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Epidemiologic Notes and Reports Apparent Transmission of Human T-Lymphotrophic Virus Type III/ Lymphadenopathy-Associated Virus from a Child to a Mother Providing Health Care

CDC has received a report from state and local health officials of a child with transfusion-associated infection caused by human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV), the virus that causes acquired immunodeficiency syndrome (AIDS). The child's mother appears to have been infected with HTLV-III/LAV while providing nursing care that involved extensive unprotected exposure to the child's blood and body secretions and excretions.

The child, a 24-month-old male, was diagnosed as having a congenital intestinal abnormality on day 4 of life. Over the next several months, he had numerous surgical procedures, including colonic and ileal resections, repairs of ostomies, a liver biopsy, and intravascular catheter replacements. The child has been hospitalized 17 months and has required intravenous hyperalimentation and continuous nasogastric feedings throughout his life. His illness was also characterized by frequent bouts of bacterial sepsis, many of which were apparently related to his gastrointestinal disease and indwelling intravascular catheter. Because of anemia due to chronic illness, multiple surgical procedures, gastrointestinal bleeding, and frequent blood drawing, the child required multiple transfusions between birth (February 1984) and early June 1985.

Because of the child's history of both recurrent bacterial sepsis and multiple transfusions, a blood sample was drawn for HTLV-III/LAV antibody in May 1985. This sample, and a second sample obtained 3 months later, were both positive by enzyme immunoassay (EIA); the second sample was tested by Western blot assay and was positive. In June 1985, the ratio of T-helper to T-suppressor lymphocytes (TH/TS) was normal (1.6). Serum obtained during an investigation in December 1985 was strongly positive for antibody to HTLV-III/LAV by EIA (absorbance

2.0, negative cutoff = 0.083, absorbance ratio 24). Western blot assay at CDC was positive for both the p24 and gp41 bands.* Cultures of the child's peripheral blood lymphocytes, saliva, and stools for HTLV-III/LAV have been negative.

Blood from 26 donors had been transfused to the child between birth and June 1985. One of these donors was a 34-year-old female whose serum, obtained in January 1986, was strongly positive for antibody to HTLV-III/LAV by both EIA (absorbance ratio

20) and Western blot assay (positive gp41 and equivocal p24 bands).* Her blood was transfused to the child in May 1984 before serologic testing of donors for HTLV-III/LAV was available. All other donors were seronegative.

The child's 32-year-old mother has been closely involved in the child's care during hospitalization and at home, which has required frequent contact with the child's blood and with other body fluids. Her activities included drawing blood through the child's indwelling catheter at least weekly, removing peripheral intravenous lines occasionally, emptying and changing ostomy bags daily for the 7 months these were in place, inserting rectal tubes daily to facilitate large-bowel clearing, changing diapers and surgical dressings, and changing nasogastric feeding tubes weekly. When interviewed, she did not recall any specific incidents of needlesticks or other parenteral exposures to the child's blood. However, the mother did not wear gloves, and on numerous occasions, her hands became contaminated with blood, feces (which often contained blood), saliva, and nasal secretions. She did not recall having open cuts or an exudative dermatitis on her hands; however, she often did not wash her hands immediately after blood or secretion contact.

In March, June, and October 1985, the mother donated blood; none of her donated blood was given to her child. As part of routine blood-donor screening, the blood was tested for HTLV-III/LAV antibody. She was seronegative by EIA in March and June. In October, a serum sample was repeatedly positive by EIA and was confirmed by Western blot assay. Serum obtained during an investigation in December 1985, and the October 1985 specimen, were both strongly positive by EIA (absorbance ratio

24) and Western blot assay (positive p24 and gp41 bands) at CDC.* The mother remains clinically well; however, her TH/TS ratio was 0.9 (normal

1.0) when tested in December 1985. Culture of her peripheral blood lymphocytes for HTLV-III/LAV was negative.

Extensive epidemiologic investigations did not reveal any other risk factors for infection in the mother or child. The mother was employed as a paramedic before the child's birth but denied needlestick injuries or exposure to AIDS patients. The child's father is negative for HTLV-III/LAV antibody* and is clinically well with a normal TH/TS ratio of 2.4. Reported by AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The child reported here most likely acquired the infection from transfusion of blood donated in May 1984 by a donor later found to be seropositive. The child's mother most likely acquired HTLV-III/LAV infection from her son while providing nursing care that involved extensive contact with his blood and other body secretions and excretions. She did not take precautions, such as wearing gloves, and often failed to wash her hands immediately after exposure.

Epidemiologic investigations did not reveal other risk factors for HTLV-III/LAV infection in the mother. The timing of her seroconversion (between June and October 1985) suggests that her exposure occurred after the birth of her child (February 1984). Limited case reports suggest that the seroconversion period for HTLV-III/LAV is approximately 1-6 months (1-3); there are no published reports of seroconversion periods greater than 6 months. Although initial attempts at virus isolation from the mother and child have been negative, the EIAs have been repeatedly reactive from multiple specimens in separate laboratories. The high absorbance ratios and presence of strong bands reacting to specific viral proteins on Western blot assay are most consistent with HTLV-III/LAV infection.

Previous CDC guidelines have emphasized that in hospital, institutional, and home-care settings, health-care workers or other persons providing care for patients with HTLV-III/LAV infection should wear gloves routinely during direct contact with the mucous membranes or nonintact skin of such patients (4). They should also wear gloves when handling items soiled with blood or other body secretions or excretions. Additional precautions, such as wearing gowns, masks, or eye coverings, may be appropriate if procedures involving more extensive contact with blood or other body secretions or excretions are performed. Education and foster care of children infected with HTLV-III/LAV, such as the child reported here, who lack control of their body secretions or excretions require special considerations as outlined previously (5).

Transmission of HTLV-III/LAV infection from child to parent has not been previously reported. The contact between the reported mother and child is not typical of the usual contact that could be expected in a family setting. None of the family members of the over 17,000 AIDS patients reported to CDC have been reported to have AIDS, except a small number of sexual partners of patients; children born to infected mothers; or family members who themselves had other established risk factors for AIDS. Seven studies involving over 350 family members of both adults and children with AIDS have not found serologic or virologic evidence of transmission of HTLV-III/LAV infection within families other than among sex partners, children born to infected mothers, or family members with risk factors for AIDS (6-12).

Although transmission of HTLV-III/LAV in the health-care setting has been reported, such transmission has been extremely rare. In five separate studies, a total of 1,498 health-care workers have been tested for antibody to HTLV-III/LAV. In these studies, 666 (44.5%) of the workers had direct parenteral (needlestick or cut) or mucous-membrane exposure to patients with AIDS or HTLV-III/LAV infection. Twenty-six persons in these five studies were seropositive when first tested; all but three of these persons belonged to groups recognized to be at increased risk for AIDS (13-17).

CDC is aware of only one other case in which HTLV-III/LAV transmission from a patient to a person providing care may have occurred through a nonparenteral route (18). In this report from England, a 44-year-old woman, who was not a health-care worker, developed AIDS after she had provided home nursing care for a Ghanaian man who was diagnosed with AIDS at postmortem examination. The care involved prolonged and frequent skin contact with body secretions and excretions. The woman recalled having some small cuts on her hands and an exacerbation of chronic eczema. She denied any sexual contact with the patient.

The occurrences of the case reported here and the English case suggest that HTLV-III/LAV infection may, on rare occasions, be transmitted during unprotected contact with blood or other potentially infectious body secretions or excretions in the absence of known

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