Nandkumar M Kamat
WHO team has begun its investigative work in China on COVID-19 and it will continue it by making several visits this year to discover the closest relative of the virus in bats. The team is expected to gather data on where and how COVID-19 jumped to humans and whether another species acted as an intermediate host. This investigation is expected to provide clues to prevention of other pandemic viruses from emerging.
On the other side, we see much euphoria about the anti COVID-19 vaccination programme but the scientific community is not very satisfied with the lack of transparency. We don’t have in India a fund like the USA that compensates people injured by vaccines. In the USA they have a $4 billion fund to compensate people if they sustain shoulder injuries after incorrectly administered injections with flu, tetanus, and other vaccines.
Since the publication of a paper by a team of American scientists led by Major Szari in August 2019 titled ‘Shoulder Injury Related to Vaccine Administration: A Rare Reaction’ there had been more claims that other vaccines also caused shoulder injuries. This team had advised that there needs to be proper awareness of shoulder injury related to vaccine administration and a high index of suspicion are
necessary to evaluate patients with shoulder concerns post vaccination.
Since after China it would be India which would see large mass anti COVID-19 vaccination drives it is important to know their findings so that there is no panic caused if cases of SIRVA (Shoulder Injury Related to Vaccine Administration) are found.
In the USA in 2010, SIRVA was described by Atanasoff and colleagues as the rapid onset of shoulder pain and dysfunction persisting as a complication of deltoid muscle vaccination in a case series of 13 patients. The above 2019 paper had described the case of a patient who had received an intramuscular (IM) quadrivalent influenza vaccine with a 25-gauge, 1-inch needle during a mass influenza immunization. The site of vaccination was slightly more than three centimetres below the top of the shoulder in a region correlating to the left deltoid and was administered while he was standing with his arm extended, adducted, and internally rotated. The patient experienced intense pain immediately after the vaccination and noted decreased ROM ( range of motion). Initially, he dismissed the pain and decreased ROM as routine but sought medical attention when there was no improvement after three weeks. Finally, he was diagnosed with SIRVA and continued in physical therapy with incomplete resolution of symptoms six months post
vaccination.
Elaborating on SIRVA this team claims that it “is one such process that can lead to persistent musculoskeletal dysfunction. SIRVA presents as shoulder pain and limited ROM that occurs after the administration of an injectable vaccine. In 2011, the Institute of Medicine determined that evidence supported a causal relationship between vaccine administration and deltoid bursitis”. They advised that –“a diagnosis of SIRVA can be considered in patients who experience pain within 48 hours of vaccination, have no prior history of pain or dysfunction of the affected shoulder prior to vaccine administration, and have symptoms limited to the shoulder in which the vaccine was administered where no other abnormality is present to explain these symptoms (eg, brachial neuritis, other neuropathy)”.
In India this paper is not much discussed by those who are managing mass anti COVID-19 vaccination programmes. This team advised: “proper vaccine administration ensures that vaccinations are delivered in a safe and efficacious manner. Safe vaccination practices include the use of trained personnel who receive comprehensive, competency-based training regarding vaccine administration.”
Is there any procedure in India to evaluate SIRVA? This team suggests – “awareness of SIRVA and a high index of suspicion are necessary to evaluate patients with shoulder concerns post vaccination. Laboratory evaluation should be considered to evaluate for other potential diagnoses (eg, infection, rheumatologic concerns). Routine X-rays are not helpful in cases of SIRVA. Ultrasound may be considered as it can show bursa abnormalities consistent with bursitis. MRI of the affected shoulder may provide improved diagnostic capability if SIRVA is suspected. MRI findings vary but include intraosseous oedema, bursitis, tendonitis, and rotator cuff tears.” Do we have any mechanism in place like the USA-Vaccine Adverse Event Reporting System (VAERS) which tracks reports of shoulder dysfunction following certain vaccinations? VAERS had reported that between 2010 and 2016, there were 1006 possible reports of shoulder dysfunction following inactivated influenza vaccination (IIV) compared with an estimated 130 million doses of IIV given each influenza season in the USA. So if more than 300 million adults are to be vaccinated in our country in coming months with one or more anti COVID-19 ‘Made in India’ vaccines then India needs to establish a Vaccine Adverse Event Reporting System (VAERS) at national and state level. The above eye-opener paper concluded that: “correct administration of vaccines is of utmost importance in preventing SIRVA and other vaccine-related shoulder dysfunctions. Proper staff training and refresher training can help prevent vaccine-related shoulder injuries. Additionally, clinicians should be aware of this potential complication and maintain a high index of suspicion when evaluating patients with post vaccination shoulder complaints.”
We need to keep our fingers crossed as first cases of SIRVA although rare begin to appear after mass COVID-19 vaccinations puzzling the doctors. The experience in the USA like above would be helpful besides a detailed plan to compensate SIRVA patients could be launched to increase the confidence of the people who are ready to take the anti COVID-19 or any other vaccine in the shoulder.
