AFP Surveillance at Iyete HC III

ACUTE FLACID
PARALYSIS
PRESENTED
BY
OJAN RONALD
IYETE HC III
INTERNATIONAL RESCUE COMMITTEE
AFP Surveillance at Iyete HC III

Definition
• What is Acute Flaccid Paralysis?
• Acute Flaccid Paralysis or AFP is a clinical syndrome,
which refers to a collection of signs and symptoms,
instead of a diagnosis.
• AFP is defined by the acute onset of weakness or
paralysis with reduced muscle tone in children.
• There are many infectious and non-infectious
causes of AFP.
AFP Surveillance at Iyete HC III

• Polio, caused by the wild poliovirus (the natural circulating

strain) is one of the causes of AFP.
• In line with the worldwide campaign to eradicate polio,
there is a global monitoring process where clinical cases of
AFP are identified and investigated to depict whether these
cases are a direct result of the wild poliovirus.
AFP Surveillance at Iyete HC III

STANDARD CASE DEFINITION

• An AFP case is any child less than 15 years of age who develops
sudden onset of flaccid/floppy paralysis affecting either one or two
two limbs, or a patient in whom a clinician suspects polio
• COMMUNITY CASE DEFINITION
• Sudden weakness or paralysis in the legs and arms, a child less than
15 years of age
AFP Surveillance at Iyete HC III

AFP surveillance and Polio

• Surveillance of AFP is used in surveillance for poliomyelitis in

the context of the global polio elimination initiative
• Polio is caused by a human enterovirus called poliovirus.
Wild polioviruses (WPV) occur naturally, of which there are
three types.
• There is no cure for polio, it can only be prevented; Polio
(poliomyelitis) mainly affects children under 5 years of age.
• 1 in 200 infections leads to irreversible paralysis. Among
those paralysed, 5% to 10% die when their breathing
muscles become immobilized
 Rationale for AFP surveillance worldwide (i)
• Polio - one of only a limited number of diseases that can be
eradicated as there are no long-term carriers of the disease and an
inexpensive vaccine is available
• Failure to eradicate polio from remaining strongholds could result
in as many as 200 000 new cases every year, within 10 years,
globally.
• In 1988, the Forty-first World Health Assembly adopted a
resolution for the worldwide eradication of polio. It marked the
launch of the Global Polio Eradication Initiative (GPEI),
spearheaded by national governments, WHO, Rotary International,
the US Centers for Disease Control and Prevention (CDC),
UNICEF AFP Surveillance at Iyete HC III
AFP Surveillance at Iyete HC III

Rationale for AFP surveillance worldwide (ii)

• Cases die to wild poliovirus have decreased by over 99% since 1988,
from an estimated 350 000 cases then, to 22 reported cases in 2017. As
a result of the global effort to eradicate the disease, more than 16 million
people have been saved from paralysis.

• Of the 3 strains of wild poliovirus (type 1, type 2, and type 3), wild
poliovirus type 2 was eradicated in 1999 and no case of wild poliovirus
type 3 has been found since the last reported case in Nigeria in
November 2012.

• The incidence of WPV1 cases in 2017 is the lowest ever recorded.

AFP Surveillance at Iyete HC III

Rationale for AFP surveillance worldwide (iii)

• Increasing number of countries where immunization systems have been
weakened/disrupted by conflict and complex emergencies underlines the
potential of serious consequences for further international spread.

• For example, after >2 years without detection of wild polio in Nigeria, the
3 laboratory confirmed WPV1 cases in children between 2 and 5 years
of age with onset between July and August 2016 were confirmed

• These detected viruses were closely linked to WPV1 last detected in the
Nigerian state of Borno in 2011, an indication that this strain had been
circulating without detection since that time

Sources: http://www.who.int/news-room/detail/13-02-2018-statement-of-the-sixteenth-ihr-emergency-committee-regarding-the-international-
spread-of-poliovirus; http://www.who.int/csr/don/06-october-2016-polio-nigeria/en/
AFP Surveillance at Iyete HC III

Rationale for AFP surveillance worldwide (iii)

• In addition to the wild polio cases reported in Nigeria in 2016, a vaccine-
derived poliovirus type 2 (cVDPV2) has also been detected in specimens
collected from a healthy household contact of one of the WPV1 cases
recently reported as part of strengthened disease surveillance activities
being implemented in the area.

• The genetic analysis of the isolated strain indicates that also this
cVDPV2 strain has been circulating in the area for at least two years.

Source: http://www.who.int/csr/don/06-october-2016-polio-nigeria/en/
AFP Surveillance at Iyete HC III

Rationale for AFP surveillance worldwide (iii)

• Populations in fragile states are vulnerable to outbreaks and are
exceedingly difficult to control and threaten the completion of global polio
eradication during its end stage.

• In February 2018
– states infected with WPV1, cVDPV1 or cVDPV3 include Afghanistan, Pakistan
and Nigeria
– states infected with cVDPV2s include Democratic Republic of the Congo,
Nigeria and Syrian Arab Republic
– States no longer infected by WPV1 or cVDPV, but which remain vulnerable to
re-infection include Cameroon, Central African Republic, Chad and Niger

Source: http://www.who.int/news-room/detail/13-02-2018-statement-of-the-sixteenth-ihr-emergency-committee-regarding-the-international-spread-
of-poliovirus
AFP Surveillance at Iyete HC III

Rationale for AFP surveillance worldwide (iv)

• In 2015 coverage with 3 doses of polio vaccine was 94% in the
European Region and 86% globally.

• In June 2002, all 53 countries in the WHO European Region were

certified polio free:
– Since certification, more than 90 million infants across the Region have
received the recommended 3 doses of polio vaccine.
– National and regional surveillance systems and laboratories have ensured that
no polio case could have been left undetected.
– A sustained effort of immunization and disease surveillance helps maintain the
Region's polio-free status.

Source: http://www.euro.who.int/__data/assets/pdf_file/0005/276485/Factsheet-Polio-en.pdf?ua=1;
http://www.euro.who.int/en/health-topics/communicable-diseases/poliomyelitis/maintaining-polio-free-status-of-european-region-as-part-of-the-
global-polio-endgame-strategy
AFP Surveillance at Iyete HC III

Polio Eradication and Endgame Strategic Plan 2013–2018

• On 26 May 2012, the World Health Assembly called for the development
of a comprehensive strategy to achieve a polio-free world by 2018.
• The plan lays out four objectives for the eradication of all polio disease,
whether caused by wild poliovirus or circulating vaccine-derived
poliovirus, and for the use of established structures to deliver other
health services in the wake of eradication.
– to detect and interrupt all poliovirus transmission;
– to strengthen immunization systems and withdraw oral polio vaccines;
– to contain poliovirus and certify interruption of transmission;
– to plan polio's legacy.

Source: http://www.euro.who.int/en/health-topics/communicable-diseases/poliomyelitis/maintaining-polio-free-status-of-european-region-as-part-
of-the-global-polio-endgame-strategy
AFP Surveillance at Iyete HC III

• For more than 10 years, no case of polio was reported in Uganda.

However, in July 2021, the Ministry of Health (MOH) confirmed new
polio virus cases in the country. (15 Apr 2022)
• Whereas Uganda and entire Africa were certified by the World Health
Organisation as wild poliovirus free in August 2020, samples collected,
particularly from sewerage plants in Bugolobi and Lubigi in August last
year, confirmed a circulating vaccine-derived poliovirus type 2.(20 Jan
2022)
AFP Surveillance at Iyete HC III

Uganda’s surveillance for AFP- methods

• Acute flaccid paralysis (AFP) in ALL children < 15
years of age

• Investigation of suspect cases of CNS infection (e.g.

meningitis, encephalitis, AFP) of all ages if travel or
epi-links to contacts from areas where polio virus
circulating
AFP Surveillance at Iyete HC III

Definition of AFP
• Acute flaccid Paralysis (AFP) is a clinical syndrome
characterised by rapid onset of weakness, including
(less frequently) weakness of respiratory and
swallowing, progressing to maximum severity within
several days to weeks.

• AFP is a complex clinical syndrome with a broad array

of potential aetiologies.
AFP Surveillance at Iyete HC III

Potential aetiologies associated with AFP

• Includes possible illness due to:

– Guillian-Barré syndrome
– Transverse myelitis
– Traumatic neuritis
– Viral infections caused by other
enteroviruses, toxins and tumours
AFP Surveillance at Iyete HC III

Causes of Acute Flaccid Paralysis (AFP1) Worldwide

Note: most common causes of AFP indicated in red (*)
AFP Surveillance at Iyete HC III

AFP may present with the following

symptoms
Paralysis- sudden onset
Floppy Limb
Can’t sit up

Acute Flaccid
Paralysiss

Can’t move leg,

arm
Can’t walk Weakness
• ACUTE Is onset within 1 to 3 days
• FLACCID Is limp or floppy limb
• PARALYSIS is loss of movement

AFP Surveillance at Iyete HC III

AFP Surveillance at Iyete HC III

Objectives of AFP surveillance

• To rapidly detect re-importation of poliovirus

into polio-free areas
• To ensure that robust surveillance systems are
in place so that if AFP caused by polio virus
that it would be identified quickly
 AFP Surveillance at Iyete HC III

AFP SURVEILLANCE
STEP 1: Detect all AFP cases using the Standard case definition

• Conduct daily/weekly active search at health facilities (Remember to include all causes
that may present with AFP)
• Sensitize communities to report all cases suspected
TYPES OF AFP SURVEILLANCE
a) ACTIVE SURVEILLANCE FOR AFP
• A designated person Visiting Health facilities, rehabilitation centers and highly
populated areas
b) ACTIVE AFP CASE FINDING
• Community case finding( VHTs, CHEWs) or HWs visiting traditional Birth attendants and
traditional healers in search for AFP
c) ROUTINE SURVEILLANCE FOR AFP (ZERO REPORTING)
• Immediate notification of AFP in children <15 years of age is required.
AFP Surveillance at Iyete HC III

STEP 2: Investigate cases immediately

( within 24hrs of detection)
• Fill in the AFP case investigation form in triplicate
• Conduct home visits to get extra detailed information (immunization Hx od
suspected case and other children in that area, sanitation condition, etc
• Collect 2 fresh stool specimens 24 -48 hrs apart, within 14 days of onset of
the paralysis.
• Place the stool samples immediately in a well-screwed and labelled stool
container (with all particulars)
• Complete a late stool questionnaire for all cases detected after 14 days of
onset of paralysis and address gaps related to late detection for future
cases.
AFP Surveillance at Iyete HC III

STEP 2: CONT
• Fill the AFP case investigation form for suspected
cases detected after 60 days from onset of paralysis
and submit to the district/HSD.

STEP 3: STORE THE SPECIMEN

• Keep the stool specimens in the laboratory fridge
or specimen carrier with frozen ice packs
• Report the case in the weekly and monthly HMIS
reporting forms (HMIS 033b and HMIS 105)
AFP Surveillance at Iyete HC III

STEP 4: TRANSPORT THE SPECIMEN

TO UVRI
• Transport the stool specimens together with the filled
AFP case investigation form to UVRI in a specimen
carrier with fresh Frozen ice packs within 72 hours.
• Notify UVRI/EPI lab before transportation of the
specimen
• Go through the DHO’s office or HSD for specimen
inspection, stamping of form and leave a copy of the
filled AFP case investigation form at the DHO’s office
and HSD
 STEP 5: MANAGE THE CASE
• Manage the case either at a hospital or health center III
• Refer all AFP cases for physiotherapy
STEP 6: CONDUCT A 60-DAY FOLLOW UP
This task will be done by a registered medical officer
• The registered MO shall review the case after 60 days from
onset of paralysis
• Use the 60-day follow up form to document the presence or
absence of residual paralysis, muscle wasting and presence of
sensation.
• Send a copy of the filled in 60 day follow up form immediately
to UVRI-EPI LAB/UNEPI through the DHO’s office
AFP Surveillance at Iyete HC III
AFP Surveillance at Iyete HC III

CASE DEFINITION OF A HOT AFP CASE

• A Hot AFP case is a highly suspected case for being polio based
on clinical characteristics as seen by a clinician and/ or based on
available data for the case i.e.
• AFP case is <15 years of age
• Has incomplete vaccination history
• Presenting with the following 3 clinical cardinal signs:
• Fever at onset of paralysis, asymmetric paralysis and rapid progression to
complete paralysis (within 3 days)
OR
Is a case where there is epidemiological evidence that the case has
been in contact with or living in and area with possible or recent polio
viral circulation
AFP Surveillance at Iyete HC III

TASKS

1.Identify HOT AFP cases using the set case

definition above
2.Label the case investigation form as “Hot”
so it is prioritized for investigation
3.Follow other steps as in previously noted
AFP Surveillance at Iyete HC III

CONTACTS OF AFP CASES

DEFINITION OF A CONTACT Rationale for contact sampling:

• A contact of an index 1. Polio is spread through contact, therefore
contacts have a higher chance of being infected
AFP case is defined as
a child less than 15 2. Most poliovirus infections are asymptomatic
years of age who had 3. An infected asymptomatic child may excrete the
been in direct contact virus for up to 2 months and sometimes longer,
within one week prior as the case of immuno-deficient children.
to the onset of
4. Even vaccinated children who are protected
paralysis and /or
from paralysis, if infected, can still excrete the
within two weeks after
virus in their stools for a short time
paralysis.
AFP Surveillance at Iyete HC III

Contacts of AFP
creteria (eligibility) for sampling contact of AFP cases
1. AFP case with inadequate stool (stool specimen collected
beyond 14 days of onset of paralysis and not exceeding 60
days of onset of paralysis)
2. “Hot” or highly suspected AFP cases
3. AFP cases from areas within limited accessibility or hard to
reach district even without reported Virus isolation
4. When there is any suspicion by the program regarding
quality of the collection process or handling of the index
AFP stool specimens.
AFP Surveillance at Iyete HC III

TASK: collect stool sample from contacts of

AFP cases
• Step 1: conduct contact sampling immediately upon
identification of an eligible AFP case.
• Step 2: select the right contact using the following
criteria:
• 1st priority – AGE
Children below 5 years of age are preferred
2nd preference is a child above 5 years but not
beyond 15 years of age.
AFP Surveillance at Iyete HC III

Cont
• Step 3:
• Collect samples from at least 3 contacts (1 stool sample per contact)
• Collection, storage and transportation of stool specimen are the same as for
AFP cases
• Fill in a specific form “contact stool collection form” for each contact selected.
• Label each specimen clearly as a contact of the specific case; include the
specific ID code of the case followed by number, e.g C1, C2 or C3
• Label the specimen with the name, date, and contact number (e.g C1, C2 or
C3
AFP Surveillance at Iyete HC III
AFP Surveillance at Iyete HC III
AFP Surveillance at Iyete HC III
AFP Surveillance at Iyete HC III
OJAN RONALD BOLD
AFP Surveillance at Iyete HC III