AFP SURVEILLANCE

Aswin S
Roll No. 7
2018 IInd Add. Batch
INTRODUCTION

• Poliomyelitis is an acute viral infection caused by an RNA virus.

• It is primarily an infection of the human alimentary tract.
• But the virus may infect the central nervous system in a very small percentage (about 1
per cent) of cases resulting in varying degrees of paralysis, and possibly death.
POLIO ERADICATION

• The Polio Eradication and Endgame Strategic Plan 2013-2018 represents a major
milestone in polio eradication and describes specific steps to take to successfully achieve
eradication.
• The plan has four objectives as mentioned below:
FOUR KEY STRATEGIES OF POLIO ERADICATION

RI (Routine Immunization) Programme [Universal Immunization Programme] – 1985.

• Mass Immunization(PPI) – 1995 -96.
• AFP Surveillance – 1997.
• Moping up in focal areas.
*

• Man is the only reservoir.

• No long term carrier state.
• Route of transmission is feco-oral.
• Half life of excreted virus in sewage sample in tropical climate like that of India is 48
hours.
• Potent and effective vaccine.
POLIO SURVEILLANCE

• Surveillance is the most important part of the whole polio eradication initiative.
• Without surveillance, it would be impossible to pinpoint where and how wild poliovirus is
still circulating, or to verify that the virus has been eradicated.
• Surveillance identifies new cases and detects importation of wild poliovirus.
“ It is the continuous scrutiny of all aspects of occurrence and spread of the disease that are
pertinent to effective control. ”
“ Surveillance is essential for effective control and prevention and includes the collection,
analysis, interpretation and distribution of relevant data for action. ” [WHO – 1981]
How can surveillance be carried out?
• Institutional surveillance :
It refers to the collection of data (actively or passively) from pre-identified and designated fixed
facilities regardless of size.

• Community-based surveillance :
It refers to the collection of data from individuals and households at the village/locality level
rather than from institutions or facilities.
Acute Flaccid Paralysis Surveillance
• There are four steps of acute flaccid paralysis (AFP) surveillance:

1. Finding and reporting children with acute flaccid paralysis (AFP).

2. Transporting stool samples for analysis.
3. Isolating poliovirus.
4. Mapping the virus.
Acute Flaccid Paralysis Surveillance
Started in 1997 October.

Achieved global benchmarks in May 1998.

Mapping of Polio cases made possible.

• Genetic sequencing capacity expanded.
• In other parts of the world at least one case of AFP (excluding polio) occurs annually for
every 100,000 children less than 15 years of age. This is referred to as the “background”
rate of AFP among children.
• In India, where the incidence of conditions such as traumatic neuritis and AFP caused by
other non-polio enteroviruses is very high, the background non-polio AFP rate is
undoubtedly much higher than 1/ 100,000. For this reason, the operational target of non-
polio AFP case detection in India has been set to 2/100,000.
Goals of Acute Flaccid Paralysis Surveillance
Identification of all reservoirs of circulating wild Poliovirus.
• (That could be Polio ) by documenting all such cases, it is possible to show that none of these
“Polio-like” cases were caused by the Poliovirus, and that Polio is no longer present or existing.
“ AFP surveillance helps to detect reliably areas where poliovirus transmission is occurring. Thus AFP
surveillance helps us to identify areas of priority for focusing immunization activities. It is the most
reliable tool to measure the quality and impact of polio immunization activities. ” [NCBI-NIH]
“ For polio free certification, it is essential to provide evidence to the certification committee of the
absence of wild polio virus transmission through a functioning and sensitive surveillance system for 3
years after attaining zero polio case status. ” [GPEI]
Why AFP surveillance instead of Polio surveillance?
Surveillance of a Polio case alone is not sufficient because it is impossible to precisely
identify all cases of polio clinically due to confusing and ambiguous clinical signs.
• Clinically Polio in acute stage, is difficult to distinguish from other causes of acute onset
of flaccid paralysis.
Finding and reporting children with acute flaccid paralysis

• The first links in the surveillance chain are staff in all health facilities from district health
centres to large hospitals. They must promptly report every case of acute flaccid paralysis
(AFP) in any child under 15 years of age. (It may be monoplegia, paraplegia, hemiplegia,
facial palsy, or any trasient weakness.)
• Besides, public health staff make regular visits to hospitals and rehabilitation centres to
search for AFP cases which may have been overlooked or misdiagnosed.
• The number of AFP cases reported each year is used as an indicator of a country’s ability
to detect polio – even in countries where the disease no longer occurs.
• A country’s surveillance system needs to be sensitive enough to detect at least one case of
AFP for every 100,000 children under 15, even in the absence of polio.
Transporting stool samples for analysis

• In the early stages, polio may be difficult to differentiate from other forms of acute
flaccid paralysis, such as Guillain-Barre Syndrome, transverse myelitis, or traumatic
neuritis.
• All children with AFP should be reported and tested for wild poliovirus within 48 hours
of onset, even if doctors are confident on clinical grounds that the child does not have
polio.
• To test for polio, faecal specimens are analyzed for the presence of poliovirus. Because
shedding of the virus is variable, two specimens taken 24-48 hours apart are required.
• Speed is essential, since the highest concentrations of poliovirus in the stools of infected
individuals are found during the first two weeks after onset of paralysis.
Transporting stool samples for analysis

• Stool specimens have to be sealed in containers and stored immediately inside a

refrigerator or packed between frozen ice packs at 4-8°C in a cold box, ready for
shipment to a laboratory.
• Undue delays or prolonged exposure to heat on the way to the laboratory may destroy the
virus.
• Specimens should arrive at the laboratory within 72 hours of collection.
Isolating poliovirus

• In a laboratory, virologists begin the task of isolating poliovirus from the stool samples.
• If poliovirus is isolated, the next step is to distinguish between wild (naturally occurring)
and vaccine-related poliovirus. This is necessary because the oral vaccine consists of
attenuated live polioviruses and resembles wild virus in the laboratory.
• If wild poliovirus is isolated, the virologists identify which of the two surviving types of
wild virus is involved. [Wild poliovirus type 2 has not been recorded since 1999].
Mapping the virus

• Once wild poliovirus has been identified, further tests are carried out to determine where
the strain may have originated.
• By determining the exact genetic make-up of the virus, wild viruses can be compared to
others and classified into genetic families which cluster in defined geographical areas.
• The newly-found poliovirus sequence is checked against a reference bank of known
polioviruses, allowing inferences about the geographical origin of the newly found virus.
• When polio has been pinpointed to a precise geographical area, it is possible to identify
the source of importation of poliovirus - both long-range and cross-border.
[DIO: District immunization officer, SMO: Surveillance medical officer,
SEPIO: State EPI officer, EPl: Expanded Program of Immunisation, RC:
Regional coordinator, NPSU: National Polio Surveillance Unit]
Surveillance
indicators

Completeness • At least 80% of expected routine (weekly or monthly) AFP. Surveillance reports should be
of reporting received on time, including zero reports where no AFP cases are seen.
• The distribution of reporting sites should be representative of the geography and
demography of the country.
Sensitivity of • At least one case of non-polio AFP should be detected annually per 100,000 population
surveillance aged less than 15 years.
• In endemic regions, to ensure even higher sensitivity, this rate should be two per 100,000.
Completeness • All AFP cases should have a full clinical and virological investigation with at least 80% of
of case AFP cases having ‘adequate’ stool specimens collected.
investigation • ‘Adequate’ stool specimens are two stool specimens of sufficient quantity for laboratory
analysis, collected at least 24 hours apart, within 14 days after the onset of paralysis, and
arriving in the laboratory by reverse cold chain & proper documentation.
Completeness • At least 80% of AFP cases should have a follow-up examination for residual paralysis at 60
of follow-up days after the onset of paralysis.
Laboratory • All AFP case specimens must be processed in WHO accredited a laboratory within the
performance Global Polio Laboratory Network (GPLN).
THANK YOU!
FIN!