Bloodborne HIV: Don't Get Stuck!

In June 1989, about the time that Russia’s Ministry of Health stopped the Elista outbreak, doctors in Bucharest, Romania, happened upon a similar but much larger disaster — during 1986-1992, doctors and nurses infected an estimated 10,000 children by reusing unsterilized instruments.[1]

It is notable that both before and after this outbreak, Romania has had a low level HIV epidemic. Even as doctors and nurses infected thousands of children during 1989-92, HIV remained rare in adults. Government began testing blood for transfusions in 1990; a 1991 paper reports 13 HIV-positive (0.006%) out of 212,891 tests.[2] UNAIDS estimates that as of 2017 only 0.1% of adults in Romania are infected.[3] Doctors who found and stopped the 1986-92 outbreak — as bad as it was — protected the population from a much larger disaster.

In June 1989, doctors at Fundini Hospital in Bucharest tested some inpatient children for HIV. “Surprisingly, the first case tested, a 12-year old girl…was found to be seropositive. Subsequently, at that hospital, 12 out of 20 children between the ages of 4 mo and 12 yr of age were found to be infected by HIV. Extending the study to other medical institutions, we discovered more and more cases, suggesting an epidemic. Communication of these findings to the Ministry of Health resulted in the interdiction to cease conducting further studies. Despite warnings from the Ministry of Health, we continued to test the infant population without reporting the results until December 1989, when the Communist regime in Romania collapsed.”[4] Testing continued and expanded after the December 1989 revolt that toppled Ceasescu. From June 1989 through May 1990, investigators tested 7,553 children aged 0-3 years, of which 1,046 (13.8%) were HIV-positive. Tests of 1,642 children aged 4-13 years found only 12 infections (0.7%).

Most of the children had no risk other than receipt of injections and other skin-piercing healthcare procedures in hospitals and orphanages. For example, a June 1990 study among children in an orphanage found that 20 of 101 were HIV-positive. The average age of the 101 children was less than 2 years, but they had received an average of more than 200 injections per child — more than 2 injections per week! A review of orphanage records showed routine reuse of unsterilized instruments: During 1989, the orphanage had given 4,427 injections, but had sterilized only 810 syringes.[5]

Continued testing found more infected children all over Romania. From the ages of the infected children (most were aged 0-3 years), it’s clear transmission began in the late 1980s all over Romania. One explanation for the coincident onset of parallel outbreaks all over Romania is that HIV somehow contaminated a Romanian-produced blood product (such as gamma globulin) that was distributed around the country.[6] According to this theory, some children got HIV from the infected blood production, after which reuse of unsterilized instruments spread HIV from child-to-child to account for most infections.

In an early report from this outbreak, 37 (7.5%) of 493 mothers of HIV-positive children tested HIV-positive.[2] Considering how rare HIV was among adults in Romania, it’s likely most if not all of these mothers got HIV from their children through breastfeeding.

References

1. Buzducea D, Lazar F, Mardare EI. The situation of Romanian HIV-positive adolescents: results from the first national representative survey. AIDS Care 2010; 22: 526-529. Available at: https://www.ncbi.nlm.nih.gov/pubmed?term=buzducea%20lazar%20mardare (accessed 13 October 2018).

2. Hersch BS, Popovici F, Apetrei RC, et al. Acquired immunodeficiency syndrome in Romania. Lancet 1991; 338: 645-649. Available at: https://www.thelancet.com/journals/lancet/article/PII0140-6736(91)91230-R/fulltext (accessed 13 October 2018).

3. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Available at: http://www.unaids.org/en/resources/documents/2018/HIV_estimates_with_uncertainty_bounds_1990-present (accessed 13 October 2018).

4. Patrascu IV, Dumitrescu O. The epidemic of human immunodeficiency virus infection in Romanian children. AIDS Res HUM Retroviruses 1993; 9: 99-104. Available at: https://www.liebertpub.com/doi/abs/10.1089/aid.1993.9.99?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed (accessed 14 October 2018).

5. Hersch BS, Popovici F, Jezek Z, et al. Risk factors for HIV infection among abandoned Romanian children. AIDS 1993; 7: 1617-1624. Available at: https://www.ncbi.nlm.nih.gov/pubmed/8286071 (accessed 14 October 2018).

6. Apetrei C, Loussart-Ajaka I, Collin G, et al. HIV type 1 subtype F sequences in Romanian children and adults. AIDS Res Hum Retroviruses 1997; 13: 363-365, Available at: https://www.ncbi.nlm.nih.gov/pubmed/9071437 (accessed 14 October 2018).