Breaches in infection control procedures were associated with genetically linked HIV transmissions among people receiving haemodialysis in Saudi Arabia, investigators report in the online edition of Clinical Infectious Diseases. The outbreak in late 2011 involved three patients.
“Our investigation of the available evidence implicates non-compliant IPC [infection prevention and control] practices as a cause of the outbreak,” comment the authors. “Using epidemiological methods, we were able to demonstrate a biological plausible association between breaks in IPC practices and the transmission of HIV infections.”
Haemodialysis is the most common form of dialysis and is often needed by people with kidney disease. It removes waste products from the blood by passing blood out of the body, through a filtering system and back into to the body. Haemodialysis has been associated with transmission of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections in healthcare settings, but is considered to involve a low risk of HIV transmission. Nevertheless, five outbreaks of haemodialysis-associated HIV occurred in the early 1990s, all in resource-limited settings.
In early 2012, health authorities in Saudi Arabia were notified of three HIV infections in patients who were receiving care at the same haemodialysis unit. The investigators used a technique called phylogenetic analysis to see if the three HIV infections were genetically linked. They also monitored infection control procedures at 16 haemodialysis units in Saudi Arabia to identify possible breaches involved in the transmissions.
The likely source patient was a new patient who had previously received care at two other haemodialysis units. The 46-year-old women had end-stage renal disease, had been receiving dialysis for twelve years and also had chronic hepatitis C infection. She had previously tested HIV negative in September 2011 but HIV testing was not completed prior to her dialysis at the new unit. However she had been admitted to hospital twice in September and October 2011 with symptoms consistent with acute HIV infection, including swollen glands, fever and anaemia.
The second patient was a 70-year-old married woman who had been receiving dialysis at the unit for 20 years and also had hepatitis C. The third patient was a married 30-year-old woman with end-stage renal disease and hepatitis C infection.
The husbands of all three women tested HIV negative, and all women denied sexual or drug use behaviours involving a risk of HIV transmission.
Phylogenetic analysis indicated a clear relationship between the three HIV infections and the results were consistent with recent transmission. The patients’ hepatitis C infections had no genetic link.
All three patients had received dialysis in the same room at the unit on 14 November 2011. The date likely coincides with the source patient’s acute phase of HIV infection, a period associated with high viral loads and increased risk of transmission.
The same dialysis machine was used for all three patients. It was disinfected for 15 minutes between use rather than the recommended 45 minutes. The treating nurse used blood-splattered gloves to handle vascular access lines for several patients and a shared syringe was used to access multiple doses of heparin.
“Risk factors for transmission include a multi-dose heparin vial from which injections were shared by all three patients, inadequately disinfected hemodialysis equipment and dialysis staff who used blood contaminated gloves to manipulate vascular access for multiple patients,” write the authors.
Intensive case finding did not identify any further HIV transmissions at this unit or the other centres providing haemodialysis in Saudi Arabia.
Mashragi F et al. HIV transmission at a Saudi Arabia hemodialysis unit. Clin Infect Dis, online edition, 2014.