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Acute Flaccid Paralysis Surveillance (AFP)

This is a presented CME about acute flaccid paralysis (AFP) surveillance.

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Acute Flaccid Paralysis Surveillance (AFP)

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  1. ACUTE FLACCID PARALYSIS (AFP) SURVEILLANCE Dr Ahmad Zhafir bin Zulkfli@Zulkifli Unit Kesihatan Awam Hospital Shah Alam 23 February 2023

  2. Content: • 1. Poliovirus in a glance • 2. cVDPV outbreak and recent case • 3. AFP case definition, reporting and investigation • 4. UKA as hospital liaison for PKD and JKN CDC • 5. Q&A

  3. Source: Centers for Disease Control Source: WHO Source: WHO

  4. Malaysia certified polio free since 29 October 2000. Four regions of the world are certified polio free - the Americas, Europe, South East Asia and the Western Pacific. By 2015, polio was believed to remain naturally spreading in only two countries, Pakistan and Afghanistan.

  5. Mode of transmission • Spread via faeco-oral route or oral-oral route through contaminated food or water. • E.g. contact with faeces contaminated hands, faecal contaminated toys. • Enters and binds to an immunoglobulin-like receptor, known as the poliovirus receptor or CD155, on the cell membrane. The virus then hijacks the host cell's own machinery, and begins to replicate. Transmission electron micrograph of poliovirus

  6. Should we be concerned? Khairy said from Jan 1, 2019 to Sept 9, 2021, a total of 426 AFP cases had been reported nationwide, out of which four cases of confirmed polio were reported in Sabah. They were aged three months, three years, eight years and 11 years old respectively when they were confirmed to be infected with polio.

  7. Should we be concerned? • Testing has confirmed that the virus is genetically linked to poliovirus circulating in the Philippines (VDPV type 2)

  8. Recent case in neighbouring country! WILAYAH ACHEH, SUMATERA, INDONESIA

  9. Kes di Aceh, Sumatra, Indonesia 2022 6 Okt • Kanak-kanaklelakiberusia 7 tahun • Tidakmempunyaisejarahimunisasi Demam, lemahpergerakan 9 Okt Lower limb paralysed Admit TeukuChikDitiro Hospital 18 Okt Suspected Polio, sampeldiambil 21 Okt RT-PCR confirmed poliovirus 7 Nov 24 Nov 3 kanak-kanaksihatpositifpolio hasilsurvelens

  10. Rationale for surveillance • Poliomyelitis is targeted for eradication. Highly sensitive surveillance for AFP, including immediatecase investigation,and specimencollectionare criticalforthedetectionofwildpolioviruscirculationwith theultimateobjectiveofpolioeradication. • AFPsurveillanceis alsocriticalfordocumentingtheabsenceofpoliovirus circulation for polio-freecertification.

  11. Case definition • “Any case of acute flaccid paralysis including Gullian-Barre Syndrome, in a child less than 15 years of age for which no other cause is apparent.” Source: Pocket Handbook of AFP Case reporting • Ensure 2 stool specimens for polio virus is sent to the lab (at least 24 hours interval between specimen) within 14 days of symptoms onset • To complete AFP investigation form urgently and send to UKA. Form can be retrived from intranet or IMR website.

  12. Adequate stool specimen Specimen container must be labelled with date and time and accompanied with AFP Investigation Form!

  13. Case Investigation Procedure at Hospital Level Start **Criteria for adequate stool sample Two stoolspecimens Collected within 14days of onset ofparalysis In cases where sample could not be collectedat 14 days, should be collected up to 60 days from onset ofparalysis Both samples shouldbe 24 hoursapart Using a clean plastic screw cap container(not necessarilysterile) AFPCases No Stop Yes Notify the nearestDHO via phone/fax (fill AFP InvestigationForm) Take 2 stool samples (**fulfil criteria) within 14 days of paralysis onset (24 hoursapart) Send samples toIMR - Lab RequestForm - Maintain cold chain duringstorage andtransport Source: Pocket Handbook of AFP Stop

  14. AFP Case Investigation Form Intranet HSAS > Borang > Direktorat Perkhidmatan Diagnostik dan Sokongan Klinikal > Unit Kesihatan Awam > Borang Penyiasatan AFP https://www.imr.gov.my/images/Services/Diagnostic_Service_Forms/Virology/AFP-Investigation-Form.xls Do not report AFP case as poliomyelitis in eNotifikasi!

  15. Our response

  16. Public Folder > Unit Kesihatan Awam > Acute Flaccid Paralysis > Pocket Book of AFP Case Investigation For Healthcare Personnel

  17. Sources: • Communicable Disease Control Unit, JKN Selangor • Pocket Book of AFP Case Investigation for Healthcare Personnel, CDC MoH Malaysia • Pathology Department, HSAS • Boy confirmed to be first polio case in M’sia in 27 years https://www.thestar.com.my/news/nation/2019/12/09/boy-confirmed-to-be-first-polio-case-in-msia-in-27-years • Khairy: WHO declares end of polio outbreak in Malaysia https://www.malaymail.com/news/malaysia/2021/09/11/khairy-who-declares-end-of-polio-outbreak-in-malaysia/2004797 • Kronologi Penemuan Kasus Polio di Aceh hingga Jadi KLB https://www.kompas.com/tren/read/2022/11/20/063000265/kronologi-penemuan-kasus-polio-di-aceh-hingga-jadi-klb • Global Polio Eradication Initiative, World Health Organization, https://polioeradication.org • World Health Organization (19 December 2022). Disease Outbreak News; Circulating vaccine-derived poliovirus type 2 (cVDPV2)-Indonesia. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON430

  18. Take home message • Be vigilance and report encounter case! • Contact lab/liaison officer/UKA if not sure. • Ensure two stool specimens sent! Q&A

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