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Poliovirus is an acute enteroviral infection that is spread from person to person, primarily via the fecal-hand-oral routes. Although most patients who acquire the infection are asymptomatic, those afflicted may develop a variety of neurologic manifestations, including aseptic meningitis, polioencephalitis, bulbar poliomyelitis, and paralytic poliomyelitis. In paralytic poliomyelitis, muscle weakness is preceded by intense myalgias of the involved limbs and axial skeleton. Following recovery, as many as 20% to 30% of individuals who develop paralytic poliomyelitis may suffer from post-polio syndrome, which produces muscle weakness, pain, atrophy, and fatigue many years after acute illness.
There has been a large worldwide effort for poliomyelitis eradication. Polio cases have decreased by over 99% since 1988, from an estimated 350,000 cases in more than 125 endemic countries to 42 reported cases in 2016 (37 wild-type and 5 vaccine-derived) (63; 70; 128; 129; 141; 72; 86). Poliomyelitis due to wild-type virus has now been eliminated from the Americas, Europe, and Western Pacific, and cases in Africa and Asia have markedly decreased. Although great strides have been made, poliomyelitis remains and is rising in some regions, including Nigeria, Afghanistan, and Pakistan, and there is a risk for new outbreaks to occur.
• Poliovirus is an acute enteroviral infection that is spread from person to person, primarily via the fecal-hand-oral route.
• Neurologic manifestations of poliomyelitis include aseptic meningitis, polioencephalitis, bulbar poliomyelitis, and paralytic poliomyelitis.
• As many as 20% to 30% of individuals who develop paralytic poliomyelitis may suffer from post-polio syndrome, which includes new muscle weakness, pain, atrophy, and fatigue many years after the acute illness.
• There has been a large worldwide effort for poliomyelitis eradication, with a decrease of polio cases by over 99% since 1988. Though great strides have been made, there remains a high risk for new outbreaks.
• On September 20, 2015, the Global Commission for the Certification of Poliomyelitis Eradication declared that poliovirus type 2 has been eradicated worldwide.
Historical note and terminology
Poliomyelitis has afflicted humans for centuries. The first recognized clinical description was by English physician and surgeon Michael Underwood (1736-1820) in the second edition of A Treatise on Diseases of Children, which was published in 1789 (190; 116; 153). Major contributions to the understanding of the disease were made by the German orthopedist Jacob Heine (1800-1879), who described the clinical features of acute poliomyelitis (80). In 1870, French neurologist Jean-Martin Charcot (1825-1893) and his junior colleague Alix Joffroy (1844-1908) recognized that the flaccid paralysis of poliomyelitis was caused by spinal anterior horn cell damage (43).
Jacob Heine (1800-1879)Shown around 1870, Heine was the first to provide a clinical description of poliomyelitis in 1840. (Contributed by Dr. Douglas Lanska. Public domain.)
Jean-Martin Charcot (1825-1893)French neurologist Jean-Martin Charcot (1825-1893), who, with colleague Alix Jaffoy, recognized that the flaccid paralysis of poliomyelitis was caused by spinal anterior horn cell damage. (Contributed by Dr. Douglas Lanska. Courte...
In the mid- to late 19th century, the general belief was that polio was not infectious; in the late 19th century, when bacteriological explanations were in vogue for almost all conditions, polio was suspected to be another bacterial disease. Numerous attempts were made to identify the responsible microorganism, with many claims to have successfully done so, but none were reproducible.
Finally, in 1908, Austrian pathologist Karl Landsteiner (1868-1943) and his colleague Erwin Popper (1879-1955) showed that the etiological agent of poliomyelitis was a filterable virus (102). The existence of more than one type of poliovirus was first inferred by Australian virologist Frank Macfarlane Burnet (1899-1984) and his collaborator Dame Annie Jean Macnamara (1899-1968) in 1931 when they demonstrated that monkeys who had recovered from infection with a strain recovered in Melbourne subsequently developed disease when given a virulent mixed virus strain (35; 59). In 1949, the three antigenic poliovirus types (poliovirus 1, poliovirus 2, poliovirus 3) were identified (29; 98).
The first recorded outbreaks of poliomyelitis occurred in the mid- and late nineteenth century in northern Europe and North America, followed by much larger epidemics in the early 20th century.
In August 1921, while vacationing with his family at their summer home on Campobello Island off the coast of Maine, politician Franklin Delano Roosevelt (FDR; 1882-1945) became ill, lost motor power in his legs, and was diagnosed with polio. Roosevelt later sought treatment at a resort in Warm Springs, Georgia. Because of his self-perceived improvement at the resort, in 1927, Roosevelt and his friend, American lawyer Basil O’Connor, created the Georgia Warm Springs Foundation, in which O'Connor served first as treasurer and later as president. The foundation was subsequently reconstituted as the National Foundation for Infantile Paralysis in 1938. A solicitation prior to Roosevelt’s birthday in 1938 resulted in a huge influx of small donations that swamped the White House mail room. As a result, radio star Eddie Cantor dubbed it the “March of Dimes” -- a play on the contemporary radio and newsreel series, The March of Time. The March of Dimes ultimately became the official name of the organization, which served as the largest source of funding for research and clinical care for poliomyelitis at the time. Indeed, the organization supported the work of Jonas Salk and others, which led to the development and testing of polio vaccines.
Basil O’Connor (1892-1972)
O’Connor was Chairman of the National Foundation for Infantile Paralysis that funded the development and testing of polio vaccines, including the Salk killed virus vaccine. He was also later Chairman and President of the Americ...
Franklin Delano Roosevelt (1882-1945) and Basil O’Connor (1892-1972)President Franklin Delano Roosevelt (1882-1945) and Basil O’Connor (1892-1972), chairman of the March of Dimes, counting dimes sent as donations for research and clinical care of people with poliomyelitis (c1944). (Contributed by ...
Prototype “iron lung” negative-pressure ventilators were developed in the late 1920s and early 1930s by industrial hygienist Philip A Drinker (1894-1972), physiology instructor Louis Agassiz Shaw Jr. (1886-1940), and inventor/medical-equipment manufacturer John Haven (“Jack”) Emerson (1908-1997). From around 1926 to 1928, Drinker and Shaw, both at Harvard Medical School in Boston, designed an electrically powered tank respirator. On October 13, 1928, Drinker and pediatrician Charles F McKhann demonstrated the potential of this device in an 8-year-old girl with poliomyelitis, respiratory failure, and coma who was treated at Boston Children’s Hospital and briefly survived before succumbing to pneumonia. A second trial on Friday, September 13, 1929, at Peter Bent Brigham Hospital in Boston, on a 21-year-old Harvard student, was unquestionably successful: Hoyt was weaned from the respirator in 4 weeks and was discharged from the hospital before Christmas. Emerson built a mechanically superior device in the summer of 1931; Emerson’s device was first used clinically to save the life of a priest with polio at the Providence City Hospital in Providence, Rhode Island.
After this, the manufacture of "iron lungs" expanded markedly over the next 2 decades. At their peak use in the early 1950s, wards at some referral centers were crowded with dozens of these devices, all in use for affected patients, with a large complement of attendant nursing and respiratory therapy staff. Indeed, the iron lung required intensive nursing care and respiratory therapy and a supporting hospital infrastructure.
Iron lung respiratorEmerson tank respirator (“iron lung”) in use during a poliomyelitis epidemic in Rhode Island in 1960. (Contributed by Dr. Douglas Lanska. Centers for Disease Control and Prevention. Public domain.)
Man with polio in an iron lung visiting with his family
If a polio patient's diaphragm was compromised, the early treatment was use of the iron lung, a form of negative pressure ventilator. (Photo ID: NPC 3631. Source collection: OHA 250: New Contributed Photographs. Repository: Nat...
A boy with polio in the Emerson Respirator (iron lung) viewing the photographer (Joe Clark) in the machine's mirror, circa 1955 (Herman Kiefer Hospita...
An Emerson Respirator, also known as an iron lung, was a machine that enabled a person to breathe on their own when muscle control had been lost (often due to poliomyelitis). It used negative pressure ventilation to induce inha...
Nurse shares a smile with a child inside of an iron lung, circa 1960-1968
(Creator: U.S. Air Force. File name: 244001_1370. Citation: Mayor John F Collins records, Collection #0244.001, City of Boston Archives, Boston. Creative Commons Attribution 2.0 Generic License [CC BY 2.0], https://creativecomm...
A boy in an iron lung at the Naval Hospital, circa 1960
(Photo by Don Pinder. Courtesy of the Florida Keys Public Library. Creative Commons Attribution 2.0 Generic License [CC BY 2.0], https://creativecommons.org/licenses/by/2.0.)
Woman in an iron lung looks at herself in a mirror
(Source: Oakenroad. Creative Commons Attribution 2.0 Generic License [CC BY 2.0], https://creativecommons.org/licenses/by/2.0.)
From the 1920s through at least the early 1940s, the orthodox treatment for poliomyelitis consisted largely of absolute and prolonged immobilization of affected limbs with splints or plaster casts, followed by often permanent orthopedic braces; in retrospect, this approach was less than ideal, and in many ways counterproductive as it caused or contributed to disuse atrophy, joint contractures, and lifelong disability. Beginning around 1911, in a sparsely populated area of Australia, “Sister” Elizabeth Kenny (1880-1952) developed an empiric approach to rehabilitation following poliomyelitis that combined physical and psychological techniques.
The physical methods she employed included the labor-intensive application of moist warm wraps for muscle spasms, passive range of motion, and massage. Kenny’s physical methods were combined with early mobilization, strong encouragement to achieve both functional independence and a prompt return to normal activities, and confident optimism for improvement. The Kenny methods were widely adopted in the United States and elsewhere in the 1940s (although not in Australia where she was strongly opposed by physicians and, particularly, orthopedic surgeons). Kenny’s approach represented a significant advance in the care of paralyzed patients and helped foster the growth of physical therapy and the medical discipline of physical medicine and rehabilitation.
It was not until the development of the first successful inactivated poliovirus vaccine in the 1950s by American virologist Jonas Salk that the severity of polio epidemics started to decrease. In 1954 and 1955, Salk’s inactivated poliovirus vaccine was successfully tested in a monumental, controlled trial involving more than 1.8 million United States schoolchildren funded by the National Foundation for Infantile Paralysis (106).
Salk's vaccine dramatically curtailed cases of polio in the United States, but one of the difficulties was the required injection.
A young girl receiving her Salk polio vaccination in her left upper arm. The girl was among local residents who had lined up at this mobile polio vaccination clinic. This photograph was taken in 1963, when the U.S. was shifting...
Various images of children in wheelchairs or wearing leg braces were used to encourage people to support the March of Dimes and to encourage vaccination.
Images like this were used to encourage individuals to receive polio vaccinations, which were made available in April 1955. (Source: CDC. U.S. Centers for Disease Control and Prevention, Public Health Image Library. Public doma...
Polish-American virologist Albert Sabin (1906-1993) developed the first effective trivalent live-attenuated (oral) poliovirus vaccine.
Polish-American virologist Albert Sabin (1906-1993) developed the first effective trivalent live-attenuated (oral) poliovirus vaccine. (Contributed by Dr. Douglas Lanska. Source: Woodward T. The Armed Forces Epidemiological Boa...
Sabin's first oral poliovirus vaccine, for use against type 1 polioviruses, was licensed in the United States in 1961. His vaccines for type 2 and type 3 polioviruses were licensed in 1962.
The oral live-attenuated Sabin vaccine was easier to administer and produced longer-lasting immunity than the killed-virus Salk vaccine that had to be administered by injection.
Healthcare worker dropping oral poliovirus vaccine on sugar cubes prior to immunization administration
(Source: CDC, 1961. U.S. Centers for Disease Control and Prevention, Public Health Image Library. Public domain.)
Child receiving oral polio vaccine
This mother was cradling her child, as he received an oral polio vaccine, which would prevent the baby from acquiring the highly infectious disease poliomyelitis (polio), caused by the poliovirus. Beginning in 1988, the efforts...
Girl receiving her polio immunization by way of a sugar cube
A young girl receiving her polio immunization by way of an orally administered sugar cube at a Dekalb County, Georgia, well-child clinic. (Source: CDC/Meredith Hickson, 1977. U.S. Centers for Disease Control and Prevention, Pub...
So, by 1962, the Sabin vaccine began replacing the Salk vaccine in the United States and in many other countries.
Historical photograph of boxes of poliovirus vaccine
Two workers standing beside a cart loaded with boxes containing poliovirus vaccine, produced at the time by the Wyeth pharmaceutical company. (Source: CDC/ Mr. Stafford Smith, 1963. U.S. Centers for Disease Control and Preventi...
Long line of people waiting for polio vaccinations in San Antonio, Texas
Aerial view of a long line of people waiting for their polio vaccinations. The line surrounded the city auditorium in San Antonio, Texas. (Source: CDC/Mr. Stafford Smith, 1962. U.S. Centers for Disease Control and Prevention, P...
Somali mother holding her infant steady for oral polio vaccine
A Somali mother holding her child steady, while a "Stop Transmission of Polio" (STOP) worker administered the oral polio vaccine to the young infant. WHO and UNICEF, working in conjunction with national Ministries of Health, re...
Unvaccinated children receiving oral polio vaccine in Pakistan
A Pakistani Field Epidemiology Training Program (FETP) 2nd cohort resident, (Dr. Muhammad Dawood Kasi) administering oral polio vaccine (OPV) to unvaccinated children in the union council locality of Kharotabad, Balochistan, Pa...
When necessary, the National Guard distributed polio vaccines to areas experiencing epidemics.
Scene at a Birmingham, Alabama airport, where the Alabama National Guard was preparing to fly polio vaccine to Haleyville during the polio epidemic of 1963. (Source: CDC/Mr. Stafford Smith, 1963. U.S. Centers for Disease Contro...
Public-health promotional campaigns for polio vaccination in the early 1960s used the Communicable Disease Center’s national symbol of public health, the "Wellbee" (Note that the Communicable Disease Center was the original name for the CDC, which changed in 1970 to the Center for Disease Control, and in 1992 to the Centers for Disease Control and Prevention).
1963 poster: “Wellbee,” reminding the public to "be well, be clean, wash your hands” (1)
This 1963 poster featured what at that time, was the Communicable Disease Center’s (CDC) national symbol of public health, the "Wellbee," who was reminding the public to "be well, be clean, WASH YOUR HANDS." CDC used Wellbee in...
1963 poster: “Wellbee,” reminding the public to "be well, be clean, wash your hands” (2)
This 1963 poster featured what at that time, was the Communicable Disease Center’s (CDC) national symbol of public health, the "Wellbee," who was reminding the public to "be well, be clean, WASH YOUR HANDS". CDC used Wellbee in...
1964 poster: “Wellbee,” reminding the public to "be well, be clean, wash your hands”
This 1964 poster featured what at that time, was the Communicable Disease Center’s (CDC) national symbol of public health, the "Wellbee," who was reminding the public to "be well, be clean, WASH YOUR HANDS." CDC used Wellbee in...