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

Abstract

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.

Keywords: China; HIV; Human immunodeficiency virus; lymphocyte immunotherapy; nosocomial transmission; viruses.

Figure 1

Timeline of HIV exposure and HIV diagnosis of the index case-patient, P0 (blue), and the HIV exposure of his wife, Mrs. P0 (orange), Hangzhou, China, November 27, 2016–January 24, 2017. CDC, Center for Disease Control and Prevention; LIT, lymphocyte immunotherapy; P, patient; WB, Western blot.

Figure 2

Timeline of HIV exposure, symptoms, diagnosis, and treatment initiation for the 5 HIV-infected women during nosocomial HIV outbreak, Hangzhou, China, December 30, 2016–February 9, 2017. P1, purple; ART, antiretroviral therapy; LIT, lymphocyte immunotherapy; P, patient; WB, Western blot.

Figure 3

Phylogenetic trees showing relationships between HIV-1 gene sequences from index case-patient and 5 women infected during nosocomial HIV outbreak, Zhejiang Province, China, 2016–2017, and reference sequences. Bootstrap values >90% only are shown for gag sequences (A), pol sequences (B), and env sequences (C). Triangles indicate index case-patient (P0) and 5 women found to have HIV infection (P1–5); dots indicate international reference sequences. Scale bars indicate nucleotide substitutions per site. P, patient.