Doctors in the Shymkent region in southern Kazakhstan discovered a child with an unexplained HIV infection in May 2006. The Shymkent prosecutor’s office began an investigation in July 2006. Through early September, investigators had found 54 HIV-positive children, of which at least 4 had already died.
In September 2006, “Kazakh Health Minister Yerbolat Dosaev said investigators may have found the cause of the infection and the reason why it spread. ‘In one of the children’s hospitals, there are 150 beds and only 13 catheter [tubes],’ he said… Catheter tubes can be inserted, for instance, into patients’ arms to put fluids into their bloodstream… It has not been proven that this is responsible for transmitting the HIV infections.”
Some reports of this outbreak attribute a lot of the infections to transfusion of contaminated blood. That is an confusion. If the children had been infected by transfusions, the infections would not have concentrated in children, but would have spread across men and women as well, because they also received transfusions. But that’s not what happened, which shows that almost all of the HIV went through through unsafe procedures in children’s wards.
In November 2006, the head of the investigation reported that sequencing of HIV from a number of children infected in the outbreak showed that “the primary source of the infection of children in southern Kazakhstan was a single blood donor.” HIV from the children was almost identical — which means that one of the children got HIV from a blood donor, after which doctors and nurses passed HIV from child to child through unsterile practices with needles and tubes (ref: SIGNpost 00375, from: Associated Press 21 November 2006, “Prosecutor: Kazakh children contracted HIV from one blood donor”).
Another study of the outbreak considered what skin-piercing procedures were common among HIV-positive children but less common among other patients (see page 79 in this link: “[A]dministration of IV [intra-venous] fluids and SVC [sub-venous catheters] were associated with infection among children, possibly because of unsafe practices.”
In June 2007, Kazakh authorities reported that the outbreak investigation has tested more than 10,000 children, finding 113 infected from unsafe health care. Mothers of 14 of the children were also HIV-positive; these mothers were likely infected by their children through breastfeeding.
In early October 2007, Dudnik, the head of the South Kazakhstan Regional Health Department reported that the ongoing outbreak investigation had so far identified 133 children infected through health care.
In Januaray 2008, the Kazakh AIDS Center reported 143 chldren infected in the outbreak. The government brought criminal trials against some of the health care workers. The judge presiding over at least on of the trials noted “The rules of the sterilization of medical equipment were blatantly violated in the central district hospital…”