Version 2013

Philippine Integrated Disease

Surveillance and Response
Case Investigation Form
Acute Flaccid Paralysis
Name of DRU:
Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Address: Gov’t Laboratory Private Laboratory Airport/Seaport
I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:
Sex: Male Female Date of Birth: ____/____/____ Age: ____ Days Months Years
MM DD YY
Complete Address: District: ILHZ:

MM DD YY
Patient Admitted? Yes  No Date Admitted/ Seen/Consult:
MM DD YY MM DD YY
Date of Report: Date of Investigation:

Name of Investigator: Contact Nos.:

II. CLINICAL DATA (Put a check [ √ ] in the appropriate box)

Deep
Sensory Motor
PRODROME PARALYSIS SITE OF FLACCID PARALYSIS Tendon
Status Status
Reflexes
Right arm:  Y  N ____________ ____________ ___________
Fever:  Y  N Date onset: _____/_____/_____
Cough:  Y  N Present at birth?:  Y  N Left arm: Y N ____________ ____________ ___________
Diarrhea/Vomiting: Asymmetric?: Y N Right leg:  Y  N ____________ ____________ ___________
Y N PROGRESSION Left leg: Y N ____________ ____________ ___________
Muscle pain: Paralysis fully developed within 3
Breathing muscles: Y  N
Y N to 14 days from onset of illness?
Y N Neck muscles: Y N NOTE: Instructions on the grading/scoring
Meningeal signs:
Facial muscles: Y N of the sensory status, deep tendon
Y N
Direction of paralysis: reflexes and motor status are presented at
 Ascending  Descending Working Diagnosis: the back of this page.
_____________________________

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 have any history of injection, trauma and/ or animal bite ?  Y  N
If YES, specify type: _____________________________________

IV. IMMUNIZATION HISTORY

Total OPV/IPV doses received: ________ Date last dose of OPV/IPV: ___/___/___ Is this a “Hot case”?  Y  N

V. LABORATORY DATA

Stool Amount of
If YES, date Date sent to Date received Stool Specimen Condition
sample Collected? Result (To be filled out by RITM)
taken RITM RITM (To be filled out by
# RITM)

 L20B+ Adequate No. of Ice packs : _______

1 Y N ___/___/___ ___/___/___ ___/___/___ NEG Inadequate
Qty of Ice packs:  Frozen  Thawed but
NPEV  Warm cold
 L20B+ Adequate Type of Container: ___________________
2 Y N ___/___/___ ___/___/___ ___/___/___ NEG Inadequate Name of Courier: ____________________
NPEV RECEIVED BY: _____________________
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: ___/___/___
Patient Died Date:___/___/___
P.E. done?  Y  N
Lost to Follow-up
Residual paralysis at 60 days?:  Y  N
OTHERS, Specify: ____________________
Flaccid/Floppy:  Spastic: 
Presence of Atrophy:  Y  N
Note other observations: _____________________________
Site: RA: Y N LA: Y N
RL: Y N LL: Y N
 Version 2013

Case Investigation Form

Acute Flaccid Paralysis

VII. CLASSIFICATION (TO BE FILLED OUT 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
Date classified: _____/_____/_____ Was this case considered as
NOT AFP?  Y  N

AFP Case Definition:

 Any child under 15 years of age with acute onset of floppy paralysis, OR
 A person of any age in whom poliomyelitis is suspected by a physician.

Hot Case Description:

 An AFP case that is <5 years old with < 3 doses of OPV and has fever at the onset of asymmetrical paralysis, OR
 An AFP case or a person of any age whose stool specimen(s) has poliovirus isolate.

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 (DTRs) 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)