Version 2022

Epidemic-prone Disease Case Investigation Form

Case Surveillance
Acute Flaccid Paralysis

Name of DRU: Type: RHU CHO Gov’t Hospital Private Hospital Clinic
DRU Complete Address:  Gov’t Laboratory Private Laboratory Airport/Seaport
Type of Site: Sentinel Non-sentinel
I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:
Sex: Male Female Date of Birth: / /
Complete Address:
Age: Days Months Years
MM DD YYYY
Name of Parent/ Caregiver: Complete Current Address:
Contact No: Complete Permanent Address:
MM DD YYYY
Patient Admitted? Yes  No Date Admitted/ Seen/Consult
MM DD YYYY MM DD YYYY
Date of Report: Date of Investigation:

Name of Investigator: Contact No:

Is the case a member of an Indigenous Group?  Y  N If YES, Specify:
II. CLINICAL DATA (Put a check [ √ ] in the appropriate box)
Deep
Previous SITE OF FLACCID Sensory Motor
PRODROME PARALYSIS Tendon
Consultation PARALYSIS Status Status
Reflexes
Name and address Fever:  Y  N Date onset: / / Right arm:  Y  N
of health facility 1: Cough:  Y  N Present at birth?:  Y  N Left arm: YN
Diarrhea/Vomiting: Asymmetric?: YN
Date of Visit: Right leg:  Y  N
YN
____/___ /____ PROGRESSION Left leg:  Y  N ___ ___ __
Muscle pain:
Name and address Paralysis fully developed within 3 Breathing muscles:  Y  N
YN NOTE: Instructions on the
of health facility 2: to 14 days from onset of illness?
Meningeal signs: Neck muscles: YN grading/scoring of the sensory
YN status, deep tendon reflexes
YN Facial muscles: YN
Date of Visit: and motor status are presented
Direction of paralysis:
____/___ /____ ________
Working Diagnosis: at the back of this page.
 Ascending  Descending
III. EPIDEMIOLOGIC DATA
History of neurologic disorder?:  Y  N If YES, specify disorder:
Did the patient travel (>10 km from house) one month prior to illness?  Y  N
If YES, specify place: Date traveled: From / / To / /
Other AFP cases in patient’s community within 60 days of patient’s paralysis?  Y  N
Does the patient had any history of injection, trauma and/ or animal bite ?  Y  N
If YES, specify type
Is there an Environmental Sample tested positive for WPV/ VDPV / Sabin-like 2 in the area?  Y  N IF YES, Specify the date: / /

IV. IMMUNIZATION HISTORY

Polio Vaccine given:  Y  N Is this a “Hot case”?  Y  N
OPV Total Routine OPV doses received: Date last OPV dose: / / Total SIA OPV doses received: Date last OPV dose:__/_ /_
IPV Total IPV doses received: Date last IPV dose: _/_ /_ _
V. LABORATORY DATA
Stool Amount of
If YES, date Date sent Date re- Stool Specimen Condition
sample Collected? Result (To be filled out by RITM)
taken to RITM ceived RITM (To be filled out
# by RITM)

 WPV If WPV, Sabin-like No. of Ice packs:

1 Y  N / / ___ / / __ / / __  Sabin-like or VDPV: Specify: Qty of Ice packs:  Frozen
MM DD YYYY MM DD YYYY MM DD YYYY
 VDPV  Type 1  Thawed but cold
 NEG  Type 2  Warm
 NPEV  Type 3
Type of Container:
 WPV If WPV, Sabin-like
2 Y  N /_ / ___ / / __ / / __  Sabin-like or VDPV: Specify:
Name of Courier:
MM DD YYYY MM DD YYYY MM DD YYYY  VDPV  Type 1
 NEG  Type 2 RECEIVED BY:
 NPEV  Type 3

VI. 60-DAY FOLLOW-UP

Expected date of follow-up: / / Follow-up done:  Y  N If NO, reason for no P.E:
If Yes, actual date of follow-up conducted: / /
P.E. done?  Y  N  Patient Died Date: / /
Residual paralysis at 60 days?:  Y  N  Lost to Follow-up
If Yes, Specify: Flaccid/Floppy  Spastic   OTHERS, Specify:
Presence of Atrophy?:  Y  N
Site: RA:  Y  N LA:  Y  N Note other observations:
RL:  Y  N LL:  Y  N
"Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act No. 11332"
 Version 2022

Case Investigation Form

Acute Flaccid Paralysis

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

FINAL CLASSIFICATION CLASSIFICATION CRITERIA FINAL DIAGNOSIS
 Confirmed wild polio  Laboratory
 Vaccine-derived paralytic polio (VDPV)  Lost to follow-up
 Vaccine-associated paralytic polio (VAPP)  Death
 Recipient VAPP  With residual paralysis
 Contact VAPP  Without residual paralysis
 Polio compatible
 Discarded as Non-Polio Was this case considered as
Date classified: / / NOT AFP?  Y  N
MM DD YYYY

AFP Case Definition:

 An AFP case is defined as a child less than 15 years of age presenting with recent or sudden onset of floppy paralysis or muscle
weakness due to any cause, OR
 Any person of any age with paralytic illness if poliomyelitis is suspected by a clinician.

‘Hot’ or ‘high risk’ Case Description:

 A case that is considered highly suspected for being polio based on clinical data and with the following presenting characteristics:
 Less than 5 years of age
 Less than 3 OPV doses
 Fever at onset of paralysis
 Asymmetric paralysis
 Rapid progression of paralysis (within 3 days)
And/or
 Has been in contact with or living in area with possible or recent Polio virus circulation.

Adequate Stool Definition:

 Two stool specimen (at least adult thumb size)
 Collected within 14 days from onset of paralysis
 With a collection interval of at least 24 hours

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 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)

"Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act No. 11332"