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Acute Flaccid Paralysis in India March 2012 - Dec 2013

Ronan Kelly

Ronan Kelly

Retired 2020
:tiphat: Crof.
This seems like a silly scare article. Dr. Day's comment at the bottom gives an indication of the number of AFP cases in India, as well as some of the causes. In our rolling report thread, there are many examples of AFP cases mostly being reported from Bihar.

2 wks after eradication, 'polio' resurfaces
Soumen Datta & Subhendu Maiti, Hindustan Times
Baruipur/Kolkata, March 13, 2012 Email to Author

First Published: 01:11 IST(13/3/2012)
Last Updated: 01:12 IST(13/3/2012)

Barely two weeks after World Health Organisation (WHO) declared India as a polio-free nation, an 18-month-old female child was admitted to a state-run hospital in Kolkata with suspected polio on Monday.

The child, Sumi, a resident of Indrabala village near Baruipur in South 24 Parganas district, was admitted with symptoms of paralysis with disability in movement and fever.

The child?s stool samples have been sent to the National Institute of Virology in Pune and School of Tropical Medicine in Kolkata for confirmatory tests. The reports are expected next week.

?It is a suspected case of polio. In medical parlance, the symptoms are called acute flaccid paralysis. The patient is under observation,? Kumar Kanti Das, superintendent of Baruipur subdivisional hospital (BSH), said.

...
If Sumi is indeed afflicted with polio, it will raise questions about the efficacy of the pulse polio drives that the administration organises with fanfare.


http://www.hindustantimes.com/India...ication-polio-resurfaces/Article1-824438.aspx

Comment by Dr Abhijit Dey
Another foolish story by HT... Dont Panic... this was case of Acute Flaccid Paralysis (AFP)... there are 40 such case in 2012 already reported in 24 Parganas (S) only. The child is completely ok now.. it was a case of transient flaccidity. stool is being collected (like any other AFP case). Dont Panic...
there will be atleast 1 AFP case/1lakh under15 population/year even after polio eradication (cause- traumatic neuritis, GB, Transverse myelitis, other viral neuritis etc)
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

NEW DELHI, March 16, 2012
?Reports on polio resurfacing inaccurate, misleading'

AARTI DHAR

Acute flaccid paralysis is only a possible symptom of polio and not a conclusive trait, says health administrator

Less than 24 hours after a prominent national newspaper sparked off worldwide concern by reporting that polio had reappeared in India just a fortnight after it had been reported as eradicated, a top health administrator has lashed out at the media for misreporting the issue.

?Incorrect and unsubstantiated information can be a major setback for any programme,? said Anuradha Gupta, Additional Secretary, Ministry of Health and Family Welfare, who is in charge of polio eradication. ?These reports are not only inaccurate, but also misleading and de-motivating for the polio workforce, who are working extremely hard to make India polio-free,? she said.

...

Ms. Gupta's said the child's case was one of over 8,000 AFP cases to have been investigated by the National Polio Surveillance Project (NPSP) with the support of local health authorities since January 1 this year. Every one of these AFP cases had tested negative for polio.

?It is important to understand that polio is one of the several causes of AFP and not the only cause for AFP. It is incorrect to call an AFP case a polio case until confirmed by laboratory test,? she said. Over 35,000 reporting units across the country reported 60,782 children with AFP cases, which were followed up and investigated by the laboratories in the year 2011. Only one tested positive for polio, in Howrah district of West Bengal in January, 2011.

...

http://www.thehindu.com/health/article2999838.ece
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

Support for children identified with acute flaccid paralysis under the Global Polio Eradication Programme in Uttar Pradesh, India: a qualitative study
Rie R Yotsu, Katharine Abba, Helen Smith and Abhijit Das

BMC Public Health 2012, 12:229 doi:10.1186/1471-2458-12-229
Published: 22 March 2012

Abstract (provisional)
Background
Cases of polio in India declined after the implementation of the polio eradication programme especially in these recent years. The programme includes surveillance of acute flaccid paralysis (AFP) to detect and diagnose cases of polio at early stage. Under this surveillance, over 40,000 cases of AFP are reported annually since 2007 regardless of the number of actual polio cases. Yet, not much is known about these children. We conducted a qualitative research to explore care and support for children with AFP after their diagnosis.

Methods
The research was conducted in a district of western Uttar Pradesh classified as high-risk area for polio. In-depth interviews with parents of children with polio (17), with non-polio AFP (9), healthcare providers (40), and key informants from community including international and government officers, religious leaders, community leaders, journalists, and academics (21) were performed.

Results
Minimal medicine and attention were provided at government hospitals. Therefore, most parents preferred private-practice doctors for their children with AFP. Many were visited at homes to have stool samples collected by authorities. Some were visited repetitively following the sample collection, but had difficulty in understanding the reasons for these visits that pertained no treatment. Financial burden was a common concern among all families. Many parents expressed resentment for their children's disease, notably have been affected despite receiving multiple doses of polio vaccine. Both parents and healthcare providers lacked information and knowledge, furthermore poverty minimised the access to available healthcare services. Medicines, education, and transportation means were identified as foremost needs for children with AFP and residual paralysis.

Conclusions
Despite the high number of children diagnosed with AFP as part of the global polio eradication programme, we found they were not provided with sufficient medical support following their diagnosis. Improvement in the quality and sufficiency of the healthcare system together with integration of AFP surveillance with other services in these underprivileged areas may serve as a key solution.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

http://www.biomedcentral.com/1471-2458/12/229/abstract
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

Lab Reports Confirm WB case is not Polio
The 18-month old girl from West Bengal, reported as a polio case in a section of media earlier this month, has tested negative for polio. Both the stool samples of the child were found negative for polio in the Institute of Serology Kolkata. As thorough investigation were being carried out, a section of media flashed Sumi?s case as a ?polio case? and reporting it as a huge setback to India?s polio eradication program.

The child Sumi Naskar from Baruipur, 24-Parganas South,was admitted to a hospital in Kolkata earlier this month from where she was picked up by the polio surveillance network for investigation. As part of surveillance for polio, any child less than 15 years of age who suddenly develops floppiness or weakness or paralysis in any part of the body is investigated thoroughly. These cases are called Acute Flaccid Paralysis (AFP) cases.Polio is one of the several causes of AFP and not the only cause for AFP.

Two stool samples of the girl were collected on 13 March and 14 March and sent to the Institute of Serology Kolkata for investigation.Stool samples are collected from all AFP cases and tested to rule out polio as a cause of the illness.

Sumi is one of the many AFP cases detected this year and investigated for polio. In 2012 so far, around 9,000 AFP cases have been investigated by NPSP with the support of local health authorities. All the stool samples of these AFP cases have tested negative for polio. An update of the Acute Flaccid Paralysis (AFP) cases under investigation and the laboratory results is available on the website of the National Polio Surveillance Project. The information is updated every week and can be accessed at www.npspindia.org.

India has not reported any case of polio since 13 January 2011 and has been struck off the list of countries with active endemic wild polio transmission in February 2012. But the job is not yet done. As the risk of polio persists, the surveillance for polio continues to be of the highest sensitivity, detecting and investigating all cases of AFP to rule out polio. An AFP case cannot be reported as polio until confirmed by a laboratory.

SBS/ls
(Release ID :81952)
http://pib.nic.in/newsite/erelease.aspx?relid=81952
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

AFP India.webp
http://www.npspindia.org/bulletin.pdf
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

Suspected polio cases reported from Sabarkatha
Radha Sharma, TNN | Jun 19, 2012, 08.50PM IST

AHMEDABAD: The health teams of Sabarkantha district administration are running from pillar to post after three children resident of Umedgadh village were suspected of polio.

Officials said that the blood samples of the three kids have been collected and sent to Ahmedabad for detailed analysis. According to the officials, the three have been suffering from acute flaccid paralysis.
The three children who have been suffering from AFP are from Umedgadh village in Idar Taluka of Sabarkantha district.
...
http://timesofindia.indiatimes.com/...rted-from-Sabarkatha/articleshow/14275872.cms
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

BIHAR
BHOJPUR
AFP villege -sandesh ,PHC-sandesh,Bhojpur 1 0 17/06/2012 2012-06-21 12:18:20 1876 A case reported by MOIC child age is11 year,Taken all dose of polio vac.case attended by SMO. stool sample collected send for test.result is awaited. RRT visitted plase investigation is going on. Investigation Open situation under control

AFP vill-gaundi,PHC-barhara,Bhojpur 1 0 26/05/2012 2012-06-21 12:07:44 876 AFP case reported by ANM, DIO and SMO visited the plase. Stool samle collected for test.Result is nagative. Direction for RI Stranthen Investigation Closed situation under control.

MUNGER
Provisional Acute Flaccid Paralysis (AFP) Vill-Kesopur, Gage No. 6 Dharahara Road Jamalpur, Munger(Bihar) 1 0 11/06/2012 2012-06-21 14:07:30 900 Case of Acute Flaccid Paralysis (AFP) reported from PHC Tetiabamber ,there wasnot any case found sinc last four months,Active case search done to find new cases. Information sent for stool test. Health education given regarding hygiene and sanitation. Stool sent for Test:-01, Result Awaited RRT visited the affected area. House to house survey done. Daily surveillance done. Investigation Open NO

Provisional Acute Flaccid Paralysis (AFP) Vill- Ghorghat, Premtola, near middle School, Bariyarpur, Munger(Bihar) 1 0 11/06/2012 2012-06-21 14:11:16 800 Case of Acute Flaccid Paralysis (AFP) reported from PHC Tetiabamber ,there wasnot any case found sinc last four months,Active case search done to find new cases. Information sent for stool test. Health education given regarding hygiene and sanitation. Stool sent for Test:-01, Result Awaited RRT visited the affected area. House to house survey done. Daily surveillance done. Investigation Open NO

http://idsp.nic.in/idsp/Disease_outbreak/Disease_outbreak_3day_report.jsp
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

ASSAM
JORHAT
AFP Block: Nakachari PHC Vill- Kakojan T.E. 1 0 04/06/2012 2012-06-22 11:37:57 3420 1. Area: Rural 2. Sex: Male 3. Age group :6-15:1 1. Type of sample : stool 2. No. of sample collected :2 nos. 3. Sample sent for test: Regional Polio Surveillance Centre, Dibrugarh 4. Result: Awaited 1. Active search in community doen 2. Surveillance4 for detection of any fresh cases in the area is going on. Investigation Open No. any other fresh cases were reported as on 21.6.12 2. Hard copy recieved on 21.6.12

AFP Block: Kakojan BPHCSub- centre: Boloma SCVill: Teok T.E. Maajline 1 0 05/06/2012 2012-06-22 11:30:56 3495 1. Area: Tea-Garden area2. Sex: Female3. Age Group: 6-15: 14. Community : Tea-Tribe5. Immuniztion Status: OPV doses received through routine immunization EPI (before onset) 4OPV doses received through SIAs (before onset) 2Total OPV doses 6 1.Type of sample: Stool2. No. of sample collected: 2 nos.3. Sample sent for test: Regional Polio Surveillance Centre, Dibrugarh- Assam4. Result: Awaited 1. Active cse search in community done.2. Surveillance for detection of any fresh cases in the area is going on. Investigation Open No any other fresh cases from the area were reported as on 18.6.12Hard copy of the report recieved on 18.6.12
http://idsp.nic.in/idsp/Disease_outbreak/Disease_outbreak_3day_report.jsp
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

ASSAM
BARPETA
Acute Flacid Paralysis 15 years of age( clinical) 1. Mandia PHC, jadavpur Sub Centre, Jadavpur Village. 2. Nityananda PHC, Borvitha Sub Centre, Pub Dalor Pathar Village. 2 0 14/07/2012 2012-07-19 12:59:24 4387 Attacked on leg of the patient Stool sample already collected from Additinal Office, oo JDH, Barpeta and sent to the Surveillance Officer, National Polio Surveillance Project, Bongaigaon, assam, on 16.7.12, Result awaited NIL Investigation Open 1 NO CASE REPORTED IN P FORM, 2NO CASESS REPORT COLLECTED FROM ADDITIONAL OFFICE, JDH, BARPETA.
http://idsp.nic.in/idsp/Disease_outbreak/Disease_outbreak_3day_report.jsp
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

Hat-tip RoRo. This might be a vaccine-derived or even wild-type polio outbreak, and is worth watching:

PHC arrived polio symptoms found in children
Aug 31, 12:55 am

Shuklaganj (Unnao), reporter: Primary Health Centre in the city on Wednesday Fever brought for treatment in a nearly four-year-old polio symptoms are met.
11 hours had brought. Mr. Washarney said that as soon as the two days of the child's parents that their son was benign fever Kumar. Ashutosh charge of PHC doctors Washarney Said Shuklaganj The Sarvodaya Nagar neighborhood resident Sushil Kumar Rawat and his wife Sarah half*Four-year-old son last two days from benign Kumar Fever coming to PHC Wednesday forenoon at approximately On Wednesday morning, he had not been able to walk. Which was his checkup. Mr. Washarney told AFP in children during the check up (Flasid Acute Paralysis) Symptoms are met. He sent her stool test for Sjeepijiai Lucknow. Mr. Washarney informed that before the primary health center and we have had 17 cases of AFP cases. This is the 18th case. He examined 16 cases reported has come. Any of the symptoms of polio are found. Just two days ago Shuklaganj He belonged to the four-year-old girl Jayshree Gajikedha also had symptoms of AFP. The samples have been sent to the Sjeepijiai Lucknow.

http://in.jagran.yahoo.com/news/local/uttarpradesh/4_1_9618400.html
 
Re: Acute Flaccid Paralysis in India

Re: Acute Flaccid Paralysis in India

Polio programme: let us declare victory and move on
Neetu Vashisht1, Jacob Puliyel2


Abstract

It was hoped that following polio eradication, immunisation could be stopped. However the synthesis of polio virus in 2002, made eradication impossible. It is argued that getting poor countries to expend their scarce resources on an impossible dream over the last 10 years was unethical.

Furthermore, while India has been polio-free for a year, there has been a huge increase in non-polio acute flaccid paralysis (NPAFP). In 2011, there were an extra 47,500 new cases of NPAFP. Clinically indistinguishable from polio paralysis but twice as deadly, the incidence of NPAFP was directly proportional to doses of oral polio received. Though this data was collected within the polio surveillance system, it was not investigated. The principle of primum-non-nocere was violated.

The authors suggest that the huge bill of US$ 8 billion spent on the programme, is a small sum to pay if the world learns to be wary of such vertical programmes in the future.
...
The elephant in the room: the problem of non-polio Acute Flaccid Paralysis (AFP)

It has been reported in the Lancet that the incidence of AFP, especially non-polio AFP has increased exponentially in India after a high potency polio vaccine was introduced (25). Grassly and colleagues suggested, at that time, that the increase in AFP was the result of a deliberate effort to intensify surveillance and reporting in India (26). The National Polio Surveillance Programme maintained that the increased numbers were due to reporting of mild weakness, presumably weakness of little consequence (27). However in 2005, a fifth of the cases of non-polio AFP in the Indian state of Uttar Pradesh (UP) were followed up after 60 days. 35.2% were found to have residual paralysis and 8.5% had died (making the total of residual paralysis or death - 43.7%) (28). Sathyamala examined data from the following year and showed that children who were identified with non-polio AFP were at more than twice the risk of dying than those with wild polio infection (27).

Data from India on polio control over 10 years, available from the National Polio Surveillance Project, has now been compiled and made available online for it to be scrutinised by epidemiologists and statisticians (29).

This shows that the non-polio AFP rate increases in proportion to the number of polio vaccine doses received in each area. Nationally, the non-polio AFP rate is now 12 times higher than expected. In the states of Uttar Pradesh (UP) and Bihar, which have pulse polio rounds nearly every month, the non-polio AFP rate is 25- and 35-fold higher than the international norms. The relationship of the non-polio AFP rate is curvilinear with a more steep increase beyond six doses of OPV in one year. The non-polio AFP rate during the year best correlates to the cumulative doses received in the previous three years. Association (R2) of the non-polio AFP rate with OPV doses received in 2009 was 41.9%. Adding up doses received from 2007 increased the association (R2 = 55.6% p < 0.001) (30). Population density did not show any association with the non-polio AFP rate, although others have suggested that it is related to polio AFP (31).

The international incidence of non-polio AFP is said to be 1 to 2/100,000 in the populations under 15 (32, 33). The benchmark of good surveillance is the ability to detect one case of AFP per 100,000 children even in the absence of polio (34). In 2011, an additional 47,500 children were newly paralysed in the year, over and above the standard 2/100,000 non-polio AFP that is generally accepted as the norm. (32-33). It is sad that, even after meticulous surveillance, this large excess in the incidence of paralysis was not investigated as a possible signal, nor was any effort made to try and study the mechanism for this spurt in non-polio AFP. These findings point to the need for a critical appraisal to find the factors contributing to the increase in non-polio AFP with increase in OPV doses ? perhaps looking at the influence of strain shifts of entero-pathogens induced by the vaccine given practically once every month.

From India's perspective the exercise has been extremely costly both in terms of human suffering and in monetary terms. It is tempting to speculate what could have been achieved if the $2.5 billion spent on attempting to eradicate polio were spent on water and sanitation and routine immunisation. Perhaps control of polio, to the level of elimination, may well have been achieved as it has been in more developed countries. When the US was badly mired in Iraq in 2005, Joe Galloway suggested that the US must simply declare victory, and then exit (35). Perhaps the time is right for such an honourable strategy with regard to polio eradication.
...
http://www.issuesinmedicalethics.org/202co114.html

National Polio Surveillance India data 2000 -2010
NPSP Polio surveillance data on Acute Flaccid Paralysis (AFP) and non-polio AFP and Demographic data (PDF)

http://jacob.puliyel.com/download.php?id=248
 
Re: Acute Flaccid Paralysis in India

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.
 
Re: Acute Flaccid Paralysis in India

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.indiat...cute-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
 
Re: Acute Flaccid Paralysis in India

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.
 
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