KARACHI: A high-level inquiry into the HIV outbreak among children at the KVSS (Valika) SITE Hospital has identified acute shortages of essential infection prevention & control (IPC) supplies, weak administrative oversight and possible reuse of disposable medical items among the key factors behind the outbreak, concluding that healthcare-associated transmission through reused syringes and other single-use items cannot be ruled out.
Acting on the inquiry’s findings, the Sindh Labour Department has initiated disciplinary proceedings to dismiss 37 hospital employees for alleged gross misconduct and criminal negligence.
The inquiry, headed by Dr Naila Zaheer, chief medical officer, City Circle of the Sindh Employees Social Security Institution (Sessi), found that while investigators cannot scientifically establish a single definitive source of HIV transmission, evidence gathered during the investigation indicates that severe shortages of disposable syringes, IV cannulas, IV sets, gloves, personal protective equipment, sanitisers and other IPC supplies created conditions in which standard infection-control practices could not be consistently followed.
Fresh show-cause notices have been issued to 37 employees, including a former medical superintendent, two former deputy medical superintendents (DMSs), two consultant paediatricians, the head of laboratory, the hospital matron, staff nurses and nurse aides, asking them to explain why they should not be removed from service. The notices supersede
earlier disciplinary proceedings initiated after an initial inquiry ordered by the Sindh ombudsman. According to the documents available with The News, the committee interviewed doctors, nurses and other staff, reviewed hospital records and assessed infection-control practices before concluding that healthcare-associated transmission through the reuse of syringes and other disposable medical items cannot be excluded.
The report states that staff from different departments told investigators that shortages of essential consumables has become routine, and that they frequently borrow supplies from other wards to continue treating patients. The committee observed that these deficiencies undermine internationally accepted IPC standards.
The inquiry also documented serious administrative failures, including weak supervision, poor enforcement of infection-control protocols, inadequate documentation, inappropriate deployment of staff and deficient managerial oversight. It also found that the HIV
status of patients was not consistently communicated to frontline healthcare workers, limiting their ability to adopt enhanced infection-control precautions.
The committee reported that 78 children contracted HIV after receiving treatment at the hospital. The first case was detected in April 2025, while infections increased sharply in August. Five of the infected children later died.
Investigators noted that most of the affected children had been treated at the hospital before testing positive, while nearly all of their parents tested HIV-negative, making mother-to-child transmission an unlikely explanation in most cases. The inquiry also found inconsistencies between hospital inventory records and claims by clinical departments regarding shortages of disposable medical supplies. It recommended a comprehensive audit of procurement, distribution, stock management and payments for medical consumables to determine whether the shortages resulted from procurement failures, poor inventory management or other administrative irregularities.
Based on the findings, Sessi has initiated major penalty proceedings under the Sessi Efficiency & Discipline Rules, 1973. Those served with notices include ex-MS Dr Mumtaz Ali Sheikh, ex-DMSs Dr Qamarul Haq and Dr Ambreen Khan, consultant paediatricians Dr Amanullah Memon and Dr Huma Aman, laboratory head Dr Syed Naqeeb Ali, matron Rukhsana Yasmeen and numerous nursing staff.
The notices claim that senior administrators had failed to ensure uninterrupted availability of disposable medical items, effective supervision and proper infection-control systems. Consultant paediatricians, laboratory officials and nursing supervisors have been accused of failing to implement or enforce standard infection prevention measures, while some nurse aides allegedly failed to report serious irregularities despite being aware of them.All officials have been directed to submit written replies within 14 days, and they may seek a personal hearing before the competent authority. The inquiry also recommended strict enforcement of infection-control protocols, uninterrupted availability of single-use disposable supplies, stronger supervision, improved documentation, and regular audits of procurement and inventory systems to prevent similar healthcare-associated outbreaks in the future.
