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AFP SURVEILLANCE PPT

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Calibri:

AFP Surveillance Dr. Monark vyas Resident Community Medicine Dept. B.J. Medical College Ahmedabad

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“Poliomyelitis is still around Make no mistake, it still can be found. For survivors lamed, Crippled may shout, Vaccinate now! Vaccinate now! Polio’s days are numbered The fight is on, the battle sure Protect your child For there’s no cure Polio kill! Polio cripple! No future regret, Protect them now! Come join the battle, Just fight the bug. The time is near, then no more fear, Just Vaccinate, Vaccinate !”

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1988 350 000 cases 125 countries Areas with Active Polio Transmission

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India Pakistan Afghanistan Nigeria Polio Endemic Countries

Agency FB:

Location of poliovirus by type, 2010* Most recent virus 7 February 2010 Jammu, J&K * data as on 19 March 2010

Wingdings:

Location of poliovirus by type, 2009* * data as on 3 rd July 2009 Most recent virus 21 st June 2009 Bareilly, UP ** One case reported mixture of P1 wild & P3 wild

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Location of poliovirus by type, 2008

Microsoft Office Excel Worksheet:

Location of poliovirus by type, 2007 ** three cases (one in UP, two in Bihar) reported mixture of P1 wild and P3 wild

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Polio cases, India P1 wild P3 wild * data as on 19 March 2010

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2005 - 1 Gujarat Wild Cases 2000-09 BAN KTC JMC RJC AML BVC KDA PML DHD VDD SRC NAV DNG AMD AND VDC SRN GNR VLD AMC NMD BRH SBK BVN JUN PAT MSN JMD POR SRT RJT 2002 - 24 2003 - 3 2001 - 1 2004 - 0 Year - Cases 2000 - 2 2006 - 4 2007 - 1 2008 - 0 2009 - 0

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Strategies of Polio Eradication 1985 – Routine immunization Individual immunity 1995 – NID’s ( PPI / IPPI ) To replace wild with vaccine virus 1997 - AFP surveillance To identify reservoir of transmission 2000 – Mopping up immunization To eliminate last foci of transmission

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Definition of AFP for surveillance purposes   Sudden onset weakness and floppiness in any part of the body in a child < 15 years of age or paralysis in a person of any age in which polio is suspected.

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Why should ALL children with current AFP or history of AFP to be investigated ? It is difficult to precisely identify all cases of paralytic polio clinically Paralysis which seem clinically polio may be non-polio Paralysis which seem clinically non-polio may be the true cases of polio To ensure that no cases of polio are missed, all cases of AFP are reported and investigated Reason why we use the Virological Classification

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selection of AFP cases in Surveillance in identifying polio cases Identify children with the SYNDROME of Acute Flaccid Paralysis Acute - Sudden onset, Rapid progression Flaccid - Floppy or Soft and yielding to passive stretching at anytime during the illness . Paralysis is loss of strength of muscles, Severe loss of motor strength is called paralysis or plegia Paresis- less severe loss of motor strength

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Objective of AFP surveillance Reliably detect areas where polio transmission is occurring or likely to occur

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The objective of AFP surveillance is to detect the exact geographic locations where wild polioviruses are circulating in the human population. All cases of acute flaccid paralysis in children aged <15 years are rigorously investigated by a trained medical officer, with collection of stool specimens to determine if poliovirus is the cause of the paralysis. Analysis of the location of polioviruses isolated from AFP cases allows programme managers to plan immunization campaigns (Pulse Polio Immunization) to prevent continuing circulation of virus in these areas.

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AFP SURVEILLANCE Components Establishment and Maintenance of Reporting Units. AFP Case Notification AFP Case Investigation. Stool Specimen Collection and Transportation. ORI with Active Case Search in Community. 60 Days FU Examination. Cross Notification and Tracking of Cases. Data Management and Analysis . Case Classification.

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Establishment and Maintenance of Reporting Units. Backbone of Surveillance Network called RU These are the medical colleges,District Hospitals, Pediatricians, Doctors, Medical / Health establishment in Gov. or Private Sectors. They Report AFP on identification & send weekly report (on MONDAY) to District Immunization Officer (DIO). Each RU should have a designated AFP Nodal officer . Activities of Nodal officer. Make report (AFP-H002) & notification 8453 RUs in India. Informer units are smaller units (child specialist, popular “quacks or Polio doctor, temples)

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AFP Case Notification RUs notify AFP cases or no AFP case means ZERO reporting immediately to the DIO by feeling AFP-H-002 form DIO reports to STATE LEVEL on TUESDAY of each week. They collect H-002 form from all RU,collate them in AFP D-002 ,compile and transmits in the AFP-D001 form to the State EPI officer (SEPIO/State SMO) SEPIO/State SMO on Wednesday collect information received from AFP-D-001 into AFP-S-002 form and prepare STATE report in the S-001 form and transmit to the A C (immunization), Ministry of H & FW,GOI,New Delhi At national level ,on Thursday at NPSU,data from the states received, compiled to prepare the national report sent to the WHO(SEARO) NEW DELHI.

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AFP Case Investigation Within 48hrs of notification, by DIO or SMO. After confirming AFP, DIO examine child, takes History & examination &fill a Case Investigation(CIF) Form & assign EPID number Ask travel history 35 days prior to onset of paralysis and inform to state SMO/NPSU/RC

Strategies of Polio Eradication:

Stool Specimen Collection and Transportation. Adequate Stool. 2 Specimens 24 Hours Apart. 8 gms . Within 14 Days of Paralysis Onset (BUT up to 60 days may be collected) Proper Cold Chain in storage and transport level Send to designated National polio virus Laboratory with filling of Laboratory Request Form (LRF) within 72 hours of dispatch.

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Logic of AFP investigation & stool sample collection Sensitivity increases when all AFP cases are investigated Testing of stools of all AFP is the most valid test for identification of Polio ALL cases with ‘Acute Flaccid Paralysis’ should be reported and their stools must be tested!! Even if other ‘tests’ (CT scan, MRI, etc.) or additional clinical information point to other diagnoses, their stools must be tested to rule out Polio

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Action when AFP is reported FIRST – Start stool collection process Investigate - SMO/ DIO - Confirm if AFP,if not reject case and record the same . There is only one category of cases - AFP Allot EPID number & Report the case as AFP CIF & LRF should be filled . Use the revised CIF/ Linelist form . Ensure that stools are transported to lab in cold chain NPSU will Classify after lab result is received Give feedback to the source that the AFP reported was/ was not polio. Maintain documentation at ALL levels.

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ORI(Outbreak Response Immunization ) with Active Case Search in Community. Following Sample collection ORI is organized. All 0 – 59 months old children given tOPV while going house to house. At least 500 children are vaccinated. Along with these Active Case Search is conducted by going house to house to find more AFP cases. Purpose is to uncover additional Polio cases.

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60 Days FU Examination. DIO / SMO revisits every case of AFP 60days after the onset of paralysis to confirm Presence or Absence of residual weakness. Assessed for weakness, Asymmetrical skin folds, & difference between Left/Right mid arm / mid thigh circumference. Activity completed before 70 th day of onset of paralysis.

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Cross Notification and Tracking of Cases. Cases are investigated anywhere in India, sending information to DIO of residing district immediately AFP case is constantly tracked by SMO to complete all activities related with surveillance. Data Management and Analysis . DIO reports to the State EPI officer the line list of all new cases of AFP. Reporting takes place even when no cases of AFP identified.

AFP SURVEILLANCE:

Data entered at National Polio Surveillance Unit (NPSU) & is used for Program monitoring, Checking quality of data & assessing progress towards eradication. Case Classification. When Lab results & 60days follow up reports are available, cases are classified at NPSU. Until 1999,case is classified as Polio if wild virus is isolated & if 2 samples report are negative then Non – Polio. If Inadequate sample & AFP case had residual weakness, died or lost to follow up then classified as Polio.

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From January 2000, cases with Inadequate sample & AFP case had residual weakness, died or lost to follow up are subjected to special investigation & are presented for the review by the Expert group, & they classify the cases as compatible or Discarded.

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VIROLOGIC CLASSIFICATION SCHEME * 2 SPECIMENS, AT LEAST 24 HOURS APART AND WITHIN 14 DAYS OF PARALYSIS ONSET; EACH SPECIMEN MUST BE OF ADEQUATE VOLUME (8-10 GRAMS) AND ARRIVE AT A WHO ACCREDITED LABORATORY IN GOOD CONDITION (i.e. NO DESSICATION, NO LEAKAGE, ADEQUATE DOCUMENTATION AND EVIDENCE THAT THE REVERSE COLD CHAIN WAS MAINTAINED) NO WILD POLIOVIRUS AFP WILD POLIOVIRUS INADEQUATE STOOL SPECIMENS TWO ADEQUATE* STOOL SPECIMENS NO RESIDUAL WEAKNESS CONFIRM COMPATIBLE DISCARD DISCARD RESIDUAL WEAKNESS, DIED OR LOST TO F/U DISCARD EXPERT REVIEW

AFP Case Investigation:

Compatible Cases 2002-2009 2002 – 14 cases 2003 – 4 cases 2004 – 1 case 2005 – 7 cases 2006 – 3 cases 2007 – 5 cases 2008 – 1 case 2009 – 0 case

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Differential diagnosis? Poliomyelitis Guillian Barre Syndrome Transverse Myelitis Traumatic Neuritis Hemiplegias / Hemipaeresis Fascial palsy Palatal palsy Others

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GOLD STANDARD FOR AFP SURVEILLANCE Non – Polio AFP Rate in children <15 years age group is > 2.0 per 1 lacs children <15 year age group(most sensitive) Adequate Stool Samples > 80% Timeliness of weekly “zero”Reporting > 80%

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HOT CASE A case of AFP with any of the following set of conditions - Age less than 5 year plus history of fever at onset plus asymmetrical proximal paralysis. Age less than 5 year with rapidly progressive paralysis leading to bulbar involvement (cranial nerves are affected) and death. Any case which in the opinion of SMO/DIO looks like polio.

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CONTACT SAMPLES To be considered for cases fulfilling criteria like Hot cases, but adequate samples from case could not be taken Such cases or any other situations where SMO / DIO feels the necessity of contact samples, should be discussed with RTL NPSP

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Thank you 36 7/29/2010

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