Monday, January 12, 2015
One of the remarks that many articles about the Cambodian HIV outbreak are mentioning now, almost as if every journalist is tweaking the same press release and putting their name on it, is about needlestick injuries and the CDC's estimate that "99.7% of needlestick occurrences involving HIV infected blood do not result in transmission".
This figure is irrelevant and entirely misleading: receiving an injection or an infusion is nothing like a needlestick injury when some or all of the equipment, or the substance being administered, are contaminated. Needlestick injuries are typically slight and shallow and the inoculant is likely to be very small.
Some of the titles also mention 'tainted needles', but this may give the incorrect impression that reused syringes are not also a likely factor in this outbreak, along with contaminated multi-dose vials of medicines, vaccines, distilled water and other substances.
An injection involves the needle going below the skin, into muscle or into a vein, depending on what kind of injection it is. Most of the contents of the syringe and needle, along with anything remaining in them from previous uses, goes into the patient's body. Some estimates of risks are given on this Don't Get Stuck With HIV webpage.
Most of the contents of the syringe and needle enter the patient's body. Some remains in the syringe and needle. In addition, it is possible for a vacuum to form in the syringe, allowing a small amount of blood from the patient to enter the syringe. To repeat, this is nothing like a needlestick injury.
Someone from the World Health Organization is reported as saying "different types of injection procedures carry different levels of risk", which is a major improvement on the CDC quotes, but the WHO remark needs to be explained further, while the CDC one needs to be removed altogether.
Similar remarks apply to infusions, intravenous drips, etc. The risk of transmission from some common procedures can be very high indeed. Visitors to Cambodia may have noticed how popular intravenous drips are, with passengers on the back of motorbike taxis holding up the bag as they ride, and small 'medical' practices opening on to streets in Phnom Penh (although I doubt if many visitors have used such clinics because they tend to be aware of the risks of infection with HIV and other viruses through unsafe healthcare).
It is also very disturbing that the single practitioner said to have been involved in the outbreak has been arrested, imprisoned and even accused of murder (though little mention has been made of any murder victims). This is not going to encourage other practitioners, or professionals of any kind, political, administrative, ancillary, etc, to come forward and assist with the inquiry.
Members of the public may be careful what they say to police if they think others may be arrested and accused of murder. But even employees of CDC, WHO, UNAIDS and the like may be reluctant to find evidence that the risk of healthcare associated HIV transmission is very high, because they have been insisting for several decades that it hardly ever occurs.
To ensure the cooperation of as many health practitioners as possible the Cambodian authorities need to consider a 'no blame' investigation. Every article so far suggests confusion, professionals not recognizing HIV risks from unsafe healthcare, politicians appearing to know nothing about it and, more importantly, members of the public not knowing about the risks they face, or how to avoid them (there is some useful advice here).
It is especially important that members of the public are involved and that they understand a 'no blame' investigation. While some people may be angry about the single unlicensed practitioner identified so far, the entire health service, department of health, and even the global health community must share some of the responsibility.
Local human rights NGO Licadho stresses this point. The government of Cambodia (and governments of every developing country) have been claiming to have implemented 'universal precautions' to prevent healthcare associated HIV transmission. But is this a mere tick in a box marked 'universal precautions'?
In the light of this and numerous other outbreaks, declarations about universal precautions may need to be questioned to establish if there is any mechanism for ensuring that these precautions are being followed, and even if it is possible to follow them in seriously under-resourced health services.
Posted by Simon at 10:50 AM