Non-polio Acute Flaccid Paralysis Rate Research Articles

Evaluation of the Acute flaccid paralysis surveillance indicators in Zambia from 2015–2021: a retrospective analysis

BackgroundThe resurgence of poliovirus infection in previously polio free regions and countries calls for renewed commitment to the global polio eradication efforts including strengthening of Acute Flaccid Paralysis (AFP) surveillance systems. Zambia is one of the countries substantially at risk for the importation of poliovirus infection from neighbouring countries including Malawi, Mozambique, and Democratic Republic of the Congo (DRC). This study describes a seven-year AFP surveillance, assesses the surveillance indicators, and highlights areas for improvement.MethodsWe conducted retrospective analysis of the routinely collected AFP surveillance data from January 2015 to December 2022. The AFP surveillance indicators performance was assessed using the World Health Organisation’s recommended minimum AFP surveillance indicators performance.ResultsCumulatively, a total of 1715 AFP cases were reported over the study period. More than half, 891 (52%) of reported cases were aged < 5 years with 917 (53.5%) of males. More than half, 1186 (69.2%) had fever at onset, 718 (41.9%) had asymmetric paralysis and 1164 (67.9%) had their paralysis progressed within 3 days of onset. The non-polio AFP rate ranges from 3.4 to 6.4 per 100,000 children < 15 years old and stool adequacy ranging from 70.9% to 90.2% indicating sensitive surveillance with late detection of cases. The percentage of cases with early stool collection, timely transportation was above the World Health Organisation (WHO) minimum of 80% but with declining proportion of stools arriving in the laboratory in optimal condition. Completeness of 60-days follow-up evaluation was suboptimal ranging from 0.9% to 28.2%.ConclusionThe AFP surveillance system in Zambia is doing well. However, additional efforts are needed to improve early detection of cases; stool sample collection, transportation and monitoring to ensure arrival in good condition in the laboratory; and improve 60-days follow-up evaluation for evidenced-based classification of inadequate AFP cases and proper care.

Trends of key surveillance performance indicators of acute flaccid paralysis: a descriptive analysis, Uganda, 2015–2020

BackgroundPolio is disease caused by poliovirus which can in turn cause irreversible paralytic disease, presenting as Acute Flaccid Paralysis (AFP). A sensitive AFP surveillance system, in which all reported AFP cases are evaluated, first to determine if they are true AFP cases or not, is key for tracking polio eradication. True AFP cases are then later categorized as polio AFP or non-polio AFP (NPAFP) cases. Sensitivity is defined by meeting an annual NPAFP rate/100,000 population < 15 years of ≥ 4/100,000, and an annual stool adequacy (SA) rate of ≥ 80%. We describe Uganda’s AFP surveillance performance between 2015–2020, based on the WHO-recommended indicators, including; NPAFP and stool adequacy rate.MethodsWe performed a descriptive analysis of national AFP surveillance data, 2015–2020 obtained from ministry of health. We evaluated proportion of reported AFP cases that were true AFP, and changes in NPAFP and stool adequacy (SA) rate over the study period. We evaluated the trends in achieving the targeted NPAFP and SA rates from 2015–2020. We used QGIS to illustrate patterns in NPAFP and SA rates across districts and subregions.ResultsAmong 3,605 AFP cases reported and investigated countrywide from 2015–2020, 3,475 (96%) were true AFP cases. All the true AFP cases were non-polio related. District reporting was near-complete (97–100% each year). Overall, the mean NPAFP rate declined from 3.1/100,000 in 2015 to 2.1/100,000 in 2020. Less than 40% of districts met the NPAFP target rate in all years. The proportion of districts achieving the NPAFP target rate of ≥ 4/100,000 significantly declined from 35% in 2015 to 20% in 2020. The mean annual SA rate nationally was 88% from 2015–2020. Only 66% of districts achieved the SA target rate of ≥ 80% in the study period. The proportion of districts with SA rate ≥ 80% significantly increased from 68 to 80% between 2015 and 2020.ConclusionMost districts reported AFP cases. However, there was a decline in the NPAFP rate from 2015–2020 and few districts achieved the target rate. The suboptimal AFP surveillance system performance leaves the country at risk of missing ongoing poliovirus transmission. We recommend health worker training on active AFP searches, intensified supportive supervision, increase the number of environmental surveillance sentinel sites to boost AFP surveillance in the country, and periodic review meetings with districts to assess AFP surveillance performance.

Acute flaccid paralysis surveillance performance from 2011 to 2020 in Jonglei State, South Sudan: progress and challenges encountered.

IntroductionSouth Sudan reported the last indigenous wild poliovirus (WPV) in 2001 in Unity State, while the country was part of Sudan. In addition, the country reported an imported case of WPV in 2004-2005 and 2008-2009. The WPV circulation in the state was interrupted in 2009 and the last case was reported in Ayod county. The country continues to be at risk of importation of circulating vaccine-derived poliovirus type 2 (cVDPV2). In 2014 and 2020 the country experienced an outbreak of cVDPV2, in which Jonglei state was one of the affected states. Four out of 50 (8%) cVDPV2 cases in 2020 were reported from Jonglei State. The purpose of this study is to review surveillance performance indicators of Jonglei and compare them with the WHO surveillance performance standard and other country´s surveillance performances.Methodsretrospective secondary data analysis was conducted using the Jonglei state Acute Flaccid Paralysis (AFP) surveillance case-based database from 2011 to 2020. The reason for selecting Jonglei is because it is one of the poor performing states and is chronically hit by flood and internal conflicts. Data analyses were carried out using the Microsoft Excel (2016) program, where descriptive analysis frequencies, tables, and graphs were generated.Resultsthe study revealed that 346 AFP cases were reported in the counties of Jonglei state from 2011 through 2020. Out of 11 counties, 11 (100%) of them have reported suspected AFP cases. Children under five years accounted for 275 (79%) of all cases. The male gender accounted for 175 (51%) of all cases. A total of 249 (72%) had received three or more doses of Oral Polio Vaccine (OPV). Non-Polio Acute Flaccid Paralysis (NPAFP) rate varies from 1.2 in 2014 to 4.4 cases per 100,000 children under 15 years in 2018. The stool adequacy ranges from 58% in 2020 to 100% in 2011.Conclusionthe performance of Jonglei´s AFP surveillance system did not meet the WHO recommended target for both major AFP surveillance indicators (non-polio AFP rate and stool adequacy) during the study period.

The sensitivity of acute flaccid paralysis surveillance - the case of South Sudan: retrospective secondary analysis of AFP surveillance data 2014-2019.

IntroductionSouth Sudan has made quite impressive progress in interrupting wild poliovirus and maintaining a polio-free status since the last case was reported in 2009. South Sudan introduced different complementary strategies to enhance acute flaccid paralysis (AFP) surveillance. Hence, the objective of this study is to evaluate the sensitivity of the surveillance system using the WHO recommended surveillance standard and highlight the progress and challenges over the years.Methodswe conducted a retrospective, descriptive, quantitative study design and used the available secondary AFP surveillance database.Resultsthe overall non-polio AFP rate was 6.2/100,000 children under 15 years old in the study period. The stool adequacy was maintained well above the certification level of surveillance. The two main surveillance performance indicators were met at the national level throughout the study period. In contrast, only five out of ten states persistently attained and maintained the two main surveillance performance indicators throughout the study period, while in 2019 all states achieved except for Jonglei state. During the analysis period, no wild poliovirus was isolated except two circulating Vaccine Derived Poliovirus Type 2 (cVDPV2) cases in 2014 and one Immunodeficiency Vaccine Derived Poliovirus Type 2 (iVDPV2) case in 2015. However, on average, three cases were classified as polio compatible with each year of the study.ConclusionSouth Sudan met the two key surveillance performance indicators and had a sensitive AFP surveillance system during the period studied. We recommend intensifying surveillance activities in the former conflict-affected states and counties to maintain polio-free status.

Innovations in the Implementation of Polio Surveillance Enhancement Plan in Oyo State, Nigeria: Key Benefits, Lessons Learned, Challenges and Opportunities

Background: Nigeria attained the milestone of being certified wild poliovirus free in the year 2020. However, a drop in the key performance indicators of polio surveillance system was across various Local Government Areas (LGAs) in Oyo State. This drop highlighted the need for an innovative way of enhancing polio surveillance in Oyo State. Methods: This study was conducted in four phases and each phase utilized a cross-sectional study design and purposive sampling technique to select eligible LGAs and participants. LGAs that met at least two of the set-out criteria (had not reported at least a case of Acute Flaccid Paralysis (AFP) 12 months preceding the survey, with decline in AFP case detection rate, had not met AFP key indicators, are densely populated, and has an international border) were selected. A concurrent mixed method of data collection was utilized, and quantitative data were collected with a semi-structured questionnaire administered using Computer Assisted Personal Interviews (CAPI) during community active case search, health facility retroactive case search (HFRACS). Qualitative data collection was done through Focus Group Discussion (FGD). Surveillance intensification activities were conducted over eight weeks period. Data were analyzed using Microsoft Excel Software; summarization was done using frequencies and percentages while presentation was done using charts and spot maps. Results: A total of 1277, 49, 259 and 632 settlements, households and health facilities respectively were visited across 24 (73%) LGAs in Oyo State. Of the 150 suspected AFP cases identified, 45 (30%) were rejected cases, 33 (22%) were missed cases and 72 (48%) were true AFP cases. Non-Polio AFP Rate (NP-AFP rate) increased from 2.7 to 6.9 (P < 0.0001) after the surveillance intensification, also, the Non-Polio Enterovirus (NPENT) isolation was increased by 40% (16% to 23%). At the end of the intensification activities, all LGAs in Oyo State had met the WHO recommended Non-Polio Acute Flaccid Paralysis (NP-AFP) rate of ≥3/100,000 population. Conclusions: Innovative strategies implemented in AFP surveillance across Oyo State have resulted in improvement in AFP surveillance performance indicators in the State. There is therefore the need for dynamic and innovative ways of conducting AFP surveillance to prevent poliomyelitis epidemics and to ensure maintenance of Nigeria polio free certification status.

An Epidemiological evaluation of Acute Flaccid Paralysis surveillance performance in Ondo State; 2016-2020

Background: The last case of the indigenous Wild Polio Virus in Ondo state was in 2008, and the last Polio compatible infection was in 2010. Poliovirus transmission was stopped thanks to the World Health Organization's (WHO) standards, which included acute flaccid paralysis (AFP) surveillance. We wanted to describe the state's polio surveillance performance during the last five years, from 2016 to 2020, using WHO-recommended measures and find areas where it could improve.Methods: Between January 2016 and December 2020, AFP case-based surveillance data was used to undertake a retrospective examination of records. Microsoft Excel was used for data processing, and Quantum Geographic Information System was used for mapping (GIS).Results: From 2016 to 2020, a total of 1,096 AFP instances were recorded, none of which were confirmed as Poliomyelitis. The bulk of the cases (77.2 percent) were found in children under the age of five. Males made up more than half of the cases (53.4%). More than 89 percent of reported cases received three or more OPV doses. Between 2016 and 2020, there was a 79 percent decline in reported incidents. Between 2016 and 2020, the average Non-Polio AFP rate was 11.2 per 100,000, with a stool adequacy of 98.4%.Conclusion: AFP surveillance in Ondo state met the minimum WHO targets during the study period, according to the findings. However, because of the possibility of poliovirus being imported from endemic countries, which might threaten Nigeria's polio-free status, all surveillance actors' sensitization and active case search should be strengthened, particularly in underperforming local government areas (LGAs).

Evaluation of acute flaccid paralysis surveillance indicators in Sokoto state, Nigeria, 2012\u20132019: a secondary data analysis

BackgroundNigeria, the last endemic country in the WHO African Region, was certified free of Wild Polio Virus (WPV) in 2020. However, due to low immunity in some communities in Sokoto, outbreaks of the circulating Vaccine Derived Polio Virus (cVDPV) occur. The aim of this study is to evaluate the Acute Flaccid Paralysis (AFP) surveillance indicators in Sokoto state, Nigeria.MethodsThis retrospective study was an analysis of routinely collected AFP surveillance data between 2012 and 2019 by the Sokoto state surveillance network. We assessed the Sokoto state AFP surveillance system using the AFP surveillance performance indicators. We performed all analyses using Microsoft Excel 2019.ResultsCumulatively, 3001 Acute Flaccid Paralysis (AFP) cases were reported over the evaluation period, out of which 1692 (56.4%) were males, and 2478 (82.4%) were below five years. More than half, 1773 (59.1%), had a fever at the beginning of the disease, and 1911 (63.7%) had asymmetric paralysis. The non-polio AFP rate (9.1 to 23.5% per 100,000 children < 15 years old) and stool adequacy rate (92.5 to 100%) indicate high sensitivity. The proportion of cases that had stool samples collected early, timely transported to the laboratory and arrived at the laboratory in optimal condition were all above the World Health Organization (WHO) minimum standard of 80%. There was inadequate profile documentation of some suspected cases.ConclusionsSokoto State has exceeded the WHO minimum standards in most of the AFP surveillance indicators. The performance of the system is sufficient enough to detect any reintroduction of WPV into the state. However, there is a need for improvement in data quality.

Surveillance to Track Progress Toward Polio Eradication - Worldwide, 2019-2020.

When the Global Polio Eradication Initiative (GPEI) was established in 1988, an estimated 350,000 poliomyelitis cases were reported worldwide. In 2020, 140 wild poliovirus (WPV) cases were confirmed, representing a 99.99% reduction since 1988. WPV type 1 transmission remains endemic in only two countries (Pakistan and Afghanistan), but outbreaks of circulating vaccine-derived poliovirus (cVDPV) occurred in 33 countries during 2019-2020 (1,2). Poliovirus transmission is detected primarily through syndromic surveillance for acute flaccid paralysis (AFP) among children aged <15 years, with confirmation by laboratory testing of stool specimens. Environmental surveillance supplements AFP surveillance and plays an increasingly important role in detecting poliovirus transmission. Within 2 weeks of COVID-19 being declared a global pandemic (3), GPEI recommended continuing surveillance activities with caution and paused all polio supplementary immunization activities (4). This report summarizes surveillance performance indicators for 2019 and 2020 in 42 priority countries at high risk for poliovirus transmission and updates previous reports (5). In 2020, 48% of priority countries* in the African Region, 90% in the Eastern Mediterranean Region, and 40% in other regions met AFP surveillance performance indicators nationally. The number of priority countries rose from 40 in 2019 to 42 in 2020.† Analysis of 2019-2020 AFP surveillance data from 42 countries at high risk for poliovirus transmission indicates that national and subnational nonpolio AFP rates and stool specimen adequacy declined in many priority countries, particularly in the African Region, suggesting a decline in surveillance sensitivity and quality. The findings in this report can be used to guide improvements to restore a sensitive surveillance system that can track poliovirus transmission and provide evidence of interruption of transmission.

Evaluation of the Acute Flaccid Paralysis Surveillance System of Polio Free in East Java, Indonesia, 2019

Background: Proving that the wild polio virus no longer exists in Indonesia, the symptoms must be found thatresemble polio. These symptoms are found in patients with AFP (Acute Flaccid Paralysis). AFP surveillanceis an observation made of all cases of acute paralysis or AFP in children aged &lt;15 years who are vulnerableto polio. The priority problem that is still found in the East Java Provincial Health Office regarding AFPsurveillance is the reduction in the discovery of non-polio AFP cases and adequate specimens.Aims: The purpose of this study was to analyze the implementation of AFP surveillance activities in the EastJava Province Health Office in 2019.Methods: Data collection was carried out by primary and secondary to study the AFP surveillance overview.Primary data were obtained from in depth interviews with AFP surveillance program holders in East JavaProvincial Health Office. Secondary data is processed using Microsoft Office Excel, Epi Info and QuantumGIS.Results: The result is in 2019 the rate of non-polio AFP and the percentage of adequate specimens in EastJava Province has under the target. In 2019 there was a decrease compared to the previous year, the nonpolio AFP rate was 1.64 and the percentage of adequate specimens was 56.2%. Only as many as six districts/ cities in East Java Province had pass these two indicators.Conclusion: The lack of visits and reports from both the hospital and the community is one of causativefactor. Intensive and routine AFP surveillance is needed to monitor the emergence of polio cases

Evaluation of acute flaccid paralysis surveillance system, 2013 to 2017 – Bayelsa State, Nigeria

Background: Nigeria is one of the three countries where transmission of Wild Polio Virus (WPV) still occurs. Documented transmission occurs mainly in the northern part of the country. Acute flaccid paralysis (AFP) surveillance is one of polio eradication and endgame strategic plan. On this basis, we evaluated the AFP surveillance system in Bayelsa state, Nigeria with the aim of assessing the attributes of the system. Methods & Materials: We interviewed Stakeholders and reviewed AFP surveillance data from 2013 to 2017 using the updated CDC guidelines for evaluating the public health surveillance systems and the WHO performance standards to assess the performance of the system. Relevant data were extracted and analyzed using Microsoft Excel spreadsheet. Results: All 27 respondents knew that poliomyelitis was caused by a virus and they all felt that AFP case definition was easy to understand. 73% percent of them reported that completion of the Case Investigation Form (CIF) was simple. All the respondents were willing to continue to participate in the AFP surveillance. The non-polio AFP rate (12.3–16.6%) and stool specimen adequacy rate (98–100%) indicate high sensitivity. Proportion of AFP cases investigated within 48 h of notification, timely transportation, specimen arriving laboratory in good condition were all above WHO minimum standard of 80%. The surveillance system has dedicated staff from state ministry of health and support from National Stop Transmission of Polio (NSTOP). Conclusion: The AFP surveillance system in Bayelsa State is performing well. The system is useful, simple, flexible, acceptable, sensitive, representative, timely and stable. We recommended that regular training of data collectors should be implemented.

Acute flaccid paralysis surveillance system evaluation-Enugu state, Nigeria 2015–2018

Background: Nigeria is one of the three polio-endemic countries worldwide. Wild polio virus was reported last in Nigeria by August 2016 although pockets of circulating vaccine derived viruses’ infection and vaccine associated paralytic polio still occur. As part of the polio endgame strategy Nigeria targets to achieve and sustain optimum surveillance performance indicators in all States by December 2018. We evaluated the acute flaccid paralysis (AFP) surveillance system in Enugu State to assess if the target for these indicators are being met. Methods and materials: We used an adapted US CDC Updated Guidelines for Evaluating Public Health Surveillance Systems. We reviewed of AFP surveillance data collected 2015–2018. We conducted key informant interviews and focus group discussion with purposively selected stakeholders. We collected data from 30 randomly selected AFP Surveillance officers in the state using an adapted questionnaire and recorded frequencies and proportions of key indicators. Results: One compatible poliovirus case was identified in 2015 among the 1211 AFP cases recorded. The case definition of AFP and tools for reporting are simple. The system is mainly funded by foreign partners although the main challenge is sustainability. The system is unstable as there are few trained staff who are regularly assigned other duties or transferred to other departments other than AFP surveillance. The system is flexible, and accepted by all stakeholders. The sensitivity of the system measured by the annualized Non-Polio AFP (NPAFP) rate is 15.1 ± 2.7 (target of ≥2/100,000 population). The mean data quality was 94%, SD: 2.8 (target ≥90). Mean stool adequacy and timeliness of reporting were 83.9 ± 14.3% and 91.0 ± 8.6% respectively both having target of ≥80%. Case investigations done in ≤48 h: Mean 89 ± 7.4, non-polio enterovirus isolation rate: Mean 39.5 ± 19.4, target >10% and 60 days follow up Mean 85.2 SD (17.0). Conclusion: Enugu State AFP surveillance is meeting most of its target although stability of the system is suboptimal. We recommended that Enugu state government train a pool of health officers on AFP surveillance and reduce staff mobility. Enugu state government should also plan to have a budget line for surveillance of AFP, and take ownership of the surveillance structure.

An epidemiological analysis of Acute Flaccid Paralysis (AFP)\xa0surveillance in Kenya, 2016 to 2018

BackgroundThe poliovirus has been targeted for eradication since 1988. Kenya reported its last case of indigenous Wild Poliovirus (WPV) in 1984 but suffered from an outbreak of circulating Vaccine-derived Poliovirus type 2 (cVDPV2) in 2018. We aimed to describe Kenya’s polio surveillance performance 2016–2018 using WHO recommended polio surveillance standards.MethodsRetrospective secondary data analysis was conducted using Kenyan AFP surveillance case-based database from 2016 to 2018. Analyses were carried out using Epi-Info statistical software (version 7) and mapping was done using Quantum Geographic Information System (GIS) (version 3.4.1).ResultsKenya reported 1706 cases of AFP from 2016 to 2018. None of the cases were confirmed as poliomyelitis. However, 23 (1.35%) were classified as polio compatible. Children under 5 years accounted for 1085 (63.6%) cases, 937 (55.0%) cases were boys, and 1503 (88.1%) cases had received three or more doses of Oral Polio Vaccine (OPV). AFP detection rate substantially increased over the years; however, the prolonged health workers strike in 2017 negatively affected key surveillance activities. The mean Non-Polio (NP-AFP) rate during the study period was 2.87/ 100,000 children under 15 years, and two adequate specimens were collected for 1512 (88.6%) AFP cases. Cumulatively, 31 (66.0%) counties surpassed target for both WHO recommended AFP quality indicators.ConclusionsThe performance of Kenya’s AFP surveillance system surpassed the minimum WHO recommended targets for both non-polio AFP rate and stool adequacy during the period studied. In order to strengthen the country’s polio free status, health worker’s awareness on AFP surveillance and active case search should be strengthened in least performing counties to improve case detection. Similar analyses should be done at the sub-county level to uncover underperformance that might have been hidden by county level analysis.

Polio Outbreak Response; Evaluation of Acute Flaccid Paralysis Surveillance in Karbala, Iraq.

Background:After the last outbreak of wild polio infection in Baghdad, April 2014, the Iraqi response to the outbreak was activated through solid surveillance of Acute Flaccid Paralysis (AFP) case detection in all governorates to interrupt the circulation of poliovirus in addition to the strengthening of Expanded Program on Immunization. This response to the last outbreak has to be evaluated independently to ensure effective mopping and surveillance to stop further outbreak all over the country including the holy province Karbala. We aimed to evaluate the response to the last polio outbreak by evaluating surveillance activities of acute flaccid paralysis cases whether they meet the recommended standards.Methods:Observational evaluation study conducted through August 15–25, 2015. Checking of Acute Flaccid Paralysis surveillance (AFP) activity through detection of nonPolio acute flaccid paralysis rate and immediate reporting with adequate stool sampling, and 60 days follow-up examination four districts of the province. The reviewing checked whether the surveillance system in Karbala met the global standards required for stopping wild poliovirus circulation. The evaluation included immunization coverage rates and active National Immunization days of oral polio vaccine campaigns.Results:During the period of review, the core surveillance indicators in Karbala met the globally set standards. Percent of acute flaccid paralysis cases with specimens reached to the reference laboratory within 3 days was 100%. Nonpolio cases was 4.2 per 100000 population under 15 years of age through week 33 of the year 2015. Eleven AFP cases were reported from all districts of Karbala among Population of children under 15 years of age. The percentage of cases with adequate specimens was 100% in 2015 versus 93% in 2014. The percent of AFP Cases notified within 7 days of paralysis onset (during first 33 weeks) was 100% in 2015 versus 87% in 2014.Conclusions:As Karbala response to polio outbreak met the target global indicators and standards of polio surveillance. The circulation of the virus in this locality was interrupted and further transmission of the disease is unlikely.

Assessment of acute flaccid paralysis surveillance performance in East and Southern African countries 2012 - 2019.

Introduction:polio eradication initiatives started in 1988, this is almost the past 32 years following the WHA resolution 41.8 of eradicating polio by the year 2000. As of 2019, only 3 countries remained to be polio endemic globally, Afghanistan, Pakistan and Nigeria. The east and southern sub-region countries had shown progressive achievement towards polio eradication and to start with the African regional certification. The availability of sensitive AFP surveillance performance is among important strategies in the achievement of polio eradication. We, therefore, decided to conduct this assessment of AFP performance from 2012 to 2019 in the ESA sub-region have evidence documentation and support the certification process of the WHO AFRO region.Methods:we reviewed all reported acute flaccid paralysis (AFP) cases from 19 countries in the ESA sub region with the date of onset of paralysis from 1 January 2012 to 31 December 2019. The data were run to descriptive analysis based on the personal characteristics and AFP surveillance performance indicators parameters.Results:a total of 46,014 AFP cases were reported from 19 countries in the ESA countries who were paralyzed from 1 January 2012 to 31 December 2019. The most affected age group was children aged 0 to 3 years old where 19,740 children with acute paralysis were reported representing 42.9% of the total reported AFP for the period. The overall assessment of the non-polio AFP rate, there is an increase from a rate of 2.7 in 2012 to 3.5 in 2019 per 100,000 population aged less than 15 years, reflects a significant change with a p-value of 0.040 (95% C.I. ranges from 0.035 to 1.564). Furthermore, the percentage of stool adequacy raised from 86.4% in 2012 to 88.5% in 2019, with an observed 2.1% difference and no significant change over the 8 years.Conclusion:we observed an overall increase in the sensitivity of the AFP surveillance performance for the ESA sub-region countries from 2012 to 2019 using the national performance indicators. The COVID-19 pandemic paused an operational challenge for AFP surveillance performances from 2020. A further subnational surveillance performance analysis is suggested.

Evaluation of the Acute Flaccid Paralysis Surveillance System in Polio-Free Jordan, 2012-2016: Retrospective Secondary Analysis.

BackgroundAs part of the polio-eradication strategy, the World Health Organization (WHO) has established a global acute flaccid paralysis (AFP) surveillance system. AFP surveillance has successfully helped Jordan achieve polio-free certification. However, there is a substantial risk of polio importation from neighboring countries including Syria and Iraq.ObjectiveThis study aimed to evaluate the AFP surveillance in Jordan and identify areas that need improvement.MethodsThis retrospective study is a secondary analysis of data that were routinely collected between 2012 and 2016 by Jordan’s Expanded Program on Immunization. The WHO’s minimum performance indicators were used to evaluate the AFP surveillance.ResultsCumulatively, 328 AFP cases had been reported. Almost half (n=168, 51.3%) of the patients were aged 1-5 years, and 55.8% (n=183) were male. All cases were discarded (classified as a nonpolio case). The most common cause of AFP was Guillain-Barre Syndrome (n=115, 35.1%). The annualized nonpolio AFP rate increased from 1.4/100,000 children below 15 years of age in 2012 to 4.3 in 2016. National and subnational sensitivities were not met in 2012 and 2013. Adequacy of stool specimens and timeliness of specimens arriving at and processed in the laboratory were constantly above the minimum target. Timeliness of the investigation met the expected target but with a decreasing trend. The nonpolio enterovirus isolation rate was below the target, except in 2016.ConclusionsThe AFP surveillance system in Jordan is performing well; however, additional efforts are needed to strengthen the subnational sensitivity. The cold chain from sample collection to laboratory testing has to be maintained to ensure the reliability of stool specimens required for isolation of the nonpolio enterovirus.

Environmental Surveillance and Vaccine Derived Polio Virus type 2 Isolation, Gombe State, Nigeria.

Environmental Surveillance and Vaccine Derived Polio Virus type 2 Isolation, Gombe State, Nigeria.

Acute flaccid paralysis in North East Delta, Egypt: A retrospective analysis of prospectively collected surveillance data

BackgroundEffective acute flaccid paralysis (AFP) surveillance is crucial in countries approaching the final phase of polio eradication. Thus this study was conducted to highlight the epidemiological pattern of AFP as a surveillance tool for polio in Egypt. MethodsA record-based descriptive study was conducted to include all AFP cases (599) reported in the last 9 years starting from January 2009 to December 2017 in Dakahlia, North East of Delta, Egypt. ResultsThe overall non-polio AFP rate in less than 15 years old children was 2.99/100,000 during the study period. The majority of cases (98%) were notified within 7 days from onset of the disease, and investigated within 48 h of reporting. The commonest diagnoses were encephalitis (21.3%), myositis (20.2%), neuropathies (19.2%) and Guillain–Barre syndrome (17.8%) with no recorded cases diagnosed as poliomyelitis. The mean annual vaccination coverage rate was 96.1 ± 1.6. ConclusionsAFP surveillance system in Dakahlia, Egypt was effective in meeting the WHO surveillance performance indicators ensuring polio-free status and absence of wild polio virus transmission over the last 9 years in this locality. High routine immunization coverage, maintenance and improvement of current levels of surveillance performance are required for optimum surveillance.

Strengthening acute flaccid paralysis surveillance post Ebola virus disease outbreak 2015 - 2017: the Liberia experience.

IntroductionLiberia remains at high risk of poliovirus outbreaks due to importation. The country maintained certification level acute flaccid paralysis (AFP) surveillance indicators each year until 2014 due to Ebola outbreak. During this time, there was a significant drop in non-polio AFP rate to (1.2/100,000 population under 15 years) in 2015 from 2.9/100, 000 population in 2013, due to a variety of reasons including suspension on shipment of acute flaccid paralysis stool specimen to the polio regional lab in Abidjan, refocusing of surveillance officers attention solely on Ebola virus disease (EVD) surveillance, inactivation of national polio expert committee (NPEC) and National Certification Committee (NCC). The Ministry of Health (MOH) supported by partners worked to restore AFP surveillance post EVD outbreak and ensure that Liberia maintains its polio free certification.MethodsWe conducted a desk review to summarize key activities conducted to restore acute flaccid paralysis (AFP) surveillance based on World Health Organization (WHO) AFP surveillance guidelines for Africa region. We also reviewed AFP surveillance indicators and introduction of new technologies. Data sources were from program reports, scientific and gray literature, AFP database, auto visual AFP detection and reporting (AVADAR) and ONA Servers. Data analysis was done using Microsoft excel and access spread sheets, ONA software and Geographic Information System (Arc GIS).ResultsAFP surveillance indicators improved with a rebound of non-polio AFP rate (NPAFP) rate from 1.2/100, 000 population under 15 years in 2015 to 4.3 in 2017. The stool adequacy rate at the national level also improved from 79% in 2016 to 82% in 2017, meeting the global target. The percentage of counties meeting the two critical AFP surveillance indicators NPAFP rate and stool adequacy improved from 47% in 2016 to 67% in 2017.The Last polio case reported in Liberia was in late 2010.ConclusionThere was significant improvement in the key AFP surveillance indicators such as NPAFP rate and stool adequacy with a 3.5 fold increase in NPAFP from 2014 to 2017. By 2017, the stool adequacy rate was up to target levels compared to 2016, which was below target level of 80%. The number of counties meeting target for the two critical AFP surveillance indicators also increased by 20% points between 2016 and 2017. Similarly there was approximately two-fold increase in the oral polio vaccines (OPV) coverage for the reported AFP cases between 2015 and 2017. Strategies employed to address gaps in AFP surveillance included enhanced active case search for AFP, re-instatement of laboratory testing, supportive supervision in addition to facilitating enhanced community engagement in surveillance activities. New technologies such as AVADAR Pilot, electronic integrated supportive supervision (ISS) and electronic surveillance (eSurv) tools were introduced to improve real time AFP case reporting. However, there remain residual gaps in AFP surveillance in the country especially at the sub-national level. Similarly, the newly introduced technologies will require continued funding and capacity building for MOH staff to ensure sustainability of the initiatives.

Reply to Comment on Dhiman, R. et al. Correlation of Non-Polio Acute Flaccid Paralysis Rate with Pulse Polio Frequency in India. Int. J. Environ. Res. Public Health 2018, 15, 1755.

We thank the authors for their interest in our paper [...].

Comment on Dhiman, R. et al. Correlation of Non-Polio Acute Flaccid Paralysis Rate with Pulse Polio Frequency in India. Int. J. Environ. Res. Public Health 2018, 15, 1755.

The authors of the published article 'Correlation between Non-Polio Acute Flaccid Paralysis Rates with Pulse Polio Frequency in India' [...].