CASE INVESTIGATION FORM - ACUTE FLACCID PARALYSIS (AFP)

Ministry of Health, Federal Democratic Republic of Ethiopia

COMPULSORY NOTIFICATION (PLEASE COMPLETE ALL INFORMATION IN FULL)
Official Use Only: Epid Number: _______ ________ _______ _______ ________ Received: ____/____/____
Ctry Region Zone Year onset case number
IDENTIFICATION:
Address _______________________________________________________________________________________________________________________________
_______________________________________________________________________ _______________Health Facility __________________________________
Province/Region: _____________________________________ Kebele:_____________________ Woreda: __________________________

Zone: _____________________________ Name(s) of patient __________________________ Father/Mother:______________________________________

Date of birth ___/___/___ Age years: ___________ Months: _________ Sex:

(if DOB Unknown) M=Male F=Female

NOTIFICATION/ INVESTIGATION:
Notified by___________________________________________ Date District Notified ____/_____/_____ Date Case Investigated: ____/____/______
HOSPITALIZATION:
Admitted to hospital: 1= Yes 2= No Date of Admission ____/____/____

Medical Record Number ________________________ Name/address of Facility: __________________________________

CLINICAL HISTORY:
Fever at onset Paralysis Site of paralysis
of paralysis 1= Yes 2=No Progressed 1= Yes 2=NO

Date Onset of Paralysis: ____/___/_____ <=3 days L.Arm R.Arm

Flaccid
paralysis Asymmetrical L.Leg R.Leg
1= Yes 2=No 1= Yes 2=NO
Y.N. Y.N

AFTER INVESTIGATION,
WAS THIS TRUE AFP? 1 = Yes 2= No if "no", then the rest of the from does not need to be completed.
Mark "6" for final classification

VACCINATION HISTORY: Total Polio doses Received 99=unknown

Date of OPV doses

Date of OPV Zero: ____/____/_____ 1st ____/____/____ 2nd _____/____/_____ 3rrd_____/____/_____ 4th ____/____/____

if>4 doses, date of last OPV dose: ____/____/_____

STOOL SPECIMEN COLLECTION:

Date 1st stool collected ____/_____/_____ Date 2nd stool collected ____/_____/______ Date stool sent from field to national level ____/____/____
STOOL SPECIMEN RESULTS: Primary isolation result
Date stool specimen Condition of stool Date result sent by Date result received by national P1 P2 P3 NP-
Ent
received by national 1=Adequate 2=Not adequate National Lab to National level Level:_____/_____/____
Lab: ____/____/_____ ____/____/_____

1= Yes 2= No 1=Yes 2=No

W1 W2 W3 V1 V2 V3 NP-Ent
Date isolate sent from Date differentiation result Date differentiation result
National Lab to Regional sent by Regional Lab: received by National Level
Lab. ___/___/___ ____/____/____ ____/____/___
1= Yes 2= No 1= Yes 2=No 1=Yes 2=No

FOLLOW-UP EXAMINATION: Residual Paralysis?

L.Ar R.Arm 1=Residual paralysis
Date follow-up
m Findings at 2=No residual paralysis
Examination: ____/____/_____
R.Leg Follow-up 3=Lost to follow-up
L.Leg 4=Death before follow-up
Y.N Y.N

FINAL CLASSIFICATION OF THE CASE:

1= Confirmed 2= Compatible 3= Discarded 4= Not an AFP

INVESTIGATOR:
Name _______________________________________________________ Title: _________________________________________________

Unit: ____________________________________Address:__________________________________ Phone: ___________________________

PLEASE SEND A COPY OF THIS COMPLETED FORM IMMEDIATELY TO:
 Disease Prevention And Control Department, Ministry of Health, Addis Ababa
IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT: Phone: 01-516889 or (09) 219555 Fax: 01-519366
Acute Flaccid Paralysis (AFP) is characterized by rapid onset of weakness of one or more
limbs, progressing to maximum severity within less than 3 days. The term “flaccid” indicates
the absence of rigidity in the group of muscles/limb affected.

Asymmetrical paralysis is defined as the presence of a notable difference in the extent of

involvement between the left and right limbs (arms or legs).

Residual paralysis is defined as the presence of some (minimal or major) motor weakness
during repeat examination (60 days after the onset of paralysis) in the limb(s) initially involved.

No residual paralysis is defined as complete improvement in muscle power during repeat

examination (60 days after the onset of paralysis) in the limb(s) initially involved.

Contact Addresses:
MoH, Surveillance team:
 159543 / 519798/ 09-219555
WHO Surveillance/EPI Unit:
 444422/444197/444199/444261/0911-200765
EHNRI Polio lab:
 771054/771055/771056/09-214969

The size of a single stool specimen has to

be 8 – 10 grams (the size of the tip of an
adult’s thumb) and two specimens need to
be collected at 24 – 48 hours interval.