral vaccine, which is still used in most places in the world, is made of a live but severely weakened strain of polio virus. The vaccine virus can be passed person to person, although it rarely becomes part of a prolonged "chain of transmission" because most people in a population are vaccinated and cannot be infected.
Occasionally, however, a vaccine strain circulates for years, passed from one unvaccinated child to another. When that happens, it undergoes genetic mutation that can restore the dangerousness of the "wild" virus.
Jane Seward, a vaccine expert at the federal Centers for Disease Control and Prevention, said genetic fingerprinting of the Minnesota strain shows it is about 2.3 percent different from the vaccine strain. This suggests it has been circulating for a little more than two years.
Where it was circulating, however, is a mystery. Hull said it is likely the virus was imported from a country where the oral vaccine is still in use, but the Amish have little contact with people outside their community. The first infected child had no known exposure to foreigners.
Public health officers are going door to door offering polio vaccine and requesting stool samples of all children. About 35 samples have been collected and 32 tested. Fewer than 20 children have been vaccinated, Hull said.


Polio - The Panic!!!!!
Polio occurred primarily in July, August, and September and hit regardless of geographic region, economic status, or population density. Relatively few people showed any symptoms and even fewer died or experienced paralysis, but the physical effects were dramatic. Communities reacted with dread because no one understood how or why people got it, and because children were the most frequently affected.
The first known polio outbreak in the United States was in Vermont in 1894. The last cases of wild (naturally occurring) polio in the United States was quite recently, in four states, among Amish residents who had refused vaccination.
Polio (also called infantile paralysis) was most often associated with children, but it affected teens and grown-ups as well http://tiny.cc/hBCPa.
 Between 1949 and 1954, 35 percent of those who contracted polio were adults.
"Many inspectors.... stationed themselves at railroad stations, ferries, and boat landings along the Delaware River .... to bar all children under 16 years of age who attempted to cross into Pennsylvania without certificates of health." Los Angeles Times - August 9, 1916
In 1916, New York City experienced the first large epidemic of polio, with over 9,000 cases and 2,343 deaths. The 1916 toll nationwide was 27,000 cases and 6,000 deaths. Epidemics worsened during the century. In 1952, a record 57,628 cases of polio were reported in the United States.

The fear of polio was a fear of something you had no defense against, something that hit without logic or reason. Yesterday, it was the man down the block. Today it could be you or your children.
—Larry Alexander, 1954
During a polio epidemic, individual rights often clashed with the need for public safety. Travel and commerce between affected cities were restricted. Public health officers imposed quarantines on homes where someone was diagnosed with polio. They required the affected person to be isolated in a hospital, often against the will of the parents or family. The same practices and conflicts are seen today where SARS (Severe Acute Respiratory Syndrome) breaks out.
"Unable to obtain a physician, he put the boy into an automobile and drove to the Smith Infirmary, but the child died on the way and the doctors at the hospital would not receive the body.... He drove around Staten Island with the boy's body for hours looking for some one who would receive it."
—New York Times, July 26, 1916



Parents outside of a hospital window trying to make contact with child in isolation ward
Polio produces no, or only minor symptoms in 95% of those infected. In about 5% of cases, a mild form results in flu-like symptoms of fever, stiff neck, nausea and fatigue, or a slight temporary paralysis. About 1% of those with polio symptoms experience a severe form called paralytic polio that has lasting effects. In the worst cases of paralytic polio, 2% to 5% of children and 10% to 20% of adults die. Humans are the only reservoir for the polio virus. The virus does not naturally reproduce in any other species.


Spinal Tap!
Lumbar puncture, or spinal tap, was introduced in 1891 as a way to relieve children with hydrocephalus (pressure on the brain from accumulation of fluid) and quickly began to be used as the primary way to diagnose polio.

"Well, it’s like this. This is the only real way we can tell what breathing you have left.... We find the amount of air you can blow into this counterbalanced floating cylinder with the gauge — that's all."
—Larry Alexander, 1954.
    México a la vanguardia en el Síndrome de Post Polio

Oct 2, 2012

Postpolio Syndrome: Treatment & Medication


Postpolio Syndrome

Author: Flor M Muñiz, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario
Coauthor(s): Gerald J Herbison, MD, Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University
Contributor Information and Disclosures
Updated: May 6, 2009
Introduction

Postpolio Syndrome: Treatment & Medication

Author: Flor M Muñiz, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario
Coauthor(s): Gerald J Herbison, MD, Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University
Contributor Information and Disclosures
Updated: May 6, 2009
Background
Accepted criteria for diagnosis of postpolio syndrome (PPS) are a prior history of poliomyelitis, a stable period after recovery, a residual deficit of the initial polio, new muscle weakness, and sometimes, new muscle atrophy. Fatigue and muscle pain need not be present to meet the criteria for the syndrome.

Pathophysiology

One possible cause of postpolio syndrome (PPS) is decompensation of a chronic denervation and reinnervation process to the extent that the remaining healthy motor neurons can no longer maintain new sprouts; thus, denervation exceeds reinnervation.1
A second possible mechanism for PPS is motor neuronal loss due to reactivation of a persistent latent virus. In addition to muscle atrophy and denervation, foci of perivascular and interstitial inflammatory cells have been found on 50% of biopsies of patients with PPS. Activated T cells and immunoglobulin M and immunoglobulin G antibodies specific for gangliosides also have been found.
Another possibility is an infection of the polio survivor's motor neurons by an enterovirus that is different from the one responsible for the patient's polio. Others sources hypothesize that PPS is merely the loss of strength due to the usual stresses of aging and weight gain. In patients with PPS, these processes occur in muscles that already are weak, so the consequences are more noticeable compared with those of patients who have not had polio.2
 Frequency

United States

The incidence of postpolio syndrome (PPS) in previous acute polio patients ranges from approximately 22-68%. PPS is estimated to occur in 28.5% of persons who had paralytic polio. The current prevalence is approximately 1.6 million cases. Suggestions have been made that 100% of polio survivors, if tracked for a long period, can develop some symptoms of PPS.

Age

The onset of postpolio syndrome is approximately 30 years after the acute polio.

Clinical

History

Symptoms of postpolio syndrome (PPS) usually appear earlier in patients who have very severe residual weakness, individuals who had early bulbar respiratory difficulty in the acute illness, and persons who were older when they contracted acute polio. PPS symptoms tend to occur first in the weaker muscles.
  • Fatigue - In individuals without polio or PPS, the functional consequences of aging and loss of motor units may be unnoticeable until a very advanced age. In the individual with PPS, any further loss of strength may be more readily apparent. In contrast to patients with chronic fatigue syndrome, postpolio fatigue is prominent in the early hours of the afternoon and decreases after brief periods of rest. PPS-related fatigue usually does not prevent patients from working.
    • Central
      • Pathogenesis can include chronic pain, type A personality, depression,dysfunctional reticular-activated system, sleep disorders, and respiratory dysfunction.
      • PPS produces somnolence and difficulty in concentrating and remembering.
    • Peripheral
      • Pathogenesis may be metabolic exhaustion of the enlarged motor units, neuromuscular junction transmission defects, scarring within the motor neurons, or loss of motor units due to aging.
      • PPS produces decreased muscular endurance and increased muscular fatigability.
  • Weakness
    • A number of functional etiologies for weakness have been hypothesized, including disuse, overuse, and chronic weakness, as well as weight gain.
    • Asymmetrical and scattered weakness may be present.
    • Some authors have found evidence that previously unaffected muscles later become weak; in these cases, they discovered that the patient was unaware or had not been told that the particular muscle had been affected during the acute episode.
  • Muscle pain1,3
    • Deep aching pain may be a component of a myofascial pain syndrome or fibromyalgia.
    • This feature is extremely prevalent in PPS. Using a retrospective, cross-sectional survey, Stoelb et al investigated the frequency and most common sites of pain in patients with postpolio syndrome.4Pain symptoms were reported by 57 (90.5%) of the 63 study participants; pain was reported most often in the shoulders, legs, hips, and lower back, with the most intense pain occurring in the legs, knees, wrists, head, and lower back.
  • Gait disturbance - Difficulty with gait is caused by progressive weakness, pain, osteoarthritis, or joint instability; it is common in patients who previously used assistive devices but later discarded them.
  • Respiratory problems
    • Respiratory disorders are most prevalent in patients with residual respiratory muscle weakness.
    • These changes cause chronic microatelectasis, diminished pulmonary compliance, increased chest wall tightness, chronic alveolar hypoventilation, decreased cough and expiratory flow, and decreased clearing of secretions.
    • The new respiratory difficulties are not only related to new respiratory muscle weakness but also to scoliosis, pulmonary emphysema, cardiovascular insufficiency, or poor posture.
    • A central component also may occur because acute bulbar polio often affects the medullary structures, including the reticular formation and sleep regulatory system.
  • Swallowing problems
    • These difficulties can occur in patients with bulbar and nonbulbar postpolio.
    • Subclinical asymmetrical weakness in the pharyngeal constrictor muscles is almost always present in all postpolio muscular atrophy patients, including those who do not complain of new swallowing difficulties.
  • Autonomic dysfunction - The cause is unclear; the peripheral component could include muscular atrophy and, therefore, diminished heat production.
  • Sleep apnea
    • This disorder is not uncommon in patients left with residual bulbar dysfunction or severe respiratory compromise.
  • Sleep apnea appears to be due to a combination of the following:
    • Central apnea, due to a residual dysfunction of the surviving bulbar reticular neurons
    • Obstructive apnea, due to pharyngeal weakness and increased musculoskeletal deformities from scoliosis or emphysema
    • Postpolio muscular atrophy, resulting in diminished muscle strength of the respiratory, intercostal, and abdominal muscle groups
  • Flat-back syndrome
    • Another possible symptom in some patients with PPS is the flat-back syndrome, which consists of the inability to stand erect because of forward flexion of the trunk and pain in the low back and legs.
    • The flat-back syndrome typically occurs in patients with diminished lumbar lordosis as a result of instrumentation of the spine for scoliosis, vertebral fracture, or degenerative joint disease.
    • The trunk extensor musculature plays an essential role in maintaining upright posture, and it may be that PPS-related weakness in this musculature represents a major contributing factor to the flat-back syndrome in these patients.
 Physical
In persons with postpolio syndrome, progressive weakness and atrophy may be observed in muscles that were affected initially by the poliovirus or in muscles that were spared clinically, which tends to happen in an asymmetrical distribution. Fasciculations sometimes can be observed in atrophic muscles, as a result of the lower motor neuron injury.
Medicine. Net. com
Post-Polio Syndrome
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What is post-polio syndrome?

Post-polio syndrome (PPS) is a condition that affects polio survivors years after recovery from an initial acute attack of the poliomyelitisvirus. Post-polio syndrome is mainly characterized by new weakening in muscles that were previously affected by the polio infection and in muscles that seemingly were unaffected.

What are the symptoms of post-polio syndrome?

Symptoms include slowly progressive muscle weakness, unaccustomed fatigue(both generalized and muscular), and, at times, muscle atrophy. Pain from joint degeneration and increasing skeletal deformities such as scoliosis are common. Some patients experience only minor symptoms. While less common, others may develop visible muscle atrophy, or wasting.
Post-polio syndrome is rarely life-threatening. However, untreated respiratory muscle weakness can result in underventilation, and weakness in swallowing muscles can result in aspiration pneumonia.
The severity of residual weakness and disability after acute poliomyelitis tends to predict the development of post-polio syndrome. Patients who had minimal symptoms from the original illness will most likely experience only mild post-polio syndrome symptoms. People originally hit hard by the poliovirus and who attained a greater recovery may develop a more severe case of post-polio syndrome with a greater loss of muscle function and more severe fatigue. It should be noted that many polio survivors were too young to remember the severity of their original illness and that accurate memory fades over time.
According to estimates by the National Center for Health Statistics, more than 440,000 polio survivors in the United States may be at risk for post-polio syndrome. Researchers are unable to establish a firm prevalence rate, but they estimate that the condition affects 25 percent to 50 percent of these survivors, or possibly as many as 60 percent, depending on how the disorder is defined and which study is quoted.
Patients diagnosed with post-polio syndrome sometimes are concerned that they are having polio again and are contagious to others. Studies have shown that this does not happen.
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México a la vanguardia en el Síndrome de Post Polio

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