Emerg Infect Dis. 2018 Dec;24(12):2141-2149. doi: 10.3201/eid2412.180117.
On January 25, 2017, a physician from ZC Hospital in Hangzhou, China, reported to the Zhejiang Provincial Center for Disease Control and Prevention that a potential HIV outbreak might have occurred during lymphocyte immunotherapy (LIT) performed at the hospital on December 30, 2016. We immediately began investigating and identified the index case-patient as an LIT patient's husband who donated lymphocytes for his wife's LIT and later screened HIV-reactive. Subsequent contamination by a technician resulted in the potential exposure of 34 LIT patients. Acute HIV infection was diagnosed in 5 persons. Phylogenetic analysis confirmed that the HIV-1 gag, pol, and env gene sequences from the index and outbreak-related cases had >99.5% similarity. Rapid investigation and implementation of effective control measures successfully controlled the outbreak. This incident provides evidence of a lapse in infection control causing HIV transmission, highlighting the need for stronger measures to protect patients from infectious disease exposure.
2017 年 1 月 25 日，中国杭州市 ZC 医院的一位医生向浙江省疾病预防控制中心报告称，2016 年 12 月 30 日该院进行的淋巴细胞免疫治疗（LIT）过程中可能发生了一起潜在的 HIV 爆发事件。我们立即开始调查，将索引病例患者确定为一名 LIT 患者的丈夫，他为妻子的 LIT 捐献了淋巴细胞，后来筛查出 HIV 反应阳性。随后一名技术员的污染导致 34 名 LIT 患者存在潜在暴露风险。5 人被诊断为急性 HIV 感染。系统进化分析证实，索引病例和暴发相关病例的 HIV-1 gag、pol 和 env 基因序列具有>99.5%的相似性。快速调查和实施有效的控制措施成功控制了疫情。这一事件提供了感染控制失败导致 HIV 传播的证据，强调需要采取更强有力的措施保护患者免受传染病暴露。
