OPV-a cause for increased counts of flaccid paralysis in rural India

Capstone Davangere Environment Health Taluk

Rural India still shows increasing counts of Acute flaccid paralysis

One fine evening in the month of July when Mallikarjun was back from school, he had his evening snack and then went off to bed for a nap. When he woke up, he was unable to stand up, his right limb was trembling and he was gasping for breath narrated Lakshminarayan, Mallikarjun’s father. He was rushed to the district hospital where it was declared that the symptoms his body showed resemblance to that of polio. This case is from Shantinagar, a remote village in the Harapanahalli Taluk.

It is not only his case that exists in the Harapanahalli Taluk in Davangere district of Karnataka which is 270 km far from Bengaluru. N Lakshmamamaik’s son got paralyzed after the OPV drops were orally registered into his body. Coming across real-life scenarios of such a deadly disease, bring us down to a big doubt if polio still exists.

Mallikarjun’s family said that he was not born paralyzed. The onset of paralysis was a few years after the intake OPV drops.

 

Pulse Polio Immunization
Credits: Getty Images

Non-Polio Acute Flaccid Paralysis is a sudden onset of paralysis or weakening of muscles in any part of the body, especially limbs when the weakened polio virus gets activated in the body of children below fifteen years of age. Poliomyelitis, on the other hand, is caused through the transfer of wild poliovirus if the virus enters the body from contaminated hands (with stool) of an infected person. Polio occurs mostly under poor hygienic conditions.

Primary Health Centre (PHC) Harapanahalli

However, there are other views to the present cases of NPAFP where the District Health Officer, Ramesh of Davangere says, “the Taluk is polio-free. The symptoms might be similar to that of polio but it is not a case of poliomyelitis”.

India has been declared polio-free. However, the rising cases of non-polio acute flaccid paralysis have put the country and thereby people of Harapanahalli and adjoining areas under threat.

The cases of non-polio acute flaccid paralysis (NPAFP) in India has been increasing since the year 2000.  It is also established that with an increase in pulse polio rounds the number of cases of NPAFP has registered an increase.  An increase of 2.7 cases of NPAFP in the year 2016-17 per under-15 population, 100,000 for each round of pulse polio has been found. It is a matter of great concern that even after India was declared Polio free in the year 2011 and got certified as a polio-free nation in 2014, still cases of non-polio acute flaccid paralysis exist.

Dr Shankar Naik, a polio specialist in Harapanahalli Taluk said that “the vaccine contains a live, weakened version of the poliovirus which mimics the symptoms of poliomyelitis. The vaccine virus replicates in the intestine and gets excreted in six to eight weeks post the drop is registered orally into the body. There are a few occasions when the vaccine-virus genetically mutates during replication and thus give way to vaccine-derived poliovirus which in turn paralyses the limbs in the children”.

 What is Vaccine Associated Paralytic Polio or VAPP?

According to Dr Ashok Munnivenkataapa who is a scientist in the National Institute of Virology, Bengaluru Vaccine-associated paralytic polio is caused by a strain of poliovirus that genetically changes in the intestine after OPV drops are registered into the body.

  • Board represents the NPAFP tree

The original attenuated or weakened vaccine strain is contained in the OPV drops. Under certain conditions, the weakened virus strain which is present in the OPV drops gets activated in children’s body and causes weakening of muscles or paralysis. The activated virus then circulates in the body. The immunity of a child and the sanitary conditions matter a lot. Children with lower immunity levels are prone to get paralyzed.

In rural areas generally, the sanitary conditions are poor and open defecation still exists. The spread of the disease is mainly through the faecal-oral route. Also, the transmission of the disease can be through having close contact, touching objects or surfaces that have the virus on them, eyes, nose and mouth secretions such as saliva, nasal mucus or sputum.

The Non-Polio Enterovirus are small viruses that are made of ribonucleic acid (RNA). They enter the body through the gastrointestinal tract and live there. They serve as a tree of which non-polio acute flaccid paralysis is a branch. There have been cases where children have suffered from mild or moderate fever before the onset of NPAFP. Once infected, a child would shed the virus into the environment through stool and exhalation for weeks even if he doesn’t bear any symptoms of the disease.

NPAFP Flow chart

The AFP is a part of the Non-Polio Enterovirus which causes paralyses in children. The symptoms of poliomyelitis and that of paralyses caused by AFP are alike.

According to the study by Indian Journal of Medical Microbiology conducted by H. Hanumaiah, CG Raut published in the year 2016 on Non-polio Enterovirus(NPEV) in Karnataka the rate of NPEV varied from 14.85% to 30.58%. The average rate was 21.45%. 99 samples were positive out of 238 samples. AFP cases 32.81% recorded in children aged 5 years and below was lower than the 90% that reported in India. However, similar to the TB bacteria—every second Indian carries the virus, but only a handful are affected.

Staffs at National Institute of Virology, Bengaluru

The detection of the poliovirus is done through checking and examining the stool sample of the suspected patient. Two stool samples which are 24 hours apart are collected and sent to the laboratories for examination. The sample is kept in optimal condition and the growth pattern of the virus is examined. The life of the virus is extended by storing the sample at -20 degrees.

The people in villages live on a very poor sanitary condition and are exposed to this deadly disease. The sanitary conditions are still manageable though, yet the poor health and the nutrition levels of the children cause lo immunity to fight against it.

NPAFP causes weakening of limb which is not curable. Paralysis is stuck with them for a lifetime.

Same was the case with Mallikarjun. He is paralysed since he was five years old; he is now ten. His family spends around rupees five to six thousand or Rs. 5,000 to 6,000 every month for his treatment but they are almost on the verge of giving up as they know what has hit Mallikarjun and it cannot be cured.

Dr Tripulmaba, a general physician at the PHC in the Harapanahalli Taluk said “a few cases of paralysis in children which exist in the Taluk might be due to some other neurological disorder. Polio is eradicated from India and in her several years of practice she hasn’t treated one such case nor recommended any patient to a polio specialist.”

A 5-year-old suspect of NPAFP at Harapanahalli PHC

The Taluk health Officer Mensenkai says, “This is a very deadly disease mostly incurable. People are not aware of this other type of polio too. Even after the immunization if this onset of disease continues, I am afraid the villagers will not bring their children for getting OPV doses”.

“The cases of non-polio acute flaccid paralysis are increasing. In 2018 around 10-15% samples were collected which equates to 1344 and out of which 213 cases were found positive in the whole of Karnataka” says Dr Ashok Munivenkatappa, a scientist at National Institute of Virology. The ideal count of the cases should be 1-2 per cent per 1 lakh population by WHO standards.

“In the L20B cell line, (these are cells of human origin which are used in the labs to culture polioviruses) which is clinically used to test the presence of the wild poliovirus in the stool sample were positive for 33 such samples in the year 2017-18 in Karnataka”, says Dr Ashok Munivekatappa, a scientist in the National Institute of Virology, Bengaluru.

Cell Cabin at National Institute of Virology, Bengaluru

According to the quarterly (July-Sep) report of the National Institute of Virology, Davangere has 19.6% of NPAFP positive cases of the total samples collected. The quarterly report of the National Institute of Virology states that in the July- Sep and Oct-Dec quarter out of 476 samples, results for 213 samples have been positive. In Uttar Pradesh (U.P.) has reported 12359 cases whereas Bihar has reported 6914 cases.

In January 2015 India’s NPAFP rate was 9.71 out of 1816 cases of Acute Flaccid Paralysis. Also, cases in other states such as U.P., Bihar has consistently increased. The NPAFP rates in both the states for the year 2016 is 23.06 and that of Uttar Pradesh is 16.37.

Earlier the vaccine consisted of three strains of weakened polioviruses namely, SL1, SL2 and SL3. Type 2 wild poliovirus has been eradicated and now the composition of the bivalent OPV contains only SL1 and 3.

“Very prolonged use of oral polio doses leads to mutation of the vaccine virus in the children’s body after the OPV doses are administered. Sometimes uneducated parents take their children at pulse polio booths to administer OPV more than it is required” says, Dr DP Sinha a virologist at the National Institute of Virology, Bengaluru.

The dangers of the Oral Polio Vaccine has never been known in totality. The reason the Oral Polio Vaccines were adopted replacing the Inactivated Polio Vaccines was that it used the attenuated poliovirus which is registered in the body and helps prepare the body to fight against the virus. On the other hand, the IPVs are directly injected and mixes with the blood.

“IPV even though is safer considering the problems with Oral Polio Vaccines, it is costlier too”. Says, H Hanumaiah, a scientist at National Institute of Virology, Bengaluru.

According to a study on Correlation of Non-Polio Acute Paralysis Rate published on 21st December 2018, “The IPV needs trained hands, that of health workers, doctors, nurses for the doses to be injected in the children whereas in case of OPV anyone can administer the drops. The problems with OPV is disregarded and the prolonged immunization causes paralysis.”

The causative agents other than faeces or contamination through flies, polio can also be spread through the migration of people from the South East Asian regions or the neighbouring countries where wild polio still thrives and has not been completely eradicated. For example, in Pakistan, the wild poliovirus is still not eradicated. The migrants from Pakistan counts to 1.1 million in the past 4-5 years.

According to the UN’s International migration report published by the Department of Economics and Social Affairs in 2017, India hosted a total of 1.3 million migrants.

The PHC in Harapanahalli Taluk was shabby and not so well maintained. There were a series of patients queued to get themselves diagnosed. There was only one doctor, a general physician present inside the PHC accompanied by a nurse to attend to the patients. According to Indian Public Health Standards, a PHC should have a minimum of two doctors.

Patients waiting for the doctor

Mallikarjun was dressed in a white stained shirt and shorts and seemed like a shy boy. He struggled to get into the bus and people had to help him to do so. He limped while he walked to the entrance of the bus could merely adjust himself on the seat. His father, Narayana sat beside him with a hope in his eyes that his state can get a little better but in reality, NPAFP had already stricken his fate.

Mallikarjun was diagnosed by Dr.Venkatesh Bhairwagdi (MD). He reconfirmed this to a be a clear case of Non-Polio Acute Flaccid Paralysis and he suggested his stool sample to the lab for a second opinion.

“Mallikarjun is a clear suspect of Non-Polio Acute Flaccid Paralysis, his stool sample should be sent to the labs for confirmation”, said Dr.Venkatesh Bhairwagdi (MD).

GB Syndrome also routes from the same genus of Enterovirus and is another factor for the cause of AFP. GB or Guillain Barre syndrome is a disorder in which the virus attacks part of the peripheral nervous system. Initial symptoms of the disease include weakness, limb pain, tingling but eventually, the whole body is left paralyzed.

Dr Anil Talikoti another polio specialist from Gulbarga presents a totally different viewpoint to this existing issue of NPAFP. He says “Numbness or weakness in the muscles is rare in people with AFP.  Some people have pain in their arms or legs because of other health problems. The respiratory failure which people associate to AFP is not true in most of the cases and can also happen when the muscles involved with breathing become weak.”

Surveillance plays a major role in the eradication of NPAFP. Where there are options for both Active and Passive surveillance, Active Surveillance should be preferred. Active Surveillance is a sensitive system that facilitates early detection of the new cases of the disease. It includes detecting, reporting and investigating disease in the hands of the surveillance staffs and the stool samples of the suspected cases are sent for virological analysis.

On the other hand, Passive surveillance can be well established but it is generally a delayed process it involves health workers reporting cases of AFP as they find them in health facilities. There are possibilities of delay in generating a report by 1-2 months. The AFP surveillance program initiated by WHO in India funds the labs for testing the samples and produces quarterly and annual reports of the number of cases detected positive.

According to the Global Eradication polio Initiative, India reported around 700 odd cases of polio due to migration in the last three years. 16 cases from Afghanistan and Pakistan have been found as a result of the migration of people from the respective countries by the global eradication polio initiative, says Dr.CG Raut, a virologist at National Institute of Virology, Bengaluru.  Polio eradication program which eradicated type 2 wild poliovirus freed India from the onset of Type 2 Poliovirus (wild) but NPAFP is still prevalent and recent years have shown increasing cases of NPAFP.

“Another important way to keep a check on the increasing number of NPAFP cases is to consider Environmental Surveillance by testing sewage samples for the polioviruses. Proper and ardent surveillance of Non-Polio Acute Flaccid Paralysis in the country can lead to eradicating the endemic disease. Routine speculation of the sanitary conditions, sewage facilities especially in the rural areas should be done”. Says, H Hanumaiah, a senior scientist in the National Institute of Virology, Bengaluru. This inspection might not detect AFP cases but can bring to light the circulating polioviruses. This may detect a continued transmission of the virus or the new importation of the virus in a polio-free area.

Hanumaiah, a senior scientist from the Environmental Surveillance department said “The environmental surveillance is a must. It takes into consideration how the other factors other than the faecal-oral route, the disease is transmitted and this is the reason why we have a separate department designated for the environmental surveillance in the Institute”.

“The use of IPV over OPV will be a better solution and option, but this switch can only be brought when there are trained doctors and the entire world is polio-free. The surveillance team should pay weekly visits to all government hospitals, PHCs etc in national, state and district levels. Pediatric hospitals and specialists should be visited every week as they are the only experts who get regular cases of NPAFP”. Says, Dr Shankar Naik, a polio expert in the district hospital, Davengere.

The Global Polio Eradication program/initiative is working towards the eradication of poliovirus from the world, still, it also needs to consider the sanitary conditions, the nutrition levels of the children especially of those in the rural areas and spread awareness amongst people on how the disease is spread and thereby suggest ways to prevent it, says Dr. Ashok, virologist at National Institute of Virology, Bengaluru.

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