Roka Commune outbreak
According to newspaper reports, residents of Roka Commune in Cambodia began to suspect something was wrong in November 2014 when a 74-year old man tested HIV-positive. He sent his granddaughter and son-in-law for tests. They also tested positive. More residents went for tests; many were HIV-positive.
The next month, 24 December 2014, Cambodia’s Ministry of Health announced: “The Ministry of Health (MOH) of the Kingdom of Cambodia, with the support of the World Health Organization (WHO), US Centres for Disease Control and Prevention [CDC], UNAIDS, UNICEF and Pasteur Institute in Cambodia is investigating a number of HIV cases which have occurred among villagers from Roka village in Roka commune in Sangke district, Battambang province.”
Strategy to avoid facing the problem: blame a scapegoat
What happened in Roka? The Government of Cambodia seems to have settled on a scapegoat. On 3 December 2015, a Cambodian court sentenced an unlicensed healthcare provider, Yem Chrin, to 25 years in jail for infecting more than 100 people with HIV.
Strategy to avoid facing the problem: Incomplete investigation, incomplete report
Chrin’s sentencing left unanswered questions. For one thing, the numbers didn’t fit. Local newspapers put the total infected around 300. For another, the court did not wait for and use evidence from the joint Government-WHO-CDC-Institute Pasteur investigation.
The first substantial (but still partial) report from that investigation appeared two months later, in February 2016, in the US CDC’s Morbidity and Mortality Weekly Report.
- As a part of that investigation, a case-control study “identified medical injections and infusions as the most likely modes of transmission.”
- A test that can identify how long people have been infected [preliminary incidence assay] “suggested that 30% of infections in this outbreak could be classified as having occurred within the 130 days preceding specimen collection.” This points not only to rapid spread but also to high risk to transmit – effectively demolishing WHO’s oft-repeated estimated risk of 0.3% to transmit through reused syringes and needles.
- As in many other nosocomial HIV outbreaks, children were on the front lines: 22% of cases were in children <14 years old.
- More than 70% of HIV-positive samples tested for hepatitis C antibodies were found to have antibodies – similar to what one would expect to find in injection drug users who routinely reuse syringes and needles to inject illegal drugs.
The joint investigation and CDC’s February 2016 report are big improvements compared to the usual silence about patients’ risks, but still fall short of telling what happened so that an informed public and experts could work together to prevent and stop similar events in Cambodia and elsewhere — eg, Africa. The report:
- does not discuss the specific procedures and errors that led to infections,
- does not estimate rates of transmission through various procedures.
- does not trace infections to specific healthcare settings, implicitly accepting what is likely a cover-up — blaming one unlicensed practitioner for the outbreak.
- does not discuss infections in neighbouring communities, even ignoring infections that showed up in testing during the year.
A December 2015 BBC article – one year after Roka broke into public view – reports continued and common unsafe practices.
A Westerner, who has worked in Cambodia’s health sector for many years says there is a general lack of knowledge about infection control throughout the country’s healthcare system. “I would say there are many more Rokas in Cambodia…The practices are so poor that it’s inevitable. I don’t think there’s a difference between licensed and unlicensed doctors. I think what we saw in this case was a breach of infection control practices [and] doctors working in the government sector get very little training – if any – in infection control.…People blame this HIV outbreak [in Roka] on an unlicensed practitioner. But it could be many practitioners, licensed or unlicensed, working for the government or not, who have bad practices which can end up with Hepatitis B, or Hep C, or HIV. If you aren’t aware of the problems then it’s harder to fix them.
Unexplained and uninvestigated infections continue
In mid-February 2016, an NGO reported 14 patients testing HIV-positive – 10 from Peam village in Kandal Province, a village of 1,000, and 4 from neighboring villages. The article reported 32 previously known infections in Peam village, for a total of 42 or 4.2% of 1,000 villagers. In interviews, persons newly identified with HIV denied sexual risks and suspected infection from injections by a specified local doctor. Cambodia’s Ministry of Health responded by testing 279 residents of Peam village; tests found 4 new infections. That would bring the total in Peam village to 46 or 4.6%. The number of Peam residents found with HIV is much greater than what could be expected from a 2005 national survey reporting 0.6% of Cambodian adults to be HIV-positive; in Peam, that would be 3 infections only (0.6% of an estimated 500 adults out of a total population of 1,000).
The information I have been able to find does not report any effort to trace and test persons who visited suspected clinics, the ages of those tested, or the ages of those testing HIV-positive. Nevertheless, by early March 2016, Cambodia’s Ministry of Health and the World Health Organization (WHO) issued a joint statement denying an outbreak in Kandal Province.
See also these dontgetstuck.org blogs posts
1. Eng Sarath. Ministry of Health, Cambodia. 24 December 2014. HIV cases in Sangke district, Battambang. Available at: http://www.cdcmoh.gov.kh/97-hiv-cases-in-sangke-district-battambang
2. Kehumile Mazibuko. News Tonight Africa, 4 December 2015. Cambodia: unlicensed medical practitioner sentenced for infecting more than 100 people with HIV. Available at: http://newstonight.co.za/content/cambodia-unlicensed-medical-practitioner-sentenced-infecting-more-100-people-hiv
3. Khy Sovuthy, Anthony Jensen. Cambodia Daily, 8 December 2015. In HIV case, key evidence trails behind guilty verdict. Available at: https://www.cambodiadaily.com/news/in-hiv-case-key-evidence-trails-behind-guilty-verdict-102320/
4. Mean Chhi Vun et al. Cluster of HIV infections attributed to unsafe injections – Cambodia December 1, 2014-February 28, 2015. Morbidity and Mortality Weekly Report 2016: 65: 142-145. Available at: http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm (accessed 28 March 2016).
5. John Murphy. BBC, 17 December 2015. A country in love with injections and drips.
Available at: http://www.bbc.com/news/magazine-35111566
6. Aun Pheap, George Wright. Doctor denies spreading HIV in latest outbreak. Cambodia Daily News 22 February 2016. Available at: https://www.cambodiadaily.com/news/doctor-denies-spreading-hiv-in-latest-outbreak-108791/ (accessed 28 March 2016).
7. Cambodia Demographic and Health Survey 2005. Available at: http://www.dhsprogram.com/what-we-do/survey/survey-display-257.cfm (accessed 28 March 2016).
8. Hean Socheata. WHO, Phnom Penh: no regional outbreak. Voice of America 4 March 2016. Available at: http://www.voanews.com/content/no-regional-hiv-outbreak-in-cambodia-world-health-organization/3220134.html (accessed 28 March 2016).