Dec 21, 2019

Polio Outbreaks Confirmed in 14 African Countries



December 15th, 2019 – The US Centers for Disease Control and Prevention (CDC) increased the polio outbreak Travel Alert for 14 African countries.
The CDC said in a new Level 2 Travel Alert published on December 11, 2019, that ‘there are confirmed polio outbreaks in various countries primarily located in central and eastern Africa.’
Additionally, the Global Polio Eradication Initiative (GPEI) reported ‘polio-endemic countries, which have never stopped the transmission of indigenous wild poliovirus, can also be affected by outbreaks of circulating vaccine-derived poliovirus.’
This ‘Practice Enhanced Precaution’ Travel Alert is an important reminder to all travelers visiting the African countries listed below, to ensure they have previously completed the full polio vaccination series.
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The CDC and the World Health Organization (WHO) both recommend visitors to infected areas for more than 4 weeks should receive an additional dose of oral polio vaccine (OPV) or inactivated polio vaccine (IPV) within 4 weeks to 12 months of travel.
And, adults should discuss with a healthcare provider if it’s appropriate to receive a single booster dose of the polio vaccine.
The CDC and the GPEI have reported the following outbreak information for these 14 African countries:  
  • Angola - There are 71 cVDPV2 cases from seven outbreaks reported in 2019.
  • Benin - There are six cVDPV2 cases in 2019 linked to the Jigawa outbreak in Nigeria.
  • Cameroon - Affected by circulating vaccine-derived poliovirus type 2 (cVDPV2).
  • Central African Republic - There are 16 reported cases in 2019 from six different outbreaks of cVDPV2 in 2019.
  • Chad - There is one cVDPV2 case in the country linked to the Jigawa outbreak in Nigeria.
  • Democratic Republic of the Congo - There are 53 cVDPV2 cases in 2019 and 20 in 2018.
  • Ethiopia - Five cVDPV2 cases reported in Ethiopia in 2019, four of them are linked to the outbreak in neighboring Somalia and the fifth case is part of a newly reported Ethiopian outbreak this week.
  • Ghana - Nine cVDPV2 cases in 2019 linked to the Jigawa outbreak in Nigeria.
  • Mozambique - Circulation of cVDPV2 has been confirmed in Mozambique.
  • Niger - There are nine cVDPV2 cases in 2019 linked to the Jigawa outbreak in Nigeria.
  •  Nigeria - There are 18 cVDPV2 cases reported in 2019. There were 34 cVDPV2 cases in 2018.
  • Somalia - A total of 15 cVDPV cases (eight type 2, six type 3 and one co-infection of both type 2 and type 3) since the beginning of the outbreaks.  
  • Togo - There are three cVDPV2 cases in 2019 in the country linked to Jigawa outbreak in Nigeria.
  • Zambia - There is one cVDPV2 case from the first outbreak in the country.
According to the CDC, the United States has been polio-free since 1979, and the IPV has been the only polio vaccine offered in the USA since 2000. 
IPV is given by a shot in the leg or arm, at 4 different times, depending on the patient’s age. IPV vaccination has not been known to cause serious problems, but side effects are a potential risk, says the CDC.
In the USA, there are various IPV vaccines available, such as Kinrix and Pediarix.
Once vaccinated, your doctor should provide you with an International Certificate of Vaccination or Prophylaxis yellow card. This will serve as your official documentation of polio vaccination.
Polio is a crippling and potentially deadly disease that affects the nervous system. Because the virus lives in the feces of an infected person, people infected with the disease can spread it to others when they do not wash their hands well after defecating. 
People can also be infected with polio if they drink water or eat food contaminated with infected feces.
In rare cases, polio can be fatal if the muscles used for breathing are paralyzed or if there is an infection of the brain, says the CDC.
Recently, there was some good news regarding the elimination of 2 out of 3 polio types.
An independent commission of experts concluded during October 2019, that wild poliovirus type 3 (WPV3) has been ‘eradicated’ around the world. This announcement follows the earlier eradication of wild poliovirus type 2 during 2015.
Additionally, global leaders affirm their commitment to eradicate polio and pledge $2.6 billion on November 19, 2019, as part of the 1st phase of the funding needed to implement the Global Polio Eradication Initiative’s Polio Endgame Strategy 2019-2023.
Prior to traveling abroad, medication and vaccine counseling appointments can be scheduled with a travel specialist at Vax-Before-Travel.
Polio vaccine news published by Vax-Before-Travel.

Post Polio Litaff, Association A.C _APPLAC Mexico

Eradicating polio includes preparing for its possible return




If poliovirus were detected in your country, what actions would be taken to prevent its spread? Who would inform the public and coordinate a campaign to vaccinate vulnerable children? How many vaccine doses would be needed? How would they be procured and stored?
These questions and many more were part of polio outbreak simulation exercises (POSEs) conducted in the past month in Albania and Ukraine to review the countries’ national polio outbreak response plans and identify any gaps in preparedness.
Dr Oleksandr Zaika, Manager of Ukraine’s National Immunization Programme, explained: “This is an important and timely exercise. Critical review of the plan by experts from the Ministry of Health, the Public Health Centre, academia, and other institutions from national and oblast levels with facilitation by WHO/Europe is crucial in ensuring the preparedness of the country to a potential polio outbreak.”

The WHO European Region is polio free – why simulate an outbreak?

In October 2019, wild poliovirus type 3 was declared eradicated. This global milestone signified that, of the three wild strains, only poliovirus type 1 continues to spread anywhere in the world. However, the number of cases caused by this remaining wild strain in Afghanistan and Pakistan has increased sharply in the past year – from 33 in 2018 to 117 in 2019, as of 11 December.
A second concern is the increased detection of circulating vaccine-derived poliovirus (cVDPV) globally, with 216 human cases detected in 16 countries as of 11 December this year (up from 104 cases in 7 countries in 2018). This global trend underlines the urgency of ensuring that countries in all parts of the world are alert and ready to respond if needed.
The Global Polio Eradication Initiative’s standard operating procedures for responding to a poliovirus event or outbreak call for all countries to plan for the eventuality of a poliovirus importation or local detection. They also encourage countries to develop a preparedness plan and test it in a polio outbreak simulation exercise to ensure that public health personnel and emergency systems are prepared to react quickly and effectively if any poliovirus isolate is detected.

Lessons learned in Ukraine

The need for quick action to prevent the re-establishment of polio in Ukraine, and thereby the European Region as a whole, was demonstrated with the detection of 2 cases of cVDPV in Ukraine in 2015. The lessons learned in responding to that outbreak, which was stopped within 6 months with no further cases detected, were a main focus of the POSE conducted in Kyiv on 9–11 December 2019.
Many of the participants responsible for disease surveillance, immunization, outbreak response, vaccine regulation, communication or laboratory services were part of the response in 2015–2016 and could share valuable insights with their colleagues while reviewing the current preparedness plan.
Based on a proposed (fictitious) polio outbreak scenario, participants identified the plan’s strengths and gaps and tested its alignment with international standards. The outcome is a compilation of proposed revisions as well as a timeline and action points for their incorporation into the updated national document.

Actual earthquake during simulated outbreak in Albania

A desktop POSE was also conducted in Tirana, Albania, on 26–27 November 2019 to draft a national polio outbreak response plan and improve understanding of the critical actions needed to respond to a polio-related event or outbreak.
Participants included national policy-makers and senior technical staff from the Ministry of Health and Institute of Public Health. Their dedication to ensuring that the country is fully prepared for a polio outbreak was profoundly demonstrated during the 2-day event, as they continued with the exercise while simultaneously responding to a 6.4-magnitude earthquake that shook the country in the early morning of 26 November.

Post Polio Litaff, Association A.C _APPLAC Mexico

Dec 16, 2019

Respiratory and Sleep problems in Post-Polio



Post-polio syndrome  [13][14]

Importance


  • Respiratory problems in PPS are an important cause of symptoms and complications, including sleep disorders.
  • They may be under-diagnosed or inadequately assessed.
  • Treatment can improve both quality of life and prognosis.

Aetiology[14]

Respiratory problems in PPS may be due

to one or more of:
  • Respiratory muscle weakness.
  • Bulbar impairment - this may affect control of the upper airway or the respiratory cycle. If the upper airway is affected, there may be obstructive sleep apnoea.
  • Skeletal deformity - scoliosis or chest wall stiffness.
  • Other pathology - eg, chronic obstructive pulmonary disease (COPD), asthma, obesity.
  • Aspiration - if swallowing is affected.
All these are likely to worsen during sleep. The pattern of respiratory impairment may be hypoventilation, obstructive sleep apnoea, or both.

Symptoms

Respiratory failure can develop insidiously - symptoms may be subtle or unnoticed. Breathlessness may not be a symptom in patients with limited mobility. Possible symptoms are:
  • Sleep disruption, eventually leading to insomnia, daytime sleepiness or fatigue.
  • Morning headaches, irritability, poor concentration, anxiety or depression.
  • Abnormal sleep movements, nocturnal confusion, vivid dreams.
  • Breathlessness which may be positional.
  • Weak cough, and chest infections.

Signs

These may be subtle - possible signs are:
  • Unexplained tachypnoea.
  • Use of accessory muscles.
  • Abdominal paradox - this is inward movement of the abdomen on inspiration while the upper chest expands.
    • May be best seen with the patient supine during a sniff manoeuvre. When upright, it can be missed, as the diaphragm passively descends at the beginning of inspiration.
  • Severe, untreated nocturnal hypoxaemia can cause pulmonary hypertension, giving signs such as raised JVP and ankle oedema.

Assessment of respiratory problems

  • Listen to the patient's story and preferences.
  • Assess:
    • Voice and cough.
    • Chest deformity.
    • Observe patients in realistic situations - eg, doing repeated tests or actions, and doing everyday actions in which they may be using the necessary breathing muscles to achieve another task.
  • Investigations:
    • Peak flow and cough peak flow.
    • Spirometry:
      • Both seated AND supine spirometry are needed.
      • A sensitive indicator of respiratory muscle weakness is reduction in maximal inspiratory pressure.
    • Oximetry (and possibly capnography).
    • Sleep study (polysomnogram).
    • ECG and CXR if appropriate.
    Full sets of lung function tests and arterial blood gases may not be helpful in this scenario, unless intrinsic lung disease is suspected.

Management of respiratory problems

There are various options - choice will depend on the patient's individual situation and preferences.
Night-time mechanical ventilation is often used. This helps by resting the respiratory muscles at night, and preventing deterioration of respiratory function during sleep. It also treats the secondary sleep disorder.

Supportive measures include:
  • Not smoking.
  • Avoiding sedatives and alcohol.
  • Optimal weight and nutrition.
  • Pneumococcal and influenza vaccination.
  • Postural support if needed.
  • Prompt treatment of chest infections.
  • Techniques such as assisted cough or glossopharyngeal breathing ('frog breathing').
  • Chest expansion exercises.
Assisted breathing options are:
  • Non-invasive ventilation (NIV), also called non-invasive intermittent positive pressure ventilation (NIPPV), is often useful - see box below.
  • Rocking bed:
    • This helps breathing by rocking a patient consecutively head up and head down. It is surprisingly effective, especially where muscle weakness is mainly diaphragmatic.
  • Pneumobelt:
    • This gives intermittent abdominal pressure ventilation and is useful for daytime assistance.
  • Negative pressure ventilation:
    • Examples are tank ventilators (iron lung), jacket ventilators (Tunnicliffe), and cuirass ventilators. The devices are cumbersome, and mainly used where NIV is not tolerated, or to provide 'respite' from NIV
  • Tracheostomy ventilation.

Non-invasive ventilation and 'bi-levels' explained[13][14]

NIV increases alveolar ventilation. It is provided by a portable ventilator and a tightly-fitting nasal or facial mask or nasal 'pillow'.
  • NB: NIV is NOT the same as continuous positive airway pressure (CPAP). CPAP is useful for obstructive sleep apnoea because it maintains the upper airway. It is not normally indicated for hypoventilation from respiratory muscle weakness.
People with neuromuscular disease may have difficulty breathing in, so require NIV with higher inspiratory than expiratory pressures. This can be provided using a 'bi-level' ventilator:
  • Bi-level ventilators were developed by modifying CPAP. The inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) settings are adjusted separately.
  • The difference between IPAP and EPAP is called the span.
  • For example, a patient may require an IPAP of 14 and an EPAP of 3.
  • Sensitive flow triggers enable normal breathing to be supported. There may be a back-up control to provide ventilation if respiratory effort fails to trigger a breath.
The symptoms of post-polio syndrome are slowly progressive, with periods of stability lasting 3-10 years.
Prevention of acute polio infection is discussed elsewhere (see separate article onPoliomyelitis).

Prevention of PPS is not much discussed in the literature. Given the various known contributing factors, it seems possible that PPS problems might be reduced by:
  • Careful management of exercise and daily living activities to optimise muscle and joint use, and prevent overuse or disuse.
  • Correct maintenance of aids and prostheses.
  • Monitoring and early treatment of associated/contributing problems such as:

Further reading & references

  1. Trojan DA, Cashman NR; Post-poliomyelitis syndrome. Muscle Nerve. 2005 Jan;31(1):6-19. [abstract]
  2. EFNS guideline on diagnosis and management of post-polio syndrome; Report of an EFNS task force, European Federation of Neurological Societies (2006)
  3. Halstead LS, Silver JK; Nonparalytic polio and postpolio syndrome. Am J Phys Med Rehabil. 2000 Jan-Feb;79(1):13-8. [abstract]
  4. Howard RS; Poliomyelitis and the postpolio syndrome. BMJ. 2005 Jun 4;330(7503):1314-8.
  5. Khan F; Rehabilitation for postpolio sequelae. Aust Fam Physician. 2004 Aug;33(8):621-4. [abstract]
  6. Boone H; Problems experienced by polio survivors and suggested solutions. Presentation for occupational therapists, given at the Neurological Occupation Therapy Conference, October 2008.
  7. My Polio Life; A patient questionnaire providing baseline information and comparison charts, for use by polio survivors and their health professionals, Polio Survivors Network, 2007
  8. Boone H; When test results do not match important symptoms. Conference presentation, Post Polio Association of South Florida, Miami, 2007.
  9. Hildegunn L, Jones K, Grenstad T, et al; Perceived disability, fatigue, pain and measured isometric muscle strength in patients with post-polio symptoms. Physiother Res Int. 2007 Mar;12(1):39-49. [abstract]
  10. Davidson AC, Auyeung V, Luff R, et al; Prolonged benefit in post-polio syndrome from comprehensive rehabilitation: a pilot study. Disabil Rehabil. 2009;31(4):309-17. [abstract]
  11. Polio Outreach of Washington
  12. Lambert DA, Giannouli E, Schmidt BJ; Postpolio syndrome and anesthesia. Anesthesiology. 2005 Sep;103(3):638-44. [abstract]
  13. Howard RS, Davidson C; Long term ventilation in neurogenic respiratory failure. J Neurol Neurosurg Psychiatry. 2003 Sep;74 Suppl 3:iii24-30.
  14. Lincolnshire Post-Polio Information Newsletter. Volume 5, issue 9, June 2006. Issue covering respiratory problems.
Original Author: Dr Colin TidyCurrent Version: Dr Colin TidyPeer Reviewer: Dr John Cox

Post Polio Litaff, Association A.C _APPLAC Mexico

Nigerians living in poverty rise to nearly 61%


El petróleo se produce en el sureste y algunos grupos militantes allí quieren mantener una mayor parte de la riqueza que proviene de sus pies. Los ataques de militantes contra instalaciones petroleras provocaron una fuerte caída en la producción de Nigeria durante la última década. Pero en 2010, una amnistía del gobierno llevó a miles de combatientes a dejar sus armas.
Los nigerianos que viven en la pobreza aumentan La pobreza ha aumentado en Nigeria, con casi 100 millones de personas viviendo con menos de $ 1 (£ 0.63) por día, a pesar del crecimiento económico, según las estadísticas.

La Oficina Nacional de Estadísticas dijo que el 60.9% de los nigerianos en 2010 vivían en "pobreza absoluta"; esta cifra había aumentado del 54.7% en 2004.
La oficina predijo que esta tendencia al alza probablemente continuaría.
Nigeria es el mayor productor de petróleo de África, pero el sector ha sido contaminado por acusaciones de corrupción.

Según el informe, la pobreza absoluta se mide por el número de personas que solo pueden permitirse los elementos esenciales básicos de vivienda, comida y ropa.
División norte-sur
La NBS, una agencia gubernamental, dijo que había una paradoja en el corazón de Nigeria, ya que la economía iba cada vez más fuerte, principalmente debido a la producción de petróleo, pero los nigerianos se estaban empobreciendo.
"A pesar de que la economía nigeriana está creciendo, la proporción de nigerianos que viven en la pobreza aumenta cada año, aunque disminuyó entre 1985 y 1992, y entre 1996 y 2004", dijo el jefe de la oficina de la NBS, Yemi Kale.
La población de Nigeria en pobreza

1980: 17,1 millones
1985: 34,7 millones
1992: 39,2 millones
1996: 67,1 millones
2004: 68,7 millones
2010: 112,47 millones

Fuente: Oficina Nacional de Estadística de Nigeria.
El petróleo representa alrededor del 80% de los ingresos estatales de Nigeria, pero apenas tiene capacidad para refinar el petróleo crudo en combustible, que debe importarse.
El mes pasado, hubo una huelga nacional cuando el gobierno intentó eliminar el subsidio al combustible, enojando a muchos nigerianos que lo ven como el único beneficio que recibieron de la vasta riqueza petrolera del país.
La NBS dijo que la pobreza relativa era más evidente en el norte del país, con la tasa de pobreza del estado de Sokoto la más alta con 86.4%.
En el noroeste y el noreste del país, las tasas de pobreza se registraron en 77.7% y 76.3% respectivamente, en comparación con el suroeste en 59.1%.
El analista de la BBC África Richard Hamilton dice que tal vez no sea sorprendente que grupos extremistas, como Boko Haram, sigan teniendo un atractivo en las partes del norte del país, donde la pobreza y el subdesarrollo son más severos.
El informe también reveló que los nigerianos se consideran cada vez más pobres.
En 2010, el 93.9% de los encuestados se sintieron pobres en comparación con el 75.5% seis años antes.
Kale dice que publicar tales estadísticas de vez en cuando es crucial para una planificación gubernamental efectiva.
"Este tipo de datos les ayuda a saber lo que realmente está sucediendo para que puedan seguir sus políticas y programas", dijo al programa Focus on Africa de la BBC.
"Les da la oportunidad de ver lo que están haciendo ... y si hay áreas que necesitan cambiar, facilita la modificación de las estrategias", agregó.
Nigeria: una nación dividida


A pesar de sus vastos recursos, Nigeria se encuentra entre los países más desiguales del mundo, según la ONU. La pobreza en el norte está en marcado contraste con los estados del sur más desarrollados. Mientras se encuentran en el sureste rico en petróleo, los residentes de Delta y Akwa Ibom se quejan de que toda la riqueza que generan fluye por el oleoducto hacia Abuja y Lagos.



Los 160 millones de personas de Nigeria están divididos entre numerosos grupos etnolingüísticos y también en líneas religiosas. En general, los hausa-fulani del norte son en su mayoría musulmanes. Los yorubas del sudoeste están divididos entre musulmanes y cristianos, mientras que los igbos del sudeste y los grupos vecinos son en su mayoría cristianos o animistas. El Cinturón Medio es el hogar de cientos de grupos con diferentes creencias, y alrededor de Jos hay frecuentes enfrentamientos entre musulmanes que hablan causa y miembros cristianos de la comunidad de Berom.



La alfabetización femenina se considera la clave para elevar el nivel de vida de la próxima generación. Por ejemplo, un niño recién nacido tiene muchas más probabilidades de sobrevivir si su madre está bien educada. En Nigeria vemos un marcado contraste entre el norte principalmente musulmán y el sur cristiano y animista. En algunos estados del norte, menos del 5% de las mujeres saben leer y escribir, mientras que en algunas áreas de Igbo más del 90% saben leer y escribir.
Nigeria es el mayor productor de petróleo de África y uno de los más grandes del mundo, pero la mayoría de su población subsiste con menos de $ 2 por día. El petróleo se produce en el sureste y algunos grupos militantes allí quieren mantener una mayor parte de la riqueza que proviene de sus pies. Los ataques de militantes contra instalaciones petroleras provocaron una fuerte caída en la producción de Nigeria durante la última década. Pero en 2010, una amnistía del gobierno llevó a miles de combatientes a acostarse.





Nigeria's population in poverty

  • 1980: 17.1 million
  • 1985: 34.7 million
  • 1992: 39.2 million
  • 1996: 67.1 million
  • 2004: 68.7 million
  • 2010: 112.47 million
Source: Nigeria's National Bureau of Statistics



































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