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Indian Journal of Community Medicine

Acute Paralytic Poliomyelitis: Change in Number over Years Impact of PPI: Sentinel Centre Experience

Author(s): K. Singh, G Kaur, R. Kumar

Vol. 29, No. 2 (2004-04 - 2004-06)


Research Question: 1. What is the number of acute poliomyelitis cases coming to our hospital for admission over the years? 2. What is the impact of Pulse Polio Immunization (PPI) on that number?

Objectives: 1) To determine the number of polio cases coming for admission to our hospital from September 1988 to September 1999. 2) To note the impact of PPI on that number.

Study design: Retrospective and ongoing.

Setting: Pediatrics ward and OPD of Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab.

Participants: Children with acute paralytic poliomyelitis.

Study variables: Age, sex, place of residence, month and year of admission in the hospital, immunization status. Statistical analysis : Simple proportions and percentages.

Results: A total of 99 cases were admitted during the study period September 1988 to September 1999. Cases from rural areas (60.6%) and males (76.8%) were predominant. About 70% were unimmunized. Though previously also the number of admission changed greatly over year, yet no year had been free of polio before 1996, the pre-PPI phases. Three cases of non-polio Acute Flaccid Paralysis (AFP) have been reported since March 1998.

Keywords: Poliomyelitis, Immunization, National Immunization Days, Pulse Polio Immunization


The 1990 World Summit for children made a commitment to the eradication of poliomyelitis by the end of 1990's. According to WHO estimates, there were almost 400,000 new victims of the disease in 1983; in 1990, the number decreased to 200,000 and by 1994, all of Western hemisphere had been free of the dreaded disease for at least three years. This, to a large extent is due to the strategy of national immunization days to supplement routine immunization programs pioneered by several countries1. World­ wide the number of polio cases dropped further to just 3997 in 19962. In the South-East Asia Region, successful eradication strategies resulted in a 96% decrease in the number of reported cases from 25,711 in 1988 to 1,116 in 1996.3

India too is following these action plans since 1995 in the format of pulse polio immunization (PPI)4. This retrospective and ongoing study is being undertaken to note the number of poliomyelitis cases coming to our hospital for admission over year and impact of PPI on that number. Our department serves as a sentinel centre for surveillance for six vaccine preventable diseases including poliomyelitis mainly for the district Faridkot. Occasionally patients from the adjoining districts of Ferozepur, Muktsar, Bathinda and Moga are also admitted. Whole of this area has been covered by the 4 phases of PPI campaign.

Material and Methods

We have been maintaining, since September 1988, in a sentinel surveillance register, record of all patients presenting with any of the six vaccine - preventable diseases. Age, sex, immunization status, place of residence, date of presentation and outcome are recorded. Diagnosis is confirmed by at least one consultant. The first author participated in a two-day workshop on Acute Flaccid Paralysis (AFP) surveillance under the aegis of UNICEF in New Delhi in November 1997 where he got himself acquainted with various aspects of AFP surveillance. So since March 1998, we have started notifying to civil surgeons all cases of AFP on weekly basis and sending stool samples for virus isolation if the cases report within 60 days off onset of paralysis. Unfortunately however, data from August 1990 to August 1992 is not available. The period till September 1999 is covered in this ongoing study.


A total of 99 cases were admitted during the study period. Year wise break up of cases shows that the number of cases has waxed and waned greatly over years e.g. 31 and 41 cases in 1989 and 1994 respectively and only 4 and 2 cases in 1993 and 1995 respectively. The last case was admitted in 1996. No child was below the age of six months, while only 8 (8.08%) were above the age of five years. As many as 69.7% were unimmunized. Season-wise distribution of cases as well as their break-up according to address and gender are also shown in the table.

Table I: Characteristics of Poliomyelitis Cases (n = 99)

  No. (.%)
6months-lyr. 30 (30.3)
1 yr. - 2 yrs. 31 (31.3)
2 yrs. - 5 yrs. 30 (30.3)
> 5 yrs. 8 (8.1)
Male 76 (76.8)
Female 23 (23.2)
Place of residence
Rural 60 (60.6)
Urban 36 (36.7)
Year wise distribution
(a) Pre-PPI years
(i) Sep 88 - Jul 90
(ii) Sep 92-Dec 95 48  
(b) Post-PPI years
Jan 96- Sep 99
Season-wise distribution
Feb-Mar 4 (4.0)
Apr-June 14 (14.1)
Jul-Sep 63 (63.6)
Oct-Jan 18 (18.1)
Immunization status
Complete 9 (9.1)
Partial 21 (2 1.2)
Nil 69 (69.7)


Ministry of Health and Family Welfare, Government of India launched PPI campaign countrywide for eradication of poliomyelitis. Four phases of the campaign, in 95-96, 96-97, 97-98, 98-99 have been completed till date. This has resulted in a dramatic reduction in the reported number of polio cases in India. Compared to 3,263 cases in 95, 1,005 cases were reported in 1996. This decrease was despite improved reporting of cases. In our study also same trend prevails. The maximum number of cases, 41, were admitted in our hospital in 1994, while in 95 and 96 we had only two cases each. In 1997, 1998 and till September 1999 we have not come across even a single case of poliomyelitis. This is in the light of the fact that total indoor admission have increased marginally during the corresponding years from 676 in 1993 to 849 in 1998, while OPD cases have almost doubled from 9,373 in 1993 to 17,353 in 1998. In fact out of the total 235 cases of AFP reported from Punjab during 1998 and till 4th September 1999, 3 were reported by us in the beginning of March 1998, the date since when we have started keeping record of all AFP cases under 15 years of age6. The virus isolation study of the stool samples of these three patients showed no polio virus strain. Though previously also, the number of cases admitted in our hospital has differed year by year, e.g. only 4 cases in 1993 and 41 cases in 1994, yet no year has been free of polio cases as have been the year 97, 98 and 99 till September. This may be due to the impact - of PPI. The PPI coverage percentage in the district Faridkot has been 110.3, 115.2, 111.6 and 108.6 for the years 95-96, 96-97, 97-98 and 98-99 respectively6. Before March 98, some of the cases clinically diagnosed as actue polimyelitis may have been AFP cases due to non-polio enteroviruses.

Sixty out of 96 cases (62%) whose addresses are entered in our data belong to rural areas while 36 (37%) hailed from urban areas. In the 96-97 coverage evaluation of PPI, it was found that a significantly lower coverage of 90.7% in rural areas as compared to 95.2% in urban areas was achieved in all the states7. One can summarize that this was and is the pattern regarding routine immunization and disease prevalence also. It indicates a need for planning to reach the unreached rural population. In our study, male babies were more than 3 times the number of females (76.7% vs 23.2%). However, during an outbreak in July 1992 in an orphanage in Delhi, males had the disease only 1.5 times more than the females8. In an outbreak of poliomyelitis in the northern part of Jordan Valley between November 1991 to March 1992 male to female ratio was of nearly 1 9. The very high male to female ratio in our study may be due to the gender bias in our society in bringing only male sick babies to the hospital.

Kalawati Saran Children's Hospital (KSCH), New Delhi serves as a sentinel centre for surveillance of poliomyelitis for Delhi as well as neighboring states of Uttar Pradesh, Haryana and Rajasthan. Out of total 2121 cases seen by them during 1994-96, 75% were between the ages of 6 months to 2 years10. Out of our 99 cases, 61(61.6%) were from six months to two years of age. Another study has documented that 85% of polio cases in Delhi occur in children less than 3 years of age11. In our study, 91.9% of cases were under 5 years of age. It is only fitting that the target age group for the PPI campaign was increased from less than three years in 1995-96 to less than 5 years in 1996-97 by Government of India4. In the epidemic in Jordan in 1991-92, all the 26 cases were below the age of 4 years, more than half being less than 1 year9. However, 8% of our cases were above the age of 5 years. This may be a pointer towards increasing the target age group to still higher age.

More than sixty percent (63.6%) of our cases presented during the months of July, August and September, the months related to rains in Northern India. KSCH in analyzing its large database of 2121 cases from 1994 to 1996 has reported that there has always been a seasonal increase in number of cases from June onwards with the peak invariably in the month of August, the rainy season in North India. Nearly 43% of their cases came in the months of August and September only10.

KSCH study has further noted that 22% and 27% of their cases were fully immunized in 1994 and 1996 respectively10. Srivastva and Israil, reported that 15% children had received full immunization with 3 doses of OPV prior to getting acute paralytic poliomyelitis12. An alarming 85% of patients were either partially or fully immunized in the report from Jordan9. In our study though,. only 9% were fully immunized, while 21% and 70% had partial or no immunization respectively.

The high and differing immunization failure rates may be, apart from the breaks in cold chain, due to the fact that there are geographic difference in the protective and immunogenic efficacy value of 3 doses of OPV13. Some studies have strongly recommended a minimum of 5 doses of OPV during infancy and at least 2 more within pre-school age, for every child.14-16

To conclude, the number of poliomyelitis cases coming to our hospital has gone up and down, but the general trend has been one of great reduction in that number since 1995. In fact we received the last case of poliomyelitis in November 1996. It reflects an all-India trend, as India achieved 88 reduction in reported poliomyelitis incidence over the decade from mid-eighties to mid-nineties11. PPI seems to have further augmented this positive trend. However, we have not lowered our guard, as we are actively involved in AFP surveillance since March 1998. This is consistent with sustained AFP reporting on a weekly basis in countries like Peru where the last case of poliomyelitis was reported in 199118.

Indeed, India is stepping up its efforts to make the country polio-free by the year 2000 in the form of Intensified PPI (IPPI). Under the strategy of IPPI, there will be four nation-wide rounds of IPPI between October 1999 and January 2000 in place of the usual two with the eight priority states organizing 2 suplementary PPI rounds between February-April 2000. Also this time each round will last 3 days and there will be house to house search and vaccination strategy to vaccinate any missed children19.


We are indebted to Dr. Karanveer Singh SMO (Punjab), National Polio Surveillance Project-India, for providing data of PPI coverage and AFP surveillance.


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From the Department of Pediatrics, GGS. Medical College, Faridkot, Reprint request Dr. Karnail Singh, 24- Medical Campus, Faridkot -151203, Punjab, India

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