POLIO

1.A 32 year old Indian man has come to you for a routine health check up before flying to Africa where he has volunteered to work in a polio endemic area. His past history has been significant for having been treated for tuberculosis 9 years back with category 2 drugs. The patient was declared disease free after about a year. However, he recollects having allergic symptoms while on treatment. He is free of symptoms now and a recent CXR shows no abnormalities. Clinical examination is unremarkable. What is the next most appropriate step?

 

  1. Reassure him that he is healthy and can proceed for his flight

  2. Obtain a sputum sample from him for AFB examination

  3. Vaccinate him with IPV as he is travelling to polio endemic area

  4. Defer IPV vaccination and contact primary health care provider

  5. Administer prophylactic isoniazid and IPV.

 

Choice D is correct – Adults need not bet routinely vaccinated for polio as it primarily affects children. However, all adults travelling to polio affected areas should be vaccinated. Hence the man in question needs polio vaccination. However, it is contraindicated or avoided in those with a know history of severe reactions to streptomycin which is a category 2 drug. It is also avoided in know cases of allergy to polymyxin B and neomycin. In these situations, deferring from vaccination and contacting the primary health care provider for assistance in further management would be ideal

 

Choice A is incorrect – He can be reassured that he is healthy but cannot proceed to his flight without polio immunisation

 

Choice B is incorrect – He was declared disease free. He is now asymptomatic and has a normal CXR. There is no need to still consider TB

 

Choice C is incorrect - IPV cannot be given in a suspected case of anaphylaxis to certain drugs such as streptomycin, polymyxin B and neomycin.

 

Choice E is incorrect – Isoniazid and IPV are not warranted for the reasons given above

 

 

2.You are part of a WHO team which will be sent to Kano, a province in Northern Nigeria, a state that is ruled by the Sharia (Islamic law). Your team has been entrusted with the work of restarting a polio immunisation campaign that has been suspended in the year 2003. Which of the following would be your main area of concern with the view of maximizing coverage in this area?

 

  1. Persuading people that not vaccinating against polio would result in massive deaths among the people

  2. Explaining to them that polio vaccine is very important in terms of preventing diarrhoea among the people

  3. Educating them that polio vaccines don’t produce ill effects like dissemination of HIV and sterility in boys

  4. Telling them that refusal to immunisation is criminal offence

 

 Choice C is correct – Answering this question demands certain specific information relating to suspension of the polio immunisation in 2003 in Northern Nigeria due to wide spread protests among the people following false rumours that polio vaccination was a strategy by the US – led nations to wipe out Islamic forces by producing sterility in boys and spreading HIV among the population through the polio vaccines.

This question enlightens the importance of religious, cultural and political factors in the improvement of community health.

 

Choice A is incorrect – Not vaccinating against polio is unlikely to result in massive deaths as in the case of plague. Spreading false claims is unacceptable

 

Choice B is incorrect – the idea of polio vaccination is not to decrease diarrhoeal diseases in the community

 

Choice D is incorrect – Though vaccinating oneself is in a way beneficial for the rest of the community (in terms of herd immunity), refusal is one’s own right and does not amount to criminal offence

 

 

3. A 8 year old boys presents with a 1 week history of weakness, abdominal cramps, lethargy and passage of loose stools. There is low grade fever and there are no other upper respiratory symptoms. Slowly the systemic symptoms seem to decrease in severity but the child displayed flaccid paralysis of both lower limbs. The paralysis was more in the proximal muscles that in the distal muscles. There was no sensory deficit. Which of the following is the most appropriate next step?

 

  1. obtain stool samples and send it for polio virus culture and stool examination

  2. obtain CSF by lumbar puncture in suspicion of Guillain – Barre syndrome

  3. administer an empiric dose of broad spectrum antibiotics and steroids

  4. provide full – scale IV rehydration and reassure that there will not be any residual paralysis

 

Choice A is correct – mild systemic and diarrhoeal illness followed by acute flaccid paralysis points a finger to the presumptive diagnosis of poliomyelitis the management of which includes collection of stool samples for polio virus isolation and thereby proceeding with aggressive polio vaccination in the community

 

Choice B is incorrect – A diagnosis of GBS is inappropriate in the absence of ascending paralysis with predominant involvement of distal rather than proximal muscles and sensory deficits. Polio produces pure motor deficits. GBS often produces sensory deficits

 

Choice C is incorrect – In case of polio, antibiotics are of no great help. Steroids are not used either, even if GBS is considered

 

Choice D is incorrect – Polio does not often cause profound dehydration unlike cholera which necessitates aggressive IV rehydration. Moreover, reassurance of no residual paralysis is again unwarranted if polio is considered

 

Prepared By

Dr. PRAGATHEESHWAR THIRUNAVUKARASU

MADRAS MEDICAL COLLEGE.