Guillain-Barre syndrome: India faces outbreak of creeping paralysis

Next month, a school teacher in the northern American town of Pune found her six-year-old child disturbed about research.

I asked him to read some thoughts that I had wiped out. I assumed he was furious and that’s why he was not holding the pencil properly”, she told the Indian Express paper.

She never imagined his struggle to hold a pencil was the first sign of Guillain-Barré Syndrome (GBS), a rare disorder where the immune system attacks nerve cells, causing muscle weakness and paralysis.

Within weeks, the child was in intensive care, able to move his arms or legs. As his situation worsened, he lost the ability to eat, talk, and finally breath, requiring valve support. He is presently recovering.

The child is one of 160 cases of GBS that have been reported in Pune, an business and IT hub, since early January. Five people have been suspected of dying. Now, 48 people are in intensive treatment, 21 on vent, and 38 have been discharged, according to official statistics.

GBS begins with tingling or numbness in the feet and hands, followed by muscle weakness and difficulty moving joints. Symptoms worsen over two to four weeks, typically starting in the arms and legs. The reported mortality rate varies between three and 13%, depending on severity and quality of health care support.

The outbreak in Pune is being traced to a pathogen called campylobacter jejuni, a leading cause of foodborne infections, and the biggest driver of GBS worldwide. The link between the two was discovered in the 1990s in rural China, where the pathogen was common in chickens, and GBS outbreaks occurred every monsoon as children played in water contaminated by chicken or duck droppings.

GBS is not entirely uncommon in India. Monojit Debnath and Madhu Nagappa, of Bangalore-based National Institute of Mental Health and Neurosciences (NIMHANS), studied 150 GBS patients over a five year period between 2014 and 2019. Their findings showed that over a third of them tested positive for campylobacter.

More recently, outbreaks linked to the pathogen have been reported from all over the world. In the first seven months of 2023, Peru reported over 200 suspected cases and at least four deaths of GBS, prompting the government to declare a national health emergency and strengthen public health measures. Two-thirds of the cases were linked to campylobacter.

In countries with good hygiene, fewer GBS cases are linked to campylobacter, with respiratory infections being a major contributor, say experts. There have been other triggers as well. In 2015 Brazil reported a cluster of GBS cases linked to the Zika virus. Vaccines can rarely trigger GBS, but one Covid vaccine was reportedly linked to a few hundred GBS cases in the UK in 2021.

” Campylobacter is endemic, with tens of thousands of cases every year,” said one researcher. It is always existing in the atmosphere”, Hugh Willison, a professor of neuroscience at University of Glasgow told me.

However, it is not easy to create GBS, scientists say.

There’s a particular strain of salmonella, which has a sugar-coated outside level, and in rare cases, its chemical composition matches the coating of mortal nerve cells.

When the patient’s immune system attacks the bacteria, it may end up targeting the emotions as well, which is known as chemical imitation, which results in GBS. However, a small fraction of salmonella isolates have this nerve-like cover.

A rise in attacks with this burden of salmonella in Pune is likely to be circulating, according to Prof. Willison, which will increase the number of GBS cases.

According to the majority of experts, one in ten people who contract salmonella strains are at risk for developing GBS, and one in ten of those who contract it build it.

That results in an “immunological Soviet roulette” that Mr. Willison refers to as an “acute cerebral tsunami” that rages through the peripheral nervous system. When the immune reaction subsides, the attack wanes – but the body also needs period, medical attention, and support to repair the damage.

The fact that there is no treatment for GBS makes things worse.

In GBS, the system produces antibodies against salmonella, which finally attack the emotions. In order to help reduce the severity of the disease, doctors use “plasma exchange,” a procedure that filters blood to remove the harmful antibodies and intravenous immunoglobulin ( IVIG), a therapeutic antibody derived from normal blood.

Another issue is that there is no one test to evaluate GBS. The examination, say physicians, is largely based on scientific features. It presents itself as a paralysis that may be brought on by rare neurological conditions like polio, infections, or numbness.

” The treatment is a cluster of scientific characteristics. Misdiagnosis or no treatment or delayed diagnosis is occur easily”, says Mr Willison.

India’s uneven public health system presents a challenge, as doctors in rural areas may struggle to diagnose GBS. One reason, possibly, why the World Health Organization (WHO) teams are in Pune, is collaborating with federal and state health workers to trace, test, and monitor cases, and analysing trends to support effective treatment.

Authorities claim to have inspected more than 60 000 homes, collected 160 liquid samples for tests, and instructed people to drink boiled water, eat clean, fresh food, and avoid” moldy food and partly grilled chicken or mutton.”

While most cases of GBS around the world come from undercooked poultry, it can also spread through water, similar to cholera or salmonella, experts say.

The bacteria can easily spread in the contaminated water used for washing dishes or preparing street food. Clearly, in Pune, a campylobacter strain with the distinctive molecular feature is circulating, affecting a large number of people.

Is it unclear whether this was caused by widespread water contamination or widespread consumption of sickening poultry? ” We appeal to people not to panic”, says a health department advisory. But in the face of uncertainty, it is easier said than done.