This case investigation form is used to collect information about cases of acute flaccid paralysis (AFP) in Ethiopia. AFP is characterized by rapid onset of weakness in one or more limbs that progresses to maximum severity within less than 3 days. Information collected includes the patient's identification details, clinical history including symptoms and vaccination history, stool specimen collection and results, follow up examination findings, and the final classification of the case. Contact information is provided for the Ministry of Health Surveillance team, WHO EPI and Polio units, and the National Health Research Institute polio laboratory. The size of adequate stool specimens for analysis is noted.
This case investigation form is used to collect information about cases of acute flaccid paralysis (AFP) in Ethiopia. AFP is characterized by rapid onset of weakness in one or more limbs that progresses to maximum severity within less than 3 days. Information collected includes the patient's identification details, clinical history including symptoms and vaccination history, stool specimen collection and results, follow up examination findings, and the final classification of the case. Contact information is provided for the Ministry of Health Surveillance team, WHO EPI and Polio units, and the National Health Research Institute polio laboratory. The size of adequate stool specimens for analysis is noted.
This case investigation form is used to collect information about cases of acute flaccid paralysis (AFP) in Ethiopia. AFP is characterized by rapid onset of weakness in one or more limbs that progresses to maximum severity within less than 3 days. Information collected includes the patient's identification details, clinical history including symptoms and vaccination history, stool specimen collection and results, follow up examination findings, and the final classification of the case. Contact information is provided for the Ministry of Health Surveillance team, WHO EPI and Polio units, and the National Health Research Institute polio laboratory. The size of adequate stool specimens for analysis is noted.
This case investigation form is used to collect information about cases of acute flaccid paralysis (AFP) in Ethiopia. AFP is characterized by rapid onset of weakness in one or more limbs that progresses to maximum severity within less than 3 days. Information collected includes the patient's identification details, clinical history including symptoms and vaccination history, stool specimen collection and results, follow up examination findings, and the final classification of the case. Contact information is provided for the Ministry of Health Surveillance team, WHO EPI and Polio units, and the National Health Research Institute polio laboratory. The size of adequate stool specimens for analysis is noted.
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CASE INVESTIGATION FORM - ACUTE FLACCID PARALYSIS (AFP)
Ministry of Health, Federal Democratic Republic of Ethiopia
COMPULSORY NOTIFICATION (PLEASE COMPLETE ALL INFORMATION IN FULL) Official Use Only: Epid Number: _______ ________ _______ _______ ________ Received: ____/____/____ Ctry Region Zone Year onset case number IDENTIFICATION: Address _______________________________________________________________________________________________________________________________ _______________________________________________________________________ _______________Health Facility __________________________________ Province/Region: _____________________________________ Kebele:_____________________ Woreda: __________________________
Zone: _____________________________ Name(s) of patient __________________________ Father/Mother:______________________________________
Date of birth ___/___/___ Age years: ___________ Months: _________ Sex:
(if DOB Unknown) M=Male F=Female
NOTIFICATION/ INVESTIGATION: Notified by___________________________________________ Date District Notified ____/_____/_____ Date Case Investigated: ____/____/______ HOSPITALIZATION: Admitted to hospital: 1= Yes 2= No Date of Admission ____/____/____
Medical Record Number ________________________ Name/address of Facility: __________________________________
CLINICAL HISTORY: Fever at onset Paralysis Site of paralysis of paralysis 1= Yes 2=No Progressed 1= Yes 2=NO
Date Onset of Paralysis: ____/___/_____ <=3 days L.Arm R.Arm
AFTER INVESTIGATION, WAS THIS TRUE AFP? 1 = Yes 2= No if "no", then the rest of the from does not need to be completed. Mark "6" for final classification
VACCINATION HISTORY: Total Polio doses Received 99=unknown
Date of OPV doses
Date of OPV Zero: ____/____/_____ 1st ____/____/____ 2nd _____/____/_____ 3rrd_____/____/_____ 4th ____/____/____
if>4 doses, date of last OPV dose: ____/____/_____
STOOL SPECIMEN COLLECTION:
Date 1st stool collected ____/_____/_____ Date 2nd stool collected ____/_____/______ Date stool sent from field to national level ____/____/____ STOOL SPECIMEN RESULTS: Primary isolation result Date stool specimen Condition of stool Date result sent by Date result received by national P1 P2 P3 NP- Ent received by national 1=Adequate 2=Not adequate National Lab to National level Level:_____/_____/____ Lab: ____/____/_____ ____/____/_____
1= Yes 2= No 1=Yes 2=No
W1 W2 W3 V1 V2 V3 NP-Ent Date isolate sent from Date differentiation result Date differentiation result National Lab to Regional sent by Regional Lab: received by National Level Lab. ___/___/___ ____/____/____ ____/____/___ 1= Yes 2= No 1= Yes 2=No 1=Yes 2=No
FOLLOW-UP EXAMINATION: Residual Paralysis?
L.Ar R.Arm 1=Residual paralysis Date follow-up m Findings at 2=No residual paralysis Examination: ____/____/_____ R.Leg Follow-up 3=Lost to follow-up L.Leg 4=Death before follow-up Y.N Y.N
FINAL CLASSIFICATION OF THE CASE:
1= Confirmed 2= Compatible 3= Discarded 4= Not an AFP
INVESTIGATOR: Name _______________________________________________________ Title: _________________________________________________
PLEASE SEND A COPY OF THIS COMPLETED FORM IMMEDIATELY TO: Disease Prevention And Control Department, Ministry of Health, Addis Ababa IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT: Phone: 01-516889 or (09) 219555 Fax: 01-519366 Acute Flaccid Paralysis (AFP) is characterized by rapid onset of weakness of one or more limbs, progressing to maximum severity within less than 3 days. The term “flaccid” indicates the absence of rigidity in the group of muscles/limb affected.
Asymmetrical paralysis is defined as the presence of a notable difference in the extent of
involvement between the left and right limbs (arms or legs).
Residual paralysis is defined as the presence of some (minimal or major) motor weakness during repeat examination (60 days after the onset of paralysis) in the limb(s) initially involved.
No residual paralysis is defined as complete improvement in muscle power during repeat
examination (60 days after the onset of paralysis) in the limb(s) initially involved.
