Creeping paralysis: India grapples with Guillain-Barré

Last month, a schoolteacher in Pune, a city in western India, noticed her six-year-old son struggling with his homework. “I had erased some words and asked him to rewrite them. I thought he was just upset and that’s why he wasn’t holding the pencil correctly,” she explained to the Indian Express.

Little did she know, her son’s difficulty in gripping the pencil was the first sign of Guillain-Barré Syndrome (GBS), a rare condition where the immune system attacks nerve cells, leading to muscle weakness and paralysis. Within days, his condition deteriorated rapidly—he was unable to move his arms or legs, and eventually lost his ability to swallow, speak, and breathe, requiring a ventilator. Thankfully, he is now on the road to recovery.

This boy is one of nearly 160 reported GBS cases since early January in Pune, a key hub for education and IT, surrounded by industrial towns and villages. There have been five suspected deaths, and as of now, 48 patients remain in intensive care, 21 on ventilators, while 38 have been discharged.

GBS typically starts with tingling or numbness in the hands and feet, followed by muscle weakness and difficulty moving the limbs. Symptoms can worsen over two to four weeks, usually beginning in the legs and arms. The mortality rate varies between 3% and 13%, depending on severity and access to healthcare.

Health authorities in Pune are linking the outbreak to Campylobacter jejuni, a pathogen commonly associated with foodborne illnesses and the leading cause of GBS worldwide. The connection between the bacteria and GBS was first identified in the 1990s in rural China, where children playing in water contaminated by poultry droppings saw outbreaks of GBS every monsoon season.

While GBS is not rare in India, studies conducted by Monojit Debnath and Madhu Nagappa at the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore found that 79% of 150 GBS patients between 2014 and 2019 had a history of prior infections, with a third testing positive for Campylobacter. Coinfections were also common, highlighting a complex interaction between bacteria and viruses.

The pathogen has caused similar outbreaks globally. In 2023, Peru reported over 200 suspected GBS cases and at least four deaths, prompting a national health emergency. Two-thirds of these cases were linked to Campylobacter. While countries with good hygiene practices report fewer cases tied to Campylobacter, respiratory infections are often the leading cause of GBS in these regions. Other triggers have included the Zika virus and, more rarely, vaccines. In 2021, several GBS cases were linked to a COVID-19 vaccine in the UK.

“Campylobacter is always present in the environment, with hundreds of thousands of cases worldwide,” said Hugh Willison, a neurology professor at the University of Glasgow. However, GBS does not occur in everyone exposed to Campylobacter. In rare cases, certain strains of the bacteria have a sugar-coated outer layer that mimics the molecular structure of human nerve cells, causing the immune system to attack both the bacteria and the nerves.

Experts believe a strain of Campylobacter with this molecular characteristic is circulating in Pune, leading to an uptick in GBS cases. While only one in 100 strains of Campylobacter carry this risk, and one in 100 people infected with these strains develop GBS, the overall risk is about one in 10,000.

This creates a scenario of “immunological Russian roulette,” where an immune response triggers an “acute neurological tsunami,” causing rapid nerve damage. Although the immune attack subsides with treatment, recovery can be slow, and the body requires medical support to repair the damage.

There is no cure for GBS. Treatment typically involves “plasma exchange” to filter harmful antibodies from the blood and intravenous immunoglobulin (IVIG) to help reduce the disease’s severity. Diagnosing GBS is challenging, as there is no single test; it is primarily diagnosed based on clinical features. Misdiagnosis, late diagnosis, or no diagnosis is common.

India’s uneven healthcare system exacerbates the problem, as rural doctors may struggle to identify GBS. To support treatment and control the outbreak, WHO teams are working with local health workers in Pune to monitor cases, trace the source, and educate the public. Authorities have tested over 60,000 homes, collected 160 water samples, and advised residents to boil water and avoid undercooked or stale food, especially poultry.

Although Campylobacter infections are commonly linked to undercooked poultry, the bacteria can also spread through contaminated water, similar to cholera or salmonella. In Pune, the outbreak seems to be tied to a strain of Campylobacter with the distinctive molecular feature, potentially due to water contamination or widespread consumption of infected poultry.

Health authorities have urged the public not to panic, but with the source of the outbreak still unclear, many are understandably concerned.

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