Surveillance for polio the key to finding poliovirus in its last hiding places
By Dr. Waheed Miraj, KP
Even in the most far-flung districts of Pakistan, Surveillance is being enhanced to ensure no case of polio is missed.
Chitral, the largest geographical district of Khyber Pakhtunkhwa, is located at the Northern Border of Pakistan. Sharing an international border with Afghanistan, it is one of the seven districts of Malakand Division, which takes between 12 and 14 hours from Peshawar to access by road. Lowari Top, a 10,800 feet high mountain, one of the only passes connecting Chitral and neighbouring district Dir, is often snow-bound in winter, leading the locals to use the route through Afghanistan to reach Peshawar or Islamabad. In such a far-flung district with the hardest terrain where it can take 4 hours to cover just 30 kilometres, it is nearly impossible to seek basic medical needs for individuals.
Despite this, the polio programme is able to reach almost every child. In the September National Immunization Days campaign polio vaccination teams and teams of supervisors and monitors, vaccinated more than 72,000 (99.84% of target) children under five with polio vaccine in Chitral district.
Living in a small village in the Union Council of Yarkhoon bordering with the UC of Upper Chitral, Mr. Mir and his family live in small home at the brink of the river. From there it takes the family on average between 6 and 7 hours to reach the main city of Chitral. When Fehmida, Mr Mir’s daughter, developed paralysis in both the lower limbs, the family became worried that it was the signs of the lifelong paralysis caused by poliomyelitis, still endemic in Pakistan. Living in very modest setting, so far from any facilities Mr Mir feared for the health of his child. Despite living in a remote village in a district that has been polio-free for a number of years, the fear that this crippling disease could have stolen away his daughters’ future prompted Mr Mir to take Fehmida to the closest hospital in Chitral to be examined. Dr Gulzar Ahmad, who first examined Fehmida, notified the case to the surveillance team in the District Health Office.
As part of normal disease surveillance for polio, a doctor reached their house to assess the child’s symptoms of paralysis and to investigate the possibility that this could be polio. Normal practice is to collect two stool samples over a period of 24 hours to send for testing for the virus. The visit of the doctor helped the family to better understand that the polio programme has expanded its surveillance network for Acute Flaccid Paralysis (AFP). This system includes collection and collation of data related to the case of AFP and disseminate it to the concerned for proper action. The family got to know that for such acute flaccid paralysis, Poliomyelitis is not the only cause, there are more than 25 causes, the important of which are Injection Neuritis (or Traumatic Neuritis), Guillain-Barre Syndrome and Transverse Myelitis etc.
The wait for the laboratory report from the National Institute of Health Islamabad, the only regional WHO accredited laboratory for Pakistan and Afghanistan, was indeed a difficult time for the parents of the 6-year-old child. However, the family did not sit idle during this time; they undertook multiple visits to the District Head Quarters Hospital in Chitral. A month later, they got the negative results for wild poliovirus from the lab report, leading to a brief celebration for the family.
Following the laboratory testing of stool, regardless of whether the test returns positive or negative for polio, a 60 day follow-up consultation is conducted with all reported AFP cases to check for residual paralysis and to ensure the family has access to the right information and services for the child. On examination, Fehmida was completely well with no residual paralysis, her sensations, power, tone and reflexes of her affected lower limbs were all in normal range. On this news, the family was so happy that they arranged a small gathering with meal during the day.
Surveillance is one of the key activities of the polio eradication initiative in Pakistan, particularly after the detection of virus in the near-by district Kohistan in September. Surveillance, both for cases of AFP and for the virus in the environment help to detect where the virus is circulating and to measure the quality and impact of polio immunization activities.
Following this experience, the Mir family are more aware than ever of the threat of polio. Mrs Mir, Fehmida’s mother, supports the polio teams in the campaigns and she intends to extend her support in future as well. She also informed the locals of the village about AFP and role of OPV in its prevention in the prayer sessions.