11/30/2013

Syrian Polio Outbreak could spread to Europe



Syrian displaced children line up to receive vaccination against polio at one of the Syrian refugee camps in the southern port city of Sidon, Lebanon,...
Mohammad Zaatari / AP
Displaced Syrian children line up to receive vaccination against polio at one of the Syrian refugee camps in the southern port city of Sidon, Lebanon, this week, following an outbreak of the crippling and highly communicable disease in neighboring Syria.
An outbreak of polio in eastern Syria that has paralyzed at least 10 children could spread to neighboring regions, including Europe — and in such a silent way that no one would know it for a year.
That’s a warning from two infectious disease experts in Germany, who say that large numbers of Syrian refugees now fleeing that conflict-torn country could settle in Europe, bringing the virus to places that have been polio-free for decades.
And it’s a worry echoed by U.S. polio experts, who say that countries around the world — including America — must be vigilant for signs of spread.
“The big issue is to assure that we have good surveillance to pick up polio as quickly as possible,” said. Dr. Walt Orenstein of Emory University, who has been working on eradicating polio for years. “As long as it circulates anywhere, it’s a risk everywhere.”
Because polio causes symptoms — including paralysis — in only about 1 of every 200 people infected, it has the potential to spread widely to others unnoticed, Dr. Martin Eichner of the University of Tubingen and Dr. Stefan Brockmann of the Reutlingen Regional Public Health Office in Germany wrote Thursday in a letter to the journal The Lancet.
“It might take … nearly 1 year of silent transmission before one acute flaccid paralysis case is identified and an outbreak is detected, although hundreds of individuals would carry the infection,” the experts wrote.
The situation will be exacerbated because most European countries, like the U.S., use inactivated polio vaccine, or IPV, rather than oral polio vaccine, or OPV, because the live-virus oral variety caused rare cases of paralysis in people who were vaccinated. While the IPV reduces transmission and protects well against paralysis, it only partially protects against infection, the experts warned.
In places with low vaccination coverage — including Bosnia, Herzegovina, Ukraine and Austria — there might not be enough widespread protection, known as “herd immunity," to prevent sustained transmission, they said.
“Vaccinating only Syrian refugees — as has been recommended by the European Center for Disease Prevention and Control — must be judged as insufficient,” they wrote.
Only a handful of European member states allow use of OPV and none has a stockpile of the live vaccine, the authors note. The U.S. has used only IPV since 2000, after eradicating polio in America in 1979.
Polio is caused by a virus that spreads between people, but it can survive in water and sewage, too. The series of vaccines can protect people for life, but babies too young to have been vaccinated and children who don’t get the full dose can be infected.
The outbreak in Syria has paralyzed at least 10 children in the country’s Del al-Zour province. They’re all younger than 2 and may have gone unvaccinated because of the ongoing conflict that has now left half the population — an estimated 9 million people — homeless and starving.
It’s unclear how polio got back into Syria, which had eradicated the virus in 1999, though officials say this bout may have originated in Pakistan. Polio immunization rates fell from 91 percent in Syria in 2010 to 68 percent in 2012, largely because of the impact of conflict, the World Health Organization says.

Video: International health care workers are providing thousands of vaccinations to prevent polio from spreading any further among Syrians, many of whom are living in squalid refugee camps. And polio isn’t the only threat -- poor sanitation in the camps provides ripe conditions for the spread of other diseases. NBC’s Dr. Nancy Snyderman reports.
Vaccination efforts are focusing on more than 2 million children in Syria, as well as in seven neighboring countries: Iraq, Turkey, Lebanon, Jordan, Israel, the Palestinian territories and Egypt.
“Without a doubt, it can go wider, go beyond Syria’s borders,” said Sarah Crowe, spokeswoman for UNICEF. “Disease knows no borders.”
Hundreds of thousands of refugees have fled the country to seek help in neighboring regions – and Europe. The German disease experts are calling for increased surveillance of sewage in settlements.
“I would agree with them, it is important to develop more use of environmental surveillance,” said Orenstein, the U.S. expert who spearheaded a global declaration by more than 400 scientists that an end to polio is possible.
In the U.S., imported cases of measles have sparked recent outbreaks of the disease, particularly in pockets of un-vaccinated children, raising the very real possibility that other infections could spread as well. 
"Measles is your canary in the coal mine," Orenstein said. "It's much more contagious than polio. With polio, we have been fortunate, so far."
JoNel Aleccia is a senior health reporter with NBC News. Reach her on Twitter at @JoNel_Aleccia orsend her an email.
Post Polio Litaff, Association A.C _APPLAC Mexico

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

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A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here