poliomyelitis

from Wikipedia, the free encyclopedia
Classification according to ICD-10
A80.0 Acute paralytic poliomyelitis due to vaccine virus
A80.1 Acute paralytic poliomyelitis from imported wild virus
A80.2x Acute paralytic poliomyelitis due to native wild virus
A80.3 Other and unspecified acute paralytic poliomyelitis
A80.4 Acute non-paralytic poliomyelitis
A80.9 Acute poliomyelitis, unspecified
ICD-10 online (WHO version 2019)

The poliomyelitis ( Greek. Πολιός , gray ' μυελός , Mark'), often short polio , German ( spinal ) polio , polio or Heine-Medin disease called, is one of polioviruses mainly caused in childhood infectious disease . It affects motor neurons and can lead to severe, permanent paralysis . These often affect the extremities. The involvement of the respiratory muscles is fatal and this led to the first mechanical ventilation procedures. The disease can recur years after infection .

The virus is usually transmitted by smear infection (urine or stool), but droplet infections are also possible. It can only reproduce in humans (and a few species of apes) and can only be transmitted from person to person.

Polio vaccines have been available since the 1950s . The number of illnesses has since declined sharply. Large health organizations, above all the WHO , have been working to eradicate polio for years . The only infectious diseases deliberately eradicated by humans in modern times are smallpox and rinderpest . However, there are always setbacks, such as two new cases in Ukraine in 2015, although Europe was declared completely polio-free as early as 2002. Polio is currently spreading in Afghanistan and Pakistan , there were 33 cases in 2018, and 72 new cases were added in Pakistan in 2019 (as of early October). After no new case of wild poliomyelitis had occurred in Africa for four years, the continent was declared "wild polio-free" by the WHO on August 25, 2020.

Occurrence

Leg atrophied from poliomyelitis

Children between the ages of three and eight are mainly affected. Occasionally older people are also affected into adulthood. There is no causal treatment for this viral disease. Due to the consistent vaccination , polio is now officially "eradicated" in Germany.

Poliomyelitis was first described clinically in the 18th century by the English physician Michael Underwood (1736-1820). The disease was presented in more detail by the Black Forest orthopedic surgeon Jakob Heine , who published a book in 1840 with the title Observations on Paralysis of the Lower Extremities and their Treatment . What he described, he called in the second edition of 1860 Spinal Polio . The Swedish doctor and researcher Karl Oskar Medin (1847–1927), who recognized the epidemic character of the disease, built on Heine's findings. Hence the further designation of polio as Heine-Medin disease .

According to current knowledge, poliomyelitis existed as an endemic disease until 1880 . This infectious disease did not appear in epidemic form until around 1880, affecting thousands of people every year. These were mainly children who died as a result or who had to live permanently with consequential physical damage. From about 1910, regional epidemics were observed in Europe and the United States every five to six years. One of the best-known victims of such an epidemic is the US President Franklin D. Roosevelt , who significantly promoted research into a vaccine during his presidency. The introduction of virus culture by J. F. Enders in 1952 led to significant advances in vaccine research , thanks to which Jonas Salk was able to develop an inactivated (dead) vaccine in 1954. However, this worked only inadequately. The attenuated live vaccine developed by Albert Sabin led to major advances in the fight against polio from 1960 onwards. Thanks to the vaccines, the number of polio cases fell from several 100,000 per year to only around 1,000 per year.

In 2010 there was a serious outbreak in Tajikistan , which was also abducted to Russia. On May 5, 2014 the World Health Organization (WHO) declared the outbreaks of poliomyelitis in several countries, in particular in Cameroon , Pakistan and the civil war-torn Syria , as well as the spread from these countries to Equatorial Guinea , Afghanistan and Iraq an "extraordinary event" , which urgently required further coordinated measures to prevent a global recurrence of this disease.

At the beginning of September 2015, the WHO reported two cases of polio in children in south-western Ukraine and therefore in Europe. This is a setback on the road to global extinction. There is a high risk of the disease spreading in this country as only 50% of children there are vaccinated against polio. Because of better vaccination rates, there is little risk for the neighboring countries Romania, Poland, Hungary and Slovakia. In August 2019, Nigeria became the last African country to be officially declared poliomyelitis-free. Worldwide there is currently only the endemic region of Afghanistan and Pakistan , from which new diseases are reported and can be spread. The war-related migration movements from this part of the world currently represent the greatest global risk for the spread of polio.

Pathogen

Poliovirus under the electron microscope

The causative agent of this disease is the poliovirus . It is a non-enveloped virus with single-stranded RNA positive polarity (ss (+) RNA) of approx. 30  nanometers in diameter, which belongs to the genus Enterovirus of the family Picornaviridae . There are three known serotypes : Type I (“Brunhilde”), which is considered to be the most paralyzing trigger and tends to spread epidemically ; it was named after a female chimpanzee named Brunhilde who was infected at the time . There are also type II ("Lansing") and type III ("Leon"), which have not been detected for years and have since been declared extinct by the WHO. There is no cross-immunity between the three types of pathogen . This means that an infection with one of the three types does not protect against further infection with one of the other two types. In addition to humans , a few great apes are also attacked, and transmission in humans occurs through other humans.

Epidemiology

The pathogen can be found worldwide except in the polar regions. The frequent occurrence of the disease in areas in Africa and Asia has been pushed back through consistent implementation of vaccination measures. Since the WHO eradication target was set in 1988, the number of cases in 125 countries worldwide has fallen by 99% from 350,000 at that time, and only the three countries Afghanistan, Pakistan and Nigeria were never pathogen-free until then. Polio was last infected in Germany in 1990. The last infections brought in were registered in 1992. In the USA in 1979 there was an outbreak in the states of Iowa , Wisconsin , Missouri and Pennsylvania exclusively among the devout Amish . Another outbreak was also reported only among adherents of that denomination in Minnesota in October 2005 . In Western Europe, the last polio epidemic occurred in the Netherlands in 1992 . This affected members of fundamentalist - Calvinist communities who, like most Amish people, refused and continue to refuse vaccinations for religious reasons.

Incidence of polio August 2015
  • 21 to 30 confirmed cases
  • 11 to 20 confirmed cases
  • 1 to 10 confirmed cases
  • no wild virus

    • The increased incidence of polio after 2003 in Nigeria - a country that was practically polio-free until 2003 - can clearly be traced back to an Islamic legal opinion issued that year by Ibrahim Datti Ahmed, doctor and President of the Supreme Sharia Council in Nigeria . The fatwa Ahmed says that polio vaccinations by the US and the UN are a "conspiracy" against the Muslim faith, and would serve the Muslims to "sterilize". In the following years, the polio cases in Nigeria increased again and spread from there to other countries. Ten years later, health workers in Kano, Nigeria, who were involved in vaccination programs, were murdered by motorcycle shooters allegedly belonging to the Islamist terrorist group Boko Haram . In Somalia , 174 cases were already detected in 2013, in 2012 it was zero.

    The World Health Organization (WHO) wants to eradicate the poliovirus worldwide in the next decades, similar to the smallpox in the 1970s ; the pathogen seems suitable for this, since it practically does not change and in fact only has humans as a reservoir . For the success of this project, however, it is essential that the willingness to vaccinate does not decrease, since the virus is environmentally stable and has to be “starved” so that it can no longer find a host. A global immunization rate that is as high as possible over a period of years is imperative. In 2007 there were 1,310 cases of wild virus poliomyelitis worldwide. In 2008, the virus was only endemic to Nigeria, India, Pakistan and Afghanistan . By mid-2015 it was possible to limit the number of new infections to two countries; So far, new infections have only occurred in Pakistan and Afghanistan. However, a country is only considered "polio-free" if there are no new infections in three years. Type 2 (WPV2) of the three types of wild polio virus has not been detected since 1999. According to the GPEI, wild type 3 was last detected in November 2012. In 2015, type 2 was declared eradicated by the WHO. Therefore, a bivalent vaccine without immunization against type 2 has now been developed for the other vaccination programs. On World Polio Day 2019 (October 28, 2019), the WHO also declared type 3 to be eradicated.

    In poor hygienic conditions, the virus is transmitted through hands or objects contaminated with faeces and is absorbed via the digestive tract (fecal-oral smear infection or contact infection ). However, there is also transmission through droplet infection . The infectiousness obviously sets in a few hours after infection. It lasts for one week in the throat (droplet infection) and three to six weeks in the feces. The incubation period is 7-14 (3-35) days.

    Pathogenesis

    The poliovirus is usually absorbed into the body through the mouth and then multiplies in the intestines. From there it first affects the local lymph nodes and after it multiplies it spreads through the bloodstream ( viraemia ). As a neurotropic virus, it prefers to get into those nerve cells in the anterior horn of the spinal cord ( α-motor neurons ) that reach and control the striated muscles with their appendages . In response to the infection, the body's own immune cells ( leukocytes ) migrate into the spinal cord, with inflammation ultimately destroying the nerve cells. The consequences are more or less pronounced, unevenly distributed flaccid paralysis , predominantly on the legs. The sense of touch is retained.

    In addition to the involvement of the spinal cord, the brain itself is almost always also affected in the paralytic form, so that one would have to speak of poliomyeloencephalitis precisely . Immigration of inflammatory cells (inflammatory infiltrates ) and nerve cell destruction occur regularly, especially in the area of ​​the cerebellum , the bridge and the elongated marrow . However, these rarely lead to their own symptoms. Only the neurons analogous to the spinal anterior horn cells in the cranial nerve nuclei of the IX. and X. cranial nerves are more frequently affected. The infestation of these cells leads to the dreaded bulbar shape , in which the function of the larynx (speaking and breathing) or swallowing can be impaired. Such paralysis can occur within a few hours of the nervous system being affected.

    Course of the disease, symptoms

    Girl with a deformed right leg as a result of polio

    In around 95 percent of the cases, the infection is asymptomatic (without any signs of illness), so that the course of the disease cannot be spoken of. Instead it comes - unnoticed by the infected - to the formation of antibodies and thus to a so-called silent celebration . In 4–8% of those infected there are temporary, unspecific symptoms.

    Abortive poliomyelitis

    After an incubation period of 6–9 days, an illness with fever , sore throat, fatigue, often diarrhea and vomiting occurs for about three days . In more than three quarters of the sick, this abortive poliomyelitis ( abortive for “abbreviated, weakened”) heals without consequences. The cells of the central nervous system (CNS) are not infected.

    Infection with CNS involvement

    In about 5-10 percent of symptomatic patients, however, the central nervous system is involved, in which the symptoms described above represent the prodromal stage (preliminary stage) of the disease. After a fever-free and symptom-free phase of about a week, these patients develop non-purulent meningitis (aseptic meningitis ) in which there is no paralysis of the muscles (non- paralytic poliomyelitis) . This form of meningitis is characterized by a renewed rise in fever to 39 ° C, headache and stiff neck . If the spinal cord fluid (the nerve fluid , the liquor cerebrospinalis ) is examined, the doctor finds an increase in the number of cells and a slight increase in the protein concentration.

    Only around 1 percent of those infected develop paralytic poliomyelitis , the most severe form of the disease, which is feared as "classic polio". This can also happen after a fever-free and symptom-free latency period of around 2–12 days, during which the symptoms of meningitis initially improve, resulting in a two-phase (biphasic) course (the course of the disease can be divided into two phases). Characteristic for the sudden onset of the paralytic form is “morning paralysis” in the child who was healthy the evening before. The paralysis is flaccid (in contrast to the spastic paralysis when the motor cortex or the pyramidal tract is damaged ), asymmetrically distributed, preferring the muscles of the thighs and is often associated with considerable pain. If the associated segments of the spinal cord are involved, the muscles of the trunk, intercostal spaces, urinary bladder , rectum, or even the diaphragm can also be affected. The areas of origin of the cranial nerves (cranial nerve nuclei) are affected much less often. In this bulbar form , swallowing disorders or respiratory and circulatory regulation disorders occur with a high fever. This serious form is burdened with a high mortality. Any additional stress, for example in the form of physical exertion or trivial interventions such as injections into a muscle or removal of tonsils, especially in the early stages of the disease, increases the risk of paralysis later on. The mortality rate ( lethality ) is around 2–20% for the total number of patients in whom paralysis occurs .

    Late complications

    The symptoms usually resolve within a year, but paralysis, circulatory disorders and disorders of the skin nutrition can remain as permanent damage. Joint damage due to paralysis and the changed statics, such as scoliosis of the spine and foot deformities, are also permanent impairments. Slowed growth in length of individual affected extremities can make the child disabled . After defever, no further progression of the paralysis is to be expected. In some cases, the post-poliomyelitis syndrome still occurs as a long-term consequence years or decades after the infection . Its symptoms are manifested in extreme fatigue, muscle pain and muscle wasting in new and previously affected muscles, breathing and swallowing difficulties. This late complication seems to be the rule rather than the exception.

    Diagnosis

    Clinically, the double-peaked fever leads the suspicion of poliomyelitis at the latest when the paralysis occurs. The virus can be grown from stool, throat rinse water, and brain water . The molecular biological detection of virus genetic information ( RNA ) using the polymerase chain reaction (PCR) is also possible. If there is no evidence of the pathogen, specific antibodies against the polioviruses in the serum can confirm the diagnosis.

    Differential diagnosis

    During the first phase of the disease, poliomyelitis must be differentiated from all febrile infections caused by other pathogens. Symptoms of meningitis, including paralysis, can also be caused by other pathogens belonging to the enterovirus group, such as coxsackie and echoviruses, as well as early summer meningoencephalitis. In bulbar-onset form, the also rare in our part of diphtheria is an important differential diagnosis. The Guillain-Barre syndrome is characterized, in contrast to poliomyelitis by symmetric, ever-ascending from the feet paralysis. There are no fever or stiff neck as signs of meningitis.

    treatment

    Since there is no causal antiviral therapy , treatment is limited to symptomatic measures. This includes bed rest with ensuring careful grooming, proper positioning, and physical therapy . In addition to pain relievers and anti-inflammatory agents , the pain that occurs can also be relieved with warm, moist packs around the affected areas. If there is the slightest suspicion of the threatening bulbar form with the occurrence of swallowing or breathing disorders, intensive medical monitoring and treatment must be ensured at an early stage. In addition to appropriate physiotherapy , follow-up treatment may also include the provision of orthopedic aids . This means that mobility can be improved for up to two years after the acute illness. Cosmetic operations such as B. a calf plasty in question.

    prevention

    Oral vaccination against polio in India

    Paul Römer , Emil von Behring's only student , is considered to be the real inventor of the protective vaccination against poliomyelitis - before Salk and Sabin .

    Vaccination with live vaccine (OPV)

    Infographic "GDR free of polio" from 1961

    A prophylactic vaccination is possible as a preventive measure and is generally recommended by the STIKO . In 1962 (in the GDR as early as 1960) the poliomyelitis “oral vaccine” (oral polio vaccine, OPV) with weakened pathogens ( attenuated live vaccine ) was introduced in Germany as well as in other European countries. As early as 1965, just a few years after the start of the first vaccination campaigns, the number of diseases recorded in Germany had fallen to less than 50 new cases, compared to the 4,670 new cases reported in 1961, that was a decrease of 99%. The last two domestic diseases caused by wild polio viruses occurred in Germany in 1986 and 1990; the last imported cases were recorded in 1992. Between 1946 and 1961, around 13,000 children in Austria contracted polio and 1,500 of them died. Only six cases have been fatal since 1961, the last being in 1973 (as of 2010).

    In this context, the delayed decrease in diseases in the FRG and GDR after the introduction of the polio vaccination in 1960 (GDR) or 1962 (FRG) is revealing. The number of reported diseases was according to the number of reports of the Federal Disease Act at that time or the law for the prevention and control of communicable diseases in humans in the GDR:

    year 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966
    FRG 2,402 1,750 2.114 4,198 4,673 296 241 54 48 17th
    GDR 1,596 958 958 126 4th 2 5 0 1 2
    Number of illnesses and deaths in Germany from 1910 to 2018, last disease acquired in Germany from a wild virus in 1990, the last two imported cases from Egypt and India in 1992; Introduction of oral vaccination (oral polio live vaccine, OPV) in 1962, conversion to the dead vaccine (inactivated polio vaccine, IPV) in 1998, 2002 the WHO declared Europe to be polio-free.

    Potential Risks of Vaccine Poliomyelitis

    After vaccination with the weakened, but viable and replicable viruses, these are excreted in the stool for some time. Under unfavorable hygienic conditions or close body contact, unvaccinated contact persons can become infected via a smear infection or contact infection (vaccination poliomyelitis). In the best case this leads to an unplanned further vaccination of the population. However, even after repeated multiplication and passage of vaccine viruses, a mutation to the virulent form of the virus can occur, as well as through improper and careless handling of the live vaccine. This can then lead to small outbreaks and localized epidemics, like 2000/01 in the Dominican Republic and Haiti and 2019 in the Philippines. In such cases, the pathogen is called "circulating vaccine-derived poliovirus" (cVDPV). Vaccination with live polio vaccine is therefore no longer recommended by the Robert Koch Institute if the wild virus does not recur.

    In Germany, the last poliomyelitis associated with the vaccine virus occurred in 2000 ( vaccine-associated paralytic poliomyelitis , VAPP). However, it was not a classic VAPP, as the sick person had already been vaccinated with OPV in 1998.

    Vaccination with dead vaccine (IPV)

    Since 1998, vaccinations against poliomyelitis have been carried out in Europe with a dead vaccine (according to Jonas Salk ) that is not swallowed, but injected (inactivated polio vaccine, IPV). The lower effectiveness of the IPV compared to the OPV does not matter, as long as the wild virus does not appear again in increased numbers. In addition, the wild polio virus type 2 is considered to be eradicated, so that an infection can only occur with types 1 and 3 as well as the cVDPVs. However, people vaccinated with IPV do not acquire reliable protection against the ingestion of wild polioviruses via the intestines, for example from contaminated drinking water. You can therefore continue to be infected with these viruses and excrete them unnoticed and thus spread them to third parties as asymptomatic carriers. This was the result of an investigation into the outbreak of a polio epidemic in Israel in 2013, in which 26 of the 28 infected people had received polio vaccinations according to the recommendations.

    Rotary International and Polio

    Announcement of a polio vaccination campaign involving Rotary International in October 2017 in Ivory Coast

    Rotary International sponsors various projects in the fight against poliomyelitis . In 1985 Rotary International expanded the program under the name PolioPlus. PolioPlus is carried out in collaboration with the World Health Organization (WHO), the United Nations Children's Fund ( UNICEF ), the US health authorities ( CDC ) and national health departments. Recent estimates suggest that Rotary will have spent approximately $ 1.2 billion to eradicate the virus for good. The polio campaign most recently benefited from a partnership Rotary International entered into with the Bill & Melinda Gates Foundation . The foundation alone donated $ 355 million. The profits of the Rotary-related association "Deckel drauf", which from 2014 to 2019 primarily collected plastic screw caps from private individuals, were tripled by the Bill & Melinda Gates Foundation.

    insulation

    Patients with poliomyelitis or suspected shedding of poliovirus should be isolated from other patients and staff for protection. Personnel should wear protective gowns and gloves during maintenance.

    history

    Depiction of a possibly polio patient, Egypt, 18th Dynasty, 1403–1365 BC BC, clearly visible the atrophy of the muscles of the right leg
    American President Franklin D. Roosevelt (photo from 1941) fell victim to poliomyelitis in 1921 and has since been largely paralyzed from the waist down
    Eminent polio researchers - immortalized in the Polio Hall of Fame
    Examination of a patient in the iron lung

    The endemic phase of poliomyelitis

    Poliomyelitis has been a disease that has been known for many centuries. Unlike the flu , smallpox and plague , however, no major poliomyelitis epidemics were known until the end of the 19th century. The earliest known evidence of poliomyelitis therefore speaks of individual cases and not of disease outbreaks that resulted in a large number of sick people.

    The oldest evidence of polio is an Egyptian stone tablet from the 18th dynasty (15th century BC) It shows a young man who was probably a priest with a deformed leg and a crutch.

    Both Hippocrates and Galen have described clubfoot deformations in their writings , which are reminiscent of the clinical pictures that are characteristic of people with polio. However, they also speak of individual cases. The same applies to the writings that have come down to us from the Middle Ages. A larger number of cases are known from the 17th and 18th centuries. One of the presumed victims of polio is Walter Scott , who fell ill at the age of 18 months and became paralyzed from then on.

    From around the middle of the 19th century, polio appeared in Western Europe and in the United States in such a form that several sufferers suffered permanent damage. A village on the French coast, a British city in Nottinghamshire and two rural communities in the US state of Louisiana and Sweden were affected . There have been dozens of consequential damage cases in each of these locations. It always affected young children and the cases always occurred in the summer.

    The increased number of cases of illness meant that polio was scientifically differentiated from other diseases at around the same time. In 1838 Jakob von Heine reported at the natural scientist meeting in Freiburg about acute paralysis of the legs in children. Two years later he described the clinical picture under the name of spinal polio in a monograph and for the first time delimited it as an independent one. Other authors subsequently referred to it as essential paralysis or atrophic polio . In 1865 Jean Louis Prévost and Edmé Vulpian described the pathological-anatomical changes in the anterior horn cells. Adolf Kussmaul underlined the anatomical localization of the disease in the gray matter of the spinal cord and in 1874 proposed the name poliomyelitis acuta anterior for the first time . Adolf von Strümpell recognized the disease as an infectious disease in 1884.

    Poliomyelitis as an epidemic

    While it was mostly isolated cases before, polio did not spread to a threatening extent until the end of the 19th century as a paradoxical consequence of improving hygienic lifestyles and thus decreasing (dirt) autoimmunization. When there was an accumulation of cases of illness in the Stockholm area in 1887, "infantile paralysis", as poliomyelitis (acuta anterior) was called at the time, was classified by the pediatrician Karl Oskar Medin as an epidemic disease . The first scientifically described polio epidemic in the United States was the Otter Valley epidemic in 1894 . The country doctor Charles Caverley evaluated 123 cases during this epidemic, of which almost 50 percent recovered quickly and without any consequential damage. His findings also indicated that polio was much more common than previously thought. A few years later, Ivar Wickman , in detailed clinical and epidemiological studies, confirmed the still controversial hypothesis that polio is transmitted through physical contact. The great Swedish epidemic in 1905 with a total of 1,031 registered cases provided him with illustrative material. Using the example of the small parish of Trästena in today's municipality of Töreboda , he showed that people with a large contact area were more easily victims of the disease. In just six weeks, 49 children were newly infected. He first made the observation that the disease spread along the roads and the railway line. After weeks of field studies , Wickman was able to prove that the local public school played an important role in the spread of what he called Heine-Medin's disease . In the autumn of 1908, Ferdinand Sauerbruch's first child, a daughter, died a few months after her birth in Marburg of the polio that had developed in Hesse at that time. In the same year Karl Landsteiner and Erwin Popper succeeded in infecting monkeys with the poliomyelitis virus, and they described a neurotropic, filterable virus . This provided proof of the infectious nature of epidemic polio and the viral nature of the pathogen. In 1910 Constantin Levaditi and the microbiologist Juste Arnold Netter (1855–1936) discovered poliomyelitis antibodies in serum, and this was followed by the discovery that serum from convalescents from large poliomyelitis epidemics in Scandinavia and the United States can neutralize the virus (neutralization reaction) . But in 1939 the differentiation was in three different serotypes of Charles Armstrong confirmed.

    In the USA, the March of Dimes organization was involved in the procurement of research funds
    Polio victims were particularly dependent on care

    In Europe and the United States, regional epidemics were observed every 5–6 years, with sporadic cases occurring at intervals. One of the first major outbreaks was the polio epidemic that struck the eastern United States in 1916. More than 6,000 people died as a result. There were larger outbreaks in Europe, for example, in 1932 in Germany with 3,700 cases and in 1934 in Denmark with 4,500 cases, whereby only the paralytic forms were registered. Young Franklin D. Roosevelt was one of the victims in the summer of 1921 . Today it cannot be ruled out that Franklin D. Roosevelt suffered from Guillain-Barré syndrome . However, he and his doctors assumed that he had polio until the end of his life. Roosevelt, who was very active in the fight against polio, founded the National Foundation for Infantile Paralysis on January 3, 1938 . The goal of the charity, now known as the March of Dimes , was to raise money for research and for the care of polio victims.

    In Canada , the recording of cases of the disease began in 1924; the annual number varied from 113 cases (1926) to just under 4,000 cases (1937). However, it cannot be ruled out that all cases with polio-like symptoms were assigned in this period. From 1949 only paralytic forms of the disease were recorded. Two epidemics occurred in Canada in the 1950s: one peaked around 1953, and another, smaller one in 1959.

    Post-treatment of the disease at the beginning of the 20th century was mainly carried out with restraint of all paralyzed limbs. This method was fundamentally questioned by the Australian nurse Elizabeth Kenny from the 1930s ; the autodidact achieved great, but highly controversial successes with heat treatment and physical therapy as well as massages. Despite initial opposition, the Kenny method was adopted into medical therapy and also used in acute cases.

    In the field of treatment, the development of measures for artificial respiration, initially in the form of the iron lung , led to a decrease in the dreaded mortality rate from poliomyelitis. The great polio epidemics of the 1950s, however, quickly demonstrated the practical limits of iron lung treatment; Due to the high acquisition and operating costs of these devices, the treatment capacities of the hospitals were limited. For example, in July 1952 , the Blegdamshospital in Copenhagen recorded between 50 and 30 daily admissions of patients with respiratory paralysis who were treated with only one iron lung and six Cuirass respirators . The Danish anesthetist Björn Ibsen succeeded in developing an alternative polio treatment method in which the patients were intubated (or tracheotomized) and long-term ventilated with a resuscitator. The mortality rate at Bledgdamshospital then fell from 87% to 25%. Long-term treatment using positive pressure ventilation led to the establishment of the world's first "intensive care unit" for seriously ill patients two years later (1953) and is now standard treatment for suspected bulbar disease. The equally frequent permanent paralysis could still hardly be influenced therapeutically, so that it was only the widespread introduction of vaccination that led to poliomyelitis beginning to become a historical disease.

    In 1952, the introduction of virus culture in non-neural cells by Nobel Prize winners John F. Enders , Thomas H. Weller and Frederick C. Robbins not only made it possible to end animal experiments, but also finally enabled Jonas to develop an inactivated (dead) vaccine (IPV) Salk 1954. In Canada the dead vaccine was introduced in 1955, between April and June of that year 800,000 children were immunized. However, the IPA was so poorly effective that an epidemic ensued in the United States and Canada. In contrast , the attenuated live vaccine (OPV) developed by Albert Sabin brought the breakthrough in 1960 . However, since American policy had relied on the apparently easier-to-use vaccine from Salk, Sabin was forced to accept a generous offer from the USSR to develop his live vaccine there; clinical studies were carried out there in 1958/1959 by Mikhail Tschumakow . Since this political constellation at the height of the Cold War made implementation in friendly states with the USA impossible, the pharmaceutical company Immuno , based in neutral Austria, took over the Soviet patent and in 1957 commissioned the Federal Bacteriological and Serological Research Institute in Vienna with the revision to the western one Standards that were successfully completed by 1958 under the direction of the Viennese bacteriologist Peter Johann Kraus .

    In 1958, a memorial to fifteen polio researchers, the Polio Hall of Fame, was unveiled in the United States .

    Chronology of the fight against poliomyelitis until 2006

    time event
    1400 BC Chr. Earliest evidence of poliomyelitis
    1840 First description of polio by Jakob von Heine
    1890 First outbreak description by K. Medin (Sweden)
    1908 Poliovirus is discovered (Landsteiner / Popper)
    1916 Outbreak in New York (27,000 paralyzed, 9,000 dead)
    1921 FD Roosevelt developed polio at the age of 39
    1928 First use of an iron lung
    1948 Poliovirus types 1-3 confirmed
    1952 Largest polio epidemic in US (57,628 cases)
    1952 Outbreak in Germany (9,500 paralyzed, 745 dead)
    1955 Salk Polio Dead Vaccine (IPV)
    1961 Sabin Polio Live Vaccine (OPV) , oral vaccination in USA
    1961 Introduction of oral vaccination in Germany as well
    1962 Introduction of OPV in Canada
    1979 Rotary Polio Engagement
    1980 Side note: the world is smallpox free
    1985 Rotary PolioPlus (donated more than US $ 500 million to date)
    1988 Program of the World Health Organization WHO to eradicate polio (polio eradication)
    1990 Last polio case in Germany
    1994 WHO America region is polio-free
    1998 In Germany only dead vaccine is recommended
    2000 WHO West Pacific Region is polio-free
    2002 WHO Europe region is polio-free
    2003 Setback due to the renewed spread of polio in West and Central Africa
    2006 Successful containment of outbreaks through extensive vaccination campaigns
    2020 WHO Africa region is wild polio-free

    Polio cases since 2006

    Sporadic outbreaks of polio occur at irregular intervals around the world, but these are mostly regional.

    • In 2006, poliomyelitis occurred in a major outbreak in northern Nigeria - an area where wild type I and III polioviruses circulate. The cause was attenuated viruses of type II used for vaccination , which became virulent again through mutation and were able to spread due to the locally inadequate immunity. According to researchers, the 69 confirmed cases and the policies of the World Health Organization , which only published them in September 2007, could hinder the eradication of the disease.
    • As of June 29, 2010, more than 643 cases of acute flaccid paralysis were reported from Tajikistan . This corresponds to about 75 percent of all cases reported worldwide for 2010. The wild poliovirus type I was detected in 334 cases, 14 of which were fatal. All cases have so far occurred in the southwestern part of the country in the Khatlon province and around the capital Dushanbe . In response to the outbreak, more than three million children have been vaccinated and vaccination campaigns have also started in neighboring Uzbekistan and Afghanistan . Originally from Uttar Pradesh in India, the virus was also carried on to Russia, where six cases had been reported by June 29. This is the first time since the certification as “polio-free” in the WHO Europe region there has been an introduction of wild polio viruses.
    • As of December 7, 2010, the WHO reported 179 deaths and 476 paralyzes from the wild poliovirus type I (WPV1) in the Congo. The virus presumably came from India and came to the Republic of the Congo via Angola . In 2000, polio was considered to be eradicated there. The outbreak in late 2010 was considered dangerous as elderly people were also infected and the mortality rate was unusually high at 42%. In addition, it was mainly men who were infected. The disease broke out in the Congo in October 2010. After a more recent analysis of this polio outbreak, researchers found that the genetic makeup of the virus variant that had appeared in the Republic of the Congo was so altered that the antibodies produced after vaccination against the conventional variants had found it difficult to paralyze this new virus variant.
    • In 2011, several dozen illnesses occurred in Pakistan and - as a result of the spread of the pathogen - several illnesses in the Xinjiang Autonomous Region of the PRC. China had previously reported cases for the last time in 1999 and responded with a mass inoculation that comprised 43 million doses in five rounds, and the last case was reported after a month and a half. China determined a cost of about 26 million US dollars for the direct control of the outbreak.
    • In 2012, another 175 new cases were registered worldwide, more than half of the cases in Nigeria, the rest in Afghanistan, Pakistan and Chad .
    • In 2013 polio eradication suffered a setback when polio reappeared in Somalia in a 32 month old girl. The country has been polio-free since 2004.
    • At the end of October 2013, ten samples - from 22 patients - were polio-positive (type I) for the first time in the civil war country of Syria . No cases of polio have been reported in Syria for 15 years, but the disease is starting to spread again due to the inadequate vaccination supply as a result of the civil war. On November 11, the World Health Organization identified the pathogen detected among Syrian refugees as a descendant of a virus strain from Pakistan, which was also detected in samples from Egypt , the Palestinian territories and Israel in 2012 .
    • For the second time in its history, the WHO imposed specific travel restrictions in May 2014. The poliovirus found its way from Pakistan to Afghanistan and from Syria to Iraq. Polio also migrated from Cameroon to Equatorial Guinea. The WHO demands that residents of Cameroon, Syria and Pakistan, should they want to leave the country, get vaccinated beforehand and have an appropriate certificate with them. The number of documented new infections increased from 223 in 2012 to 417 in 2013.
    • In 2014 the White House assured that the CIA would no longer use vaccination campaigns to obtain information. Apparently, as part of Operation Neptune's Spear in 2011, the CIA attempted to obtain the unquestionable identity of the residents of the Bin Laden property in Pakistan as part of a vaccination campaign . Although the rejection of everything “Western” in Islamist circles is fundamentally much older, the fact that it became known led to an additional setback for the polio vaccination campaign.
    • In 2015, one four-year-old and one ten-month-old child developed polio in the Transcarpathian Oblast in southwestern Ukraine . These are the first cases in Europe since 2010. The WHO stated that in 2014 only 49% of all children in Ukraine could be vaccinated against polio due to a lack of vaccine. In children under one year of age, the vaccination rate is only 14.1%.

    Reporting requirement

    In Germany, poliomyelitis is a notifiable illness according to Section 6 (1) of the Infection Protection Act (obligation to notify in the event of suspicion, illness and death). In Austria, polio is a notifiable disease in accordance with Section 1 (1) of the 1950 Epidemic Act (suspected illnesses and deaths). In Switzerland, poliomyelitis is also a reportable disease according to the Epidemics Act (EpG) in conjunction with the Epidemics Ordinance and (Appendix 1) the Ordinance of the FDHA on the reporting of observations of communicable diseases in humans (reporting of clinical suspicions).

    literature

    • German Society for Pediatric Infectious Diseases V. (DGPI) (Ed.): Handbook infections in children and adolescents. 4th edition. Futuramed, Munich 2003, ISBN 3-923599-90-0 .
    • Fabian Feil, Adolf Windorfer, Sabine Diedrich, Eckhard Schreier: From prevention to extinction. WHO project on polio eradication and its monitoring as a health policy challenge for medicine in Germany . In: Deutsches Ärzteblatt . tape 97 (40) , 2000, ISSN  0012-1207 , pp. A2598-A2599 .
    • Adolf Windorfer, Fabian Feil: The fight against poliomyelitis - eradicating an epidemic of civilization . In: Federal Health Gazette . tape 43 , 2000, pp. 2-6 , doi : 10.1007 / s001030050002 .
    • David M. Oshinsky: Polio: An American Story . Oxford University Press, USA 2005, ISBN 0-19-530714-3 .
    • Axel Karenberg : Polio. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 750.
    • Herwig Kollaritsch, Maria Paulke-Korinek: DFP Literature Studies - Poliomyelitis. (PDF) Retrieved January 5, 2020 .
    • Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 184-191.

    Fiction:

    Web links

    Commons : Poliomyelitis  - Collection of Images, Videos, and Audio Files
    Wiktionary: Poliomyelitis  - explanations of meanings, word origins, synonyms, translations
    Wiktionary: Polio  - explanations of meanings, word origins, synonyms, translations

    Individual evidence

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    This version was added to the list of articles worth reading on October 6, 2006 .