National Guidelines

For

ACUTE FLACCID PARALYSIS SURVEILLANCE

Ministry of health Ethiopia and WHO

APRIL 2006

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Acknowledgement

This national AFP surveillance guide line is adopted basically from the AFRO

surveillance field guideline.

How ever it also encompasses points that has come out of the experience of

conducting AFP surveillance at national, regions, districts and community levels,

including the recommendations made and lessons learned during the multiple AFP

Surveillance external and internal reviews that have been conducted in the country.

We wish to recognize the authors of AFRO surveillance field guide and

reports used to develop this guideline, and the oral and written

contributions from colleagues to make this document a national field

Guide for AFP surveillance in Ethiopia.

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Table of contents

I. Background ............................................................................................................................4

II. Polio eradication strategies. ......................................................................................................4

1. Routine Expanded Program of Immunization (EPI) coverage. ............................................................................ 4

2. Supplemental Immunization Activities (SIAs). .................................................................................................... 4

3. Acute Flaccid Paralysis (AFP) Surveillance. ....................................................................................................... 4 3.1 What is 'acute flaccid paralysis' (AFP) surveillance? ...................................................................................................... 5 3.2. Goal of AFP surveillance. .............................................................................................................................................. 5 3.3. Why surveillance for AFP is needed. ............................................................................................................................. 6 3.4 How should AFP surveillance be organized in Ethiopia? ............................................................................................... 6 3.5 Searching for AFP cases and wild poliovirus. ................................................................................................................. 6 3.6 Expansion of the surveillance system. ............................................................................................................................. 6 3.7 Nature of the surveillance. ............................................................................................................................................... 6 3.8 Selecting reporting sites................................................................................................................................................... 6 3.9 Sensitization and mobilization of clinicians and the community. ................................................................................... 7 3.10 Preparing the reporting sites. ......................................................................................................................................... 7 3.11 How to conduct regular ‘active surveillance’ visits ....................................................................................................... 8 3.12 Problems encountered during active surveillance visit. ................................................................................................. 8 3.13 How to find cases of AFP - which patients to look for .................................................................................................. 8 3.14 What to do when a case is found. .................................................................................................................................. 8 3.15 Following up suspicious cases. ...................................................................................................................................... 8 3.16 How to investigate a case of AFP .................................................................................................................................. 9 3.17. Stool specimen collection and handling ....................................................................................................................... 9 3.18. Stool specimen transport to National Laboratory, EHNRI ......................................................................................... 11 3.19. 60-day follow-up examination .................................................................................................................................... 11 3.20. Final case classification. ............................................................................................................................................. 11 3.21. Flow of forms and data ............................................................................................................................................... 11 3.22. Monitoring AFP surveillance ..................................................................................................................................... 12 3.23. Roles and responsibilities in AFP surveillance ........................................................................................................... 13

4. Mopping up ......................................................................................................................................................... 15

III. Documentation of activities and information/data .................................................................. 16

IV. Importation/detection of Wild Poliovirus in a Polio Free Areas .............................................. 17

a. Possible situations of poliovirus importation include: ........................................................................................ 17

b. Monitoring and detection of importation/circulation of WPV ............................................................................ 18

c. Rapid Investigation of importation/WPV report ................................................................................................. 19

d. Responses ........................................................................................................................................................... 19

V. Document Cessation of Transmission .................................................................................... 20

VI. Administrative and Financial procedures of WHO ................................................................. 21

Annex 1: Differential diagnosis for Acute Flaccid Paralysis Surveillance .................................... 22

Annex 2: CASE INVESTIGATION FORM - ACUTE FLACCID PARALYSIS (AFP) .................... 23

Annex 3: List of Heath Facilities for Active Surveillance ............................................................. 26

Annex 4: Procedure for acute flaccid paralysis (AFP) case investigation ................................... 27

Annex 5: Line Listing of AFP Cases at Regional / Zonal Level, Year 200 .................................. 28

Annex 6 : 1Care seeking questionnaire for AFP cases ............................................................... 29

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Annex 7: Format for sixty-day follow up examination for cases of acute flaccid paralysis .......... 30

Annex 8: Sample form for recording timeliness and completeness of monthly reporting. ........... 32

Annex9: Ten indicators of disease surveillance and laboratory performance ............................. 33

Annex 10: Documentation monitoring table for AFP surveillance. ............................................. 34

Annex 11: Flow chart of AFP case classification ....................................................................... 35

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I. Background

Global Polio Eradication Initiative was started in 1988 when there were about 23 endemic countries in the

world. In 1996, the African Heads of State attending the 32nd Ordinary Session of the African Union

(AU), then known as the Organization of the African Union (OAU), committed the continent to the

eradication of polio and declared its full support for the implementation of strategies recommended by the

World Health Organization (WHO) to eradicate polio. Since the initiation of the program, the number of

endemic countries reduced to 4 in 2005 and the total number of polio cases reported globally reduced

from an estimate of 350,000 to less than 2000 in 2005. It is estimated that about 5 million children are

saved in the last 17 years who could be paralyzed due to poliomyelitis. Currently it is possible to make at

least 70% of the world population leave in polio free environment.

II. Polio eradication strategies. There are four strategies for the global initiative to eradicate poliomyelitis. These are:

Reaching and maintaining high routine immunization coverage (>80%) with oral polio vaccine (OPV);

Conducting successful national immunization days (NIDs) and sub-national immunization days

(SNIDs);

Establishing surveillance for acute flaccid paralysis (AFP); and

Targeted 'mopping-up' immunization in the later phase of eradication.

Ethiopia has embraced three of these global strategies with varying degrees of success.

1. Routine Expanded Program of Immunization (EPI) coverage.

Routine immunization coverage with OPV varies from region to region, but available data suggest that

national coverage is around 70%. Routine EPI is one way of immunizing the new cohort every year.

2. Supplemental Immunization Activities (SIAs).

Between 1996 and 2005, Ethiopia conducted many rounds of NIDs and SNIDs. Available data show that

the coverage in the campaigns was in general satisfactory. The country is currently conducting NIDS and

SNIDs to interrupt circulation of wild poliovirus (WPV) that occurred following importation. The

advantages of NIDs/SNIDs are:

It will be possible to cover large population at the same time

It will enable to maintain the potency of the vaccine as it will be used in short period

It give an option to vaccinate children at low transmission season

3. Acute Flaccid Paralysis (AFP) Surveillance.

AFP Case Definition:

"Any child under 15 years of age with weakness or floppiness of one or more limbs or any person of

any age in whom a clinician suspects polio."

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Symptoms of Acute Flaccid Paralysis

3.1 What is 'acute flaccid paralysis' (AFP) surveillance?

It is the process of detecting and investigating (including stool sample collection) of all AFP cases in

children below 15 years of age.

3.2. Goal of AFP surveillance.

The goal of AFP surveillance is to identify and document the presence or absence of wild poliovirus in

the country. This goal is best achieved by finding all cases of acute flaccid paralysis and testing stool

specimens from each case for the presence of wild poliovirus.

Reliable AFP surveillance data will guide targeted immunization activities in areas with continued wild

poliovirus circulation. Additionally, surveillance data is accepted as the most reliable way to monitor

how effectively routine and supplementary OPV immunization has succeeded in decreasing poliovirus

transmission. Ultimately, surveillance data will be the basis for certification of polio eradication.

Surveillance for AFP should be sensitive enough to detect polio cases, should they exist. Therefore there

is an urgent need to strengthen the surveillance system in the Country.

Polio Eradication Strategies:

High routine immunization coverage with more than three doses of OPV

Annual National Immunization Days (NIDs)

Acute Flaccid Paralysis Surveillance

'Mopping-up' immunization

Acute Flaccid Paralysis

Weakness Floppy limb

Can’t move leg, arm

Can’t walk Can’t sit-up

Paralysis - sudden onset

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3.3. Why surveillance for AFP is needed.

Acute paralysis can result from various causes and diseases including paralytic polio. A sensitive system

for detecting and reporting flaccid paralysis is therefore, required to ensure that polio cases are not

missed. To avoid missing any polio case, all children less than 15 years of age with acute flaccid

paralysis (AFP) should be reported and their stool specimens should be tested in WHO accredited

laboratory for the presence of wild poliovirus.

It is important to remember that AFP is a term given to any flaccid paralysis caused by many different

diseases. AFP can occur due to Gullian Barre’ syndrome, transverse myelitis, traumatic neuritis (post

injection neuritis), poliovirus, other entero virus etc. It is not possible to differentiate between the cases

of AFP that occurred after poliovirus infection or other causes based on clinical findings. There fore, all

clinicians should investigate all AFP cases with stool specimen collection following the procedure of

case investigation described in this guideline.

3.4 How should AFP surveillance be organized in Ethiopia?

Levels of surveillance. Health workers at all levels (health facility, woreda, zone, region, or national)

should participate in AFP surveillance.

3.5 Searching for AFP cases and wild poliovirus.

All health facilities should be visited during active cases search. Special attention should be given to

health facilities with higher probability of seeing AFP cases. The probability of an AFP case presenting to

any particular health facility should be determined by patient volume, observation, and experience. In

Ethiopia, 40-45% of the AFP cases in 2003, 2004 and 2005 were investigated in health centers, 27-34% in

hospitals and 20-27% in health stations or health posts). Therefore, although visits to health facilities

should be prioritized, no health facility should be completely neglected. .

3.6 Expansion of the surveillance system.

Early in the history of AFP surveillance, priority was given only to health centers and hospitals. How

ever, it is now known that traditional healers, holy water sites or some other community structure, are

important sites where AFP cases seek treatment and hence should be covered by active surveillance for

AFP.

3.7 Nature of the surveillance.

The most efficient way to find AFP cases is to introduce 'active surveillance system' at the health facilities

and community level.

Active surveillance strategy. For many disease conditions, cases may not be reported on time or

may not be reported at all. AFP cases are no exception. Therefore, instead of passively waiting for

cases to be reported, unreported cases should be ’actively‘ identified, and information collected

through visiting government and non government health facilities and other potential sites where

AFP cases might present.

3.8 Selecting reporting sites

Hospitals and health centers as important sentinel sites.

Experience in Ethiopia has shown that 80% of AFP cases are most likely to be identified in hospitals and

health centers, and particularly in pediatric units. Nevertheless, any health facility that sees pediatric

patients (children 0-15 years) as either inpatients or outpatients should be included in the active

surveillance system. These facilities include pediatric hospitals and general hospitals with pediatric

wards, health centers, health stations and health posts, physiotherapy centers, private facilities with a

pediatrician, and MCH clinics.

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Other places to look for AFP cases outside the health facilities.

For religious, economic or cultural reasons, parents may prefer to take their children with acute paralysis

to religious leaders, traditional healers, or drug vendors. Rehabilitation / physiotherapy clinics located

outside the hospitals are also potential sites to find AFP cases. There fore all these sites should also be

targeted for active case search.

3.9 Sensitization and mobilization of clinicians and the community.

Community leaders and clinicians should be continuously oriented and mobilized to report AFP cases.

Production and distribution of simple key messages for community use is very essential to augment

community support. All clinicians should be made aware of the need for repeated vaccination of all

children less than five years of age during NIDs and SNIDs regardless of previous vaccination status.

In emergency situations, such as when the risk for importation is high or when WPV is identified

in the area, all health facilities in the area, regardless of ‘active’ or ‘non-active’ status should make

weekly “ zero” AFP reports to confirm that no case of AFP is missed.

Briefing sentinels sites about AFP surveillance.

Regardless of the frequency of previous visits, not all hospital administration and clinical staff will be

familiar with AFP surveillance. The selected facility / clinic should be officially contacted to explain the

objective of the program and to ask permission for health staff to conduct regular active surveillance

visits. Permission and support for surveillance activities should be obtained through formal channels.

3.10 Preparing the reporting sites.

The following activities should be completed during planning i.e., before beginning regular visits:

reporting sites should be identified and ranked in terms of priority (high, medium, and low) based

on the probability of finding an AFP case. The high priority facilities being the ones with the

greatest probability based on size and type of patient population, patient volume, and the presence

of physicians and specialists. High, medium and low priority sites should be visited once a week,

once every two weeks and once a month respectively.

prioritized hospitals and facilities (including the private sector) should be contacted to introduce

the concept;

a meeting between national/regional/zonal/woreda surveillance staff and hospital administration

(director of hospital) / clinical staff (head of pediatrics) / private physicians should be arranged to

explain background, purpose and status of AFP surveillance;

A contact person ('focal person') inside the facility should be identified, who will serve as the main

contact and the principal source of information about patients admitted or seen in the health

facility. 'Focal points' should be oriented in a training session about AFP surveillance and their

roles and responsibilities.

The focal person for AFP surveillance (national/regional/zonal/Woreda /health facility) who will

visit for active surveillance should be introduced to health facility staff and prioritize their visit.

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3.11 How to conduct regular ‘active surveillance’ visits

Activities during active surveillance visit.

During the active surveillance visit, the following should be done:

Contact the 'focal point' inside the health facility and ask (preferably in the presence of other senior

staff) about any children with AFP who were admitted or seen in the outpatient department since

the last active surveillance visit;

Review logbooks (emergency room, admissions, outpatient department, neurology departments,

pediatric ward, etc.) for patients with conditions associated with AFP (Annex 1).

Visit appropriate outpatient department, wards, particularly the pediatric and neurology wards to

look for AFP cases.

Hold brief discussions with the clinicians especially on the need to hold patients for a few days (2

days) to facilitate stool collection.

3.12 Problems encountered during active surveillance visit.

When talking to 'focal points' and other hospital / clinical staff, individuals doing active surveillance

should be aware that clinicians need some time before fully understanding the concepts of AFP

surveillance. Physicians should be informed about the need to report cases that they think are 'not polio'

(i.e., Guillain-Barre Syndrome, transverse myelitis, injection paralysis etc.). If AFP cases found during

active surveillance have not been previously reported, the 'focal point' should be reminded of his/her

reporting responsibility.

3.13 How to find cases of AFP - which patients to look for

Looking for key symptoms and diagnoses. Patients with many different underlying problems

can present with acute flaccid paralysis (AFP). Persons conducting active case search should be

looking for either symptoms (usually listed in emergency room or admission log books, before a

clear diagnosis has been made), or for diagnoses, (i.e., disease names, usually in ward or discharge

logbooks, Annex 1).

Most important index symptoms and diagnoses. A list of the most important diagnoses and

symptoms, which should be used by staff doing active surveillance, is given in Annex 1. Note that

not all patients diagnosed with one of these conditions will present as AFP; some conditions will

always present with AFP, while other conditions may or may not present as AFP.

3.14 What to do when a case is found.

If a case of AFP is found in the hospital during the visit, the case should be investigated immediately

using the AFP case investigation form. Stool specimens should be collected, and the case should be

immediately reported to the next level.

3.15 Following up suspicious cases.

Not every symptom or diagnosis in a log book will actually be a case of AFP. When a suspicious case is

found in a log book (i.e., there is a description of 'weakness' of a limb, etc.), the case needs to be followed

up to check if AFP was or is present. If still on the ward, the patient should be seen and examined. If the

patient was seen only in the outpatient department, or is already discharged, the medical records should be

reviewed. If the onset of paralysis was less than 60 days ago, the patient should be visited at home for

examination and specimen collection.

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3.16 How to investigate a case of AFP

After the initial report of an AFP case, case investigation should proceed in the following sequence:

1. Verify the diagnosis of AFP. Is it consistent with the case definition? Is it flaccid (floppy)

paralysis? Is it within two months of paralysis onset? Is the patient less than 15 years old? If the

answers to the above questions are “NO”, the investigation can stop and stool specimens need not be

taken.

2. Complete the case investigation form. All relevant sections of the case investigation form should

be completed, taking particular care to note the exact address of the patient, site of the paralysis and

the number of OPV doses received (Annex2).

3. Take the history. Documenting a good clinical history and physical examination findings will

make it easier to determine later whether or not the case has polio.

4. Do a physical examination. This should be done together with the attending physician. It is

difficult to examine small children. Initially, do not touch the child - much can be learned by just

observing. Save 'threatening' parts of the examination for last (reflexes, strength testing, etc.)

5. Collect stool specimen. Stool specimen collection is the most important activity during case

investigation and it is described in detail below.

3.17. Stool specimen collection and handling

If wild poliovirus is still circulating in an area, the stool specimens collected from AFP cases are

the most likely source to find it Investigation of AFP case is incomplete without submitting a

stool specimen. Therefore, extra effort and care should be taken to make sure that each case of

AFP has specimens properly collected, stored, transported and processed.

Collect two specimens, 24-48 hrs apart, within 14 days of onset. Specimen collection is the

most important component of investigating a case of AFP. Two stool specimens must be collected

from each AFP case as soon as

possible after the onset of paralysis.

To have the greatest chance of

isolating virus, specimens should be

collected within 14 days of onset of

paralysis. There should be at least

24 hours between collecting the first

and the second specimen. Try to

collect the first specimen at the

beginning of the case investigation.

Collection equipment to use.

Special equipment (i.e., specimen

collection containers, labels, carrier

boxes for transporting specimens)

may be provided to each health

facility. However, special

equipment is not essential as long as

it does not cause leakage and it is

possible to put the stool sample in locally available containers like photo film cups.

How to improvise collection material: If for some reason, you do not have the special stool collection

tube, use any small, dry, leak-proof container, which can be firmly closed. Write the name, the date of

collection, and the specimen number (1 or 2) on small pieces of paper or on adhesive tape and attach them

Print LS

8 of 31

Packing stool samples

Icepacks

Containers:With

Screw cap

Forms

Plastic bag

Proper sealing

‘Stool sample’ carrier

Cotton wool

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to the specimens. Old vaccine carriers or thick-walled Styrofoam boxes can be used as specimen carrier

boxes. Specimen collection should always be done, even if special collection materials are not

available.

Stool specimen collection is easiest in the hospital or at health institution where refrigerator is

available.

Because supervision is more effective, collection of stool samples is easier if done in the hospitals.

Specimen collection is much more difficult after patients have returned to their homes. This is one of the

reasons why regular visits to hospitals for active surveillance are useful because it is more likely that AFP

patients are found while they are still in the hospital, and stool specimens can be more easily collected.

'Focal points' and physicians in the hospital should be encouraged that, whenever possible, children with

AFP should be admitted for at least two days, to ensure collection of two stool specimens. When

admission is not feasible, then there must be clear information for the address of patient to facilitate the

collection of the second sample.

Specimen collection procedure: It is not difficult to collect stool specimens. The following steps

to collect specimens should be explained and made clear to everyone collecting specimens from

AFP cases:

If available, use the special screw-top specimen container. However, any small, dry, leak-proof

container (i.e., medicine bottle or photo film cup) can be used.

If possible, collect fresh stool from the child’s diapers or try to get the child to defecate onto a

piece of paper.

Using the small spatula attached to the lid of the container (or a small piece of wood), collect a

volume of stool about the size of two adult thumb nails (about 8 grams).

Use the spatula to place the specimen in the cup and firmly screw the cap onto the container.

On the self-adhesive label provided (or on a small piece of paper or adhesive tape, if you don't

have a special label) write the name of the patient, date when the specimen was collected, the

number “1” or “2” to show if this is specimen number one or number two.

Attach the label to the specimen container, and put the container into the small plastic bag, then

close the plastic bag.

Place the specimens immediately in the cold box (specimen carrier box) with frozen ice-packs and

carry the cold box to a refrigerator/freezer of the health facility. (this is the reverse cold chain

system)

VERY IMPORTANT: a copy of the case investigation form MUST be put into a separate

plastic bag (folded-up) to avoid smearing in case of leakage before sending the box to the

National Laboratory in Addis Ababa at EHNRI.

Wash your hands with water and soap after completion of specimen collection.

If the patient cannot produce a specimen, leave the cup, cold box and frozen ice-packs in the

health facility or with the family, explain to them how to collect specimens, and return to collect

the specimens later.

If the specimens can reach the laboratory within 72 hours (three full days) or less after collection,

keep them at 4 to 8 degree centigrade during transportation to the laboratory.

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In the event that the specimens cannot reach the laboratory within 72 hours, place them in a deep

freezer (best at minus 20 degree centigrade) until shipment within 72 hours can be arranged. The

specimens will be safe for a long time in the frozen condition.

. 3.18. Stool specimen transport to National Laboratory, EHNRI

Health workers should make arrangements to transport the stool samples to Addis Ababa, EHNRI.

It is strongly advisable to notify the laboratory staff if you are bringing samples during weekends,

holidays or if the time of arrival is after working hours. The telephone number of the polio

laboratory is as follows: Mobile 091-1214969, 011-2778480; 011-2778477, 011-2778479

3.19. 60-day follow-up examination

Importance of follow-up examination. A follow-up examination must be conducted at least 60 days

after onset of paralysis for a case of AFP investigated 14 days after onset of paralysis. The main

purpose of the follow-up is to check whether or not there is residual paralysis. Residual paralysis is

typical for paralytic polio but very uncommon for other causes of AFP. Therefore, the follow-up

result is important for final classification of cases - i.e., to either classify the case as clinical

poliomyelitis (polio compatible), or to discard the case as non-polio AFP.

How to conduct the 60-day follow-up. Follow-up is best done by the same person who first

investigated the case. Usually, it will be necessary to visit the case at home. In some cases, it may be

possible to bring the child into the hospital to be examined by a pediatrician. The follow-up visit

requires that surveillance staff conducting the initial case investigation note the exact address and any

other information (directions) needed to relocate the case.

3.20. Final case classification.

After all relevant results and information for the AFP case have been assembled (i.e., case investigation

form, case history, follow-up results, laboratory results), the National Polio Expert Committee (NPEC)

will classify the case as either polio compatible, or discard the case as non-polio AFP. (See Annex 11)

3.21. Flow of forms and data

This section describes how AFP surveillance information flows and how forms are copied and forwarded

between various points in the surveillance structure.

Immediate AFP report. Immediate notification of an AFP case should be made using the ‘case-

based investigation form’ (Annex 2) at the reporting site. All the data should be extracted and filled

properly

Four copies of the form should be made – one is to be kept at the reporting site, one is sent to the next

higher level and one is sent to the lab with the stool samples. Please remember to bring another copy

to WHO EPI when you come for reimbursement of expenses).

Routine AFP reporting. All sub regional offices and facilities should send summary of monthly

AFP reports including zero reports if no AFP cases are found within that month. Regional surveillance

focal persons or staff should provide the national surveillance team a report on the number of AFP

cases detected each month, including ‘zero reports’ if no case is seen. A copy of the monthly report

should be sent each month to the Federal Ministry of Health (MOH) surveillance team.

Laboratory results. The National Laboratory should forward laboratory results of stool specimens

from investigated AFP cases to the National Department of Disease Prevention and Control (DPC)

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and to the World Health Organization (WHO) EPI Team. From the MOH, the national focal person

should share the results with the Regional Health Bureaus (RHB) and through the RHB, results will

then be disseminated to districts and then to the reporting facilities. WHO surveillance officers should

facilitate notification of laboratory results to reporting facilities, to focal persons, clinicians and

families.

Line-listings. Line-listing of data on AFP cases should be maintained jointly by the National AFP

Focal Person and WHO EPI staff (Annex 5). A copy of the updated and cumulative line-listing for

each Region should be shared with WHO surveillance officers.

Timing for exchange of routine information. The routine monthly reports, copies of updated case

investigation forms, and line-listings should reach the National AFP Focal Person in Addis Ababa no

later than the seventh day of the subsequent month.

Feedback. It is expected that there will be regular feedback provided to all partners and reporting

institutions. The DPC and Family Health Department (FHD) of the MOH in conjunction with WHO

EPI publish a quarterly bulletin or newsletter that will be widely circulated to all Regions.

Figure 2: Surveillance Information Flow, Ethiopia

AFP case detected in Health facility

(clinician)

Dept of Health

(Zonal focal person)

Regional Health Bureau

(Regional focal person)

National MOH/WHO

Polio Laboratory

AFP data to AFRO

Lab data to MOH

and WHO EPI

3.22. Monitoring AFP surveillance

AFP surveillance requires close monitoring for prompt identification of problems and weaknesses that

must be corrected through feedback, training, increased supervision and logistical support.

Regular (weekly, bi-weekly or monthly) active surveillance visits. To ensure that the selected

health facilities are being visited regularly by AFP surveillance staff and that patient registration or

log books are thoroughly reviewed during these visits, the active surveillance monitoring form (annex

3) should be used to monitor the quality of active surveillance. This form should be completed by

AFP surveillance staff and signed by the focal points and other clinicians in the health facilities.

Regional AFP surveillance officers must review these forms each month and provide appropriate

feedback to the surveillance staff and focal points in the health facilities. The National AFP Focal

Person must monitor active surveillance through regular monitoring and supervisory visits to Regions

and by reviewing reports from the Regions.

Timeliness of routine monthly reporting. National surveillance staff should monitor routine

monthly reporting using the attached form (annex 7). These forms should be submitted monthly to the

National surveillance team by the seventh day of each month.

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Sensitivity of AFP surveillance. Based on the known incidence of non-polio AFP (2 cases per

100,000 children under 15 years of age) and the population in the surveillance catchment area, each

region must calculate the minimum expected annual number of non-polio AFP cases. This figure

should be used to monitor the sensitivity of the AFP surveillance system at regional and national

levels.

Mapping. The distribution of AFP cases should be presented graphically, by the National AFP Focal

Person, using EPI map software to show “silent” Regions or Zones.

Adequate stool collection. Collection of adequate stool specimens is the most important part of AFP

case investigation. WHO recommends that two stool samples be collected at least 24 hours apart

within 14 days of paralysis onset from 80% or more of AFP cases. The proportion of AFP cases that

have two adequate stool samples collected should be monitored closely at the regional and national

levels.

60-Day follow-up examination. Every late AFP case must be examined at least 60 days after onset

of paralysis for residual paralysis or weakness. The proportion of AFP cases with completed 60-day

follow up examination should also be monitored regularly at all levels.

Monitoring visits. These visits will be used not only to assess the quality of the surveillance

activities, but also for continuous advocacy with the clinicians and the community.

Analyze the care seeking questionnaire regularly

3.23. Roles and responsibilities in AFP surveillance

Responsibilities of staff involved in active surveillance.

Each Woreda, zone, and region, as well as at the national level, the disease prevention and control

department should designate person(s) responsible for coordinating surveillance activities, conducting

active surveillance visits and completing case investigation forms. In addition to the WHO surveillance

officer, the person/s responsible for active AFP surveillance should do the following:

Visit the high priority facilities once per week, the medium priority once in two weeks and the low

priority once each month.

Conduct an active search for AFP cases, and report the result, (including zero reporting) to the

next higher level on a monthly basis. They may include other priority diseases like measles, NNT

and others.

Immediately report every AFP case and submit the completed case investigation form (four copies

- investigator keeps one, one is sent to the next higher level and the third goes with the stool

samples to the national level and the fourth one to WHO EPI).

Investigate each AFP case, and collect two stool specimens 24 hours apart within 14 days of

paralysis onset.

If it is more than 14 days since paralysis onset, stools should still be collected up to 60 days

following paralysis onset.

Do a follow-up examination 60 days after the onset of paralysis for cases investigated later than 14

days after onset of paralysis.

Sensitize health workers and community during active surveillance visits

Ensure availability of surveillance forms, specimen collection kits and posters

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The following will be the roles and responsibilities of EPI surveillance / AFP surveillance focal points at

different level and WHO EPI- surveillance staff.

a) National surveillance focal person

The designated staff will:

1. Closely monitor AFP surveillance activities in the country.

2. Monitor, supervise, and support EPI staff responsible for AFP surveillance. This includes:

- Completing monitoring visits to selected health facilities within the Region;

- Monitoring monthly AFP case reporting, including ‘zero’ case reports from selected

reporting sites;

- Providing continuous capacity building for EPI staff;

- Providing the necessary logistic and financial support.

3. Orient clinicians and sustain their involvement through ongoing contact and advocacy.

4. Produce and distribute forms, guidelines, posters and other educational materials needed for AFP

surveillance with assistance from WHO EPI and other agencies.

5. Publish a newsletter on polio eradication activities in Ethiopia.

6. Establish Expert Review Committees and participate in their meetings.

b) Regional Surveillance focal person

The designated staff will be primarily responsible for the following:

1. Conduct scheduled active surveillance visits to selected sites.

2. Immediately report AFP cases to the national level.

3. Coordinate investigation of each AFP case, (stool samples collection and transportation to National

Lab at EHNRI, Addis Ababa)

4. Complete or coordinate the 60 day follow-up examination, do this with the WHO surveillance

officer.

5. Maintain the line listing of AFP cases.

6. Provide monthly AFP reports, including ‘zero’ reports, from selected reporting sites to the next

higher level (from the Woreda to the region and from the region to the National Focal Person).

7. Regularly analyze AFP and IDSR surveillance data and provide feedback to reporting sites.

c) Zonal/District surveillance focal person

1. Do active case search on out patient and inpatient registry of the health facility/priority sites in

his area and report if there is any unreported case of measles, NNT or AFP

2. Sensitize health workers/community members in the priority sites on AFP and Measles

surveillance and IDSR

3. Prepare regular IDSR report and send to the next higher level

4. Analyze & present IDS data

5. Make available surveillance guideline in your office for reference

6. Prepare case file for each reported AFP and measles case

7. Maintain line listing of reported AFP /suspected measles cases

8. Prepare line listing for any epidemic encountered in the catchments area

15

9. Ensure proper documentation of surveillance report

10. Ensure the presence of health workers' and community reminders

11. Prepare annual plan of action for surveillance

12. Give feed back on reported AFP or measles cases to the health facilities, clinician as well as to

the patient's family

13. Do follow up of reported AFP cases after sixty days

d) Health facility surveillance focal person

1. Do active case search on out patient and inpatient registry of the respective health facility

on weekly basis to detect if there is any unreported case of measles, NNT or AFP

2. Sensitize health workers in the health facility on AFP and Measles surveillance and IDSR

3. Prepare regular IDSR report and send to the next higher level

4. Analyze & present IDS data

5. Make available surveillance guideline in your office for reference

6. Prepare case file for each reported AFP and measles case

7. Prepare line listing for any epidemic encountered in the catchments area

8. Ensure proper documentation of surveillance report

9. Ensure the presence of health workers' and community reminders

10. Prepare annual plan of action for surveillance

11. Give feed back on reported AFP or measles cases to the clinician as well as to the patient's

family

12. Do follow up of reported AFP cases after sixty days

WHO EPI and MOH IDSR team

Close coordination between the two agencies is essential to provide the necessary support to strengthen

AFP surveillance in Ethiopia. The responsibilities include:

1. Monitoring progress in implementation of AFP surveillance in the country.

2. Providing technical input and logistic and financial support to regions and sub-regional focal

person to cover shortfalls in funding.

3. Producing and distributing forms, guidelines, posters and other educational materials needed for

establishing AFP surveillance.

4. Compiling, managing and regularly analyzing national AFP surveillance data jointly with the

National AFP Focal Person.

5. Conducting quarterly national review of AFP surveillance activities.

6. Regularly supporting AFP surveillance training workshops at Regional and national levels.

7. Supporting the publishing of a national newsletter on polio eradication in Ethiopia.

8. Supporting the National Polio Expert Review and Certification Committees.

4. Mopping up

To eliminate the last reservoir of wild polio virus circulation, mopping up vaccination campaigns are

conducted. These campaigns target children younger than 5 years of age with two doses of OPV separated

by an interval of 4 weeks. Risk areas for mopping map include those areas with recent circulation of wild

poliovirus, low vaccination coverage, suboptimal surveillance, large migrant or refugee populations and

common borders with known poliovirus endemic areas.

16

III. Documentation of activities and information/data Polio-free certification is the ultimate goal of all efforts mentioned above. Countries are expected to

document all information related to their PEI activities. This includes vaccination information from

routine and campaigns, active case search visits, analysis and quality of surveillance information, clinical

and epidemiologic information of hot AFP cases and reports of investigations of confirmed outbreaks as

well as all other information listed in the various chapters of this guideline. Such information and data

should be documented to justify that circulation of WPV has been adequately interrupted. This

information will be submitted to the national and regional polio certification committees for review. In-

order to facilitate the polio free certification process, all clinicians and AFP surveillance focal persons

should keep documentation of such activities.

DOCUMENTS THAT SHOULD BE AVAILABLE IN AFP SURVEILLANCE

A. AT WOREDA LEVEL

1. On the wall

o Line listing of AFP cases detected in the Woreda

o Spot map of AFP cases detected in the Woreda

o AFP/polio eradication initiative reminder posters (for health workers and communities)

2. Case file of each AFP case detected in the Woreda

o Case investigation form with all the information’s completely filled (please include sketch

map of the child’s home on the back of the form or in a different paper)

o Clinical note copy of the case written by the examining health worker

o Sixty days Follow up examination result

o Laboratory result sent from the polio laboratory

o Late stool questionnaire for each case detected in the Woreda

3. General file

o Plan of action (this at least should include: the total population of the Woreda, the total number

of <15 years old population, the expected number of AFP case from the Woreda, the frequency

of active case search trips to be done with time line, the facilities where to conduct the active

case search, etc…)

o Line list of AFP cases detected in the Woreda

o Management tools filled during the active case search visit to the facilities

o Copy of IDS surveillance report sent to the zone

o The detailed Active case search visit reports

o List of health facilities and other sites prioritized depending on their importance for AFP

surveillance

o NID/routine EPI activity plans and reports

o Any other activity related to polio eradication initiative

B. At health facility level

1. Case file of each AFP case detected in the health institution

o Case investigation form with all the information’s completely filled (please include sketch

map of the child’s home on the back of the form or in a different paper)

o Clinical note copy of the case written by the examining health worker

o Sixty days Follow up examination result

o Laboratory result sent from the polio laboratory

o Late stool questionnaire for all cases detected in the woreda

17

2. General file

o Copy of surveillance report (if it is Health center/hospital or if it is a reporting unit for

Integrated disease surveillance)

o EPI and NID activity and planning reports

o AFP surveillance plans and achievements

o The focal person should put his signature in the patient register after he/she checked for AFP

3. On the wall

o Line listing of AFP cases detected by the health facility

o Spot map of AFP cases detected by the health facility

o AFP/polio eradication initiative reminder posters (for health workers and communities)

4. The following references should be available

o The case definition of AFP

o The strategies for polio eradication

o How to collect stool specimen for AFP cases

o How to transport stool specimen to Addis Ababa polio laboratory using the reverse cold chain

o The different (differential diagnosis) causes of AFP

o How to fill the case investigation and follow up forms

o What residual paralysis means?

o The status of polio eradication in their zone and region

IV. Importation/detection of Wild Poliovirus in a Polio Free Areas

a. Possible situations of poliovirus importation include:

1. Imported case of poliomyelitis: when wild poliovirus is isolated from the stool specimens of any

person (with or without AFP) with history of recent travel to a polio endemic area.

2. When genetic sequencing of the virus isolated from a polio case is most closely associated with virus

circulating in another country.

3. Wild poliovirus is isolated from sewage or other environmental samples.

Detection of wild poliovirus in a polio-free country is a public health emergency. Countries should be

prepared to respond appropriately to contain the situation in order to maintain the polio-free status.

Importation of wild poliovirus cannot be prevented until global polio eradication is achieved, but its

spread within the country can be controlled.

The main lessons learned from recent importation into polio-free areas include:

High quality surveillance is the key for early detection of virus. There is absolute necessity of

maintaining high quality AFP surveillance for several years after interrupting transmission

Mobile groups play a key role in virus importation

Areas affected by cross-border movements or risk of distant importation must be identified, (including

areas away from national borders)

Special immunization and surveillance efforts in high-risk, minority, and cross-border populations are

needed

High population immunity achieved by routine and supplementary immunization activities limits virus

spread

A national plan for responding to poliovirus importation should be prepared and periodically

updated by each country. The key elements of the plan should include:

1. Mechanism for ongoing monitoring and early detection of importation,

18

2. Ability to rapidly investigate the importation

3. Activities to enhance surveillance for AFP and wild poliovirus,

4. Ability to conduct an immediate and appropriate immunization response, and

5. Activities to document interruption of transmission.

b. Monitoring and detection of importation/circulation of WPV

High quality AFP surveillance system forms the basis for monitoring and early detection of

importation

A High Quality AFP Surveillance should satisfy the following criteria

Non-polio AFP rate of at least 2/100,000 children under 15 years of age per annum

At least 80% of AFP cases have adequate stool specimens (two stool specimens collected

within 14 days of paralysis onset, at least 24 hours apart and received in the lab in good

condition)

Appropriate geographic representation i.e., AFP cases with adequate specimens are

representative of the population distribution in general

Quality of AFP surveillance should be monitored at the sub-national level and should be ensured in

border areas and in areas resided by minorities, refugees and high risk populations

Mobile and minority high-risk populations should be identified in border areas, as well as in other

locations, where these groups may reside. Strategies to access these populations through routine

and supplementary immunization activities should be planned. Special surveillance activities

should cover such populations in order not to miss any AFP cases.

Countries should ensure prompt cross-border notification of any cross border AFP case through

the most efficient and direct route. Notification could be done through the respective WHO and

UNICEF country, as well as regional offices.

All district level staff in border areas should be trained on proper epidemiological investigation of

AFP cases including history of travel and contacts.

Complete clinical and epidemiological investigation of all AFP cases should be done to identify

“high-risk AFP cases” (hot cases).

A case should be considered high-risk/Hot case/ whenever AFP is discovered in any child

under five years of age with incomplete immunization status, OR belonging to a high risk

group (minority group, displaced or refugee populations, etc.), OR have had contact with

persons from polio-endemic countries, AND presents with symptoms typical for poliomyelitis

(fever at onset, short progression period, asymmetric paralysis, etc. When such an AFP case

is discovered, two stool specimens should be collected as soon as possible, arrangements made

for the immediate transportation of specimens, and the laboratory alerted to test the specimens

as a priority, immediately upon arrival in order to shorten the time from onset to test results.

Laboratories should immediately notify the program when any poliovirus is isolated and refer

it within 14 days for ITD and genomic sequencing.

19

c. Rapid Investigation of importation/WPV report

Any wild poliovirus isolation should lead to an immediate investigation. A full clinical, epidemiological

and virological investigation should be initiated immediately to determine the source of the virus. Case

investigation should include the collection of all relevant travel and contact/exposure history and other

relevant information and epidemiological data needed to establish whether the individual came in contact

with the virus in a polio-endemic country. Specimens should also be collected from contacts and all wild

polioviruses should be submitted to a WHO-accredited specialized laboratory to assist with the

determination of the geographic origin of the virus through genetic sequencing. Surveillance quality and

vaccination coverage in the area should be assessed.

After thorough investigation cases must be classified as imported or indigenous. If the genomic

sequencing data shows that the virus is closely related to virus circulating in another country and this

finding is consistent with epidemiologic data, the virus can be considered as an importation. However, if

sequencing data shows that the virus is not closely related to previously detected virus or is related to

virus previously circulating in the country (whether it is also circulating in other countries or not) the

virus should be considered indigenous unless there is convincing epidemiologic evidence to the contrary

and good surveillance in the local area.

d. Responses

Enhanced surveillance

Detection of a confirmed polio case in a polio-free country should be followed immediately by enhanced

surveillance for AFP and polioviruses to:

Ensure that it is not a reflection of missed ongoing indigenous transmission through checking the

quality of surveillance including active retrospective search for cases and re-testing of specimens.

Exclude re-established virus transmission due to importation through active search for cases and

widening surveillance activities to include contacts.

Determine the extent of virus circulation and the impact of control measures.

The following actions should be conducted:

Immediate notification of WHO, other international partners and neighboring countries.

Immediate call on the group of experts established for preparedness and response to importation to

advise and coordinate activities nation-wide.

Immediate notification by telephone, to all regional surveillance units and major hospitals nationally

to inform staff that an imported wild poliovirus has been detected, and to alert staff of the possibility

of further cases.

Regions must remind all zones and Woredas that 100% timely and complete active surveillance

reports, including zero reports, are required from every district without exception. Full information

should be provided on names, addresses, telephone, and fax and e-mail address of the responsible

persons in the Ministry of Health. The details of proper case investigation and stool collection should

be emphasized.

Regional and national staffs begin immediate enhanced active surveillance by visiting all woreda

surrounding the case and the AFP sites within that region to conduct active searches for unreported

AFP cases.

Collect stool specimens from household and school contacts of the case before giving OPV.

20

Type all enteroviruses isolated in virological laboratories and submit all poliovirus isolates for

intratypic differentiation.

Monitor reports at national and regional level;

Daily reports to regions from woredas surrounding the case

Weekly reports from all regions by telephone – regions reports must include all woredas.

Weekly review of situation by experts using mapping and other means of documenting the

functioning of surveillance.

Immunization Response

Any importation of wild poliovirus should be followed by an immediate large scale supplementary

immunization response. This would require availability of stockpile of OPV vaccine.

The target population and magnitude of immunization response should be determined by:

Evidence of ongoing transmission,

Extent of circulation,

Local vs. distant importation,

General population versus under-vaccinated minority group.

Potential for widespread transmission, such as in areas with poor sanitation, urban overcrowding and

areas with low immunization coverage where the potential for rapid spread of poliovirus is high.

Immunization activities need to be widespread in order to stop transmission. Limited response could

result in a national disaster.

In general the following steps will be required:

Emergency meeting of national and international experts should be convened to decide on the

response according to the local situation.

Immediate large scale two rounds of supplementary immunization for all children less than 5 years of

age in an area equivalent to at least one region (i.e., several woredas surrounding the case) should be

conducted. Immunization of the contacts of the case should be done after collection of stool

specimens if necessary

Detailed planning, including targeting of high risk groups and house-to-house approaches should be

used.

If secondary spread has occurred, the magnitude of the immunization response should be increased to

include several regions or nationwide. If a border area is involved, the neighbouring country must be notified immediately, through WHO, followed by cross-border coordination in supplementary immunization between the countries concerned.

V. Document Cessation of Transmission

An equally important part of the response to imported wild poliovirus is the documentation of the interruption of transmission of wild poliovirus.

Enhanced surveillance must be maintained for a period of at least 12 months after the last wild poliovirus associated case is detected.

Countries must maintain enhanced surveillance through the existing AFP and virological systems. In addition, supplementary surveillance activities such as stool and/or environmental surveys may be needed to confirm cessation of transmission.

As the detection of any wild poliovirus is considered a national emergency, detailed and comprehensive documentation is required to describe the epidemiological background, findings of case investigation and surveys including laboratory results, description of immunization response and results of enhanced surveillance.

21

VI. Administrative and Financial procedures of WHO

WHO transfer funds to regions to financially support various health related activities. The amount is

based on the availability of funds and country’s priority. The procedure is that RHB/MOH prepares

annual plan and budget proposals to be verified and endorsed by WHO. Then after, the fund will be

released. Upon completion of the project work for which funding has been secured, full technical and

financial report is awaited. If, however, the activity is not completed within envisaged period, progress

technical and financial reports should be sent to WHO.

It should be underlined that funds should be used for the intended purpose. If change of plan is inevitable,

WHO prior consent has to be sought. The program officer is the primary responsible person for the

mobilization and utilization of and reporting on the funds.

Once the fund is deposited in government account, it is subjected to government financial policies and

practices without compromising the accountability requirements of funds to WHO. Accordingly, perdiem

and other rates will be in line with government practice,

WHO has been exerting effort to support regions and FMoH to retire funds in time. To this end, the

organization has hired and deployed a private accounting firm to go around and assist regions to retire the

funds allocated to them. Moreover, it has also prepared and distributed financial management manual to

serve as a tool by finance and programme officers at all levels.

WHO has been covering the cost of perdiem and transportation for those who bring AFP and measles

samples to the central laboratory. WHO’s policy and practice in this regard is stated below.

- WHO pays DSA for the total number of days spent in transporting sample from the collection spot

to the central laboratory and until returning back to the duty station.

- Transport is paid upon presenting valid receipt or as per public transport rate. The responsible

person is advised to come with complete supporting documents and should report to WHO office

immediately after handing over the samples to the central laboratory.

- If government vehicle is used, an official letter should be presented to the office stating name of

the driver, plate number. WHO basically covers the cost of fuel only.

- WHO uses per diem rates applicable to WHO staff member. According to current rates, the

officer will be paid ETB 150/day whereas the driver will be paid ETB 120/day.

- WHO pays 100% of the rate for the day of departure and 0% for the day of arrival to duty station

regardless of the hour of departure/arrival.

- A person who does not spend the night away from the duty station but has to spend more than 8

hours away from his duty station will be paid 35% of the applicable DSA rate.

- To use rental vehicle, WHO’s prior consent has to be sought and an official letter justifying to use

such means of transportation has to be produced from the respective health office.

- If air transport is used, round trip will be paid upon producing original receipt. It is advisable to

register round trip upon departure from duty station.

22

Annex 1: Differential diagnosis for Acute Flaccid Paralysis Surveillance Definition of Acute Flaccid Paralysis: Acute: means that it is less than or equal to three days since the beginning of paralysis onset to its final manifestation. Flaccid: decreased tone, floppy or non-rigid Paralysis: there is loss of muscle strength If you see a child less than 15 years of age who has flaccid paralysis that is acute i.e., if it fulfils the above case definition regardless of cause, then it is a case of AFP. What are the differential diagnoses of AFP? Poliomyelitis, Gullian Barre’ Syndrome, traumatic neuritis, transverse myelitis, acute hemi paresis or quadriparesis, foot drop, etc… Why AFP surveillance and not Poliomyelitis surveillance? In an eradication program the sensitivity of the case definition should be 100% so as not to miss a single case of poliomyelitis which has presented differently from the classical presentation resembling any of the above diseases. There is a stool virological test to confirm whether it is polio or other viruses resulting in the flaccid paralysis. The only way to measure the impact of polio eradication is identifying all cases of AFP and testing the stool samples of these patients and proving that there is no poliovirus identified. What to do when you see a case of AFP? Immediately report to your woreda/zonal focal surveillance officer or Regional Health Bureau so that the case is reported and stool samples are collected from the patient for virological analysis. Consider the diagnosis of Polio whenever a patient less than 15 years of age and meets the AFP case definition even if the diagnosis of polio is remote but real. Ministry of Health, Federal Democratic Republic of Ethiopia

23

Annex 2: 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: ____/____/____ City Prov/Region Zone Year onset case number

IDENTIFICATION: Address: Region: _______________________Zone:____________________Woreda: ________________________ Kebele______________________________

Village/Gote____________________________________Specific location/

identifier__________________________________________________________________

Name(s) of patient __________________________________ Father’s name________________________Grand father’s name______________________ Mother’s name full: ______________________________________Name of health facility reporting____________________________________________________ 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:

Date Onset of Paralysis: ____/___/_____

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: Has the child received any dose of OPV during routine Yes N o Unknown Has the child received any dose of OPV during Supplemental immunization? Yes No Unknown If yes, total no. of polio doses received during routine or S/NIDs If date of administration is known, 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- Net

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? Date follow-up examination: ____/____/_____ Y.N Y.N

FINAL CLASSIFICATION OF THE CASE: 1= Confirmed 2= Compatible 3= Discarded 4= Not an AFP

INVESTIGATOR: Full name ________________________________________________________________ Title: ___________________________________ Health unit: ____________________________________Address:__________________________________ Phone: __________________________

PLEASE fill 5 COPIES AND SEND A COPY OF THIS COMPLETED FORM IMMEDIATELY TO: Woreda health office, Zonal health office, RHB, WHO and to Disease Prevention And Control Department, Ministry of Health, Addis Ababa. Keep one copy at health facility level.

Fever at onset Paralysis Site of paralysis of paralysis 1= Yes 2=No Progressed 1= Yes 2=NO <=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

L.Arm L .Leg

R. Arm R. Leg

1=Residual paralysis

Findings at 2=No residual paralysis Follow-up 3=Lost to follow-up 4=Death before follow-up

1. confirme

24

IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT: Phone: 01-159543 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 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.

Vaccination history. Should be filled after exploring all sources of information (investigation of the vaccination

card, Taking detail history with parents, checking of EPI register if applicable). If the dates are not known please

fill the doses received

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/ 0911-219555

WHO Surveillance/EPI Unit:

011-5514031/0911-233901/0911242398/0911406593/0911249842

EHNRI Polio lab:

011-2771054/011-2771055/011-2771056/011-2778477/78/79/0911-214969

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.

P r in t L S

8 o f 3 1

P a c k in g s to o l s a m p le s

I c e p a c k s

C o n ta in e r s :

W ith la b e l

P la s t ic (n o t g la s s )

S c re w c a p p re fe ra b ly

F o r m s

P la s tic b a g

P r o p e r s e a lin g

‘S to o l s a m p le ’ c a r r ie r

C o tto n w o o l

26

Annex 3: List of Heath Facilities for Active Surveillance

No. Name of Facility Zone/ Wereda Priority

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

27

Annex 4: Procedure for acute flaccid paralysis (AFP) case investigation

Step 1a: Complete case investigation form

Fill AFP investigation form and care seeking questionnaire by interviewing the parents/caretakers and

medical staff, for every child with weakness and/or floppiness of sudden onset. Try to collect as much

information as possible on the first contact with the patient.

Step 1b: Draw a sketch map of the location of the patient's house

Ensure that elaborate and correct information is obtained about the patient's address. Draw a sketch

map of the patient's home to enable the investigator to find the patient for home visit and follow-up after

60 days. Complete all questions on the case investigation form.

Step 2: Collect two stool specimens

Collect two stool specimens 24 hours apart, in two separate clean containers. The sufficient amount of

specimen is a teaspoonful or thumb head. Record the date of collection and name of the patient on each

container and on the case investigation form. You do not need to fill a separate laboratory request form.

Keep the stool specimens in a refrigerator till transport is available.

Step 3: Transport stool specimens to National Laboratory, Addis Ababa

Transport the two stool specimens and one copy of the case investigation form in the transportation kit

with frozen ice parks to the National Laboratory in Addis Ababa. Inform WHO and the Ministry of Health

on your travel plans for timely refund of transport costs. Pass through WHO office for refund of your

transport and perdiem expenses. On spot and prompt reimbursement of these expenses will be done.

Laboratory results and feedback will be dispatched to you as soon possible by WHO and the Ministry of

Health.

Step 4: Follow up of patients after 60 days

The patients should be examined for presence of any residual paralysis 60 days after onset of paralysis.

This can be done by requesting the patient to come to the health facility/hospital after 60 days for a

check-up or through a home visit initiated at the zonal level. Findings of the follow up assessment should

be filled on the remaining copies of the case investigation form. Keep one completed copy for your own

filing.

1This form is to be completed by WHO surveillance officer

28

Annex 5: Line Listing of AFP Cases at Regional / Zonal Level, Year 200

Region: _____________________________ Zone: ____________________________ Zonal Focal Person:__________________________

EPID Number

Name

Age

Sex

Address

Health Facility

Date of onset

Date of 2nd specimen Collection

Condition of specimen (good/bad)

Date of follow-up

60 day of follow-up

Lab Result

Case Classification

P1

P2

P3

Non-polio entrovirus

29

Annex 6 : 1Care seeking questionnaire for AFP cases

EPID NO:______________ 1. Patient’s full Name __________________________________2. Age ____ 3. Sex __________ 4. Religion a. Islam b. Christian c. Other 5. Ethnicity __________________ 6. Parents educational status a. Primary b. Secondary c. Tertiary d. No formal education 7. Parents income in Birr per month a. <200 b.200-400 c.401-600 d. 601- 800 e. >800 8. Address a. Region __________ b. Zone ___________ c. Woreda___________ d. Kebele/PA ___________ 9. Respondent’s relationship with patient a. Father b. Mother c. Guardian d. Other/Specify ______________________ 10. Parent’s Occupation a. Farmers b. Nomads/Pastoralists c. Civil servants d. Merchant e. Private employee f. Others/Specify __________________ 11. Site of paralysis: RA RL LA LL Is it true AFP case: Yes No 12. Has your child taken OPV? Yes ____if yes no. of doses received_______ No

13. Date of onset: Date of notification: Date of first stool: Date of 2 nd stool 14. How many days after child’s paralysis did you seek help? _________________ If late (>14 days) why late? __________________________________________________________ 15. What measures were taken at home? a. Prayer b. Holy water c. Traditional treatment d. Massage e. Nothing f. Other/Specify _________________________________________ 16. Where do people in your community take their children in such types of diseases?________________ 17. Where did you take the child first? a. Health institution b. Holy water c. Traditional healer d. Witch craft e. Prayer place f. Other / Specify __________________ Mention name of the place _____________________________________________ 18. Distance of residence from the nearest health facility in Kms /Hrs. ____________________ 19. Did you take the child to the nearest health institution a. Yes b. No If No. Why not? _____________________________________________________________ 20. How many days after onset of paralysis did you take the child to health institution? _____ Days. Mention the name of the institution___________________________ 21. If Other than a. IN Q 16, why did you take the patient to the above-mentioned place before modern health institution?__________________________________________________________ 22. Who decided to take the patient to the mentioned place? a. Father b. Mother c. Relatives d. Neighbors e. Other /Specify ______________ 23. What is your source of health related information in your surrounding? a. Radio b. Newsletter c. Health personnel d. TV 5.Other source e. No source of health information 24. Have you ever heard about Polio eradication and AFP surveillance? 1. Yes 2. No

Name of surveillance officer __________________________ Signature _________________

30

Annex 7: 1Format for sixty-day follow up examination for cases of acute flaccid paralysis

EPID Number _________________________Data of onset of paralysis (dd/mm/yy)

___/___

Patients Name _________________________ Age in months ________ Sex

Address ________________________________________________

Has 60-day follow up been done already? Yes No If no why not?

________________________ Patient lost to follow up

_____________________________________________

Any other reason, specify

_______________________________________________________

Date of examination (dd/mm/yy) ____________________

Result of examination (i.e. indicate whether patient still has some paralysis or has

completely improved

Can patient use both arms and hand

Is patient able to walk?

Any limp during walking?

In a younger baby below 18 months: (answer only question appropriate to baby’s

expected neuromotor development)

Able to sit?

Able to crawl?

Able to stand?

Bearing weight on legs?

Obvious difference in size of upper limbs

Obvious difference in size of lower limbs

1 This form is expected to be completed by the WHO surveillance officer

F M

Still some paralysis completely improved

yes no yes no

yes no

yes no

yes no

yes no

yes no

Yes no

Yes no

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Muscle Tone

Rt upper limb normal Increased decreased

absent

Lt upper limb normal increased decreased

absent

Rt lower limb normal increased decreased

absent

Lt lower limb normal increased decreased

absent

Deep tendon reflexes

Rt upper limb normal increased decreased

absent

Lt upper limb normal increased decreased

absent

Rt lower limb normal increased decreased

absent

Lt lower limb normal increased decreased

absent

Sensation

Response to painful stimuli affected limb

normal absent

Bladder/Bowel function

normal impaired

Working diagnosis (Clinical impression): ________________________________________ Brief clinical notes to support your clinical impression: Name of investigator:_____________________________________ Signature of investigator_________________ Address of investigator (incl. Phone Number) _________________________________________________________ Thank you for your cooperation!!! Please send this form to the Surveillance Team and retain your own copy.

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Annex 8: Sample form for recording timeliness and completeness of monthly reporting. SIMILAR FORM FOR WEEKLY AND QUARTERLY

Legend: T = arrived on time L = arrived late W = report not received

Date of reporting to be included or should be known Region ___________________ Woreda/zone _________________ Year _____________________

Name of health Facility/Woreda/zone/region

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Total number of reports expected (N)

Total reports sent on time (T)

Total reports sent late (L)

Total number of reports not received (W)

Timeliness of the reports = 100 * T / N

Completeness of reporting = 100 * (N-W) / N

Please note that timeliness and completeness are expressed in percentage figures (%). When the surveillance system is good, the rates for timeliness and completeness should approach 100%. This table allows for monitoring the progress of these two indicators in the woreda/zone so that action can be taken to improve timeliness of reporting for each health facility in the woreda/zone.

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Annex9: Ten indicators of disease surveillance and laboratory performance 1. Non-polio AFP rate in children <15 years of age. (Target > 2/100,000)

Non-polio AFP rate = number of reported non-polio AFP cases < 15 years of age total number of children < 15 yes of age

The non-polio AFP rate is an indicator of surveillance “sensitivity”. If it is < 1/100 000, then the surveillance system is probably missing cases of AFP. When there is an ongoing polio transmission in a certain area, a highly sensitive surveillance system becomes very critical to detect all cases of AFP and polio. Under such circumstances, the target for NPAFP raises to 2/100,000.

2. Completeness of monthly reporting. (Target > 90%)

% complete = number of monthly reports received x 100% number of monthly reports expected

3. Timeliness of monthly reporting. (Target > 80%)

% Timely = number of reports receive before a specified deadline x 100% number of monthly reports expected

4. Reported AFP cases investigated < 48 hours of report (Target > 80%)

5. Reported AFP cases with 2 specimens collected < 14 days since onset. (Target > 80%)

6. Reported AFP cases with a follow-up exam at least 60 days after paralysis onset to verify the presence of residual paralysis or weakness. (Target > 80%)

7. Specimens arriving at national laboratory < 3 days of being sent (Target > 80%)

8. Specimens arriving at laboratory in «good condition ». (Target > 80%).

“Good condition” means that upon arrival :

there is ice or a temperature indicator (showing < 8°C) in the container

the specimen volume is adequate (>8 grams)

there is no evidence of leakage or desiccation

appropriate documentation ( laboratory request/reporting form) is completed.

9. Specimens with a turn-around time < 28 days (Target > 80%).

The turn-around time is the time between specimen receipt and reporting of results

10. Stool specimens from which non-polio enterovirus was isolated (Target > 10%).

This is an indicator of the quality of the reverse cold chain and how well the laboratory is able to perform in the routine isolation of enteroviruses.

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2

Annex 10: Documentation monitoring table for AFP surveillance.

Items Health facility

Woreda/Zone Region National

1 Line listing of AFP cases

2 Completed investigation form(with sketch of map of the child’s home)

3 Individual file per AFP case - -

4 Lab result

5 A copy of clinical note

6 Completed care seeking questionnaire

7 Completed follow up/detailed case investigation form

8 A copy of IDSR report

9 Documents on the wall

AFP line listing

AFP spot map

Case definition, posters

10 List of traditional healers/holy water sites

11 Status of surveillance fund(received, dispersed/utilized/retired/balance

12 List of Focal person

22

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Annex 11: Flow chart of AFP case classification