Author's reply
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《美国医学杂志》
National Polio Surveillance Project, Gate No. 31, 2nd Floor, Jawaharlal Nehru Stadium, New Delhi-110 003, India
We appreciate Dr. Mahadevan's thoughtful comments on traumatic neuritis and AFP surveillance, and would like to make a few comments in response.
We agree with Dr. Mahadevan that injections should only be given necessary, and that unnecessary injections can lead to a number of serious health consequences. In addition to the possibility of provocation or aggravation paralysis, unnecessary injections carry an even higher risk of infection with viral diseases. One recent study estimated that up to 39 per cent of all hepatitis b infections were caused by unsafe injections, as well as 40% of hepatitis C inections, and at least 5% of all HIV infections.[1] Clearly, programs to minimize the use of injections should be promoted.
With respect to surveillance for polio and the case definition of traumatic neuritis (TN), we agree that diagnosing TN on clinical grounds alone may be difficult. In fact, a purely clinical diagnosis of the various potential etiologies of AFP may be very defficult, if not impossible, which has led to the current classification system using both clinical and laboratory (virological) data. The vague definition of TN in the Field Guide,[2] and failure to report details of site and data of injections was done because of the difficulty in actually using these data for diagnosis and more importantly because the purpose of national AFP surveillance is not to detect TN, but to identify circulating wild polio virus.
If wild polio virus is circulating, it will eventually cause paralysis. By identifying and evaluating all cases of paralysis and evaluating for presence of wild poliovirus, we can locate areas with active wild poliovirus circulation. The current AFP surveillance (used globally as a primary component of the polio eradication initiative), "casts the net widely" and identifies all cases of acute flaccid paralysis in children less than 15 years of age. Cases of TN, Guillain Barre, and other entities, as well as polio, will be included, but that is fine for the purpose of identifying wild poliovirus. From each AFP case, no matter what the etiology, stool specimens are collected in a timely manner, and if wild poliovirus is grown, the case is recorded as a case of polio. This allows identification of areas of continued circulation of wild polio virus. Thus, for the purposes of the National Polio Surveillance Project, it does not matter whether we accurately diagnose all cases of TN, but it does matter that we properly identify all cases of AFP, and collect appropriate and timely stool specimens. With appropriate collection and culture of stool samples, sensitivity for wild polio virus among AFP cases with polio over 80%, and thus there is very little chance that cases of polio will be misdiagnosed as TN.
References
1. Hauri AM, Armstrong GL, Hutin YJF. Contaminated Injections in Health Care Settings. Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Risk Factors. Geneva: World Health Organization, 2003.
2. MCH Division, Department of Family Welfare, Ministry of Health and Family Welfare, New Delhi, India. Surveillance of Acute Flaccid Paralysis. 2nd edn. 2000: 22-23, 35.(Wenger Jay D, Gupta Dhana)
We appreciate Dr. Mahadevan's thoughtful comments on traumatic neuritis and AFP surveillance, and would like to make a few comments in response.
We agree with Dr. Mahadevan that injections should only be given necessary, and that unnecessary injections can lead to a number of serious health consequences. In addition to the possibility of provocation or aggravation paralysis, unnecessary injections carry an even higher risk of infection with viral diseases. One recent study estimated that up to 39 per cent of all hepatitis b infections were caused by unsafe injections, as well as 40% of hepatitis C inections, and at least 5% of all HIV infections.[1] Clearly, programs to minimize the use of injections should be promoted.
With respect to surveillance for polio and the case definition of traumatic neuritis (TN), we agree that diagnosing TN on clinical grounds alone may be difficult. In fact, a purely clinical diagnosis of the various potential etiologies of AFP may be very defficult, if not impossible, which has led to the current classification system using both clinical and laboratory (virological) data. The vague definition of TN in the Field Guide,[2] and failure to report details of site and data of injections was done because of the difficulty in actually using these data for diagnosis and more importantly because the purpose of national AFP surveillance is not to detect TN, but to identify circulating wild polio virus.
If wild polio virus is circulating, it will eventually cause paralysis. By identifying and evaluating all cases of paralysis and evaluating for presence of wild poliovirus, we can locate areas with active wild poliovirus circulation. The current AFP surveillance (used globally as a primary component of the polio eradication initiative), "casts the net widely" and identifies all cases of acute flaccid paralysis in children less than 15 years of age. Cases of TN, Guillain Barre, and other entities, as well as polio, will be included, but that is fine for the purpose of identifying wild poliovirus. From each AFP case, no matter what the etiology, stool specimens are collected in a timely manner, and if wild poliovirus is grown, the case is recorded as a case of polio. This allows identification of areas of continued circulation of wild polio virus. Thus, for the purposes of the National Polio Surveillance Project, it does not matter whether we accurately diagnose all cases of TN, but it does matter that we properly identify all cases of AFP, and collect appropriate and timely stool specimens. With appropriate collection and culture of stool samples, sensitivity for wild polio virus among AFP cases with polio over 80%, and thus there is very little chance that cases of polio will be misdiagnosed as TN.
References
1. Hauri AM, Armstrong GL, Hutin YJF. Contaminated Injections in Health Care Settings. Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Risk Factors. Geneva: World Health Organization, 2003.
2. MCH Division, Department of Family Welfare, Ministry of Health and Family Welfare, New Delhi, India. Surveillance of Acute Flaccid Paralysis. 2nd edn. 2000: 22-23, 35.(Wenger Jay D, Gupta Dhana)