Poliomyelitis Surveillance in Ireland

4th April, 2014

Acknowledgement

The health Protection Surveillance Centre (HPSC) would like to thank all those who have contributed to polio surveillance, the National Virus Reference Laboratory, the Irish Paediatric Surveillance Unit (IPSU), paediatricians and all others who have provided data in relation to polio surveillance.

Rationale for polio surveillance• Europe has been polio free since 2002, but poliomyelitis

virus continues to circulate in other countries• In 2013, polio was identified in

– Afghanistan, Nigeria and Pakistan – endemic – Syria, the Horn of Africa, Cameroon, Somalia , other African

countries – outbreaks – Egypt, Israel, the West Bank and Gaza Strip – environmental or

asymptomatic individuals • As long as a single child remains infected, children in all

countries are at risk of contracting polio.

Cases of polio in Ireland

The last notified case of polio was in 1984

1948

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

0

100

200

300

400

500

600

Number Polio Cases Notified in Republic of Ireland 1948-2013, and year of vaccine in-troduction

Year

Num

ber o

f Cas

es N

otifi

ed Polio vaccine, 1957

Irish surveillance for Poliomyelitis- methods

• Acute flaccid paralysis (AFP) in ALL children < 15 years of age

• Investigation of suspect cases of CNS infection (e.g. meningitis, encephalitis, AFP) of all ages if travel or epi-links to contacts from areas where polio virus circulating,

Definition of AFP

Acute flaccid Paralysis (AFP) is a clinical syndrome characterised by rapid onset of weakness, including (less frequently) weakness of respiratory and swallowing, progressing to maximum severity within several days to weeks.AFP is a complex clinical syndrome with a broad array of potential aetiologies.

AFP surveillance and Polio

• Surveillance of AFP is used in surveillance for poliomyelitis in the context of the global polio eradication initiative

• Polio is caused by a human enterovirus called the poliovirus. Wild polioviruses are those that occur naturally. There are three serotypes of wild poliovirus – type 1, type 2, and type 3

• Polio is one of only a limited number of diseases that can be eradicated as there are no long-term carriers of the disease and an inexpensive vaccine is available

Potential aetiologies associated with AFP

Includes possible illness due to: • Guillian-Barré syndrome • Transverse myelitis • Traumatic neuritis • Viral infections caused by other enteroviruses

toxins and tumours

Causes of Acute Flaccid Paralysis (AFP1) Worldwide Note: most common causes of AFP in Ireland indicated in red (*)

Peripheral neuropathy Guillain-Barré syndrome* Acute axonal neuropathy Neuropathies of infectious diseases

(diphtheria, Lyme disease) Acute toxic neuropathies (heavy metals) 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 Periodic paralyses Corticosteroids and blocking agents Post viral myositis

Acute Myelopathy Cord compression Demyelinating diseases

multiple sclerosis transverse myelitis* acute disseminated

encephalomyelitis (ADEM)* Ischaemic cord damage

Systemic disease Acute porphyrias Critical illness neuropathy Acute myopathy in ICU patients

Acute Flaccid Paralysis

Disorders of neuromuscular transmission Myasthenia gravis Botulism* Insecticide (organophosphate poisoning) Tick bite paralysis Snake bites

Ver

sion

1.0

(22/

07/2

013)

Objectives of AFP surveillance

• To rapidly detect re-importation of poliovirus into polio-free areas

• To ensure that robust surveillance systems are in place so that if AFP caused by polio virus that it would be identified quickly

Investigation of AFP in children < 15 years of age

1. AFP case admitted to hospital2. Collect 2 stool specimens as early as possible, 24 hours apart, within 2

weeks of paralysis onset and send to National Virus Reference Laboratory (NVRL)

3. Complete AFP enhanced surveillance form and return to Paula Flanagan, HPSC, 25‐27 Middle Gardiner Street, Dublin 1, Tel: 01 876 5300, Fax: 01 856 1299

4. Surveillance forms available on ward or available at http://www.hpsc.ie/hpsc/A-Z/VaccinePreventable/Polio/AcuteFlaccidParalysisAFP/

5. When returning your monthly IPSU (Irish Paediatric Surveillance Unit) card indicate if you have seen a case in previous month

* Acute flaccid Paralysis (AFP); a clinical syndrome characterised by rapid onset of weakness, including (less frequently) weakness of respiratory and swallowing, progressing to maximum severity

Investigation of Acute Flaccid Paralysis (AFP)* in children < 15 years of age

REMEMBER!

PLEASE REPORT AND INVESTIGATE ALL AFP PAEDIATRIC CASES < 15 YEARS OF AGE AS PART OF INTERNATIONAL POLIO ELIMINATION CAMPAIGN

Child admitted to hospital with AFP* (photo courtesy CDC)

Send 2 faecal samples, 24 hours apart to NVRL

Sample 1 Sample 2

...24 hours later...

Report

Results

Complete monthly report card √ - send to IPSU

Complete enhanced questionnaire (acute and 60 day follow-up) √ - return to HPSC

Ver

sion

2.0

(24/

07/2

013)

V

ersi

on 1

.0 (2

5/07

/201

3)

AFP reports in children < 15 years of age, by year of onset of paralysis,

2009-2013

Year of Onset of Paralysis Total2009 6

2010 4

2011 9

2012 6

2013 8

Total 33

AFP cases by Age Group 2009-2013

Age Group Total

0-4 13

5-9 5

10-14 7

Not specified 8

Total 33

AFP cases by Diagnosis2009-2013

Final Clinical Diagnosis Category Diagnosis Total

Polyradiculneuritis/Guillain-Barre Syndrome/Landry Syndrome

Guillain Barre Syndrome 10

Not specified 3

Transverse myelitis Transverse Myelitis 3

Other specific neurologic diseases 

Acute Disseminated Encephalomyelitis 5Botulism 1

Conversion Disorder 1Other Disorder Neuromus Transmission 2

Not AFP* Not AFP* 4Not specified Not specified 4**

Total 33

*Isolated facial paralysis of any cause, spastic or chronic paralysis, meningitis, coma etc.** No enhanced surveillance form completed, suspect case reported via Irish Paediatric Surveillance Unit (IPSU) only

Vaccination uptake of 3 doses polio vaccine at 12 months, by LHO, Q3 2013*

*Source: HPSC Q3 2013 report located at http://www.hpsc.ie

National uptake = 92% (range 88%-95%)

N

EW

S

No Data95 - 10090 - 9485 - 8980 - 840 - 79

% Immunisation Uptake

G

L

DL

KY

MO

CE

TS

RN

NC

MH

NSL

WX

LS/OY

WC

SO/LM

WD

KE/WW

LD/WH

LHCN/MN

CW/KKTN/EL

WW

DN

DW

DN W

DSW DSDSE

DN C

DSC

DSC

DNC

DSE DSDSW

DNW

DW

DN

Vaccination uptake of 3 doses polio vaccine at 24 months, by LHO, Q3 2013*

*Source: HPSC Q3 2013 report located at http://www.hpsc.ie

National uptake = 96% (range 94%-98%)

N

EW

S

0 - 7980 - 8485 - 8990 - 9495 - 100No Data

G

L

DL

KY

MO

CE

TS

RN

NC

MH

NSL

WX

LS/OY

WC

SO/LM

WD

LD/WH

LHCN/MN

CW/KK

WW

EL/TN

KE/WW

DN

DW

DNW

DSW DSDSE

DNC

DSC

DN

DW

DNW

DSW DSDSE

DNC

DSC

WHO recommendations to decrease risk of Wild Polio Virus (WPV) importation and possible

spread and diseaseVaccination recommendations• Maintain national vaccination

coverage with completed polio vaccination > 90%

• Identify those at risk of low immunisation and implement vaccination as needed

National data • 3 doses at 12 months is

92% (Q3 2013)• 3 doses at 24 months is

96% (Q2 2013)

• Currently national data is not available by ethnicity, migrant or other risk factor status

Recommendations to decrease the risk of WPV importation and possible spread and disease in Ireland(2)

• Improve surveillance- Paediatric AFP surveillance – All AFP cases in children < 15 years of age (regardless

of presumed diagnosis) should be investigated for enteroviral/polio virus specific infection

– Children < 15 years of age who present with aseptic meningitis, encephalitis, other neurological symptoms (non-AFP) should be systematically tested for polio virus IF they have links (direct travel or contact with individuals from these countries where wild polio has been identified)

For older child and adult surveillance for polio virus

• Older children (> 15 years) and adult patients, with a history of travel to, or contact with individuals from, countries where wild polio has been identified AND who present with AFP, aseptic meningitis, encephalitis, other neurological symptoms (non-AFP) should be systematically tested for polio virus.

Laboratory investigation (NVRL) - Summary

Two stool samples should be taken as soon as possible (at least within 2 weeks of onset and 24 hours apart) and sent to the NVRL with clinical detail to facilitate rapid investigation and feedback

– All paediatric cases of AFP – All cases of AFP, aseptic meningitis, encephalitis, other

neurological symptoms (non-AFP) especially IF there are epi-links to countries (or individuals returned from these countries) where polio virus is circulating

Thank you

For more information http://www.hpsc.ie/hpsc/A-Z/

VaccinePreventable/Polio/