Epidemic Transmission of HIV in Renal Dialysis Centers in Egypt
abstract & commentary
Synopsis: Practicing clinicians need to inquire in some detail about the dialysis history of patients coming from countries where dialysis practices for control of bloodborne pathogens are inadequate.
Source: El Sayed NM, et al. Epidemic transmission of human immunodeficiency virus in renal dialysis centers in Egypt. J Infect Dis 2000;181:91-97.
This epidemic of hiv in dialysis centers in egypt was detected in 1993 and occurred on the heels of a larger outbreak reported in part by Hassan and associates in 1994.1 The outbreak occurred even though after the 1990 outbreak the Egyptian Ministry of Health had instituted an effective plan for control of HIV in dialysis units. The WHO, the CDC, and other agencies got more involved after 1993 in this most unfortunate outbreak.
In the current article, two dialysis centers, a private dialysis center (PDC), and a university dialysis center (UDC), are involved. At the time of the investigation, a total of 39 patients were identified, but subsequent to the analysis, a total of 64 patients were identified, representing 32% of all known HIV-infected Egyptians.
Of the original 39 patients identified, 21 were from the UDC and 11 of these had been previously dialyzed at the PDC. Ten of these 11 had been dialyzed from 1 to 48 times at the PDC. Transfusion history was positive in 20 of the 39 patients, with all but one transfusion having occurred in Egypt.
The PDC was located in a "poorly maintained private apartment" where there was a staff with no formally trained dialysis nurses. A single syringe, admittedly unlabeled at times, was probably used for more than one patient. Nurses also reported carrying in their pockets a syringe with heparinized saline.
The UDC resided in the university hospital, but its medical director was the same as that for the PDC. There were three shifts a day for dialysis patients using six dialysis machines. As in the PDC, nurses admitted to using a single syringe for more than one patient. Prefilled heparinized saline syringes were refrigerated overnight. Nurses carried these syringes in their pockets or placed them on a wheeled tray shared by patients in all shifts.
A control center that used more careful procedures had no HIV infection among 75 patients who received dialysis. In this center there were no reprocessing dialyzers.
The V3 loop of the HIV glycoprotein 120 was sequenced in 14 samples from 13 patients related to the outbreak. All sequences from the outbreak belonged to HIV-1 serogroup B and were 96% homologous. Individual variations in the V3 amino acid further supported that the outbreak strains were the same.
The PDC was closed from July to October of 1993 and the UDC was limited in the number of dialysis shifts. Educational programs emphasized national guidelines.
Comment by Joseph F. John, MD
Surely this epidemic caused a stir, evidenced by the lateness of this report—seven years later—and the non-emotive language used in this report. Much credit goes to the Joint UN Program on HIV/AIDS, the WHO, the CDC, and certainly valiant Egyptian physicians and scientists who finally brought this report to light.
The report is important since it shows that HIV may be relatively easily transmissible in a dialysis unit where there is a break in technique or repeat exposure to blood products. Further, it is important since it uncovered a mode of transmission for HIV that may be underappreciated throughout the world.
How many unrecognized reservoirs of HIV are there worldwide? A recent unrecognized epidemic reported in the New York Times of HIV among young heroin users in Siberia highlights another example of reservoirs of unrecognized HIV-infected individuals.2 Patients exposed to practices in certain dialysis centers may be another global reservoir. Patients from dialysis centers that use ineffective infection measures may end up at other medical facilities throughout the world. Practicing clinicians need to inquire in some detail about the dialysis history of patients coming from countries where dialysis practices for control of bloodborne pathogens are inadequate.
References
1. Hassan NF, et al. HIV infection in renal dialysis patients in Egypt. AIDS 1994;8:853.
2. Wines M. Heroin Carries AIDS to a Region in Sibers. New York Times. April 24, 2000.
In outbreaks of HIV involving dialysis units, what likely mode of transmission has been uncovered?
a. Unsuspected sexual exposure
b. Lack of glove use in initiating dialysis
c. Contaminated dialysis tubing
d. Reuse of heparinized tubing
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