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Referral and warning signs
When to refer
IMMEDIATE URGENT REFERRAL/REPORTING to District Health Team / Surveillance Focal Person for ALL suspected cases of Acute Flaccid Paralysis (AFP). Patient requires Hospital admission (H/RR) for supportive care, monitoring, and investigation.
Red flags
- Acute onset of flaccid paralysis in a child <15 years.
- Asymmetric weakness.
- Reduced/absent reflexes.
- Signs of respiratory distress or difficulty swallowing (bulbar involvement).
Signs and symptoms
- Asymptomatic Infection (~90-95%): No illness.
- Abortive Poliomyelitis (Minor Illness, ~4-8%): Non-specific symptoms: Fever, malaise, headache, sore throat, vomiting, abdominal pain. Resolves in <1 week.
- Non-Paralytic Poliomyelitis (Aseptic Meningitis, ~1-2%): Symptoms of minor illness plus neck stiffness, back pain, muscle tenderness. Resolves completely.
- Paralytic Poliomyelitis (<1%):
- - Initial minor illness symptoms.
- - Followed by onset of Acute Flaccid Paralysis (AFP):
- - Rapid onset of weakness/paralysis (develops over hours to days).
- - Typically asymmetric distribution.
- - Affects proximal muscles more than distal.
- - Lower limbs more commonly affected than upper limbs.
- - Muscle pain and spasms common initially.
- - Loss of deep tendon reflexes in affected limbs.
- - Sensation usually intact.
- - Fever present during acute phase.
- - Spinal Polio: Paralysis of trunk/limb muscles.
- - Bulbar Polio: Involvement of cranial nerves/brainstem -> Difficulty swallowing, speaking, breathing; potential respiratory failure.
- - Bulbo-spinal Polio: Combination of spinal and bulbar involvement.
Risk factors
- Lack of immunization (Oral Polio Vaccine - OPV, Inactivated Polio Vaccine - IPV).
- Travel to or residence in areas with ongoing poliovirus transmission (wild or vaccine-derived).
- Poor sanitation and hygiene.
- Immunodeficiency (prolonged viral shedding, risk from OPV).
Diagnosis
Clinical assessment
Suspicion based on clinical presentation of AFP (acute onset, flaccid, asymmetric paralysis with reduced reflexes, no sensory loss) in a child <15 years (or any age during outbreak). Bulbar symptoms highly suggestive.
Differential diagnosis
- Guillain-Barré Syndrome (GBS) (usually symmetric ascending paralysis, sensory symptoms common, areflexia).
- Transverse Myelitis (usually symmetric, sensory level present, bladder/bowel dysfunction).
- Traumatic Neuritis / Spinal Cord Injury.
- Acute Motor Axonal Neuropathy (AMAN) (variant of GBS).
- Other enteroviral myelitis (e.g., Enterovirus D68, EV-A71).
- Botulism (descending paralysis, cranial nerve involvement first).
- Tick paralysis.
- Toxic neuropathy / Heavy metal poisoning.
Investigations
- Stool Sample Collection: CRITICAL. Collect 2 stool samples, 24-48 hours apart, within 14 days of paralysis onset. Keep samples cold (refrigerated/frozen) for transport to reference lab (UVRI) for Virus Isolation and Typing (Wild vs Vaccine vs Vaccine-Derived).
- CSF Analysis (LP): Usually shows mild pleocytosis (lymphocytes or neutrophils early), normal/slightly elevated protein, normal glucose (consistent with aseptic meningitis if non-paralytic). Done mainly to rule out other diagnoses like bacterial meningitis or GBS (high protein, normal cells).
- Nerve Conduction Studies / EMG: Help differentiate from GBS/neuropathies (shows motor neuron damage in polio).
Diagnostic criteria
Clinical diagnosis of AFP triggers investigation. Confirmed Polio requires laboratory isolation of poliovirus from stool.
Management
Non-pharmacological management
- Supportive Care: (LOC: H)
- - Bed rest during acute phase.
- - Pain Management: Analgesics (Paracetamol, NSAIDs), moist heat applications.
- - Physiotherapy: Gentle passive range of motion exercises early to prevent contractures. Active exercises later during recovery phase.
- - Respiratory Support: Close monitoring for respiratory muscle weakness/bulbar involvement. Mechanical ventilation may be required for respiratory failure.
- - Nutritional support, bladder/bowel care.
- - Orthotics/bracing for residual paralysis.
- - Avoid Intramuscular (IM) injections during acute phase (may provoke/worsen paralysis - 'provocation paralysis').
Pharmacological treatment
- No specific antiviral therapy.
- Treat complications (e.g., UTI, pneumonia).
Monitoring
Monitor respiratory function closely in acute phase. Monitor muscle strength recovery. Long-term follow-up for rehabilitation and management of residual paralysis/deformity (Post-Polio Syndrome can occur decades later).
Complications
- Permanent muscle paralysis and atrophy.
- Limb deformities, contractures, scoliosis.
- Respiratory failure.
- Aspiration pneumonia.
- Post-Polio Syndrome (new weakness/fatigue years after recovery).
- Death (usually from respiratory failure).
Prevention
- Vaccination: Key strategy. Global Polio Eradication Initiative relies on OPV (live attenuated) and IPV (inactivated). Routine immunization schedule and supplementary campaigns (SNIDs/NIDs) crucial.
- Surveillance: Active surveillance for ALL cases of Acute Flaccid Paralysis (AFP) with prompt investigation and stool sample collection.
- Improved sanitation and hygiene.
- Containment measures during outbreaks.
Patient education
- Explanation of polio as a viral infection causing paralysis.
- Importance of supportive care and physiotherapy.
- Need for stool sample collection for diagnosis/surveillance.
- Long-term nature of potential disability.
- CRITICAL importance of vaccination for prevention in community.
- Rehabilitation options.
Uganda-specific notes
Uganda is certified polio-free (Wild Polio), but risk of importation and outbreaks of Vaccine-Derived Poliovirus (cVDPV) exists. High vaccination coverage (OPV/IPV) and sensitive AFP surveillance are essential. ALL AFP cases must be reported and investigated immediately.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.3.4
- Uganda National Polio Eradication / AFP Surveillance Guidelines
(Specific MOH/WHO program documents)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 18 (Immunization)