Philippine Integrated Disease Case Investigation Form

Surveillance and Response

Acute Flaccid Paralysis

Name of DRU:
Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Gov’t Laboratory Private Laboratory Airport/Seaport

I. PATIENT Patient Number Patient’s First Name Middle Name Last Nam
INFORMATION:
Complete Address: MM DD YY Age: Days
Male Date of
Sex:
Birth: Months
Female
Years
Patient Admitted? Yes  No Unknown MM DD YY
Date Admitted/ Seen/Consult
MM DD YY MM DD YY
Date of Report: Date of Investigation:

II. CLINICAL DATA (Put a check [ √ ] in the appropriate box)

Deep
Sensory Motor
PRODROME PARALYSIS SITE OF FLACCID PARALYSIS Tendon
Status Status
Reflexes
Fever:  Y  N  U Date onset: ________________ Right arm:  Y  N  U ______ __________ ________
Cough:  Y  N  U Present at birth?:  Y  N  U Left arm: Y N U ______ __________ ________
Diarrhea/Vomiting: Asymmetric?: Y N U
Right leg: Y N U ______ _________ ________
Y N U
PROGRESSION Left leg: Y N U ______ _________ ________
Muscle pain: (pain on hip)
Paralysis fully developed within 3 Breathing muscles:  Y  N  U
Y N U
to 14 days from onset of illness?
Meningeal signs: Neck muscles: Y  U
Y N U NOTE: Instructions on the grading/
Y N U Facial muscles: Y N U scoring of the sensory status, deep
Direction of paralysis: tendon reflexes and motor status are
Working Diagnosis:___________________
 Ascending  Descending presented at the back of this page.
_____________________________
 Unknown

III. EPIDEMIOLOGIC DATA

History of neurologic disorder?:  Y  N  U If YES, specify disorder:_________________________________
Did the patient travel (>10 km from house) one month prior to illness?  Y  N  U
If YES, specify place:____________________________________ Date traveled: From_____/_____/_____ To _____/_____/_____
Other AFP cases in patient’s community within 60 days of patient’s paralysis?  Y  N  U
Does the patient had any history of injection, trauma and/ or animal bite ?  Y  N  U
If YES, specify type _______________

IV. IMMUNIZATION HISTORY

Total OPV doses received: ______ Date last dose of OPV : _____/_____/_____ Is this a “Hot case”?  Y  N

V. LABORATORY DATA
Date
Stool If YES, date Date sent to
Collected? received Result Date result
sample # taken RITM
RITM
1 Y N __________ _______ ___/___/___  0  1  2  3  NPEV  Inadeq  Other ___/___/___

2 Y N ___/___/___ ___/___/___ ___/___/___  0  1  2  3  NPEV  Inadeq  Other ___/___/___

VI. 60-DAY FOLLOW-UP
Expected date of follow-up_______________ Actual date of follow-up conducted:_____/_____/_____
P.E. done?  Y  N If NO, reason for no examination:  Patient died  Lost to follow-up  Other, specify____________________
Residual paralysis at 60 days?:  Y  N  U Atrophy?:  Y  N  U
Other observations:_____________________________________________

VII. CLASSIFICATION (TO BE FILLED UP BY THE EXPERT PANEL ONLY)

FINAL CLASSIFICATION IF VAPP CLASSIFICATION CRITERIA FINAL DIAGNOSIS
 Confirmed wild polio  Recipient VAPP  Laboratory
 Vaccine-derived paralytic polio (VDPV)  Contact VAPP  EPI linked
 Vaccine-associated paralytic polio (VAPP)  Unknown  Lost to follow-up
 Polio compatible  Death
 Discarded  With residual paralysis
Date classified: _____/_____/_____  Without residual paralysis
 Philippine Integrated Disease Case Investigation Form
Surveillance and Response

Acute Flaccid Paralysis

AFP Case definition:

 Any child less than 15 years of age with acute flaccid paralysis, OR
 A person of any age in whom poliomyelitis is suspected by a physician.

Hot Case Description:

 An AFP case that is <5 years old with < 3 doses of OPV and has fever at the onset of asymmetrical paralysis,
OR
 An AFP case or a person of any age whose stool specimen(s) has poliovirus isolate.

Grading/Scoring of Sensory Status, Deep Tendon Reflexes and Motor Status:

A. Sensory status is presented in percentage and categorized as follows:

 ≤ 25% = Absent
 ≥ 25% but <100% = Reduced
 100% = Normal

B. Deep tendon reflexes (DTRs) are presented in (+) symbol and categorized as follows:

 none or 0 = absent
 + = reduced
 ++ = normal
 +++ with/without clonus = increased or exaggerated

C. Motor status is presented in fraction and categorized as follows:

 0/5 = absent or no movement

 1/5 to 3/5 = reduced movement (with movement but not against resistance or gravity)
 4/5 to 5/5 = normal (movement with full resistance and against gravity)