Bloodborne HIV: Don't Get Stuck!

In early 1989, an article in Nature reported an ongoing investigation of HIV transmission to children through hospital procedures in Elista, a town in Russia, at that time part of the Soviet Union.[1] The investigation was spurred by the discovery of two people with unexpected HIV infections – a child tested because of illness (both parents were HIV-negative), and a woman tested during routine screening of blood donors (she had no HIV-positive sexual contacts).

In 1990, the British Medical Journal published an account of the ongoing investigation – including tracing and testing patients and others to find and stop whatever was happening.[2] “[A]n outbreak of HIV infection was discovered in the small town of Elista…after an investigation in November 1988 of an unusual case of a baby who was found to be HIV positive although both his parents were negative. A team of experts arrived from Moscow’s Central Institute of Epidemiology and started wider screening. Within two months 12,000 tests were done. It was established that all the children who were found to be HIV positive had at some point been treated in the same central children’s hospital… At the end of May 1989 the report acknowledged 58 infected children and nine mothers. [The mothers “had probably become infected while breast feeding through cracks in the nipple as many of the infected children had stomatitis and bleeding gums.”] The suspected source of infection was provisionally identified as the husband of one of the mothers, who was HIV positive and who had worked in the Congo for several years and had been given a blood transfusion in one of the local African hospitals during emergency surgery. His child, born in Elista, had AIDS and was suspected as the main source of the transmission of the virus within the hospital. A joint medical and criminal investigation found that syringes were routinely reused by nurses without proper sterilisation…”

But that was only part of the story. Extending the investigation to other hospitals, the Ministry of Health found that from May 1988 through August 1989 (on this link search for PoC 4138):[3] “288 Soviet citizens (265 children under 15 years of age and 23 adult women) were infected in 13 hospitals of Elista, Volgograd, Stavropol, Rostov-on-Don, Shakhty, Grozny, Astrakhan (Southern Russia)… All children and 1 woman were infected due to inadequate sterile technique, mainly by using shared syringes. 22 women got most probably infected via breast-feeding their children having been infected in hospitals. Correlation of time of the patients’ hospitalization to the foci and transfer of some of them to other hospitals pointed to one index patient of the outbreak — a child born to HIV-seropositive parents and admitted to Elista hospital in May 1988…. CONCLUSIONS: Active contact tracing and HIV-antibody testing of inpatients, education of medical staff and strict sanitary inspection in hospitals resulted in localizing nosocomial foci and ceasing HIV-transmission in hospitals of Russia.”

Most child-to-child transmissions during this outbreak came from inpatient children who themselves had been infected not more than six weeks earlier.[4] If we assume each infected child infected an average of 1-2 children over 1-2 months, this would produce the observed infections. If HIV-positive children had an average of 10-50 procedures per month, after which instruments were subsequently reused without sterilization, the calculated average risk to transmit HIV per procedure would be 2 percent to 10 percent (see paras 10-11 in this link).[5]

References

1. Belitsky V. Children infect mothers in AIDS outbreak at a Soviet hospital. Nature 1989; 337: 493. Available at:  https://www.nature.com/articles/337493a0.pdf (accessed 14 October 2018).

2. Medvedev ZA. Evolution of AIDS policy in the Soviet Union. II. The AIDS epidemic and emergency measures. BMJ 1990; 300: 932-934. Available at: https://www.bmj.com/content/bmj/300/6729/932.full.pdf (accessed 14 October 2018).

3. Pokrovsky VV. Localization of nosocomial outbreak of HIV-infection in southern Russia in 1988-1989. 8th Int Conf AIDS. 19-24 July 1992; abstract no. PoC 4138. Available at: https://quod.lib.umich.edu/c/cohenaids/5571095.0050.029?rgn=main;view=fulltext (accessed 14 October 2018).

4. Bobkov A, Cheingsong-Popov R, Garaev M, et al. Identification of an env G subtype and heterogeneity of HIV-1 strains in the Russian Federation and Belarus. AIDS 1994; 8: 1649-1655. Available at: https://www.ncbi.nlm.nih.gov/pubmed/7888112 (accessed 14 October 2018).

5. Gisselquist D. Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. oon-line 2009 (minor revisions from Adonis & Abbey 2008 edition). Available at: https://sites.google.com/site/davidgisselquist/chapter8 (accessed 14 October 2014).