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Pakistan J Med. Res. . Vol. 43 No.3, 2004

Case definition of traumatic injection neuropathy (TIN)

Faisal Mansoor National Institute of Handicaped, Islamabad "It is more dangerous to inject medicine than to give it by mouth especially in children. I have seen children reduced to being cripples because an ill trained health worker aimed the needle straight in to the Sciatic nerve".1 This is not an alien situation for our children in Pakistan. Many of our children suffer at the hands of untrained people who set themselves as experts of injections. The poor in the rural society have no access to quality health workers who live in the cities and the urban poor are afraid of modern doctors and their expensive prescriptions, they rely on someone friendly and cheap who appears more knowledgeable than they are. These formal and informal health care workers routinely prescribe injections to patients. Many of these injections are unnecessary2. WHO 1999 health report revealed that at least 75% of these are unnecessary 1 Twenty three million doses of Vitamin B injections were given in 2000 alone.3 90-100% patients receive an injection while visiting a health worker4. Approximately 12 billion injections per year are given worldwide,5.6 of which 600 million are given in Pakistan7,8. Pakistan is one of those 5 countries where highest number of injections are administered 9, 90% of which are for therapeutic purposes 10. The commonest condition for which injections are given is fever.11 The injection healing ritual brings comfort even if it appears irrational.12 The use of injections in tropical and sub tropical countries dates back before 1924: But their greatest veneration was for the syringe which immediately put the lost health back in to the blood. 13 The injections are administered by public private doctors, doctor assistants, barbers, friends relatives and housekeepers.14 In many countries injections have become the modern magic, people demand them because doctors and health workers often prescribe them, and doctors and health workers prescribe them too often because people demand them. An international campaign is needed to reeducate doctors, health workers, traditional healers (many

11 (An unnecessary injection is the one where oral

alternatives are available, where the injected substance is inappropriate or harmfu or where the symptoms or diagnosis do not warrant l, treatment by injections1.)

of whom give injections), and most of all the people themselves. Combating misuse and overuse is as important as vaccination, clean water, or the correct use of latrines. 15 A countrywide survey in 2002 to assess injection safety in Pakistan showed gross overuse and unsafe injection practices in the country.16 The relative risk of complications increase with increasing number of injections17 Unsafe injections result in multiple complications particularly infections such as Hepatitis B, Hepatitis C and HIV.18,19,20 In addition injections may lead to injury to the nerve causing acute flaccid paralysis of the limb21. The injection induced paralysis, that is termed as Traumatic Injection Neuropathy (TIN) , often results in life long disabilities 22 23. TIN affects in almost 100% of the cases, two major nerves of the body the Sciatic nerve and the Radial nerve. 24, 21 The commonest site at which Radial nerve is injured is the Axilla and Radial groove of Humerus, this results in wrist drop and variable distribution of sensory loss 25,26. Injection Injury to the sciatic nerve is in the gluteal region resulting in foot drop & loss of sensation and extensor muscles function21 There is scarcity of literature that have drawn attention to the dangers of injections27 and studies of actual cases in developing countries and the extent of the problem is not known.28 It is a highly understudied issue29. The literature on nerve injuries due to injections is very little. Case reports of median nerve injury, 30 and radial nerve injury has been reported. 22,23,29. The Pakistan Polio Eradication Program has identified paralysis caused by injury to these nerves in children under 15, which is designed to detect all cases of new onset paralysis (Incident cases) (including Guillian Barre syndrome) in children less than 15yrs around the country, so that they can be tested for Polio.31 The Acute Flaccid Paralysis (AFP) Surveillance in Pakistan is a very efficient system that meets all international standards32 All cases in which Polio is determined not to be the cause of paralysis, an alternative diagnosis is assigned by the treating or investigating physician.31,33 During a review of the surveillance data for the year 2001 and 2002 by Federal Surveillance Cell

Faisal Mansoor

Islamabad, it was seen that many of the non polio cases were labeled as Traumatic Neuritis.

Table 1: Distribution of AFP cases for the year 2001 and 2002 AFP cases 2001 1573 2002 1791 Sourse Polio update Islamabad Year. Polio confirmed 119 98 National polio Non polio Traumatic inj. cases neuropathy 1454 180 1693 188 surveillance bulletin Feb.2003.

Polio do not normally cause paralysis. It may occur when infection is coincident with an intramuscular injection (Provocation). Without isolation of polio virus, such cases may be mistaken for TIN42. Neurophysiological test is a quick and easy method to differentiate polio from other AFPs.43 Aims & objectives 1. Improvement in the health of the children by preventing disabilities through safe injection practices. 2. To come up with a valid case definition of traumatic injection neuropathy , in virologically confirmed non polio cases, so that the Polio surveillance program could identify true cases of Injection neuritis. 3. To make recommendations, so as to combat this menace.

Are all these 368 reported cases true cases of TIN? It is important that specific, simple, acceptable and understandable case definitions be developed for a surveillance program and publicized to all persons so that they may accurately report cases34. Case definition is a combination of signs, symptoms & tests of a condition that help in its identification. so that the efforts based on safe injection principals of WHO35 can be initiated to combat this menace. It is an essential step for descriptive epidemiology.36 Generally stringent criteria for case definitions are desirable.36 Cases may be divided into possible, probable, and definite, depending on how well specific criteria are satisfied.36,37 Case definition is like a Screening test. An early case definition (possible) is usually broad enough to pick up all true cases ("sensitivity") of the disease. 100% sensitivity would mean that it would identify all persons with the disease in a community & 100% specificity would mean that it would identify all cases in the community without disease, 34-36. Consensus building techniques such as Delphi and Nominal group are widely used in health research. They can be used to develop and standardize clinical guidelines for developing case definitions. These methods are most appropriately used when there is little or no evidence available about a process.37 By use of the consensus or Delphi Panel approach rather than evidence, some organizations have formulated case definitions.38 Dr. Yvan Hutin (SIGN, WHO Geneva) on hearing of this project commented, " A practical outcome of this research could be a case definition for: Injection Neuritis: so that Acute Flaccid Paralysis could actually capture cases of injection Neuritis to estimate incidence."39 A child with Polio infection also has fever in the prodromal period and hence probability of receiving an injection before the onset of paralysis is very high.28 A history of I/M injection in the Gluteal region would favor the diagnosis of traumatic injection neuropathy is misleading because most children with polio paralysis will have received injections for fever.40 If the child already has the Poliovirus and the I/M injection is given the chance of paralysis due to provocative or aggravative poliomyelitis is increased2,28. In Pakistan Greetham also found that 60% of 1279 Afghan refugee children with polio had received I/M injections just prior to paralysis.41 Enteroviruses other than

MATERIALS AND METHODS

Study site The Islamic republic of Pakistan has 4 provinces, (capitals in brackets) Punjab (Lahore), Sindh (Karachi) NWFP (Peshawar) and Balochistan (Quetta) and 2 regions AJK & FANA., Pakistan has 106 districts and 397 Tehsils. Study design A Qualitative study design was adopted to develop a case definition of traumatic injection neuropathy. Methods used Consensus building techniques. Delphi Technique followed by Nominal group discussion was adopted. List of the subjects interviewed is placed at fig.4 Tools used 1. A semi structured questionnaire based on published and unpublished literature related to Acute Flaccid Paralysis was developed to interview all the Delphi. 2. Structured proposals, summarizing the interview findings, were presented for Nominal group discussions at the Federal Polio surveillance cell. Consensus building technique Pakistan Polio eradication program have established expert review committees in every province. Members include the EPI manager, an Epidemiologist, an expert neurologist, a pediatrician, a senior professor from a medical school who is the chairman and a virologist. The responsibilities of the committee are to meet on a monthly basis to make the final classification of all AFP cases. (figure 1 shows the flow chart of case classification).

Case definition of traumatic injection neuropathy (TIN)

V iro lo g ic classificatio n sch em e

W ild p olioviru s R esidu al w eak ness, d ied or lost to follow -u p con firm com p atib le E xp ert review d iscard N o resid ual w eak ness A deq u ate sp ecim en s

Figure 1 Flow chart of case classification :

AFP

In ad eq u ate or n o sp ecim en s

N o w ild p olio viru s

d iscard d iscard

and others. The researcher had the honor of visiting and interviewing all the Federal and provincial ERC chairmen and experts in the field of neurophysiology and neurosurgery, field surveillance officers in all the 4 provinces and Islamabad were also considered in the final consensus . The classical method of self-administered questionnaire of Delphi technique was replaced with semi structured interviewing technique. A second round of Delphi was followed by Nominal group discussions at the Federal Polio Surveillance cell and at the Neurosurgical department of Pakistan Institute of Medical Sciences. The groups consisted of team members of the Federal Surveillance cell and the consultant neurosurgeons in the department at PIMS. A final consensus definition was then developed. Figure 2 summarizes the consensus methodology.

The commonest non-polio diagnoses are Guillion Barre syndrome, Transverses myelitis, Traumatic neuritis

Figure 2: Consensus Methdology

Summary of consensus methodology · Personal experiences, literature review · Two rounds of interviews, data gathered and collated. Nominal group discussions. · Nominal group discussions and editing of the definition done · Results analyzed for final consensus · Case definition finalized Ethical considerations The general ethical principals were observed during the study, including respect for all the persons. Approval of the ethical committee of the Health Services Academy was sought before proceeding in the field.

Sponsorship The study was sponsored by the Polio eradication initiative Pakistan. List of Nominal group/Delphi 1. Dr khaliq uz Zaman. Professor and the head of Neurosurgery PIMS.Isbd. 2. Dr. Matloob. Associate Professor(NeuroPaeds) Member ERC PIMS Isbd. 3. Dr. Irshad. Neuro Physician (EMG/Nerve conduction expert) PIMS Islamabad. 4. Dr. Farukh Neuro Physiologist (EMG/Nerve conduction expert) Shifa Int.Isbd. 5. Dr. Khurram Habib Consultant Ortho,National Institute for Handicapped(NIHd) Isbd. 6. Prof. Dr. Mehr Taj Roghani Minister of Health NWFP Chairperson ERC NWFP.

Faisal Mansoor

Prof. Dr. Azmat Talat Acting Chairman ERC NWFP. Dr. Abraham WHO medical Officer NWFP. Professor Dr. Tahir Masood Chairman ERC Punjab. Professor Dr. Iqbal Memon Chairman ERC Sindh. Professor Dr. Nagi Chairman ERC Balochistan. Dr. Shazia pediatrician NIHD. Isbd. Mr.Qamar & Ashfaque Physiotherapist NIHD Isbd. Polio Surveillance officers NWFP including Dr. Hassan 15. Polio Surveillance officers Sindh including Dr. Mehboob, Dr. Ashraf, Dr. Hussain nDr. Shams un nisa and Tanvir 16. Polio Surveilance officer Islamabad Dr Abaid 17. Dr Imtiaz pathologist. Policlinic Islamabad

7. 8. 9. 10. 11. 12. 13. 14.

causes. Two of the experts commented that the site of the nerve trauma in injection neuropathy, in most of the cases, leads to distal limb paralysis, causing foot drop or wrist drop. In polio, however, it is generally the proximal muscle involvement. But then again it needs special training and skills to elicit that. All experts agreed that EMG (Electromyography) studies could help in that. Fever History of fever is not always present. It may also be a feature of other causes of AFP. All agreed that fever is the commonest condition for which injections are given to the children. History of fever almost always precedes polio paralysis. Progression The progression of paralysis in TIN is rapid, setting in completely within few hours. In some cases, however, where the drug is deposited outside the nerve sheath, the progression due to pressure on the nerve caused by chemical or the haematoma may take 2-4 days. One of the Delphi said that tingling is felt in the limb seconds after an injection injury. All the pediatricians were of the opinion that although the effect may be produced within 3-4 hours, the paralysis goes unnoticed for 12- 24 hours as the child is invariably given a sedative. Residual paralysis Residual paralysis in TIN depends upon the type and severity of the injury to the nerve. The experts in neurology and the neurophysiology commented that if it is only neuroprexia the recovery occurs within weeks. But if it is neurontemesis or axontemesis the child may end up with residual paralysis for life. Some times the vasanervosum go into spasm due to an injection, which leads to ischemia of the nerve and subsequent sequel. One of the Delphi commented that the chemical composition of injection causes the muscles, surrounding the nerve, to go into spasm and that entraps the nerve, which leads to temporary paralysis. Generally they agreed that more than 60% of the affectees have complete recovery. Type of injury The experts concluded that the type of injury incurred is due to the chemical injected. It is chemical neuritis and not physical damage. It is therefore important to know which drug has been injected. One of the neurologists commented,"Needle injury very unlikely because we our self put the needle close to the nerve to do NCV(nerve conduction velocity) studies. Tip of the needle can hardly damage the nerve. Its truly chemical neuritis but has to be accompanied with injection at the wrong site by an untrained person." Injury could be immediate and direct due to physical trauma or due to substance injected or bacteria or a

RESULTS

After the Delphi panel and the nominal group discussions, certain characteristics pertaining to the case definition of injection neuritis were highlighted. The findings are summarized below: History of Injection. All agreed that the history of injection, just prior to non-polio paralysis, is mandatory to label a case as traumatic injection neuropathy. It was, therefore, included in the "confirmed" case definition. Trauma other than injection such as fall, accidents or pull to the limb, may also injure the nerve. The presentation would then be similar to injection neuritis. The child most often gets injection for the pain due to trauma and this complicates the diagnosis. All such cases are thus labeled as "suspect" traumatic neuropathy .All those cases in which the presentation is that of injection neuropathy, but the clinical notes do not show any definite history of injection, need to be included in "probable" case definition of Injection neuropathy. Personal experiences of the experts as regards the common injections resulting in injection neuropathy are magnopyrol, dipyron and dicloran (all antipyretic analgesic drugs). Sensory Motor loss Two mixed peripheral nerves, the Radial and the Sciatic, are affected due to injection trauma. All agreed that it would cause both sensory and motor loss in the limb that they supply. But practically when it comes to neurological examination of a child, who is commonly less than 3 years old, it is very difficult to elicit sensory loss, more so when the loss is fine touch only. It needs special training and skills. Every one agreed that there is no sensory loss in Polio. Motor loss in all cases of AFP is easy to notify because the child is functionally incapacitated. Here again the group of muscle involvement is different for different

Case definition of traumatic injection neuropathy (TIN)

combination of these. Delayed indirect injury may be due to an abscess in the vicinity19. Some times the needle hits a blood vessel close to the nerve and causes Haematoma. This affects the nerve through pressure and later leads to fibrosis and adhesions. Neurologist said that complete recovery is possible if Neurolysis (releasing the adhesions) is done immediately. Neurosurgical department performs on the average 1 neurolysis per week14. Adhesions around the nerve are released by injecting normal saline around the nerve and within the epineurium. Recovery is seen in 3-6 months. The uncertainty in the pathophysiology of the injury is the reason that it carries different labels, some call it injection neuritis others call it injection neuropathy and still others traumatic neuritis. Asymmetry All agreed that the paralysis in TIN cases is asymmetrical. It is very rare that both limbs could be involved because both have been injected simultaneously in the same erroneous manner. Nerve Conduction Velocity studies (NCV) All, but one, agreed that these studies help in confirmation of the case. One expert from Islamabad disagreed and commented, " It's a difficult test to do and not very useful. NCV is the test of choice for injection neuritis". Nerve conduction is not helpful in polio because the axon is intact, but it helps in the diagnosis of injection neuropathy. Reverse is the case with Electromyography studies.. EMG findings are diffusely distributed in the affected limb in polio whereas they are focally distributed in injection neuritis. NCV study is done on all cases of injection neuritis prior to neurolysis at the neurosurgical department PIMS Public health problem All agreed that it is a major health problem and should be considered on priority basis. The most costeffective solution is the behavior change strategies. Commitment has to come from all sides, the provider, user, and the culture at large. The government's role is that of the steward. The final case definition that was developed as a result of consensus is as follows: Case definition of traumatic injection neuropathy Suspect case Asymmetrical acute flaccid paralysis in which onset of paralysis is acute, its progression is rapid and in

which no other neurological signs and symptoms of recent onset are present. It is virologically negative for polio. Probable Suspect case plus diagnosed by the clinician as traumatic neuritis or traumatic injection neuropathy, for which detail clinical history or records not available. Confirmed Suspect case in which there is one limb involvement and definite history of injection in that limb less than 24 hours before the onset of paralysis. Support findings The experts also discussed the situation where the virological evidence is missing because the child with AFP reported late and adequate stool specimens could not be sent to the lab or the child is lost to the followup. Table 2 shows features that help differentiate polio and traumatic injection neuropathy.

Table 2: Showing features to support the case definition. Support findings Clinical Favors compatible Favors injection findings polio neuritis H/O Confirmed Yes within the last 60 No. Polio in the days community Sensory loss No Yes, on the dorsal side between 1st and 2nd digit. of hand or foot Progression None after 4 days None after 24hrs Symmetry commonly asymmetrical Only injected limb is involved

Muscle groups involved Residual paralysis 60 days followup H/O fever Nerve conduction EMG findings

Predominantly proximal Usual(>60%)

Predominantly distal Less likely <40%

Yes Normal

Yes & No. Characteristic velocity & Focal & characteristic.

Low

Diffuse characteristic

non

Age

Commonly <5yrs old

Commonly < 3 yrs old

CONCLUSION

The case definition of injection neuritis thus developed, is sensitive enough to pick true cases and

Faisal Mansoor

specific enough to leave the cases with other causes of acute flaccid paralysis. Injection neuritis is not only an indicator of injection safety but an indicator of quality of care that these children have access to. A coordinated effort at all levels of health care is needed to prevent this complication. Implications of the findings There was no unified case definition of injection neuritis. The field-investigating officers generally diagnosed the cases on exclusion criteria. The literature support on the subject is also very limited. The case definition developed through consensus would soon be adopted by the entire polio surveillance system in Pakistan. This definition would also benefit the pediatricians, neurophysicians, neurophysiologists, neurosurgeons and other clinicians in differential diagnosis of AFP cases. The study has convinced the surveillance system to tease out traumatic injection neuritis cases from the group of traumatic neuritis. Injection is a trauma, but not all cases of "Traumatic neuritis" are "TIN." The polio surveillance cell has appreciated the importance of injection history and now the question on injection history has been included in the WHO detailed epidemiological form since January 2003.

RECOMMENDATIONS

Injection neuritis is not only an issue of patient safety or quality of care; it is an issue of medical ethics, as well. WHO 2002 report states, "Reducing major risks can reduce inequities in society and promote sustainable development. Exercising stewardship means fulfilling the government's responsibility to protect its citizens53." · A bold National Policy and plan on appropriate use of injections is required that would include the entire health sector in Pakistan( Public, private, preventive and curative) in close cooperation with the key national players ( general public, politicians and health practioners). The policy needs to be strengthened by the scientific and empirical evidence and ethical issues.43 · Intraglutael injections to the infants should be prohibited and health workers trained to give necessary injections in the thigh. · Raise awareness of injection safety and facilitate behavior change by creating a consumer demand for necessary injections through nation-wide information, education and communication campaign. A joint national effort with a major promotive and educative campaign and logistic support is needed to improve the

situation. This is perhaps the most effective way to target unlicensed practioners and their clients. · Safe injection messages should be included in all EPI promotional campaigns viewed by parents and practioners. · Direct distribution of information and advocacy materials to practioners. Surveillance officers make frequent visits to the offices of health care workers to distribute information and advocacy materials for AFP reporting. The same officers can be used for this purpose. · Information can also be disseminated through professional associations such as Pakistan Medical and Dental Council. Information material along with a letter from the Chairman PMDC can be send to all members and to major health care professional associations such as Pakistan Pediatrics Association and Pakistan Medical Association, etc. · Implementation of policies in true letter and spirit is mandatory. Political and vested interests and economic constraints often drain away priceless policies. Injection safety is not only a medical issue but a social issue of considerable importance. It should be dealt with beyond our personal interests. · Include a budget line for injection safety in the 5 year EPI budget plan16 · Establish EPI injection safety units and /or injection safety officer positions at the federal, provincial and district level, using existing human resources and possible GAVI assistance.16 Training and supervision of health providers. Educate and retrain health workers, including the noncertified injection providers (which could be very difficult, as they would be reluctant to be recognized by the government authorities). Involvement of NGOs in such training on the rational use of injections could be helpful Rational use of injections and injection safety should be an important component of all trainings of vaccinators, LHVs, LHWs, mid-wives and medical schools. Refresher courses, related to neurological examination of children, be started at the district levels for all tehsil pediatricians. Professors at the provincial levels could be given this task44 Intersectoral and international collaboration should be strengthened to achieve greater health benefits. The great potential of the community based organizations, local groups media and others should be encouraged and expanded. Quality rehabilitation services free of charge should be extended to all the disabled children of this country.45

Case definition of traumatic injection neuropathy (TIN)

Research is needed to explore in detail the determinants of traumatic injection neuropathy.

REFERENCES

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. The Weekly guardian, 75 Farringdon Road, London UK. April 28,1999 "Trau matic Neu ritis" a letter from Robert Lacville, Raglow et al. Therapeu injections in Pakistan from the tic patients perspective. Trop. Med. Int. 2001 J an,6(1),69-75 Mu jeeb SA. Unsafe injections a potential sou rce of HCV spread. JPak Med Assoc 2001); 51(1):1-3. Altaf A. SIGN 2001Irrational injection practices in Sindh. [email protected] cited on 10.04.03. Approach of SIGN Unsafe injection practices and transmission of blood borne pathogens ,www.injectionsafety.org. cited on 12/4/2003. Safety of injections; WHO-UNICEF-UNFPA joint policy statement on the use of au disable syringes in immu to nization 1999. Hu tin, "Injection safety Pakistan statistics"; SIGN(WHO),www.injectionsafety.org;; [email protected], cited in Dec.2002. Lu SP. Epidemiology infection 1997; 119: 349-56. by Wyatt HV. Unnecessary injections and poliomyelitis in Pakistan. Trop Doctor 1996; 26 : 179-80. Wyatt HV. Differential diagnosis in AFP poliomyelitis in developing countries. Cu Sci 1998; 75: 936-8. & Indian J rr Pediatr 65 (Suppl) S1-S98. Lu S. Injection safety: Conference presentations. Emerging by Infectious Diseases. 2001J n; 7(3 Su u ppl). Pirajno ADD. A cu for the serpents. A doctor in Africa . re (Trans K Naylor) London: Reprint Society; 1956. Talat M, Elou S. Overview of injection practices in 2 n governorates of Egypt,Tr. Med. Int. H. march 2003; (8)234-41 Werner D. Disabled village children. 2nd edition. USA: the Hesperian Foundation; 1988. Mantel CF. WHO consu ltant safety of injections in the Islamic Repu blic of Pakistan, Execu tive action docu ment 8-28 April, for Gov. of Pakistan. 2002. Khan AJ Infection by Injections from health care providers . .Epidemiolo Infec 1999; Dec.123(3):515-8. Miller MA, Pisani E. The cost of u nsafe injections. World Health Organ Bu 1999; 77(10),808-11. ll Simonsen L. Unsafe injections in the developing world and transmission of blood borne pathogens. A review World Health Organ Bu 1999; 77.789-800 ll Kane A. Transmission of hepatitis B hepatitis C and HIV throu u gh nsafe injections in developing world. WHO bu lletin, ,77,801-807. Bailey and Love. A Short Practice of Su rgery, UK : Peripheral Nerves 1983; 496-7. Arshad .A. (2001) Unnecessary Therapeu injections A case tic of Physical disability. Infect Dis J Pak. Oct-Dec 2001; 10(2): 22-3. Azhar M, Irshad M. Radial nerve palsy an analysis of 50 cases. J Coll Physicians Su Pak 2001; 11(7): 417-20. rg Zaman K. Head of the neu rgical department, Pakistan rosu Institu of Medical Sciences. (Personal observation & te Literatu review) personal communication. 2003. re

24. Lenmon J AR, Ritchie AE. Clinical electromyography. 4th edition. Edinburgh. Churchill Livingston; 1989. 25. Evans NA. Local complications of self administered anabolic steroid injections. Br.JSports Med 1997; 31: 349-50. 26. Chatru vedi P. Intramuscu injections. Indian JPaediatr 1985; lar 52: 445-8. 27. Wyatt HV. Diagnosis of acu flaccid paralysis: injection inju te ry or polio? Indian JPediatrics. (In press) 28. Gau SC, Swarup A. Radial nerve palsy caused by injections. J r Hand Su (Br) 1996; 2; 338-40. rg 29. Fremling MA. Injection to the median nerve. Ann Plastic Su rg 1996; 37: 561-7. 30. Modu for case investigation & disease surveillance, EPI le provincial headqu arters Sindh 20th May 1998. 31. Pakistan polio eradication initiative Federal EPI Cell NIH, MOH Govt of Pakistan (Docu ment). Nov. 2001. 32. Mir T. National polio surveillance coordinator. Islamabad. Personal commu nication 2003 33. Bender AP, Williams AN. Appropriate pu health responses blic to clu sters :the art of being responsibly responsive. Am J Epidemiol 1990; 132: S48-52. 34. Injection safety. World Health Organization Aide Memo ire 2002: www.injectionsafety.org. cited on 24/3/03. 35. Epidemiology Series Lancet 2002 (Special edition) J ary 5; anu 359:145-9. www.thelancet.com cited in Dec. 2002. 36. Vau ghn J Morrow RI. Manu of epidemiology for district P, al health management. 2nd edition. Geneva: WHO; 1991. 37. J ones J MG, Hunter D. Consensus methods for medical and health services research. BMJ1995; 311,376-80. 38. Zinn J Zaloowski A. The u of delphi panel for consensu , se s development on indicators of Laboratory performance. Clin Lab Menage Rev; 1999; 13: 368-408. 39. Hu Y. Head of the SIGN Geneva: WHO, Personal tin commu nication Dec. 2002 40. Anon. Acu te onset of flaccid paralysis , WHO/MNH/EPI/93.3, Geneva, 1993. 41. Greetham CJ Poliomyelitis among Afghan refu . gees. Physiotherapy 1991; 77: 421-2 . 42. Anon. case of paralytic illness associated with enteroviru se71 infection. MMWR 1988;37:107-108. 43. Agboatwalla M, Kirmani SR. .Nerve condu ction stu dies and its importance in the diagnosis of acute Polio.; Indian J Paediatr 1993; 60: 265-8. 44. Talat T. Chairman Expert review committee NWFP, December 2002, personal commu nication. 45. Mu sharaf S, First lady of Pakistan; Key note address at the first national symposiu on disabilities organized by the National m Institu for Handicapped Islamabad, 4-5th J te anuary 2003.

Faisal Mansoor

REFERENCES

1. The Weekly guardian, 75 Farringdon Road, London UK. April 28,1999 "Traumatic Neuritis" a letter from Robert Lacville, Raglow et al , (2001) Therapeutic injections in Pakistan from the patients perspective ; Trop. Med. Int. Jan,6(1),69-75 Mujeeb SA (2001),Unsafe injections A potential source of HCV spread. Journal of the Pakistan Medical association, 51(1):1-3. Dr Arshad Altaf (SIGN Pk.) (2001), ,Irrational injection practices in Sindh , [email protected] cited on 10.04.03. Approach of SIGN Unsafe injection practices and transmission of blood borne pathogens ,www.injectionsafety.org. cited on 12/4/2003. Safety of injections; WHO-UNICEF-UNFPA joint policy statement on the use of auto disable syringes in immunization 1999. Hutin, "Injection safety Pakistan statistics"; SIGN(WHO),www.injectionsafety.org;; [email protected], cited in Dec.2002. Luby SP, (1997) Epidemiology infection 119,349356 Simonsen L.et al(1999) Unsafe injections in the developing world and transmission of blood borne pathogens. A review. WHO bulletin,77.789-800 H V Wyatt ; (1996). Unnecessary injections and poliomyelitis in Pakistan, Tropical Doctor, , 26 : 179-180. Wyatt, HV (1998).Differential diagnosis in AFP; poliomyelitis in developing countries. Current science 1998; 75: 936-938. & Indian J of Pediatrics,65,supplement S1-S98 Luby S. (2001) Injection safety: Conference presentations. Emerging Infectious Diseases. Vol.7, No 3 Supplement June. Pirajno ADD, (1956),A cure for the serpents. A doctor in Africa . (Trans K Naylor) Reprint society London 25-26. Talat M, Eloun S. et al( 2003), Overview of injection practices in 2 governorates of Egypt,Tr. Med. Int. H. march,(8)234-41 David Werner , Disabled Village children The Hesperian foundation USA second edition 1988. Dr. Carston F Mantel, WHO of injections in the Islamic Republic of Pakistan, Executive action document 8-28 April, for Gov. of Pakistan. Amir J Khan et al; (1999) Infection by Injections from health care providers .Epidemiolo Infec Dec.123(3):515-8 Miller M.A. and Pisani E, (1999) The cost of unsafe injections WHO bulletin,77(10),808-811.

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Case definition of traumatic injection neuropathy (TIN)

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