AFP Surveillance

Zonal, Woreda and Health Facility

Focal Persons
 Outline of Presentations
• AFP surveillance process and its purpose in GPEI
• Key definitions for AFP surveillance:
– Standard case definitions
– hot case
– community case definition
• Clinical clues for AFP and Differential diagnosis
• Standard operating procedures for AFP investigation
• AFP surveillance performance monitoring indicators
• Additional investigations for certain AFP cases
• Challenges and gaps in AFP surveillance

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 Objectives of the Presentation
• At the end of the training, PHEM officers and health
facility surveillance focal persons are expected to:
– Understand the different concepts and definitions in AFP
surveillance
– Provide standard case definitions of AFP
– Describe the standard operating procedures of AFP
surveillance ( detection, notification, investigation, sample
collection and transportations )
– List and analyze the AFP surveillance performance indicators
– Understand the need for and procedures for conducting
additional investigations for selected AFP cases

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 Acute Flaccid Paralysis-AFP: Key Terms

Acute: rapid progression of paralysis, <2-3 days

(from onset to maximum paralysis)

Flaccid: loss of muscle tone, “floppy” (as

opposed to spastic or rigid)

Paralysis: weakness, loss or diminution

of motion
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 Surveillance for AFP
What is the real process?
 Process of detecting and investigating of all AFP
cases in children below 15 years of age.
 This includes:
 Identifying and reporting of all AFP cases,
 Investigating them and
 Laboratory testing of all stool specimens
collected from such cases for polioviruses
 In specialized laboratories.

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 Surveillance for Global Polio Eradication
Why do AFP surveillance?
1. Detect circulation of wild polioviruses or

2. Demonstrate absence of wild polioviruses

3. Show that surveillance meets the performance

needed for certification

4. Guide immunization activities

 Surveillance for AFP…How ?
Standard Case definition of AFP
•  "Any child under 15 years of age with
acute/sudden weakness or floppiness of one
or more limbs regardless of the cause
or
• Any person of any age in whom a clinician
suspects polio."
– Acute: rapid progression of paralysis, <2-3 days (from
onset to maximum paralysis)
– Flaccid: loss of muscle tone, “floppy” (as opposed to
spastic or rigid)
– Paralysis: weakness, loss or diminution of motion
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 Surveillance for AFP…
• “Hot” AFP case:
– An AFP case likely to be paralytic polio,
• Age less than five years,
• asymmetric paralysis,
• fever at the onset,
• incomplete OPV doses,
• rapid progression of paralysis)
• and/or AFP case with direct contact to a confirmed case
or a case from endemic area.
– Investigation, stool collection and laboratory processing of
specimen should be prioritized for “hot” cases.

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 Surveillance for AFP…How ?...

• Community case definition

– Any person with sudden onset of paralysis of the
limbs.

• Why AFP not polio surveillance?

– In an eradication program the SENSITIVITY of the case
definition should be 100 %
– i.e. not to miss a single case of polio.

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A case of AFP

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Clues to the Presence of AFP

Paralysis - sudden onset

Weakness
Floppy limb

Acute Flaccid Paralysis

Can’t move leg, arm Can’t sit-up

Can’t walk

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 Differential Diagnosis for AFP
Transverse myelitis

Traumatic neuritis Other enteroviruses

Acute Flaccid Paralysis

Coxsackie virus
Echovirus

Guillain - Barre Syndrome Poliovirus

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 AFP Surveillance System
Polio
AFP
Case
Hospitals Investigation
and
Clinics Lab Analysis
AFP Community Non-Polio
cases AFP

Non-polio AFP rate should be ≥2/100,000 <15 years

How to investigate a case of AFP? (Steps)
• Verify the diagnosis of AFP for investigation.
– Is it consistent with the case definition?
• Is it flaccid (floppy) paralysis?
• Is it within 14 days (60 days) of paralysis onset?
• Is the patient less than 15 years old?
• Take the history and document on the patient card.
• Do a physical examination (observation of young child)
• Complete the case investigation form.
– All relevant sections should be completed,
• Address of the patient,
• site of the paralysis and
• the number of OPV doses received (Routine and SIAs doses)
• Collect stool specimen after filling the forms

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 What Forms to be filled for an AFP case?
S. Form/file No. of Offices to have the form
N copies
1 AFP investigation form 5 1 for reporting facility ; 1 for
woreda where case came from;1
Zone, 1 WHO and 1 EHNRI/FMOH

2 Care seeking 3 1 for reporting facility , 1 for

/validation form woreda and 1 for Zone

3 Clinical note ( short 3 1 for reporting facility , 1 for

summary of Sn/Sx with woreda and 1 for Zone
Rx Plan or Copy of card)
4 Sketch map of 3 1 for reporting facility , 1 for
residence of case woreda and 1 for Zone

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 Stool specimen collection, storage and transport
• Collect two specimens, 24 hours apart, within 14 (60) days of
onset.
– Two stool specimens must be collected from each AFP case as soon as
possible after the onset of paralysis.
– There should be at least 24 hours between collecting the first and the
second specimen. (what to if no stool immediately after 24 h?)
• Contact sample for inadequate and other cases as
recommended
• Collection equipment to use
– Place in clean plastic container, such as wide mouthed plastic bottle with
an external screw-on cap.
– Side of container should be labeled with name, number of specimen (1 or
2), and date of collection using a water-resistant pen.
– Place specimen container in sealed plastic bag. .

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 Stool specimen collection, storage and transport (2).
• Place the specimens immediately in the designated vaccine carrier
with frozen ice-packs
• Keep the sample in a refrigerator until collecting the 2nd sample or
until you are ready to travel to the polio lab.
• Try to take the samples as quick as possible maintaining the
reverse cold chain to deliver the sample in less than 72 hours.
• NB:
– Collect fresh stool
– Amount of stool to be collected = two adult thumb nail size (>8 gram)*2
– The reverse cold chain (2 – 8 oC) should be kept through out transportation.
– If it cannot reach within 72 hrs put it in a deep freezer until within 72 hrs
reach can be arranged.
– In rare circumstances, the sample can be stored in deep freezer up to seven
days

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 Packing stool samples
Forms
Proper sealing

Containers:
With Screw cap
Cotton wool

Plastic bag

Icepacks

‘Stool sample’ carrier

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Polio virus excretion over time

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 Maintain a reverse cold chain for specimens

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GPV/EPI Oct 6, 2022
 Adequate Stool Specimen Characteristics:
o Two stool specimens
o Collected at least 24 hours apart
o Collected ≤14 days of paralysis onset
o Each specimen of adequate quantity (8 – 10 g)
o Packed adequately and shipped in a cold box below 8ºC
o Arriving within 3 days (72 hours)
o No desiccation (not dried out)
o No leakage
NB: Sixty-day follow up should be done for all AFP cases with
inadequate specimen collected.
Before you leave for Polio Lab, check that
–  You properly filled the form with adequate copies (5 copies)
with official stamps
– You wrote date of onset of disease: Onset of paralysis for
AFP/Polio & Onset of Rash for measles
– You put exact number of total OPV and IPV doses case
received both in routine and campaign. Never put unknown
(‘99’).
– You have properly labeled sample containing kit(s)
– You are using most frozen icepacks ( 4 in number) in the
vaccine carrier
– You have an ID card for you
– Official letter from your health facility or woreda ( preferable)
or Zone Health Office
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 Additional Investigations for Inadequate Cases
• All inadequate cases will have contact sample collected
• Clinical evaluation of inadequate cases will be done between 60-
80 days of paralysis
• The examination is done by an experienced clinician using the 60-
day FUP form.
• Whenever possible, follow up examination should be conducted
by the clinician who did the initial examination
• Main purpose of the follow-up:
– To check for residual paralysis(typical feature for paralytic
polio but very uncommon for other causes)
• The findings will be presented to the National Polio Expert
Committee for classification

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Virologic Classification of AFP cases

Wild poliovirus 1.CONFIRM

Residual
weakness, died or 2.Compatible
lost to follow-up national expert
AFP Inadequate committee

specimens 3. Discard
No wild poliovirus no residual
weakness 3. Discard

2 adequate 3. Discard
specimens
Other codes: 6- Non-AFP 7- VDPV 28
 AFP Surveillance Indicators
Indicators Target

NP-AFP rate per 100,000 < 15 Yrs >2

Stool Adequacy Rate >80%
T/C including zero reporting >80%
Investigated < 2 days of notification >80%
Specimen arriving at lab < 3 days >80%
Specimen arriving in good condition >90%
Non-polio enterovirus isolation rate >10%
Lab result within 14 days of receipt >80%
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 Detailed Calculations of Selected Indicators
Indicator Numerator Denominator Constant Remark
NP-AFP Rate No. of non-polio AFP No. of expected 100,000 WPV, VDPV and
cases cases per year compatible
per 100,000 <15 cases excluded
population
Stool No. AFP cases reported Total reported 100 ETH has not
adequacy within 14 days of onset AFP cases excluding BAD
rate(%) and fulfilled other stools from
adequate stool sample numerator
criteria
Good stool No. of AFP cases with Total No. of AFP 100 Only instant
condition stool samples submitted cases reported to temperature on
rate(%) to Lab in “GOOD” the Lab submission is
condition considered
NPENT No. of stool samples from Total no. of stool 100 No. of stool
Rate(%) which Enterovirus is samples samples and not
isolated processed by the AFP cases
laboratory considered as
denominator30
Contact sample collection

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 Criteria for Contact Sampling
• All inadequate cases require contact sample collection i.e.
– AFP cases reported after 14 days of onset of paralysis
– An AFP case for whom one or no sample collected for various
reasons (e.g. death, lost before two samples collected, failed
to pass stool despite several trials, etc.)
– Samples of AFP cases transported with poor reverse cold
chain or labelled as ‘BAD’ by national polio lab regardless of
duration of paralysis.
• All cases reported from Somali, Gambella and Benishangul
Gumuz and other targeted high risk zones
• When requested by higher levels or prevailing epidemiological
situations
• It’s recommended to collect contact sample from a minimum of
80% of the index AFP cases.
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The Contacts and Sample Collection Procedures(1)
• Under five children who are siblings or other family
members or playmates for the AFP case
• Three contacts for one AFP case
• One stool sample ( same size) is enough from each case.
• Timing:
– As soon as the AFP case is detected and preferably with the
stool collection of AFP case
– If not possible, collect up to three months of paralysis of the
index case
• Collect using same procedure and precaution as we do for
AFP case
• Label each cup for the contact samples
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The Contacts and Sample … Procedures(2)

• Fill the contact sample form (five copies for

each contact):
– Name and EPID No. of Index AFP case followed by
Contact No. (1, 2, or 3).
• Packaging is similar to sample of AFP case
• Transport contact samples using a different
vaccine carrier. If not possible, use one carrier
for both AFP and contact samples but in a
different zip lock bag.
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How are results interpreted and responded?
• Presence of wild poliovirus or vaccine-derived
polio virus in any one of the contact
specimens is highly suggestive that the index
case was also infected with wild poliovirus.
• Any index AFP case with one or more contacts
testing positive for wild poliovirus will be
classified as confirmed wild polio case.
• The new Polio Outbreak SOPs will be applied
for response
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 Additional Slides for Discussion
• Prioritizing active sites for AFP case search
• Frequency of active case search by priority
levels
• The New AFP Investigation Form
• Roles and responsibilities at each level

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 Challenges and gaps at National Level
• Inadequate prioritization of sites for active search
– Private facilities, holy water and traditional sites
not/inadequately included
– Prioritization not regular
– No evidence based prioritization
• Inadequate active case search by surveillance officers
(e.g. visit not regular or based on priority level)
• Gaps in case investigation (e.g. form filling, timeliness of
detection and investigation, etc.)

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 Challenges and gaps at National Level
• Poor reverse cold chain
• Low NPENT isolation rate
• Delayed validation and 60-day follow up of AFP cases
• Suboptimal AFP surveillance indicators at sub regional levels
• Weaknesses in proper documentations of surveillance
activities
• Challenges
– Logistical and financial constraints
– Inadequate staffing and capacity at woreda levels
– Multiple responsibilities and competing priorities
– High turnover of trained staff

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 Next
• The AFP forms ( CIF, the validation , the 60-day FUP,
contact investigation forms)
• Polio Risk Assessment Template
• The Active Site Prioritization Template
• Exercises
• Clinical Evaluation presentation and demonstrations
• Lab SOPs (sample collection and transportation SOP)

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THANK YOU !