On 2015 May 31, Neetu Vashisht commented:

Kenneth Rochel de Camargo2015 May 19 6:41 p.m. commented on PubMed Commons with regard our presentation at the Excellence in Pediatrics Conference <Pediatrics. 2015 Feb;135 Suppl 1:S16-7. doi: 10.1542/peds.2014-3330DD PMID:26005734> writing that we have not considered alternate explanations for non-polio AFP (NPAFP) suggested by Mohammadi Dara in Lancet Neurology Mohammadi D, 2014. I am responding directly to the Lancet article because the original links of Camargo’s comment has moved.

We originally did this analysis in 2011 for a paper published in 2012 Vashisht N, 2012 using data up to 2010. The data for the analysis was obtained from the WHO (and National Polio Surveillance Program of the Government of India) and we included all cases defined by them as NPAFP.

In that paper Vashisht N, 2012 we reported that the NPAFP rate in an area increases in proportion to the number of polio vaccines doses/child given in that area. (The coverage rate in these areas is also monitored and is excellent, by and large.) Nationally, the NPAFP rate was 12 times higher than expected. In the states of Uttar Pradesh (UP) and Bihar, which have pulse-polio administered to individual children nearly once every every month, the NPAFP rate is 25 and 35 times higher than expected. Population density did not show any association with the NPAFP rate.

We calculated that 47,500 children were paralyzed in India in 2011, over and above the standard numbers expected assuming a 2/100,000 NPAFP rate. This is a huge burden of disease. The Lancet paper < PMID:24943341> was published after our 2012 paper Vashisht N, 2012. Given that 47500 children were affected we are not sure if it was ‘Much Ado about Nothing’ as suggested by Mohammadi in the title.

Mohammadi has quoted various experts giving numerous possible explanations for the high NPAFP rate. For example Dr T Jacob John explains it away saying “India’s health-care is at near anarchy”. This assertion cannot be tested or falsified in a scientific paper.

I will discuss 3 possible explanations given in the paper by Mohammadi for the (47500) extra cases of NPAFP seen in the country in a year.

a) One expert - Dr Hamid Jafari - suggests it may be due to improved surveillance. This is a non sequitur as excellent surveillance can result in detecting all cases of NPAFP but it cannot create new cases of paralysis and it cannot explain why the number of cases has increase 35 fold above what is expected, in Bihar.

b) Over reporting of mild weakness as NPAFP. We have reported Vashisht N, 2012 that this is unlikely to be a satisfactory explanation. We quoted studies where a cohort of NPAFP was followed-up, showing their chance of death as a result of the disease, was double that of children with wild polio infection. NPAFP was a more lethal disease than polio. This militates against the ‘mild weakness wrongly diagnosed as AFP’ theory

c) Dr Jacob John suggests a list of test book causes of paralysis like ‘post traumatic Neuropathy - due to intramuscular injections’ as the explanation for the NPAFP rates. He does not explain why such trauma must increase proportionately with number of oral polio vaccine doses given per child in the area.

Our latest work presented at the Pediatrics conference in Dubai whose abstract was published in Pediatrics <Pediatrics. 2015 Feb;135 Suppl 1:S16-7. doi: 10.1542/peds.2014-3330DD PMID 26005734> is a follow-up analysis. After the original analysis in 2011, the number of polio-rounds (each year) in many states was curtailed. In some states 6 doses began to be given each year instead of 10 doses. This provided an opportunity to recheck if our original hypothesis was correct. The analysis was done again for this paper with data up to date till 2013. It shows that the number of cases of NPAFP has begun to come down following reduction in the number of oral polio vaccine doses (given per child in the community). This follow up analysis adds credibility to the conclusions of the previous ecological study of the relationship of NPAFP rates with number of OPV doses administered per child.

We have placed all the data used in the analyses in a freely downloadable format on the net and it is referenced in our papers. The full data used up to 2013 is here http://jacob.puliyel.com/download.php?id=357 We are keen that others can add to it and we will welcome reanalysis of this data and new ideas to explain and then mitigate the suffering of these children.

On 2015 May 31, Neetu Vashisht commented:

Kenneth Rochel de Camargo2015 May 19 6:41 p.m. commented on PubMed Commons with regard our presentation at the Excellence in Pediatrics Conference <Pediatrics. 2015 Feb;135 Suppl 1:S16-7. doi: 10.1542/peds.2014-3330DD PMID:26005734> writing that we have not considered alternate explanations for non-polio AFP (NPAFP) suggested by Mohammadi Dara in Lancet Neurology Mohammadi D, 2014. I am responding directly to the Lancet article because the original links of Camargo’s comment has moved.

We originally did this analysis in 2011 for a paper published in 2012 Vashisht N, 2012 using data up to 2010. The data for the analysis was obtained from the WHO (and National Polio Surveillance Program of the Government of India) and we included all cases defined by them as NPAFP.

In that paper Vashisht N, 2012 we reported that the NPAFP rate in an area increases in proportion to the number of polio vaccines doses/child given in that area. (The coverage rate in these areas is also monitored and is excellent, by and large.) Nationally, the NPAFP rate was 12 times higher than expected. In the states of Uttar Pradesh (UP) and Bihar, which have pulse-polio administered to individual children nearly once every every month, the NPAFP rate is 25 and 35 times higher than expected. Population density did not show any association with the NPAFP rate.

We calculated that 47,500 children were paralyzed in India in 2011, over and above the standard numbers expected assuming a 2/100,000 NPAFP rate. This is a huge burden of disease. The Lancet paper < PMID:24943341> was published after our 2012 paper Vashisht N, 2012. Given that 47500 children were affected we are not sure if it was ‘Much Ado about Nothing’ as suggested by Mohammadi in the title.

Mohammadi has quoted various experts giving numerous possible explanations for the high NPAFP rate. For example Dr T Jacob John explains it away saying “India’s health-care is at near anarchy”. This assertion cannot be tested or falsified in a scientific paper.

I will discuss 3 possible explanations given in the paper by Mohammadi for the (47500) extra cases of NPAFP seen in the country in a year.

a) One expert - Dr Hamid Jafari - suggests it may be due to improved surveillance. This is a non sequitur as excellent surveillance can result in detecting all cases of NPAFP but it cannot create new cases of paralysis and it cannot explain why the number of cases has increase 35 fold above what is expected, in Bihar.

b) Over reporting of mild weakness as NPAFP. We have reported Vashisht N, 2012 that this is unlikely to be a satisfactory explanation. We quoted studies where a cohort of NPAFP was followed-up, showing their chance of death as a result of the disease, was double that of children with wild polio infection. NPAFP was a more lethal disease than polio. This militates against the ‘mild weakness wrongly diagnosed as AFP’ theory

c) Dr Jacob John suggests a list of test book causes of paralysis like ‘post traumatic Neuropathy - due to intramuscular injections’ as the explanation for the NPAFP rates. He does not explain why such trauma must increase proportionately with number of oral polio vaccine doses given per child in the area.

Our latest work presented at the Pediatrics conference in Dubai whose abstract was published in Pediatrics <Pediatrics. 2015 Feb;135 Suppl 1:S16-7. doi: 10.1542/peds.2014-3330DD PMID 26005734> is a follow-up analysis. After the original analysis in 2011, the number of polio-rounds (each year) in many states was curtailed. In some states 6 doses began to be given each year instead of 10 doses. This provided an opportunity to recheck if our original hypothesis was correct. The analysis was done again for this paper with data up to date till 2013. It shows that the number of cases of NPAFP has begun to come down following reduction in the number of oral polio vaccine doses (given per child in the community). This follow up analysis adds credibility to the conclusions of the previous ecological study of the relationship of NPAFP rates with number of OPV doses administered per child.

We have placed all the data used in the analyses in a freely downloadable format on the net and it is referenced in our papers. The full data used up to 2013 is here http://jacob.puliyel.com/download.php?id=357 We are keen that others can add to it and we will welcome reanalysis of this data and new ideas to explain and then mitigate the suffering of these children.