Pakistan refugee crisis creates Polio challenge

(AP) / 30 June 2014

Army operation gives authorities a chance to immunise people living in camps 

The rugged region of North Waziristan emerged as a hotbed of polio infections after Taleban militants in the isolated area banned immunizations. Now the government’s offensive against the militants has sent a half-million refugees fleeing the territory, creating both perfect conditions for the disease to spread and a golden opportunity to immunise many thousands of people.
“We know polio is a disease, but we also know the Taleban can kill if you violate their instructions,” said Mohammed Gul, who fled North Waziristan this week and is living in an empty government school with his nine children.
Taleban militants banned vaccinations in the summer of 2012, saying they would allow them only if the US stopped drone strikes. The result has been a spike in polio infections in Pakistan, which is one of only three countries where the disease has never been eradicated.

The number of cases in Pakistan dropped from 198 in 2011 to 58 in 2012. Infections then rose to 93 in 2013. So far this year, 54 of Pakistan’s 83 confirmed polio cases have been in North Waziristan. In fact, North Waziristan accounts for roughly half of the total polio cases confirmed worldwide so far in 2014, according to the World Health Organisation.
The massive Pakistani military operation started on June 15. Health officials did not have any advance notice of the offensive, but the WHO made plans as early as February to be prepared if anything happened.

Polio, a highly contagious virus transmitted in unsanitary conditions, is easily fended off with a vaccine. But once a person’s nervous system is infected, paralysis can happen within hours, and there is no cure. The virus affects mostly children under 5.
“In a nutshell, this is an opportunity, but the risk is also there,” said Dr Nima Saeed Abid of WHO’s Pakistan office, which helps the government with its polio-eradication programme. “If we reach the children with this opportunity, there is great hope.”

The government has been trying to vaccinate refugees as they cross into the neighbouring regions. Dozens of checkpoints are set up along the roads where refugees are offered drops of the oral polio vaccine. About 265,000 people have been vaccinated that way in June, said WHO officials.
But polio-eradication efforts usually rely on multiple rounds of vaccination. The goal is to have enough people immunised so the disease can’t find a suitable host and eventually dies out. But there is no central place in which to give vaccinations because almost all the refugees from North Waziristan have chosen to stay with family members or to rent homes instead of living in the government-run camp.

Instead, officials will go door-to-door in blanket vaccination campaigns that target all residents, including refugees. One such campaign just finished, and Dr Raheem Khattak, who’s in charge of the provincial immunisation programme, says four more are being planned. But the massive influx of refugees taxes the region’s health services and basic water and sanitation. Huge numbers of people living in close, dirty conditions create perfect conditions for the virus. The refugee crisis also comes in the hot summer months, when the virus is most likely to spread.

There’s also no guarantee that the refugees will stay in one place, meaning they could take the disease with them wherever they go. After previous military operations in the northwest, tens of thousands of refugees have gone to places such as Karachi along the southern coast.
So far, health officials say, few people are rejecting the vaccination. Many Pakistanis have been distrustful of anti-polio drives, fearing they were a plot to sterilise Muslims.
At the main hospital in Bannu, polio worker Mohammed Saqib said he vaccinated hundreds of children in the past two weeks, and the families happily agreed. But in an indication of how much fear the militants still command, parents did not want the vaccinations to leave any evidence.
“They say, ‘Just give polio drops to our children, and don’t put any mark on their fingers with ink, so that when they go back, Taleban don’t harm them,’” he said.
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Post Polio Litaff, Association A.C _APPLAC Mexico

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno




A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left


What is that nature of the acute illness in infancy?
What is the nature of the subsequent deterioration?
What investigations should be performed?
What is the differential diagnosis of the cause of the progressive calf hypertrophy?



An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.


A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3


Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition


The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies



  • tumours

  • amyloidosis

  • cysticercosis

    Link here