Polio and Acute Flaccid Paralysis
Filed under: Parents' Pages, Vaccine Myths, Vaccine/Disease Analysis, WHO Watch
Acute Flaccid Paralysis is a term which applies to the exact clinical symptoms you would expect to see from poliovirus infection, but which are not necessarily caused by polioviruses. Paralytic polio is actually considered a sub-category in the broad umbrella of acute flaccid paralysis. See pages 300-312  for a chart and summary of many other causes of AFP, a few of which are: Guillaine-Barre syndrome, Cytomegalovirus polyradiculomyelopathy, Acute transverse myelitis, Lyme borreliosis, nonpolio enterovirus and Toxic myopathies.
For many years the medical profession assumed that when they saw paralysis with a particular cluster of symptoms, it was poliomyelitis. The 1954 Francis Trials of the Salk vaccine  triggered a reconsideration of this assumption, and a major change in the diagnostic criteria.
How were polio cases counted in 1954?
In 1954 most health departments worked with the WHO definition:
“…Signs and symptoms of nonparalytic poliomyelitis with the addition of partial or complete paralysis of one or more muscle groups, detected on two examinations at least 24 hours apart.” [3, p. 88]
How were polio cases counted in 1955?
In 1955 the criteria were changed to conform more closely to the definition used in the 1954 field trials: residual paralysis was determined 10 to 20 days after onset of illness and again 50 to 70 days after onset. [3, p. 88]
Thus, simply by changes in diagnostic criteria, the number of paralytic cases was predetermined to decrease in 1955-1957, whether or not any vaccine was used. At the same time, the number of nonparalytic cases was bound to increase because any case of poliomyelitis-like disease which could not be classified as paralytic poliomyelitis according to the new criteria was classified as nonparalytic poliomyelitis. Many of these cases, although reported as such, were not non-paralytic poliomyelitis. [3, p. 88] (emphasis added)
It was after the SALK vaccine was introduced, when fully vaccinated people continued to get “polio”, that doctors started looking a lot more carefully at the viruses in individuals. Many viruses were found to cause paralysis, for example coxsackie B, enterovirus 71, etc.
Paul Meier, looking back at the problem of misdiagnosis of polio during the Francis Trials.
Next, we said, the diagnosis of polio is tricky, but we need to have the entire country’s physicians participate, because we can’t look over every case where there’s some kind of paralysis. So physicians reported the cases they thought were polio according to the protocol, and we accepted those cases. Now about half those cases were probably not polio at all, but still, we did have total reported cases, compared with paralytic and nonparalytic cases. 
By 1960, in order to be defined as “poliomyelitis”, virus tests on stool samples were required. If polioviruses were not seen, additional tests to find other viruses were run, and sometimes, no virus could be found at all. Whatever the “cause”, paralysis following sickness was no longer automatically classified as polio. It was now re-classified under many different diagnoses, with “Acute Flaccid Paralysis” as the loose umbrella heading under which paralysis caused by poliomyelitis viruses was a sub-category.
The history of polio in the U.S. is presented with numbers like this:
…in seven years the Salk vaccine reduced the incidence of polio in the United States by more than 96 percent, from 38,476 reported cases in 1954 to 1,312 in 1961. 
These statistics are simply not accurate. The 1954 “polio” data includes all paralysis. While some of this may have been from polio, in reality, much of it was from other causes. With the change of diagnostic criteria in 1955 that reduced case numbers, followed by laboratory testing that excluded vast numbers of other causes, the 1961 data only includes the small subgroup of paralysis caused by poliomyelitis. This is then compared with the catch-all 1954 definition. Because it was impossible to know what proportion of 1954 data were really caused by poliomyelitis viruses, the 1954 data was left as it was, and nothing of the back story is revealed to the readers. When people say: “we know the polio vaccine saved us from huge epidemics of this devastating disease” they are basing their knowledge on misinformation.
If polio is wiped out, will that mean the end of “infantile paralysis?”
How was the prevaccine data from developing countries collected, before they implemented vaccination programmes?
Doctors used “lameness surveys” as a means to look for people with deformed or shrivelled legs, on the presumption that such problems were causes by the polioviruses, and then multiplied that data to cover the surrounding areas which weren’t directly surveyed.
1970 – 1980
Lameness surveys demonstrate that polio is widespread in many developing countries, leading to the introduction of routine immunization with OPV in almost all national immunization programs. 
What was the case definition used for these lameness surveys?
The case definition used most frequently consists of (1) flaccid paralysis with atrophy, (2) no decrease in sensation, and (3) a history of acute onset with no subsequent progression of disease. This definition assumes that the sequelae of residual paralytic poliomyelitis are observable and distinctive enough to be reliably attributed to poliomyelitis; however, the sensitivity and specificity of the definition have not been evaluated. 
Were the surveys conducted with consistent methodology around the world and throughout the 10 year process?
The percentage of all lame children who are categorized as having paralysis due to poliomyelitis has varied markedly from one survey to another…Some variation is to be expected, but the specificity of the case definition is a reasonable concern. Also, the case definition has not been applied uniformly. 
How can we be sure lameness surveys were accurate?
We can’t be. Lameness surveys were essentially a “look and guess” exercise. Even though poliomyelitis researchers knew from the U.S experience that large numbers of polio cases had other causes, lameness surveys were used as factual evidence that poliomyelitis viruses were the sole cause of lameness around the world.
1992 – 1993
The Global Polio Laboratory Network is formally established to facilitate high quality virologic investigation in all countries. 
This process appears to parallel what occurred in the U.S, whereby a loose definition of polio is used to collect the pre-vaccine incidence of the illness.
As vaccination programs are implemented, a formal process of accurate and consistent diagnosis is put into place. Only at this point, after vaccination is in use, is there any attempt to accurately and consistently separate the non-polio caused cases of acute flaccid paralysis from the polio caused cases.
When polio has been eradicated from an area, how much acute flaccid paralysis is still occurring?
Here is an example from the Americas after the eradication of polio:
In 1993, regional vaccination coverage among children with at least three doses of oral poliovirus vaccine was 87%; 33 of 38 countries had achieved and maintained coverage of more than 80%. Routine vaccination has been supplemented by annual national immunization days *. Since August 21, 1991 (when the last confirmed case was reported), approximately 6000 acute flaccid paralysis cases have been investigated; however, none of these cases were confirmed as paralytic polio resulting from wild poliovirus. In addition, approximately 25,000 stool specimens obtained from these patients and their contacts were negative for wild poliovirus (Figure_1). Finally, key surveillance indicators have been at acceptable levels in all countries during the past 3 years. Based on review of these data, all 26 national or multinational certification commissions recommended that their countries be certified as polio-free. (emphasis added)  (4th paragraph)
This World Health Organization database, which goes back to 1996, provides a lot of information about polio cases and acute flaccid paralysis cases.
How many cases of acute flaccid paralysis (excluding cases due to polio) occurred from 1996 to 2009?
608,832 cases of AFP were reported, worldwide. Looking at the data, year by year, certain countries have ND in the AFP cases reported column. ND means No Data. Which means that the 608,832 cases is incomplete and that there were even more cases of non-polio AFP during this period.
In the same period, there were 39,131 cases of polio identified. 
Here is some information on Acute Flaccid Paralysis in India:
In India polio cases had come down from 24,257 in 1988 to 4793 cases in 1994 with the help of routine immunization, well before the ‘eradication programme’ started in India, In those days all cases of acute flaccid paralysis (AFP) with residual paralysis beyond 60 days were diagnosed as polio. 
There was also an unexplained increase in AFP – especially non polio AFP. In 2005 there were 10,055 non polio AFP cases in Uttar Pradesh (UP) where 561 cases were expected. A delegation from the Public Report on Health (PRoH) (Council for Social Welfare, New Delhi) in November 2006 investigated the problem of residual paralysis in ‘non polio AFP’. The PRoH found that most cases of AFP were not being followed up (unless they cultured virus in the stools). Information provided under the Right to Information Act and available from National Polio Surveillance Project (NPSP) is shown in the Table. Of the 10264 cases of AFP, 209 were cases of polio or compatible with polio. Of the remaining 10055, only 2553 were followed up; of these, 898 had residual paralysis (that would qualify them to be diagnosed as polio using the old definition) and 217 died. Projecting these figures on those not followed up, it will appear that approximately 4800 cases had residual paralysis or died in UP after acquiring non polio AFP in the year 2005. This figure must be compared to the all India figures of 4793 polio cases in 1994. It is not surprising the NPSP is not keen on the follow up of these cases. The data from 2006, after 6 doses of mOPV had been administered in 2005, in districts of UP, are worse. 
The Acute Flaccid Paralysis cases in India continue to increase, year by year. For the year 2009, using the WHO data, we find 50,416 total cases. Out of this total 752 were polio. 
In 2000 WHO announced:
There were 719 cases of wild poliovirus in 2000. This represents a 99% reduction in cases since the programme began in 1988, with 350,000 estimated cases from lameness surveys. 
Note the similarity to the announcement of a 96% reduction in the U.S. by 1961, based on enlarged pre-vaccine numbers and selective post-vaccine numbers.
The rest of the story of polio in the year 2000:
There were a total of 2,971 cases of polio in the year 2000. 
Of these cases, 719 were identified as cases due to wild poliovirus. 
The other 2,252 may have been due to wild poliovirus or they may have been due to the vaccine virus. They were left off of the WHO timeline.
There were 27,654 cases of non-polio acute flaccid paralysis, which were left off of the WHO timeline. 
Based on the quotes from the Bernier article  (see above) the accuracy of the claimed 350,000 annual cases of polio-caused paralysis based on the lameness surveys, is dubious at best.
Puliyel also questions the validity of these numbers:
WHO claims five million children have been saved from polio paralysis. It is instructive to see how this figure is arrived at. In 1988, there were 32,419 cases of paralytic poliomyelitis. The WHO arbitarily raised this number ten-fold to 350,000 claiming incomplete reporting. In 2004 with the changed definition, only culture positive paralysis was considered polio and there were 2000 such cases. Subtracting 2000 from 350,000, the WHO calculated that 348,000 children were saved from paralysis that year. 
To sum up:
The numbers used in the U.S. to claim that the Salk vaccine caused a huge reduction in the number of cases of paralysis due to polio were manipulated by changing the criteria for diagnosing the disease.
The numbers used in the worldwide program to eradicate polio were estimates using very loose standards that hypothesized the number of cases, and extrapolated them across large areas before vaccination campaigns were ignited. This was followed by much stricter diagnostic standards that weeded out Acute Flaccid Paralysis from other causes.
As the number of cases subjected to laboratory analysis rose, and the number of cases of polio dropped, the number of cases of acute flaccid paralysis rose.
Is there an epidemic of acute flaccid paralysis occurring due to various non-polio causes? Are any steps being taken to deal with this expanding problem?
Over 600,000 people coming down with some degree of paralysis in a period of 13 years seems like cause for concern.
The Global Polio Eradication Initiative (GPEI), spearheaded by national governments, the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC) and UNICEF, is the single-largest, internationally-coordinated public health project the world has ever known. Since 1988, more than two billion children around the world have been immunized against polio thanks to the unprecedented cooperation of more than 200 countries and 20 million volunteers, backed by an international investment of more than US$ 5 billion. 
$5,000,000,000.00 and 20 million volunteers.
What about the 608,832 cases of AFP worldwide since 1996 (not counting the 26,014 cases of AFP from January 1st through May 21, 2010)?
Further information on the changes in methodology for the diagnosis of polio can be found here. 
Coming up next: Polio and Sanitation.
 Differential Diagnosis of Acute Flaccid Paralysis and Its Role in Poliomyelitis Surveillance, Arthur Marx, Jonathan D. Glass, and Roland W. Sutter. Epidemiologic Reviews, Vol. 22, No. 2, 2000. http://epirev.oxfordjournals.org/cgi/reprint/22/2/298.pdf
 “A calculated risk”: the Salk polio vaccine field trials of 1954, Marcia Meldrum, BMJ 1998, 317: 1233-1236 (31 October) http://www.bmj.com/cgi/content/extract/317/7167/1233
 The Present Status of Polio Vaccines (a panel discussion), Illinois Medical Journal, August, 1960.
 A Conversation with Paul Meier, Harry M. Marks. Clinical Trials 2004, 1, 131. http://www.hopkinsmedicine.org/histmed/people/faculty/papers/meier.pdf
 The Making of the Polio Vaccine, Douglas Hand, Invention and Technology Magazine, Summer 1985, Volume I, Issue 1. http://www.americanheritage.com/articles/magazine/it/1985/1/1985_1_54.shtml
 World Health Organization. Global Polio Eradication Initiative, The History. (site visited on May 30, 2010) http://www.polioeradication.org/history.asp
 Some Observations on Poliomyelitis Lameness Surveys, Roger H. Bernier, Reviews of Infectious Diseases, Vol. 6, Supplement 2. International Symposium on Poliomyelitis Control (May – Jun., 1984), pp. S371-S375
 MMWR Weekly, October 7, 1994, 43(39); 720-722 http://www.cdc.gov/MMWR/preview/mmwrhtml/00032760.htm
 WHO, Immunization Monitoring, Diseases, Poliomyelitis Case Count, accessed multiple times between May 1 and June 1, 2010. http://apps.who.int/immunization_monitoring/en/diseases/poliomyelitis/case_count.cfm
 Polio eradication & the future for other programmes:
Situation analysis for strategic planning in India (Editorial), Jacob S. Puliyel, Manoj Anand Gupta, Joseph L. Mathew, Indian J Med Res 125, January 2007, pp 1-4 http://jacob.puliyel.com/download.php?id=132
 Guide to Poliovirus Isolation and Serological Techniques for Poliomyelitis Surveillance, I. Domok and D. I. Magrath, WHO, Geneva, 1979. http://whqlibdoc.who.int/offset/WHO_OFFSET_46.pdf