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Human Immunodeficiency Virus Transmission in Household Settings -- United States

Transmission of human immunodeficiency virus (HIV) has been reported in homes in which health care has been provided and between children residing in the same household (1-6). CDC has received reports of two cases of HIV infection that apparently occurred following mucocutaneous exposures to blood or other body substances in persons who received care from or provided care to HIV-infected family members residing in the same household. This report summarizes the findings of the epidemiologic and laboratory investigations, which underscore the need to educate persons who care for or are in contact with HIV-infected persons in household settings where such exposures may occur. * Patient 1

A 5-year-old child whose parents were both HIV-infected tested negative for HIV antibody in 1990 and July 1993 but tested positive in December 1993. In February 1994, all other close household contacts of the child tested HIV-antibody negative.

From January through December 1993, when the child was likely to have become infected, the child's parents were the only known HIV-infected persons with whom the child had any contact. During this period, the child lived with both parents until the father's death as the result of acquired immunodeficiency syndrome (AIDS) in May 1993. The child continued to live with the mother, who had AIDS, until 8 days before the child's last negative antibody test in July 1993. The child then lived in foster care.

The child had several opportunities for contact with HIV-infected blood and exudative skin lesions. Based on the mother's medical records and history, from March through August 1993 the mother had recurrent, purulent, exudative skin lesions (diagnosed as prurigo nodularis) on her face, neck, torso, buttocks, and extremities. She frequently scratched the lesions until they bled, left the lesions uncovered, and discarded onto the furniture or the floor the gauze and tissues used to wipe the exudate. During periods when the mother's skin lesions were uncovered and draining, the child frequently hugged and slept with the mother. In addition, the child intermittently had scabs from impetigo and abrasions that the mother sometimes picked off and caused to bleed. When the mother had intermittent gingival bleeding, she periodically shared a toothbrush with the child. From January through May 1993, the child had no known contact with the father's blood or body fluids, although the child sometimes used his toothbrush.

No other situations were identified in which the child potentially may have been exposed to HIV-infected blood or had contact with an HIV-infected person. There were no known HIV-infected persons in either the foster home or the school, and the child had no known contact with blood in these settings. Based on interviews and medical record reviews, no household members at either the parents' home or foster home engaged in injecting-drug use. Based on history and physical examination, sexual abuse of the child was believed to be unlikely. During 1993, the child had no injections, blood transfusions, vaccinations, or invasive dental or medical procedures.

Proviral DNA from peripheral blood mononuclear cells obtained from the mother and the child was amplified by polymerase chain reaction. By direct sequencing, the two DNA fragments encompassing 343 nucleotides of the V3 and flanking regions of the gene encoding the HIV-1 envelope glycoprotein (gp120) were genetically similar, differing by only 2.6%. No specimen was available from the child's father. Patient 2

In August 1991, a 75-year-old woman was evaluated because of fatigue and malaise and tested positive for HIV antibody; her adult son died in August 1990 as the result of AIDS. Her CD4+ T-lymphocyte count was 837 cells/uL. She had been married for approximately 50 years; her husband tested negative for HIV antibody. The patient reported no other sex partners and denied all risk factors for HIV infection, including injecting-drug use and receipt of blood or blood products since 1978; she had not been employed in a health-care setting. The woman had a cholecystectomy in December 1990; in February 1992, all members of the surgical team tested negative for HIV antibody.

Her son had lived in the household from September 1989 until his death. He initially was able to care for himself; however, in July 1990 (6 weeks before his death), his mother began to provide daily nursing care for him (e.g., bathing, feeding, changing diapers, and repositioning his urinary catheter). Although she had been informed of the need to wear gloves while providing such care, she reported inconsistent adherence to this recommendation. She could not recall any direct exposures to her son's blood. Her son did not require intravenous fluids or medication in the home nor did he have an intravascular device. No needles or other sharp instruments related to his care were in the home. Dermatologic conditions had not been noted.

The son had hemorrhoids and diarrhea, but neither visible blood nor melena had been noticed at home. The mother reported skin contact with her son's feces on at least one occasion. While hospitalized in February 1990, he had upper gastrointestinal bleeding; endoscopy revealed chronic gastritis and duodenitis. During hospitalization in June 1990, he had an episode of lower gastrointestinal bleeding. No such bleeding episodes occurred at home.

The son had poor dentition and gingivitis around his upper molars, and his mother frequently handled the cotton-tipped swabs her son used for his oral hygiene care, although she attempted to avoid touching the cotton tips with bare hands. She reported having infrequent small cuts on her hands but had no history of dermatitis or other skin lesions. There were no blood specimens available from the son for HIV DNA sequencing.

Reported by: Div of HIV/AIDS and Hospital Infections Program, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The findings of the investigations described in this report indicate the transmission of HIV as the result of contact with blood or other body secretions or excretions from an HIV-infected person in the household. In both instances, exposures occurred after the source-patients had developed AIDS; consequently, relatively high HIV titers may have been present in their blood.

For patient 1, who had had direct exposure to purulent and bloody exudates from the mother's open skin lesions, transmission may have been facilitated by the child's broken skin and the mother's manipulation of the child's skin lesions. Patient 2 most likely became infected while providing nursing care for her son. Although the precise mode of transmission is unknown, she had direct contact with her son's urine and feces; because of his chronic gastritis and duodenitis, some blood could have been present in his feces, even though the blood was inapparent to his mother. In addition, she could have had other unrecognized or unrecalled exposures to her son's blood.

Even though previous reports have documented HIV transmission as the result of skin or mucous-membrane exposure to HIV-infected blood, HIV is not easily transmitted by this route. Based on assessment of health-care workers exposed to HIV-infected blood, the risk for HIV transmission has been estimated to be less than 0.1% for a single mucous-membrane exposure (95% confidence interval=0.006-0.50) (7). The risk is probably lower for skin exposures to HIV-infected blood and even lower, if present at all, for skin exposures to body secretions and excretions without visible blood (7,8). Although previous reports document that HIV has been isolated from urine (9) and that HIV nucleic acid -- but not infectious HIV -- has been detected in feces (10), transmission of HIV by urine or feces has not been reported.

Although contact with blood and other body substances can occur in households, transmission of HIV is rare in this setting. In addition to the two patients in this report, six previous reports have described household transmission of HIV not associated with sexual contact, injecting-drug use, or breast feeding (Table_1). Of these eight reports, five were associated with documented orprobable blood contact ({1,3-5} and patient 1 in this report). In the sixth report, HIV infection was diagnosed in a boy after his younger brother had died as the result of AIDS; however, a specific mechanism of transmission was not determined (6). Two reports involved nursing care of terminally ill persons with AIDS in which a blood exposure might have occurred but was not documented ({2} and patient 2 in this report); in both reports, skin contact with body secretions and excretions occurred.

Persons who provide nursing care for HIV-infected patients in home settings should employ precautions to reduce exposures to blood and other body fluids (11). In particular, needles and sharp objects contaminated with blood should be handled with care. Needles should not be recapped by hand or removed from syringes. Needles and sharp objects should be disposed of in puncture-proof containers, and the containers should be kept out of reach of children and visitors. Bandages should be used to cover cuts, sores, or breaks on exposed skin of persons with HIV infection and of persons providing care. In addition, persons who provide such care should wear gloves when there is a possibility of direct contact with HIV-infected blood or other body fluids, secretions, or excretions. Because urine and feces may contain a variety of pathogens, including HIV, persons providing nursing care to HIV-infected persons should wear gloves during contact with these substances. In addition, even when gloves are worn, hands should be washed after contact with blood and other body fluids, secretions, or excretions.

Because of the social, economic, and medical benefits of home care, the number of persons with AIDS who receive health care outside of hospitals is increasing. Persons infected with HIV and persons providing home care for those who are HIV-infected should be fully educated and trained regarding appropriate infection-control techniques. In addition, health-care providers should be aware of the potential for HIV transmission in the home and should provide training and education in infection control for HIV-infected persons and those who live with or provide care to them in the home. Such training should be an integral and ongoing part of the health-care plan for every person with HIV infection.

Additional infection-control recommendations are contained in a recently updated brochure published by CDC, Caring for Someone with AIDS: Information for Friends, Relatives, Household Members, and Others Who Care for a Person With AIDS at Home. This brochure is available free in English or Spanish from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023.

References

  1. CDC. Apparent transmission of human T-lymphotrophic virus type III/lymphadenopathy-associated virus from a child to a mother providing health care. MMWR 1986;35:76-9.

  2. Grint P, McEvoy M. Two associated cases of the acquired immunodeficiency syndrome (AIDS). Communicable Disease Report 1985;42:4.

  3. CDC. HIV infection in two brothers receiving intravenous therapy for hemophilia. MMWR 1992;41:228-31.

  4. Fitzgibbon JE, Gaur S, Frenkel LD, et al. Transmission from one child to another of human immunodeficiency virus type 1 with a zidovudine-resistance mutation. N Engl J Med 1993;329: 1835-41.

  5. CDC. HIV transmission between two adolescent brothers with hemophilia. MMWR 1993;42:948-51.

  6. Wahn V, Kramer HH, Voit T, Bruster HT, Scrampical B, Scheid A. Horizontal transmission of HIV infection between two siblings {Letter}. Lancet 1986;2:694.

  7. Ippolito G, Puro V, De Carli G, Italian Study Group on Occupational Risk of HIV Infection. The risk of occupational human immunodeficiency virus infection in health care workers: Italian Multicenter Study. Arch Intern Med 1993;153:1451-8.

  8. Henderson DK, Fahey BJ, Willy M, et al. Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures: a prospective evaluation. Ann Intern Med 1990;113:740-6.

  9. Levy JA. Pathogenesis of human immunodeficiency virus infection. Microbiol Rev 1993;57:183-289.

  10. Yolken RH, Li S, Perman J, Viscidi R. Persistent diarrhea and fecal shedding of retroviral nucleic acids in children infected with human immunodeficiency virus. J Infect Dis 1991;164:61-6.

  11. CDC. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(no. 2S).

* Single copies of this report will be available free until May 20, 1995, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217- 0023.


Table_1
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TABLE 1. Reported cases of HIV infection in which transmission not associated with sexual contact, injecting-drug use, or
breast feeding occurred from an HIV-infected person to a person residing in the same household or providing home care
===========================================================================================================================================
                                                                 Body substance
                         Activity during which                   through which       HIV DNA
              Source-    transmission              Type of       transmission        sequence
Case-patient  patient    may have occurred         exposure      may have occurred    match    Comment
-----------------------------------------------------------------------------------------------------------------------------------------
Mother        Child      Home nursing              Cutaneous     Blood/Stool           ND *    Mother provided extensive care without
                                                                                               gloves (e.g., drawing blood, removing
                                                                                               intravenous catheters, and emptying and
                                                                                               changing ostomy bags) (1).

Child         Child      Home intravenous therapy  Possible      Blood                  Y      Mother administered intravenous therapy
                         for hemophilia            intravenous/                                to both children in succession and
                                                   Percutaneous +                              placed used needles in bag within reach
                                                                                               of case-patient (3).

Child         Child      Living in same household  Cutaneous +   Blood                  Y      Source-patient had frequent bleeding;
                                                                                               case-patient had excoriated rash (4).

Adolescent    Adolescent Living in same household  Cutaneous/    Blood                  Y      Case-patient and source-patient shared a
                                                   Percutaneous                                razor; each cut himself while shaving
                                                                                               with the razor and bled as a result.
                                                                                               Both have hemophilia (5).

Child         Mother     Living in same household  Cutaneous     Blood/Exudate          Y      Source-patient had draining skin
                                                                                               lesions; source-patient picked at
                                                                                               case-patient's scabs. (Patient 1
                                                                                               presented in this report).

Child         Child      Living in same household  Bite +        Not specified         ND      Source-patient bit case-patient, skin
                                                                                               was not broken, and there was no bleeding.
                                                                                               Details of home care not reported (6).

Adult         Adult      Home nursing              Cutaneous     Body secretions and   ND      Case-patient wore no gloves while
                                                                 excretions, including         caring for source-patient; case-patient
                                                                 urine and saliva              had eczema and small cuts on her
                                                                                               hands (2).

Mother        Adult son  Home nursing              Cutaneous     Body secretions and   ND      Case-patient usually wore gloves
                                                                 excretions, including         (Patient 2 presented in this report).
                                                                 urine and feces
-----------------------------------------------------------------------------------------------------------------------------------------
* Not done.
+ No definite exposure documented.
===========================================================================================================================================

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