Doctors Revision

Infectious Diseases

Poliomyelitis

An acute viral infection caused by poliovirus (an enterovirus), transmitted faecal-orally. While most infections are asymptomatic or cause minor illness, about 1% result in acute flaccid paralysis (AFP) due to viral invasion of motor neurons in the spinal cord/brainstem. A notifiable disease targeted for global eradication.

Also known as: Polio, Infantile Paralysis

Open in the interactive guide
On this page

Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL/REPORTING to District Health Team / Surveillance Focal Person for ALL suspected cases of Acute Flaccid Paralysis (AFP). Patient requires Hospital admission (H/RR) for supportive care, monitoring, and investigation.

Red flags

  • Acute onset of flaccid paralysis in a child <15 years.
  • Asymmetric weakness.
  • Reduced/absent reflexes.
  • Signs of respiratory distress or difficulty swallowing (bulbar involvement).

Signs and symptoms

  • Asymptomatic Infection (~90-95%): No illness.
  • Abortive Poliomyelitis (Minor Illness, ~4-8%): Non-specific symptoms: Fever, malaise, headache, sore throat, vomiting, abdominal pain. Resolves in <1 week.
  • Non-Paralytic Poliomyelitis (Aseptic Meningitis, ~1-2%): Symptoms of minor illness plus neck stiffness, back pain, muscle tenderness. Resolves completely.
  • Paralytic Poliomyelitis (<1%):
  • - Initial minor illness symptoms.
  • - Followed by onset of Acute Flaccid Paralysis (AFP):
  • - Rapid onset of weakness/paralysis (develops over hours to days).
  • - Typically asymmetric distribution.
  • - Affects proximal muscles more than distal.
  • - Lower limbs more commonly affected than upper limbs.
  • - Muscle pain and spasms common initially.
  • - Loss of deep tendon reflexes in affected limbs.
  • - Sensation usually intact.
  • - Fever present during acute phase.
  • - Spinal Polio: Paralysis of trunk/limb muscles.
  • - Bulbar Polio: Involvement of cranial nerves/brainstem -> Difficulty swallowing, speaking, breathing; potential respiratory failure.
  • - Bulbo-spinal Polio: Combination of spinal and bulbar involvement.

Risk factors

  • Lack of immunization (Oral Polio Vaccine - OPV, Inactivated Polio Vaccine - IPV).
  • Travel to or residence in areas with ongoing poliovirus transmission (wild or vaccine-derived).
  • Poor sanitation and hygiene.
  • Immunodeficiency (prolonged viral shedding, risk from OPV).

Diagnosis

Clinical assessment

Suspicion based on clinical presentation of AFP (acute onset, flaccid, asymmetric paralysis with reduced reflexes, no sensory loss) in a child <15 years (or any age during outbreak). Bulbar symptoms highly suggestive.

Differential diagnosis

  • Guillain-Barré Syndrome (GBS) (usually symmetric ascending paralysis, sensory symptoms common, areflexia).
  • Transverse Myelitis (usually symmetric, sensory level present, bladder/bowel dysfunction).
  • Traumatic Neuritis / Spinal Cord Injury.
  • Acute Motor Axonal Neuropathy (AMAN) (variant of GBS).
  • Other enteroviral myelitis (e.g., Enterovirus D68, EV-A71).
  • Botulism (descending paralysis, cranial nerve involvement first).
  • Tick paralysis.
  • Toxic neuropathy / Heavy metal poisoning.

Investigations

  • Stool Sample Collection: CRITICAL. Collect 2 stool samples, 24-48 hours apart, within 14 days of paralysis onset. Keep samples cold (refrigerated/frozen) for transport to reference lab (UVRI) for Virus Isolation and Typing (Wild vs Vaccine vs Vaccine-Derived).
  • CSF Analysis (LP): Usually shows mild pleocytosis (lymphocytes or neutrophils early), normal/slightly elevated protein, normal glucose (consistent with aseptic meningitis if non-paralytic). Done mainly to rule out other diagnoses like bacterial meningitis or GBS (high protein, normal cells).
  • Nerve Conduction Studies / EMG: Help differentiate from GBS/neuropathies (shows motor neuron damage in polio).

Diagnostic criteria

Clinical diagnosis of AFP triggers investigation. Confirmed Polio requires laboratory isolation of poliovirus from stool.

Management

Non-pharmacological management

  • Supportive Care: (LOC: H)
  • - Bed rest during acute phase.
  • - Pain Management: Analgesics (Paracetamol, NSAIDs), moist heat applications.
  • - Physiotherapy: Gentle passive range of motion exercises early to prevent contractures. Active exercises later during recovery phase.
  • - Respiratory Support: Close monitoring for respiratory muscle weakness/bulbar involvement. Mechanical ventilation may be required for respiratory failure.
  • - Nutritional support, bladder/bowel care.
  • - Orthotics/bracing for residual paralysis.
  • - Avoid Intramuscular (IM) injections during acute phase (may provoke/worsen paralysis - 'provocation paralysis').

Pharmacological treatment

  • No specific antiviral therapy.
  • Treat complications (e.g., UTI, pneumonia).

Monitoring

Monitor respiratory function closely in acute phase. Monitor muscle strength recovery. Long-term follow-up for rehabilitation and management of residual paralysis/deformity (Post-Polio Syndrome can occur decades later).

Complications

  • Permanent muscle paralysis and atrophy.
  • Limb deformities, contractures, scoliosis.
  • Respiratory failure.
  • Aspiration pneumonia.
  • Post-Polio Syndrome (new weakness/fatigue years after recovery).
  • Death (usually from respiratory failure).

Prevention

  • Vaccination: Key strategy. Global Polio Eradication Initiative relies on OPV (live attenuated) and IPV (inactivated). Routine immunization schedule and supplementary campaigns (SNIDs/NIDs) crucial.
  • Surveillance: Active surveillance for ALL cases of Acute Flaccid Paralysis (AFP) with prompt investigation and stool sample collection.
  • Improved sanitation and hygiene.
  • Containment measures during outbreaks.

Patient education

  • Explanation of polio as a viral infection causing paralysis.
  • Importance of supportive care and physiotherapy.
  • Need for stool sample collection for diagnosis/surveillance.
  • Long-term nature of potential disability.
  • CRITICAL importance of vaccination for prevention in community.
  • Rehabilitation options.

Uganda-specific notes

Uganda is certified polio-free (Wild Polio), but risk of importation and outbreaks of Vaccine-Derived Poliovirus (cVDPV) exists. High vaccination coverage (OPV/IPV) and sensitive AFP surveillance are essential. ALL AFP cases must be reported and investigated immediately.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.3.4

  • Uganda National Polio Eradication / AFP Surveillance Guidelines

    (Specific MOH/WHO program documents)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 18 (Immunization)

Scroll to Top