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Acute flaccid paralysis, a common paediatric disorder, is fundamentally caused by disorders involving neuromuscular diseases of acute onset. It generally presents as an acute or extremely acute motor disorder which is progressive or extremely progressive. Successful management depends on a rapid, accurate differential diagnosis, based on the patient s history of muscular weakness.
The last case of poliomyelitis due to transmission of indigenous wild poliovirus occurred in Italy in 1982. To achieve the certification of the eradication of poliomyelitis in Italy, an active surveillance of acute flaccid paralysis (AFP) in the population aged less than 15 years was set up following the World Health Organization (WHO) guidelines. The survey started in 1996 with a pilot study involving 4 out of 21 regions, and was gradually extended to a national level in 1997. The two-year survey identified five patients with diagnosis of vaccine associated paralytic poliomyelitis (VAPP). Polioviruses type 2 and 3 Sabin-like were isolated and characterized in three of them. In the remaining two cases, samples were collected late after the onset of symptoms, and poliovirus could not be isolated. No wild polioviruses were detected during the survey. The rate of non-polio AFP found in Italy in 1997 was 0.61 cases per 100,000, which is lower than the level of 1.0 case per 100,000 considered as acceptable by the WHO. This was mainly due to the delay in organizing the hospital network and starting the active search of AFP cases in the largest and most densely populated regions. Therefore, the overall rate of AFP found in Italy underestimates the global effectiveness of the program, which however will be better evaluated in the next few years. This study is the first systematic attempt to determine the rate of AFP in Italy.
Acute weakness associated with West Nile virus (WNV) infection has previously been attributed to a peripheral demyelinating process (Guillain-Barré syndrome); however, the exact etiology of this acute flaccid paralysis has not been systematically assessed. To thoroughly describe the clinical, laboratory, and electrodiagnostic features of this paralysis syndrome, we evaluated acute flaccid paralysis that developed in seven patients in the setting of acute WNV infection, consecutively identified in four hospitals in St. Tammany Parish and New Orleans, Louisiana, and Jackson, Mississippi. All patients had acute onset of asymmetric weakness and areflexia but no sensory abnormalities. Clinical and electrodiagnostic data suggested the involvement of spinal anterior horn cells, resulting in a poliomyelitis-like syndrome. In areas in which transmission is occurring, WNV infection should be considered in patients with acute flaccid paralysis. Recognition that such weakness may be of spinal origin may prevent inappropriate treatment and diagnostic testing.
Surveillance for cases of acute flaccid paralysis provides a means for detecting circulating wild poliovirus in a population and therefore is crucial to the global polio eradication effort. An initial step toward developing a more general framework for understanding the sensitivity of the acute flaccid paralysis surveillance system is presented by first specifying four categories of sensitivity involved: laboratory sensitivity, specimen sensitivity, person sensitivity, and population sensitivity. Using this framework, estimates for specimen sensitivity (the probability that virus will be detected in a specimen collected from an infected person) and the prevalence of infection are derived and applied to surveillance data from three regions. On the basis of the framework, our analysis indicates that a second specimen may significantly increase person sensitivity under some circumstances but provides little improvement under others.
PURPOSE OF REVIEW: Although acute flaccid paralysis (AFP) is more frequently seen in the tropics than in temperate regions, recent outbreaks of West Nile virus (WNV) in North America have drawn attention to this important presentation. Starting with anatomical and neurophysiological considerations, this article examines data on AFP caused by WNV, and considers recent data on paralysis caused by enteroviruses, and Guillain-Barré syndrome (GBS). RECENT FINDINGS: Neurophysiological, radiological and pathological studies suggest WNV causes AFP by damaging anterior horn cells in the spinal cord. The clinical presentation is probably best described as a 'poliomyelitis-like illness', and the disease as 'WNV myelitis'. Other findings during the recent outbreaks include increasing recognition of a Parkinson's-disease like presentation, and descriptions of virus transmission in blood transfusions and transplanted organs. GBS is now recognized as several disorders characterized by immune-mediated attack on peripheral nerves: in acute inflammatory demyelinating polyneuropathy the myelin sheath and Schwann cell of sensory and motor nerves are targeted; acute motor axonal and acute motor and sensory axonal neuropathy often follow Campylobacter jejuni enteritis and are associated with antibodies against the ganglioside component of the nerve axolemmal membrane. In Asia-Pacific, enterovirus 71 has caused outbreaks of neurological diseases with AFP and encephalitis, but no single genogroup of virus appears responsible for severe disease. SUMMARY: Despite the near eradication of poliomyelitis, AFP caused by viruses remains an important clinical presentation. Distinguishing direct viral causes from GBS is important for public health reasons, and to avoid inappropriate therapies.
OBJECTIVES: To describe the characteristics of patients reported with acute flaccid paralysis between 1997 and 2002, and to evaluate the performance of the acute flaccid paralysis surveillance system using indicators recommended by the World Health Organization. DESIGN: Retrospective study. SETTING: Department of Health, Hong Kong. PARTICIPANTS: Children aged younger than 15 years who were reported to the Department of Health between 1997 and 2002 with acute flaccid paralysis. RESULTS: Of 120 children with acute flaccid paralysis reported between 1997 and 2002, 42% were younger than 5 years of age. None of the cases were acute poliomyelitis or polio-compatible. A neurological cause was identified in 67.5% of cases, of which the most common was Guillain-Barre syndrome (42%), followed by transverse myelitis (15%). All except one of the performance indicators consistently met World Health Organization requirements and thus demonstrated the effectiveness of the acute flaccid paralysis surveillance programme. The acute flaccid paralysis notification rate consistently exceeded 1.0 per 100 000 population below 15 years of age. The requirement for adequate stool investigation was the single indicator that did not satisfy World Health Organization requirements. This highlighted the importance of maintaining physicians' awareness of acute flaccid paralysis surveillance. CONCLUSION: Hong Kong should remain vigilant for acute flaccid paralysis. The effective surveillance system and its evaluation may serve as a model for surveillance of other infectious diseases.
BACKGROUND: Acute flaccid paralysis (AFP) is the most common clinical presentation of acute poliovirus infection, occurring in 0.1-1% of infected cases. AFP surveillance has been used world-wide to monitor the control and eradication of circulating wild poliovirus. This study aims to review the significance of all enteroviruses, including polioviruses, isolated from patients with AFP in Australia between 1996 and 2004. METHODS: We undertook a retrospective review of all notified cases of AFP, aged 0-15 years and resident in Australia at the time of notification. We reviewed all available clinical and virological data for these cases and all records of the Polio Expert Committee, which determined the final classification for all cases. RESULTS: There were 335 notified cases that satisfied the case definition for AFP, 162 (48%) of whom had at least one faecal sample tested. Enteroviruses isolated from the faeces of 26 (16%) of the 162 cases were Coxsackie A24, Coxsackie B5, enterovirus 71, enterovirus 75, echovirus 9, echovirus 11 and echovirus 18. In addition, one or more polioviruses were isolated from the faeces of seven patients. Six of seven polioviruses were characterised as Sabin-like, one was not characterised, but all were considered to be incidental isolates. Five of these cases were classified as infant botulism, one case as transverse myelitis and one as a focal mononeuropathy. CONCLUSION: With the eradication of circulating wild polioviruses, other enteroviruses are being more commonly identified as the cause of polio-like illnesses. In the polio end game, when there is increased testing for polioviruses, it is important to consider infant botulism as a differential diagnosis in cases presenting with AFP.
Enteroviruses can cause outbreaks of acute flaccid paralysis (AFP), mimicking wild poliovirus infections. Coxsackie virus A24 has never been implicated and yet it is a virus with high outbreak potential. We describe the association of coxsackie virus A24 with AFP in East Timor.
The objective of this study was to investigate the incidence of acute flaccid paralysis in the pediatric population of Honduras over an 11-year period, determine what percentage of acute flaccid paralysis was Guillain-Barré syndrome, and identify the epidemiologic features of Guillain-Barré syndrome. There were 546 childhood cases of acute flaccid paralysis seen between January 1989 and December 1999 at the Hospital Escuela Materno-Infantil in Tegucigalpa, Honduras. Of these cases with acute flaccid paralysis, 394 (72.2%) were diagnosed with Guillain-Barré syndrome. Our incidence of Guillain-Barré syndrome in the Honduran pediatric population (1.37/100,000 per year) is higher than that shown in other studies. There was a significantly higher incidence of Guillain-Barré syndrome in younger children (ages 1-4 years), a significant preponderance of cases from rural areas, and a mild predominance in boys but a typical clinical presentation. The Honduran pediatric Guillain-Barré syndrome population had an increased mortality rate. Guillain-Barré syndrome has become the leading cause of childhood paralysis in Honduras. A better understanding of the population at highest risk and opportunities for earlier intervention with more effective therapeutic modalities may permit reducing the mortality among Honduran children who develop Guillain-Barré syndrome.
An outbreak of acute flaccid paralysis in Jamaica in 1986 associated with echovirus type 22 is described. Six patients aged 1 to 27 years developed acute onset of severe flaccid paralysis, with inability to walk. Three cases had facial weakness, four required intensive care with assisted ventilation, and two died. Echovirus type 22 was isolated from the stool of two patients who showed a significant increase in antibody titre. Echovirus type 22 was also isolated from the stool of another patient who had aseptic meningitis without any neurological deficit. There was no evidence of poliovirus infection in any of these patients, most of whom were fully immunized. Of the four surviving cases with flaccid paralysis, three had residual weakness in their lower limbs and walked with an abnormal gait 3 years after the acute paralytic attack. This is the first report in the literature of acute flaccid paralysis associated with type 22 echovirus.
OBJECTIVE: Australia had to demonstrate adequate acute flaccid paralysis (AFP) surveillance by achieving a rate of one per 100,000 in children under the age of 15 to fulfil one of the requirements of the Regional Commission for the Certification of Poliomyelitis Eradication to be declared polio free. To increase the ascertainment rate of AFP cases, a hospital search was conducted to identify cases not reported to the active AFP surveillance. METHODS: A computerised search of hospital admissions in New South Wales (NSW) and Western Australia (WA) on ICD-9 codes of Guillain Barré Syndrome (GBS), unspecified encephalitis, poliomyelitis, vaccine-associated paralytic polio (VAPP) and flaccid paralysis was conducted for the period 1995-98. Medical records of cases that were not reported to the active surveillance were reviewed in three hospitals of NSW and two hospitals in WA. RESULTS: Twenty additional cases recorded as GBS and five as transverse myelitis (TM) were identified through the searches, which increased the average four-year AFP rate from 1.0 to 1.4 per 100,000 in children under the age of 15 years in these two states and the overall AFP rate in Australia increased from 0.78 to 1.14. There were no cases of polio or VAPP found. Nine cases of GBS and five of TM reported to the active AFP surveillance were not found in the hospital searches. CONCLUSION: A combination of active surveillance and hospital-based searches increased the investigated AFP rate, which fulfilled one of the certification requirements for Australia to be certified polio free. IMPLICATIONS: Until global certification is achieved, AFP surveillance needs to be improved to identify cases of importation of wild poliovirus.
Accurate surveillance for polio is essential for eradication. Surveillance systems for polio has been developed under the guidance of the global polio eradication initiative. Surveillance of cases of acute flaccid paralysis among children less than 15 years of age is a key component for a well functioning polio surveillance system. The surveillance system works through a network of surveillance medical officers, the responsibility of them lies in assisting the health services departments of all states and maintaining a network of acute flaccid paralysis reporting sites and rapidly investigating the cases. Surveillance activities begin when a child comes in contact with a healthcare provider who in turn informs the officer in charge of acute flaccid paralysis surveillance. The goal of the polio network laboratories is to provide accurate and timely results of wild poliovirus detection in stool samples of cases of acute flaccid paralysis. Strong linkages have been established between the acute flaccid paralysis surveillance system and the laboratory network. Laboratories complete poliovirus isolation and if poliovirus is isolated, these are submitted for intratypic differentiations. Acute flaccid paralysis surveillance in India has demonstrated that the eradication activities implemented in India led to dramatic reduction and restriction in the number of cases and geographic spread of poliovirus transmission.
OBJECTIVE: Human enteroviruses are the major cause of aseptic meningitis and also cause a wide range of other acute illnesses, including neonatal sepsis like disease, meningitis, acute flaccid paralysis and acute hemorrhagic conjunctivitis. Infection in neonates is particularly life threatening. METHODS: Stool samples of 523 children (age < 4 years) showing symptoms of acute flaccid paralysis (AFP) were studied. National Polio Surveillance Project workers from different parts of Uttar Pradesh and Bihar collected the samples during June to October 1998. Non-polio enteroviruses (NPEV) were isolated in 191 cases only, by cell culture based neutralization assay. These NPEV isolates were further studied to find the frequent enterovirus serotype detected in stool of children having AFP. RESULTS: Data generated will help future studies on NPEV serotypes circulating in this area. CONCLUSION: In addition it may reduce unnecessary hospitalization, allow immune globulin batches of high titres to frequently circulating serotypes, to be reserved for intravenous therapy of neonates and guide the formulation of antigens for rapid and less expensive diagnosis.
WNV infection can cause meningoencephalitis (MNE) and acute flaccid paralysis (AFP). Both syndromes are associated with high morbidity and mortality. Interferon alpha-2b (IFN-alpha-2b) inhibits WNV replication in vitro. To date, 5 patients with WNV-CNS disease have recovered neurologic function with IFN-alpha-2b. We report the first failure of IFN-alpha-2b in the treatment of WNV-MNE-AFP.
We studied 29 children admitted to Beijing Children's Hospital (BCH) with acute flaccid paralysis between June 1991 and June 1993. Twenty-seven patients had Guillain-Barré syndrome--7 with acute inflammatory demyelinating polyneuropathy and 20 with acute motor axonal neuropathy (AMAN). Two had poliomyelitis. The most common cause of acute flaccid paralysis at BCH is the AMAN pattern of GBS.
Surveillance of acute flaccid paralysis (AFP) is the milestone to monitor the progress toward poliomyelitis eradication aim, fixed by WHA in 1988. Active AFP surveillance started in Apulia in 1997; this work evaluates five-year period activities. In this period, the total number of cases notified was 48, 7 of which were resident out of Apulia. Twenty-five were males and 23 females; the age ranged between 1 month and 15 years. Any collected serum specimens showed protective antibody levels against polioviruses. Polioviruses type 1 and type 2 Sabin-like were isolated from stool samples collected from two AFP patients. AFP surveillance targets improved in the years, with only exception, in 2001, of second serum specimen collected within 14 days because of children were discharged earlier form the hospitals. Apulia experience demonstrates the achievement of good levels of AFP surveillance targets. System sensitivity has been optimal in 2001 with a number of notified cases threefold the expected value and adequate specimen sampling (80%). Additional involved hospitals and availability of increased and dedicated human resources contributed to this outcome. The effort to achieve WHO targets for AFP surveillance needs to be maintained in next years until global certification of eradication will be declared.
A study on the incidence of Acute Flaccid Paralysis (AFP) among 0-14 year-old children in 1990-1992 was carried out in all over 12 prefectures and cities level hospitals in Hebei. The county level hospitals were investigated in 3 of 12 prefectures and cities. A total of 214 hospitals were investigated. The result showed that the annual average incidence of AFP and non-polio AFP among 0-14 year-old children in 1990-1992 were 1.498/100000 and 0.988/100000, respectively. The annual average incidence of them among < 5 year-old children were 2.917/100000, 1.591/100000, respectively. The incidence of AFP and non-polio AFP were different in each prefecture and city. GBS accounts for 54.06% of all AFP cases.
OBJECTIVES: To describe the epidemiology and causes of acute flaccid paralysis (AFP) in Australian children, and the clinical features of the two most common causes of AFP, Guillain-Barré syndrome and transverse myelitis. METHODS: Monthly active surveillance for AFP was carried out through the Australian Paediatric Surveillance Unit, with AFP defined as 'acute onset of flaccid paralysis in one or more limbs or of bulbar paralysis in any child less than 15 years of age'. RESULTS: Between March 1995 and December 1999, 143 cases of AFP were reported (approximately 0.8 per 100000 children < 15 years of age per annum). The age range was 2 months-14 years and 59% were boys. Out of these children, 137 (96%) were hospitalized and 47 required intensive care. No case of wild or vaccine-associated poliomyelitis was identified. The most common causes of AFP were Guillain-Barré syndrome in 67 (47%) and transverse myelitis in 27 (19%). Other diagnoses included acute disseminated encephalomyelitis, trauma, tick-bite paralysis and infantile botulism. CONCLUSION: The participation of paediatricians in AFP surveillance contributed to the accreditation of Australia (along with the other 36 countries of the western Pacific region) as 'polio free' by the World Health Organization in October 2000. The surveillance also provided data on the frequency of AFP and identified Guillain-Barré syndrome and transverse myelitis as the most common diagnoses. In this large national series, many other conditions that may present as non-polio AFP were identified.