Health Alert
ACUTE FLACCID MYELITIS: CLINICAL REMINDERS AND REPORTING REQUIREMENTS

The Delaware Division of Public Health (DPH) is issuing this health advisory regarding clinical reminders and reporting requirements related to acute flaccid myelitis.

Summary

An increased number of acute flaccid myelitis (AFM) cases have been reported nationally in 2018. Health care providers should report any suspect cases of AFM to DPH by calling 302-744-4990 or 1-888-295-5156 (24/7). Cerebrospinal fluid (CSF), blood, stool, and respiratory specimens should be collected as close to illness onset as possible for laboratory testing. DPH can facilitate testing of clinical specimens.

Background

During the summer, the Centers for Disease Control and Prevention (CDC) began receiving an increasing number of suspected acute flaccid myelitis (AFM) cases. Since January 1, 2018, CDC has had 127 patients under investigation and 62 cases have been confirmed in 22 states. Ninety percent of cases are in patients 18 years or younger with the average age about 4 years old. In 2014 and 2016, increases in AFM cases that peaked seasonally from August through October were documented. Given this biennial trend, an increase in AFM cases during 2018 is anticipated.

Clinical Syndrome: AFM generally presents with a prodromal respiratory or gastrointestinal illness for one week, and neck or back pain followed by onset of weakness of one or more limbs. Other neurologic symptoms include cranial nerve findings such as slurred speech, difficulty swallowing, eyelid or facial droop, poor tone, and diminished reflexes. Weakness can also affect respiratory muscles, leading to respiratory failure. Cerebrospinal fluid may show a lymphocytic pleocytosis and elevated protein, and MRI findings include lesions in the central or gray matter of the spinal cord. There is no specific treatment for AFM. Most patients recover with supportive care and physical and occupational therapy but severe neurologic complications can result in death.

Reporting

Although AFM is not a mandatory reportable condition in Delaware, clinicians are strongly encouraged to notify the DPH Office of Infectious Disease Epidemiology of any patient you are evaluating for AFM by calling 302-744-4990 or 1-888-295-5156 (24/7). Approval from DPH is required for specimen testing. To receive approval, clinicians must complete the Patient Summary Form (https://www.cdc.gov/acute-flaccid-myelitis/hcp/data.html) and include (if available) admission and discharge notes, neurology and infectious diseases consults, magnetic resonance imaging (MRI) images and reports, and vaccination history. Laboratory results including initial hospital or commercial laboratory testing for enteroviruses, arboviruses, and adenoviruses should also be provided. Information should be submitted to DPH regardless of any laboratory or MRI results. AFM neurology experts at CDC will review all case information and lab results to determine case classification.

Recommendations

Although enteroviruses, West Nile virus, other flaviviruses, and adenoviruses can cause AFM, surveillance efforts aim to explore and identify all possible etiologies for this illness. DPH advises collecting specimens from patients as early as possible after symptom onset, preferably on the day that limb weakness develops. Specimens to collect for submission to CDC include: CSF, Serum, Stool, and nasopharyngeal (NP) or oropharyngeal (OP) swabs. All specimens must be accompanied by the CDC Form 50.34 https://www.cdc.gov/laboratory/specimen-submission/form.html. "Picornavirus Special Study" must be selected for test order name. Additional instructions regarding specimen collection and shipping to CDC are available at https://www.cdc.gov/acute-flaccid-myelitis/hcp/instructions.html.

Additional information

• CDC Acute Flaccid Myelitis website: https://www.cdc.gov/acute-flaccid-myelitis/index.html
• AFM Surveillance in the US: https://www.cdc.gov/acute-flaccid-myelitis/afm-surveillance.html
• Materials for Clinicians and Health Departments: https://www.cdc.gov/acute-flaccid-myelitis/hcp/index.html
• Job Aid for Clinicians: https://www.cdc.gov/acute-flaccid-myelitis/downloads/job-aid-for-clinicians-508.pdf
• References: https://www.cdc.gov/acute-flaccid-myelitis/references.html

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