Hepatitis A in day care centre

A focal outbreak of hepatitis was detected in a day-care centre for children centrally located in Pune. The source of infection was suspected to be an 11-year-old child who probably got the infection from his school. Seven out of 15 children from day-care centre developed clinical hepatitis. Two cases of secondary infection were identified among the family contacts of infected children. Sera from all the nine sick children were positive for anti-hepatitis A virus-IgM antibodies. A stool sample from a case of secondary infection showed presence of HAV-RNA by RT-nested PCR. These findings proved that the outbreak was caused by hepatitis A virus.     

Outbreak of invasive group A streptococcal disease among children attending a day-care center

BACKGROUND: Most cases of invasive group A streptococcal (GAS) disease arise sporadically in the community, but outbreaks of severe invasive GAS infections have been reported in closed environments, such as military populations, family communities and hospitals. An outbreak of invasive GAS disease involving 3 cases of streptococcal toxic shock syndrome (TSS), one with a fatal course, occurred among children attending a day-care center located in Cantabria, Northern Spain. OBJECTIVE: To determine the characteristics of GAS isolates obtained from the outbreak environment. METHODS: GAS isolates obtained from children attending the same day-care facility, staff members, and family contacts were assayed for emm typing, pulse-field gel electrophoresis (PFGE), and toxin-gene content. One isolate obtained from the fatal case was also characterized by multilocus sequence typing. Antimicrobial susceptibility testing was done. Strains from patients unrelated to the outbreak were included for comparison. RESULTS: All GAS isolates from children attending the day-care center, including those from streptococcal TSS cases, shared the same emm type 4, genomic pattern by PFGE (A) and toxin-gene profile. Neither the emm type nor the PFGE pattern or toxin gene profile of the outbreak-associated strains were encountered among GAS isolated from household or staff contacts. CONCLUSIONS: A clone of GAS belonging to emm type 4 and characterized by a specific PFGE pattern and toxin-gene profile was responsible for a community outbreak of streptococcal TSS disease in a child day-care center in Spain. This is the first day-care outbreak reported in our country.     

Risk factors for TB infection and disease in young childhood contacts in Malawi

BACKGROUND: Screening of children in household contact with smear-positive tuberculosis (TB) is universally recommended but seldom practiced in resource-poor settings. It has huge potential to reduce the burden of TB disease in children, particularly if streamlined to focus on those at greatest risk.AIMS: To assess the prevalence of infection and disease amongst children aged < or = 5 yrs in household contact with smear-positive TB. To identify which source case characteristics are risk factors for infection. METHODS: A prospective, hospital-based audit was conducted over a 17-mth period in Southern Malawi. Smear-positive adults were identified and encouraged to bring their children to the outpatient clinic, in accordance with the national TB programme guidelines. Full assessment was performed, including tuberculin skin test. RESULTS: 195 children aged < or = 5 yrs who were contacts of 161 source cases were assessed. Prevalences of TB infection and disease were high (45% and 23%, respectively). The likelihood of a child being infected was significantly greater with increasing smear-positivity of the source case, and also if the source case were female (OR 2.25, 95% CI 1.19-4.27, p = 0.01). CONCLUSIONS: The high prevalence of TB infection and disease in child contacts attending this hospital-based clinic supports the current policy of contact-screening in Malawi. However, community-based studies are needed to provide a more accurate assessment of prevalence and risks for child contacts.     

Transmission of multidrug-resistant tuberculosis

AIM: To compare the Mycobacterium tuberculosis isolates of adult index cases with multidrug-resistant (MDR) tuberculosis to the isolates obtained from their child contacts. PATIENTS AND METHODS: A 4-year prospective study in the Western Cape Province of South Africa. We evaluated 149 child contacts of 80 adult MDR pulmonary tuberculosis cases. This report includes those cases where a culture for M. tuberculosis was obtained from both the adult source case and the child contact. Isolates were compared by drug susceptibility pattern and restriction fragment length polymorphism analysis. RESULTS: Six adult-child pairs with cultures for M. tuberculosis were identified. Two children had contact with more than one adult tuberculosis case. One child received previous isoniazid prophylaxis. Drug susceptibility pattern and restriction fragment length polymorphism analysis were identical for five adult-child pairs. One child, with no other known source case, had a strain different from that of the identified source case, but the MDR M. tuberculosis strain with which he was infected was prevalent in the community in which he resided. All children responded well to treatment. CONCLUSION: This study confirms that most of the childhood contacts of adults with MDR tuberculosis are likely to be infected by these MDR source cases despite their exposure to other drug-susceptible adults with tuberculosis in some instances. Child contacts of adults with MDR tuberculosis should be treated according to the drug susceptibility patterns of the likely source cases' M. tuberculosis strains unless their own strain's susceptibility testing indicates otherwise. Contact tracing remains of fundamental importance in identifying children at risk.     

Communitywide outbreak of cryptosporidiosis in rural Missouri associated with attendance at child care centers

OBJECTIVE: To determine risk factors for infection during a cryptosporidiosis outbreak in a rural Missouri community. DESIGN: Community-based case-control study. SETTING: Madison County, Missouri. PARTICIPANTS: Case patients had laboratory-confirmed Cryptosporidium infection. Controls were randomly selected from the community. INTERVENTIONS: Pool water and municipal tap water were analyzed for Cryptosporidium oocysts. Univariate and multivariable logistic regression analyses were performed to evaluate potential risk factors. OUTCOME MEASURES: Risk factors for cryptosporidiosis infection. RESULTS: In total, 56 case patients (median age, 7.0 years) who developed cryptosporidiosis from July 27 to August 30, 2005, and 76 controls (median age, 8.4 years) participated in this study. The main risk factors for cryptosporidiosis were attending child care center A or B (adjusted odds ratio, 42.11; 95% confidence interval, 4.88-363.57) and using a water park (adjusted odds ratio, 6.02; 95% confidence interval, 1.25-29.01). A pool-based case-control study indicated that the highest risk for infection was associated with eating at the pool (adjusted odds ratio, 7.26; 95% confidence interval, 2.57-20.48). The epidemiologic curve for cases without child care exposure peaked 4 days later than that for the child care-associated cases. Samples of water from the city water plant and the water park tested negative for Cryptosporidium oocysts. CONCLUSIONS: Children attending child care center A or B were the likely sources of this cryptosporidiosis outbreak. Recreational pool water probably served as a vehicle for disease transmission in the community. Early recognition of first cases of cryptosporidiosis by health care providers (ie, pediatricians and family physicians) caring for children could play an important role in limiting community outbreaks.     

The high morbidity associated with a measles outbreak in a West Australian town

Objective : To determine the effectiveness of the measles vaccine and to record the morbidity during a measles outbreak.
Methodology : A retrospective cohort study was carried out. It was a community-based study in Bunbury. Western Australia, between February and May 1994, of 53 cases of measles and their household contacts.
Results : Of the 53 cases of measles, 24 were from one high school. Only two cases occurred in the high school class that had received the National Health and Medical Research Council of Australia recommended measles, mumps and rubella (MMR) booster 12 months earlier. Neither had been vaccinated. Vaccine effectiveness was 91% (95% confidence interval 67-97%). Ten cases had complications of measles and a further five were admitted to hospital. Doctors prescribed antibiotics to 29 cases and metoclopramide to five cases. One month elapsed between the day the index case became ill and the first notification to the community health centre.
Conclusions : The low herd immunity that led to this high school outbreak can be attributed to low vaccine coverage. There was a significant morbidity associated with this outbreak that may have been averted if earlier notification had occurred. The MMR booster dose should be offered to all 10-16 year olds to prevent high school outbreaks.     

Outbreak of Escherichia coli O157 in a nursery: lessons for prevention.

OBJECTIVES: To identify risk factors for transmission of verocytotoxin producing Escherichia coli O157 (VTECO157) and means of prevention. STUDY DESIGN: Outbreak investigation: retrospective cohort study. SETTING: A nursery (child care centre) in North Wales. SUBJECTS: Children attending (n = 104). METHODS: Faeces were examined using sorbitol MacConkey agar (SMAC), with cefixime, tellurite, and rhamnose; enrichment in modified tryptone soya broth; and immunomagnetic separation. Symptoms and exposure data were obtained from questionnaires to parents/guardians and children's toiletting and feeding records kept at the nursery. MAIN OUTCOME MEASURE: A "case" was defined as a child with verocytotoxin producing E coli O157 isolated from faeces, or a history of haemolytic uraemic syndrome (HUS) and antibodies to E coli O157 lipopolysaccharide, during the period 10 August to 30 September 1995. RESULTS: The attack rate was 31 in 104. Two children developed HUS. There were higher attack rates among girls and friends who played together. Cases were more likely to attend the nursery more frequently. The mean number of recorded bowel motions/child/half day was 0.51 in cases and 0.21 in well children. Child to staff ratios were high preceding and during the outbreak. CONCLUSIONS: A sick child is the most plausible source of infection with subsequent person to person transmission. The record of children's toiletting discriminated between cases and well children and might have allowed earlier detection of the outbreak. This simple record could be considered by other child care facilities as a means of giving early warning of problems with infectious intestinal diseases.     

Outbreak of cryptosporidiosis in a day-care center

An outbreak of diarrhea due to infection with Cryptosporidium occurred in a day-care center. During a period of 2 months, 23 of 53 (43%) children attending the day-care center and 15 of 104 (14%) household contacts had diarrhea. Cryptosporidium oocysts were identified in 13 of 20 (65%) symptomatic children tested compared with three of 27 (11%) asymptomatic children (chi 2 = 12.56, P less than .001). Enteropathogenic bacteria, enteroviruses, rotavirus, and other protozoan parasites were ruled out as the cause of the diarrhea. A history of diarrhea in household contacts was associated with excretion of Cryptosporidium oocysts by the children. Human-to-human transmission of the infection was suggested by the epidemiology.     

Haemophilus influenzae type b disease in an Amish population: studies of the effects of genetic factors, immunization, and rifampin prophylaxis on the course of an outbreak

In 1982, an outbreak of Haemophilus influenzae type b disease occurred in a 379-member Amish community. In an attempt to control the outbreak after the occurrence of the second case of disease, we investigated the combination of (1) rifampin chemoprophylaxis of all carriers of H influenzae type b and their household contacts from 1 month to 5 years of age and (2) H influenzae type b polysaccharide vaccine immunoprophylaxis of all community members 12 months of age and older. Despite our intervention, two additional cases of bacteremic H influenzae type b disease occurred in the ensuing 5 months, one in a 22-month-old infant who had been immunized at 19 months of age and the other in a child who had not been immunized because she was younger than 12 months of age. The outbreak ended following rifampin prophylaxis of all community members younger than 15 years of age. All of the children with disease were genetically related to one another, and three of the four were inbred. However, analysis of their coancestry revealed that neither the average level of kinship nor the average inbreeding level of the affected children differed significantly from those of the other children in the community. Furthermore, none of the four children with disease shared a human leukocyte antigen haplotype. Our observations suggest that inbreeding was not a risk factor in this community.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hepatitis B virus transmission between children in day care

We investigated two situations involving hepatitis B virus exposure among children in day care. In the first a 4-year-old boy who attended a day care center developed acute hepatitis B; another child at the center, who had a history of aggressive behavior (biting/scratching), was subsequently found to be a hepatitis B carrier. No other source of infection among family and other contacts was identified and no other persons at the center became infected. In the second situation a 4-year-old boy with frequently bleeding eczematous lesions was discovered to be a hepatitis B carrier after having attended a day care center for 17 months. Testing of contacts at the center revealed no transmission to other children or staff (representing 887 person months of exposure). Nationwide surveillance data showed that for the period 1983 to 1987, 161 children 1 to 4 years of age were reported with acute hepatitis B. After children with known hepatitis B risk factors were excluded, 25% (7 of 28) of children with known day care status were reported as day care attendees, a percentage comparable to national estimates of day care attendance by this age group. This is the first reported case of hepatitis B virus transmission between children in day care in the United States. Although it appears that day care transmission of hepatitis B is infrequent, further studies are needed to define the risk more accurately.     

Management of an outbreak of invasive Kingella kingae skeletal infections in a day care center

BackgroundKingella kingae (Kk) is frequently responsible for invasive skeletal infections in children aged 3–36 months. However, few outbreaks of invasive Kk infections in day care centers have been reported. The objective of the present study was to describe (a) the clinical and laboratory data recorded during an outbreak of invasive Kk skeletal infections, and (b) the management of the outbreak.MethodFour children from the same day care center were included in the study May and June 2019. We retrospectively analyzed the children's clinical presentation and their radiological and laboratory data. We also identified all the disease control measures taken in the day care center.ResultsWe observed cases of septic arthritis of the wrist (case #1), shoulder arthritis (case #2), knee arthritis (case #3) ans cervical spondylodiscitis (case #4). All cases presented with an oropharyngeal infection and concomitant fever prior to diagnosis of the skeletal infection. All cases were misdiagnosed at the initial presentation. The mean (range) age at diagnosis was 10.75 months (9–12). The three patients with arthritis received surgical treatment. All patients received intravenous and then oral antibiotics. In cases 1 and 2, Kk was detected using real-time PCR and a ST25-rtxA1 clone was identified. The outcome was good in all four cases. Four other children in the day care center presented with scabies during this period and were treated with systemic ivermectin. The Regional Health Agency was informed, and all the parents of children attending the day care center received an information letter. The day care center was cleaned extensively.ConclusionOur results highlight the variety of features of invasive skeletal Kk infections in children and (given the high risk of transmission in day care centers) the importance of diagnosing cases as soon as possible.     

Outbreak of group A streptococcal infection in a day-care center.

During an outbreak of streptococcal infections in a day-care center it is often difficult to determine the source and extent of the outbreak and the optimal means of management. An intervention strategy based on repeated throat cultures and initial antibiotic treatment of culture-positive individuals was used during an outbreak of respiratory tract infections with Group A streptococci at a day-care center. The spread of streptococci carriers was studied. Two weeks after the diagnosis of the index case, 61% of the 30 children were colonized with Group A streptococci. From 20 to 30% of the children remained streptococcal carriers, but they did not give rise to secondary cases. Initially the environment was heavily contaminated with Group A streptococci. Damp material might constitute a potential source of streptococcal spread. All Group A streptococcal strains belonged to the same serotype, T12M12. Prompt recognition and intervention are important to prevent spread of streptococcal infection to many day-care attenders.     

Evaluation of household contacts of children with positive tuberculin skin tests

BACKGROUND: Associate investigation, defined as screening the contacts of children with positive tuberculin skin tests (TST) and normal chest radiographs, has been recommended to improve case finding for active tuberculosis (TB). The success of this strategy has not been adequately studied in either adults or children. METHODS: A 2-year prospective study was conducted wherein 187 children and adolescents with infection caused by Mycobacterium tuberculosis (positive TST and normal chest radiograph) were referred to a TB Screening Clinic. An associate investigation was performed among their 659 household contacts who were interviewed to assess risk factors for TB and screened with TSTs and with chest radiographs when appropriate. RESULTS: No cases of active TB were detected, but 32% of household contacts had TSTs > or = 10 mm and were candidates for preventive therapy. Logistic regression analysis revealed that household contacts with Calmette-Guérin bacillus immunization and foreign birth were 2.26 and 3.92 times more likely (P < 0.001 and 0.002, respectively) to be tuberculin-positive. Univariate analysis of the 187 households revealed that the following risk factors present in a household member were associated with detecting a household contact with a positive TST: Calmette-Guérin bacillus immunization (P = 0.001), foreign birth (P = 0.017) and a history of having hosted foreign visitors (P = 0.032). CONCLUSION: In this Hispanic immigrant population, primarily from the Dominican Republic, screening household contacts of children with positive TSTs did not identify new cases of active TB. However, this strategy did identify household contacts who were eligible for preventive therapy.     

Methicillin-resistant Staphylococcus aureus carriage in a child care center following a case of disease. Toronto Child Care Center Study Group.

OBJECTIVES: To study the prevalence of methicillin sodium-resistant and methicillin-sensitive Staphylococcus aureus colonization in a child care center following the diagnosis of community-acquired methicillin-resistant S. aureus (MRSA) disease in a previously well 2 1/2-year-old attendee and to determine the optimal site of detection of S. aureus. DESIGN: Point prevalence survey and questionnaire administration. SETTING: A Toronto, Ontario, child care center. INTERVENTIONS: Parents were provided with general information. Consenting parents completed a questionnaire and permitted screening of their child at 1 or more of throat, nose, and perianal sites. Families of children who were culture positive for MRSA were offered screening and suppressive therapy. Nasal and perianal swabs were obtained from child care center staff and screened. RESULTS: Of 201 children, 164 (81.6%) had completed questionnaires and had undergone screening at 1 or more sites; 38 staff members (100%) completed questionnaires and were screened. A 26-month-old classroom contact with chronic dermatitis had MRSA detected only on perianal swab. Of 3 adult household contacts of the index case and 2 adult and 1 child contacts of the classroom contact, only the 7-year-old sibling of the classroom contact was positive for MRSA. By pulse-field gel electrophoresis, these isolates were identical and not related to any of the common strains circulating in regional health care institutions. Of 40 children with S. aureus (24.4%), 33 had cultures at 3 sites, of which the throat was more sensitive (22 [67%]) than the nostrils (15 [46%]) or perianal sites (8 [24%]). There was a tendency for higher carriage of S. aureus in children with certain risk factors, including personal hospitalization (prevalence ratio, 2.9; 95% confidence interval, 0.6-12.1), family member hospitalization (prevalence ratio, 2.0; 95% confidence interval, 0.6-6.6), and visiting the hospital emergency department (prevalence ratio, 3.2; 95% confidence interval, 0.7-14.5), all in the previous 6 months. CONCLUSIONS: To our knowledge, this is one of the first recognized cases of MRSA disease and apparent transmission in a child care center. Throat and perianal site screenings have a higher sensitivity in identifying children colonized with S. aureus than nasal culturing. Infection with MRSA should be suspected in disease unresponsive to standard antibiotic therapy.     

Effectiveness of measles vaccination after household exposure during a measles outbreak: a household contact study in Coburg, Bavaria

BACKGROUND: A measles outbreak was recently observed in Coburg, Bavaria, in a population with vaccination rates of 76.5% in 5- to 6-year-old children in the years preceding the outbreak. Only a small proportion of children had received 2 vaccinations against measles. Vaccine effectiveness is estimated in a household contact study and also by a screening method. METHODS: A household contact study was conducted in families with at least 1 measles case by standardized computer-assisted telephone interviews to assess secondary attack rate and to estimate vaccine effectiveness. Vaccine effectiveness was also estimated with Farrington's screening method with information from school entry examinations and from questionnaires of confirmed measles cases in the Coburg outbreak. RESULTS: Thirty-eight children were primary cases. Of their contacts, 20 children were included in the study as secondary cases (1 vaccinated), and 23 children were contacts who did not develop measles (12 vaccinated once and 4 vaccinated twice), resulting in a vaccine effectiveness of 90% (95% confidence interval, 35-97%) for one vaccine dose. The proportion of the population vaccinated reached 81.5% during the outbreak and the proportion of the cases vaccinated was 10.9%, resulting in a vaccine effectiveness estimated using the screening method of 97.2% (95% confidence interval, 95.7-98.3%). CONCLUSIONS: With the use of 2 approaches to estimate the effectiveness of measles vaccination, a consistently high vaccine effectiveness of 90% or above was shown during a measles outbreak in Western Europe.     

Evaluating the use of penicillin to control outbreaks of acute poststreptococcal glomerulonephritis

INTRODUCTION: Outbreaks of acute poststreptococcal glomerulonephritis (APSGN), occur every few years in remote Australian Aboriginal communities. Intervention with benzathine penicillin G (BPG) to all children is effective in reducing streptococcal carriage in a community, but its effectiveness in arresting outbreaks of APSGN has not been established. OBJECTIVE: To study nine recent community outbreaks of APSGN in Australia's Northern Territory and compare them with outbreaks reported in the literature to assess the impact of intervention with BPG. METHODS: Because randomized controlled trials have not been conducted for this purpose, we assessed data from published observational studies and relevant experiences in the Northern Territory (NT). Eight of the nine outbreaks in the NT were studied prospectively. An outbreak was defined as two or more clinical cases of APSGN occurring within 1 week in a single community. Three intervention methods were used: intramuscular BPG to all children ages 3 to 15 years; BPG only to children with skin lesions; and BPG only to child contacts of clinical cases. The attack rates, number of clinical cases before and after the interventions were documented and the coverage of children with penicillin were estimated. RESULTS: A review of the literature found very little evidence either for or against the effectiveness of intervention with BPG. In our study four communities used the first method of intervention. The community with the lowest uptake of penicillin continued to have cases in untreated children for 9 further weeks, two communities had no new cases from 3 weeks after the intervention and the fourth had a single further case after 4 weeks. The one community that used the second method had a high initial attack rate but no further cases from 1 week after the intervention. Three communities used the third method and in one community no intervention was attempted. CONCLUSION: Our observational study supports the use of BPG in the community to prevent new cases of APSGN. It suggests that targeted treatment of children with skin sores and household contacts of cases, rather than attempted treatment of all children in the community, could be an effective method of intervention.     

Contact investigation and genotyping to identify tuberculosis transmission to children

BACKGROUND: Tuberculosis (TB) in young children is an indicator of ongoing community transmission. We examined contact investigations related to pediatric TB, yield for source case identifications and genotypes for relevant Mycobacterium tuberculosis isolates in a low-incidence setting. METHODS: We reviewed public health data for all patients with TB aged <18 years reported to Montreal authorities during 1996 to 2000. M. tuberculosis isolates from patients of all ages were subjected to IS6110-based genotyping, supplemented by spoligotyping, to compare isolates from children and adults during the same years. RESULTS: Sixty-six patients aged <18 years were diagnosed with active TB from 1996 to 2000. Mean age was 11.1 years (standard deviation 6.7 years). Twenty-five children (38%) were Canadian-born, all with at least one foreign-born parent. Nineteen children were diagnosed after contact investigations of known adult cases; 8 underwent no contact investigation. For the remaining 39 children, a total of 616 contacts were identified. The median number of contacts per child was 9 (interquartile range, 6-10). Four hundred eighty-one contacts (78%) underwent tuberculin testing; 188 (39%) were reactors and 186 (39%) began treatment of latent TB. Investigations uncovered 4 probable source cases, all involving parents or other relatives. M. tuberculosis genotyping for 38 children identified up to 14 additional possible source cases; in only one was a possible epidemiologic link evident from public health records. CONCLUSIONS: Among largely foreign-born children with active TB, contact investigations were extensive and often identified latent tuberculosis infection--but rarely source cases. However, genotyping suggested substantial, previously unrecognized transmission to children despite low overall incidence.     

Evaluation of young children in household contact with adult multidrug-resistant pulmonary tuberculosis cases.

BACKGROUND: The prevention and management of multidrug-resistant (MDR) tuberculosis has received much attention, but little attention has been given to children with MDR tuberculosis or children in contact with adults with MDR tuberculosis. The aim of this study was to determine the prevalence of tuberculous infection and disease in childhood contacts of adults with MDR pulmonary tuberculosis. METHOD: All children <5 years of age in household contact with 75 recently diagnosed adults with MDR pulmonary tuberculosis were evaluated. Evaluation included clinical examination, tuberculin skin test, chest radiography and culture for Mycobacterium tuberculosis from gastric aspirates. RESULTS: One hundred twenty-eight children, median age 27 months, were evaluated. Fifty children had recent contact with other adult tuberculosis cases. Sixty-six children previously had chemoprophylaxis or treatment of whom 36 defaulted treatment or received insufficient chemoprophylaxis. One child had HIV infection. Forty-seven children were classified as noninfected, 66 were considered infected only (Mantoux test, > or = 15 mm) and 15 had disease. Three children, who had not previously received antituberculosis drugs, had positive cultures for M. tuberculosis; all were multidrug-resistant. CONCLUSION: This study documents the transmission of multidrug-resistant M. tuberculosis to childhood contacts, the development of disease in these contacts and the importance of knowing the index case's M. tuberculosis susceptibility pattern in choosing a proper treatment regimen for the childhood contact.     

Growth status and the risk of contracting primary tuberculosis.

A case of open tuberculous infection in a member of staff at a primary school resulted in an outbreak in which nearly a quarter of the children in the school contracted a primary infection. The growth status of these children was compared with that in the non-infected children before the outbreak and on two occasions after the outbreak. The children with tuberculous infection were taller and fatter than the controls before and after the outbreak but differences were not always statistically significant. Among children with a good nutritional status the thin and small child is at no greater risk of contracting primary tuberculous infection than other children.     

HIV infection of undetermined origin during infancy

Abstract:   The case histories of two children with horizontally acquired HIV infection are described. These children were diagnosed at a paediatric hospital in sub-Saharan Africa. Although the source(s) of infection was not identified, both children had had several contacts with the health service, experienced invasive procedures and ingested expressed milk from their own mothers during hospital admission. Health-care institutions, particularly those located in high HIV prevalence areas, must implement effective infection control measures to ensure that the risk of horizontal infection is minimized. Attention should be given to practices that are unique to each clinical discipline.