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ACUTE FLACCID PARALYSISSUBIN S MATHEWVINITHA
Classification of causes of AFPCan be classified acc to the levels of motor units involved a) Muscles - hypokalemic paralysis, myoglobinuric myopathy b) Neuromuscular junction- myasthenia gravis, botulism c) Peripheral nerves- Guillian Barre syndrome, diphtheric neuropathy d) Anterior horn cells- poliomyelitis
APPROACH TO A PATIENT OF AFPHistory - complaints -weakness of all 4 limbs -onset;proximal /distal;symmetry -all 4 limbs involved at the same time or in ascending pattern -h/o pain -h/o respiratory distress -h/o swallowing difficulty,nasal regurgitation, weak cough,pooling of secretions,nasal twang
HISTORY -h/o sensory disturbances -bladder and bowel disturbances -autonomic disturbances -features of raised ICT -h/o IM injection -h/o tonsillectomy -h/o diarrhea and fever
HISTORY -h/o trauma -h/o similar episodes in community -h/o rash associated with fever -h/o pica -h/o recent throat pain in unimmunised
HISTORYImmunisation history (polio vaccines,vaccine assoc.paralysis)Socioeconomic history( sewage disposal, latrine facilities- polio)
Examination- Complete CNS examination - RS (involvement of diaphragm)
InvestigationsLumbar punctureEMG/ NCVSTOOL surveillance in polioCPK in myositisSerum K levelXray spine for paravertebral abscess in TBMRI spine if tumor compression is suspected
Differential Diagnosis for AFPCommon diagnosis in a child - poliomyelitis - Guillian Barre syndrome - Transverse myelitis - Traumatic neuritis - Polymyositis - Spinal cord compression by tumor,TB
Differential diagnosis-contdRare - diphtheria - porphyria - Pb poisoning - Botulism - Myasthenia gravisPseudoparalysis - Scurvy, rheumatic fever, osteomyelitis, syphilis etc.
In India, the most common causes for AFP are polio, GBS, traumatic neuritis and transverse myelitis of which polio is the leading one
DDS for AFP
PoliomyelitisCaused by poliovirus types 1,2,3Transmitted person to person via feaco- oral routeMaximum excretion of the virus just before the paralysis and in the first 2 weeks after the onset of paralysisHumans are the only reservoirsHighly communicable; 1 week before and 2 weeks after the onset of paralysis
Contd All unimmunised are susceptible to polioImmunity( humoral and local intestinal) obtained on exposure to either the wild virus or through immunisationOPV should be given as early as possible in the newborn
Stages in poliomyelitisInapparent infectionAbortive polio- minor febrile illnessNon paralytic aseptic meningitisParalytic polio- minor and major i) Spinal polio ii) Bulbar polio iii) Bulbospinal polio
Strategies for polio eradication in IndiaConduct Pulse or Polio Immunization days every yr for 3-4 yrs or until polio is eradicatedSustain high levels of routine immunization coverageMonitor OPV coverage at district level and belowImprove surveillance capable of detecting all cases of AFP due to polio and non-polio aetiology
ContdEnsure rapid case investigation,including colletion of stool samples for virus isolationArrange followup of all cases of AFP at 60 days to check for residual paralysisConduct outbreak control for cases confirmed or suspected to be polio to stop tansmissionMopping up door-to-door immunization in high risk districts.
Polio Vaccines2 vaccines- IPV and OPVOPV is widely used because of ease of administration, induction of circulating and intestinal immunity Dosage- 1 dose( 2 drops) at birth, 6, 10, 14 weeks
Surveillance - contdSteps for reporting include:Network of AFP reporting units - hospitals, community health centres etc. - each unit reports every week even when no cases of AFP identified.b) Initial identification and reporting of AFP cases- nodal officer reports to the District Immunisation Officer by quickest means
Cont..Initial investigation of reported AFP cases -All reported cases should be investigated by DIO within 48 hrs after notification,in order to confirm the presence of AFP and to obtain stool specimens of cases -He should assign the EPID number and fill out the case investigation form
Cont.60 day follow up DIO must re-visit every case of AFP 60 days after the onset of paralysis to confirm the presence or absence of residual weakness -measurement of mid arm or mid thigh circumference,asymmetry in the skin folds on the medial aspect of thighs
Cont.Weekly reporting -at the end of each week, the DIO should report to the state EPI officer the line lists of all new cases reported to DIO in that week -nil reporting
ContActive surveillance -most critical unit in reporting system is hospital -case finding through the emergency department, pediatric and neurology wards as well as through out patient clinics
AFP case classificationShould be classified within 90 days as :Polio : if wild virus isolated from any stool specimenCompatible polio: stool specimens inadequate/ residual weakness present 60 days after onset of paralysis/ 60 day follow up was not done( death or absenceNon-polio AFP
VIROLOGICAL CASE CLASSIFICATIONWILD POLIOVIRUSCONFIRMCOMPATIBLEDISCARD (non-polio AFP)DISCARD(non-Polio AFP)DISCARD(non-Polio AFP)Expert reviewResidual weakness,Died or lost to fluInadequate stool specimensNo residual weakness2 adequate stool specimensNo wild PoliovirusAFP
CASE INVESTIGATIONCollect all available demographic and clinical information on the caseFill out the API case investigation form and send to the state EPI officerDetermine whether the infection is local or acquired. Ask about outside travel or visitors from outside community[ 33 days maximum ] preceding onset of paralysis
7.Onset of paralysis a)2 months earlier,additional focus given to the area during the next PPI
OUT BREAK RESPONSE IMMUNISATION - ORI should begin as one or more cases of AFP that fit the case definition is detected - ORI should cover a minimum of 500 children < 5 yrs around the reported AFP cases -vaccine trivalent OPV - stool specimen should be collected before initiating of ORI
Programme surveillance indicators Rate of non polio AFP annual rate of 1 AFP case per 100,000 children < 15 yrs of ageProportion of AFP cases with 2 adequate stools taken within 2 weeks after onset of paralysis >or = 80 %
DATA ANALYSIS AND MONITORINGMonitoring a) case reporting b) investigations c) laboratory d) control response
ReferencesSurveillance of Acute Flaccid Paralysis 3rd editionIAP textbook of PaediatricsO.P.GhaiParks Textbook of Community Health
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