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 states under 15 population should ideally throw up. This year,the figure till May 6 has been 6,213. The total number of AFPs in India in 2011 was 60,753. This year,it has been 18,324,approximately 2,000 more than last year. The countrywide figure is about eight times the global incidence rates. AFP is a condition in which the patient has weakness or paralysis in his/her muscles,accompanied by reduced muscle tone. Apart from polio,the reasons for AFP could be poisoning (curare,botulinum),nerve lesions,transverse myelitis,Guillain Barre Syndrome,Reyes 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. In the current issue of the Indian Journal of Medical Ethics,an article by Dr Jacob Puliyel,consultant paediatrician at St Stephens Hospital,says: 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. The same article argues that while it is an efficient surveillance system that has picked up these AFP cases,the reasons for the increase were never investigated properly. . 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, it says. In other words,Dr Puliyel thinks many of these cases would actually be vaccine-derived polio. Senior officials associated with the polio programme in the health ministry say it is only the anti-vaccine lobby that is trying to push injectibles over oral polio vaccine that has been playing up AFP figures. 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. Dr Puliyel claims the spurt in AFP has a direct correlation to the number of doses of OPV administered. Dr Manish Kakkar,an epidemiologist associated with the Public Health Foundation of India,says the truth may be somewhere in between. While it is possible that the surveillance system is so good that there is some amount of over-reporting,it is equally possible that some of these huge numbers of AFPs could be explained if we take into account the possibility of vaccine-derived polio cases. A 1700% rise or a 2300% rise cannot be otherwise explained. More transparency is needed in dealing with the matter, he says.
