Polio free does not mean paralysis free
http://www.thehindu.com/opinion/lead/polio-free-does-not-mean-paralysis-free/article4266043.ece
There is no room for complacency that India has eliminated this
crippling disease as Uttar Pradesh and Bihar have recorded a high
incidence of a condition symptomatic of it
Identifying children who suddenly display muscle weakness, often not
moving one or more of their limbs as a result, forms the cornerstone of
polio surveillance. Such children could have “acute flaccid paralysis”
(AFP) that is symptomatic of polio , a disease caused by a virus. But AFP
can also arise for other reasons, including infection by non-polio
pathogens.
No child in India has been diagnosed with polio for nearly two years now
and all the indications are that the virus responsible for it is no
longer circulating here. However, the country’s polio surveillance
system has indicated a sharp increase during recent years in the number
of non-polio AFP cases.
Alarming data
Data published by the World Health Organisation show that close to 8,000
non-polio AFP cases were identified in India during 2003. They went up
to over 12,000 the following year, more than 26,000 in 2005 and crossed
40,000 by 2007. In 2011, there were more than 60,000 non-polio AFP
cases.
A good polio surveillance system ought to pick up all AFP cases among
children so that they can be screened for poliovirus infection. On
average, only about one child out of every 200 children carrying the
poliovirus develops AFP. Such cases must be identified so that
appropriate immunisation measures can be undertaken.
India’s polio surveillance shows that the country is polio-free. But it
also indicates that the country now has the world’s highest rate of
non-polio AFP cases. According to data published in WHO’s Weekly Epidemiological Record,
India’s annualised non-polio AFP rate for 2011 stood at 15.06 per one
lakh children below 15 years of age, compared to a global rate that year
of 5.48.
Moreover, most of the country’s non-polio AFP cases occur in just two
States — Bihar and Uttar Pradesh. They accounted for about 61 per cent
of the 53,000-odd non-polio AFP cases identified in the country in 2012,
according to data from WHO’s National Polio Surveillance Project. As a
result, the two States have far higher annualised non-polio AFP rates
than other States — around 34 for Bihar and about 23 for Uttar Pradesh.
The rate for the country as a whole is slightly over 12.
“The increased non-polio AFP rate is due to increased reporting of AFP
cases due to deliberate efforts of the programme to increase the
sensitivity of the surveillance system since 2004,” according to the WHO
Country Office for India. In a written response provided to this
correspondent, the health body said these efforts were more intense and
closely monitored in the traditionally polio-endemic states of Bihar and
U.P., resulting in even higher rates of reporting of AFP cases in those
States.
In 2004, a number of steps were initiated to strengthen surveillance in
order to accurately and more rapidly detect all polio cases in the
country, it said. Those measures included expanding the definition of
AFP; increasing the number of AFP reporting sites; increasing the number
of active surveillance visits; and more training for health
professionals on what constituted an AFP case.
Since then, the number of AFP cases that were reported and investigated
continued to increase, it noted. This was not due to an increase in the
incidence of a specific disease that might cause these symptoms. Rather,
it was the direct result of surveillance activities for AFP cases being
strengthened.
The programme in India had taken a much broader interpretation of what
would qualify as an AFP case than other countries have. Although facial
paralysis would not be part of a standard definition of AFP, it was
included in that definition for India. Other similar examples were
diseases like meningo-encephalitis, Bells palsy, post-diphtheria
polyneuritis and spinal muscular atrophy. Data had shown that broadening
the case definition led to the detection of some polio cases that would
have otherwise been missed, the WHO Country Office noted.
Moreover, in the remaining polio-endemic countries of Nigeria, Pakistan
and Afghanistan too, efforts to strengthen polio surveillance were
resulting in increased non-polio AFP cases being reported, it added.
The high non-polio AFP rates in the country ought to be a “red flag”,
remarked T. Jacob John, a leading virologist who was with Christian
Medical College, Vellore, and is known for his work on polio
eradication.
With heightened polio surveillance, sick children with suspected
paralysis or possible neurological maladies were being identified and
tested by the polio surveillance system, he remarked. However, the
neurological disorders given by the WHO Country Office as examples of
the expanded definition of AFP were likely to account for only a small
part of the increase in non-polio AFP cases being seen in India.
No clear picture
Unfortunately, the cases of children with non-polio AFP were not being
monitored by either the polio eradication programme or the larger state
health care system. As a result, there was no clear picture of what was
causing the AFP, the kind of diseases these children displayed, or how
many of them were seriously affected, he pointed out.
A range of non-polio pathogens could produce AFP, said Dr. John. With
many such pathogens, the paralysis they caused would often disappear in a
short period of time. However, others were capable of causing quite
serious diseases, disability and even death.
Two teams of Indian scientists recently studied the sorts of
enteroviruses found in children with non-polio AFP. Enteroviruses are a
diverse group, most of which replicate in the alimentary tract. The
poliovirus is part of this group. Several non-polio enteroviruses have
been associated with a range of acute and chronic human diseases,
including polio-like paralysis.
In a study published in 2009, a team at the Sanjay Gandhi Postgraduate
Institute of Medical Sciences in Lucknow tested over 46,000 stool
samples from children with AFP in U.P., Bihar and other northern States
between 2004 and 2007. In the other study, C. Durga Rao of the Indian
Institute of Science, Bangalore, and his colleagues looked for
enteroviruses in stool samples collected from more than 2,700 children
with non-polio AFP in Kerala, Karnataka and Uttar Pradesh between 2007
and 2009.
Enteroviruses
Both groups found that only about 30 per cent of the non-polio AFP cases
were associated with enteroviruses. These viruses could therefore only
partially explain the non-polio AFP cases being detected.
In a paper published early last year in the Indian Journal of Medical Ethics,
Neetu Vashisht and Jacob Puliyel of the St. Stephens Hospital, Delhi,
gave another perspective on the issue. Children in Bihar and U.P. have
received more doses of oral polio vaccine than elsewhere in the country.
The oral vaccine, it was found, became less efficacious in the face of
gut infections and diarrhoea that were widely prevalent in those States.
In their paper, Dr. Vashisht and Dr. Puliyel analysed the non-polio AFP
rates across all States over 10 years up to 2010, and found that the
rate “increased in proportion to the number of polio vaccine doses
received in each area.” In 2012, the number of doses of oral vaccine
given to children in Bihar and U.P. had come down and, for the first
time, there was a decrease in the non-polio AFP cases in those States,
Dr. Puliyel told this correspondent.
There was need for “a critical appraisal to find the factors
contributing to the increase in non-polio AFP with increase in OPV [oral
polio vaccine] doses — perhaps looking at the influence of strain
shifts of entero-pathogens induced by the vaccine,” said Dr. Vashisht
and Dr. Puliyel in the paper.
The non-polio AFP rate was not correlated with the number of oral
vaccine doses that were administered, countered the WHO Country Office
in its response. The largest number of oral vaccine doses given in India
was in 2004, which had the lowest non-polio AFP rate in the last eight
years. Moreover, although the number of oral vaccine doses given in the
country had shown a continuous decline since 2007, the non-polio AFP
rate had increased during the same period. In Bihar and U.P. too, there
were similar trends of reduced oral vaccine doses and rising AFP rates
during 2007-2011.
“The ICMR [Indian Council of Medical Research] is leading the
investigations into non-polio causes of AFP,” the WHO Country Office
stated.