Evaluation of acute flaccid paralysis surveillance system in Kerkuk governorate

Context: High quality acute flaccid paralysis surveillance system is a aquite important strategy for polio eradication. Surveillance data are the cornerstone to document a national polio free status. The aim of the present study is to evaluate the acute flaccid paralysis surveillance system in Kerkuk Governorate. Methods: Program evaluation of the Directorate of health, primary health care districts (sectors), hospitals, and primary health care centers in Kerkuk Governorate. All the responsible personnel for the acute flaccid paralysis surveillance system were interviewed and included in addition to the relevant records. Ordinary percentages were used in the description of acute flaccid paralysis cases. While rates were used in the evaluation of the performance indicators. Results: The study revealed a sensitive acute flaccid paralysis surveillance system (Non polio acute flaccid paralysis rate 3.98 and 3.1 in 2005 and 2006 respectively) with clear field guidelines. All the performance indicators were high indicating a high quality surveillance system in Kerkuk Governorate. Conclusions: Solid surveillance structure, regular contract and excellent case management were observed, in addition to regular passive and active surveillance. ةصلاخلا : فدهلا : كوآرآ ةظفاحم يف داحلا يوخرلا للشلل يئابولا دصرلا جمانرب مييقت ىلإ ةيلاحلا ةساردلا فدهت . ةساردلا ةقيرط : مييقت ةسارد جمانرب ةساردلا ناكم : تايفشتسملاو ة يلولأا ةيحصلا ةياعرلا تاعاطق ىلإ ةفاضإ كوآرآ ةحص ةرئاد يف ةساردلا تيرجأ كوآرآ ةظفاحم يف . ة ساردلا ي ف نوآرا شملا : لل شلل يئا بولا دصرلا جما نرب ذ يفنت ن ع نيلوؤ سملا صاخشلأا ة لباقم ة ساردلا تلم ش جمانربلا تلاجس ىلع علاطلإا ىلإ ةفاضلإاب ةظفاحملا يف داحلا يوخرلا . ةساردلل ةيئاهنلا ةلصحملا سايق : ل ة يوئملا بسنلا مادختساب جئا تنلا ل يلحت م ت ى لإ ةفاضلإاب ءادلأا تارشؤم سا يق داحلا يوخرلا للشلا تلااحل تاراركتلا باسح . جئاتنلا : ةساردلا ترهظأ ذ ناآ يئابولا دصرلا جمانرب نأب ا ةيلاع ةيساسح يف ءادلأا . ة فاآ نأ ب اًضيأ ةساردلا تدآأ ةدوج ىلع لدي امم اًدج ةيلاع تناآ ءادلأا مييقت تارشؤم جمانربلا . اتنتسلاا ج : نأب جاتنتسلاا نكمي ةساردلا نم ةصلختسملا جئاتنلا ءوض يف ى لإ ةفاضإ لماكتم دصرلا جما نرب لكيه نأ جمانربلل ءادلأا ماظتنا ىلإ ىدأ امم لماآ لكشب لهؤم جمانربلا نع لوؤسملا رداكلا . 7 , 200 &2 1 No 3 Vol. 3 Annals of the College of Medicine Mosul College of Medicine 7 © 200 60 oliomyelitis is a highly contagious disease caused by poliovirus. High fraction (about 95%) of all polio infections are inapparent or subclinical; only 2% result in acute flaccid paralysis (AFP) . Acute flaccid paralysis is a complex clinical syndrome with a broad array of potential etiologies including paralytic polio, Guillian Barre syndrome, transverse myelitis, traumatic neuritis, meningitis, encephalitis, and brain tumours. In 1988, the world health assembly adopted a resolution calling for global eradication of poliomyelitis by the year 2000. Iraq has made significant progress in polio eradication, National activities started since 1995, by conducting a series of activities including increase in oral polio vaccine (OPV) routine coverage and strengthening AFP surveillance system. The last indigenous wild poliovirus was isolated in Iraq in January 2000. All endemic and many non-endemic countries including Iraq implement both intense programs of supplementary immunization campaigns and continue to improve AFP surveillance systems. Surveillance is the collection, analysis, interpretation, and dissemination of information about a selected health event. As more countries become polio free the ability to prove the absence of circulating virus or to identify importation of poliovirus into free areas become increasingly crucial for national eradication programs; this makes high quality surveillance is quite important for both endemic and polio free countries. Data generated by high quality, reliable AFP surveillance system form the cornerstone to formally document national polio free status Acute flaccid paralysis surveillance performance indicators in Iraq suffered immediately after the war but a lot of efforts were conducted by the national staff with the support of the World Health Organization (WHO) which were quite successful. Acute flaccid paralysis surveillance is considered as an essential strategy in polio eradication. It has many important roles which are: identifying high risk areas or groups, monitoring the progress of eradication programs, certifying a country polio free, and utilizing data to chose supplementary activities The aim of the present study is to evaluate the quality of the AFP surveillance system in Kerkuk Governorate through calculating the performance indicators and comparing it with the international targets. Material and Methods: The present study is a part of a national program of AFP surveillance evaluation; it is conducted after approval of the Ministry of Health (MOH) and the support of the WHO during the period from 10 of Dec. 2006 to the 29 of Jan. 2007. The investigator participated in a training workshop on the national and international guidelines of AFP surveillance evaluation and its performance indicators before the initiation of the present study. Moreover the investigator has been chosen by the MOH to conduct the evaluation in Kerkuk Governorate. The investigator paid a visit to the Directorate of Health (DOH) in Kerkuk Governorate to conduct a primary meeting with the director general, the main objectives of the study were explained and the administrative approval of the director general was obtained. The evaluation process was conducted at three levels, regional (DOH), intermediate i.e. Districts (sectors), and local level (primary health care centers (PHCCs) and hospitals). Field visits were conducted to the department of primary health care (PHC), in addition to all the AFP surveillance focal points in the PHC districts and hospitals. On the other hand 12 PHCCs in the governorates were visited centers. Those which are located in areas with bad security circumstances were excluded. Figure (1) shows the levels of evaluation of the present work. Focal points personnel, active surveillance personnel, PHC district and PHC center managers were interviewed in addition to P 7 , 200 &2 1 No 3 Vol. 3 Annals of the College of Medicine Mosul College of Medicine 7 © 200 61 specialist pediatricians, community medicine specialists, general practitioners, medical and laboratory technicians to evaluate their knowledge about the surveillance system according to the WHO field guidelines. Furthermore, all the relevant records of the active and passive surveillance were observed and evaluated, the AFP cases data were recorded using a special form prepared by the investigator based on the WHO protocol of the assessment of national AFP surveillance system. All the performance indicators were calculated and compared to the international targets; these indicators were adopted by the WHO and calculated as follows(10): .Non polio AFP Rate in children < 15 years = No. of reported Non polio AFP cases<15 / total No of children <15 *1 .Completeness of weekly and monthly reporting = No of reports received / No of reports expected *100. .Timeliness of weekly and monthly reporting = No of reports received before a specified deadline/ No of reports expected *100. .Reported AFP cases with 2 stool specimens collected in ≤ 14 days since onset = No of AFP cases with 2 stool specimens collected in ≤ 14 days since onset / total AFP cases reported *100. .Reported AFP cases with 60 days follow up to verify residual paralysis = No of AFP cases with 60 days follow up / total AFP cases reported *100. .Reported AFP cases investigated ≤ 48 hours of report = No of AFP cases investigated ≤ 48 hours of report / total AFP cases reported *100. .Specimens arriving at national lab. ≤ 3 days of being sent = No of Specimens arriving at national lab. ≤ 3 days / total AFP cases reported *100. .Specimens arriving national lab. in good condition = No of Specimens arriving national lab. in good condition / total No of specimens arriving national lab. *100. .Specimens with turnaround time ≤ 28 days (Reporting result from lab.) = No. of specimens with lab. Result within 28 days/ total No. of specimens arrived the lab. *100. .Stool Specimens from which non polio enterovirus was isolated = No. of Specimens from which non polio enterovirus was isolated / total No. of specimens arrived the lab. *100 Regarding data management ordinary percentages were used in the description of acute flaccid paralysis cases. While rates were used in the evaluation of the performance indicators. DOH and PHC department (Regional level) PHC districts (sectors) (N=5) (Intermediate level) PHCCS (N=26) (Local level) Hospitals (N=4) (Local level) Figure (1) Levels of evaluation of AFP surveillance system in the present study. 7 , 200 &2 1 No 3 Vol. 3 Annals of the College of Medicine Mosul College of Medicine 7 © 200 62 Results: A total of 47 medical and health personnel were interviewed, including 4PHC districts managers, 4 hospitals managers,12 PHCCs managers, 10 physicians, 9 AFP focal point personnel, and 8 laboratory technicians. Table (1) reveals that there is specific AFP surveillance structure; it is evident that more than 60% of the settings were surveyed through 39 visits. AFP surveillance focal points are present in the DOH, districts, and hospitals. Clear field guidelines, complete documentation, regular supervisory activities, and regular contact and information exchange between different levels at the DOH were observed during the investigator's visits. Table (2) shows the age and sex distribution of the AFP cases detected during 2 years period (2005 and 2006) in Kerkuk Governorate. The table reveals that about 52% and 46% of AFP cases were males in 2005 and 2006 respectively. Around three quarters of AFP cases were 1-5 years of age (81.1% and 69% in 2005 and 2006 respectively); nevertheless no cases below one year of age were recorded It is evident from Figure (2) that most frequ