1. Poliomyelitis Surveillance in Ireland 4 th April, 2014

2. Acknowledgement The health Protection Surveillance Centre (HPSC) would like to thank all those who have contributed to polio surveillance, the National Virus Reference Laboratory, the Irish Paediatric Surveillance Unit (IPSU), paediatricians and all others who have provided data in relation to polio surveillance.

3. Rationale for polio surveillance Europe has been polio free since 2002, but poliomyelitis virus continues to circulate in other countries In 2013, polio was identified in –Afghanistan, Nigeria and Pakistan – endemic –Syria, the Horn of Africa, Cameroon, Somalia, other African countries – outbreaks –Egypt, Israel, the West Bank and Gaza Strip – environmental or asymptomatic individuals As long as a single child remains infected, children in all countries are at risk of contracting polio.

4. Cases of polio in Ireland The last notified case of polio was in 1984

5. Irish surveillance for Poliomyelitis- methods Acute flaccid paralysis (AFP) in ALL children < 15 years of age Investigation of suspect cases of CNS infection (e.g. meningitis, encephalitis, AFP) of all ages if travel or epi-links to contacts from areas where polio virus circulating,

6. Definition of AFP Acute flaccid Paralysis (AFP) is a clinical syndrome characterised by rapid onset of weakness, including (less frequently) weakness of respiratory and swallowing, progressing to maximum severity within several days to weeks. AFP is a complex clinical syndrome with a broad array of potential aetiologies.

7. AFP surveillance and Polio Surveillance of AFP is used in surveillance for poliomyelitis in the context of the global polio eradication initiative Polio is caused by a human enterovirus called the poliovirus. Wild polioviruses are those that occur naturally. There are three serotypes of wild poliovirus – type 1, type 2, and type 3 Polio is one of only a limited number of diseases that can be eradicated as there are no long-term carriers of the disease and an inexpensive vaccine is available

8. Potential aetiologies associated with AFP Includes possible illness due to: Guillian-Barré syndrome Transverse myelitis Traumatic neuritis Viral infections caused by other enteroviruses toxins and tumours

10. Objectives of AFP surveillance To rapidly detect re-importation of poliovirus into polio-free areas To ensure that robust surveillance systems are in place so that if AFP caused by polio virus that it would be identified quickly

11. Investigation of AFP in children < 15 years of age 1.AFP case admitted to hospital 2.Collect 2 stool specimens as early as possible, 24 hours apart, within 2 weeks of paralysis onset and send to National Virus Reference Laboratory (NVRL) 3.Complete AFP enhanced surveillance form and return to Paula Flanagan, HPSC, 25 ‐ 27 Middle Gardiner Street, Dublin 1, Tel: 01 876 5300, Fax: 01 856 1299 4. Surveillance forms available on ward or available at http://www.hpsc.ie/hpsc/A- Z/VaccinePreventable/Polio/AcuteFlaccidParalysisAFP/ http://www.hpsc.ie/hpsc/A- Z/VaccinePreventable/Polio/AcuteFlaccidParalysisAFP/ 5.When returning your monthly IPSU (Irish Paediatric Surveillance Unit) card indicate if you have seen a case in previous month

13. AFP reports in children < 15 years of age, by year of onset of paralysis, 2009-2013 Year of Onset of Paralysis Total 20096 20104 20119 20126 20138 Total33

14. AFP cases by Age Group 2009-2013 Age GroupTotal 0-413 5-95 10-147 Not specified8 Total33

15. AFP cases by Diagnosis 2009-2013 Final Clinical Diagnosis CategoryDiagnosisTotal Polyradiculneuritis/Guillain-Barre Syndrome/Landry Syndrome Guillain Barre Syndrome10 Not specified3 Transverse myelitisTransverse Myelitis3 Other specific neurologic diseases Acute Disseminated Encephalomyelitis5 Botulism1 Conversion Disorder1 Other Disorder Neuromus Transmission2 Not AFP* 4 Not specified 4** Total33 *Isolated facial paralysis of any cause, spastic or chronic paralysis, meningitis, coma etc. ** No enhanced surveillance form completed, suspect case reported via Irish Paediatric Surveillance Unit (IPSU) only

16. Vaccination uptake of 3 doses polio vaccine at 12 months, by LHO, Q3 2013* *Source: HPSC Q3 2013 report located at http://www.hpsc.ie National uptake = 92% (range 88%-95%)

17. Vaccination uptake of 3 doses polio vaccine at 24 months, by LHO, Q3 2013* *Source: HPSC Q3 2013 report located at http://www.hpsc.ie National uptake = 96% (range 94%-98%)

18. WHO recommendations to decrease risk of Wild Polio Virus (WPV) importation and possible spread and disease Vaccination recommendations Maintain national vaccination coverage with completed polio vaccination > 90% Identify those at risk of low immunisation and implement vaccination as needed National data 3 doses at 12 months is 92% (Q3 2013) 3 doses at 24 months is 96% (Q2 2013) Currently national data is not available by ethnicity, migrant or other risk factor status

19. Recommendations to decrease the risk of WPV importation and possible spread and disease in Ireland(2) Improve surveillance- P aediatric AFP surveillance –All AFP cases in children < 15 years of age (regardless of presumed diagnosis) should be investigated for enteroviral/polio virus specific infection –Children < 15 years of age who present with aseptic meningitis, encephalitis, other neurological symptoms (non-AFP) should be systematically tested for polio virus IF they have links (direct travel or contact with individuals from these countries where wild polio has been identified)

20. For older child and adult surveillance for polio virus Older children (> 15 years) and adult patients, with a history of travel to, or contact with individuals from, countries where wild polio has been identified AND who present with AFP, aseptic meningitis, encephalitis, other neurological symptoms (non-AFP) should be systematically tested for polio virus.

21. Laboratory investigation (NVRL) - Summary Two stool samples should be taken as soon as possible (at least within 2 weeks of onset and 24 hours apart) and sent to the NVRL with clinical detail to facilitate rapid investigation and feedback –All paediatric cases of AFP –All cases of AFP, aseptic meningitis, encephalitis, other neurological symptoms (non-AFP) especially IF there are epi-links to countries (or individuals returned from these countries) where polio virus is circulating

22. Thank you For more information http://www.hpsc.ie/hpsc/A- Z/VaccinePreventable/Polio/