Medical Journal of Zambia, Vol. 43 (2): pp 57 - 60 (2016) ORIGINAL ARTICLE Increased Sensitization of Health Workers Leading to Detection of Unintended Cases of Acute Flaccid Paralysis: A Case of a “Konzo” Outbreak in Western Zambia A Mtonga1, P Mwaba2, MLM Mazaba1,3, E Chizema2, M Kapina2, S Mwangala4, A Silumesi4, F Masaninga5, T Masuka4, L Hachambwa5, O Siddiqi5, I Mweene-Ndumba1, JS Kachimba5, B Vwalika5, S Kagulura5, P Songolo1, J Mufunda1 1World Health Organization, Lusaka, Zambia, 2Ministry of Health, Lusaka, Zambia 3Copperbelt University School of Medicine, Ndola, Zambia 4Ministry of Health, Mongu, Zambia, 5University of Zambia, School of Medicine, Lusaka, Zambia ABSTRACT comprehensively investigated the cases. To improve the diagnosis a detailed case investigation form and checklist Background: The threat of high profile diseases causing were used to capture clinical data and socio demographic outbreaks has drawn attention to public health information. surveillance systems, much needed for the timely detection of outbreaks. A disease characterized by Laboratory investigations included routine urine weakness of the lower limbs in Luatembo rural health microscopy and full blood count. Further analysis facility was reported to the province in 2013. Through the included viral analysis for enteroviruses, Acute Flaccid Paralysis surveillance (AFP) program the cytomegalovirus among others, copper levels and Western Province in Zambia recorded an increase in the thiocyanate levels. numbers of people affected with spastic paraparesis. The disease affected clusters of families, especially women Results: Preliminary laboratory results indicated no viral and children. The disease was found to be in specific infections. Thiocyanate and copper levels are yet to be geographic areas, with the initial cases being identified in analysed. Mongu district followed by Luampa and Senanga Discussion: As a result of the increased sensitization of districts. Surveillance for a particular disease condition health workers and communities, more cases were may sometimes lead to detection of a related or unrelated reported in other parts of Western Province, namely condition. This study aims to assess the sensitivity of the Luampa and Senanga districts. All the cases were detected Acute Flaccid Paralysis surveillance program through active surveillance for AFP. This study indicates a surveillance program to detect other diseases of public potential role for integrating AFP surveillance with other health importance using the suspected 'Konzo' outbreak notifiable diseases within the integrated disease in Western Province as a case study. surveillance and response for early notification of unusual Methods: Through the surveillance system and medical events in the community and community involvement to records review, patients with spastic paraparesis were foster health seeking behaviors. identified and brought for clinical examination to Conclusion: This paper reflects on the role of AFP selected health facilities. A team of specialists comprising surveillance in integrated disease surveillance and of an infectious disease specialist and neurologist, response that resulted in the detection of an uncommon supported by physiotherapists, epidemiologist, spastic paralysis 'Konzo' disease in Mongu, Western surveillance officers and laboratory scientists Province. 57 Medical Journal of Zambia, Vol. 43 (2): pp 57 - 60 (2016) INTRODUCTION of the disease timely. The WHO emphasizes the importance of ongoing surveillance before, during and Public health surveillance is a monitoring tool that after any program interventions7. An integrated approach involves systematic collection, analysis and built on AFP surveillance in the context of IDSR in many interpretation of data about health related occurrences of developing countries has increased the sensitivity of the public health significance. This system helps in case surveillance system to detect other diseases beyond AFP detection of potential and monitoring public health 1 by providing functional infrastructure, trained personnel interventions . Early warning of potential threats, and other resources. This approach has facilitated the outbreak detection, detection of new diseases, and detection and investigation of diseases such as SARS, changes in epidemiology of endemic diseases through cholera, dengue, Rift Valley fever, shigellosis, program monitoring are some of the benefits obtained hemorrhagic fevers, meningitis, and malaria8. through a good surveillance system2. The timely warning functions of health security be it at national, regional or As AFP surveillance systems matured, countries global level cannot be overemphasized. Recent outbreaks increasingly applied the AFP structure and system to including severe acute respiratory syndrome, Pandemic detect other priority diseases, mostly measles and other H1N1v, Ebola and now Zika underscore the need to vaccine-preventable diseases.Outbreaks typically have invest in effective national surveillance and response been recognized either based on accumulated case reports systems2,3. Various disease specific surveillance programs of reportable diseases or by clinicians and laboratories' with different programmatic goals exist globally who alert public health officials about clusters of including Influenza surveillance, Measles surveillance diseases8. We document in this study how an adequate and and acute flaccid paralysis surveillance. Through the sensitive AFP surveillance system enabled the detection 1988 World Health Assembly resolution to eradicate of unintended cases of Acute Flaccid Paralysis. poliomyelitis a sensitive global surveillance system was established. As AFP surveillance systems matured, METHODOLOGY countries increasingly applied the AFP structure and In September 2013, Mongu district reported 7 AFP cases system to detect other priority diseases, mostly measles from 3 different locations within the same geographical and other vaccine-preventable diseases. In the WHO area. Stool specimens were collected and sent to UTH African Region, AFP surveillance provided the nucleus to Virology Laboratory for investigation for suspected develop an "Integrated Disease Surveillance and poliomyelitis. Response" (IDSR) system for priority infectious diseases4. A sensitive and effective surveillance system On 60 days follow up from the date of onset of paralysis of should be able to detect potential health threats timely3, 5. the first three cases from Luandui as per standard Through active AFP surveillance, Zambia detected an guidelines for AFP surveillance, an increased number of ongoing increase in the number of persons presenting persons presenting with spastic paraparesis which turned with spastic paraparesis. out to be non- polio and non entero virus were detected and the district medical office notified authorities 2013. All countries are mandated through the International In 2015, having noted a continued trend of these cases, the Health Regulation 2005 legal framework to develop and national level was notified. A team of specialists maintain surveillance systems so as to enable timely comprising of an infectious disease specialist and detection and containment of outbreaks. A poor neurologist, supported by physiotherapists, surveillance system may cost a country and even epidemiologist, surveillance officers and laboratory multination in the event of an infectious disease. In 2002, scientists comprehensively investigated the cases. the first cases of Severe Acute Respiratory Syndrome Through the surveillance system and medical records (SARS) were not recognized as a potential threat and not review, patients with spastic paraparesis were identified reported to WHO as per IHR mandate. The disease spread and brought for clinical examination to selected health causing deaths and spread to another country causing a facilities for further investigations to determine the cause 4,6 global threat . Shortcomings in the surveillance system of this etiology. Physical examinations were conducted overlooking the control of schistosomiasis in China have and specimen collected for laboratory investigations. To been recognized as reason for detecting the reemergence improve the diagnosis a detailed case investigation form 58 Medical Journal of Zambia, Vol. 43 (2): pp 57 - 60 (2016) and checklist were used to capture case history, clinical Using the concept of active surveillance, regular visits to data and socio demographic information. The laboratory health facilities are carried out during which registers are investigations were carried out to rule out infectious reviewed to determine the type of cases admitted or seen process and suspected 'Konzo'. at the facilities and clinician sensitization is carried out2. Thus all cases with sudden onset of paralysis or weakness RESULTS are investigated by taking stool specimens to the WHO In 2013 Findings were that three (3) clients in Luandui accredited laboratory (UTH Virology laboratory) to map had all debilitated and one of them was unable to walk the virus and to determine the origin of the virus strain. anymore and had stopped going to school. In Lwatembo 'Konzo' is characterised by abnormal walking, stiffness of (Kaote Village), the 3 clients had also debilitated. During the legs and a permanent paralysis.'Konzo' is distinct this follow up visit, 8 more clients were discovered that from polio which is a flaccid paralysis and most often had not previously reported to the facility, bringing the affects a person asymmetrically10.