ACUTE FLACCID PARALYSIS

Dr. RAJAKUMAR
Professor
Dept of Pediatrics
SSSMC&RI
ACUTE FLACCID PARALYSIS
Paralysis of acute onset < 4 weeks.
Affected limbs flaccid i.e. floppy or limp.
Tone diminished .
DTR diminished or absent.
Sensation not affected.
Case definition
Case of AFP any child < 15 years who has acute onset
of flaccid paralysis for which no obvious cause ( severe
Trauma / Electrolyte imbalances ) is found /
Paralytic illness in a person of any age in which polio is
suspected.
Definition taken for surveillance and should be
capable of detecting all cases of AFP due to polio / non
polio etiology.
All cases of AFP regardless of age should be reported
and investigated as Poliomyelitis.

Case definition (contd.)
Poliomyelitis may occur in older childern therefore
AFP surveillance must focus on children aged < 15
years.
High sensitivity of AFP reporting will ensure that all
cases of paralytic poliomyelitis - detected, reported
and investigated resulting in preventive control
measures to interrupt transmission of disease.

In other parts of world indicates atleast 1 case of AFP
occurs per year for every 1,00,000 population of
children aged < 15 years referred to as background
rate of AFP among children - and is account for
Nonpolio causes of AFP such as
a) Guillain Barre syndrome.
b) Transverse Myelitis.
c) Traumatic neuritis, etc
regardless of whether acute poliomyelitis exists in the
community.

Goal of AFP surveillance in India is to have all states
reporting AFP rate of atleast 1 case per year per
1,00,000 population aged < 15 years.
This would ensure adequacy of surveillance if
reported less suggest that surveillance is not sensitive
to detect all cases of paralytic poliomyelitis.
CLASSIFICATION OF AFP
Polio / Non polio- based on isolation of virus in stool
specimens.


FOR AFP SURVEILLANCE
Clinical classification as indicated below used so that
true epidemologic data are collected.
Non-Polio causes
Non-Polio causes
Other DDs
1. Non-Polio enteroviruses - coxsackie A, B viruses, Echo,
entero types 70,71, mumps.
2. Hypokalemia.
3. Peripheral neuropathies.
4. Pseudo paralysis non specific toxic synovitis.
5. Scurvy.
6. Congenital syphilitic osteochondritis.



Surveillance of AFP
Surveillance data collection for action.
- carried out for all cases of acute flaccid
paralysis, not just for polio myelitis.
Surveillance data must support the principle if polio
cases had occured they would have been detected,
reported and investigated in an expeditious manner.

FOR ACHIEVING THE GOAL OF POLIO ERADICATION
Defined as absence of clinical cases of poliomyelitis for
atleast 3 years and the absense of detectable wild polio
viruses from the community.

Stool sample
2 stool specimens should be collected at interval of
24 48 hrs apart and within 14 days of onset of
paralysis.
When AFP cases are seen late ( i.e. > 2 weeks after
paralysis onset may be collected upto 60 days after
onset of paralysis).
Specimen placed in clean container and covered.
One thumb sized 8 gms of stool is required to WHO
accredited lab.
Should be stored in refrigerator or any container
maintain a temperature below 8C till they reach the
laboratory.
Vaccine carrier with frozen ice packs used for the
purpose.

Stool sample (contd.)
Actions
Once a case of AFP reported, following measures to be
taken:
1. All reported cases should be investigated by District
Immunization Officer(DIO) as per the case
investigation form, with in 48 hrs after notification by
a reporting unit.
2. Reporting unit: a center where paralytic cases are
brought for diagnosis, treatment or rehabilitation it
includes medical college hospital, pediatric hospital,
district hospital.
3. DIO should send the copy to the State Head quarters.



4. DIO should not wait for lab results to conduct
immunization. Decision should be made on the spot,
regardless of whether the laboratory results are
available are not.
5. DIO should initiate appropriate action for outbreak
response immunization as and when indicated.
6. DIO should revisit every case of AFP 60 days after
onset of paralysis to confirm the presense or absence
of residual paralysis.
7. Minimum level of residual weakness can usually be
detected by the measurements of arm / mid thigh
circumference as well as by skin folds on medial
aspect of thighs.
8. DIO should take part in active surveillance by regularly
visiting the reporting units and private practitioners.
9. All health workers, traditional birth attendants must
be encouraged to report AFP cases immediately to
nearest PHC. The medical officer inturn immediately
inform the DIO.
10.Surveillance medical officer to supervise all the
activities.