Months ago, 5 kids with thalassemia tested positive for HIV in Madhya Pradesh. Yet, no alarm bells rang

* HIV infections confirmed in March and April were not documented in writing to hospital management or state authorities. Local officials tracked cases and prepared transfusion lists, but the information remained at the district-level Aids control society officials.

* The State Blood Transfusion Council learned of the infections months after confirmation, eliminating the possibility of immediate preventive action across districts.

* Of nearly 200 donors linked to the transfusions, only 10 to 12 have been successfully traced. Phone numbers were incorrect or disconnected, and donors moved out of state or refused testing. The entire exercise is being handled by two people.

According to Satna district hospital records, in all five cases, the children received blood transfusions at the district hospital, while in three cases, they also got transfusions at a private hospital.

The first case involved a 15-year-old girl who tested positive on March 20, after having received 126 blood transfusions over the course of her treatment. A second case was confirmed on March 26, when a nine-year-old boy who had undergone 24 blood transfusions tested positive.

Two days later, on March 28, a nine-year-old boy was diagnosed with HIV. Medical records show that he had received 26 blood transfusions. A fourth case was confirmed on April 3, involving a 15-year-old boy who had undergone 13 blood transfusions. The fifth and youngest patient, a three-year-old girl, tested HIV positive on April 1. She had received nine blood transfusions.

In four of the five cases, both parents tested HIV negative.

On December 16, nine months after the first infection was confirmed, Civil Surgeon Dr Manoj Shukla issued a formal notice to Dr Pooja Gupta, the Aids control nodal officer in Satna, seeking an explanation over alleged lapses in reporting HIV infections among thalassemia patients.

Shukla wrote that the HIV infection “was confirmed during HIV testing conducted in March/April 2025” and “it was your responsibility to keep the hospital management and senior authorities informed from time to time about the factual position and the actions taken by you; however, this was not done by you”.

Shukla wrote that the “image of the hospital management has been tarnished, but the department’s image has also been adversely affected, and senior authorities have expressed their displeasure over this”.

Shukla told The Indian Express, “Although internal processes were initiated, the hospital management was not formally informed in writing.”

“Local officials had processed the cases, tracked each child and prepared lists of blood transfusions. They said donors were contacted and attempts were made to trace them, but nothing was communicated to us officially,” he said.

Dr Pooja Gupta told The Indian Express that senior officials were informed orally when the first case was detected earlier this year, though no written communication was sent at the time.

“We informed the civil surgeon orally when the first case came in March. Because of the sensitive nature of the case and to protect the child’s identity, it was not put down in writing,” Gupta said.

She said donor verification began soon after the infections were detected. “Within four days, donors were checked, and blood bank details were verified. All the donors who could be traced tested HIV negative,” she said.

The blood bank officials have, in an official note, explained that “all blood transfusions were issued only after mandatory testing procedures were completed” and that the “full protocol for donor screening was followed”. Officials said that “all potential blood donors linked to these transfusions are being contacted by phone and called in for further testing as part of the ongoing verification process”.

Ruby Khan, Deputy Director of the State Blood Transfusion Council and a member of the six-member committee constituted to investigate how the children contracted HIV, said the processes followed at the local level were to maintain confidentiality of the victims, but the failure to escalate information had limited the scope for timely intervention.

“This was handled as a routine process. Information did not reach us at the state level; otherwise, action would have been taken earlier,” Khan said.

She said the state was now working on corrective measures to prevent a recurrence. “We will be drafting fresh guidelines. At the very least, district-level authorities must inform the state immediately so that preventive action can be taken,” she said.

Health department officials are trying to discern how contaminated blood was used for transfusion.

CHMO Dr Shukla said blood transfusions were conducted only after testing, in line with prescribed norms, but acknowledged that rare technical limitations exist. “There are cases where HIV antibodies are not detected during the window period. Sometimes it can take weeks or even months before infection shows up in tests,” he said, adding that this possibility is also being examined.

He said that all procedures at the blood bank were carried out as per the National AIDS Control Organisation guidelines. “Even with the latest methods, detection during the window period is not always possible,” he said.

Dr Shukla said donor tracing has emerged as one of the biggest challenges in the investigation. “There are nearly 200 donors linked to the transfusions. So far, only 10 to 12 donors have been successfully traced. Many are voluntary donors and refuse to come back for retesting. There is a lot of stigma attached to HIV, and without consent, we cannot force testing,” he said.

He also pointed to additional complexities in tracing possible sources of infection, particularly in rural areas. “Some donors belong to small villages. There is a possibility of infection through unsafe medical practices, such as the use of unsterilised needles during local treatments. We are exploring those angles as well,” he said.

Dr Gupta said tracing donors has been a major challenge, given the scale of the exercise and limited manpower. “There are more than 200 donors linked to these cases. Some phone numbers are incorrect, some donors are outside the state, and some have refused to come to meet us. It is difficult to trace them,” she said. “This work is being done by a team of two people.”

Khan said the committee is examining long-term data to determine when the children may have contracted HIV. “We are looking at data from the past year. It is not possible at this stage to say exactly where the infection occurred or during which transfusion it happened,” she said.

She added that blood transfusions linked to the affected children were carried out not only in Satna but also in other districts. “There are indications that some transfusions took place in Rewa and Jabalpur. We are still trying to trace donors across districts,” Khan said, adding that the investigation remains ongoing.

But for the father of the 15-year-old girl, these explanations don’t answer why she contracted HIV. “She was diagnosed with thalassemia when she was nine years old. Since then, we had to take her for blood transfusions regularly,” he said.

The frequency of transfusions increased as her condition worsened. “Initially, we went once a month. Later, it became more frequent, sometimes three times a month. Her health kept getting worse,” he said.

His daughter received transfusions across multiple facilities over several years. “About three years ago, she received blood transfusions in Jabalpur and at a private clinic in Satna. But all her recent transfusions were done only through the Satna district hospital blood bank,” he said.