巴基斯坦兒童愛滋病毒流行疫情引起了人們的關注

資料來源：剌胳針醫學期刊，www.thelancet.com Vol 393 June 8, 2019；財團法人台灣紅絲帶基金會編譯

可以發現這波流行亦已經傳染給成年人，專家懷疑它是衛生保健提供上系統性失誤的一個標記。 Andrew Green報導。

據巴基斯坦政府報導，巴基斯坦東南部拉多德羅自4月下旬爆發病毒疫情以來，已有超過730人，包括近600名兒童被診斷感染愛滋病毒。專家警告說，這一數字可能會繼續增長，因為超過25,000名接受篩檢的人中大多數是婦女和兒童，遺留很大部分的成年人口並沒有接受過檢測。

 「可以肯定地說，這是兒童的流行疫情。我從未見過在一般人群中有如此大量的兒童參與其中」，卡拉奇阿迦汗大學兒科和兒科傳染病助理教授法蒂瑪·米爾說，他是調查疫情的早期專家之一。「我們還沒有篩選足夠多的成年人，去表示它是否真的是成年人群中的一項流行疫情」。

據世界衛生組織稱，在此次疫情爆發之前，全巴基地區僅有1,200名兒童被診斷出感染愛滋病毒並接受了抗反轉錄病毒治療。

拉多德羅所在的信德省的官員已經建立了一個兒科治療中心，當他們繼續篩查病患並繪製疾病爆發的地圖時，並正努力地支撐起抗反轉錄病毒藥物的供應。世界衛生組織發言人瑪麗亞姆·尤努斯告訴「刺胳針」醫學期刊，由世衛組織協調的國際小組正在與地方官員合作制定一項長期對策。他們希望在6月中旬之前向省級和聯邦官員介紹該項策略。

流行病學家仍在試圖找出爆發的原因。信德省首府卡拉奇印度醫院傳染病科主任納西姆·薩拉赫丁告訴「刺胳針」醫學期刊，她懷疑並沒有單一來源，但疫情的爆發是多年來普遍存在感染控制不良行為的結果。

她說，在許多社區當中，患者往往轉向規模小、監管不足的診所，這些診所可以提供快速和負擔得起的醫療服務。那裡的衛生工作者在提供注射和實施靜脈注射治療時可能會重複地使用針頭。更還有不受管制的血庫，可以輕易傳播病毒。

「我們執行上的假設就是……持續不斷地污染的針頭，這些針頭被一再地重複使用、重複使用和重複使用」。

米爾說：「將[感染控制]稱為糟透了，我們甚至不能判斷它有多糟糕」。在最初幾天對疫情作出反應的當地專家小組報告說，只有少數被感染兒童的父母也感染這種病毒，並且幾乎所有兒童在前幾個月都接受過多次的注射。「我們的執行上的假設就是有這麼多人不斷進出這些診所」，米爾說，「持續不斷地污染的針頭，被一再地重複使用、重複使用和重複使用」。

4月底，當一名當地兒科醫生發現至少有8名患有異常疾病的患者時，疫情引起全國和國際的關注。他懷疑是愛滋病毒，並對他們進行了檢測。當結果是陽性時，便開始進行更廣泛的篩查。隨著感染病人數量的增加，省級官員在附近城市Larkana的一家醫院建立了一個兒科愛滋治療中心，並開始將患者與醫療照護聯繫起來。他們還呼籲當地專家開始進行系統發生上之分析。世界衛生組織組織的國際專家小組亦很快抵達。

即使調查仍在繼續，官員們仍在努力改善感染控制措施。據當地媒體報導，官員已關閉無牌診所和血庫。該地區亦拼命努力地加快建立為受到感染的患者提供長期醫療照護的計畫。

薩拉赫丁說，政府必需與國際機構合作，增加抗反轉錄病毒藥物的供應，特別是兒科處方藥物。官員們表示他們有足夠的供應來提供幾個月的治療，但他們正在通過全球採購流程來快速獲取其他藥物。但米爾表示，他們還需要將愛滋病服務與更廣泛的兒童健康服務聯繫起來，包括治療營養不良，結核病和伺機性感染。她說：「除了愛滋病毒之外，還有很多健康問題」。

官員還必須建立支持系統，以提醒人們獲取藥物，並在有其他感染時尋求治療。尤努斯說，可能還會透過社區外展之努力以提高有關愛滋病預防和治療的知識。當愛滋病預防和治療的知識很少時，「我們將必需在社區中去實現行為以及社會上之變革」，她說。

 「這是一項艱鉅的任務」，薩拉赫丁說。「當想到[政府官員們]將如何去解決這個問題就實在令人難以想像」。

HIV epidemic in children in Pakistan raises concern

The epidemic could be found to have reached adults as well. Experts suspect that it is a marker

of systematic failures in health-care provision. Andrew Green reports.

More than 730 people, including almost 600 children, have been diagnosed with HIV in Ratodero, southeast Pakistan, since an outbreak of the virus was reported in late April, according to the Pakistani Government. Experts warn the number might continue to grow as most of the more than 25 000 people who have been screened are women and children, leaving a large portion of the adult population who have not been tested.

 “It is safe to say it is an epidemic in children. I have never seen such a large amount of children in the general population involved”, said Fatima Mir, an assistant professor of paediatrics and paediatric infectious diseases at Aga Khan University in Karachi, who was among the early experts brought in to investigate the outbreak. “We haven’t screened enough adults to say if it is actually an epidemic in the adult population, yet.”

Before this outbreak, there were only 1200 children diagnosed with HIV and receiving antiretroviral treatment in all of Pakistan, according to WHO.

Officials in the Sindh province, where Ratodero is located, have set up a paediatric treatment centre and are trying to shore up supplies of antiretroviral drugs as they continue to screen patients and map the disease outbreak. An international team coordinated by WHO is working with local officials to assemble a long-term strategy, Maryam Yunus, a WHO spokesperson, told The Lancet. They expect to present the strategy to provincial and federal officials by mid-June.

Epidemiologists are still attempting to identify the cause of the outbreak. Naseem Salahuddin, the head of the Infectious Disease Department at Indus Hospital in Sindh’s capital, Karachi, told The Lancet that she suspects there is no single source but that the outbreak is the result of years of widespread practice of poor infection control.

She said that, in many communities, patients often turn to small, underregulated clinics which can provide quick and affordable medical care. Health workers there might reuse needles when giving injections and administering intravenous therapy. There are also unregulated blood banks, which could easily spread the virus.

“‘Our working hypothesis is just that …there was a constant contamination of needles that were reused and reused and reused.’”

“To call [infection control] abysmal doesn’t even do justice to how bad it is”, Mir said. The team of local experts who responded to the outbreak in the first few days reported that only a few parents of infected children also had the virus, and that almost all of the children had received multiple injections in the preceding months. “Our working hypothesis is just that there were so many people who kept coming in and out of these clinics”, Mir said, “there was a constant contamination of needles that were reused and reused and reused.”

The outbreak came to national and international attention at the end of April after a local paediatrician flagged at least eight patients who appeared with unusual illnesses. He suspected HIV and had them tested. When the results came back positive, broader screening began. And as the number of infected patients swelled, provincial officials set up a paediatric HIV treatment centre at a hospital in the nearby city of Larkana and began linking patients to care. They also called in local experts to begin phylogenetic analysis. The international team of experts organised by WHO arrived soon after.

Even as the investigation continues, officials are working to improve infection control practices. Local media reports that officials have shut down unlicensed clinics and blood banks. And the district is grappling with rapidly building up the programme to provide long-term care to infected patients.

Salahuddin said the government would have to work with international agencies to increase its supply of antiretroviral drugs, particularly paediatric formulations. Officials have said they have enough supplies to provide treatment for a few months, but they are working through global procurement processes to rapidly access additional drugs. But Mir said they will also need to link HIV services to a broader spectrum of health services for children, including treatment for malnutrition, tuberculosis, and opportunistic infections. “There are so many health problems other than just HIV”, she said.

Officials will also have to set up support systems to remind people to access their medicines and to seek treatment when they have other infections. Yunus said there are probably also going to be efforts to improve knowledge about HIV prevention and treatment through community outreach. “We will have to bring about behavioural and social change in the community”, she said, where knowledge about HIV prevention and treatment is low.

 “It is a mammoth task”, Salahuddin said. “It is mind boggling to think how [government officials] are going to deal with this.”

Andrew GreenReuters/Akhtar Soomro

This online publication has been corrected. The corrected version first appeared at thelancet.com on June 7, 2019