PESHAWAR: Frequent administration of injections was causing “provocative poliomyelitis” as three of the four polio affected children detected so far in the province had paralysis caused by wrong injections administered mostly in rural areas of Khyber Pakhtunkhwa.

Skeletal muscle injury makes sufferers exposed to complications of concurrent poliovirus infection. The phenomenon, labelled as “provocation poliomyelitis” (PPM), continues to haunt polio programme in the province as detection of polio cases in the past few months have baffled the people associated with the programme.

This phenomenon continues to cause numerous cases of paralysis in the province due to unnecessary administration of injections to children.

Seven districts are endemic for poliovirus in the province. However, most children did not develop the disease because they were vaccinated. PPM is an issue because these cases are counted in polio tally. Traumatic injection neuritis renders recipients crippled like poliovirus.

Three of four polio patients have traumatic injection neuritis

According to World Health Organisation (WHO), the condition is a result of unsafe practices of healthcare providers. It estimates that of the 12 billion injections administered worldwide annually, 50 per cent are unsafe and 75 per cent are unnecessary. In Pakistan, injections are overprescribed and are often given without regard to the patient’s chief complaint.

The rate of injection prescription is estimated to be from 6.5 to 15 injections per person per year, with children under five years receiving as many as 21 injections annually, according to experts.

A recent national survey indicated that a high proportion of these injections were unnecessary and they were administered in unsafe manner. Traumatic injection neuritis can occur because of unsafe intramuscular injection practice as it involves the sciatic and radial nerves and presents as acute peripheral neuropathy with flaccid paralysis of the injected limb within 24 hours after injection.

The world health agency said that geographic distribution of cases was uneven and more prominent and noticed in rural areas.

The survey said that traumatic injection neuritis was responsible for an increasing proportion of cases of paralysis of children in Pakistan whereas it was important to alert licensed healthcare providers to the dangers of gluteal injections to children.

“It is unlikely that this will completely solve the problem as a large portion of the responsible injections are given by unlicensed practitioners,” it said.

A study conducted to determine the magnitude of traumatic injection neuritis (TIN) among children presenting with acute flaccid paralysis (AFP) in Hayatabad Medical Complex and published in Journal of Rehman Medical Institute concluded that in Pakistan with an ongoing massive polio eradication programme, the magnitude of TIN in children presenting with AFP was common in rural parts of Khyber Pakhtunkhwa.

Authored by Majid Ali Shah, Abdul Ahad, Muteaullah, Sijadur Rehman, Romana Bibi and Naveed Mohammad, it recommended that the disease was more common in patients from rural areas due to intramuscular injections given by untrained practitioners.

During the study, 193 AFP patients were observed. Of them, 72 per cent children aged one to seven years, 28 per cent eight to 15 years and 57 per cent were male and 43 per cent were female. Of them, 17 children had TIN, of whom 13 belonged to rural areas.

Health department found 26 TIN cases in 2019, six in 2020 and 69 in 2022. All of the affected children were given injections by unqualified medical practitioners.

Senior paediatricians, however, say that TIN occurs usually due to accidental trauma to sciatic nerve by giving injection in buttocks. “Muscles are prone to weakness due to many causes including polio patients, who are infected but yet not paralysed. They may be precipitated with intra-muscular injection,” they said.

Paediatricians say that it is a coincidence and injection is not the cause. They say that real cause of polio infection is non-vaccination in the country. “Intra-muscular injection can precipitate paralysis in a polio infected child,” they said.

Published in Dawn, October 14th, 2024