AFP Case Finding &

Investigation
Ms. Jezza Jonah D. Crucena - Aclan, RN, MPH
National Vaccine Preventable Disease Surveillance Coordinator,
Epidemiology Bureau

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Case Detection
 Process of identifying cases from the population using
standard case definitions

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Acute Flaccid Paralysis Case Definition
An AFP case is defined as a child < 15 years of age presenting with recent or
sudden onset of floppy paralysis or muscle weakness of the limb/s due to any
cause,
OR
Any person of any age with paralytic illness if poliomyelitis is suspected by a
clinician.
Acute: sudden onset of paralysis. Usually the interval from the onset (first sign of muscle weakness to
inability to move the affected limb/s) takes 3-4 days but may extend to two weeks.

Flaccid: is the loss of muscle tone of the affected limb(s) giving it a “floppy” appearance (as opposed to
spastic or rigid)

Paralysis: is the reduced or loss of ability to move the affected limb(s)

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Differential Diagnosis

 Diagnoses that is similar or most likely to have the

same signs and symptoms as the disease of interest
for surveillance

 Guide surveillance officers in detection

 Warrants further investigation

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What are the Differential Diagnosis used to
Detect AFP Cases?
 Poliomyelitis
 Guillain-Barre Syndrome (GBS)
 Myelitis (i.e Transverse myelitis, Pott’s disease)
 Traumatic neuritis
 Other disease as long as AFP is manifested

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How AFP Surveillance works

Case  Polio
investigation
and lab
analysis

Community
AFP

Hospitals
Clinics
cases Non-
Polio AFP

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IMPORTANT NOTE
 AFP is NOT a disease per se but a syndrome that can have
several causes. Viral stool culture of all AFP cases is
necessary to determine whether or not the AFP is caused by
poliovirus.

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In essence, what we really want to prove
is that
None of the AFPs are due to polio.

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What is an AFP “Hot” Case?
 A case that is considered highly suspected for being polio based on
clinical data and with the following presenting characteristics:
 Less than 5 years of age
 Less than 3 OPV doses
 Fever at onset of paralysis
 Asymmetric paralysis
 Rapid progression of paralysis (within 3 days)
and/or
 Has been in contact with or living in area with possible or
recent Polio virus circulation

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Where cases are expected to be seen?

 Disease Reporting Units (DRUs) such as:

• Barangay Health Stations (BHS), Community
• Municipal Health Offices (MHOs), City Health Offices (CHOs)
• Hospitals and clinics

 Community/Household

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AFP Surveillance in the Hospitals…

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Preparatory Steps in conducing Hospital AFP Surveillance
Step 1: Orientation of hospital staff on AFP case definition:
a. Hospital staff MUST be oriented how to detect an AFP
b. Orient physicians and nurses who see patients coming in at
the hospital
Step 2: Assign surveillance nurses per ward:
a. Designate a Disease Surveillance Coordinator (DSC) and a
Ward Surveillance Nurses in ward
b. Surveillance nurses from the wards work with DSC in
surveillance activities
Surveillance is everyone’s responsibility!
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Steps in Active Reporting of AFP Case at the ER
Immediately report to the RESU
3 any AFP case detected

Investigate any patient fits the AFP case

2 definition using the AFP CIF

Physicians and nurses immediately report to the DSC

any patients currently admitted due to “paralysis /
1 weakness of extremity” or any health condition
or diagnosis with such manifestation
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Steps in AFP Case Detection in the Ward

Immediately report to the RESU

3 any AFP case detected

2 Investigate any admitted patient that fits the AFP

case definition by completing the AFP CIF

Do DAILY PEDIATRIC WARD VISIT to detect for patients

currently admitted due to “paralysis / weakness of
1 extremity” or any health condition or diagnosis with such
manifestation
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Steps in AFP Case Detection: Records Review
Immediately report to the RESU
3 any AFP case detected

Investigate any of the admitted patient fits the AFP

case definition using the AFP CIF.
2 *If the patient has already been discharged, inform
the RESU or CESU immediately so appropriate
follow-up investigation in the community is done
Review the admission logbook and look for patients
1 admitted due to “paralysis / weakness of extremity” or any
health condition or diagnosis with such manifestation
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 Steps in Community-based Active Case Finding
1I Identify/assign areas to be visited for the day

Approach a household and ask if anyone in the family is <15 years old. List this down in
2 the Community Survey Tool
If there are any, further ask how many of the <15 years old have sudden
3 onset or recent weakness/paralysis occurring within the last 2 months

4 If any of the children fits the AFP case definition, investigate the case;
collect stool samples and fill out the AFP CIF

5 Consolidate findings for the day and immediately report any AFP
5 case found to RESU

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When we find a case, what
do we do now?
Steps in Investigating an AFP Case

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 Steps in AFP Investigation
1 Verify if the case satisfies the case definition for AFP

2 Interview and examine the case

Collect additional info by reviewing patient’s records an

3 d/or discussing the case with the attending physician

4 Collect specimen(s) from each AFP case

Secure a photocopy of the patient’s medical chart

5 and laboratory test results
Send the completed AFP investigation form and attached
6 documents to the next higher level/ESUs

7 Search for additional cases

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 Data collection through:
 Filling out of the Case Investigation Form: ensure accuracy and
completeness
 Interview : document complete contact information and exact
residential address
 Physical examination
 Focus of the P.E.
• Is paralysis symmetrical (same on both sides) or asymmetrical
(one-sided)?
• Is there a decrease in muscle strength?
• Is there a decrease in deep tendon reflexes?

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AFP Case Investigation Form

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Physical examination
 General Appearance: observe the child
 Can the child walk/get up without assistance?
 Is the child able to lift/move his or her arms/legs?
 Is there a limp or foot drag?
 Are the arms/legs floppy?
Are neurologic signs present in one side of the body
(asymmetrical) or both sides (symmetrical) of the body ?

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Physical examination
 Check for floppy paralysis
• For older children: do passive flexion/extension of
extremities. If no resistance, then the paralysis is flaccid.
Muscles of patient would feel “flabby”

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Physical examination
Check for floppy paralysis
• For infants: observe extremities. The paralyzed extremity/ies will have
decreased or no spontaneous movement. It will also have no resistance
to passive extension/flexion.

“Frog-like” position
indicates loss of muscle
tone

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• Physical examination
 Check Reflexes
• Using a reflex hammer, elicit
deep tendon reflex by the
patellar, Achilles and triceps
reflex
• Normal response is a jerk
• Reflexes may be graded as:
(0) absent (+) diminished
(++) normal (+++)
exaggerated (++++) clonus.

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 Physical examination
 Check motor status
 For older children: Observe if patient can move all extremities. If
with observed paralysis, ask the patient to do the following:
• raise the arm and reach out for object
• stand on either leg
• observe the gait

Note: For infants, other activities such as crawling, walking and playing may be used
to assess symmetry of movements and presence of paralysis.
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• Physical examination
 Check motor status
o Assess the degree of paralysis as follows:
0 No movement
1-2 Minimal movement
3 patient is able to raise the extremity/ies against gravity
4 patient is able to move extremity/ies against minimal resistance
5 normal movement, patient is able to move all extremities against
gravity and against full resistance

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 Usually, when the patient is hospitalized, the attending physician makes a working
diagnosis. The investigator should coordinate with the attending physician to
determine whether or not this is a true AFP.

 Because this is an enhanced surveillance, for every AFP case with inadequate stool
specimen, collection from 3-5 close contacts is also directed (preferably children).
 A close contact is a sibling, a household member, a school-mate, a playmate and
others with history of direct contact with the AFP case.
 If patient is admitted in the hospital, refer immediately to RESU/PESU or CESU for
the identification and collection of stools from close contacts
 Use the AFP Close Contact Form

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 For hospitalized patients, the attending physician makes a working diagnosis. The
investigator should coordinate with the attending physician to determine whether or
not this is a true AFP.

 Check for completeness and consistency prior to submission

 Copy of CIF should be submitted to RITM together with stool
specimen
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 • Determine if there are clusters (2 or more AFP cases in a barangay
within 4 weeks)
 If there is a cluster, do the following activities:
 coordinate with local health facilities to find out if there are
more cases, including key community persons (community
leaders, teachers, traditional healers, religious healers etc.)
 Review patient’s record individual treatment records of health
facilities
 Conduct case investigation and specimen collection for AFP
cases found
*Done in the community
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  Determine if there is residual paralysis
 AFP cases that falls in any of the following:
• no stool samples
• stool samples were collected beyond 14 days from paralysis onset
• cases classified as polio-compatible
• AFP Hot case

*Done in the community

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• Determine if there is residual paralysis
For cases with inadequate stool specimens or cases
classified as polio-compatible, neurologic evaluation
should be conducted by a physician or trained health
worker.

If an AFP case migrated to another province/ region,

coordinate with the DSO of that province/region for
follow up

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• Determine if there is residual paralysis
“lost to follow-up” – unable to locate the case after
three failed attempts to locate the case within 90 days
after paralysis onset

Death of the case before the scheduled follow-up should

be reported immediately to RESU and EB. This should be
considered timely follow up.

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 Maraming salamat po!

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