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Acute Flaccid Paralysis

Queensland Health Guidelines for Public Health Units

Revision History

 Version  Date  Changes
1.0 June 2011 Full revision of guideline

To be read in conjunction with poliomyelitis and enterovirus 71 guidelines.

Infectious Agent

Acute flaccid paralysis (AFP) is a clinical syndrome which has many infectious and non-infectious causes. Causes of AFP are listed in Table 1 below.

Notification Criteria

Clinical Evidence

A person of any age with acute flaccid paralysis. [1] [2]

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[1] WHO defines AFP syndrome as “characterised by rapid onset of weakness of an individual’s extremities, often including weakness of the muscles of respiration and swallowing, progressing to maximum severity within 1-10 days. The term ‘flaccid’ indicates the absence of spasticity or other signs of disordered central nervous system (CNS) motor tracts such as hyperflexia, clonus, or extensor plantar responses” (World Health Organization 1993) WHO/MNH/EPI/93.3. Geneva)

[2] APSU defines AFP as “the acute onset of flaccid paralysis in one or more limb/s or acute onset of bulbar palsy”.

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Notification Procedure

Attending Medical Practitioners/Medical Superintendents (or delegates)

To notify on a clinical diagnosis of AFP, by telephone or facsimile.

The public health unit should immediately notify the Communicable Diseases Branch (CDB) of AFP where suspected to be due to poliomyelitis or EV71 (see relevant guidelines).

Reporting to NOCS

Report all cases meeting clinical criteria (ie. do not wait for determination of cause).

Objectives of Surveillance

  1. To identify AFP cases due to poliomyelitis and EV71, so that appropriate public health measures can be taken.
  2. To meet the WHO AFP surveillance performance indicator for polio-free countries.

Public Health Significance and Occurence

In the past, the most common cause of AFP in Australia was poliomyelitis. Now that polio has been eliminated, the two leading causes of AFP are Guillain-Barré syndrome and transverse myelitis. AFP surveillance is important to document maintenance of Australia's polio-free status and to detect imported cases.

The Australian National Poliovirus Reference Laboratory (NPRL), in collaboration with the Australian Paediatric Surveillance Unit (APSU), co-ordinates surveillance for cases of AFP in children in Australia. Specimens are referred from AFP cases in children and suspected cases of poliomyelitis in people of any age, and are classified by the Polio Expert Committee, a subcommittee of the Communicable Diseases Network Australia (CDNA). The WHO AFP surveillance performance target is one non-polio AFP case per 100,000 children less than 15 years of age. From 2000 to 2009, Australia met this target in 6 of 10 years. The majority of cases reported to APSU are not notified separately to Queensland Health and therefore are not captured in NOCS data.

Clinical Features

Table 1. Causes of AFP

Peripheral neuropathy

  • Guillain-Barré syndrome
  • Acute axonal neuropathy
  • Neuropathies of infectious diseases (diphtheria, Lyme disease)
  • Acute toxic neuropathies (heavy metals, snake toxin)
  • Arthropod bites
  • Focal mononeuropathy

Anterior horn cell disease

  • Acute anterior poliomyelitis
  • Vaccine-associated paralytic polio
  • Other neurotropic viruses (eg. enteroviruses and herpesviruses)

Muscle disorders

  • Polymyositis, dermatomyositis
  • Trichinosis
  • Periodic paralyses
  • Corticosteriods and blocking agents
  • Mitochondrial diseases (infantile type)
  • Post viral myositis

Systemic disease

  • Acute porphyrias
  • Critical illness neuropathy
  • Acute myopathy in ICU patients

Acute Myelopathy

Cord compression

  • tumour
  • trauma
  • paraspinal abscess
  • haematoma
  • vascular malformation with thrombosis/bleeding

Demyelinating diseases

  • multiple sclerosis
  • transverse myelitis
  • acute disseminated encephalomyelitis (ADEM)

Ischaemic cord damage

  • anterior spinal artery syndrome
  • peri-operative complication

Disorders of neuromuscular transmission

  • Myasthenia gravis
  • Botulism
  • Insecticide (organophosphate poisoning)
  • Tick bite paralysis
  • Snake bite

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Management

Cases

Investigation
Ask about the patient’s travel history and attendance at school, childcare or other institution.

In all cases of AFP in children less than 15 years of age, the Australian Paediatric Surveillance Unit (APSU) questionnaire should be completed in consultation with the medical practitioner and sent to the National Polio Reference Laboratory at VIDRL with a copy to APSU as listed on the form and a copy to CDB.  The APSU questionnaire attempts to ascertain poliomyelitis vaccination status, clinical details, investigations performed and the provisional diagnosis. A follow up questionnaire is sent by APSU to the treating clinician to complete at 60 days after the onset of illness.

It is important that faecal specimens for viral culture be collected from all children less than 15 years of age, even when an alternative diagnosis to poliomyelitis has been confirmed. Two faecal samples should be collected as soon as possible after the onset of illness, 24 hours apart and within two weeks of onset of paralysis.

The patient should be identified as having AFP on the request form and the collecting laboratory should be advised that the specimens must be sent to the National Polio Reference Laboratory at the Victorian Infectious Diseases Reference Laboratory (VIDRL) Melbourne.  Specimens must reach VIDRL within 72 hours of collection.

If poliomyelitis is suspected, other appropriate specimens should be collected (see poliomyelitis guideline). If there is an epidemiological link to a confirmed EV71 case, or a high index of clinical suspicion that the case could be EV71 neurological disease, appropriate specimens for EV71 isolation (refer to EV71 guideline) should be collected as soon as possible after the onset of illness.

Restriction
If the patient is hospitalised, isolate with contact precautions until a communicable cause has been excluded. If polio is suspected, polio non-immune health care workers should not care for the patient.

Further management according to guideline for the relevant suspected or confirmed causative agent.

Contacts
Manage according to guideline for the relevant suspected or confirmed causative agent.

References

Annual report of the Australian National Poliovirus Reference Laboratory, 2009. Communicable Diseases Intelligence, 2009;34(3).

Australian Department of Health and Ageing, 2008. An Acute Flaccid Paralysis and Poliomyelitis Response Plan for Australia. Accessed 6/12/10.

Australian Paediatric Surveillance Unit, 2008. Acute flaccid paralysis study protocol. Accessed 23/05/11.

Heymann D (Ed) 2008. Control of Communicable Diseases Manual, 19th edition. American Public Health Association: Washington.

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Last Updated: 25 September 2012
Last Reviewed: 21 June 2011