Retrospective Record Review for Acute Flaccid Paralysis

A five year retrospective review of hospital records should be carried out in the two major hospitals (CHCSJ and KW) under the supervision of CEP hospital coordinators, and should be completed before the end of 1997. The review will be for conditions that present with AFP (Guillain-Barré Syndrome, transverse myelitis, traumatic neuritis, etc.), and all cases should be (re)evaluated by an expert committee composed of pediatricians and neurologists.

The objective of the review is to detect and re-assess all suspected AFP cases in children less than 15 years old, who have been observed in the outpatient or emergency departments, or admitted to the wards of CHCSJ and KW, between 01 January 1993 and 31 December 1997.

This protocol considers the reality of CHCSJ, but KW can adopt a similar methodology, considering the features of its information system and human resources. The review can be divided into five steps as presented in the specific flowchart.

Step 1: Listing

Two lists of users, with the Medical and Health Department (SSM) code and name, should be obtained from the Informatics Department.

The first one (List A) should include all clients/patients under 15 years of age observed in the outpatient and emergency departments, or admitted to the infirmaries, during the previously defined period. The diagnosis or symptoms and signs to re-assess should consider the groups I-III-VI-VIII-XVI-XVII of the International Classification of Disease, 9^th revision (ICD.9). If possible, the list should be sorted out by "SSM code", with duplication eliminated, and enabling the automatic subtraction of the second list.

The second one (List B) should include all clients/patients from List A with the following possible diagnoses: Guillain-Barré syndrome, poliomyelitis (ruled out, suspected), transverse myelitis, traumatic neuritis, hypotonia, hypokalemic paralysis, Pott’s disease, meningitis (TB and all other causes), osteomyelitis, and any other diagnoses related to paralysis/weakness (in operation, these pathologies should be first translated into ICD.9 codes).

Step 2: Manual search

All individual records of patients included in List A should be withdrawn from the central archive-storage sector and reviewed manually by doctors to search for any of the following terms: paralysis, paresis, flaccid (floppy or reduced tone), weakness, frequent falls, gait disturbance, cannot walk, as well as poliomyelitis Guillain-Barré syndrome, transverse myelitis, traumatic neuritis, hypotonia, hypokalemic paralysis, Pott’s disease, meningitis, and osteomyelitis (both english and portuguese terms should be considered).

The records that contain any of these terms, as well as those in doubt should be submitted to further assessment.

Step 3: Specialist assessment

A pediatrician should review all selected cases from List A, as well as all cases of List B. Those clearly not AFP cases should be discarded (no paralysis, onset >3 months ago, >15 years old, not flaccid). The expert committee should review those clearly AFP cases and those in doubt.

Step 4: Expert review

All cases selected in step 3 should be located and convoked for investigation and observation by an expert committee. In case the patient has died or lost to follow up, the review will be based on all clinical records available. The expert committee should classify the cases as "non-AFP", "non-polio AFP" (specific diagnoses needed) or "polio-compatible" according to available information.

Step 5: Reporting

All AFP cases detected and their final classification should be reported to UTVE, and in turn to the WHO-WPR.

Instruments for data management

For step 1, the Informatics Department should provide lists in diskette in a format recognizable by Microsoft Excel software. The List A should then be transformed in Excel-Table 1 (see next draft matrix) to be filled-in during step 2. A key-term list for reference should also be provided to doctors who perform the search.

 Table 1 (draft matrix): List A

Key-term list (draft matrix)

For step 3, selected cases from list A and all cases from list B should be copied to Table 2 and submitted to pediatrician assessment.

Table 2 (draft matrix): List B and selected cases from List A

For step 4, selected cases from Table 2 should be copied to Table 3 and reviewed by the expert committee. For each case, the committee should fill out a "standard AFP case investigation form" and a "AFP notification form" - UTVE-SSM-MOD.100, Modelo 1 and Cep1AFPform.

 Table 3 (draft matrix): Selected cases for expert review

Results of the retrospective record review for acute flaccid paralysis

© Fernando Costa Silva, 1999

© Tong Ka Io, 1999