Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 77-82
The epidemiology and type of injuries seen at the accident and emergency unit of a Nigerian referral center


1 Department of Otorhinolaryngology, Head and Neck Surgery, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State, Nigeria
2 Department of Surgery, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State, Nigeria

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Date of Submission17-Apr-2013
Date of Acceptance27-Sep-2013
Date of Web Publication16-Apr-2014
 

   Abstract 

Background: A plethora of injuries present at any accident and emergency unit, but the pattern of the injuries varies from region to region especially in ours with the increased ethno-religious clashes and terrorist attacks. This study aims to determine the epidemiology and type of injuries presenting to our center with the possibility of developing injury surveillance initiatives in our center and Nigeria as a whole. Materials and Methods: Injured patients consecutively presenting to the accident and emergency department of the Jos University Teaching Hospital within the period February 2011 to January 2012 were prospectively recorded. Results: A total of 720 injured patients admitted with an age range of 8 months to 75 years (mean = 37.9; SD = ±52.4), which consists of 544 males and 176 females giving a male to female ratio of 3.1:1. Patients aged 20-29 years were in the majority (n = 220, 30.6%) with peak incidences in the period of communal clashes. Injuries sustained from motorcycles were the highest (n = 248, 34.4%). Others were 160 (22.2%) in other vehicular and pedestrian injuries, machete (n = 128), gunshots (n = 92), burns (n = 36), bomb blast injuries (n = 16), fall from heights (n = 32) and miscellaneous (n = 8). Injuries sustained in communal clashes and terrorist attacks accounted for 236 (32.8%) presentations. The most common site of injury was the head (n = 30 4, 42.2%). Relatives, passersby and law enforcement agencies brought patients to the hospital with times between injury and presentation ranging from 1 h to 3 weeks. 40 (5.6%) patients were brought in dead. Conclusion: A collective effort - on the part of the government and the citizenry is required to ensure better outcomes and a safer society for all.

Keywords: Accident and emergency, epidemiology, injury pattern, Jos-Nigeria

How to cite this article:
Adoga AA, Ozoilo KN. The epidemiology and type of injuries seen at the accident and emergency unit of a Nigerian referral center. J Emerg Trauma Shock 2014;7:77-82

How to cite this URL:
Adoga AA, Ozoilo KN. The epidemiology and type of injuries seen at the accident and emergency unit of a Nigerian referral center. J Emerg Trauma Shock [serial online] 2014 [cited 2019 Dec 14];7:77-82. Available from: http://www.onlinejets.org/text.asp?2014/7/2/77/130875



   Introduction Top


Injuries are said to be the leading cause of death and a major source of disability amongst children and young adults in industrialized countries [1],[2] and this is more so in the developing countries like Nigeria where increasing industrialization, high velocity vehicles, increasing ethno-religious clashes and recently widespread terrorist attacks have resulted in sudden, unexpected mass casualties presenting to secondary and/or tertiary health centers. [3] These are now competing favorably with under-nutrition and infections as causes of morbidity and mortality especially in children.

Rapid unplanned industrialization and urbanization especially in the developing countries has led to an unprecedented surge in the number of vehicles in these countries, invariably leading to an increase in morbidity and mortality from these high velocity means of transportation. World-wide, the number of road traffic accident fatalities is estimated at 1.2 million annually with the number of those injured being as high as 50 million. [4] It is estimated that by the year 2030, motor vehicle accidents, which currently rank 9 th as a cause of disability-adjusted life- years (DALYs) in the world would be ranked 3 rd[5] therefore, road traffic accidents are considered to be the new global epidemic. Developing countries especially sub-Saharan Africa accounts for more than 85% of all road traffic accident deaths world-wide. [6],[7],[8] More than 90% of the DALYs lost world-wide from road traffic accidents occur in developing countries. [9] South East Asia records the highest number of global road fatalities in the world. It is difficult to have true epidemiological figures of these accidents in Nigeria due to poor record keeping and unreported accidents. Trauma registries are non-existent and documentation of injuries inadequate. [10]

In Nigeria, the use of motorcycles as a means of commercial transportation has completely changed the type, prevalence and outcome of injuries resulting from road traffic accidents, contributing a major neglected public health problem.

Ethnic and religiously motivated crises, which are also said to have political undertones have been in existence for decades in Nigeria, as far back as the pre-colonial era. [11]

Terrorist attacks have been non-existent in Nigeria until very recently with the proliferation of a variety of terrorist groups. These days it is common place to have bombings orchestrated by these insurgents targeted at the public.

Records of injuries following the above events in developing countries are primarily based on hospital logs [12],[13] and police records [14],[15],[16] both of which are relatively unreliable as these sources underestimate the total burden of these injuries.

These events are characteristics, which can be modified for a better outcome for the people and prompted this study to determine the epidemiology and trend of injuries that present to our Teaching Hospital with a view to developing injury surveillance initiatives in our center and Nigeria as a whole by identifying the causes of these injuries and implementing appropriate preventive measures on a routine basis.


   Materials and Methods Top


This was a prospective descriptive hospital based study.

Consecutively injured patients presenting to the accident and emergency unit of the Jos University Teaching Hospital (JUTH), Jos, Plateau State, Nigeria from February 2011 to January 2012 were analyzed for age, gender, cause of injury, type/site of injury and the outcome of injuries sustained.

Clearance for this study was obtained from the Ethical Clearance Committee of the JUTH and consent obtained from the patients.

Patients were rescucitated using the principles of Advanced Trauma Life Support. Investigations such as full blood count, urgent grouping and cross match of blood with necessary blood transfusions were effected. Skull, limb, thoraco-abdominal X-rays and cranial computerized tomographic scans were done where necessary. Management of these patients involved the trauma surgeons, neurosurgeons, otolaryngologists and cardiothoracic surgeons.

Patients presenting with medical emergencies and other surgical emergencies not attributable to trauma were excluded from this study.

Data was analyzed using EPI Info database version 3.5.3 (EPI Info, Center for DIsease Control, Atlanta, Georgia, 2011) and statistical software version 3.3.5.

The hospital is a tertiary health institution that subserves functions of health-care for people of neighboring states.


   Results Top


A total of 2318 patients presented to the accident and emergency unit with medical and surgical emergencies within the study period of which 720 injured patients presented aged between 8 months and 75 years (mean = 37.9; SD = ±52.4) comprising 544 males and 176 females giving a male to female ratio of 3.1:1. This gives an injury prevalence of 31.1%.

Patients aged 20-29 years were in the majority (n = 220, 30.6%) [Table 1] with a peak incidence of injuries in the period of ethnic and religiously motivated crises. Injuries sustained from motorcycles were the highest (n = 248, 34.4%) consisting of 145 motorcyclists and 103 passengers. Others were 160 (22.2%) in other vehicular and pedestrian injuries, machete (n = 128, 17.8%), gunshots (n = 92, 12.8%), burns (n = 36, 5%), bomb blast injuries (n = 16, 2.2%), fall from heights (n = 32, 4.5%) and miscellaneous (n = 8, 1.1%) [Table 2]. Injuries sustained in communal clashes and terrorist attacks accounted for 236 (32.8%) presentations. There were 472 (65.6%) multiply injured and 248 (34.4%) singly injured patients. The most common site of injury was the head (n = 304, 42.2%) followed by limb injuries in 236 (32.8%) and other anatomical site injuries were recorded in 180 (25%) patients [Figure 1]. 8 (1.1%) of the victims of motorcycle injuries used protective helmets.
Figure 1: Anatomical sites of injury

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Table 1: Age and sex distribution of injured patients

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Table 2: Etiology of injuries presenting at the accident and emergency

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Eleven (1.5%) males were under the influence alcohol.

Relatives, passersby and law enforcement agencies brought patients to the hospital with times between injury and presentation ranging from 1 h to 3 weeks. One hundred and sixty three (22.6%) patients were brought in within 1 h, 376 (52.2%) within 24 h, 115 (16%) within 1 week, 47 (6.5%) within 2 weeks and 19 (2.7%) within 3 weeks.

Forty (5.6%) patients were brought in dead all from head injuries and 12 (1.7%) died within 24 h of hospital presentation-9 (1.3%) from intracranial hemorrhage and 3 (0.4%) from severe multiple injuries (other than head injuries) sustained following bomb blasts [Figure 2]. This gives a mortality rate of 7.3%.
Figure 2: Outcome of injuries

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   Discussion Top


Road traffic accidents have continued to be an increasing source of morbidity and mortality world-wide with the developing countries worse hit. [17] This study further highlights this fact with road traffic accidents accounting for 408 (56.7%) of injuries comprising of 248 motorcycle injuries and 160 other vehicular and pedestrian injuries. Though the prevalence rate recorded in this study is not as high as others previously mentioned, [7],[18] but it is certainly not among the least. This rate is still higher than those recorded in Kenya, [19] the West Indies [20] and the Netherlands. [21] These are a result of several factors, which include poor attitudinal characteristics of road users, road unworthy vehicles, poverty and extremely bad road conditions.

There has been an influx of motorcycles into Africa, Nigeria in particular in recent years. These are used for commercial transportation, a practice, which began during periods of economic recession in the late 1970s and early 1980s. [22] Almost all income groups except the elite use the motorcycle to commute within the cities. [23] They became popular because they provided a means of livelihood to a teeming number of unemployed youths and the ease they offer in circumventing road traffic hold ups and the ability to navigate remote and non-motorable parts of cities. [22] These youths as stated are in their productive and reproductive stages of life. They are undisciplined, reckless, tend to over-speed, lack respect for other road users and traffic rules and overload their motorcycles for quick returns. In so doing, they and their passengers most times do not use protective helmets resulting in often fatal injury patterns especially head and limb injuries. [22],[24],[25],[26] Owing to the minimal use of protective helmets by motorcyclists as noted in this study (1.1%), it is not surprising level of head injuries recorded. The head injury prevalence rate is similar to that obtained from a previous study in our center. [22] Motorcyclists and passengers equally recorded injuries signifying the injury risks they both face. Eleven (1.5%) of motorcyclists were found to be influenced by alcohol, but we do not have the facility to measure blood alcohol levels in these patients, which is a limitation in this study.

Flouting traffic rules and regulations applies to other road users as well-commercial bus drivers, taxi drivers etc. Many of whom exhibit similar characteristics as the motorcyclists. The outright refusal to use seat belts (where available) by these bus and taxi drivers and their passengers is also a recognizable factor in the increased prevalence in morbidity and mortality from road traffic accidents.

In February 1988, the Federal Government of Nigeria established the Federal Road Safety Commission through decree with the responsibility of policy making, organization and administration of road safety. The commission also states clearly that its members have the power to arrest and prosecute persons reasonably suspected of having committed any traffic offence. [27] However, sadly, these functions have not been effective and achieved very little going by the surge in the prevalence of road traffic accidents. Traffic laws have been ineffective because they are flouted. Motorcyclists and other motorists disobey traffic laws with so much impunity by overloading their vehicles with passengers, not using protective helmets, not using seat belts where available, stopping in the middle of a flowing traffic to pick and drop passengers, etc., The list of wrong doing is endless. Women with babies strapped to their backs mounting motorcycles are a very frequent occurrence therefore infants and the very young have become a major group at risk of injuries and death resulting from motorcycle accidents. [28],[29]

The mortality rate in this report of 7.3% is the same as that reported on motorcycle injuries alone from the same center [22] with the majority of deaths resulting from head injuries. This may be due to the increase in the rate of injuries and deaths from ethno-religious and terror attacks as that from motorcycles reduced as a result of the restriction of movement of motorcycles imposed by the government from 7 pm to 7 am.

A large percentage of the vehicles, which ply our roads especially those used for commercial purposes are road unworthy, but still not checked by the law enforcement agents to be kept off the roads thereby constituting unprecedented level of hazard for the people especially pedestrians who were largely affected in this study. Environmental pollution from the fumes emitted by the exhaust pipes of these vehicles with their attendant acute and chronic respiratory sequels is also important to consider.

The combination of low level law enforcement, frequent and uncontrolled corruption on the part of law enforcement agents and very low public awareness militates against the success of these traffic regimes.

Riding motorcycles as a means of livelihood stems from unemployment and poverty, which are offshoots of wanton corruption on the part of individuals in government whose responsibility it is to create employment and provide basic amenities for the citizenry. Funds required for the provision of better, safer and more efficient means of transportation as it obtains in other parts of the world and other people oriented projects such as good, motorable roads and proper health facilities to cater for the injured (as these road traffic accidents though preventable are inevitable) are embezzled.

Similar to the findings in previous studies, burns and fall injuries were noted in a significant number in this study [7],[30] with a spinal injury recorded in 1.25% of cases.

Ethno-religious clashes and terror attacks accounted for a very significant number of injuries and deaths in this study. Though ethnic and religious clashes among communities in Nigeria have been in existence as far back as the pre-colonial era because of the multi-ethnic and multi-religious nature of the Nigerian society, the spate of these clashes especially on the Jos, Plateau has increased over the years with politics being a recently introduced motivating factor. This is also true for insurgent terror attacks. These clashes and acts of terrorism leave in their wake, mass casualties of injuries and the dead with disruption in health infrastructure, environmental destruction, profound psychological damage, refugee crises, increased interpersonal, self-directed and collective violence. [31] It is estimated that over 100,000 Nigerians have lost their lives from ethnic and religious crises since 1979. The number of those injured triples the number of the dead and several million people displaced in these unfortunate events. [11] This has put Nigeria in focus with debates on whether or not to include her in the global list of terrorist nations. With the very recent terror attacks on the public in our region, we have also witnessed an increase in the number of injuries and deaths presenting to our health facility as a result of such attacks.

It is noted that the 20-39 years age group were the most affected in this study. These are individuals in their reproductive and productive stages of life. These are people mostly responsible for socio-economic development of the society. Having this group injured, disabled or dead is inimical to development.

In a country without emergency medical services [32] and in which comprehensive regional and national injury data is nonexistent, [30] there is an urgent need for defining the epidemiology of injury with a view to developing violence and injury prevention strategies.

In preventing these injuries, the development of proper injury surveillance systems at a regional and national level is important. These systems have been developed on a regional and national level by many industrialized nations and are based in the accident and emergency departments designed to specifically monitor injury events. Surveillance helps to characterize events leading to injury, helping to prioritize effective interventions by allocating appropriate resources toward prevention.

Efforts at primary and secondary prevention of road traffic accidents should be made involving human factors such as the behavior of the motorcyclists, condition of motorcycles and the condition of the roads.

Public education is important in the prevention. Public perception of the risks of injury must be understood in order to adapt and apply prevention campaigns that have proven to be successful elsewhere in the world. The risks associated with riding a motorcycle or driving a car under the influence of alcohol or dangerous substances must be clearly stated, understood and completely avoided.

Adhering to traffic rules and regulations and control of speed carries a great potential to saving lives. Road safety law enforcement agents must ensure strict adherence to these rules, fining and prosecuting traffic offenders.

The importance of proper vehicle maintenance should be stressed and regular vehicular checks by appropriate authorities effected.

Use of seatbelts by motorists, wearing of helmets by both the motorcyclist and passenger should be enforced. Motorcycles as a means of commercial transportation should be completely discouraged. Government should be responsible enough to provide other better, safer and more efficient means of transportation for the citizenry as it obtains in other parts of the world.

Currently, road infrastructures which are the responsibility of government and funding organizations are inadequate. These need to be addressed. Good roads must be built and existing ones properly maintained.

Facilities for pre-hospital and hospital emergency care of the injured are grossly inadequate. Decreasing trained surgeons, intensive care staff, properly trained field paramedics; inappropriate means of transportation of the injured; grossly underserved medical facilities and a disorganized or non-existent emergency trauma service thrives leaving the severely injured at risk. Improvement of the health sector with proper and judicious funding for equipment and training of health personnel is needed to improve outcomes.

Analysts are of the opinion that poverty, ignorance, injustice, politics, religious fanaticism and over-zealousness on the part of religious leaders are the factors responsible for the ethno-religious crises in Nigeria, but certain individuals are thought to fuel these crises for their selfish benefits at the detriment of the citizenry. [33] To stem this tide, government needs to establish an active conflict management unit, to help provide proper information, identification, interpretation and policy options, from which appropriate responses can be undertaken. In the long-term, government should actively fight corruption, improve the economy and job creation. These should improve human development and reduce the spate of crises.

The above should also apply to terror attacks and government should strictly adhere to the United Nations General Assembly resolution on Global Counter-Terrorism strategy. [34]


   Conclusion Top


The trend of injuries in our region has changed remarkably especially with the increase in the spate of ethno-religiously motivated communal clashes and terrorist attacks.

Majority of these injuries though inevitable are to a very large extent preventable.

Appropriate measures should be instituted by government in the provision of basic amenities, creation of jobs, providing effective rescue and response facilities in cases of emergencies, good roads and enforcing traffic laws in order to improve outcomes and ensuring a safer society for citizens.

 
   References Top

1.World Health Organization. World Health Statistics Annual Report. Geneva: WHO; 1995.  Back to cited text no. 1
    
2.Robertson LS. Injury epidemiology. In: Injury Prevention: An International Perspective: Epidemiology, Surveillance and Policy. Oxford, New York: University Press; 1993. p. 49-69.  Back to cited text no. 2
    
3.Nwadiaro HC, Yiltok SJ, Kidmas AT. Immediate mass casualty management in Jos University Teaching Hospital: A successful trial of Jos protocol. West Afr J Med 2000;19:230-4.  Back to cited text no. 3
    
4.Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA. World Report on Road Traffic Injury Prevention. Geneva: World Health Organization; 2004. Available from: http//www.who.int/world-health-day/2004/infomaterials/worldreport/en. [Last accessed 2012 May 30].  Back to cited text no. 4
    
5.Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.  Back to cited text no. 5
    
6.Ameratunga S, Hijar M, Norton R. Road-traffic injuries: Confronting disparities to address a global-health problem. Lancet 2006;367:1533-40.  Back to cited text no. 6
    
7.Mohan D. Road safety in less-motorized environments: Future concerns. Int J Epidemiol 2002;31:527-32.  Back to cited text no. 7
[PUBMED]    
8.Nantulya VM, Reich MR. The neglected epidemic: Road traffic injuries in developing countries. BMJ 2002;324:1139-41.  Back to cited text no. 8
    
9.Murray C, Lopez A. The Global Burden of Disease. Vol. 1. Cambridge MA: Harvard University Press; 1996.  Back to cited text no. 9
    
10.Thanni LO, Kehinde OA. Trauma at a Nigerian teaching hospital: Pattern and docu-mentation of presentation. Afr Health Sci 2006;6:104-7.  Back to cited text no. 10
    
11.Yusuf U. Ethno-religious crisis: The north and the rest of Nigeria. Vanguard Newspaper. Vanguard Media Limited, Nigeria. August 8, 2009.  Back to cited text no. 11
    
12.Balogun JA, Abereoje OK. Pattern of road traffic accident cases in a Nigerian university teaching hospital between 1987 and 1990. J Trop Med Hyg 1992;95:23-9.  Back to cited text no. 12
    
13.Weddell JM, McDougall A. Road traffic injuries in Sharjah. Int J Epidemiol 1981;10:155-9.  Back to cited text no. 13
[PUBMED]    
14.Asogwa SE. Road traffic accidents in Nigeria: A review and a reappraisal. Accid Anal Prev 1993;25:485-7.  Back to cited text no. 14
    
15.Jayasuriya R. Trends in the epidemiology of injuries due to road traffic accidents in Papua New Guinea. Asia Pac J Public Health 1991;5:41-8.  Back to cited text no. 15
[PUBMED]    
16.Oluwasanmi AJ. Road accident trends in Nigeria. Accid Anal Prev 1993;25:485-7.  Back to cited text no. 16
[PUBMED]    
17.Krug E, editor. Injury: A Leading Cause of the Global Burden of Disease. Geneva: WHO; 1999. Available from: http://www.who.int/violenceinjuryprevention/index.html. [Last accessed 2012 Oct 10].  Back to cited text no. 17
    
18.Osifo OD, Osagie TO, Iribhogbe PE. Pediatric road traffic accident deaths presenting to a Nigerian referral center. Prehosp Disaster Med 2012;27:136-41.  Back to cited text no. 18
    
19.Odero WO, Kibosia JC. Incidence and characteristics of injuries in Eldoret, Kenya. East Afr Med J 1995;72:706-10.  Back to cited text no. 19
    
20.Crandon I, Carpenter R, McDonald A. Admissions for trauma at the University Hospital of the West Indies. A prospective study. West Indian Med J 1994;43:117-20.  Back to cited text no. 20
    
21.Oskam J, Kingma J, Klasen HJ. The Groningen Trauma Study. Injury patterns in a Dutch trauma centre. Eur J Emerg Med 1994;1:167-72.  Back to cited text no. 21
    
22.Nwadiaro HC, Ekwe KK, Akpayak IC, Shitta H. Motorcycle injuries in North-Central Nigeria. Niger J Clin Pract 2011;14:186-9.  Back to cited text no. 22
[PUBMED]  Medknow Journal  
23.Nzegwu MA, Aligbe JU, Banjo AA, Akhiwui W, Nzegwu CO. Patterns of morbidity and mortality amongst motorcycle riders and their passengers in Benin-City Nigeria: One-year review. Ann Afr Med 2008;7:82-5.  Back to cited text no. 23
[PUBMED]  Medknow Journal  
24.Oluwadiya KS, Oginni LM, Olasinde AA, Fadiora SO. Motorcycle limb injuries in a developing country. West Afr J Med 2004;23:42-7.  Back to cited text no. 24
    
25.Peek-Asa C, McArthur DL, Kraus JF. The prevalence of non-standard helmet use and head injuries among motorcycle riders. Accid Anal Prev 1999;31:229-33.  Back to cited text no. 25
    
26.Seleye-Fubura D, Ekere AU. Vehicular road deaths in the Niger Delta. Orient J Med 2003;15:41-4.  Back to cited text no. 26
    
27.Federal Road Safety Corps. In. Available from: http://www.frsc.gov.ng/about-us/what-we-do. [Last accessed 2009 Aug 12].  Back to cited text no. 27
    
28.Ekenze SO, Anyanwu KK, Chukwumam DO. Childhood trauma in Owerri (south eastern) Nigeria. Niger J Med 2009;18:79-83.  Back to cited text no. 28
    
29.Emejulu JK, Shokunbi MT. Aetiological patterns and management outcome of paediatric head trauma: One-year prospective study. Niger J Clin Pract 2010;13:276-9.  Back to cited text no. 29
[PUBMED]  Medknow Journal  
30.Thanni LO. Epidemiology of Injuries in Nigeria-A Systematic review of Mortality and Etiology. Prehosp Disaster Med 2011;26:293-8.  Back to cited text no. 30
[PUBMED]    
31.Sidel VW. War, terrorism and the public's health. Med Confl Surviv 2008;24 Suppl 1:S13-25.  Back to cited text no. 31
[PUBMED]    
32.Solagberu BA, Ofoegbu CK, Abdur-Rahman LO, Adekanye AO, Udoffa US, Taiwo J. Pre-hospital care in Nigeria: A country without emergency medical services. Niger J Clin Pract 2009;12:29-33.  Back to cited text no. 32
[PUBMED]    
33.Adeyemi LO. Ethno-religious conflicts and the travails of national integration in Nigeria's fourth republic, 2006. Available from: http://www.Dawodu.com. [Last accessed 2012 Aug 3].  Back to cited text no. 33
    
34.The Unite Nations. Global Counter-Terrorism strategy, 2006. Available from: http://www.un.org/terrorism/strategy-counter-terrorism. [Last accessed 2012 Aug 3].  Back to cited text no. 34
    

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Correspondence Address:
Adeyi A Adoga
Department of Otorhinolaryngology, Head and Neck Surgery, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.130875

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