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Republic of the Philippines

Department of Health

OFFICE OF THE SECRETARY

DEPARTMENT ORDER

No. 2019 -_

0380

August 15, 2019

SUBJECT:

Guidelines for the Intensified Acute Flaccid Paralysis (AFP) Case Finding and Stool Specimen Collection

free in 2000, along with other countries in the

Western Pacific Region. However, in 2001, three (3) cases of circulating vaccine derived-

poliovirus (CVDPV) were detected in the country. Further in 2011, the country was identified at high risk for polio virus re-introduction as AFP surveillance performance, OPV coverage and OPV supplemental immunization activities continue to be a challenge. This is further

from

ongoing

neighboring countries transmission of cVDPV.

The

Philippines

was

certified

polio

compounded

by

the

fact

like

that

Philippines

is

at

risk

for

importation

of polioviruses

there is

an

Indonesia,

and Papua New Guinea where

measures

Prioritization was based on three criteria: (1) OPV vaccination coverage in routine

vaccination; (2) AFP surveillance performance; and, (3) cordition of environmental sanitation.

Based on the National Certification Committee for Polio Progress Report

provinces and cities in the 17 regions categorized as HIGH RISK AREAS infection in the Philippines.

against polio.

In response, DOH identified priority areas which need to strengthen preventive

for

2018, identified

Poliovirus Re-

Thus,

to

halt the threat

of re-infection,

immediate

actions

must

be

instituted.

One

component that needs to be heightened is the active search (surveillance) of children below 15

years of age who have developed acute flaccid paralysis (AFP).

I. Target Areas

AFP active surveillance should be established in communities and health facilities in areas classified as high risk for polio re-infection. This will be done through supervision and collaboration with the Regional and Local Epidemiology and Surveillance Units (ESU). Priority will be given to high risk cities and municipalities:

Geographical Area

Municipalities

categorized as

Poliovirus Re-infection

and Cities that are HIGH RISK AREAS for

based on the Certification

Rest of municipalities and cities not

Assessment of the National Committee for Polio

eran

as

includedin hd igh risk areas

Active Community-based Surveillance (Human Resource for Health)

House-to-house

To be determined based on the results of the AFP Surveillance in priority areas

:

Active Hospital Surveillance

py pasar

Peeve

Surveillance Officers)

Enhanced AFP

surveillance daily

rounds in sentinel

hospitals

AFP surveillance

daily rounds in

.

:

sentinel hospitals

Building

1, San Lazaro Compound, 1 Rizal Avenue, Sta. Cruz,

Direct Line:

711-9502;

711-9503 Fax: 743-1829 @ URL:

Page 1

1003

Manila @ Trunk Line 651-7800

local 1113, 1108,

http://www.doh.gov.ph;

of 14

e-mail:

ftduque@doh.gov.ph

1135

Te

II.

Implementation

A.

1.

Case Detection

AFP active surveillance will use the following AFP standard case definition:

An AFP case is defined as a child < 15 years of age

onset of floppy paralysis or muscle weakness

of

presenting with recent or sudden the limb/s due to any cause,

OR

Any person of any age with paralytic illness if poliomyelitis is suspected by a clinician

2. The following diseases will manifest acute flaccid paralysis (AFP):

Poliomyelitis

Guillain-Barre

Syndrome (GBS)

Myelitis (i.e. Transverse

Traumatic neuritis Potts Disease Other disease as long as AFP is manifested

myelitis)

B. Active AFP Case Finding

1. Community-based

Surveillance (CBS) Active Case Finding

Priority should be given to areas with the following conditions:

1. Low OPV Coverage

2. Poor AFP surveillance (below target)

3. Poor environmental sanitation (e.g. poor sanitary toilet or percentage of open defecation in the community and poor access to safe water supply and poor waste disposal system)

4. Areas with informal settlers and over crowding

_ Areas where polio virus isolate was detected in the environment through

environmental

surveillance

a. Community-based

active case finding:

Step 1: Local health authority with the EPI coordinator, sanitary inspector, and

development

management officer (DMO) of DOH will

barangays

barangays for CBS-Active

assess the

based on the above mentioned condition to prioritize

Case finding.

Step 2: Once the list of barangays is made, the local health authorities

the local chief executives

(municipal/city

coordinate with

and barangay officials) the need to

heighten AFP surveillance in the area.

Step 3: Community preparation will be done by conducting AFP orientation for BHWs, Barangay Nutrition Scholars, school authorities and officers of Parent-Teacher

health

Associations (PTAs). These

facilities in identifying children thatfits the description of AFP.

will be

partners

of the

group

barangay

Page 2 of 14

ae ir

Step 4: Active AFP Surveillance case finding will commence in the next three (3) days

and ask if anyone in the

Survey Tool

after community orientation.

family is <15 years old.

Approach a household

List this down in the AFP

Community

(Annex A).

Step 5: If yes,

ask further how many of the <15 years old children have sudden onset

Once a child

has been identified as an AFP case in the community, the child will be reported to the health center. Information to be collected are the following: name of the child, age, sex, complete address and date when weakness or paralysis developed or noticed.

or recent weakness/paralysis

occurring within the last 2 months.

For those children with onset of AFP before 2 months and within the six (6)

Form only. It is important to

identify these children and classify them

months period, complete the Case

Investigation

as “missed” case.

For a child whose condition occurred in the last two (2) months, complete the CIF and collect stool specimens for laboratory.

a child with AFP is reported to the health center, local health authorities with the human resources for health (HRH) will investigate using the

AFP CIF (Annex B). Collection of stool specimen will also be done. If stools

collected from the case are inadequate, identify three (3) to five (5) close contacts and their names will be entered in the AFP Close Contact Form (Annex E). Stool specimens will also be collected from close contacts. Stool samples collected will be place in a stool specimen container (Section C, see table on specimen collection).

address and

date of collection) stools specimens and place in the stool collection box (with ice) and to be transported and received by RESU within 24 hours after collection. Transport specimens to the National Reference Hospital a day after RESU

Step 6: When

together

Step 7: Submit accomplished forms to RESU.

Label properly (name,

age,

received the specimen.

b. Review of all consultations seen and managed by the health center:

Step 1: HRH will request access the record of consultations logbook in the health center. Step 2: Review carefully all consultations for the last six (6) months and check for any chief complaint that fits the definition of AFP. Step 3: Any potential AFP case identified will be enrolled in the Retrospective Records Review Form (Annex C) Step 4: Request for the medical record (if there is any) or family envelope of cases enrolled in the Retrospective Records Review Form to verify and assess if any patient fits the definition of an AFP. The following information must be verified: Check the chief complaint, present medical history, physical assessment, diagnosis, physician’s notes and nurse’s notes for any

documentation of “sudden onset of floppy paralysis”.

Step 5: If any

of the retrieved case/s fit the AFP definition,

previously

reported.

If not reported,

patient has been

check with RESU if the

classify the child as a

“missed” case. Step 6: If any of the missed case/s fit the AFP definition, with onset within the last 2

months, fill-out the AFP CIF.

Page 3

of 14

Step 7: For a child who developed AFP within the last two (2) months stool specimen will be collected. If stools collected from the case were inadequate, identify three (3) to five (5) close contacts and their names will be entered in the AFP Close Contact Form (Annex E). Collect stool specimens also likewise be collected from close contacts. Stool samples collected will be place in a stool specimen container (Section C, see table on specimen collection).

Step 8: Submit accomplished forms to RESU.

Label properly (name, age, address

and date of collection) stools specimens will be placed in the stool collection box (with ice) and to be transported and received by RESU within 24 hours

collection. Transport specimens to the National Reference Hospital a day

after

after RESU had received the specimen.

Step 9: Secure a copy of the patient’s medical record and laboratory results.

Send to

RESU for submission to the AFP Expert Panel Committee for classification.

2. Health Facility-based AFP Surveillance Active Case Finding

AFP Surveillance Officers (AFPSO), Disease Surveillance Officers (DSO) or Disease Surveillance Coordinators (DSC) of the RESU, PESU, and CESU or of the hospital will conduct regular surveillance through hospital ward visits and retrospective medical records review

The following steps shall be taken:

A.

Hospital Ward Surveillance

Step 1: Assign AFPSO/DSO to designated hospitals Step 2: RESU Head coordinates with hospital authorities (medical Center Chief and the hospital surveillance focal person) where assigned AFPSO will conduct the AFP Surveillance. Step 3: On the day of the hospital visit, AFPSO will make sure that he/she has the

needed surveillance materials.

surveillance focal person so

AFPSO will be properly endorsed to the head nurse of the Pediatric Ward

Step 5: In the ward, AFPSO checks the logbook

currently admitted

with a chief complaints of “paralysis / weakness of extremity” or diagnosed an admitted patient due to the AFP differential diagnosis. Step 6: If admitted patient/s fit the AFP case definition, check with the hospital DSC

Step 4: RESU Head will coordinate with the

hospital

of admission

and go through the list

of admissions, checking on any patient

<15 years old who is

or with RESU if the patient has already been reported or a “missed” case.

Step 7: If case has not been reported,

AFPSO/DSO/DSC investigates

the case and

accomplish the AFP CIF (Annex B).

patient,

specimen containers and

Step

8:

For

admitted

Give two stool

instruct the patient or the patient’s guardian to collect

stool

specimen will be collected.

two stool

specimens 24 hours

apart.

Step 9: Endorse to the nurse-on-duty

of admitted patient that two stool specimens

must be collected.

Step 10: If stools collected from the case are inadequate (as in the case where the patient was discharged and failed to give the 2 stool specimen), refer the case to appropriate DMO for community follow-up. In the community, HRH identify three (3) to five (5) close contacts and their names will be entered in the AFP Close Contact Form (Annex E). Stool specimens will also be

Page 4 of 14

ae

collected from close contacts. Stool samples collected will be place in a stool specimen container (Section C, see table on specimen collection).

Step 11: Submit accomplished forms to RESU.

and date of collection) stools specimens and place in the stool collection box (with ice) and to be transported and received by the RESU within 24 hours after collection. Transport specimens to the National Reference Hospital a day after RESU had received the specimen. Step 12: Secure a copy of the patients medical record and laboratory results. Send these to RESU for submission to the Epidemiology Bureau (EB) for classification. Step 13: Consolidate findings for the day and immediately report any AFP case found to RESU.

Label properly (name, age, address

. Retrospective AFP Surveillance Records Review

Step 1: Assigned

AFPSO/DSO visits the Hospital Records Section and borrow the

Step 2:

consultation / admission

AFPSO/DSO will carefully review the all consultations / admissions for the last six (6) months and check for any chief complaint that fits the definition of

an AFP.

logbook.

Step 3: Any case identified, enroll in the Retrospective Records Review Form (Annex C) Step 4: Ask the records keeper to retrieve the medical charts of patients listed in the Retrospective Records Review Form to verify and assess if the such condition

fits the definition of an AFP. The following

Check the chief complaint,

nurse’s

diagnosis,

“sudden onset of floppy paralysis”.

check with the

hospital DSO or with RESU if the patient has been previously reported or “missed”.

been

“missed” and the onset of paralysis is within the last 2 months, fill-out the

AFP CIF.

Step

Step 5: If any of the retrieved charts fit the AFP case definition,

information must be verified:

history,

physical

assessment,

for any

documentation

of

present

medical

physician’s

notes and

notes

6:

If any of the

retrieved

charts that fit the

AFP case

definition

has

Step 7: If the case is not yet reported; The DSO will investigate the missed case and fill-out the AFP CIF (Annex B). Stool specimen collection will likewise be done. If stools collected from the case were inadequate, identify three (3) to five (5) close contacts and their names will be entered in the AFP Close Contact Form (Annex E). Stool specimens will likewise be collected from the close contacts. Stool samples collected will be place in a stool specimen container (see table on specimen collection). Step 8: Accomplished forms will be submitted to the RESU. Properly labelled (name, age, address and date of collection) stools specimenswill be placed in the stool collection box (with ice) and will have to be transported to and

Specimens will have

to be received by the National Reference Hospital the day after RESU had

received by the RESU within 24 hours after collection.

received the specimen.

Page 5 of 14

ies

C.

Surveillance

Unit

(CESU)

AFP case in the field.

concerned

for the

follow-up

investigation

of the

Stool Specimen Collection

1. From a child who developed AFP. Stool specimen will be collected two (2) adult thumb- sized stool specimens at least 24 hours apart within 14 days from paralysis onset (adequate stool specimen). Both the stool sample should be collected within 14 days. If the first sample is collected in day 12 and second sample is collected on day 15, this will be inadequate sampling. If only one stool sample is collected before 14days and second

sample

is

not collected, this is classified as inadequate sampling.

2. For AFP case with inadequate stool specimen, identify 3-5 close contacts, aged 14 years old and below, regardless of symptoms. List them down in the AFP Close Contact Form

(Annex E).

One

stool

3. stool specimen will be collected once the close contact is identified.

4. Each

specimen

shall be

properly

labeled

with

patients

name,

collection and stool number.

date and time

of

5. After each stool collection, not place the stool specimen

6. All

specimen shall be kept in refrigerator at temp of 2-§ °C.

in the freezer.

Do

stool samples will be forwarded to the RESU. RESU shall transport specimens to the

Research Institute for Tropical Medicine (RITM) for testing within 3 days from the day of stool collection.

7. RITM will provide RESU and EB with initial laboratory results within 14 days from receipt of specimen (Annex F).

8. RESU shall provide feedback of laboratory results received from RITM to the reporting DRU/LGU.

9. Laboratory results of stool specimens must be communicated by the RESU to the local health authority authorized to inform the family of the child with said result.

The table below,

summarizes the process in stool specimen collection:

Community and Hospital AFP surveillance

Child with AFP

Condition

Condition

a

Condition

1

2

3

weakness or

paralysis

Notified and Investigated within 14 days of paralysis onset

Notified and Investigated after 14

days to 2 months after

the paralysis onset

Notified and

Investigated 2 months

to within a 6 months

after paralysis onset

i

Child with AFP

i

> senmins

enilntend 38

siiaas

P

2 samples collected 24

hours apart

Not needed

Page 6 of 14

310 5 close

eemkuees

Not needed

At least 3 close

contacts, 1 stool

sample per contact

to be collected

Not needed

Remarks

2 samples should be

collected

samples should be

and both

collected

within 14 days

after the paralysis onset

oe poled lsat

i

ibli

i

roe

foaes

Case Investigation form is

.

completed as a missed

es

D. Flow of Reporting

L Results of the community-based and health-facility-based active AFP case finding shall

be submitted to the RESU for consolidation and encoding (Annex

RESU shall validate and ensure

accuracy RESU shall maintain the database, analyze and geneiate a daily report for dissemination to stakeholders.

RESU shall submit daily a copy of the AFP database to EB

a scanned

submission to the National AFP

Expert

EB shall consolidate the CIF and medical records for

D).

of information written in

the CIF.

every 5:00

PM, together with

copy of the patient’s CIF and medical records (if available).

Panel Committee for final classification of cases.

- EB

shall update the RESU and the submitted database with the AFP final classification.

EB shall analyze and generate a daily update for dissemination to DOH Executive Committee Members andother stakeholders.

Il.

Repealing Clause:

All other issuances inconsistent with this Order are hereby repealed/rescinded.

By Authority of the Secretary of Health:

RNA C. CABOTAJE,

/MD, MPH, CESO III

Undersecretary of Health Public Health Services Team

Page 7 of 14

Annex A:

AFP Community Survey Tool

AFP Community Survey Tool

Region:

Muncity:

Date:

Brgy/Area:

Name of Surveillance

Officer:

Household

How many children are <15 years old?

Page

8

of 14

How many children had weakness/

within the last 2 months?

paralysis

* Fill-out AFP CIF

S

Annex B: AFP Case Investigation Form

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Page 10 of 14

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