Differential Diagnosis of Acute Flaccid Paralysis and its Role in Poliomyelitis Surveillance

Emory University, Atlanta, Georgia, United States
Epidemiologic Reviews (Impact Factor: 6.67). 02/2000; 22(2):298-316. DOI: 10.1093/oxfordjournals.epirev.a018041
Source: PubMed
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    • "Infection is mostly by the faecal-oral route, typically in susceptible children without prior or adequate vaccination with potent and efficacious polio vaccines, living in areas of poor hygiene and sanitation. Nearly 95% poliovirus infection is asymptomatic with about 2% of people experiencing viral replication in the central nervous system which may lead to permanent neuronal damage and paralysis [5-7]. "
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    ABSTRACT: Background Ghana recorded the last case of indigenous wild poliovirus in 1999 but suffered two more outbreaks in 2003 and 2008. Following the World Health Organization (WHO) guidelines, transmission was interrupted through high routine immunisation coverage with live-attenuated oral polio vaccine (OPV), effective acute flaccid paralysis (AFP) surveillance and supplementary immunisation activities (SIA). This article describes the results of a five-year surveillance of AFP in polio-free Ghana, evaluate the surveillance indicators and identify areas that need improvement. Methods We investigated 1345 cases of AFP from children aged less than 15 years reported to the Disease Surveillance Department from January 2009 to December 2013. Data on demographic characteristics, vaccination history, clinical presentation and virological investigation on stool specimens collected during investigation were analysed. Results Of the specimens analysed, 56% were from males and 76.3% were from children less than 5 years of age. Twenty-four percent of the children received up to 3 doses of OPV, 57% received at least 4 doses while the status of 19% was unknown. Core AFP surveillance indicators were partly met for non-polio AFP rate while the WHO target for stool adequacy and timeliness was exceeded over the period of study. All the cases were classified virologically, however no wild polio was found. Sixty-day follow-up was conducted for 56.3% of cases and 8.6% cases classified as compactible with polio. Conclusion Both laboratory and epidemiological surveillance for AFP were efficient and many WHO targets were met. However, due to the risk of poliovirus importation prior to global eradication, longterm surveillance is required to provide a high degree of confidence in prevention of poliovirus infection in Ghana. Thus, efforts should be made to strengthen regional performance and to follow–up on all AFP cases in order to establish proper diagnoses for the causes of the AFP leading to proper care.
    Full-text · Article · Jul 2014 · BMC Public Health
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    • "spinal cord, and it may cause temporary or permanent damage of the nerve cells due to the inflammation process (Shibuya and Murray, 2004). According to Marx et al. (2000) as many as 1% of infected individuals develop paralytic disease. Polio usually affects children under 12 months of age (Ebnezar, 2003), but the probability of developing paralytic polio increases with age since paralysis in children occurs in 1/1000 cases, while in adults 1/75 may develop paralysis (Gawne and Halstead, 1995). "
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    ABSTRACT: Osteological changes consistent with neurogenic paralysis were observed in one male and one female skeleton recovered from two Croatian medieval sites – Virje and Zadar. Both skeletons display limb asymmetry typical of neurogenic paralysis that occurs during the childhood. The male skeleton displays atrophy and shortening of the right arm and the right femur, while the female skeleton exhibits identical changes on the right arm and both legs. Additionally, both skeletons exhibit scoliotic changes of the spine, and the female skeleton also displays bilateral hip dysplasia. Differential diagnosis included disorders such as cerebral palsy, poliomyelitis, cerebrovascular accident, and Rasmussen's encephalitis. These are the first cases of neurogenic paralysis (cerebral palsy and/or paralytic poliomyelitis) identified in Croatian archeological series. The Virje skeleton is only the third case of hemiplegia identified from archeological contexts (first with spinal scoliosis), while the Zadar skeleton represents the first case of triplegia reported in the paleopathological literature.
    Full-text · Article · Jul 2014 · International Journal of Paleopathology
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    • "Information regarding age, onset date, parent-reported oral polio vaccine (OPV) dose history, and clinical symptoms is collected as part of the initial case investigation, before the laboratory polio diagnosis is completed. AFP can be caused by viruses other than WPV, though the distribution of these viruses and other causes of AFP are not well understood [27]. AFP cases without confirmed poliovirus in either stool sample, that is, non-polio AFP (NP-AFP), are considered to be a random sample of the population [28-30]. "
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    ABSTRACT: Background One of the challenges facing the Global Polio Eradication Initiative is efficiently directing limited resources, such as specially trained personnel, community outreach activities, and satellite vaccinator tracking, to the most at-risk areas to maximize the impact of interventions. A validated predictive model of wild poliovirus circulation would greatly inform prioritization efforts by accurately forecasting areas at greatest risk, thus enabling the greatest effect of program interventions. Methods Using Nigerian acute flaccid paralysis surveillance data from 2004-2013, we developed a spatial hierarchical Poisson hurdle model fitted within a Bayesian framework to study historical polio caseload patterns and forecast future circulation of type 1 and 3 wild poliovirus within districts in Nigeria. A Bayesian temporal smoothing model was applied to address data sparsity underlying estimates of covariates at the district level. Results We find that calculated vaccine-derived population immunity is significantly negatively associated with the probability and number of wild poliovirus case(s) within a district. Recent case information is significantly positively associated with probability of a case, but not the number of cases. We used lagged indicators and coefficients from the fitted models to forecast reported cases in the subsequent six-month periods. Over the past three years, the average predictive ability is 86 ± 2% and 85 ± 4% for wild poliovirus type 1 and 3, respectively. Interestingly, the predictive accuracy of historical transmission patterns alone is equivalent (86 ± 2% and 84 ± 4% for type 1 and 3, respectively). We calculate uncertainty in risk ranking to inform assessments of changes in rank between time periods. Conclusions The model developed in this study successfully predicts districts at risk for future wild poliovirus cases in Nigeria. The highest predicted district risk was 12.8 WPV1 cases in 2006, while the lowest district risk was 0.001 WPV1 cases in 2013. Model results have been used to direct the allocation of many different interventions, including political and religious advocacy visits. This modeling approach could be applied to other vaccine preventable diseases for use in other control and elimination programs.
    Full-text · Article · Jun 2014 · BMC Medicine
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