LET’S START WITH the good news first: there has been a dip in the number of new cases of the Guillain-Barré Syndrome in Pune and adjoining districts. The bad news? Nearly a month since the outbreak, there has still been no official confirmation on what led to it. Worse, what looks like the most probable cause could have easily been avoided in the first place.
GBS—an autoimmune disorder where the immune system attacks the nerves, causing muscle weakness and paralysis—is rare, with an estimated incidence of one or two per lakh population. But, in Maharashtra, nearly 160 people have so far been diagnosed with GBS. Of these, 38 patients have recovered, while 48 are in the ICU, with 21 of them on ventilator. The state has also seen five deaths attributed to GBS, the latest one from Nanded, about 500km from Pune, on February 1.
GBS begins with a tingling or numbness in the feet and hands, followed by muscle weakness and difficulty in moving joints. Over a period of three to four weeks, symptoms worsen, typically starting in the arms and legs and eventually leading to complete paralysis, if not treated in time. The reported mortality rate varies between 3 and 13 per cent, depending on severity and time taken for accessing treatment. GBS occurs because of viral or bacterial infections in the upper respiratory or gastrointestinal tract, with symptoms including diarrhoea and dysentery more often seen 15 to 20 days prior to the initiation of GBS.
There is no known cure for GBS, but timely treatment can lessen its severity and help in faster recovery. However, early diagnosis is not easy when it comes to GBS. Ashwini Bhore, 22, from Pune would know. She had mild pain in the calves that only kept getting worse by the day. She also felt weak and fatigued. A physician first prescribed her multivitamin injections. When that did little to ease her pain, he put her on saline drip and then suggested blood transfusion when her blood report showed low haemoglobin levels. But her condition only worsened—she could not walk, talk or chew. “All this happened in a span of hours after the third day of the onset of the symptoms,” her husband Sagar told THE WEEK. It was only when she had trouble talking that they were advised to see a neurosurgeon, who diagnosed her with GBS and treated her immediately. Today, she is “totally fine”. “Had we lost more time in learning about this condition and seeking treatment, we would have lost Ashwini forever,” said Sagar.
While the rise in GBS cases—there was a case reported in Telangana and a death in Tamil Nadu recently as well—have sort of created a scare, the condition is not new to or uncommon in India. “A tertiary hospital sees one or two cases per month. World over, you see around a lakh patients every year. So maybe we see a few thousand in India,” said Dr Annu Aggarwal, specialist, cognitive and behavioural neurology, Centre for Neurosciences, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai. But it is the scale of the outbreak in Pune that is atypical. “We have two to three GBS cases per month,” said Dr Himmatrao Bawaskar, a Padma Shri awardee and renowned scientific researcher. “Only, there are many more cases detected in the Pune Municipal Corporation area this year.”
Experts said that the outbreak is most likely caused by a pathogenic bacteria called campylobacter jejuni, known to be the biggest driver of GBS worldwide. It is often found in undercooked poultry, meat or eggs, unwashed vegetables and faeces. “The most common infectious agents that cause GBS include campylobacter jejuni (C. jejuni), mycoplasma pneumoniae and cytomegalovirus,” wrote Josef Finsterer in the International Journal for Molecular Sciences. “C. jejuni is responsible for about a third of GBS cases. GBS due to C. jejuni is usually more severe than that due to other causes.” Also, scientists believe that only a specific strain of C.jejuni causes GBS. The said strain has a sugar-coated outer layer, and in rare cases, its molecular structure matches the coating of human nerve cells. When the patient’s immune system attacks the bacteria, it may end up targeting the nerves as well, leading to GBS.
Health experts in India, however, believe that the Pune outbreak is because of contaminated water, and not food. Samples of soil and water have been sent to the National Institute of Virology, and the reports are awaited. “We believe that these cases occurred because of the ingestion of contaminated water,” said Dr Eknath Pawar, dean of B.J. Medical College and Sassoon General Hospital, Pune. “We have cluster cases from a few areas and sporadic cases from areas outside Pune and nearby district, too. In Pune, we have the norovirus in water, too. However, we still need to confirm it.” Norovirus could also be a possibility, but it is not easily detected. “In short-lived diarrhoeal illnesses, the PCR test for norovirus may not be checked or may be negative when sought at the time of the onset of GBS (10 to 14 days later),” said the authors of a study published in the British Medical Journal that aimed to establish a link between GBS and norovirus infection.
But the residents and experts in Pune whom THE WEEK spoke to agreed that the Pune Municipal Corporation had failed to provide clean water. “People have now gotten used to it and the corporation does not see it as its duty to provide clean water for drinking and domestic purposes,” said Bawaskar.
Authorities are now urging people to “not panic and only drink purified water, whether it is purification by chlorination or by filtration method or consumption of mineral water”. Also, experts said that steroids and alternative therapies should be avoided. The treatment for GBS includes plasma exchange and intravenous immunoglobulin therapy, followed by physiotherapy, speech and other therapies to treat the symptoms. Recovery may take from weeks to months.
“GBS is one of the very well treatable diseases,” said Aggarwal. “Ninety-five per cent of patients do very well. Two to five per cent are left with some degree of neurological disability. But a majority do exceedingly well with treatment. And it is a once-in-a-lifetime condition—it is very, very rare for GBS to occur again in a person’s life.”
Early treatment, however, is crucial, emphasise experts. “The moment one notices the symptoms of dysentery and diarrhoea and tingling numbness, they should report to the hospital immediately, as then the chances of recovery are almost 100 per cent,” said Pawar. “We recently discharged five patients after recovery and they are able to walk by themselves. They have been advised to continue physiotherapy. Within a day or two, we will be able to discharge 10-12 patients. New cases have decreased now and the numbers will come down.”