APSU VIDRL Victorian Infectious Diseases Reference Laboratory

Acute Flaccid Paralysis Initial Questionnaire
(Revised October 2016)

If you wish to discuss this questionnaire, please ring:
Dr Bruce Thorley, VIDRL: (03) 9342 9607
Prof. Elizabeth Elliott (APSU): (02) 98453005

Please report any child less than 15 years of age with acute flaccid paralysis (AFP) in one or more limbs or acute onset of bulbar paralysis.
All cases are reviewed by the Polio Expert Panel and classified as: confirmed poliomyelitis; non-polio AFP; polio compatible or non-AFP.

It is important that stool specimens are collected from all patients with AFP, even when an alternative definitive diagnosis has been confirmed.

Please collect 2 stool samples, more than 24 hours apart and within 2 weeks of onset of paralysis and send them to your local laboratory who will forward them to the National Enterovirus Reference Laboratory, VIDRL, Doherty Institute, 792 Elizabeth Street Melbourne VIC 3000.

On the request form the patient must be identified as having AFP.

Please inform the laboratory that the specimens must be forwarded to VIDRL for exclusion of poliovirus.

All costs for transport and analysis will be borne by VIDRL.
Information regarding specimen transport can be obtained from the National Enterovirus Reference Laboratory at VIDRL on (03) 9342 9607 or https://www.vidrl.org.au/laboratories/poliovirus-reference/specimen-referral/

If this patient is primarily cared for by another physician who you believe will report the case, please complete the reporting clinician and patient details only and return to VIDRL. If no other report is received for this child we will contact you for information requested in the remainder of the questionnaire.
The primary clinician caring for this child is

    REPORTING CLINICIAN’S DETAILS

  1. /

  2. * must provide value

  3. * must provide value
  4. PATIENT DETAILS

  5. PATIENT VACCINATION HISTORY

  6. In the 6 weeks prior to presentation, did the child;
  7. CLINICAL FEATURES & INVESTIGATIONS

  8. In the 6 weeks prior to presentation, did the child;
  9. If YES,
  10. Encephalopathic is defined as an alteration in consciousness (e.g. stupor, lethargy) or behavioural change unexplained by fever, systemic illness or postictal symptoms.
  11. If YES, Cerebrospinal Fluid (CFS)
    (g/L)   Please check that the CSF protein result has been entered in g/L
    Please enter the CSF protein result in g/L not mg/L (mmol/L) (x106/L) (x106/L) (x106/L) (x106/L)
  12. OUTCOME

  13. (days)
  14. (days)
  15. DIAGNOSIS

  16. In light of currently available evidence, what is the patient’s diagnosis? (Please indicate on list below)

    Peripheral neuropathy

    Anterior horn cell disease

    Acute myelopathy

    Muscle disorders

    Systemic disease

    Disorders of neuromuscular transmission

    Other (specify)