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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