Outbreak of HIV Infection Linked to Nosocomial Transmission, China, 2016–2017

• Main Authors: Xiaohong Pan, Jianmin Jiang, Qiaoqin Ma, Jiafeng Zhang, Jiezhe Yang, Wanjun Chen, Xiaobei Ding, Qin Fan, Zhihong Guo, Yan Xia, Shichang Xia, Zunyou Wu
• Format: Article
• Language: English
• Published: Centers for Disease Control and Prevention 2018-12-01
• Series: Emerging Infectious Diseases
• Subjects: Human immunodeficiency virus; HIV; viruses; nosocomial transmission; lymphocyte immunotherapy; China
• Online Access: https://wwwnc.cdc.gov/eid/article/24/12/18-0117_article

On January 25, 2017, a physician from ZC Hospital in Hangzhou, China, reported to the Zhejiang Provincial Center for Disease Control and Prevention that a potential HIV outbreak might have occurred during lymphocyte immunotherapy (LIT) performed at the hospital on December 30, 2016. We immediately began investigating and identified the index case-patient as an LIT patient’s husband who donated lymphocytes for his wife’s LIT and later screened HIV-reactive. Subsequent contamination by a technician resulted in the potential exposure of 34 LIT patients. Acute HIV infection was diagnosed in 5 persons. Phylogenetic analysis confirmed that the HIV-1 gag, pol, and env gene sequences from the index and outbreak-related cases had >99.5% similarity. Rapid investigation and implementation of effective control measures successfully controlled the outbreak. This incident provides evidence of a lapse in infection control causing HIV transmission, highlighting the need for stronger measures to protect patients from infectious disease exposure.