WEBVTT - Why is polio still around?

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<v Speaker 1>Health Matters with Daniel Martin.

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<v Speaker 1>It's Health Matters. Welcome aboard, everybody. Thank you so much

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<v Speaker 1>for joining me, Daniel Martin. Many of you would have

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<v Speaker 1>heard about or read about on CNA.Asia how Singapore's confirmed

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<v Speaker 1>one imported case of vaccine associated polio. It was an

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<v Speaker 1>infant who was flown in from I came in from

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<v Speaker 1>Indonesia and taken directly to NUH upon arrival in Singapore

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<v Speaker 1>and then isolated upon admission.

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<v Speaker 1>We want to know more about why are we still

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<v Speaker 1>hearing about polio and what is vaccine associated polio as well.

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<v Speaker 1>I'm pleased to welcome Doctor Nicholas Chuu, infectious disease specialist,

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<v Speaker 1>Fair Park Hospital, joining us on today's edition of Health Matters.

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<v Speaker 1>It's been a wild off you. Hello, welcome back to

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<v Speaker 1>the show.

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<v Speaker 2>Hi, um, yeah, so polio is a highly contagious virus

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<v Speaker 2>that causes an infection, and really the, the concern is

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<v Speaker 2>that the virus will infect the spinal cord, and this

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<v Speaker 2>might lead to a severe disabling and also potentially life-threatening condition.

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<v Speaker 1>I was talking to some of my colleagues before the

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<v Speaker 1>show began who are all very interested in this topic

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<v Speaker 1>and they say, yeah, yeah, yeah, because they're of a

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<v Speaker 1>certain age and they're like, I remember in the 60s

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<v Speaker 1>and 70s, people were really affected by this and it

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<v Speaker 1>was highly contagious. So it was highly contagious and it

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<v Speaker 1>was preval not prevalent, but it was common in Singapore.

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<v Speaker 2>Um, well, the polio vaccine's been rolled out in Singapore

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<v Speaker 2>since 1962, and, and obviously, it's, it's, it's taken off.

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<v Speaker 2>It's not mandated by law, but I think the uptake is, is,

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<v Speaker 2>is very robust in Singapore. And as a result, you know, we,

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<v Speaker 2>we haven't seen any local transmission of, of cases since 1972.

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<v Speaker 1>So, in

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<v Speaker 2>fact, the last reported case was in, uh, 2006, and

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<v Speaker 2>that was also an

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<v Speaker 2>And uh imported case, same as the current one. OK,

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<v Speaker 1>so the full name for it is poliomyelitis. uh,

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<v Speaker 2>it's polio virus that causes a condition called poliomyelitis. So myelitis, uh, uh, uh,

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<v Speaker 2>refers to inflammation of the spinal cord and therefore you

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<v Speaker 2>get all the paralysis in your limbs and it could also,

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<v Speaker 2>also affect your, your, uh, diaphragm, i.e. your breathing muscles,

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<v Speaker 2>and that could impair someone's ability to breathe.

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<v Speaker 1>And how is it transmitted?

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<v Speaker 2>Um, well, polio is normally acquired through, through the oral route.

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<v Speaker 2>So say if you have a patient who's contagious, they

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<v Speaker 2>will be shedding the virus through their, their oral secretions.

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<v Speaker 2>Then the virus kind of passes through your gut and

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<v Speaker 2>it starts to replicate in the bowel. And because of that, your,

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<v Speaker 2>your index patient will then start to secrete the virus

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<v Speaker 2>in the feces.

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<v Speaker 1>So fecal oral transmission,

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<v Speaker 2>correct. So most likely this patient would, uh, well, I

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<v Speaker 2>suppose this particular infant would be different, but, uh, in

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<v Speaker 2>general for most patients, they would have acquired it through

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<v Speaker 2>contamination of whatever.

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<v Speaker 2>So

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<v Speaker 1>in the past, it could have been, yeah, through food

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<v Speaker 1>prepared by people who've not washed their hands, for example,

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<v Speaker 1>or I guess,

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<v Speaker 2>you know, sharing of saliva or respiratory secretions, for

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<v Speaker 2>example.

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<v Speaker 1>It can be transmitted in the saliva and respiratory secretions

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<v Speaker 1>as well. It's not necessarily just oral fecal

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<v Speaker 1>transmission,

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<v Speaker 2>not necessarily. So if someone in the acute phase is infectious, uh,

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<v Speaker 2>they will start producing the, the virus in, in their

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<v Speaker 2>mouth as well.

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<v Speaker 1>I go for something to be transmitted so easily and

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<v Speaker 1>to have such deleterious effects on the individual as well. No,

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<v Speaker 1>no wonder the world celebrated when we so-called eradicated polio.

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<v Speaker 1>Doctor Chu, why are we still talking about polio if

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<v Speaker 1>we supposedly eradicated it?

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<v Speaker 2>Well, um, as of 2020, um, polio has been largely

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<v Speaker 2>eradicated in most parts of the world, but what we

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<v Speaker 2>don't know is that there are still 22 countries in

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<v Speaker 2>the world where polio is endemic, i.e. Afghanistan and Pakistan, OK.

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<v Speaker 2>Um, but the current imported case probably has, uh, uh,

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<v Speaker 2>been the polio infection has been acquired as a result of,

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<v Speaker 2>of vaccination potentially.

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<v Speaker 1>Let's talk about that. The articles are saying, um, vaccine

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<v Speaker 1>associated polio. What is vaccine associated polio by definition?

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<v Speaker 2>Well, the, the WHO term for this is actually VDPV,

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<v Speaker 2>which is vaccine-derived poliovirus.

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<v Speaker 2>So to understand that, um, um, you need to appreciate

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<v Speaker 2>that there are currently two types of polio vaccines. The

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<v Speaker 2>first one is the oral uh vaccine, which is OPV

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<v Speaker 2>or the inactivated vaccine, which is IPV, OK? Um, traditionally,

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<v Speaker 2>we would have used the oral vaccine.

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<v Speaker 2>Uh, for, and the oral vaccine remains the mainstay of

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<v Speaker 2>vaccination for large parts of the world. And the reason

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<v Speaker 2>for that is because it's, um, you don't need to

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<v Speaker 2>inject it. You just put it into an infant's mouth.

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<v Speaker 2>So because of that, you get easier access, um, um,

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<v Speaker 2>but the problem with the oral vaccine is that it's

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<v Speaker 2>actually a live virus. It's a live attenuated virus, which

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<v Speaker 2>means that the virus has been weakened.

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<v Speaker 2>So in general, in, in uh uh a healthy uh infant,

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<v Speaker 2>healthy host, um, the immune system will, will keep that

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<v Speaker 2>under check.

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<v Speaker 1>So live attenuated the virus, the concept is I introduce

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<v Speaker 1>a weakened form of the virus to your body and

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<v Speaker 1>your body develops immunity against

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<v Speaker 1>it.

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<v Speaker 2>It's almost as if you were, you were infecting somebody with,

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<v Speaker 2>with polio, but because it's a weakened form, you're not

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<v Speaker 2>likely to develop severe complications from it, OK? But the

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<v Speaker 2>caveat to that is that if you use the oral

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<v Speaker 2>vaccine in, in the live viral form in an immunocompromised host,

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<v Speaker 2>what might happen then is this live virus might mutate.

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<v Speaker 2>As it regenerates in the host, it may mutate and

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<v Speaker 2>regain its virulence, i.e. its ability to cause the severe, uh, uh,

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<v Speaker 2>downstream effects of polio. Oh

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<v Speaker 1>dear. And in this case, is that what we know

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<v Speaker 1>that this poor infant received the oral form of the vaccine, i.e., um,

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<v Speaker 1>the live attenuated form of polio, and is also immunocompromised.

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<v Speaker 2>Based on the information that is out in the public domain, um,

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<v Speaker 2>it looks as if this, this infant is 5 months old,

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<v Speaker 2>received the first dose of the polio vaccine in the,

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<v Speaker 2>in the oral form at 2 months, and then at

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<v Speaker 2>4 months, received the inactivated form, OK? Um, and then

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<v Speaker 2>symptoms may have begun at about 4 months of age.

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<v Speaker 2>So the question is whether or not.

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<v Speaker 2>Uh, because of the immunocompromised state, the initial dose of

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<v Speaker 2>the live vaccine may have, you know, reactivated and caused, uh, paralysis.

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<v Speaker 1>Which form of the vaccine is utilized in Singapore for

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<v Speaker 1>our

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<v Speaker 1>children?

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<v Speaker 2>And in Singapore since 2021, uh, we have already phased

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<v Speaker 2>out the oral form of the vaccine. So, i.e., we

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<v Speaker 2>no longer use the life attenuated virus form. So it's

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<v Speaker 2>all injected now and it's the inactivated vaccine.

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<v Speaker 1>OK, which still efficacious in terms of building up resistance

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<v Speaker 1>to polio? Yeah,

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<v Speaker 2>of

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<v Speaker 2>course. Um, so both vaccines have, have a high level

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<v Speaker 2>of efficacy, although in the past, 1 may have argued

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<v Speaker 2>that the oral form may have been more immunogenic, so, i.e.,

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<v Speaker 2>the amount of immune response that you get from the

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<v Speaker 2>oral life form would have been slightly higher, but I

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<v Speaker 2>think in general, the inactivated form, uh, for clinical purposes

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<v Speaker 2>is highly effective.

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<v Speaker 1>How rare is this, doctor, this idea of vaccine-related um development,

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<v Speaker 1>vaccine associated polio developing?

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<v Speaker 2>Um, well, if we're talking about paralysis as a result

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<v Speaker 2>of polio from the, the vaccine, from the oral form

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<v Speaker 2>of the vaccine, I think the recognized risk is about

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<v Speaker 2>1 in 2 million, so it's highly unlikely, but with

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<v Speaker 2>an immunocompromised patient, um, you know, the, the risk is

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<v Speaker 2>obviously much higher, but what we don't know is why

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<v Speaker 2>this infant is immunocompromised, to what, to what degree of, of, uh.

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<v Speaker 2>Uh, immune dysfunction this person has, and how did they

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<v Speaker 2>discover it? Because obviously, the first dose was the oral form, i.e. the,

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<v Speaker 2>the live virus was given.

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<v Speaker 2>So clearly at 2 months, they may not have recognized

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<v Speaker 2>the immunocompromised state of, of the patient.

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<v Speaker 1>And it, it is possible that a parent might not

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<v Speaker 1>know that their child is immunocompromised in some cases, is it?

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<v Speaker 1>That's correct. OK, but that's a big umbrella term. Maybe

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<v Speaker 1>if you can shoot out some examples of what we

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<v Speaker 1>mean by the term immunocompromised because I mean, a listener

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<v Speaker 1>might think it could be anything from

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<v Speaker 1>Having asthma to having HIV. Do you know what I mean?

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<v Speaker 1>So it's a very wide range.

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<v Speaker 2>Yeah. Um, well, for adults, in general, uh, causes of,

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<v Speaker 2>of poor immune system could include chemotherapy for cancer, somebody

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<v Speaker 2>with advanced HIV infection, uh, if they're on, uh, high dose,

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<v Speaker 2>high-dose steroids, for example, for lupus, OK.

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<v Speaker 2>But for, for somebody who's 2 months old for an infant,

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<v Speaker 2>it's likely that the cause of the, the immuno compromised

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<v Speaker 2>state may have been an inherited immunodeficiency

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<v Speaker 2>problem,

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<v Speaker 1>something

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<v Speaker 2>that they were speculating because we don't have that information,

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<v Speaker 1>right, but that, but that is what we mean when

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<v Speaker 1>somebody has an immunocompromised state, it means that therefore, um,

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<v Speaker 1>it's affecting their own body's ability to respond to an infection. Correct.

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<v Speaker 1>Got it.

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<v Speaker 1>Now I wanna understand.

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<v Speaker 1>There are many things, obviously, a lot of people are

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<v Speaker 1>wondering like, oh my goodness, poor thing, this poor child,

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<v Speaker 1>what's the, but then there's also a group of people

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<v Speaker 1>asking questions, especially in the comment sections like, oh, does

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<v Speaker 1>this mean that with one imported case of vaccine associated polio,

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<v Speaker 1>that this somehow increases the risk of community transmission in

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<v Speaker 1>any way? What do we know about that? Because as

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<v Speaker 1>I mentioned in my introduction, was immediately um taken to

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<v Speaker 1>NUH upon arrival and isolated upon admission. Obviously, our medical

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<v Speaker 1>teams are wonderful and, and know their stuff and do

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<v Speaker 1>their work very well. What is the risk of community infection?

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<v Speaker 1>What do we know?

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<v Speaker 2>Um, well, in relation to Singapore, I think that the

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<v Speaker 2>risk of community transmission is, is virtually zero, and the

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<v Speaker 2>reasons for this are several fold. Um, firstly, the patient

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<v Speaker 2>was admitted directly into NUH, so I think, you know,

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<v Speaker 2>the duration that this patient.

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<v Speaker 2>May have been in, in, out in the open, potentially

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<v Speaker 2>shading the virus to the community is negligible. Secondly, the

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<v Speaker 2>family members were here only for a brief period before

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<v Speaker 2>the diagnosis was made and then they were quickly isolated and,

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<v Speaker 2>and screened as well. So again, um, the likelihood of

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<v Speaker 2>them shedding the virus out in the community is unlikely.

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<v Speaker 2>Thirdly, I think the level of sanitation in Singapore is

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<v Speaker 2>first world, so it's again, uh, a factor in our favor. Um,

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<v Speaker 2>and fourthly, um, as I said earlier, Singaporeans and Singapore

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<v Speaker 2>residents are largely vaccinated against, uh, polio.

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<v Speaker 1>Are there multiple shots required for polio vaccination? I forget actually.

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<v Speaker 2>Well, in general, there, there are 5 for Singapore, but

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<v Speaker 2>um other parts of the world may have only 4

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<v Speaker 2>shots that are required, but in general, you would give

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<v Speaker 2>it to infants at age.

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<v Speaker 2>2 months, 4, and 6 months, and then again at

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<v Speaker 2>18 months and then probably at the end of the

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<v Speaker 2>primary school years at about 11 or 12 years old.

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<v Speaker 2>Got it.

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<v Speaker 1>OK. And the example that you mentioned of oral first

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<v Speaker 1>followed by the uh non-oral version, that kind of combination

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<v Speaker 1>approach is not practiced here in Singapore, right?

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<v Speaker 2>No, that's that's not the norm. I suspect what happened

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<v Speaker 2>is that the, the uh

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<v Speaker 2>Infant probably got the oral form first, and then they

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<v Speaker 2>realized that there may have been a problem with the,

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<v Speaker 2>the patient's immunity, then they switched over to the inactivated

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<v Speaker 2>form,

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<v Speaker 1>potentially. Yes. Before we wrap up, let's spend a few

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<v Speaker 1>minutes talking about what parents should be concerned about because

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<v Speaker 1>I'm wondering whether the parents are reading the story, even

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<v Speaker 1>though we've very clearly said how rare this case is

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<v Speaker 1>and how the chances of it is something like 1

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<v Speaker 1>in 2 million as you described earlier on.

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<v Speaker 1>Should parents worry for their own kids' safety when taking

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<v Speaker 1>the polio vaccine?

0:12:06.349 --> 0:12:09.080
<v Speaker 2>Um, the form of polio vaccine that we use in

0:12:09.080 --> 0:12:12.869
<v Speaker 2>Singapore is the inactivated form, so I would absolutely have,

0:12:12.989 --> 0:12:16.760
<v Speaker 2>have no concerns there. Um, but on, on the flip side,

0:12:16.869 --> 0:12:20.590
<v Speaker 2>I would be worried if a parent were to decide

0:12:20.590 --> 0:12:23.679
<v Speaker 2>not to vaccinate their child because, you know, with, with

0:12:23.679 --> 0:12:27.750
<v Speaker 2>Singaporeans traveling for holidays for work, um, that you may

0:12:27.750 --> 0:12:31.940
<v Speaker 2>come into contact with, with somebody shading the polio virus overseas.

0:12:32.469 --> 0:12:34.229
<v Speaker 2>So it's important that you get vaccinated.

0:12:34.559 --> 0:12:36.510
<v Speaker 2>And one of the things that I, I haven't mentioned

0:12:36.510 --> 0:12:39.309
<v Speaker 2>earlier is that even though we think that wild type

0:12:39.309 --> 0:12:43.468
<v Speaker 2>polio uh polio infections are largely eradicated in most parts

0:12:43.469 --> 0:12:46.469
<v Speaker 2>of the world, um, one of the things that people

0:12:46.469 --> 0:12:50.189
<v Speaker 2>don't know about is that, say in the last 18 months, OK,

0:12:50.270 --> 0:12:55.650
<v Speaker 2>from early January 2023 up until the middle of 2024, uh,

0:12:55.710 --> 0:13:01.700
<v Speaker 2>there have been multiple outbreaks of, of vaccine-derived um polio infections.

0:13:02.169 --> 0:13:07.659
<v Speaker 2>So the WHO has recorded over 70 outbreaks.

0:13:08.330 --> 0:13:08.849
<v Speaker 2>And

0:13:09.570 --> 0:13:12.070
<v Speaker 1>that's more than 1 in 2 million risk that I'm, I'm,

0:13:12.130 --> 0:13:13.589
<v Speaker 1>that seems to buck the trend of the 1 in

0:13:13.590 --> 0:13:14.098
<v Speaker 1>2 million.

0:13:14.750 --> 0:13:18.270
<v Speaker 2>Uh, well, the, the, the outbreaks may not have led

0:13:18.270 --> 0:13:22.439
<v Speaker 2>to paralysis, so essentially we're talking about people who have

0:13:22.440 --> 0:13:26.090
<v Speaker 2>presented with uh a multitude of other symptoms that have

0:13:26.090 --> 0:13:29.200
<v Speaker 2>been proven to be related to polio. So the reason

0:13:29.200 --> 0:13:32.520
<v Speaker 2>for that really is because, um, um, all these countries

0:13:32.520 --> 0:13:35.719
<v Speaker 2>would have relied on the oral form of the vaccine and.

0:13:36.469 --> 0:13:39.460
<v Speaker 2>They would have had a lot of uh patients who

0:13:39.460 --> 0:13:42.340
<v Speaker 2>are immunocompromised and continue to shed the virus as a

0:13:42.340 --> 0:13:45.228
<v Speaker 2>result of getting the live virus. And because if the

0:13:45.229 --> 0:13:48.859
<v Speaker 2>uptake within your community, within your country is low, then

0:13:48.859 --> 0:13:52.270
<v Speaker 2>the risk obviously of an outbreak is going to be

0:13:52.270 --> 0:13:52.489
<v Speaker 2>much

0:13:52.489 --> 0:13:52.940
<v Speaker 2>higher.

0:13:53.190 --> 0:13:56.770
<v Speaker 1>Would that not have contributed to the seesage, the cease

0:13:57.150 --> 0:13:59.979
<v Speaker 1>of use of the oral version one would imagine?

0:14:00.630 --> 0:14:03.789
<v Speaker 2>Um, not, not necessarily, because if you can imagine.

0:14:04.130 --> 0:14:08.270
<v Speaker 2>The inactivated vaccine would, would require the patient to be

0:14:08.270 --> 0:14:12.390
<v Speaker 2>injected with a vaccine. Um, so obviously that adds to

0:14:12.390 --> 0:14:15.809
<v Speaker 2>one level of complexity in order to, to be able

0:14:15.809 --> 0:14:18.228
<v Speaker 2>to roll out your vaccine compared to something like a

0:14:18.229 --> 0:14:20.200
<v Speaker 2>liquid that you just pop into an infant's mouth.

0:14:20.659 --> 0:14:24.229
<v Speaker 1>If you're talking about supply chains or chains to certain

0:14:24.229 --> 0:14:28.229
<v Speaker 1>countries with lack of logistics or medical facilities, this all

0:14:28.229 --> 0:14:29.510
<v Speaker 1>plays a part. Yeah.

0:14:30.200 --> 0:14:33.250
<v Speaker 1>Got it. OK, final point, just a reiteration. I, I, I,

0:14:33.400 --> 0:14:35.719
<v Speaker 1>I don't want people to start questioning something that's been

0:14:35.719 --> 0:14:39.489
<v Speaker 1>around since 1978 and has served so much in terms

0:14:39.489 --> 0:14:43.479
<v Speaker 1>of preventing disability and even death potentially from how serious

0:14:43.479 --> 0:14:48.369
<v Speaker 1>polio was. Remind us why vaccination against polio remains our

0:14:48.369 --> 0:14:50.909
<v Speaker 1>best events against a very serious illness.

0:14:52.150 --> 0:14:54.840
<v Speaker 2>Well, it's got to do with, with uh risk-benefit uh

0:14:55.030 --> 0:14:58.450
<v Speaker 2>uh ratios. So I think even though the risk whenever

0:14:58.450 --> 0:15:02.349
<v Speaker 2>you acquire polio, the risk of you developing paralysis is low.

0:15:03.130 --> 0:15:03.440
<v Speaker 2>Um,

0:15:04.260 --> 0:15:08.099
<v Speaker 2>But if you're unvaccinated, you're gonna put yourself, you know,

0:15:08.359 --> 0:15:12.119
<v Speaker 2>at harm's way, um, in terms of the, of getting paralysis.

0:15:12.159 --> 0:15:16.270
<v Speaker 2>And this paralysis is permanent. There's no treatment for it. Um,

0:15:16.479 --> 0:15:20.640
<v Speaker 2>so once your arms or legs are disabled, you're, that's,

0:15:20.750 --> 0:15:23.840
<v Speaker 2>that's you for life. And also the fact that it's

0:15:23.840 --> 0:15:27.440
<v Speaker 2>life-threatening if it affects your, your, your uh nerves controlling

0:15:27.440 --> 0:15:29.229
<v Speaker 2>your breathing apparatus, then

0:15:29.630 --> 0:15:31.750
<v Speaker 2>You know, we're gonna be in, in serious trouble that

0:15:31.750 --> 0:15:32.659
<v Speaker 2>we cannot reverse.

0:15:32.830 --> 0:15:36.309
<v Speaker 1>And it's easily transmissible as well, unfortunately. We cannot afford

0:15:36.309 --> 0:15:38.429
<v Speaker 1>a community outbreak and so it's wonderful that we do

0:15:38.429 --> 0:15:43.690
<v Speaker 1>have in place um vaccination for everyone born after 1978.

0:15:43.960 --> 0:15:45.349
<v Speaker 1>And that has played a big part in terms of

0:15:45.349 --> 0:15:49.130
<v Speaker 1>keeping us polio-free to a large extent in Singapore. Doctor Chuu,

0:15:49.190 --> 0:15:50.830
<v Speaker 1>it's been a pleasure. Thank you so much for speaking

0:15:50.830 --> 0:15:51.700
<v Speaker 1>to my listeners today.

0:15:51.989 --> 0:15:53.789
<v Speaker 1>Thank you for having me on again. My guest on

0:15:53.789 --> 0:15:57.010
<v Speaker 1>the program, Doctor Nicholas Chou is an infectious diseases specialist

0:15:57.010 --> 0:15:59.700
<v Speaker 1>at Farrer Park Hospital. This has been Health Matters. I'm

0:15:59.700 --> 0:16:01.539
<v Speaker 1>Daniel Martin for CNA 938.

0:16:07.369 --> 0:16:10.799
<v Speaker 1>Before making any decisions based on the information in our program,

0:16:10.969 --> 0:16:12.890
<v Speaker 1>please consult a medical professional.