Acute Flaccid Paralysis in India March 2012 - Dec 2013

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Re: Acute Flaccid Paralysis in India

Nice find, RoRo. I noticed that in the data, too. India is reporting higher numbers of non-polio AFP cases then would be otherwise expected. By comparison, Mexico, with about 1/10th the population of India, reports about 500 cases a year. By that comparison, India should report only 5000 cases a year. Instead, they reported over 60,000 cases last year, about 12 times the number expected.

Your post above raises one possibility; that large numbers of VDVP cases are occurring and not being diagnosed. I don't know the quality of that article, however, as it does in the first paragraph try to blame some of the failures of eradication of WPV on the 2002 laboratory synthesis of poliovirus. There is no reason to think that laboratory virus has infected ANY human beings ANYWHERE.

Another possibility is the presence of some other pathogen causing paralysis. I cannot help but notice that the higest numbers of AFP cases are coming from the states with the undiagnosed AES cases, namely Bihar and Uttar Pradesh. One of the suspects in those cases is an unknown enterovirus. Might this unknown enterovirus be causing the AFP as well? The known enteroviruses are suspected in many cases of AFP elsewhere in the world.

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

Some earlier news reports;

Acute flaccid paralysis cases on the rise in UP, Bihar

Abantika Ghosh : New Delhi, Mon Jun 18 2012, 02:03 hrs



India may celebrate as it has not reported any wild polio case for more than a year, but Uttar Pradesh and Bihar, the two states that were once hotbed of the poliovirus, are reporting innumerable cases of acute flaccid paralysis (AFP).

AFP is the clinical symptom of polio, though it may be caused by several other agents too.

Bihar with 17,609 cases in 2011 reported 23 times the global incidence figures of 1-2 per 100,000 population under 15 years old. Till the first week of May 2012, there were 5,152 cases, comparable to figures for the same period last year. Uttar Pradesh reported 22,357 cases of AFP in 2011 — according to the global incidence figures, this is 17 times the cases the state’s under 15 population should ideally throw up. This year, the figure till May 6 has been 6,213.
...
Apart from polio, the reasons for AFP could be poisoning (curare, botulinum), nerve lesions, transverse myelitis, Guillain Barre Syndrome, Reye’s syndrome and enteroviral encephalopathy.

The last is infection of the brain by enteroviruses — of which family polio is also a member — and many of them spread through the faeco-oral route, like polio.
...
“There is nothing wrong either with the vaccine or with the incidence rates. It is just that we have developed such an efficient surveillance mechanism that we have started picking up more cases. Had the vaccine been a problem, Delhi would have shown comparable rise in AFP because we have had as many rounds of pulse polio in UP as in Delhi because of their proximity,” said a key immunisation official. Delhi had 707 AFP cases in 2011.
...

http://www.indianexpress.com/news/acute-flaccid-paralysis-cases-on-the-rise-in-up-bihar/963294/0

‘Symptoms of acute flaccid paralysis similar to polio’
TNN May 4, 2012, 04.32AM IST


KANPUR (Uttar Pradesh): Though the city maintains its position of not having even a single polio case in past four years but according to the health department, a large number of cases of acute flaccid paralysis (AFP) are being reported in the past one year. The health authorities have planned to launch surveillance projects in all the 10 blocks of the district. Educational and awareness campaign will also be organized to spread awareness about AFP.
...
As per the data provided by the heath department, 44 new AFP cases were reported in the district till April, this year. The number of AFP cases in 2011 was 178. The district immunization officer (DIO) said that testing of AFP is done on the examination of the stool of a person. No polio case has been reported in Kanpur after 2007. Though, many people claimed their wards of having polio after witnessing the symptoms but that was AFP and not polio.
...

http://articles.timesofindia.indiatimes.com/2012-05-04/kanpur/31572249_1_acute-flaccid-paralysis-polio-virus-polio-case

2007 paper by Puliyel referred to in a previous post;

Indian J Med Res 125, January 2007, pp 1-4
Editorial
Polio eradication & the future for other programmes:
Situation analysis for strategic planning in India
...
Residual paralysis in non-polio AFP: Concentrating
on this programme resulted in a decline in routine
immunization and increase in incidence of vaccine
preventable disease1,16,17. There was also an
unexplained increase in AFP - especially non polio
AFP. In 2005 there were 10,055 non polio AFP cases
in Uttar Pradesh (UP) where 561 cases were
expected11. A delegation from the Public Report on
Health (PRoH) (Council for Social Welfare, New
Delhi) in November 2006 investigated the problem of
residual paralysis in ‘non polio AFP’. The PRoH found
that most cases of AFP were not being followed up
(unless they cultured virus in the stools). Information
provided under the Right to Information Act and
available from National Polio Surveillance Project
(NPSP) is shown in the Table8. Of the 10264 cases of
AFP, 209 were cases of polio or compatible with polio.
Of the remaining 10055, only 2553 were followed up;
of these, 898 had residual paralysis (that would qualify
them to be diagnosed as polio using the old definition)
and 217 died. Projecting these figures on those not
followed up, it will appear that approximately 4800
cases had residual paralysis or died in UP after
acquiring non polio AFP in the year 2005. This figure
must be compared to the all India figures of 4793 polio
cases in 1994 (11). It is not surprising the NPSP is not
keen on the follow up of these cases. The data from
2006, after 6 doses of mOPV had been administered
in 2005, in districts of UP, are worse8.
...

http://jacob.puliyel.com/download.php?id=132

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.indianpediatrics.net/oct2005/oct-1049-1050.htm

Letters to the Editor

Indian Pediatrics 2005; 42:1049-1050

Acute Flaccid Paralysis: Guillain - Barre Syndrome with Enterovirus Infection


An eighteen-month-old boy presented with a limp of 4 days dmation, a week following fever, cough and loose stools. Oral polio vaccine (OPV) was administered a month earlier. Systemic examination was unremarkable. He was afebrile, buckled at the knees and muscle stretch reflexes were inelicitable. Laboratory evaluation for porphyria, hepatitis-B, HIV, cytomegalo virus, infectious mononucleosis, collagen vascular disorders, dyselectrolytemia and lymphoreticular malignancies was negative. Cerebrospinal fluid (CSF) contained 3 lymphocytes/mm3, 113 mg% protein and 54 mg% sugar. Stool viral cultures grew non-polio enterovirus (NPEV). Weakness extended to the upper limbs within a week; respiratory musculature and cranial nerves including facial remained unaffected.

Electrophysiological findings are tabulated (Table I). Guillain-Barre syndrome (GBS) was diagnosed, intravenous immunoglobulin (IVIG) infused and progression arrested. With physiotherapy he recovered without sequelae within a month.


see link for data

Acute flaccid paralysis (AFP) in children has been the focus of the polio eradication initiative of the World Health Organization (WHO). Major diagnostic considerations are GBS and poliomyelitis. Compared with poliomyelitis, GBS has more symmetrical paralysis, greater likelihood of sensory and autonomic disturbances and electroneuro-myographic evidence of peripheral nerve demyelination. In vaccinated children, however, poliomyelitis may mimic GBS in symmetry(1). The characteristic CSF albwninocytological dissociation, slow nerve conduction velocities, conduction block and absent F waves on electroneuromyography confmned Guillain-Barre syndrome.

Prodromal infection or vaccination may trigger immune responses causing GBS. A large series from Vellore included a 2-month-old infant(2). Vaccination related GBS has disconcerting implications for immunization programs highlighted by a Finnish study of OPV(3). Reassuringly, despite aggressive polio immunization and surveillance, no increase in pediatric GBS has been reported from India.

Genus Enterovirus comprises polio-viruses, group A and B Coxsackie, echo-viruses and newer enteroviruses. The latter four are labeled NPEV. Poliomyelitis is caused by poliovirus or, rarely, vaccinia virus. Infrequently NPEVs, particularly enterovirus-71, cause paralysis indistinguishable from poliomyelitis(4) but carrying less probability of bulbar involvement or permanent disability. NPEV was isolated from 191 of 523 children with AFP of undisclosed etiology from Uttar Pradesh(5).

Plasmapheresis and IVIG are the only measures effective in arresting progression of GBS. IVIG is preferred in children since it does not decrease blood volume or require central venous access. It has been safely administered for GBS in children as young as 2 years(6).

We reiterate that GBS mandates consideration in childhood AFP regardless of age. IVIG is a therapeutic option in those children with progressive paralysis.

M. Madhukar,
A. Menon,
Department of Neurology,
Little Flower Hospital
and Research Center, Angamaly,
Kerala 683 572, India.
E-mail: menonesq@yahoo.co.in

References

1. Yohannan MD. Ramia S. al Frayh AR. Acute paralytic poliomyelitis presenting as Guillain -Barre syndrome. J Infect 991; 22: 129-133.

2. Samantray SK, Johnson SC. Mathai KV, Pulimood BM: Landry-Guillain-Barr-Strohl syndrome. A study of 302 cases. Med J Aust 977; 2: 84-91.

3. Kinnunen E. Farkkila M, Hovi T, Juntunen J, Weckstrom P. Incidence of Guillain -Barre syndrome during a nationwide oral poliovirus vaccine campaign. Neurology. 1989; 39: 1034-1036.

4. Melnick JL. Enterovirus type 71 infections: a varied clinical pattern sometimes mimicking clinical poliomyelitis. Rev Infect Dis 1984; 6(Supp12) S 387-390.

5. Kapoor A, Ayyagari A, Dhole TN. Non-polio enteroviruses in acute flaccid paralysis. Indian J Pediatr 2001; 68: 927-992.

6. Sater RA, Rostami A. Treatment of Guillain -Barre syndrome with intravenous immuno globulin. Neurology 1998; 51(Suppl5): S9-15.

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

http://www.npspindia.org/bulletin.pdf

14 'highly suspected polio cases' found in state (Maharashtra)
Umesh Isalkar, TNN | Jun 29, 2013, 06.46 AM IST

PUNE: Fourteen children with acute flaccid paralysis (AFP) found during a routine surveillance in the state this month are considered "highly suspected polio cases" on the basis of their clinical characteristics and epidemiological data.
...
"The 14 children with AFP are classified as 'hot cases' based on clinical characteristics and the epidemiological data available about them. This is the routine process of AFP surveillance. We have to keep our suspicion of index very sharp to detect and examine every AFP case to rule out polio and vaccine derived polio virus (VDPV)," V K Rokade, in charge of the vaccination programme at the directorate of state health services, told TOI.

http://timesofindia.indiatimes.com/city/pune/14-highly-suspected-polio-cases-found-in-state/articleshow/20826307.cms

For thread on confirmed fatal VDPV case in Maharashtra see - Maharashtra infant gets polio from vaccine.

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

Extracts from http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

AFP Surveillance Bulletin - India
Report for week 36, ending 7 September 2013 http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

AFP Surveillance Bulletin - India
Report for week 40, ending 5 October 2013

http://www.npspindia.org/bulletin.pdf

[Ronan Kelly]

Re: Acute Flaccid Paralysis in India

Now, polio surveillance programme covers AFP cases to rule out virus
Anuradha Mascharenhas : Pune, Thu Oct 24 2013, 02:49 hrs

When Jagannath Kalokhe's son Sagar (11) was paralysed after a viral fever, the 40-year-old worker at a rubber factory in Satara was devastated. After four months of treatment at Pune's Sassoon hospital, Sagar although weak, has now started walking and also assists his family in household chores. Similarly, 10-year-old Sanket Ulhalkar from Bhor, who also suffered a paralysis and underwent five-month treatment at Sassoon, is now able to stand on his feet.
These two cases are among the many cases of Acute Flaccid Paralysis (AFP) that are now being covered under the polio surveillance programme. To mark the World Polio Day, which is observed on October 24, the surveillance programme has been expanded to include severe forms of paralysis to rule out the virus.

Dr Aarti Kinikar, nodal officer for AFP surveillance programme at Sassoon, said that any child with paralysis is closely monitored so that polio viral infection can be ruled out.

"If the children are brought early for treatment, injection immunoglobulin can be administered to help their immediate recovery. This year, six cases of AFP were registered at the hospital. Of the six patients, five were on put ventilator support and have now recovered and regained strength in their limbs. Last year, there were 10 cases," said Kinikar.

Officials said with the surveillance programme picking up momentum, as many as 132 cases of AFP have been detected in Pune district this year.
...

http://www.indianexpress.com/news/now-polio-surveillance-programme-covers-afp-cases-to-rule-out-virus/1186549/0