1/11/2016

The parents refusing to vaccinate their children against polio

By Shaimaa Khalil

  • 23 November 2014
  •  
  • From the section Magazine
Abrar Khan
There have been more than 200 cases of polio in Pakistan since January - the first time infections have reached this level in nearly 15 years. Despite this, not everyone wants their children to be vaccinated. 
Abrar Khan, who is 26, makes his way into a poor neighbourhood of Karachi called Baldia. 
On his crutches, he carefully avoids potholes and dirty cesspools in the narrow alleyways lined, on both sides, with small houses. 
He contracted polio when he was three. Now he's part of a team trying to change the minds of families who refuse to have their children vaccinated. 
Many people here think the polio vaccination campaign is a western conspiracy to sterilise their children - it's an idea the Taliban have been putting about for 10 years now. 
In 2012 the militants ordered a complete ban on vaccinations in the tribal areas in western Pakistan as a response to US drone attacks. 
Since then there's been no immunisation in that area. 
As a result, says the children's charity Unicef, nearly 300,000 children have missed out on vaccination in that area in the last two years.
Most of the residents of Baldia came originally from Pakistan's tribal areas and most are reluctant to immunise their children. 
Yet this is considered a high risk area for polio and I can see why. There's no sanitation to speak of. 
As I walk through the narrow streets, I pass an open sewer running through a residential area. 
Even before you see this canal full of sewage and rotten rubbish, you can smell it. 
It's just the sort of environment in which polio thrives yet around us are about a dozen children, who all look under the age of five, playing in these squalid conditions.
Khan and the other health workers are being escorted by armed policemen. Without their protection the polio team can't do their job. 
Armed guards protect vaccination teams
Many health workers and security personnel have been killed during immunisation campaigns across the country - I'm told there was a shooting in this neighbourhood not long ago.
We stop at one of the houses and an elderly woman answers the door. Four curious little children pop out next to her. 
"None of the neighbours' kids has had it," she says of the vaccine. "Why are you after my grandchildren? I don't want this, I don't trust it," she adds angrily as she waves us away. 
Khan moves on to the next house. A man stands in front of the entrance and starts shouting at him: "My children don't need this. Leave them alone! Why are you after them? And why just polio? There are other diseases why are you focusing on this one?" he yells.
Khan calmly replies: "We're trying to eliminate polio. We're trying to show that we can do this." 
But the man shouts back: "Show who? America? I don't care about them." 
People start to gather round us as he shouts: "I don't trust this team." 
Khan tries again, this time he takes out a small brochure from a folder he has with him. It's a fatwa, a religious decree from a well-known cleric, which condones polio vaccination. 
A man argues against having his children vaccinated
Image captionA man argues against having his children vaccinated
"What's this?" the father says, now more agitated than ever. "I can't read," he says, "why are you giving me this?"
Finally he tells Khan to leave, goes back into the house and slams the door. 
As we walk away from the house, Khan explains: "I try to tell them in any way I can, but they aren't willing to listen. I say 'look at me, I'm a victim of polio. Your children could be like me,'" he says, pointing at his legs. 
I can hear the frustration in his voice: "This man is doing his children a big injustice. He's taking them down a path of lifelong disability. He's the children's worst enemy." 
This refusal to vaccinate is one of many reasons why Pakistan is failing to eradicate polio. But it's not just the influence of the Taliban - experts now point the finger at government mismanagement as well. 

Polio

A health worker gives polio vaccine drops to a child in Peshawar, 2012
  • Poliomyelitis mainly affects children under five
  • Invades the nervous system and can cause total paralysis within hours
  • One in 200 infections leads to irreversible paralysis
  • Polio cases have decreased by more than 99% since 1988
  • Endemic in three countries - Afghanistan, Nigeria and Pakistan
  • There is no cure but the virus can be prevented by immunisation

A recent report described Pakistan's polio programme as a disaster. Campaigns take a long time to organise and when they finally get under way, they're inefficient. 
The polio workers themselves are overworked and underpaid and they risk their lives trying to do their job. 
Some tell me they have to wait for days to get the proper security personnel to escort them. 
And so there have been more than 200 cases this year - that's more than 200 families watching their loved ones suffer from something that could easily have been prevented. 
At the end of a long day Khan invites me back to his family house. He got married recently and I meet his bride and about a half a dozen other women. his sisters and sisters-in-law. 
Altogether there are seven families in the house and between them around 26 children. 
"How many children do you want?" I ask him. "Three inshallah, God willing," he says, "and I will vaccinate them," he adds, with a hopeful smile.
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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

video

movie

movie2

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

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

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.

QUESTION 2

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

QUESTION 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

QUESTION 4

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

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here