Have you heard the one about the global conspiracy that polio is rampant in India because thousands of cases of acute flaccid paralysis (AFP) occur there each year? Follow me over here dear readers, we have another lie to debunk, driven by that small but loud cabal of confused pro-disease activists I call hardcore anti-vaxxers.
Bustling New Delhi India
Source: Adam Cohn, Flickr
In my last post, “No, they didn’t rename polio“, I tried to make it clear that India and the region it sits within were declared free of polio transmission years ago (see that evolve in the tables below). Part of that declaration was the development of a helluva lot of polio surveillance.
India and other countries free of wild or vaccine-derived poliovirus-induced disease keep watch to make sure it doesn’t appear. Which makes sense right? An easily transmitted infection somewhere can become an outbreak anywhere in an interconnected world.
But along with the conspiracy theory that renaming is behind the hidden poliovirus scourge we (absolutely do not) face, is the use of India’s large number of AFP cases to reinforce the myth. Let’s look at India and its AFP cases.
Yes, India has a lot of AFP cases
First things first. India is the second most populated country on earth. At writing, India hosts around 1,300,000,000 lives. In the six years of 2013 to 2018 inclusive, that massive population has reported between 36,107 and over 54,000 cases of AFP each year. Sounds vast, right? Compare that to the United States. Wait. No. You can’t because the US doesn’t seem to conduct AFP surveillance, or don’t provide those data to the World Health Organization (WHO). Let’s compare it to other countries then.
Australia has reported 53-62 cases during that same timespan. Australia currently has a population of 25,000,000.
Is there some simpler way we can look at these figures, accounting for population size difference and growth? Yes. The WHO tabulate non-polio AFP cases per 100,000 people under the age of 15 years (children).
In a country that no longer has polio, it is expected that 1 case per 100,000 children would still be found. Fewer than that may mean surveillance isn’t capturing AFP. Australia reached this indicator between 2009 and 2014 although there were some gaps to close.[9-13] But how does the world stack up?
AFP rates around the world
There are still a lot of AFP cases the world over (Table below). In the South-East Asia Region (SEAR), India contributed the majority of cases with 27,322. Its rate per 100,000 children was 8.7. That’s not the highest rate though. Afghanistan saw 16.2 AFP cases per 100,000 children, Pakistan reported 14.4 and Nigeria listed 12.35 per 100,000 children. Afghanistan and Pakistan have had wild poliovirus cases in 2019 and Nigeria had vaccine-derived poliovirus cases.
The highest non-polio AFP rates occur in the South-East Asia (SEAR), Africa (AFR) and Eastern Mediterranean (EMR) regions. India is the largest contributor of NPAFP cases in the SEAR.
Source: WHO Weekly Epidemiological Record No. 47, 2018, 93, 633-648.
How many of India’s cases are due to polio?
According to the World Health Organizations, precisely no AFP cases are caused by poliovirus infection.
This information was missed by authors of a recent publication who astonishing pointed to the polio vaccine as the source of India’s AFP caseload. And yet….no AFP cases were due to poliovirus.
If it isn’t laboratory confirmed, it isn’t polio. And samples are collected and they are tested for poliovirus. Ensuring this is happening is cleverly also part of the surveillance system.
This isn’t a conspiracy, this is a highly successful global collaboration with lots of hard work to ensure the world we share is getting closer to 100% polio eradication. And we’re almost there.
A total of 59,436 AFP cases were investigated in India in 2012, another 53,421 in 2013 and 53,383 in 2014. Not a single AFP case has tested positive for polio in 2012, 2013 and 2014. All AFP cases during the last 3 years have been due to non-polio causes.
World Health Organization. Acute Flaccid Paralysis (AFP) surveillance: the surveillance strategy for poliomyelitis eradication 
Despite a lot of testing. India had its last polio case in January 2011 and was considered polio-free from February 2012 and the South-East Asia region followed.[6-8]
Despite all this, some will wrongly say “but these successes are all due to sanitation, not vaccination.” Improved hygiene and sanitation does reduce the spread of many gastrointestinal viruses. No argument.
Ironically the fact that India still has tens of thousands of NPAFP cases each year – and not a single polio case among them – highlights that the polio vaccine is what made the real difference. Vaccines work. And polio is almost eradicated because of their effectiveness.
It’s also worth noting that we, in our shiny white tiled, mirrored, LED-lit, laminated-bench bedecked bathrooms in our PVC sewer-piped houses in our rich neighbourhoods, also come down with gastro viruses every year.
We do have community outbreaks. If these outbreaks were due to poliovirus, we’d still be getting polio were it not for the bloody vaccine!
In the United States, there is a virus which seems to be heading in the direction of becoming a “new polio”. It isn’t the first. It is an enterovirus called D68. EV-D68 is linked to a syndrome that is a more technically diagnosed and defined subset of AFP called acute flaccid myelitis or AFM.
AFM comes in waves every two years and every wave sees its numbers rise. More cases may just be due to better surveillance (see above) or they may be something new. But it’s happening. Not in India, in the US. And do you know what prevents the illnesses EV-D68 causes? A vaccine. And that’s all that will.
What are the non-polio causes of AFP then?
For a start – not poliovirus. Have I said that already? Because of this, let’s call these cases by a more obvious name – non-polio AFP or NPAFP.
In my last post, I listed a bunch of non-viral things linked with AFP. Polio is just one of many causes.
Staying in my lane, let’s talk about viruses. There are around 100 cousins of poliovirus nicknamed “non-poliovirus enteroviruses (NPEVs). NPEVs are found in India among people that develop NPAFP.
The enteroviruses belong to a huge viral super-group called the family Picornaviridae. Among the picornaviruses are other viral groups containing members seemingly capable of causing problems for our nervous system. Cardioviruses are one example. Cosaviruses another. And there are the parechoviruses as well.
In one 2019 study, 34 distinct NPEVs were identified from among 20% of stool samples collected mostly from children under the age of five years, with AFP in India. NPEVs were more often circulating where the population density was highest. Some of these viruses were distinct from those found elsewhere in the world.
The implication is that – for some reason – India has a problem with these viruses. One reason could be that transmission is being encouraged in some way. Let’s keep in mind a few things:
- Outbreaks happen because of humans, not viruses
- Enteroviruses are mostly spread by faecal-oral infection (droplets and contamination of hands and surfaces)
- Sanitation and hygiene-related issues are important factors to consider in transmission fo viruses in densely populated regions.[5,19]
To wrap up
India has a lot of NPAFP cases but no polio cases and no sign of poliovirus.
Inadequate sanitation, insufficient hygiene, human habits and population density have likely created an ideal storm for virus transmission. Among these viruses are some capable of causing NPAFP. This is on top of the many non-viral causes.
The pro-disease cult will try and convince us otherwise, but polio is not on the rampage and being covered up. Lies are the only thing rampaging here.
- Worldometers | India population
- World Health Organization | AFP case count
- Acute Flaccid Paralysis (AFP) surveillance: the surveillance strategy for poliomyelitis eradication
- Identification and characterization of nonpolio enterovirus associated with nonpolio-acute flaccid paralysis in polio endemic state of Uttar Pradesh, Northern India
- New strategies for the elimination of polio from India.
- Progress Toward Interruption of Wild Poliovirus Transmission — Worldwide, January 2011–March 2012
- World Health Organization in South-East Asia
- Twenty-eighth meeting of the Eastern Mediterranean Regional Commission for Certification of Poliomyelitis Eradication
- Australian National Enterovirus Reference Laboratory annual report, 2009
- Australian National Enterovirus Reference Laboratory annual report, 2010-2011
- Australian National Enterovirus Reference Laboratory annual report, 2012
- Australian National Enterovirus Reference Laboratory annual report, 2013
- Australian National Enterovirus Reference Laboratory annual report, 2014
- WHO Weekly Epidemiological Record No. 47, 2018, 93, 633-648
- Enterovirus D68 – The New Polio?
- Enterovirus 71: emergence of the new poliomyelitis
- Oral polio drops linked to paralysis in India | SciDevNet
- Cardioviruses Are Genetically Diverse and Cause Common Enteric Infections in South Asian Children
- A highly prevalent and genetically diversified Picornaviridae genus in South Asian children
- Genomic Characterization of Novel Human Parechovirus Type
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