acute flaccid paralysis - any case of acute flaccid paralysis in a child under 15 years of age (14 years 11 months 29 days), including Guillain-Barré syndrome, or any paralytic disease, regardless of age, with suspected polio;
acute paralytic poliomyelitis caused by wild polio virus - a case of acute flaccid spinal paralysis with residual effects on the 60th day after onset, in which the “wild” polio virus was isolated (according to ICD 10-A80.1.A80.2);
acute paralytic poliomyelitis associated with a vaccine in a recipient - a case of acute flaccid spinal paralysis with residual effects on the 60th day, which usually occurred no earlier than 4 and no later than 30 days after taking the OPV vaccine, in which the vaccine-derived poliovirus was isolated ( according to ICD 10 - A80.0.);
acute paralytic poliomyelitis associated with the vaccine in a contact - a case of acute flaccid spinal paralysis with residual effects on the 60th day, which usually occurred no later than 60 days after contact with a vaccinated person with OPV vaccine, in which the vaccine-derived poliovirus was isolated (according to the ICD 10 - A80.0.);
acute paralytic poliomyelitis of unspecified etiology - a case of acute flaccid spinal paralysis in which negative laboratory results were obtained (poliomyelitis virus was not isolated) due to inadequate collected material(late detection of the case, late selection, improper storage, insufficient volume of material for research) or laboratory research was not carried out, but residual flaccid paralysis is observed by the 60th day from the moment of its occurrence (according to ICD10 - A80.3.);
acute paralytic poliomyelitis of another, non-poliovirus etiology - a case of acute flaccid spinal paralysis with residual effects on day 60, in which a full adequate laboratory examination was carried out, but the polio virus was not isolated, and a diagnostic increase in antibody titer was not obtained or another neurotropic virus was isolated (according to ICD 10 - A80.3.).
III. Identification, registration, registration of patients with poliomyelitis, acute flaccid paralysis, statistical observation
3.1. Identification of cases of POLI/AFP diseases is carried out by medical workers of organizations engaged in medical activities and other organizations (hereinafter referred to as medical workers of organizations), as well as persons who have the right to engage in private work. medical practice and received a license to carry out medical activities in the manner established by law (hereinafter referred to as private medical workers) when applying for and providing medical care, conducting examinations, examinations, and when carrying out active epidemiological surveillance.
When AFP is detected, priority (“hot”) cases of diseases are identified, which include:
Children with AFP who do not have information about preventive vaccinations against polio;
Children with AFP who do not have a full course of vaccination against polio (less than 3 doses of vaccine);
Children with AFP who arrived from polio-endemic countries (territories);
Children with AFP from migrant families, nomads population groups;
Children with AFP who communicated with migrants, people from nomadic groups,
Children with AFP who had contact with those arriving from countries (territories) endemic (unaffected) with polio;
Persons suspected of having polio, regardless of age.
3.2. If a patient with PIO/AFP is identified, medical workers of organizations and private medical workers are obliged to report this by phone within 2 hours and within 12 hours to send an emergency notification of the established form (N 058/u) to the body exercising state sanitary and epidemiological supervision at the territory where a case of the disease was detected (hereinafter referred to as the territorial body exercising state sanitary and epidemiological supervision).
3.3. Upon receipt emergency notice In case of a case of Polio/AFP, within 24 hours, specialists from the territorial body carrying out state sanitary and epidemiological supervision will organize an epidemiological investigation. Based on the results of the epidemiological investigation and examination of the patient by a neurologist (infectious disease specialist), part 1 of the epidemiological investigation card of POLI/AFP cases is filled out in accordance with the form given in Appendix 2
3.4. Copies of epidemiological investigation cards for polio/AFP cases as they are completed (and parts 2) on electronic and paper media are submitted in the prescribed manner to the Coordination Center for the Prevention of Poliomyelitis and Enterovirus (non-polio) Infection.
3.5. Patients with poliomyelitis or suspected of poliomyelitis (without age restrictions), as well as children under 15 years of age who have been diagnosed with AFP syndrome in any nosological form of the disease, are subject to registration and registration. Registration and accounting are carried out in the “Register of Infectious Diseases” (Form N 060/u) at the place of their detection in medical and other organizations (children’s, adolescents, health and other organizations), as well as by territorial bodies carrying out state sanitary and epidemiological supervision.
3.6. Territorial bodies carrying out state sanitary and epidemiological supervision submit a monthly report to the Coordination Center for the Prevention of Poliomyelitis and Enterovirus (non-polio) Infection (hereinafter referred to as the Coordination Center) on the registration of cases of POLIOT/AFP based on preliminary diagnoses and virological studies in accordance with the form presented in the Appendix 3 to these sanitary rules.
3.8. The list of confirmed cases of Polio/AFP is submitted by the body exercising state sanitary and epidemiological supervision in the constituent entity of the Russian Federation to the Coordination Center within the established time frame in accordance with the form presented in Appendix 4 to these sanitary rules.
IV. Measures for patients with polio, acute flaccid paralysis and carriers of the wild polio virus
4.1. A patient with suspected POLIIO/AFP disease must be hospitalized in a ward infectious diseases hospital. The list of medical organizations to which patients with POLI/AFP are hospitalized is determined by the bodies exercising state sanitary and epidemiological supervision, together with the executive authorities of the constituent entities of the Russian Federation in the field of protecting the health of citizens.
4.2. The referral for hospitalization of a patient with Polio/AFP indicates: personal data, date of illness, initial symptoms of the disease, date of onset of paralysis, treatment provided, information on preventive vaccinations against polio, contact with a patient with Polio/AFP, contact with an OPV vaccine within 60 days, about visiting polio-endemic countries (territories), as well as about communicating with persons arriving from such countries (territories).
4.3. When a patient with POLIIO/AFP is identified, two fecal samples are taken for laboratory virological testing with an interval of 24-48 hours. Samples should be taken as soon as possible, but no later than 14 days from the onset of paresis/paralysis.
If polio (including VAPP) is suspected, paired blood sera are collected. The first serum is taken upon admission of the patient to the hospital, the second - after 2-3 weeks.
In the event of a fatal outcome of the disease, in the first hours after death, sectional material is collected for laboratory research.
Collection and delivery of materials for laboratory research is carried out in accordance with established requirements.
4.4. If acute poliomyelitis is suspected, an immunological status study (immunogram) and electroneuromyography are performed.
4.5. A person who has recovered from polio caused by wild poliovirus can be discharged from the hospital after receiving a single negative result of a virological test.
4.6. In order to identify residual paralysis, a patient with POIO/AVP is examined 60 days from the onset of the disease (provided that the paralysis has not recovered earlier). The examination data is entered into the child’s medical documentation and into part 2 of the epidemiological investigation card of the PIO/AFP case in accordance with the form given in Appendix 2 to these sanitary rules.
4.7. Repeated examination and collection of fecal samples for laboratory testing from patients with poliomyelitis, including VAPP, is carried out on 60 and 90 days from the onset of paresis/paralysis. Examination data and laboratory results are included in the appropriate medical documentation.
4.8. The final diagnosis in each case is established by a commission based on analysis and assessment medical documentation(history of child development, medical history, epidemiological investigation card of a case of POLI/AFP, laboratory test results and others).
4.9. The medical organization that established the initial diagnosis is informed about confirmation of the diagnosis. The final diagnosis is entered into the relevant medical documentation of the patient and part 3 of the card in accordance with the form given in Appendix 2 to these sanitary rules
4.10. Persons who have had polio are subject to immunization against polio with an inactivated vaccine in accordance with their age.
4.11. A carrier of a wild strain of poliovirus (hereinafter referred to as a carrier of wild poliovirus) is isolated in an infectious diseases hospital for epidemic reasons - if there are children in the family who have not been vaccinated against polio, as well as persons belonging to decreed contingents (medical workers, trade workers, public catering workers, children's educational organizations).
When detected, a carrier of wild poliovirus must be immunized three times with the OPV vaccine with an interval between vaccinations of 1 month.
Carriers of wild poliovirus who visit organized groups of children or belong to a decreed contingent are not allowed into groups of children and to professional activity until a negative laboratory test result for wild poliovirus is obtained. Material for virological studies is collected from such individuals before the next dose of OPV vaccine is administered.
V. Sanitary and anti-epidemic (preventive) measures in the outbreak where a patient with POLI/AFP was identified
5.1. A specialist from the territorial body carrying out state sanitary and epidemiological supervision, when identifying a patient with POLIOT/AFP or a carrier of wild poliovirus, conducts an epidemiological investigation, determines the boundaries of the epidemic focus, the circle of people who communicated with the patient with POLIOT/AFP, a carrier of wild poliovirus, and organizes a set of sanitary and anti-epidemic measures ( preventive) measures.
5.2. Sanitary and anti-epidemic (preventive) measures in the outbreak of polio/AFP are carried out by medical and other organizations under the control of territorial bodies carrying out state sanitary and epidemiological supervision.
5.3. In the epidemic focus where a patient with POLI/AFP has been identified, measures are taken in relation to contact children under the age of 5 years:
Medical examination by doctors - pediatrician and neurologist (infectious disease specialist);
Taking one fecal sample for laboratory testing (in the cases provided for in paragraph 5.5);
Single immunization with OPV vaccine (or inactivated polio vaccine - IPV - in the cases provided for in paragraph 5.4.) regardless of previous preventive vaccinations against this infection, but not earlier than 1 month after the last immunization against polio.
5.4. Children who have not been vaccinated against polio, who have been vaccinated once with the IPV vaccine, or who have contraindications to the use of the OPV vaccine, are vaccinated with the IPV vaccine.
5.5. Taking one fecal sample from children under 5 years of age for laboratory testing in epidemic foci of Polio/AFP is carried out in the following cases:
Late detection and examination of patients with POLI/AFP (later than 14 days from the onset of paralysis);
Incomplete examination of patients with POLI/AFP (1 stool sample);
If you are surrounded by migrants, nomadic population groups, as well as those arriving from polio-endemic (polio-affected) countries (territories);
When identifying priority ("hot") cases of AFP.
5.6. Taking samples of feces from contact children under 5 years of age for laboratory testing is carried out before immunization, but not earlier than 1 month after last vaccination against polio with OPV vaccine.
VI. Sanitary and anti-epidemic (preventive) measures in the outbreak where a patient with poliomyelitis caused by a wild strain of poliovirus or a carrier of wild poliovirus has been identified
6.1. Activities in an outbreak where a patient with poliomyelitis caused by a wild strain of poliovirus or a carrier of wild poliovirus have been identified are carried out in relation to all persons, regardless of age, who have had contact with them, and include:
Primary medical examination of contact persons by a therapist (pediatrician) and a neurologist (infectious disease specialist);
Daily medical observation for 20 days with registration of observation results in the relevant medical documentation;
A one-time laboratory examination of all contact persons (before additional immunization);
Additional immunization of contact persons against polio as soon as possible, regardless of age and previous preventive vaccinations.
6.2. Additional immunization is organized:
Adults, including medical workers - once, OPV vaccine;
Children under 5 years of age - in accordance with clause 5.3. these sanitary rules;
Children under 15 years of age who arrived from countries (territories) endemic (problematic) for poliomyelitis, once (if there is information about vaccinations received in the Russian Federation) or three times (without information about vaccinations, if there are vaccinations carried out in another country ) - OPV vaccine;
Pregnant women who do not have information about preventive vaccinations against polio or have not been vaccinated against polio - a single dose of IPV vaccine.
6.3. In the population or in the territory where a patient with polio caused by wild poliovirus (a carrier of wild poliovirus) has been identified, an analysis of the state of vaccination is carried out with the organization of the necessary additional anti-epidemic and preventive measures.
6.4. In the outbreak of polio after hospitalization of the patient, current and final disinfection is carried out using disinfectants approved for use in the prescribed manner and having virucidal properties, in accordance with the instructions/guidelines for their use. Organization and conduct of final disinfection are carried out in accordance with the established procedure.
VII. Organization of laboratory tests of biological material from patients with poliomyelitis, patients with suspected POLIOS/AFP
7.1. From a patient with polio, with suspicion of this disease and AFP, two fecal samples are taken at the maximum early dates from the moment of onset of paresis/paralysis (but no later than 14 days). The material is collected by medical workers of the treatment and prevention organization where the patient is hospitalized. The first fecal sample is taken in the hospital on the day of clinical diagnosis, the second - 24-48 hours after taking the first sample. The optimal size of a fecal sample is 8-10 g, which corresponds to the size of two nails thumb adult.
7.2. The collected samples are placed in special plastic containers with screw caps for collecting fecal samples and delivered to the Regional Center for Epidemiological Surveillance of Poliomyelitis and AFP (hereinafter referred to as the RC for POLIO/AFP) or to the National Laboratory for the Diagnostics of Poliomyelitis (hereinafter referred to as the NLDP), depending on the diagnosis and classification of AFP cases.
7.3. Delivery of the collected samples to the RC for Polio/ACP or to the NLDP must be carried out within 72 hours from the moment the second sample was taken. Samples are stored before shipment and during transportation at a temperature of 2 to 8 degrees C. In some cases, if delivery of samples to the virology laboratory of the Republican Center for Polio/AFP or to the NLDP will be carried out at a later date, then the samples are frozen at a temperature of minus 20 degrees C and delivered frozen.
7.4. Samples are delivered with a referral for laboratory testing, which is drawn up in 2 copies in accordance with the form presented in Appendix 5 to these sanitary rules.
7.5. The territorial body carrying out sanitary and epidemiological supervision, responsible for sending the material, informs the RC for Polio/OVP or the NLDP in advance about the route of its departure.
7.6. Sent to NLDP for research biological materials from all subjects of the Russian Federation in the cases specified in clauses 7.7.-7.9. of these rules.
7.7. For virological studies, fecal samples are sent to the NLDP from:
Patients with polio (including VAPP) with suspected these diseases;
Patients with priority (“hot”) cases of AFP;
Contacts in the epidemic focus with a patient with polio (including VAPP), with suspicion of these diseases, with a priority (“hot”) case of AFP.
Persons traveling to polio-endemic countries (territories) who are not vaccinated against this infection, who do not have information about vaccinations against polio, and also at the request of the receiving party; persons who have not been vaccinated against polio, regardless of age, are recommended to get vaccinated at least 10 days before departure;
For children under the age of 15 years who arrived from countries (territories) endemic (problematic) for polio, who are not vaccinated against this infection, and who do not have information about vaccinations against polio, immunization against polio is carried out once (upon arrival), subsequent vaccinations are carried out in in accordance with the national calendar of preventive vaccinations;
Children under 15 years of age from migrant families, nomadic groups of the population, not vaccinated against this infection, who do not have information about vaccinations against polio - immunization against polio is carried out once (at the place of their detection), subsequent vaccinations are carried out at the place of their residence in accordance with national calendar of preventive vaccinations;
Persons with negative results of a serological study of the level of individual immunity to poliomyelitis to all three types of poliovirus or to one of the types of poliovirus - immunization is carried out twice with an interval of 1 month;
Persons working with material infected or potentially infected with a “wild” strain of poliovirus - once upon entry to work, then in accordance with the requirements of clause 8.7.
8.7. Persons working in the laboratory and having contact with material infected or potentially infected with the “wild” strain of poliovirus are examined every five years for the strength of immunity to polioviruses; based on the results of the examination, the issue of additional immunization is decided.
8.8. Immunization against polio according to epidemic indications in the territory (in the population) in the form of additional immunization campaigns is carried out:
In the territory (in the population) where the importation of wild poliovirus or the circulation of vaccine-related polioviruses has been detected;
In the territory (in the population) where a case of polio caused by wild poliovirus has been registered;
In an area (in a population) where wild poliovirus has been isolated in materials from people or objects environment;
On the territory of a constituent entity of the Russian Federation (in cities, districts, settlements, medical organizations, at medical and paramedic stations, in preschool organizations and general educational institutions) with a low (less than 95%) level of vaccination coverage against polio among children within the prescribed period: vaccination at the age of 12 months and a second revaccination against polio at the age of 24 months;
On the territory of a constituent entity of the Russian Federation (in cities, districts, settlements, at medical and paramedic stations, in preschool organizations and educational institutions) with a low (less than 80%) level of seropositive results serological monitoring individual age groups children in representative studies;
On the territory of a constituent entity of the Russian Federation (in cities, districts, settlements, at medical clinics, paramedic stations, in preschool organizations and educational institutions) with unsatisfactory quality indicators of epidemiological surveillance of polio and acute flaccid paralysis (no detection of AFP in the subject for 2 years) .
8.9. Additional immunization against polio is carried out in the form of organized immunization campaigns throughout the country (National Immunization Days), in individual constituent entities of the Russian Federation (Subnational Immunization Days), in certain territories (districts, cities, towns, pediatric areas and others) in addition to routine immunization of the population against polio and targets a specific age group, regardless of vaccination status. Additional immunization against polio is carried out in accordance with the resolution of the Chief State Sanitary Doctor of the Russian Federation, which determines the age of those subject to additional immunization against polio, the timing, procedure and frequency of its implementation.
8.10. Additional immunization on the territory of a constituent entity of the Russian Federation, in certain territories (districts, cities, towns, medical organizations, pediatric sites, paramedic stations, children's educational organizations) is carried out in the form of additional immunization campaigns in accordance with the resolution of the Chief State Sanitary Doctor of the constituent entity of the Russian Federation, which determines the age of those subject to immunization against polio, the timing, location (district, city, town, etc.), the procedure and frequency of its implementation.
8.11. Immunization against polio according to epidemic indications (additional immunization) is carried out regardless of previously administered preventive vaccinations against this infection, but not earlier than 1 month after the last immunization against polio.
If the timing of immunization against polio of children for epidemic reasons coincides with the age regulated by the National Calendar of Preventive Vaccinations, immunization is counted as planned.
8.12. Information on immunization against polio according to epidemic indications is entered into the appropriate medical records.
8.13. Subsequent preventive vaccinations against polio for children are carried out in accordance with age within the framework of the national calendar of preventive vaccinations.
8.14. Additional immunization against polio with OPV for children at risk is carried out regardless of the date of arrival, if detected, without preliminary or additional serological testing.
8.15. A report on additional immunization against polio in children for epidemic indications is submitted in the prescribed form and within the established time frame.
8.16. The main criteria for assessing the quality and effectiveness of additional immunization against polio for children with OPV is the timeliness and completeness of vaccination coverage of at least 95% of total number children subject to additional immunization.
IX. Measures to prevent vaccine-associated polio (VAPP) cases
9.1. To prevent VAPP in a vaccine recipient:
The first 2 vaccinations against polio are carried out with the IPV vaccine within the time limits established by the national calendar of preventive vaccinations - for children under one year old, as well as for older children who have not received vaccination against polio previously;
Children who have contraindications to the use of the OPV vaccine are immunized against polio only with the IPV vaccine within the time limits established by the national schedule of preventive vaccinations.
9.2. To prevent VAPP in contacts of children who have received OPV vaccinations, measures are taken in accordance with paragraphs 9.3-9.7 of these sanitary rules.
9.3. When children are hospitalized in a hospital, the referral for hospitalization indicates the child’s vaccination status (number of vaccinations given, date of the last vaccination against polio and the name of the vaccine).
9.4. When the wards in medical organizations are full, it is not allowed to hospitalize children who have not been vaccinated against polio in the same ward with children who have received the OPV vaccine within the last 60 days.
9.5. In medical organizations, preschool organizations and general educational institutions, summer health organizations, children who do not have information about immunization against polio, who have not been vaccinated against polio, or who have received less than 3 doses of polio vaccine, are separated from children vaccinated with OPV vaccine within the last 60 days for a period 60 days from the date the children received their last OPV vaccine.
9.6. In closed children's groups (orphanages and others), in order to prevent the occurrence of contact cases of VAPP caused by the circulation of vaccine strains of polioviruses, only the IPV vaccine is used for vaccination and revaccination of children.
9.7. When immunizing one of the children in the family with the OPV vaccine, the medical worker must check with the parents (guardians) whether there are children in the family who have not been vaccinated against polio, and if there are any, recommend vaccinating the unvaccinated child (in the absence of contraindications) or separating the children for a period of 60 days .
X. Serological monitoring of population immunity to polio
10.1. Serological monitoring of population immunity to polio is organized by territorial bodies exercising state sanitary and epidemiological control, together with health authorities of the constituent entity of the Russian Federation in the field of public health in order to obtain objective data on the state of population immunity to polio in accordance with current regulatory and methodological documents .
10.2. The results of serological tests must be included in the appropriate medical records.
10.3. A report on serological monitoring of population immunity to polio is submitted in the prescribed manner.
XI. Activities aimed at detecting the importation of wild poliovirus, the circulation of wild or vaccine-related polioviruses
In order to timely detect the importation of wild poliovirus and the circulation of vaccine-related polioviruses:
11.1. Territorial bodies carrying out state sanitary and epidemiological supervision organize:
Periodically informing medical and other organizations about the global epidemiological situation regarding polio;
Active epidemiological surveillance of Polio/AFP in medical organizations;
Door-to-door (door-to-door) inspections for epidemic indications;
Additional laboratory testing of fecal samples for polioviruses in specific population groups;
Laboratory research of environmental objects;
Identification of all strains of polioviruses, other (non-polio) enteroviruses isolated in fecal samples from environmental objects;
Monitoring compliance with sanitary legislation requirements to ensure biological safety of work in virology laboratories.
11.2. Additional laboratory tests are carried out on fecal samples for polioviruses in children under 5 years of age:
From migrant families, nomadic population groups;
From families arriving from polio-endemic countries (territories);
Healthy children - selectively (according to epidemiological indications in accordance with paragraph 11.3 of these sanitary rules and as part of surveillance to monitor the circulation of enteroplioviruses).
11.3. Epidemiological indications for laboratory testing of fecal samples from healthy children for polioviruses are:
Lack of registration of AFP cases in a constituent entity of the Russian Federation during the reporting year;
Low indicators of quality, efficiency and sensitivity of epidemiological surveillance of Polio/AFP (detection of less than 1 case of AFP per 100 thousand children under 15 years of age, late detection and examination of AFP cases);
Low (less than 95%) rates of immunization against polio among children in decreed groups;
Unsatisfactory results of serological monitoring of population immunity to poliovirus (seropositivity rate less than 80%).
11.4. Laboratory tests are carried out when those specified in paragraph 11.2 are identified. contingents of children, regardless of the date of their arrival, but not earlier than 1 month. after the last immunization against polio with OPV.
Organization and conduct of laboratory tests of samples of feces, material from environmental objects and their delivery to the laboratory are carried out in accordance with Chapter VII of these sanitary rules.
XII. Measures in case of importation of wild poliovirus, detection of circulation of vaccine-related polioviruses
12.1. In the event of the importation of wild poliovirus or the detection of the circulation of vaccine-related polioviruses, territorial bodies carrying out state epidemiological surveillance, together with executive authorities of the constituent entities of the Russian Federation in the field of protecting the health of citizens, carry out a set of organizational and sanitary-anti-epidemic (preventive) measures aimed at preventing the spread of infection.
12.2. Organize an epidemiological investigation of cases of diseases suspected of poliomyelitis, cases of isolation of wild poliovirus, vaccine-related polioviruses in fecal samples, material from environmental objects in order to identify the possible source of infection, routes and factors of transmission.
12.3. They are working to identify children who have not been vaccinated against polio and who do not have medical contraindications to vaccination, and immunize them in accordance with the national calendar of preventive vaccinations.
12.4. Organize supplementary immunization campaigns as quickly as possible. It is recommended that the first round of immunization be carried out within four weeks from the moment of detection of the first confirmed case (carrier) of polio caused by wild or vaccine-related poliovirus, and detection of circulation of wild poliovirus in environmental objects. The procedure for additional immunization is set out in paragraphs. 8.8.-8.16.
12.5. Take measures to strengthen active epidemiological surveillance of Polio/AFP, including:
Expanding the list of objects of active epidemiological surveillance;
Conducting a retrospective analysis of medical records to actively identify unregistered patients with suspected POLIIO/AFP;
Organizing door-to-door (door-to-door) visits to identify missed cases of AFP.
12.6. An assessment is made of the degree of risk of the spread of infection, taking into account the number of detected cases, the intensity of migration flows of the population, the number of children who have not been vaccinated against polio, and the quality indicators of epidemiological surveillance of Polio/AFP.
12.7. They are expanding the population for laboratory testing of fecal samples and increasing the volume of research.
12.8. They are expanding the list of environmental objects for laboratory research and increasing the volume of research.
12.9. Strengthen control over compliance with biological safety requirements in virology laboratories.
12.10. Organize informing medical workers and the population about the epidemiological situation and measures to prevent polio.
XIII. Safe handling of materials contaminated or potentially contaminated with wild poliovirus
In order to prevent intra-laboratory contamination with wild poliovirus, the release of the pathogen into the human population from virology laboratories, work with materials infected or potentially infected with wild poliovirus, or storing such materials, must be carried out in strict accordance with biological safety requirements.
XIV. Monitoring the circulation of polioviruses in environmental objects
14.1. In order to monitor the circulation of polioviruses in environmental objects (EPS), a virological method is used to study materials from the EPA (wastewater).
Research is carried out by virological laboratories of the Federal Budgetary Institution of Health "Center for Hygiene and Epidemiology" in the constituent entities of the Russian Federation, RCs for Polio/AFP, NLDP on a planned basis and according to epidemic indications.
14.2. When conducting planned research, the objects of research are wastewater generated in the territory where surveillance is carried out in relation to certain groups of the population. Sampling locations are determined jointly with representatives of the engineering service. In accordance with the set goals, untreated wastewater is examined. Wastewater that may be contaminated with industrial waste is not selected for research.
14.3. The duration of planned studies should be at least one year (the optimal period is 3 years), the collection frequency should be at least 2 samples per month.
XV. Organization of state sanitary and epidemiological surveillance of polio and acute flaccid paralysis
15.1. Epidemiological surveillance of POLI/AFP is carried out by bodies carrying out state sanitary and epidemiological surveillance in accordance with the legislation of the Russian Federation.
15.2. The effectiveness and sensitivity of epidemiological surveillance of Polio/AFP is determined by the following indicators recommended by the World Health Organization:
Identification and registration of cases of POLIOS/AFP - at least 1.0 per 100 thousand children under 15 years of age;
The timeliness of identifying patients with POLI/AFP (no later than 7 days from the onset of paralysis) is at least 80%;
The adequacy of fecal sampling from patients with POLI/AFP for virological research (taking 2 samples no later than 14 days from the onset of the disease) is at least 80%;
The completeness of laboratory tests of fecal samples from patients with POLI/AFP (2 samples from one patient) in the RC for POLI/AFP and NCLPDP is at least 100%;
Timeliness (no later than 72 hours from the moment of taking the second fecal sample) of delivery of samples from patients with Polio/AFP to the RC for Polio/AFP, NCLPDP - at least 80%;
The proportion of fecal samples received by the laboratory for research that meet the established requirements (satisfactory samples) is at least 90%;
Timely submission of results by the laboratory (no later than 15 days from the date of receipt of the sample if the test result is negative and no later than 21 days if the test result is positive) to the institution that sent the samples - at least 90%;
Epidemiological investigation of POLIOS/AFP cases within 24 hours after registration - at least 90%;
Repeated examination of patients with POLI/AFP 60 days from the onset of paralysis - at least 90%;
The proportion of polio patients examined virologically on days 60 and 90 from the onset of paralysis is at least 90%;
The final classification of POLI/AFP cases 120 days from the onset of paralysis is at least 100%;
Timely submission of monthly information on the incidence of Polio/AFP (including zero) in a timely manner and in accordance with the established procedure - at least 100%;
Timeliness of submission of copies of epidemiological investigation cards of cases of Polio/AFP diseases in a timely manner and in the prescribed manner - at least 100%;
The completeness of presentation in a timely manner and in the prescribed manner of isolates of polioviruses and other (non-polio) enteroviruses isolated in fecal samples from people and from environmental objects is at least 100%.
15.3. Activities to prevent polio are carried out within the framework of the implementation of the National Action Plan to maintain the polio-free status of the Russian Federation, the corresponding action plans to maintain the polio-free status of the constituent entities of the Russian Federation and the established requirements of federal legislation in the field of diagnosis, epidemiology and prevention of polio.
15.4. An action plan to maintain the polio-free status of a constituent entity of the Russian Federation is developed by the executive authorities of the constituent entities of the Russian Federation in the field of protecting the health of citizens together with the bodies exercising state sanitary and epidemiological supervision, and is approved in the prescribed manner, taking into account specific local conditions and the epidemiological situation.
In the constituent entities of the Russian Federation, a plan for conducting active epidemiological surveillance of Polio/AFP is annually developed and approved.
15.5. Documentation confirming the polio-free status of a subject of the Russian Federation is prepared and submitted by the subject of the Russian Federation in the prescribed manner.
15.6. The executive authorities of the constituent entities of the Russian Federation in the field of protecting the health of citizens, together with the bodies exercising state sanitary and epidemiological supervision in the constituent entities of the Russian Federation, are creating Commissions for the diagnosis of polio and acute flaccid paralysis (hereinafter referred to as the Diagnostics Commission).
15.7. If there are laboratories in a subject of the Russian Federation that store a wild strain of poliovirus or work with material potentially infected with a wild strain of poliovirus, the body exercising sanitary and epidemiological supervision in the subject of the Russian Federation shall create a Commission for the safe laboratory storage of wild polioviruses.
The activities of the commissions are carried out in accordance with the established procedure.
15.8. National commissions provide organizational and methodological assistance to the constituent entities of the Russian Federation: Commission for the Diagnosis of Poliomyelitis and Acute Flaccid Paralysis, Commission for Safe Laboratory Storage of Wild Polioviruses, Commission for Certification of Poliomyelitis Eradication.
The organizational structure of the bodies and organizations implementing the National Action Plan to maintain the polio-free status of the Russian Federation is presented in Appendix 6 to these sanitary rules.
XVI. Hygienic education of the population on the prevention of polio
16.1. In order to increase sanitary literacy, hygienic education of the population is carried out, which includes informing about the main clinical forms, symptoms of polio, preventive measures, the global situation on the incidence of polio, with the involvement of funds mass media and the release of visual propaganda tools: leaflets, posters, bulletins, as well as conducting individual interviews.
16.2. Work on organizing and conducting information and explanatory work among the population is carried out by bodies exercising state sanitary and epidemiological supervision, executive authorities of the constituent entities of the Russian Federation in the field of protecting the health of citizens and organizing healthcare, and medical prevention centers.
- Appendix 1. Codes for the final classification of cases of diseases with acute flaccid paralysis syndrome (in accordance with the International Classification of Diseases, 10th revision)
Resolution of the Chief State Sanitary Doctor of the Russian Federation dated July 28, 2011 N 107
"On approval of SP 3.1.2951-11 "Prevention of polio"
2. Put into effect the specified sanitary and epidemiological rules from the date of entry into force of this resolution.
3. From the moment of the introduction of SP 3.1.2951-11, the sanitary and epidemiological rules SP 3.1.1.2343-08 “Prevention of polio in the post-certification period”, approved by the Decree of the Chief State Sanitary Doctor of the Russian Federation 03/05/2008 N 16, are considered invalid (registered with the Ministry of Justice Russian Federation 04/01/2008, registration N 11445), put into effect by the specified resolution from 06/01/2008.
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G. Onishchenko |
New sanitary and epidemiological rules regarding the prevention of polio have been developed.
Acute poliomyelitis is an infection of viral etiology. It is characterized by a variety of clinical forms - from abortive to paralytic.
The source of infection is a person, a patient or a carrier. Poliovirus appears in nasopharyngeal secretions 36 hours later and in feces 72 hours after infection.
The incubation period for acute polio ranges from 4 to 30 days. Most often it lasts from 6 to 21 days.
The pathogen is transmitted by water, food and household routes, as well as by airborne droplets and airborne dust.
The disease is recorded mainly in children who are not vaccinated against polio or are vaccinated in violation of the preventive vaccination schedule.
It is detected during requests for and provision of medical care, examinations, examinations, and active epidemiological surveillance.
A patient with suspected disease should be hospitalized in an infectious diseases hospital. When such a patient is identified, 2 fecal samples are taken for laboratory virological testing with an interval of 24-48 hours. They must be taken as soon as possible, but no later than 14 days from the onset of paresis/paralysis.
At least 95% of the total number of children to be vaccinated at the age of 12 months must be vaccinated and the same number at the second revaccination at the age of 24 months.
Sanitary and epidemiological rules come into force from the date the resolution comes into force. From this moment SP 3.1.1.2343-08 “Prevention of polio during the post-certification period” loses its force.
Resolution of the Chief State Sanitary Doctor of the Russian Federation dated July 28, 2011 N 107 “On approval of SP 3.1.2951-11 “Prevention of polio”
Registration N 22378
This resolution comes into force 10 days after the day of its official publication
Poliomyelitis ( infantile paralysis ) is caused by a virus and is a highly contagious viral infection. In its most serious form, polio can cause rapid and irreversible paralysis; until the late 1950s, it was one of the most dangerous infectious diseases and often occurred in epidemics. Post-polio syndrome or post-polio progressive muscular atrophy can occur 30 years or more after the initial infection, gradually leading to muscle weakness, wasting, and pain. Polio can be prevented by building immunity and is now virtually extinct in developed countries; however, the risk of disease still exists. Polio is still common in many countries around the world, and there is no way to cure it; therefore, until the polio virus is eradicated, vaccination remains the main method of protection.
In summer and early autumn, when polio epidemics most often occur, parents first of all remember it when their child gets sick. The disease, like many other infections, begins with general malaise, fever and headache. Vomiting, constipation, or mild diarrhea may occur. But even if your child has all these symptoms, plus leg pain, you should not rush to conclusions. There's still a good chance it's the flu or a sore throat. Of course, you call a doctor anyway. If he is away for a long time, you can reassure yourself this way: if the child can lower his head between his knees or tilt his head forward so that his chin touches his chest, he probably does not have polio. (But even if it fails these tests, it is still not proof of disease.)
Despite significant progress in eradicating polio in our country, the problem of diseases accompanied by acute flaccid paralysis (AFP) has not lost its relevance. Pediatricians often have to deal with various infectious diseases of the brain and spinal cord, peripheral nerves. The study of the structure of neuroinfections indicates that lesions of the peripheral nervous system occur in 9.6% of patients, infectious diseases of the spinal cord - in 17.7%. Among the latter, acute infectious myelopathies predominate, while acute paralytic vaccine-associated poliomyelitis, acute myelopathy, and enceare much less common. In this regard, in modern conditions it is necessary to pay special attention to the differential diagnosis of AFP, monitoring the epidemic situation, which will avoid overdiagnosis, improve treatment results, and reduce the frequency of unfounded registration of post-vaccination complications.
Acute paralytic poliomyelitis is a group of viral diseases united according to the topical principle, characterized by flaccid paresis, paralysis caused by damage to motor cells in the anterior horns of the spinal cord and the nuclei of the motor cranial nerves of the brain stem.
Etiology. Etiological structure Infectious diseases of the nervous system are diverse. Among the etiological factors are “wild” polioviruses type 1, 2, 3, vaccine polioviruses, enteroviruses (ECHO, Coxsackie), herpesviruses (HSV, HHV type 3, EBV), influenza virus, mumps virus, diphtheria bacillus, borrelia, UPF (staphylococci, gram-negative bacteria).
Of particular interest is spinal paralysis caused by the “wild” polio virus, which belongs to the picornavirus family, a genus of enteroviruses. The pathogen is small in size (18-30 nm) and contains RNA. Virus synthesis and maturation occur inside the cell.
Polioviruses are not sensitive to antibiotics and chemotherapy. When frozen, their activity persists for several years, in a household refrigerator - for several weeks, at room temperature - for several days. At the same time, polio viruses are quickly inactivated when treated with formaldehyde, free residual chlorine, and do not tolerate drying, heating, or ultraviolet irradiation.
The polio virus has three serotypes - 1, 2, 3. Its cultivation in laboratory conditions is carried out by infecting various tissue cultures and laboratory animals.
Causes
Poliomyelitis is caused by a viral infection with one of three forms of the polio virus.
The virus can be transmitted through contaminated food and water or through contaminated saliva during a cough or sneeze.
The source of infection is a sick person or carrier. The greatest epidemiological significance is the presence of the virus in the nasopharynx and intestines, from where it is released into the external environment. In this case, the release of the virus in feces can last from several weeks to several months. The nasopharyngeal mucus contains the polio pathogen for 1-2 weeks.
The main routes of transmission are nutritional and airborne.
Under conditions of mass specific prevention, sporadic cases were recorded throughout the year. Mostly children under seven years of age were ill, of which the proportion of patients early age reached 94%. The infectiousness index is 0.2-1%. Mortality among unvaccinated people reached 2.7%.
In 1988, the World Health Organization raised the question of the complete eradication of polio caused by the “wild” virus. In this regard, 4 main strategies have been adopted to combat this infection:
1) achieving and maintaining a high level of population coverage with preventive vaccinations;
2) carrying out additional vaccinations on national immunization days (NDIs);
3) creation and operation of an effective epidemiological surveillance system for all cases of acute flaccid paralysis (AFP) in children under 15 years of age with mandatory virological examination;
4) carrying out additional “cleaning up” immunization in disadvantaged areas.
At the time of the adoption of the Global Polio Eradication Program, the number of patients in the world was 350,000. However, by 2003, thanks to ongoing activities, their number dropped to 784. Three regions of the world are already free from polio: American (since 1994), Western Pacific (since 2000) and European (since 2002). However, polio caused by wild poliovirus continues to be reported in the Eastern Mediterranean, African and South-East Asia regions. India, Pakistan, Afghanistan, and Nigeria are considered endemic for polio.
Since December 2009, an outbreak of polio caused by type 1 poliovirus has been registered in Tajikistan. It is assumed that the virus came to Tajikistan from neighboring countries - Afghanistan, Pakistan. Taking into account the intensity of migration flows from the Republic of Tajikistan to the Russian Federation, including labor migration and active trade relations, the “wild” polio virus was imported into the territory of our country, cases of polio in adults and children were registered.
Russia began implementing the Global Polio Eradication Program on its territory in 1996. Thanks to maintaining high level vaccination coverage of children of the 1st year of life (more than 90%), improved epidemiological surveillance, the incidence of this infection in Russia decreased from 153 cases in 1995 to 1 in 1997. By decision of the European Regional Certification Commission in 2002, the Russian Federation received polio-free status.
Before switching to use inactivated vaccine Against polio in Russia, diseases caused by vaccine polioviruses were recorded (1 - 11 cases per year), which usually occurred after the first dose of live OPV was administered.
Diagnostics
Medical history and physical examination.
Blood tests.
Lumbar puncture (spinal tap).
Laboratory diagnostics. Only based on the results of virological and serological studies can a final diagnosis of polio be made.
The following are subject to virological testing for polio in the laboratories of regional centers for epidemiological surveillance of polio/AFP:
- sick children under 15 years of age with symptoms of acute flaccid paralysis;
- contact children and adults from foci of poliomyelitis and AFP in the case of late (later than the 14th day from the moment of detection of paralysis) examination of the patient, as well as if there are people around the patient who arrived from areas unfavorable for poliomyelitis, refugees and internally displaced persons (one-time) ;
- children under 5 years of age who arrived within the last 1.5 months from the Chechen Republic, the Republic of Ingushetia and applied for medical care to medical and preventive institutions, regardless of the profile (once).
Patients with clinical signs polio or acute flaccid paralysis are subject to mandatory 2-fold virological examination. The first fecal sample is taken within 24 hours of diagnosis, the second sample is taken 24-48 hours later. The optimal volume of feces is 8-10 g. The sample is placed in a sterile special plastic container. If the delivery of collected samples to the regional polio/AFP surveillance center will be carried out within 72 hours from the date of collection, then the samples are placed in a refrigerator at a temperature of 0 to 8 ° C and transported to the laboratory at a temperature of 4 to 8 ° C (reverse cold). chain). In cases where the material is planned to be delivered to the virology laboratory at a later date, the samples are frozen at a temperature of -20 °C and transported frozen.
The frequency of virus isolation in the first two weeks is 80%, in the 5th-6th week - 25%. No permanent carriage was detected. Unlike the Coxsackie and ECHO viruses, the polio virus is isolated extremely rarely from the cerebrospinal fluid.
In case of death, material is taken from the cervical and lumbar extensions of the spinal cord, cerebellum and contents colon. With paralysis lasting 4-5 days, it is difficult to isolate the virus from the spinal cord.
The following are subject to serological examination:
— patients with suspected polio;
- children under the age of 5 years who arrived during the last 1.5 months from the Chechen Republic, the Republic of Ingushetia and sought medical care in medical institutions, regardless of their profile (one time).
For serological testing, two samples of the patient’s blood (5 ml each) are taken. The first sample should be taken on the day of the initial diagnosis, the second - after 2-3 weeks. Blood is stored and transported at a temperature of 0 to +8 °C.
RSC detects complement-fixing antibodies to the N- and H-antigens of poliovirus. In the early stages, only antibodies to the H-antigen are detected, after 1-2 weeks - to the H- and N-antigens, in those who have recovered - only N-antigens.
During the first infection with poliovirus, strictly type-specific complement-fixing antibodies are formed. Upon subsequent infection with other types of polioviruses, antibodies are formed predominantly to heat-stable group antigens, which are present in all types of polioviruses.
PH detects virus-neutralizing antibodies in the early stages of the disease; it is possible to detect them during the hospitalization of the patient. Virus-neutralizing antibodies can be detected in urine.
RP in agar gel reveals precipitins. Type-specific precipitating antibodies can be detected during the recovery period and circulate for a long time. To confirm the increase in antibody titers, paired sera are examined with an interval of 3-4 weeks; a dilution of the serum that is 3-4 times or more higher than the previous one is taken as a diagnostic increase. The most effective method is ELISA, which allows one to quickly determine a class-specific immune response. It is mandatory to carry out PCR to detect RNA viruses in individual feces and cerebrospinal fluid.
Symptoms
Fever.
Headache and sore throat.
Stiff neck and back.
Nausea and vomiting.
Muscle pain, weakness, or spasms.
Difficulty swallowing.
Constipation and urinary retention.
Irritability.
Extreme symptoms; muscle paralysis; difficulty breathing.
Pathogenesis. The entry point for infection in polio is the mucous membrane of the gastrointestinal tract and upper respiratory tract. The virus multiplies in lymphatic formations the posterior wall of the pharynx and intestines.
Overcoming the lymphatic barrier, the virus penetrates the blood and is carried by its current throughout the body. Fixation and reproduction of the polio pathogen occurs in many organs and tissues - lymph nodes, spleen, liver, lungs, heart muscle and, especially, in brown fat, which is a kind of virus depot.
Penetration of the virus into the nervous system is possible through the endothelium of small vessels or along peripheral nerves. Distribution within the nervous system occurs along cell dendrites and possibly through intercellular spaces. When the virus interacts with cells of the nervous system, the most profound changes develop in motor neurons. The synthesis of polioviruses occurs in the cytoplasm of the cell and is accompanied by suppression of the synthesis of DNA, RNA and proteins of the host cell. The latter dies. Within 1-2 days, the titer of the virus in the central nervous system increases, and then begins to fall and soon the virus disappears.
Depending on the state of the macroorganism, the properties and dose of the pathogen pathological process can stop at any stage of viral aggression. In this case, various clinical forms polio. In most infected children, due to an active reaction immune system the virus is eliminated from the body and recovery occurs. Thus, with the inapparant form, there is a nutritional phase of development without viremia and invasion into the central nervous system, with the abortive form, there are nutritional and hematogenous phases. Clinical variants accompanied by damage to the nervous system are characterized by the sequential development of all phases with damage to motor neurons on different levels.
Pathomorphology. Morphologically, acute poliomyelitis is most characterized by damage to large motor cells located in the anterior horns of the spinal cord and the nuclei of the motor cranial nerves in the brain stem. In addition, the pathological process may involve the motor area of the cerebral cortex, the nuclei of the hypothalamus, and the reticular formation. In parallel with damage to the spinal cord and brain, the soft meninges are involved in the pathological process, in which acute inflammation develops. At the same time, the number of lymphocytes and protein content in the cerebrospinal fluid increase.
Macroscopically, the spinal cord appears swollen, the border between the gray and white matter is blurred, and in severe cases, the cross section shows retraction of the gray matter.
Microscopically, in addition to swollen or completely disintegrated cells, unchanged neurons are found. This “mosaic” nature of the lesion nerve cells clinically manifested by an asymmetric, random distribution of paresis and paralysis. In place of dead neurons, neuronophagic nodules are formed, followed by the proliferation of glial tissue.
Classification
According to modern requirements, the standard definition of polio and acute flaccid paralysis (AFP) is based on the results of clinical and virological diagnostics (Appendix 4 to Order M3 of the Russian Federation No. 24 dated January 25, 1999) and is presented as follows:
- acute flaccid spinal paralysis, in which the “wild” polio virus is isolated, is classified as acute paralytic poliomyelitis (according to ICD 10 revision A.80.1, A.80.2);
- acute flaccid spinal paralysis that occurred no earlier than the 4th and no later than the 30th day after taking the live polio vaccine, in which the vaccine-derived poliovirus was isolated, is classified as acute paralytic polio associated with the vaccine in the recipient (according to ICD 10 revision A .80.0);
- acute flaccid spinal paralysis that occurs no later than the 60th day after contact with a vaccinated person in which vaccine-derived poliovirus is isolated is classified as acute paralytic poliomyelitis associated with a vaccine in a contact (according to ICD 10 revision A.80.0). Isolation of vaccine-derived poliovirus in the absence of clinical manifestations does not have diagnostic value;
- acute flaccid spinal paralysis, in which the examination was not carried out completely (the virus was not isolated) or was not carried out at all, but residual flaccid paralysis is observed by the 60th day from the moment of their onset, is classified as acute paralytic poliomyelitis, unspecified (according to ICD 10 revision A .80.3);
- acute flaccid spinal paralysis, in which a full adequate examination was carried out, but the virus was not isolated and no diagnostic increase in antibodies was obtained, is classified as acute paralytic poliomyelitis of another, non-poliomyelitis etiology (according to ICD 10 revision A.80.3).
Isolation of a “wild” strain of the virus from a patient with catarrhal, diarrheal or meningeal syndromes without the occurrence of flaccid paresis or paralysis is classified as acute non-paralytic poliomyelitis (A.80.4.)
Acute flaccid spinal paralysis with the release of other neurotropic viruses (ECHO, Coxsackie viruses, herpes viruses) refers to diseases of a different, non-poliomyelitis etiology.
All these diseases, based on the topical principle (damage to the anterior horns of the spinal cord), appear under the general name “Acute poliomyelitis”.
Classification of polio
| Forms of polio | Phases of virus development |
| Without CNS damage | |
| 1. Inapparant | Alimentary phase of virus development without viremia and invasion into the central nervous system |
| 2. Abortive form | Alimentary and hematogenous (viremia) phases |
| Forms of poliomyelitis with damage to the central nervous system | |
| !. Nonparalytic or meningeal form | Sequential development of all phases with invasion into the central nervous system, but subclinical damage to motor neurons |
| 2. Paralytic forms: a) spinal (up to 95%) (with cervical, thoracic, lumbar localization of the process; limited or widespread); b) pontine (up to 2%); c) bulbar (up to 4%); d) pontospinal; e) bulbospinal; e) pontobulbospinal | Sequential development of all phases with damage to motor neurons at different levels |
Based on the severity of the process, mild, moderate and severe forms of polio are distinguished. The course of the disease is always acute, and the nature can be smooth or non-smooth, depending on the presence of complications (osteoporosis, fractures, urolithiasis disease, contracture, pneumonia, bedsores, asphyxia, etc.).
Clinic. Duration incubation period for polio it is 5-35 days.
The spinal form of polio in children occurs with greater frequency than other paralytic forms. In this case, more often the pathological process develops at the level of the lumbar thickening of the spinal cord.
During the course of the disease, there are several periods, each of which has its own characteristics.
The preparalytic period is characterized by an acute onset of the disease, a deterioration in general condition, an increase in body temperature to febrile levels, headache, vomiting, lethargy, adynamia, and meningeal signs. General infectious, cerebral and meningeal syndromes can be combined with catarrhal or dyspeptic symptoms. In addition, there are positive symptoms of tension, complaints of pain in the back, neck, limbs, pain on palpation of nerve trunks, fasciculations and horizontal nystagmus. The duration of the preparalytic period is from 1 to 6 days.
The paralytic period is marked by the appearance of flaccid paralysis or paresis of the muscles of the limbs and torso. The main diagnostic signs of this stage are:
- sluggish nature of paralysis and its sudden appearance;
- rapid growth movement disorders for a short time (1-2 days);
- damage to proximal muscle groups;
- asymmetrical nature of paralysis or paresis;
- absence of disturbances in sensitivity and function of the pelvic organs.
At this time, changes in the cerebrospinal fluid occur in 80-90% of patients with poliomyelitis and indicate the development of serous inflammation in the soft meninges. With the development of the paralytic stage, general infectious symptoms fade away. Depending on the number of spinal cord segments affected, the spinal form can be limited (monoparesis) or widespread. The most severe forms are those accompanied by impaired innervation of the respiratory muscles.
The recovery period is accompanied by the appearance of the first voluntary movements in the affected muscles and begins on the 7-10th day after the onset of paralysis. If 3/4 of the neurons responsible for the innervation of any muscle group die, the lost functions are not restored. Over time, atrophy increases in these muscles, contractures, joint ankylosis, osteoporosis, and limb growth retardation appear. The recovery period is especially active during the first months of the disease, then it slows down somewhat, but continues for 1-2 years.
If after 2 years the lost functions are not restored, then they speak of a period residual effects(various deformities, contractures, etc.).
The bulbar form of polio is characterized by damage to the nuclei of 9, 10, 12 pairs of cranial nerves and is one of the most dangerous variants of the disease. In this case, there is a disorder of swallowing, phonation, pathological secretion of mucus in the upper respiratory tract. Of particular danger is the localization of the process in the medulla oblongata, when damage to the respiratory and cardiovascular centers poses a threat to the patient’s life. Harbingers of an unfavorable outcome in this case are the occurrence of pathological breathing, cyanosis, hyperthermia, collapse, and impaired consciousness. Damage to the 3rd, 4th, 6th pairs of cranial nerves in polio is possible, but less common.
The pontine form of polio is the most mild, but the cosmetic defect can remain with the child for life. Clinical characteristics This form of the disease involves damage to the nucleus of the facial nerve. In this case, immobility of the facial muscles on the affected side suddenly occurs and lagophthalmos, Bell's symptoms, “sails”, and pulling of the corner of the mouth to the healthy side when smiling or crying appear. The pontine form of polio most often occurs without fever, general infectious symptoms, or changes in the cerebrospinal fluid.
The meningeal form of poliomyelitis is accompanied by damage to the soft meninges. The disease begins acutely and is accompanied by a deterioration in general condition, an increase in body temperature to febrile levels, headache, vomiting, lethargy, adynamia, and meningeal signs.
Symptoms characteristic of the meningeal form of poliomyelitis are pain in the back, neck, limbs, positive symptoms of tension, pain on palpation of the nerve trunks. In addition, fasciculations and horizontal nystagmus may be observed. The electromyogram reveals subclinical damage to the anterior horns of the spinal cord.
When conducting spinal tap The cerebrospinal fluid usually flows out under pressure and is transparent. His research reveals:
— cell-protein dissociation;
— lymphocytic pleocytosis (the number of cells increases to several hundred per 1 mm3);
- normal or slightly increased protein content;
- increased sugar content.
The nature of changes in the cerebrospinal fluid depends on the timing of the disease. Thus, the increase in cytosis may be delayed and in the first 4-5 days from the onset of the disease the composition of the cerebrospinal fluid remains normal. Moreover, sometimes, in initial period There is a short-term predominance of neutrophils in the cerebrospinal fluid. After 2-3 weeks from the onset of the disease, protein-cell dissociation is detected. The course of the meningeal form of poliomyelitis is favorable and ends with complete recovery.
The inapparent form of polio is characterized by the absence of clinical symptoms with the simultaneous isolation of a “wild” strain of the virus from feces and a diagnostic increase in the titer of antiviral antibodies in the blood serum.
The abortive form or minor disease is characterized by an acute onset, the presence of general infectious symptoms without involvement of the nervous system in the pathological process. Thus, children may experience fever, moderate lethargy, decreased appetite, headache. Often the listed symptoms are combined with catarrhal or dyspeptic symptoms, which serves as the basis for the erroneous diagnosis of acute respiratory viral or intestinal infections. Usually the abortive form is diagnosed when the patient is hospitalized from the outbreak and receives positive results virological examination. The abortive form proceeds benignly and ends with complete recovery within a few days.
The development of vaccine-associated poliomyelitis is associated with the use of live oral vaccine for mass immunization and the possibility of reversing the neurotropic properties of individual clones of vaccine virus strains. In this regard, in 1964, a special WHO committee determined the criteria by which cases of paralytic poliomyelitis can be classified as vaccine-associated:
- onset of the disease no earlier than the 4th and no later than the 30th day after vaccination. For those who have been in contact with a vaccinated person, this period is extended to the 60th day;
- development of flaccid paralysis and paresis without impaired sensitivity with persistent (after 2 months) residual effects;
— absence of progression of the disease;
- isolation of a polio virus similar in antigenic characteristics to the vaccine virus and at least a 4-fold increase in type-specific antibodies.
Treatment
Rest in bed is necessary until severe symptoms subside.
Painkillers may be used to reduce fever, pain, and muscle spasms.
Your doctor may prescribe betanekol to combat urinary retention and antibiotics to treat associated bacterial infection urinary canal.
Urinary catheter, a thin tube connected to a urine collection bag, may be needed if bladder control has been lost due to paralysis.
Artificial respiration may be needed if breathing is difficult; In some cases, surgery to open the throat (tracheotomy) may be necessary.
Physiotherapy is necessary in cases of temporary or permanent paralysis. Mechanical devices such as bandages, crutches, wheelchair and special shoes can help you walk.
A combination of occupational and psychological therapy can help patients adjust to the limitations imposed by the disease.
Treatment of polio in the acute period should be etiotropic, pathogenetic and symptomatic.
The development of clinical variants of polio with damage to the nervous system requires mandatory, as early as possible hospitalization of the patient, provision of careful care and constant monitoring of basic vital functions. A strict orthopedic regimen must be followed. Affected limbs are given physiological
position with the help of plaster splints and bandages. The diet must meet the child’s age-related needs for basic ingredients and includes the exclusion of spicy, fatty, and fried foods. Particular attention should be paid to feeding children with bulbar or bulbospinal forms, since due to impaired swallowing there is a real threat of developing aspiration pneumonia. Tube feeding of the child allows you to avoid this dangerous complication.
Concerning drug treatment, then an important point is the maximum limitation of intramuscular injections, which contribute to the deepening of neurological disorders.
As etiotropic drugs for meningeal and paralytic forms, it is necessary to use antiviral drugs(pleconaril, isoprinosine pranobex), interferons (viferon, roferon A, reaferon-ES-lipint, leukinferon) or inducers of the latter (neovir, cycloferon), immunoglobulins for intravenous administration.
Pathogenetic therapy of the acute period involves the inclusion of complex therapy:
— glucocorticoid hormones (dexamethasone) in severe forms for health reasons;
- vasoactive neurometabolites (trental, actovegin, instenon);
— nootropic drugs (gliatilin, piracetam, etc.);
— vitamins (A, B1, B6, B12, C) and antioxidants (vitamin E, mexidol, mildronate, etc.);
- diuretics (diacarb, triampur, furosemide) in combination with potassium-containing drugs;
— infusion therapy for the purpose of detoxification (5-10% solutions of glucose with electrolytes, albumin, infucol);
- inhibitors of proteolytic enzymes (Gordox, Ambien, Contrical);
- non-narcotic analgesics (for severe pain);
— physiotherapeutic methods (paraffin or ozokerite applications on the affected limbs, UHF on the affected segments).
The appearance of the first movements in the affected muscle groups marks the beginning of the early recovery period and is an indication for the prescription of anticholinesterase drugs (prozerin, galantamine, ubretide, oxazil). As the pain syndrome is relieved, exercise therapy, massage, UHF are used, then electrophoresis, pulsed current electromyostimulation, and hyperbaric oxygenation.
After discharge from the infectious diseases department, the course of treatment with the medications described above continues for 2 years. The optimal solution should be considered the treatment of polio convalescents in specialized sanatoriums.
It is not yet known whether the infection can be stopped once it has started. On the other hand, many infected children do not suffer from paralysis. Many who are temporarily paralyzed then make a full recovery. Most of those who do not recover permanently make significant improvement.
If mild paralysis is observed after the acute phase of the disease, the child should be under constant medical supervision. Treatment depends on many factors. At each stage, the decision is made by the doctor, and there are no general rules. If paralysis persists, possible various operations, restoring the mobility of members and protecting them from deformation.
Prevention
When there are cases of polio in your area, parents start asking how to keep their child safe. Your local doctor will give you the best advice. There is no point in panicking and depriving children of all contact with others. If there are cases of the disease in your area, it is wise to keep children away from crowds, especially indoor areas such as shops and cinemas, and away from swimming pools that are used by many people. On the other hand, as far as we now know, it is not at all necessary to prohibit a child from meeting close friends. If you take care of him like this all your life, you won’t even allow him to cross the street. Doctors suspect hypothermia and fatigue increase susceptibility to the disease, but both are wise to avoid at all times. Of course, the most common case of hypothermia in the summer is when a child spends too much time in the water. When he begins to lose his color, he should be called out of the water - before his teeth chatter.
. There are a number of vaccines that are recommended to be given at two months of age, then again at four and 18 months, and a booster dose when the child starts school (between four and six years of age).
Immunization of children is the basis of the polio eradication strategy, and the level of vaccination coverage during routine immunization should be at least 95% among children of decreed ages in accordance with the Preventive Vaccination Calendar.
National immunization days are the second important component of the polio eradication strategy. The goal of these campaigns is to stop the circulation of wild poliovirus by immunizing as quickly as possible (within a week) all children in the age group at highest risk of disease (usually children under three years of age).
In Russia, National Polio Immunization Days covering about 4 million children under 3 years of age (99.2-99.5%) were held for 4 years (1996-1999). Immunization was carried out in two rounds, with an interval of one month, with live oral polio vaccine (OPV), with vaccination coverage of at least 95% of the number of children of the specified age groups located in the given territory.
Main prophylactic drug both in our country and throughout the world there is the Seibin live vaccine (LVS), recommended by WHO. In addition, registered in Russia imported vaccines Imovax Polio (Sanofi Pasteur, France), Tetracok (Sanofi Pasteur, France). The Pentaxim vaccine (Sanofi Pasteur, France) is under registration. The listed vaccines are inactivated polio vaccines. Vaccines are stored at 2-8 °C for 6 months. An opened bottle should be used within two working days.
Currently, for immunization of the child population against polio, OPV is used - oral types 1, 2 and 3 (Russia), IPV - Imovax Polio - inactivated enhanced (types 1, 2, 3) and Pentaxim (Sanofi Pasteur, France).
Vaccination begins at the age of 3 months three times with an interval of 6 weeks with IPV, revaccination at 18 and 20 months, and at 14 years with OPV.
The dose of domestically produced live vaccine is 4 drops per dose. It is administered orally an hour before meals. It is not allowed to drink the vaccine, eat or drink within an hour after vaccination. If regurgitation occurs, a second dose should be given.
Contraindications to VPV vaccination are:
- all types of immunodeficiency;
— neurological disorders due to previous VPV vaccinations;
- presence of acute diseases. In the latter case, vaccination is carried out immediately after recovery.
Non-severe illnesses with an increase in body temperature up to 38 °C are not a contraindication for VPV vaccination. If diarrhea is present, vaccination is repeated after stool normalization.
The oral polio vaccine is considered the least reactogenic. However, when using it, the possibility of an adverse post-vaccination event cannot be excluded. The greatest degree of risk is observed during primary vaccination and during contact infection of non-immune children.
It is possible to prevent the occurrence of vaccine-associated polio in children, especially from risk groups (IDF, born to HIV-infected mothers, etc.), by using an inactivated polio vaccine for initial vaccination or by conducting a full course of immunization.
According to epidemiological indications, additional immunization is carried out. It is carried out regardless of previous preventive vaccinations against polio, but not earlier than 1 month after the last immunization. Children under the age of 5 years are subject to a single immunization with OPV (the age composition of children can be changed), who communicated in epidemic foci with patients with polio, diseases accompanied by acute flaccid paralysis, if these diseases are suspected in the family, apartment, house, preschool educational and medical -preventive institution, as well as those who communicated with those arriving from polio-prone areas.
Nonspecific prevention of polio infection involves hospitalization and isolation of the patient, and monitoring contact children under 5 years of age for 20 days. According to epidemiological indications, a one-time virological examination of contacts is carried out. In the epidemic focus of POLI/AFP, after hospitalization of the patient, final disinfection is carried out.
In adults, polio vaccination is recommended only before traveling to areas where polio is common.
Contact your doctor immediately if you or your child experience symptoms of polio or if you may have been infected with the virus and have not yet been vaccinated.
Contact your doctor to get the polio vaccine if you have not been vaccinated and plan to travel to areas where polio is common.
Attention! Call " ambulance” if someone is having difficulty breathing or has paralysis of a limb.
HEALTH DEPARTMENT OF THE ADMINISTRATION OF THE KRASNOYARSK REGION
KRASNOYARSK STATE MEDICAL ACADEMY
DEPARTMENT OF CHILDREN'S INFECTIOUS DISEASES
FGUZ CENTER OF HYGIENE AND EPIDEMIOLOGY OF THE KRASNOYARSK REGION
Analysis of diagnostic and tactical errors in the management of patients with polio and other acute flaccid paralysis.
Informational and analytical writing.
Compiled by:
Doctor of Medical Sciences professor head department
childhood infections. L.A. Gulman,
Ph.D. assistant professor T.S.Krivshych,
epidemiologist of the Federal State Institution "Center for Hygiene and Epidemiology of the Krasnoyarsk Territory" Dranishnikova N.A.
Krasnoyarsk, 2005
In May 2002, Russia received a certificate of polio-free zone. Despite this, the attention of medical workers to the problem of polio and acute flaccid paralysis (AFP) should not be reduced, since the possibility of importing wild strains of polio viruses from other countries where it is still found cannot be ruled out. In addition, one should remember about the circulation of vaccine strains of polio viruses among the population, and the possibility of the development of vaccine-associated polio in unvaccinated persons and with reduced post-vaccination immunity, as well as in recipients of vaccination with live polio vaccine and diseases in persons in contact with vaccinated people.
In a letter from the National Commission of Experts on the Diagnostics of Poliomyelitis (dated October 3, 2003), it was noted that in 2002 and 2003. in Russia there were cases of vaccine-associated polio in recipients and contacts. The contacts were not vaccinated against polio and interacted with vaccinated children. One child was infected in a clinical hospital, where he was admitted with a diagnosis of ARVI. On the 21st day of contact, while in a box with a child vaccinated against polio, he becomes ill with acute paralytic vaccine-associated polio and releases serotype III of the vaccine poliovirus. Thus, unvaccinated children are at great risk of becoming infected with vaccine strains of poliovirus. In Russia, in 2002 and 2003, 11 cases of vaccine-associated polio and, respectively, 402 (1.6 per 100 thousand) and 346 cases of AFP (1.43 per 100 thousand) were observed in the Krasnoyarsk Territory, in the city of Krasnoyarsk , 3 cases of vaccine-associated poliomyelitis were diagnosed in recipients: in 1999, 2004 and 2005.
The data presented indicate that obtaining a certificate of polio eradication in no way diminishes the importance of surveillance of all diseases and conditions accompanied by the development of flaccid paresis and paralysis.
The main areas of AFP surveillance include:
Timely identification of patients with AFP (in the first 7 days of paresis, paralysis)
Registration of all cases within 12 hours at the place where the patient was identified.
Timely and high-quality virological examination (feces - 2-fold examination with an interval of 24 - 48 hours in the first 14 days)
Timely clinical examinations with the participation of an infectious disease specialist, a neurologist, a member of the expert commission in acute period and after 60 days.
Timely and full implementation complex of anti-epidemic measures in the outbreak.
Qualitative indicators of polio and AFP surveillance in the Krasnoyarsk Territory for the period 1998-2004.
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WHO standards |
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Incidence rate per 100 thousand children |
1.0 per 100 thousand up to 15 years |
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Indicator of timely identification of patients with AFP in the first 7 days. |
At least 80% |
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Number of patients from whom 2 stool samples were taken at an interval of 24-48 hours. |
At least 80% |
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Number of samples collected in the first 14 days from the onset of paralysis. |
At least 80% |
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Proportion of AFP cases evaluated clinically after 60 days. |
From the table it follows that for the period 1998-2000. The quality indicators of epidemiological surveillance in the region are quite satisfactory. Meanwhile, over the past 3 years (2002-2004) The regional expert commission on the diagnosis of polio and AFP notes a deterioration in the diagnosis of AFP, late hospitalization of this group of patients, untimely examination and late implementation of anti-epidemic measures. The reason for this situation is most often the incorrect diagnosis and management tactics of this group of patients by clinicians.
Thus, out of 7 case histories of patients with AFP, reviewed at a meeting of the expert council in 2002, in 3 cases there was late diagnosis (43%) and late hospitalization (Smirnova Vika, Krasnoyarsk - 30 days of illness, Kosuho Yulia Krasnoyarsk Territory - 17 day of illness, Anya Dushchak, Krasnoyarsk - 12th day of illness). In 2003 out of 6 patients with AFP, 3 (50%) were hospitalized late (Ivan Smirnov, Krasnoyarsk - 45 days of illness, Sasha Petrov, Krasnoyarsk - 26 days of illness, Anya Provodko, Krasnoyarsk - 14 days of illness).
In 2004 of 5 patients with AFP, 3 (60%) were hospitalized late (Daria Andriyanova, Krasnoyarsk - 16th day of illness, Egor Kolonichenko, Krasnoyarsk - 30th day of illness, Malikov Alexey, Kansk - 10th day of illness). In 2005 among 2 hospitalized patients Nikolay Danilenko (Krasnoyarsk) is admitted on the 21st day, Igor Kurzin (Achinsk) is admitted on the 11th day of illness.
In fact, all patients with symptoms of flaccid paralysis or paresis should be sent to the hospital of the MUZ GK DIB No. 1 from the site with a diagnosis of AFP.
The preliminary diagnosis of the emergency room doctor is formulated according to ICD-X based on the topical lesion of the peripheral nervous system. In the hospital, after studying the epidemiological history, vaccination history, commission examination of patients by an infectious disease specialist, neurologist, member of the expert council, after observation over time, laboratory examination (cerebrospinal fluid, 2-fold virological study of feces, if polio is suspected, 2-fold serological study for an increase in antibody titer to polioviruses) and obtaining the results, a clinical diagnosis is drawn up indicating the topic of damage to the nervous system and the etiology of the disease
Of the 18 reviewed case reports, only 9 patients (50%) were referred from the site with a diagnosis of AFP. The rest were admitted with various other diagnoses: enterovirus infection (2), neuritis of the sciatic nerve (4), consequences of tonsillitis (1), secondary infectious encephalitis due to chickenpox(1), circulatory disorders in peripheral vessels (1).
In the hospital, after observation and examination, the following diagnoses were made:
"Acute paralytic poliomyelitis associated with the vaccine in the recipient, spinal, severe form" (2004 Krasnoyarsk) - 1
"Acute paralytic poliomyelitis, other non-polio etiology (Coxsackie B), spinal form." Norilsk 2002 - 1
"Encephalomyelopolyradiculoneuritis, flaccid tetraparesis syndrome" - 2
"Infectious - allergic polyneuropathy" (Guillain-Barre syndrome) - 8
"Post-traumatic neuropathy peroneal nerve"- 6
The incorrect, non-core hospitalization of this group of patients is noteworthy. According to the order of the Health Department of the Krasnoyarsk Territory Administration dated September 2000 No. 313, hospitalization of patients with AFP should be carried out in the City Clinical Hospital No. 1 of Krasnoyarsk. In fact, the majority of patients are first admitted to Clinical Hospital No. 1 (5) or the neurological department of the Emergency Hospital (6), and then they are transferred to the Clinical Hospital No. 1.
The result of non-core hospitalization is:
Risk of infection in children in somatic hospitals and neurological departments.
The need to carry out a set of anti-epidemic measures where the patient with AFP was located (CDC, emergency hospital).
Loss of time for the examination.
The danger of infecting others when transferring children with AFP by public transport and negative reactions of parents.
Here are some specific examples of late diagnosis and incorrect medical tactics:
Petrov Sasha: 14 years old, Krasnoyarsk, Novaya str. 32-20. Was in DIB No. 1 from 11/24/5. 12.2003 I received 9 vaccinations against polio, R 4 - in May 2003.
I fell ill on October 28, 2003, the day of vaccination against tick-borne encephalitis, with a fever up to 40 o, pain in the shoulder and throat. 29.10. examined by a local doctor and diagnosed with ARVI. 29. and 30.10. received penicillin injections intramuscularly (the injections were not given by a medical professional). There was pain in the buttock, a feeling of numbness in the right leg. He was examined by the local pediatrician on October 30 and 31. - Improvement in ARVI. There is no record of leg pain.
3.11. examination at the clinic. "Healthy for ARVI." A certificate was given to the school. But the pain in right leg and the feeling of numbness persisted on November 20. the patient again turned to the pediatrician. DS: "Blood circulation in peripheral vessels?" On the same day, he was examined by a surgeon, a neurologist, and the DS was assigned: “Neuroinfection.” The patient is sent to the emergency department. IN emergency room examined by a neurologist, diagnosed with AFP, the child was sent to the Children's Hospital No. 1, where he appeared only on November 24. those. The patient was admitted on the 24th day of illness.
Upon admission, the gait was disturbed - "steppage", does not stand on the right heel, muscle strength in the main groups is 5 points, and in the flexors of the right foot - 3 points. Liquor without pathology. Results of virological studies: feces for polioviruses from November 26. and 27.11. negative. The study was conducted late: on the 26th and 27th day of illness. DS clinical and expert committee: "Post-traumatic (post-injection) neuropathy of the right peroneal nerve."
In this case, the expert commission makes the following comments:
The local pediatrician, despite the appearance of pain and anesthesia in the right leg, after an intramuscular injection of penicillin on October 29-30, does not pay due attention to these symptoms, but makes a diagnosis of "ARVI".
03.11. The boy was declared healthy according to ARVI and was discharged to school, although at that time there was a disturbance in his gait and a feeling of numbness in his right leg. This indicates a superficial examination of the patient.
20.11. The patient is again seen by the local pediatrician with the same complaints. The doctor should have first thought about “ORP”, but he makes a diagnosis: “Impaired peripheral circulation” and refers the patient for a consultation with a neurologist.
The neuropathologist at the clinic also does not put “AFP”, diagnoses “Neuroinfection” and gives a referral to the emergency department.
In the neurological department, he is diagnosed with "AFP", the child is sent to the MUZ of the Group of Children's Hospital No. 1, but an emergency notification is not submitted to the CSES.
The patient appears in DIB No. 1 only on November 24. If an emergency notification had been given by the emergency hospital doctor, the patient would not have been lost for 4 days.
As a result: late diagnosis, late hospitalization (24 days of illness), late virological examination (26 and 27 days of illness), late implementation of anti-epidemic measures.
Smirnov Ivan, 13 years old. Krasnoyarsk, Leninsky district, Leningradskaya 15-66. The child is vaccinated against polio 8 times
He was hospitalized in hospital No. 1 from 14.10-24.10. 03 He was admitted with complaints of weakness in the right foot and the inability to walk on heels. These complaints appeared at the end of August 2003. I only saw a surgeon on September 24 (a month later). He was examined and an R-graph was taken of the right ankle joint. Consultation with a neurologist is recommended. Due to the long queue, he was examined by a neurologist only on 14.10. those. in another 3 weeks. DS: "Right peroneal nerve neuropathy."
Sent for hospitalization to the Emergency Hospital, and then to Children's Hospital No. 1. Hospitalized 45-50 days after illness and 20 days after contacting a surgeon.
Upon admission in a neurological status: a decrease in the tone and strength of the flexor muscles of the right foot to 3 points. Decreased tendon reflexes on the right, “steppage” gait, “toe-type” hyposthesia.
Liquor from 14.10. without pathology, virological examination of feces for polioviruses - negative on October 15 and 16 (on the 50th day of illness). During treatment, the condition improved, muscle strength and the range of active movements of the right foot increased. Muscle strength in the foot flexors 4 points. Tendon reflexes D=S. The gait is not changed, but he still walks poorly on his heels. Re-examined by a neuropathologist at DIB Group No. 1 after 3.5 months - there are no residual effects. DS clinical and expert advice: "Mononeuropathy of the peroneal nerve on the right, unspecified etiology."
DS of the Expert Committee of the Ministry of Health of the Russian Federation: "Acute flaccid paresis of the right peroneal nerve."
Comments from the expert committee:
Late presentation of the patient, about a month after the onset of signs of AFP.
The surgeon who examined the patient on September 24, 2003 did not provide immediate consultation with a neurologist.
The neuropathologist who examined the patient, 50 days after the disease, makes the correct diagnosis (neuropathy of the peroneal nerve on the right), but refers the child not to DIB No. 1, but to the emergency hospital
There is no mark on submitting an emergency notification either in the direction of the neurologist or in the direction of the emergency hospital.
The virological examination was carried out very late: on the 50th day of illness and 20th day from the moment of seeking medical help.
Zlobin Dima, 6 months, Krasnoyarsk, Sverdlovsk district, Matrosova, 20. Was in DIB No. 1 from 01.15.04.-02.13.04.
A child from the first term birth, with PPCNS of hypoxic-ischemic origin, hypertension syndrome, natal cervical spine injury, spastic tetraparesis.
In November-December 2003 suffers from acute respiratory viral infection, complicated by bronchitis, left-sided catarrhal otitis.
12/24/03. - recovery. The next day - (December 25) vaccinated with v 1 DTP + v 1 polio.
01/09/04. (on the 14th day after vaccination) falls ill: T-38.4, weakness, loss of appetite. Parents contact their local pediatrician. DS: "ARVI". The neurological status is practically not described by the pediatrician. 12.01. (on the 4th day of illness) my mother noticed a lack of movement in her right leg. 13.01. again goes to the clinic, where he is examined by a pediatrician and neurologist. There is no suspicion of polio or AFP despite the presence of obvious complaints and previous vaccination. 14.01. and 01/15/04. is examined in another clinic (in the rehabilitation center of the First City Children's Hospital) by a pediatrician and neurologist. A diagnosis of "AFP" is made, the child is sent to Children's Hospital No. 1, and an emergency notification is issued. On January 15, 2004, the patient was admitted to the DIB Group No. 1 on the 6-7th day from the moment of illness, 3-4 days from the development of paralysis and on the 20-21st day from the moment of vaccination.
Upon admission in somatic status without pathology. From the side of the nervous system: there is practically no movement in the right leg, motor activity is preserved in the arms and left leg. In the right leg there is diffuse muscle hypotonia, more pronounced in the proximal sections. The knee reflex on the right is not evoked, the Achilles is reduced. Pain sensitivity is preserved. The volumes of the limbs are equal. Analysis of cerebrospinal fluid from January 16, cytosis of 10 cells in 1 μl, protein 580 mg/l. Virological examination of feces from January 16 and 17, 2004 - vaccine strain polioviruses of types II and III were detected. A serological study in paired sera in PH revealed an increase in the titer of antibodies to type II poliovirus. After 2 months (03/10/04) residual effects persist in the form of decreased muscle tone in the adductor muscles of the right thigh and right buttock, decreased right knee reflex, hypotrophy of the upper third of the right thigh up to 1 cm.
Clinical diagnosis confirmed by the regional expert commission: “Acute paralytic poliomyelitis, vaccine-associated in the recipient, spinal, severe form.”
Concomitant diagnosis: "PPNSL, hypertension syndrome, syndrome of increased neuro-reflex excitability, spastic tetraparesis, recovery period."
Comments from the expert committee:
A child with a sharply changed premorbid background (PPNSL, natal trauma of the spinal cord, hypertensive syndrome) has just suffered from an acute respiratory viral infection, complicated by bronchitis, otitis, and is vaccinated the day after recovery (12/24/04), which is likely. and was the cause of the development of vaccine-associated poliomyelitis.
The child becomes ill on the 14th day after vaccination. He should be examined at home, and not in a clinic, he was diagnosed with ARVI, and his neurological status was not described in the outpatient card.
A 6-month-old child, even with ARVI, must be actively examined for 3 days at home, which was not done.
In a vaccinated child, 3 days from the onset of the disease and on the 17th day after vaccination, motor activity in the right leg disappears, and he is examined again in the clinic on January 13, and on January 14-15, in the rehabilitation department of the 1st Children's Hospital, where he is diagnosed with AFP.
It is noteworthy that a child who fell ill after vaccination against polio on the 14th day visits the children's clinic on 01/09/01/13/01/14/01/15/15. How many children came into contact with him in 2 clinics, and how many unvaccinated children were at risk of infection with the vaccine-associated strain of poliovirus?!!!
Anti-epidemic measures were carried out only in the family hearth, but they should also have been carried out in 2 clinics.
Danilenko Nikolay 1 year 8 months. Krasnoyarsk, st. Govorova 40-44.
Was in the DIB Group No. 1 from 01/14/05-11/02. 2005 Vaccinated against polio 3 times. The boy fell ill on December 23. 2004 from the appearance of loose stools up to 3-4 times a day. From 25.12. T 37-38 o, cough, runny nose. After 3 days, we noticed that the child began to walk poorly, weakness appeared in his legs, and began to fall. 27.12. went to the doctor for the first time, was exposed ARVI diagnosis. The neurological status was not described, a consultation with a neurologist was not carried out. From 31.12. the boy stopped walking, weakness appeared in his arms, catarrhal symptoms and low-grade fever persisted.
We contacted the local pediatrician again only on January 12, 2005. The child does not walk, does not sit, does not hold toys in his hands. A blood and urine test is prescribed. DZ: “ARVI”, there is no description of the neurological status, consultation with a neurologist is not carried out. 14.01. (on the 17th day from the moment of development of paralysis) is sent to DIB No. 1 with the diagnosis: “Consequences of previous lacunar tonsillitis.”
Upon admission - symptoms of ARVI. and obvious neurological symptoms. The child does not sit up on his own, there is no support on his legs, and he does not roll over. There is diffuse muscle hypotonia, more pronounced in the distal arms and legs. Knee reflexes are weak, quickly depleted, Achilles are absent, muscle strength in the proximal limbs is reduced to 3 points, in the distal limbs - to 2 points. No convincing sensitivity disorders were identified.
In the cerebrospinal fluid: cytosis 3kl in 1 μl, protein - 815 mg/l. Results of virological examination of feces from 15.01.-16.01. negative for poliovirus.
DS clinical, confirmed by a commission of experts: “Infectious-allergic polyneuropathy (Guillain-Barré syndrome), severe form.” There is a late admission (on the 17th day from the development of paralysis)
Comments from the expert committee:
The DS directions are absurd: the sore throat is not fixed, there are deep neurological symptoms (the child does not sit or walk) and the DS is given “Consequences of a previous lacunar sore throat.”
The child's monitoring regime is puzzling: for the first time, the mother turned to the local pediatrician for help on December 27. when the child began to walk poorly, weakness appeared in the legs, and he was given DS: “ARVI.” Neurological symptoms are not described, and a neurologist is not consulted.
Symptoms of damage to the nervous system are increasing over time, and the mother consults the doctor again only on January 12, 2005. These days the boy does not sit, does not walk, does not hold toys in his hands, and the doctor prescribes urine and blood tests. the patient is examined in the clinic, instead of being immediately sent to DIB No. 1 with a diagnosis of “AFP” or at least urgently shown to a neurologist.
As a result, with severe paralysis that increases over at least 2 weeks, the child is hospitalized on the 17th day from the moment of development of paralysis.
Virological examination is carried out just as late - on the 18th and 19th day of paralysis.
Thus, the Regional Commission of Experts on the Diagnosis of Poliomyelitis and Other Acute Flaccid Paralysis notes that the results of the work for the period 2002-2004. not reassuring, since late diagnosis of AFP occurs, it was 43% in 2002 and 60% in 2004. The timeliness of virological examination, registration and implementation of anti-epidemic measures suffers. Late treatment causes residual effects in patients; long-term rehabilitation is required.
All these shortcomings must be eliminated immediately, especially since they do not require material costs. There is a need for a certain wariness towards the group of patients with AFP, strict compliance with such regulatory, methodological and administrative documents as: " Sanitary and epidemiological rules SPZ.1.1.1118-02."Prevention of polio", Order of the Ministry of Health of the Russian Federation No. 24 dated January 25, 1999."On strengthening efforts to implement the Polio Eradication Program in the Russian Federation by the year 2000.", "Action algorithms employees of treatment and preventive institutions of the State Sanitary and Epidemiological Supervision when registering patients with polio, acute flaccid paralysis and those arriving from endemic territories" of the Ministry of Health of the Russian Federation dated October 31, 2003, Methodological recommendations“Diagnostics of acute flaccid paralysis in children and the algorithm of doctors’ actions for this pathology” (Krasnoyarsk, 2005)
