Acute flaccid paralysis

Text WHO office in Ethiopia, Photos Pierre Virot (WHO)

Acute flaccid paralysis (AFP) surveillance started in Ethiopia in May 1997 and has seen a significant improvement over the years with the involvement of more and more staff. The program started off with 1 surveillance officer in 1997 and has now 18 fully committed officers and a number of regional and district surveillance officers. These officers regularly do active case search for AFP, measles and neonatal tetanus in their respective areas of activity, and conduct training and sensitization sessions to local health staff on AFP surveillance as well as supporting routine EPI and integrated communicable diseases surveillance. The surveillance network comprises 459 active sites, mainly hospitals and health centers, each with a designated AFP focal person. Health stations and health posts as well are targeted for early case notification through regular sensitization and district level reviews.

The initial challenges were the lack of awareness on the part of clinicians and health workers, and the lack of resources like communication facilities to allow for early case reporting. Training and sensitization sessions, initially targeting clinicians and surveillance AFP focal persons from governmental, non-governmental and private health institutions, are expanding to include traditional healers and holy water sites and influential community leaders recognizing the fact that late reporting occurs due to a high rate of visits to alternative practitioners.

In the last 5 years emphasis had been laid on the sensitization of community leaders as well as health workers in order to stimulate reporting of AFP cases. The case reports have improved dramatically ever since. In 1997 only 14 cases of AFP had been reported, while up until Sept 2002, the case report for the year has already reached 315 cases. The non-polio AFP rate has increased from 0.28 in 1999 to 1.6 in 2001 and the proportion of AFP cases with 2 stool specimens collected within 14 days of onset of paralysis improved from 23% in 1999 to 47% in 2001. The figure for 2002 stands at 71% as of Sept 20^th. As of late September, there remain eleven “silent zones” (out of a national total of 78 zones) which have not reported any AFP case for the year. However, these zones comprise of only less than 7% of the country’s population. The population in these areas is mainly nomadic and thus poses more of a challenge.

All stool specimens are routinely tested in the polio laboratory at the Ethiopian Health and Nutrition Research Institute (EHNRI). The lab has attained WHO accreditation status in
2001. In 1999 and 2000, four polio cases due to wild poliovirus were detected. The fifth and last case of wild poliovirus was detected in Kembata Zone of Southern region in January 2001. Even though intensive surveillance activities over the last 18 months have not yielded any more polio viruses, the quality of AFP surveillance is not uniform throughout the country and performance indicators have yet to attain the recommended standards.

An international review conducted in August 2002 has identified these weaknesses and the review team decided that, in view of doubts concerning the quality and completeness of the AFP surveillance system, it could not confirm the absence of transmission of wild poliovirus anywhere in the country. The review team has recommended establishing an effective infrastructure for AFP surveillance and for provision of immunization in the Afar/Somali zone, the identification of high risk areas as well as areas with difficult or remote access followed by the drawing up of a regular schedule of visits. Efforts are currently underway to ensure proper implementation of these recommendations.