AFP Surveillance in the

21st Century

Gloria Rey, Regional Advisor,

Special Program Comprehensive
Immunization(CIM)
May 25, 2023
 The virus and disease

Progress on polio eradication

Content
Acute flaccid paralysis surveillance

Polio situation in the Region of the Americas

 Polio
Poliovirus Poliomyelitis
(the agent) (the disease)
• Poliovirus is an RNA virus, • Poliomyelitis is an infectious
member of the genus Enterovirus, disease caused by the poliovirus.
Picornaviridae family.
• The virus invades the nervous
• There are three poliovirus system and can cause permanent
serotypes (1, 2 and 3) with paralysis.
minimal immunity between them
• Most people infected (72%) have no
(heterotypic).
symptoms.
• Poliovirus only infects people.
• One in 200 infections results in
• Person-to-person transmission: permanent paralysis and can cause
fecal - oral and pharyngeal death.
secretions.
https://www.paho.org/es/temas/poliomielitis
https://www.cdc.gov/polio/what-is-polio/index.htm
https://www.cdc.gov/polio/what-is-polio/hcp.html
 Poliomyelitis
Wild poliovirus Vaccine-derived
WPV poliovirus or VDPV*.

In communities with low

Viruses originally present in vaccination coverage, the virus
nature. mutates and recovers the
WPV2 and WPV3 have been neurovirulence => VDPV.
eradicated. There is a risk of transmission.
WPV1 is endemic in AFG and Can be generated in
PAK. immunodeficient individuals
They are highly transmissible. (PID).

Final classification of VDPV

• cVDPV circulating, evidence of H – H transmission.
• iVDPV associated with immunodeficiency.
• aVDPV ambiguous, the case is immunocompetent and
the virus is not genetically related.
 Poliomyelitis vaccines
mOPV

OPV IPV
• Licensed in 1963, created by Albert Sabin. • Introduced in 1955, created by Jonas Salk.
• Live attenuated virus vaccine that may contain • Inactivated vaccine containing the three PV
one, two or three serotypes. serotypes (1, 2 and 3).
• It is administered orally. • Administered by intramuscular or intradermal
injection (for fIPV).
• Provides humoral immunity and long-term
intestinal immunity; effective in stopping • No risk of VAPP or VDPV.
transmission.
• Generates good humoral immunity but induces
• In communities with low vaccination coverage, very low levels of antibodies in the intestinal
the virus can mutate and revert to neurovirulent mucosa.
(VDPV) and in rare cases, can cause vaccine-
• Protects against paralytic disease but does not
associated paralytic poliomyelitis (VAPP).
stop intestinal viral replication.
 Polio Eradication
Eradication: permanent decrease to zero of the worldwide incidence of infection caused by a
specific agent as a result of deliberate efforts.

Last case of polio Last case of polio

by WPV2 in 1999 by WPV3 in 2012

Declared eradicated in Declared eradicated in

September 2015 October 2019
 WPV1 & cVDPV1 polio cases, previous 12 months2

VIRUS COUNTRIES CASES

WPV1 3 21
cVDPV1 5 201
cVDPV2 19 475

Endemic country (WPV1)

1Excludes viruses detected from environmental surveillance; 2Onset of paralysis: 24 May 2022 to 23 May 2023 Data in WHO HQ as of 23 May 2023
 Milestones in the eradication of Polio in the
Americas

Outbreak of cVDPV1, 2000 -

2001

Polio cases, 1985 Certified polio-free 1994

 Polio Surveillance

Polio surveillance is
conducted through the
acute flaccid paralysis
syndrome (AFP). All cases in children under
Paralysis: weakness, loss 15 years of age presenting
or decrease of movement. AFP for any reason except The syndromic
Flaccid: loss of muscle severe trauma, or any definition allows the
tone. person of any age in surveillance system to All cases should be
Acute: rapid progression whom poliomyelitis is
of paralysis. be sensitive as it
suspected, should be thoroughly investigated
captures polio cases,
investigated. including stool sample
but also other
diseases present in collection for laboratory
similar ways. diagnosis.

Source:
- Pan American Health Organization. Eradication of poliomyelitis: a practical guide. Third edition. 2005
- Polio Global Eradication Initiative. Global guidelines for acute flaccis paralysis surveillance in the context of poliocirus eradication. Pre-publication version.
Differential diagnoses
of poliomyelitis
There are many infectious and non-
infectious diseases that can cause
paralysis, and therefore be confused with
poliomyelitis.
Acute Flaccid Paralysis (AFP) Surveillance in the Americas

1995 2005 2023*

Investigation of a suspected case of poliomyelitis
Decision tree for case investigation
 Obtaining samples for laboratory diagnosis
• Obtain a stool sample within 14 Packaging of biological samples
days of the onset of paralysis.
• Use a clean, empty container to
collect 8 g of stool (two-inch
size).
• Label all samples (case or
contact name, case number, date
of sample obtained).
• Refrigerate samples
immediately after collection (4 -
8 oC).
• Rectal swab is a non-suitable
sample.
 Laboratory diagnosis of poliovirus
1 2 3
Virus Isolation in Cell Cultures Intratypic differentiation of poliovirus Genetic sequencing of VP1 region

Timely reporting of results = 14 days Timely reporting of results = 7 days

Timely reporting of results = 7 days
 AFP Surveillance, case definitions

Acute flaccid paralytic disease

associated with isolation of wild

2 Confirmed case poliovirus (or derived poliovirus VDPV),

with or without residual paralysis.

Acute paralytic disease with residual polio-

like paralysis after 60 days, or failure to

1 3 Compatible case
follow up or death, in which a stool sample
was not obtained within 15 days of
paralysis.

Probable case Any case of acute paralytic disease for

4 Dismissed case
which an adequate stool sample has been
obtained within 14 days of the onset of
Any person under 15 years of age paralysis and with a negative laboratory
presenting AFP, for any reason except result for poliovirus.
severe trauma, or any person of any
age in whom poliomyelitis is
suspected.
AFP Surveillance Indicators
Indicator
Detection of at least 1 case of AFP/100,000 children under 15 years
System sensitivity
of age.

Adequate investigation of the ≥80% of cases investigated (clinical, epidemiological) within 48

case hours of notification.

≥80% of cases had adequate stool samples collected for enterovirus

Adequate stool sample
detection (within 14 days of onset of paralysis)

≥80% of investigated AFP cases will be clinically evaluated within 60

Case follow-up
days of onset of paralysis.
AFP Surveillance Indicators, Region of % casos PFA investigados <= 48 hs
the Americas 2019 – 2022* 100 92 93
86 86 85
80
Tasa anual de casos de PFA
60

40

20
2.00

0
2019 2020 2021 2022* Last 52w*
1.50 1.33 1.32
1.16

1.00 0.82
0.93 % casos PFA con muestra adecuada
100
90
0.50 73 74 70 77 77
80
70
60
50
0.00
40
2019 2020 2021 2022* Last 52w 30
20
10
0
2019 2020 2021 2022* Last 52w*

Source: Country reports to PAHO. PAHO Polio Bulletin. Information as of May 6, 2023.
 Polio Cases in the Americas, 2022-2023
Case of cVDPV2 Polio in NY, USA Case of polio due to VDPV1 in Loreto, PER
- In an unimmunized immunocompetent young adult - Male, 14 months old, with no history of vaccination or
with no history of travel during the exposure period. travel history.
- Provenance: Rockland County, NY State - Origin: Manseriche district, department of Loreto.
- Onset of paralysis: June 20, 2022 - Onset of paralysis: December 29, 2022.
- Notification to PAHO/WHO: 21 July 2022 - Stool sample collection: January 18, 2022
- Classification as cVDPV2: 10 Sept 2022 - VDPV1 confirmation: March 21, 2023
- GPLN confirmed genetic linkage of virus to cVDPV2 Investigation and clinical evaluation of the case ruled out
detected in UK and Israel. primary immunodeficiency.
 Detection of cVDPV2 in wastewater,
USA and Canada, 2022
Detection of PV2 in wastewater, NYS
cVDPV2 in wastewater, Quebec, CAN
- Notification to PAHO/WHO 06 Jan 2023,
detection of VDPV2 in two samples collected in
August 2022
- CDC confirmed genetic linkage to cVDPV2 case
detected in Rockland, NYS
- No confirmed cases of polio or increase in AFP
cases have been observed in the province of
Quebec.
- Ambiguous, case is immunocompetent and the
virus is not genetically related.
No confirmed cases of poliomyelitis or an increase in AFP cases
have been observed in the province of Quebec in 2022.
Source: https://health.ny.gov/diseases/communicable/polio/docs/waste_water_surveillance_report.pdf

Source: Canada IHR National Focal Point

Polio Bulletin

Polio Bulletin

https://www.paho.org/es/boletin-semanal-
polio
 GTA Recommendations
1. Countries should make an effort to improve the performance of AFP surveillance
indicators to avoid undiagnosed cases of paralysis caused by poliovirus.
2. Countries with a very high risk of outbreaks should consider collecting a second
stool sample on a temporary basis while they strengthen their immunization
program and surveillance system.
3. If a stool sample cannot be collected from the AFP case within 14 days of the
onset of paralysis, or if the sample arrives at the laboratory in poor condition, it is
recommended that a sample from three contacts be collected.

XXVI Meeting of PAHO’s Technical Advisory Group (TAG) on Vaccine-Preventable Diseases. Vaccines bring us closer, 14-16 July 2021 (virtual). Full
report available at: https://iris.paho.org/handle/10665.2/54833
IX Ad Hoc Meeting of the PAHO Technical Advisory Group (TAG) on Vaccine-Preventable Diseases, 25 July 2022 (Virtual). Full report available at:
https://iris.paho.org/handle/10665.2/56566
The commitment to keep the region polio-freeResolution
CSP30.R13, September 2022
Develop and implement a prioritized and
targeted mitigation plan based on the
recommendations of the GTA and the RCC.
• Increase vaccination coverage
• Improve surveillance
• Ensure adequate preparedness for outbreak
response
Engage civil society, community leaders, NGOs,
private sector, academia and other
stakeholders to move forward and work in a
joint and coordinated manner.
 Acknowledgment
s
To all health professionals in the
countries of the Region who have
collaborated with polio program
activities.
To the Ministries of Health for
maintaining their commitment to
the polio program and sharing
information with PAHO/WHO.
To the CAN and the NCCs for their
ongoing support and
recommendations to keep the
Region polio-free.