Iatrogenic Blood-borne Viral Infections in Refugee Children from War and Transition Zones

Paul N. Goldwater

Author affiliation: Women’s and Children’s Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide

Abstract

Pediatric infectious disease clinicians in industrialized countries may encounter iatrogenically transmitted HIV, hepatitis B virus, and hepatitis C virus infections in refugee children from Central Asia, Southeast Asia, and sub-Saharan Africa. The consequences of political collapse and/or civil war—work migration, prostitution, intravenous drug use, defective public health resources, and poor access to good medical care—all contribute to the spread of blood-borne viruses. Inadequate infection control practices by medical establishments can lead to iatrogenic infection of children. Summaries of 4 cases in refugee children in Australia are a salient reminder of this problem.

Blood-borne viruses (BBVs) have benefitted from internal political strife, migration, prostitution, intravenous/injection drug use, and defective public health resources in some Central Asian republics and Southeast Asian and sub-Saharan African countries. Iatrogenic transmission of HIV in children in Romania (1) and the Russian republic of Kalmykia (2) are well-known examples. Refugee children are a special risk category for infection with BBVs (3). When iatrogenic transmission was encountered in a pediatric infectious diseases clinic in Adelaide, South Australia, Australia, concern was raised about whether it was an isolated or a more widespread phenomenon.
The United Nations High Commissioner for Refugees estimates that there were 43.7 million forcibly displaced persons worldwide at the end of 2010, the highest number in 15 years. Of these, 27.5 million were internally displaced persons, 15.4 million were refugees, and 837,500 were asylum seekers (4). Children constituted more than half of the humanitarian refugee population in Australia (5). A refugee is legally defined as a person who is outside his or her country of nationality and is unable to return due to a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a particular social group. By receiving refugee status, persons are guaranteed protection of their basic human rights and cannot be forced to return to a country where they fear persecution (4).
Australia receives refugees from all countries experiencing internal conflict. Some arriving refugees have parasite infestations and bacterial and viral infections, especially undiagnosed BBVs (6,7). During 2010–2011, a total of 13,799 persons were admitted under Australia’s Humanitarian Program.
The extent of the unusual problem of iatrogenic transmission of BBVs remains unknown because modes of transmission of individual cases are difficult to document. This report summarizes cases in 4 children from South Asia that illustrate the conditions extant in 1 city in Uzbekistan (Andijan), where medical procedures have resulted in transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV). Among the case-patients are 2 children with BBV co-infection.

Methods and Definitions

Detecting possible iatrogenic BBV infections in children relies on a careful history. However, accurate histories are difficult to obtain because, in many cases, details are acquired through interpreters and facts are lost in translation. Nevertheless, several encounters with a family, during which family members are encouraged to tell their life stories (8), usually results in an accurate medical history. For orphans, learning the mode of BBV acquisition usually is impossible, except in cases of maternal HIV-associated deaths and mother-to-child transmission. The Australian Paediatric Surveillance Unit collects data for all HIV-positive children in Australia and reports these data to the National HIV Registry. For HIV-positive children from high-risk countries whose mothers are known to be HIV negative, the information recorded does not indicate mode of transmission (compare surrogate breast-feeding); nevertheless, such cases should be considered suspicious in regard to the manner by which the virus was acquired. The Australian Paediatric Surveillance Unit has recorded a few cases of HIV in children from high-risk countries whose mothers were HIV negative, thus indicating the problem. Since data collection began in May 1993, a total of 77 HIV infections have been reported in children (9); 8 cases in children (<12 years of age) from high-prevalence countries were notified to the Australian National HIV Registry through the end of 2011. The mother of 1 child was reported as HIV negative. No information was available about the HIV status for the mothers of the 7 other children (A. McDonald, pers. comm.).