Nosocomial Spread of HIV in Pediatric Hospitals: Lessons Learned

1. Nosocomial Spread of HIV in Pediatric Hospitals: Lessons Learned Jadranka Mimica, Ruslan Malyuta UNICEF Regional Office for CEE/CIS countries Ashgabad, 2008

2. Presentation Outline: • WHO assessment of pediatric hospital care: findings and recommendations • Outbreaks of HIV in pediatric hospitals in Central Asia • Measures for decreasing risk of HIV transmission in hospital settings

3. Global scale of the problem • Poor injection and sharps waste disposal practices for preventative and curative services unnecessarily expose patients, health care providers, and communities to HIV and other bloodborne pathogens. • The World Health Organization estimates that each year around the world, more than 20 million people are infected with HIV (80.000-160.000), hepatitis B (8-16 million), or hepatitis C (2.3-4.7 million) through unsafe and reused needles.

4. WHO EURO Assessment of Quality of Paediatric Hospital Care, 2002 • An assessment of paediatric hospital care was carried out in • Russian Federation, • RepublicofMoldova • Republic of Kazakhstan • as part of a broader WHO\EURO initiative to improve quality of hospital care in NIS

5. Findings: Unnecessary Admissions, Excessive or Potentially Harmful Drugs

6. Recommendations: • Development of essential drug and supplies list for paediatric purposes • Re-organisation of hospital services procedures, with priority to • establishment of day-care hospital services, • revised criteria for admission • revised criteria for intensive care • Improved links and collaboration between hospitals and family doctors

7. Shimkent and Osh nosocomial HIV reported cases among children Y2006-2007 (CDC - CAR) • 157 HIV positive child identified in SKO since Y2006 • 85% of mothers are HIV negative • Median age 2-3 years old • 133 children stayed in the hospital with average duration of 49 days per patient • 86 HIV positive children identified in Osh since Y2007 • Median age 2-3 years old • 80% of mothers are HIV negative • Average 4 hospitalizations per child

8. Exposure to unsafe practices during hospitalization • Extensive multiple transfusions of blood and blood products and injections • 74% of children had subclavian vein catheterizations • All facilities reported shortage of medical supplies and commodities

9. Multivariate analysis of risk factors in SKO (CDC-CAR)

10. System issues: high rates of hospitalization among children • Almost 80,000 children who were hospitalized were tested for HIV in SKO in 2005-2006 • 10,000 children are planned to be HIV tested due to hospitalization in Osh in 2005-2007 • Total children population (0-14) in SKO is ~800,000 • Total children population (0-14) in Osh 70,1 thousands and Osh oblast is 373,7 thousands

11. The goal • The goal is to reduce nosocomial transmission of bloodborne infections such as HIV and hepatitis

12. Framework of action Legislation & Policy Family & Community Health and Nutrition Outpatient care and IMCI Hospital inpatient care Improving family & community practices Improving health worker skills Improving Health Systems

13. Critical areas for improvement • Improving family and community practices • Infant and young child nutrition (exclusive breastfeeding) • Management of common childhood illnesess (Oral re-hydration) • IMCI • Improve treatment outcome • Decrease the number of referrals • Hospital • Decrease the duration of hospitalizations to minimal • Injection safety and infection control • Commodity supply and logistics

14. Change of blood transfusion practices in SKO, Y2005-2007 HIV outbreak in SKO 5.1% 2.4% 2005 2006 2007

15. Advocacy and behavior change • It is critical requirement for a deliverable of a national level advocacy strategy: • Decrease community demand for invasive treatment • Behavior change of HCW towards less aggressive treatment • Promote reduction of hospitalizations and minimize duration of stay in hospitals

16. Safe injection commodity management • Strengthen PSM system with tools to insure continuous supply of injecting equipment • Policy level actions to add safe injection commodities to national procurement lists and essential medicine kits support sustainability of the supply chain • Mobilize additional resources to address injection device security

17. Sharps Waste Management • Focus on developing effective strategies for sharps waste in the broader context of HCWM policies, standards, and guidelines. • Support the development and promotion of realistic, sound practices in the handling of health care waste. • Facilitate the evolution of waste disposal systems from less effective to more effective and environmentally responsible disposal options, such as needle removal, terminal sterilization, and recycling.

18. Monitoring and Evaluation • The M&E plan focuses on critical outcomes or measurement of change in knowledge, behaviors, and availability of supplies. Secondary analysis of data from other sources will be used to estimate impact. • M&E indicators are divided into 3 sections: • Training, support, and capacity-building • Equipment, supplies, and commodity management • Change of common treatment practices

19. Conclusions • Reducing the risk of nosocomial HIV transmission to children starts before and goes beyond just infectious control in medical settings. It requires major changes in system: • Community and family practices • Adoption of evidence based medicine approaches Reduction of hospitalizations • Reduction of duration of hospitalizations • Reliable infection control in hospitals • Reliable support systems (syringes supply etc.)