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Acute Flaccid Paralysis

Queensland Health Guidelines for Public Health Units

Revision History

 Date  Changes
June 2011 Full revision of guideline
July 2014 Full revision of guideline

To be read in conjunction with poliomyelitis, enterovirus 71 and botulism 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).

Requires immediate notification on clinical diagnosis by telephone or fax to the local public health unit

The public health unit should immediately notify the Communicable Diseases Unit (CDU) of a clinical diagnosis of AFP by telephone with follow-up email to Senior Director CDU.  If telephone contact is not possible, notify Senior Director CDU by email with the subject line clearly noting that the email is for urgent attention.  For suspected poliomyelitis or EV71 see the relevant guidelines.

Reporting to NOCS

Report all cases meeting clinical criteria without delay. Do not wait for determination of cause.

Objectives of Surveillance

  1. To identify and monitor AFP cases due to poliomyelitis, EV71 and botulism, so that appropriate and timely public health measures can be taken to meet the WHO AFP surveillance performance indicator target 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 in Australia, 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. Notification and public health response of AFP in all ages is required.

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 all AFP cases, both adults and children regardless of age.    All cases are reviewed by the National Polio Expert Committee a subcommittee of the Communicable Diseases Network Australia (CDNA). Cases are classified as confirmed poliomyelitis, polio-compatible, non-polio AFP, or non-AFP.

WHO indicators of surveillance performance include a target annualised non-polio AFP rate of ≥1/100 000 children under 15 years of age.

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 borne viruses
  • 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
  • Corticosteroids 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

Dmeyelinating 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

1)    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) initial questionnaire (available at http://www.vidrl.org.au/surveillance/afp-surveillance/ ) should be completed in consultation with the medical practitioner and sent to the National Polio Reference Laboratory at Victorian Infectious Diseases Reference Laboratory (VIDRL) with a copy to APSU as listed on the form and a copy to Communicable Diseases Unit.  The APSU questionnaire attempts to ascertain poliomyelitis vaccination status, clinical details, investigations performed and the provisional diagnosis. A follow up questionnaire (available at http://www.vidrl.org.au/surveillance/afp-surveillance/ ) 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 VIDRL Melbourne. Specimens must reach VIDRL within 72 hours of collection. 

Detailed instructions for referral, labelling and shipment of stool specimens as well as contract details can be found here[3].

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. For suspected cases of botulism appropriate specimens should be collected. For suspected and confirmed cases try to identify the source of toxin/exposure and identify others who may have been exposed to it (refer to botulism guideline)

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 to be undertaken according to relevant guideline for the suspected or confirmed causative agent. Please refer to Poliomyelitis, EV71or botulism.

2)    Contacts

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


 [3] http://www.vidrl.org.au/laboratories/poliovirus-reference/specimen-referral/

References

Australian Department of Health and Ageing, 2013. ,Annual report of the Australian National Poliovirus Reference Laboratory, 2012. Communicable Diseases Intelligence 2013;37(2). http://www.health.gov.au/internet/main/publishing.nsf/Content/cdi3702-pdf-cnt.htm/$FILE/cdi3702a.pdf   Accessed 14/03/2014

Australian Department of Health and Ageing, 2013. Australia’s notifiable disease status, 2011: Annual report of the National Notifiable Diseases Surveillance System. https://www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-2011-annual-report.htm Accessed 14/03/2014

Australian Department of Health and Ageing, 2008. An Acute Flaccid Paralysis and Poliomyelitis Response Plan for Australia. http://www.health.gov.au/internet/publications/publishing.nsf/Content/polio-plan-lAccessed 14/03/2014.

Australian Paediatric Surveillance Unit, 2008.  Acute flaccid paralysis study protocol. http://www.apsu.org.au/assets/current-studies/AFP-Study-Protocol-APSU-Final-110810.pdf    Accessed 14/03/2014

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

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Last Updated: 03 September 2014
Last Reviewed: 03 September 2014