POLIO ERADICATION PROGRAMME: ACUTE FLACCID PARALYSIS

CASE INVESTIGATION FORM

Official Use
Only: EPID Number: ___________-___________-_________-__________-________ Received: _____/______/_______
Country Region/Prov. Districts Year onset Case Number by the Programme at National level

IDENTIFICATION Name nearest Health

District:_____________________ Region/Province: _____________________ Facility: ____________________________________
Address:_____________________ Village:_____________________ City: _______________________

AFP case coordinates (WGS 1984 format) : Longitude :___________________ Latitude :_______________

Patient name: ______________________________ Father/Mother:_____________________

Date of Birth (DOB)____/______/_______ Age: _______ years _______months M=Male

(If DOB Unknown) Sex: F=Female

NOTIFICATION/INVESTIGATION:
Date of Date of
Notified by:_____________________ Notification____/______/_______ Investigation: ____/______/_______

HOSPITALIZATION Hospitalized: 1=Y Date of admission to hospital, if applicable: ______/______/_________

2=N

Hospital record #:___________________ Name of hospital/Address:__________________________________________________

CLINICAL HISTORY Fever at the onset Progressive Paralysis

of paralysis? < 3 days?
1=Y, 2=N, 99=Unknown 1=Y, 2=N, 99=Unknown LA RA

Date of onset: Is Paralysis Asymmetric? Site of Paralysis LL RL

of paralysis: ____/______/_______ flaccid and acute?
1=Y, 2=N, 99=Unknown 1=Y, 2=N, 99=Unknown

Paralysed limb (s) Sensitive to pain: Yes/No

Was there any injection just before onset of paralysis: Yes/No

If yes mention the site of injection in the table below

Arm Fore-arm Buttocks Thigh Leg

Right
Left

PROVISIONAL DIAGNOSIS----------------------------------------------------------------------------------------------------------------------------------

AFTER INVESTIGATION, WAS THIS A TRUE AFP? 1=Y If not, do not fill the rest of the form and record 6 under
2=N final classification

IMMUNIZATION HISTORY

Total Number of Exclude OPV dose at birth _____/_____/____ 2nd _____/_____/____ 4th ____/_____/____
Polio vaccine doses dose at birth If > 4
1st _____/_____/____ 3 rd_____/_____/____ Last _____/_____/____
99=Unknown dose

Total OPV doses received through SIA: 99=Unknown Total OPV doses received through RI: 99=Unknown.

Date of last OPV dose received through SIA: _____/_____/____

Total IPV doses received through SIA: 99=Unknown Total IPV doses received through RI 99=Unknown

Date of last IPV dose received through SIA: _____/____/______ Source of RI vaccination information: Card Recall Choose one
STOOL SPECIMEN COLLECTION: _______/______/_______ ______/______/_____ _____/______/_______
Date 1st specimen Date 2nd specimen Date specimen sent to the
to the national level
_______/______/_______ _______/______/_____
Date specimen received at Date specimen sent
the national level inter-county/national Laboratory

STOOL SPECIMEN RESULTS:

____/______/_______ 1= Adequate ___/______/__________ ____/______/_______ ____/______/_______

Date specimen received at 2=Not adequate Date combined Cell Culture Date Results sent to Date Results received at
inter country (I-C)/national Lab Results available national EPI national EPI
Status of specimen at
Reception at the lab Final cell 1=Suspected poliovirus
Culture Results 2= Negative
3=NPENT
4-Suspect poliovirus + NPENT

Discordant
W1 W2 W3 Sabin SL1 SL2 SL3 (R) NPENT NEV
____/______/_______ ____/______/_______ ____/______/______
Date sent from I-C/National Date I-T differentiation Date I-T differentiation
Laboratory to regional lab results sent to EPI results received at EPI 1=Y, 2=N Type 1,2,3 1=Y, 2=N 1=positive, 2=Negative

Final Lab Results

____/______/_______ ____/______/______
Date isolate sent for sequencing Date seq results sent to program

FOLLOW-UP EXAMINATION
1 = Residual Flaccid Paralysis
____/______/________ Residual LA RA Results 2=No residual paralysis
Date of Follow-up exam. Paralysis? of exam 3= Lost follow-up
LL RL 4=Died before follow-up
5= Residual Spastic Paralysis

Immunocompromised status suspected: 1=Y, 2=N, 99=Unknown

FINAL CLASSIFICATION
1=Confirmed Polio 7=cVDPV Sero-type (1, 2, 3)
2=Compatible
3=Discarded 8=aVDPV
6=Not an AFP case
9=iVDPV

Fill in this section before signing the form

Where has the child been seeking help for this problem before presenting at present place (in sequence of visits)?

(1). Place: _________________________ Duration: months_____ days____ (2) Place:__________________________ Duration: months_____ days____

(3). Place: _________________________ Duration: months_____ days____ (4) Place:__________________________ Duration: months_____ days____

INVESTIGATOR: Name__________________________________ Title___________________________

Unit:___________________ Address_________________________________ Tel:_____________________________