巴基斯坦持續與兒童愛滋病毒爆發作鬥爭
儘管感染控制有所改善，但巴基斯坦拉托德羅的兒童 HIV 疫情仍在繼續。
資料來源：塔爾哈·伯基報導/ http://www.thelancet.com/hiv / 2022 年 5 月 9 日 / 財團法人台灣紅絲帶基金會編譯
2021 年 12 月 1 日，巴基斯坦在全國範圍內禁止使用多次性使用之注射器。現在，全國四個省份的醫護人員都必須使用只能使用一次的自動銷毀設備進行注射。該措施是為了應對 2019 年南部信德省爆發的愛滋病毒疫情，主要影響兒童。疫情的爆發是由不安全的注射做法和當地醫生重複使用靜脈滴注裝置引起的。在過去 20 年左右的時間裡，巴基斯坦的醫療機構至少有四次與 HIV 傳播事件有關。
該問題於 2019 年 4 月首次曝光。信德省農村小鎮 Ratodero 的一名泌尿科醫生向媒體通報了一批新的兒科 HIV 病例。這些孩子的父母都沒有感染愛滋病毒。截至7月中旬，拉卡納周邊地區已有930人被確診感染愛滋病病毒，其中15歲及以下兒童763人，其中5歲以下兒童604人。 89% 的兒童有多次注射史。
2019年4月至2020年7月，紮法爾·米爾扎擔任巴基斯坦總理衛生特別助理。「注射藥物的不合理使用在巴基斯坦非常普遍；我們是世界上人均注射率最高的國家之一，而這些注射中的絕大多數是完全沒有必要的」，米爾扎告訴《刺胳針愛滋病毒》。兒童接受注射治療腹瀉疾病和呼吸系統疾病。「巴基斯坦人，尤其是社會經濟地位較低的群體，往往對醫學有錯誤的信念」，米爾扎補充道。「人們認為更多的藥物總是一件好事，注射藥物更有效」。
鼓勵醫生開注射處方，患者和製藥公司都可以為此付費，使重複使用針頭和注射器使利潤最大化。 「注射負擔過重的背後有很多不正當的激勵措施」，米爾扎說。巴基斯坦一半以上的醫療保健支出流向私營部門，那裡的醫療標準、感染控制和廢物處理實踐上存在巨大差異。
關於被污染的針頭被傾倒在溢出的垃圾箱或醫療中心外的街道上的故事比比皆是。由於無證從業者（所謂的庸醫）的廣泛存在，情況變得更加複雜，尤其是在信德省龐大的首府卡拉奇等城市中心。在 Ratodero 事件爆發後，省衛生部關閉了 900 家診所和無照血庫，但很難知道這些設施是否仍然關閉。「信德省醫療保健委員會訪問、評估和關閉不符合最低標準的醫療保健設施」，阿加汗大學（巴基斯坦卡拉奇）兒科和兒童健康系副教授法蒂瑪·米爾解釋說。「地方只需等待幾週 [或] 幾個月，然後在同一地點或附近重新開張」。
米爾負責監督拉托德羅為應對疫情而設立的愛滋病毒治療中心。迄今為止，約有 1,300 名兒童的愛滋病毒檢測呈陽性，新病例不斷出現。「儘管在感染預防和控制以及在拉托德羅和拉卡納的主要醫院建立焚化爐方面已經採取了一些非常好的行動，但我們尚未能夠阻斷傳播」，米爾說。全國各政府免費提供愛滋病毒治療。 Larkana 的 HIV 檢測設施已被大量使用，但如果要對整個高危人群進行篩查，還有一段路要走。
據米爾說，大多數正在接受治療的愛滋病毒感染兒童的臨床表現都很好。然而，已經有數十人死亡，儘管不確定這些是否是由與愛滋病毒相關的疾病引起的。「該系統旨在收集死亡率數據；不是為什麼會發生死亡」，米爾說。數據收集缺乏協調可能解釋了Ratodero爆發發現的延遲。例如，巴基斯坦的愛滋病毒檢測由一系列提供者完成，包括非政府組織、私人醫療保健機構和政府機構。但是，結果並未提交給省級政府一級的中央儲存庫。
「雖然在信德省和整個巴基斯坦，傳染病的數據收集非常健全」，Mir 說。「但我們需要一個共同的論壇，讓所有利益相關者定期開會，審查愛滋病毒照護數據，並了解令人擔憂的模式或趨勢」。聯邦對多次性使用注射器的禁令是否會阻止 Ratodero 發生的事情再次發生還有待觀察。信德省已於 2011 年提出了一項法律，強制使用自動銷毀注射器，但顯然並沒有強制執行。
Pakistan continues to battle paediatric HIV outbreak
Despite improvements in infection control, the Ratodero, Pakistan paediatric HIV outbreak continues.
Talha Burki reports.
http://www.thelancet.com/hiv / Vol 9 May 2022
On Dec 1, 2021, Pakistan introduced a nationwide ban on multiple-use syringes. Health-care workers across all four provinces in the country are now required to administer injections with autodisable devices, which can only be used once. The measure comes in response to the 2019 outbreak of HIV in the southern province of Sindh, predominantly affecting children. The outbreak has been driven by unsafe injection practices and reuse of intravenous drip sets by local medical practitioners. Health-care facilities in Pakistan have been linked to HIV transmission on at least four occasions over the past 20 years or so.
The problem first came to light in April, 2019. A urologist in Ratodero, a small town in rural Sindh, alerted the media to a cluster of new cases of paediatric HIV. None of the children’s parents were living with HIV. By mid-July, 930 people in the surrounding district of Larkana had been diagnosed with HIV, including 763 children aged 15 years and younger, 604 of whom were no older than 5 years. 89% of the children had a history of multiple previous injections.
From April, 2019, to July, 2020, Zafar Mirza served as special assistant on health to Pakistan’s prime minister. “Irrational use of injectable medications is very prevalent in Pakistan; we have one of the highest per-capita rates of injections in the world, and the vast majority of these injections are totally unnecessary”, Mirza told The Lancet HIV. Children are given injections for diarrhoeal diseases and respiratory ailments. “Pakistanis, particularly those in lower socioeconomic groups, tend to have erroneous beliefs about medicine”, added Mirza. “People think more drugs are always a good thing, and that injected medicines are more effective.”
Doctors are incentivised to prescribe injections, for which they can be paid both by patients and by pharmaceutical companies. Reusing needles and syringes maximises profits. “There are a lot of perverse incentives behind the excessive burden of injections”, said Mirza. Well over half of expenditure on health care in Pakistan goes to the private sector, where there are enormous variations in standards of care, infection control, and waste disposal practices.
Stories abound of contaminated needles being dumped in overflowing rubbish bins or on the streets outside health-care centres. The situation is further complicated by the widespread presence of unlicensed practitioners (so-called quacks), especially in urban centres such as Karachi, the sprawling capital of Sindh. In the aftermath of the Ratodero outbreak, the provincial ministry of health closed 900 clinics and unlicensed blood banks, but it is difficult to know whether these facilities are still shuttered. “The Sindh Healthcare Commission visits, assesses and closes down health-care facilities which are not meeting the minimum standards”, explained Fatima Mir, associate professor in the Department of Paediatrics and Child Health at the Aga Khan University (Karachi, Pakistan). “Places just wait a few weeks [or] months and then re-open, either at the same spot or nearby.”
Mir oversees the HIV treatment centre that has been set up in Ratodero to deal with the outbreak. Around 1300 children have so far tested positive for HIV and new cases continue to emerge. “We have not yet been able to interrupt transmission, even though there have been some very good actions in terms of infection prevention and control, and the establishment of incinerators at the main hospitals in Ratodero and Larkana”, said Mir. HIV treatment is freely provided by the national government. HIV testing facilities in Larkana have been heavily used, but there is still some way to go if the entire at-risk population is to be screened.
Most of the children with HIV who are in treatment are doing clinically well, according to Mir. However, there have been several dozen deaths, although it is uncertain whether these resulted from HIV-related illnesses. “The system is built to collect mortality data; not why the mortality happened”, said Mir. A lack of coordination in data collection probably explains the delay in uncovering the Ratodero outbreak. For example, testing for HIV in Pakistan is done by a range of providers, including nongovernmental organisations, private health-care facilities, and government agencies. However, the results are not submitted to a central repository at provincial government level.
“Data collection for infectious diseases is pretty robust in Sindh, and in Pakistan as a whole”, said Mir. “But we need a common forum where all the stakeholders meet regularly, review HIV care data, and pick up on worrying patterns or trends.” Whether the federal ban on multiple-use syringes will prevent a recurrence of what happened in Ratodero remains to be seen. Sindh already had a law, introduced in 2011, mandating the use of autodisable syringes. It was clearly not enforced.