Vous avez tout à fait raison! La cause de cette surmortalité et morbidité?
Les soins sont sales. Les pays ne mettent pas l'accent sur le controle
infectieux, et pas seulement le lavage des mains mais aussi la désinfection
des surfaces, des locaux, les injections sales.. (voir les Etudes réalisés
en Afrique de l'Ouest pour la CIMSEF par exemple, montrant que 25% de la
morbidité et mortalité materno infantile étaient dues à des infections
nosocomiales).
De même on ne parle jamais des cas de transmission du VIH à des nouveaux
nés par les kits pour accouchement qui ne sont utilisé que pour un nouveau
né en France mais pour 10 ou 30 en pays pauvres! Et les quelques 6
milliards d'injections sales en milieu de soins annuellement! Or le VIH se
transmet mieux par le sang que sexuellement, mais les gens ne sont pas
informés, et la pauvre femme qui se retrouve VIH+ lors de sa maternité se
fera jetée dans la rue par la famille si son mari est VIH négatif, on dira
qu'elle a découché...qu'elle était pas vierge au mariage etc.
Or elle peut avoir contracté le VIH en milieu de soin, par une injection de
vitamine, par le dentiste, en se faisant percer les oreilles, par un
tatouage...
C'est ainsi que les accouchement à domicile sont aujourd'hui plus sûrs, car
au moins la femme n'attrapera pas la pathologie du voisin, et /ou un bug
pharmaco-résistant, tandis qu'après 35 millions de morts du SIDA et 35
millions de survivants, après Ebola, on continue de faire du racisme contre
les Africains, en ne parlant que de responsabilisation des comportements
sexuels...
Je pense que tout le monde devrait lire l'histoire de l'épidémie de VIH
dans un village au Cambodge, plus de 250 personnes contaminées par
l'utilisation d'une seringue utilisée sur un patient TB/VIH. étude menée
par les CDC des Etats unis, donc tout ce qu'il y a de plus sérieux ( voir
ci dessous in English,)
Garance
Cluster of HIV Infections Attributed to Unsafe Injection Practices —
Cambodia, December 1, 2014–February 28, 2015
*Weekly* / February 19, 2016 / 65(6);142–145
Format:
Select one <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#>
- PDF [293 KB] <http://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6506a2.pdf>
Recommend on Facebook
<http://api.addthis.com/oexchange/0.8/forward/facebook/offer?url=http%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Fwr%2Fmm6506a2.htm&title=Cluster%20of%20HIV%20Infections%20Attributed%20to%20Unsafe%20Injection%20Practices%20—%20Cambodia%2C%20December%201%2C%202014–February%2028%2C%202015%20|%20MMWR&description=&via=CDCgov&ct=0&media=>
Tweet
<http://api.addthis.com/oexchange/0.8/forward/twitter/offer?url=http%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Fwr%2Fmm6506a2.htm&title=Cluster%20of%20HIV%20Infections%20Attributed%20to%20Unsafe%20Injection%20Practices%20—%20Cambodia%2C%20December%201%2C%202014–February%2028%2C%202015%20|%20MMWR&description=&via=CDCgov&ct=0&media=>
[image:
Share]
<http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#socialMediaShareContainer>
Mean Chhi Vun1; Romeo R. Galang2; Masami Fujita3; William Killam4; Runa
Gokhale2; John Pitman5; Dejana Selenic5; Sovatha Mam1; Chandara Mom1;
Didier Fontenille6; Francois Rouet6; Saphonn Vonthanak7 (View author
affiliations <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#contribAff>
)
View suggested citation
<http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#suggestedcitation>
*Summary**What is already known about this topic?*
Unsafe medical injection practices have been reported in Cambodia during
the last decade. Current national human immunodeficiency virus (HIV)
prevalence estimates do not include HIV transmission risk associated with
unsafe injection or blood transfusion. HIV testing and surveillance in
Cambodia are focused on high risk groups, including men who have sex with
men, persons who inject drugs, and commercial sex workers.
*What is added by this report?*
The largest cluster of new HIV infections ever attributed to unsafe
injections among a general population was reported in a rural area of
Cambodia; 2.7% of residents were infected. The outbreak was detected after
increased demand for HIV testing by residents who perceived themselves to
be at risk after exposure to an unlicensed provider of injections and
intravenous infusions.
*What are the implications for public health practice?*
HIV prevention strategies that target specific populations often do not
consider the risk for HIV transmission via unsafe injections in the general
population. Further studies are needed to clarify HIV prevalence in general
populations where HIV risk perception is low; quantify the risk for other
bloodborne infections (e.g., hepatitis C) via unsafe injections; understand
public demand for medical injections; and improve health care workers’
injection practices in the public and private sectors. Measures to reduce
both the demand for unnecessary medical injections and the provision of
unsafe injections are needed.
In December 2014, local health authorities in Battambang province in
northwest Cambodia reported 30 cases of human immunodeficiency virus (HIV)
infection in a rural commune (district subdivision) where only four cases
had been reported during the preceding year. The majority of cases occurred
in residents of Roka commune. The Cambodian National Center for HIV/AIDS
(acquired immunodeficiency syndrome), Dermatology and Sexually Transmitted
Diseases (NCHADS) investigated the outbreak in collaboration with the
University of Health Sciences in Phnom Penh and members of the Roka Cluster
Investigation Team. By February 28, 2015, NCHADS had confirmed 242 cases of
HIV infection among the 8,893 commune residents, an infection rate of 2.7%.
Molecular investigation of the HIV strains present in this outbreak
indicated that the majority of cases were linked to a single HIV strain
that spread quickly within this community. An NCHADS case-control study
identified medical injections and infusions as the most likely modes of
transmission. In response to this outbreak, the Government of Cambodia has
taken measures to encourage safe injection practices by licensed medical
professionals, ban unlicensed medical practitioners, increase local
capacity for HIV testing and counseling, and expand access to HIV treatment
in Battambang province. Measures to reduce the demand for unnecessary
medical injections and the provision of unsafe injections are needed.
Estimates of national HIV incidence and prevalence might need to be
adjusted to account for unsafe injection as a risk exposure.
The Roka Cluster Investigation Team initiated an investigation to confirm
cases, identify risk factors, and recommend control strategies. Data from
antiretroviral therapy (ART) sites and registers of community-based
HIV/AIDS care programs were reviewed to exclude persons with existing HIV
diagnoses. Specimens that had tested HIV-positive by HIV rapid test kit
were laboratory confirmed using an enzyme immunoassay (Serodia, Fujirebio
Diagnostics, Japan). Specimens were also tested for antibody to hepatitis C
(anti-HCV) and hepatitis B surface antigen (HBsAg). A case-control study
was undertaken to identify risk factors associated with HIV infection.
Controls were selected from commune residents who tested HIV-negative at
the time of the study and were matched by age, sex, and place of residence.
To describe the number and size of HIV infection clusters among the
outbreak cases, phylogenetic analysis was performed on blood specimens from
case patients by the Institut Pasteur du Cambodge. Limiting-antigen (LAg)
Avidity assay testing was performed to identify recent infection.
The index patient was a resident of Roka commune with tuberculosis, aged 74
years, who received a diagnosis of HIV infection on November 12, 2014. (
Figure <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#F1_down>\) Two of
the index patient’s family members also tested positive for HIV during the
same period. The family alleged that the infections were linked to medical
injections received from an unlicensed health practitioner. These
allegations triggered a surge in demand for HIV testing by other commune
residents. During November 2014–February 2015, a total of 2,045 commune
residents underwent HIV testing. Overall, 242 confirmed HIV cases were
identified, including 52 (22%) in children aged <14 years, and 51 (21%) in
adults aged >60 years. One hundred fifty cases (62%) were in females. Four
women aged >60 years and one girl aged 7 months died after their HIV
diagnoses; the causes of death are unknown. As of January 19, among 102
patient specimens tested, 72 (70.6%) were positive for anti-HCV, and eight
(7.8%) were positive for HBsAg. Current national data are not available for
comparison; however, population prevalence of anti-HCV and HBsAg in the
neighboring province of Siem Riep are estimated at 5.8% and 4.6%,
respectively (*1*). An investigation of the provincial blood transfusion
center ruled out blood transfusion as a source of infection in this
cluster. Preliminary results from the case-control study indicated that
cases were nearly five times as likely as controls to have received an
intravenous or intramuscular injection, and four times as likely as
controls to have received an intravenous infusion during the preceding 6
months.
Phylogenetic analyses of the C2-V3 region of the HIV-1 gp120 gene, and
related protease and reverse transcriptase genes demonstrated clustering of
HIV viral strains among the outbreak cases and similarity between strains
identified in the outbreak and other strains in Southeast Asia. Preliminary
incidence assay results (Sedia LAg Avidity enzyme immunoassay, Sedia
Biosciences Corporation, Portland, Oregon) suggested that 30% of infections
in this outbreak could be classified as having occurred within the 130 days
preceding specimen collection.
Concurrent to the case-control study, NCHADS implemented confirmatory HIV
testing, conducted community outreach, and supported the scale-up of
voluntary HIV testing and counseling in the commune and in the provincial
capital (Battambang City). ART services were established at the Roka
village health center, complementing existing ART services at the
Battambang regional hospital. By January 16, 2015, a total of 207 patients,
including 179 adults and 28 children (86% of the 242 identified patients
with HIV) had initiated ART; the remaining patients were registered in
pre-ART care.
A majority of the confirmed cases in this outbreak were from a population
not associated with commercial sex work, men who have sex with men (MSM),
or injection drug use, the primary risk factors driving Cambodia’s HIV
epidemic (*2*). The clustering of HIV cases across age groups and other
evidence indicating high demand for medical injections in Cambodia further
support the likelihood of transmission via injection, intravenous infusion,
or other invasive medical procedures (*3*).
Top <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#>
Discussion
Cambodia has successfully reduced national HIV incidence and contained HIV
prevalence among commercial sex workers, MSM, and persons who inject drugs.
However, this outbreak highlights the risk for HIV transmission in the
general population through unsafe medical injections (*2*). HIV
transmission by unsafe medical injections has not historically been
prioritized in Cambodia’s national HIV prevention strategy, which has
focused on transmission associated with sex and injection drug use, and, to
a lesser extent, blood safety.
Demand for medical injections among Cambodian adults is high, averaging 2.6
injections per person per year, compared with countries such as Vietnam
(1.5 injections per person per year), India (2.0), and Nepal (1.2) (*4*).
On average, women in Cambodia receive more injections per year (3.3 per
person per year, weighted 95% confidence intervals [CI] = 3.1–3.6) than men
(1.9, 95% CI = 1.7–2.2), but in some provinces, women receive as many as
5.9 injections per year on average (*5*). The proportion of injections
administered with reused equipment in this cluster is unknown; however, a
2013 study estimated 5.5% reuse in the Western Pacific region (*4*).
Analyses of Cambodia’s 2005 Demographic Health Survey data indicate that
14,618 HIV-negative persons received an average of 2.0 (95% CI = 1.8–2.1)
medical injections per person per year, whereas 84 HIV-positive persons
received an average of 7.2 (95% CI = 2.6–11.8) medical injections per
person per year. Despite this substantial difference, it is not known
whether HIV infection resulted from medical injections, or whether persons
living with HIV receive more medical injections because they are sicker.
Furthermore, a portion of the association among HIV-infected persons might
be confounded by injections received for other sexually transmitted
infections (*6*).
The per-act risk for HIV transmission from unsafe medical injections has
been estimated among select populations and within nosocomial outbreak
settings globally. The risks for transmission among persons who inject
drugs and share needles and among health care workers with occupational
exposure through percutaneous needle-stick injuries were estimated at 63
and 23 per 10,000 acts, respectively (*7*); however the authors reported
wide confidence intervals because of a lack of uniformity in these
exposures. A recent outbreak of HIV infections among persons who inject
drugs in a rural community in the United States also illustrated the
explosive outbreak potential when HIV is introduced into settings where
contaminated needles are shared (*8*).
Nosocomial HIV outbreaks, as recently demonstrated in Kyrgyzstan, have
demonstrated the potential for overuse of medical injections to cause
outbreaks in low-risk populations in countries with HIV epidemics that are
concentrated in certain high-risk groups (*9*). In these nosocomial
outbreaks, HIV transmission risk per injection with HIV-contaminated
equipment has been estimated to be as high as 2%–7% (*7*,*10*). In 2004, it
was estimated that 1%–5% of new HIV infections in sub-Saharan Africa might
be associated with unsafe medical injections (*6*).
The findings in this report are subject to at least three limitations.
First, case identification might be limited to persons who sought HIV
testing because of perceived risk of infection related to an unlicensed
practitioner rather than with an unsafe injection, leading to a possible
underestimation of the total number of cases. Second, findings from the
case-control study support an association between medical injection and HIV
infection; however, a causal relationship could not be established.
Finally, the type and frequency of procedures and the type of equipment
used are unknown, limiting ability to identify specific practices (e.g.,
contamination of multidose medication vials, and sharing of needle or
infusion equipment) associated with HIV infection.
The Cambodian government has issued guidance to local health departments to
increase enforcement of medical licensing regulations and holds monthly
meetings to monitor progress toward this goal. Planning is underway to
expand HIV surveillance and evaluate medical injection risk factors
elsewhere in Cambodia. Future interventions will seek to reduce public
demand for medical injections nationally, and raise health care worker
awareness about infection control as well as noninjectable alternatives.
Cambodia’s current national HIV prevalence and incidence estimates are
based on models that do not include risk factors associated with unsafe
injections or blood transfusion. Given the high prevalence of medical
injection use in Cambodia, the contribution of medical injection overuse to
Cambodia’s national HIV burden might be higher than estimated. Efforts
should be made to educate health care workers and communities at large on
safe injection practices to reduce the demand for unnecessary medical
injections and increase injection safety. National HIV prevention
strategies should be expanded to monitor unsafe injections as a mode of
transmission. Globally, a need exists for tools to estimate HIV risk in
low-prevalence countries where substantial proportions of the population
are regularly exposed to unnecessary and potentially unsafe injections.
Top <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#>
Acknowledgments
Students, faculty, staff members, Cambodia University of Health Sciences;
FHI 360, North Carolina; ARV Users Association, Cambodia; AIDS Healthcare
Foundation, the Netherlands; Khmer Soviet Friendship Hospital, Cambodia;
Dr. Dora Warren, CDC Cambodia Country Director (2009–2015).
Top <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#>
------------------------------
*Corresponding author:* Romeo R. Galang, RGalang@cdc.gov, 404-639-6387.
Top <http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm#>
1Cambodia National Center for HIV/AIDS, Dermatology and STD; 2Epidemic
Intelligence Service, CDC; 3World Health Organization, Cambodia; 4Division
of Global HIV/AIDS, CDC, Phnom Penh, Cambodia; 5Division of Global
HIV/AIDS, CDC; 6Institut Pasteur du Cambodge, Phnom Penh, Cambodia; 7Cambodia
University of Health Sciences.