AIDS in the Workplace Marco Cusini, MD Roberto Zerboni, MD
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T
he problem of human immunodeficiency virus (HIV) infection in the workplace has three major components: (1) the occupational risk, mainly for health care workers (HCWs), of acquiring HIV infection at work; (2) the risk of transmitting HIV infection during work; and (3) the risk of the toxicity of work to HIV-infected workers at various stages of the disease. An occupational risk of acquiring AIDS was hypothesized at the beginning of the pandemic before discovery of the etiologic agent. The fear of AIDS has generated a huge number of reactions among health care workers, often only emotional. Several cases of doctors or nurses who refused to take care of patients with HIV infection have been reported.‘** Rules to reduce the risk of acquiring AIDS have been established by international health organizations, and cases of occupational infection reported by June 1991 approached 50. 3 The risk of transmission of AIDS involves not only health care workers and other professionals who have close contact with the public, but also HIV-infected workers who have work accidents with blood loss from wounds. Moreover, there are several professions in which the use of apparatus (needles, razors, etc) could be an indirect means of transmission of HIV infection. The third point deals with the working capacity of and the specific risk of some occupations to HIV-positive individuals. It must be remembered that HIV infection comprises different stages of immunodepression with a variety of clinical pictures that can involve almost all organs and functions.
From the Department of Dermatology I, University of Milan, Milan, My. Address correspondence to Marco Cusini, Deparfmenf of Dermatology I, University of Milan, Via Pace, 0, 20122 Milan, Italy.
0 1992 by Elsevier Science Publishing
Co., Inc.
l
0738-082x/92/$5.00
History and Epidemiology of AIDS The first sporadic cases of AIDS were reported in the United States and Europe as early as 19524; however, the beginning of the AIDS epidemic is usually demarcated in mid-1981 in Los Angeles and New York, when unusual infections and/or tumors where reported in previously healthy homosexual men. 5,6AIDS was recognized in Europe in 1982 and since then cases have been reported from almost all over the world.‘The first report of occupational AIDS occurred in 1984, in a health care worker infected in Africa by a needle-stick injury,s but little attention was paid to the occupational transmission of HIV at that time.3 As of September 1991, AIDS has been reported in more than 1,500,OOO patients, and almost 10,000,000 people have been estimated to be infected with HIV. Homosexual and bisexual men still remain the major risk group, but the incidence of HIV infection among intravenous drug abusers and among the heterosexual population is increasing. There are large geographic differences in the distribution of the infection among the different risk groups. The epidiomiology of HIV infection acquired at the workplace, excluding prostitution, involves about 50 cases worldwide. The majority of these cases have occurred in HCWs infected by patients with AIDS, through hollowbore needles; reports about transmission of HIV from HCWs to patients and from patient-to-patient remain doubtful.
Risk of Acquiring HIV Infection at Work Health care is still considered the only profession, besides prostitution, with a significant occupational risk of acquiring HIV infection. Workers are exposed to HIV through needle-stick injuries, cuts with sharp instruments, contamination of mucous membranes, and contamination of
201
202
CUSINI
AND
Clinics in Dermatology 1992:10:201-204
ZERBONI
Table 1. Mode of Exposure to HIV of Health Care Workers
Needle-stick injuries Cuts with sharp instruments Exposure to mucus Contamination of damaged Reprinted, Ippolito.’
with
permission,
skin
United States
Canada
68% 8% 14% 10%
61% 6% 13% 20%
from
damaged skin (Table 1). The most frequent route of transmission is deep needle-stick injuries with hollowbore needles; the estimated risk seems to be less than 0.5% per accident.3 Transmission of HIV through contact of skin or mucous membranes with infected blood or other fluids may occur but the rate of risk is unmeasurable because it is so low. The risk increases when the skin is in some way damaged, but the actual rate is still difficult to establish.g There are some reports of seroconversion after prolonged skin contact with blood, after contact of blood with eczematous skin of the hands and arms, or after contact of blood with skin and mucous membranes of the mouth and eyes. l”sl* Among HCWs, nurses seem to be involved most frequently in needle-stick injuries (60%), followed by laboratory workers (
--
T
he problem of human immunodeficiency virus (HIV) infection in the workplace has three major components: (1) the occupational risk, mainly for health care workers (HCWs), of acquiring HIV infection at work; (2) the risk of transmitting HIV infection during work; and (3) the risk of the toxicity of work to HIV-infected workers at various stages of the disease. An occupational risk of acquiring AIDS was hypothesized at the beginning of the pandemic before discovery of the etiologic agent. The fear of AIDS has generated a huge number of reactions among health care workers, often only emotional. Several cases of doctors or nurses who refused to take care of patients with HIV infection have been reported.‘** Rules to reduce the risk of acquiring AIDS have been established by international health organizations, and cases of occupational infection reported by June 1991 approached 50. 3 The risk of transmission of AIDS involves not only health care workers and other professionals who have close contact with the public, but also HIV-infected workers who have work accidents with blood loss from wounds. Moreover, there are several professions in which the use of apparatus (needles, razors, etc) could be an indirect means of transmission of HIV infection. The third point deals with the working capacity of and the specific risk of some occupations to HIV-positive individuals. It must be remembered that HIV infection comprises different stages of immunodepression with a variety of clinical pictures that can involve almost all organs and functions.
From the Department of Dermatology I, University of Milan, Milan, My. Address correspondence to Marco Cusini, Deparfmenf of Dermatology I, University of Milan, Via Pace, 0, 20122 Milan, Italy.
0 1992 by Elsevier Science Publishing
Co., Inc.
l
0738-082x/92/$5.00
History and Epidemiology of AIDS The first sporadic cases of AIDS were reported in the United States and Europe as early as 19524; however, the beginning of the AIDS epidemic is usually demarcated in mid-1981 in Los Angeles and New York, when unusual infections and/or tumors where reported in previously healthy homosexual men. 5,6AIDS was recognized in Europe in 1982 and since then cases have been reported from almost all over the world.‘The first report of occupational AIDS occurred in 1984, in a health care worker infected in Africa by a needle-stick injury,s but little attention was paid to the occupational transmission of HIV at that time.3 As of September 1991, AIDS has been reported in more than 1,500,OOO patients, and almost 10,000,000 people have been estimated to be infected with HIV. Homosexual and bisexual men still remain the major risk group, but the incidence of HIV infection among intravenous drug abusers and among the heterosexual population is increasing. There are large geographic differences in the distribution of the infection among the different risk groups. The epidiomiology of HIV infection acquired at the workplace, excluding prostitution, involves about 50 cases worldwide. The majority of these cases have occurred in HCWs infected by patients with AIDS, through hollowbore needles; reports about transmission of HIV from HCWs to patients and from patient-to-patient remain doubtful.
Risk of Acquiring HIV Infection at Work Health care is still considered the only profession, besides prostitution, with a significant occupational risk of acquiring HIV infection. Workers are exposed to HIV through needle-stick injuries, cuts with sharp instruments, contamination of mucous membranes, and contamination of
201
202
CUSINI
AND
Clinics in Dermatology 1992:10:201-204
ZERBONI
Table 1. Mode of Exposure to HIV of Health Care Workers
Needle-stick injuries Cuts with sharp instruments Exposure to mucus Contamination of damaged Reprinted, Ippolito.’
with
permission,
skin
United States
Canada
68% 8% 14% 10%
61% 6% 13% 20%
from
damaged skin (Table 1). The most frequent route of transmission is deep needle-stick injuries with hollowbore needles; the estimated risk seems to be less than 0.5% per accident.3 Transmission of HIV through contact of skin or mucous membranes with infected blood or other fluids may occur but the rate of risk is unmeasurable because it is so low. The risk increases when the skin is in some way damaged, but the actual rate is still difficult to establish.g There are some reports of seroconversion after prolonged skin contact with blood, after contact of blood with eczematous skin of the hands and arms, or after contact of blood with skin and mucous membranes of the mouth and eyes. l”sl* Among HCWs, nurses seem to be involved most frequently in needle-stick injuries (60%), followed by laboratory workers (
