Nepal stays vigilant to prevent polio’s return

March 2014

High up in the Nepalese district of Humla, where most villages lie at between 3000 and 5000 metres above sea level, a female community health volunteer visits five-year-old Kiran* at his home. Kiran is complaining that he is unable to move his legs and is starting to become paralysed in his arms as well.

Muscle weakness or paralysis could be due to a number of different viral or bacterial infections or other causes. In Nepal, community health volunteers are trained to be on high alert for these symptoms. This is because acute flaccid paralysis is a sign that Kiran might have poliomyelitis.

Immediate action - reporting, testing, surveillance

Polio vaccination reaches some of the most remote parts of Nepal.
Tinje VDC, Dolpa
Polio vaccination reaches some of the most remote parts of Nepal.

“A single confirmed case of this highly infectious disease is cause for extreme concern,” says Dr Rajendra Bohara, from WHO's office in Nepal. “Female community volunteers are the pillar to detect and report any case of acute flaccid paralysis, even from the most remote villages. Every time there is a suspected case of polio, we take urgent action.”

The health volunteer immediately reports the suspected case to the district health officer and organises for Kiran to travel to Humla District Hospital, a formidable challenge in this remote mountainous district where it can take 10 days to walk to the nearest road.

At the hospital, Kiran is thoroughly examined and two stool samples are taken 24 hours apart. As the highest concentrations of poliovirus are found within 2 weeks of the first paralysis symptoms, speed is crucial. The samples are stored immediately in a refrigerator and transported in ice packs to the WHO Country Office in Kathmandu. From there, they are sent to a WHO-accredited polio testing laboratory in Bangkok, Thailand – one of 7 specialist laboratories in the Global Polio Laboratory Network.

While waiting for the laboratory results, one of WHO Nepal’s surveillance medical officers travels to Humla District Hospital to conduct a thorough investigation, which includes searching for other children with the same symptoms as Kiran and checking the coverage of routine polio vaccination.

Nepal - polio-free since 2010

Preparations also begin for a vaccination campaign of the surrounding community and districts to ensure that, if it turns out that Kiran has polio, the disease is stopped in its tracks.

Children line up for polio vaccination at a school in Nepal
Children line up for polio vaccination at a school in Nepal

Last year almost 600 cases of acute flaccid paralysis were reported in Nepal but fortunately not one of these children, including Kiran, were found to have polio. The country has remained free of polio infection since September 2010.

“This is a critical period, we must remain vigilant,” says Dr Shyam Raj Upreti, manager of the Expanded Programme on Immunization in Nepal.

Routine immunization is the number one method of preventing the re-introduction of polio in Nepal. More than 90% of Nepalese children now receive DPT (diphtheria, pertussis, tetanus) and polio vaccine through the routine immunization programme. However this coverage is not uniform throughout the country.

Nepal’s rigorous polio surveillance system is key to identifying which communities are at risk and where vaccination campaigns and or strengthening of routine immunization are most needed. Until polio is eradicated worldwide, there is always the threat that the virus could be imported.

Regional interaction

“When polio still existed in India, we struggled to prevent the disease travelling across the border,” says Dr Upreti. “Thousands of people cross that border every day.”

India is now polio-free. But every year, national polio immunization days are held to boost immunity among children in both India and Nepal. In particular, mobile vaccination booths are sent to remote rural communities and set up at cross-border entries.

“We have developed very good working relations with our Indian counterparts, meeting with them regularly. Whenever there is a case of acute flaccid paralysis reported in Nepal, we immediately report it to the Indian authorities and vice versa,” says Dr Bohara.

“Neighbouring countries must work together to ensure that we all maintain the highest possible vigilance against this crippling disease.”

*not his real name