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Amsterdam conference review: Health care workers B. Tindall



Senior Project Scientist, National Centre in HIV Epidemiology and Clinical Research , University of New South Wales, and Research Fellow Centre for Immunology, St Vincent's Hospital , Sydney, Australia Published online: 25 Sep 2007.

To cite this article: B. Tindall (1992) Amsterdam conference review: Health care workers, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:4, 425-429, DOI: 10.1080/09540129208253114 To link to this article:

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AIDS CARE, VOL. 4, NO. 4, 1992



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A group of guest editors agreed to study a set of themes during the Amsterdam AIDS Conference and to present their work in the form of a brief report. This serves to provide an insightful summary of some of the major psychosocial and clinical issues presented. References are quoted by the first author only with an Abstract Number. These can be found in the Amsterdam Conference Abstracts Volumes.

Amsterdam Conference Review

Health care workers Transmission studies Patient to health care worker. Studies continue to demonstrate a low risk of occupationally-acquired HIV infection, consistent with previously reported rates of approximately 0.3% following percutaneous injury. Of 8,467 cases of AIDS among health care workers in the United States (US), six (0.07%) were due to occupational transmission (Ciesielski et al., PoC4143). In the remaining cases, there was no difference between the age, gender or race of health care workers with AIDS compared with cases occurring among persons of other occupations. Including these six cases of AIDS, a total of 31 subjects were documented with HIV infection following an occupational risk (Ciesielski et al., PoC4143). Of these subjects 24 (92%) acquired infection through needlestick injury, 29 (94%) were through exposure to blood and in 22 (71%) of the cases the source patient had AIDS. Most of the cases occurred among nurses or laboratory technicians. Metler et al. (PoC4147) further reviewed the US experience regarding seroconversion in laboratory workers. They identified 11 laboratory workers who had become infected with HIV occupationally; 8 reported percutaneous injuries and all had direct contact with HIV-infected blood. Most exposures (711 1) occurred during phlebotomy. Chamberland et al. (PoC4131) conducted an anonymous, confidential serosurvey of 3,420 orthopaedic surgeons in the US, of whom 87% reported cutaneous or mucocutaneous contact with blood in the previous month and 39% reported percutaneous injury. Of 3,267 surgeons with no reported nonoccupational risk for HIV infection, none was HIV seropositive (upper limit of 95% CI 0.1%). Puro et al. (PoC4148) investigated 224 cases of occupational exposure in Italy and found no incident of HIV seroconversion in an eight month follow-up period (all but ten subjects were treated with zidovudine). From Brazil, Santos Abreu et al. (PoC4139) found no seroconversions among 304 health care workers with exposure who did not have other risk factors. Ippolito et el. (PoC4133) reported 1,613 exposures to blood or body fluids of HIV-infected persons over a four-year period in Italy. Of these, 67% occurred among nursing staff. Most of these occurred in the patients’ rooms during routine procedures. Only 48% of the health care workers used adequate barrier protection. Two seroconversions occurred (0.12%; 95% CI 0.02-0.45%). In South Africa, Tait et al. (1PoC4141) identified two cases (5.4%) of seroconversion among 37 health care workers with documented exposure. A third was detected who tested positive and denied other risk factors. The reason for such a high incidence of infection in this study was not clear and compared unfavourably with all other data presented to date. Levin et al. (PoA2193) reported the detection of T-cell helper responsiveness to synthetic HIV peptides in six seronegative health care workers who had been exposed to HIV-infected body fluids. The significance of such a finding is unclear but might suggest that a low inoculum of HIV may result


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in a cellular but not a humoral response (and that cellular response may be effective in limiting infection). Further investigation of this area is clearly indicated.

Health care worker to patient. A major issue at the 1991 International AIDS Conference was the report that an HIV-infected dentist from Florida had transmitted infection to five patients. In the ensuing year, this has resulted in much discussion in the literature, and major policy decisions including the formulation of guidelines on HIV-infected health care workers (Rango et al., PoD5457). One year later, the mechanism of transmission in the case of the Florida dentist remains unclear. Gooch et al. (PoC4668) found that patient-to-patient transmission was unlikely, as re-use of anaesthetic equipment was never reported and opportunities for sharing of contaminated equipment were limited. Direct transmission from the dentist to the patients seems more likely. Importantly, despite extensive investigation, this remains the only known case of health care worker to patient transmission, suggesting that this is a rare event (if routine infection control procedures are employed). However, one study reported that 10% of physicians believed there was a major risk of transmission from an infected health care worker to a patient (Taylor & White, PoD5856). In the US, Smith et al. (PoC4150) identified and tested a total of 1,136 subjects who had been operated on by an HIV-infected orthopaedic surgeon (representing 43% of all procedures over an 11.5 year period). No case of HIV infection was identified. Robillard (PoC4776) modelled the theoretical risk of transmission from an infected surgeon to a patient in Canada. Assuming a transmission rate of 1 in 14 million procedures, a pool of 7,600 surgeons and 500 procedures per surgeon per year he estimated that one case would occur in four years. However, the cumulative incidence for any one infected surgeon would be 10.5% (1.2-46%) over seven years of practice. Bell et al. (PoC4130) observed 1,382 operations that were conducted in four US hospitals and found that one or more sharps injuries occurred in health care workers in 6.9% of these operations (consistent with the 8.5% reported by Hasan & Barsoum, PoC4129). They further found that a sharp object contacted the patient wound after injuring the health care worker in 2% of the procedures, potentially exposing the patient to the health care worker’s blood. Post-exposure use of zidovudine Despite the lack of any demonstrated efficacy of zidovudine as a post-exposure prophylactic agent in humans, there were several reports of its use in this role. These reports showed that it is a safe drug to administer, that prompt administration following injury is feasible (Fahrner et al., PoC4132) and that its short term toxicity is mild, dose-related and reversible; but there remains no demonstrated efficacy. Campbell et al. (PoC4142) surveyed more than 200 US hospitals and found that only 32% had a policy to utilize zidovudine as a post-exposure agent and that these were generally teaching hospitals located in large cities and with extensive experience in the management of HIV disease. Approximately 50% of health care workers who had been offered zidovudine were reported to have accepted and the acceptance rate was higher among physicians than among nurses. In Italy, Puro et al. (PoC4148) treated 214 subjects with a dose of 1000-1250 mg zidovudine per day for four weeks (with 63% of subjects complying). At least one adverse event was reported by 118 (56%) of the subjects. These were mainly constitutional (e.g. nausea in 85 subjects) and all were reversible. No seroconversions were observed a mean of eight months after treatment. Similarly, Falciano (PoC4813) treated 26 exposed Italian health care workers with 1000 mg zidovudine per day for at least 40 days. Headaches and nausea were the most commonly reported sideeffects and there was mild anaemia beginning in the third week of treatment (which resolved after completion of treatment).

Universal precautions

In a study of 265 health care workers, Descamps et al. (PoD5757) documented a percutaneous

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incidence rate of 0.25Ihealth care workedyear. Forty per cent of these injuries were preventable. Kelen (PoD5760) found that factors related to blood/body fluid contamination were: bleeding patient, heavy procedure-related bleeding, and more than one attempt at a procedure. Needlestick injuries continut: to be the most common percutaneous injury accounting for 70-90% of occupational injuries (Puro et al., PoC4148; Fahrner et al., PoC4132; Hasan i 3 Barsoum PoC4129; Ippolito et al., PoC4133). Keith et al. (PoC4145) estimated that 4800 (95% CI 1300-8300) needlestick injuries from HIV-infected patients had occurred in inpatient settings in the US in 1990. Given a seroconversion rate of 0.3%and assuming that 75%were hollow bore this yields an estimate of 1 1 cases (95% CI 5 to 18) of new infection through this route in 1990. Studies showed a wide range of adherence to universal precautions, which was presumably related to hospital-based differences in training, knowledge and experience. In Canada, Fortin et al. (PoD5455) found that only 20% of health care workers complied with recommended procedures in the emergency room. Physicians fared most poorly with a 3% rate of adherence compared with 17% among nurses. Garcia et al. (PoC4041) found that up to 57% of 1,265 Mexican health care workers recapped needles and only 34% used gloves when indicated. Fantini (PoD5454) found that adherence to universal precautions was unsatisfactory in 56% of events. In a Dominican hospital, Koenig et al. (PoC4135) followed 100 patients from admission to emergency room to completion of surgery. Students drew the initial blood sample in 84%of cases and failed to wear gloves in 39% of cases. None of the doctors or nurses used gloves in the remaining cases and 24% had cutaneous contact with blood or body fluid as a result. In surgery, 30 surgeons reported breakage of gloves and nine did not change them immediately. 62% of the emergency room cleaning personnel failed to wear gloves. Sullivan (PoD5459) surveyed self-reported compliance with universal precautions among US emergency room physicians and nurses at 212 hospitals. Physicians reported a higher rate of recapping than nurses (16% vs 10%) and cited lack of time (77%), patient appearance (63%) and dexterity concerns (41%) as reasons for not complying with universal precautions. Lyons et al. (PoC4137) found that US medical housestaff used needles a mean of 1.67 times per day and scalpels a mean of 0.17 times per day. The risk of injury occurring during use of needles was 0.0051 (5 in 1,000) per use and for sharps was 0.0058 per use. Exposure to sharps was three times more frequent in critical care units than on general wards. McCabe et al. (PoC4146) examined 39 phlebotomists performing 2,463 procedures at three hospitals who had each implemented CDC universal precautions. Gloves were used for 38% of draws and were used significantly more frequently when the patient was male or non-white indicating an influence of gender and race on decisions. The one hospital that actually mandated correct use of gloves achieved a 99% use rate with 99.8% correct disposal, suggesting that strict enforcement of policies may be fruitful. Korniewicz et al. (PoC4820) found a 20% leakage from gloves used in emergency room and Hansen et al. (PoC4547) found a leakage rate of 7.7% in a similar setting. Visible holes were observed in the minority of gloves with leaks, suggesting that gloves should be changed regularly during protracted procedures regardless of whether visible holes are present. Brantsma (PoD5755) found that Australian hospital administrators viewed staff exposures as inevitable, particularly in larger hospitals or in those with full-time infection control staff. Respondents reported a median acceptable rate of exposures of 4 per year and these rates needed to be surpassed before further action to prevent exposures was indicated. An Indian study provided some of the first data regarding universal precautions from this part of the world. Faroqui et al. (PoC4144) found that gloves were routinely worn during examination or surgery by only 38% of 50 surgeons. An average of 3.5 needlestick injuries per month were reported. Sharp objects were handled incorrectly by 83% of subjects and 41% were not aware of correct methods of sterilisation of instruments. In a further study, Sharma et al. (PoC4149) found that none of ten Indian hospitals surveyed had any policy for waste management. Pathological and infectious waste was generally thrown on the open ground or into open cans Only one of the ten hospitals had an operational incinertor. The haphazards disposal of such waste reflects an attitude toward infection control that is clearly suboptimal.

428 AMSTERDAM SUMhURIES In Australia, Boswarva (PoD5453) found that counselling in safe working practice immediately following exposure had a greater effect on subsequent behaviour than pre-incident lectures. There was significant improvement in behaviour among those who did attend versus those who did not attend for post-exposure counselling.

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HIV-infected health care workers A prominent theme at this year’s conference was the impact of HIV infection on the careers of health care workers and on the medical resources necessary for dealing with the HIV pandemic. These are important issues given that it is estimated that 50-70,000 health care workers in the United States alone are HIV-1 seropositive. It has often been muted that HIV-infected health care workers should be required to inform patients of their HIV-status. However, Kern et al. (PoD5424) and Closen et al. (PoD5756) summarized that such a policy was inconsistent with principles of informed consent, set untenable standards of disclosure to patients regarding remote risk activities, violated principles of medical ethics and legal standards of reasonable medical care and inappropriately shifted professional responsibility to patients. Both suggested that more affirmative emphasis on adoption of universal precautions was the better strategy. Similarly, Van Grunsven (PoD5763) found that there was no justification for recommending alterations to the work practices of infected health care workers. Wojcik et al. (PoD5442) reviewed the range of civil and criminal actions that could result from transmission in the health care setting. La Croix & Russo (PoD5456) found that the costs of mandatory HIV testing for all health care workers and hospital patients exceed their benefits and that such strategies represent inefficient use of scarce resources. In a timely study, Schatz et al. (PoD5815) found that 67% of HIV-infected health care workers had avoided or planned to avoid seeking HIV treatment or submitting HIV-related health insurance claims because of concerns about confidentiality. Further, 55% feared that restricting their practices may lead others to suspect that they were HIV-infected. They also found that any attempt to restrict the practices of health care workers would disproportionately impact on the poor and disadvantaged as 30% of their respondents cared primarily for patients with no private health care insurance. As a result of widespread media coverage of the Florida dentist case, 57% of Schatz’s untested health care workers were less likely to be tested for HIV infection (only 7% were more likely to be tested). From New York, Sharp et al. (PoC4140) reported an increase in the number of health care workers working on HIV wards who developed mycobacterium tuberculosis (MTB). Since January 1991, at the one institution, 8 health care workers developed MTB (two of whom developed multi-drug resistant MTB). As a result of these outbreaks, four health care workers applied for a change in placements or resigned. Further resignations can be predicted and recruitment problems anticipated. Other US studies found that 26% of physicians and 22% of nurses reported that they had considered leaving direct health care due to HIV-related concerns (Sullivan et al., PoD5459) and that one third of medical students felt that HIV would influence their decision to practise clinical medicine (Culbert et al., PoD5831). The negative social, financial and public health consequences of such action would be considerable. Burnout amongst health care workers continues to be a problem that will have a significant impact on medical resources (Hawkins et al., PoB3432; Erlicher et al., PoB3851; Fisher & Bradley PoB3431; Guerra et al., PoD5577). Kleiber et al., PoB3433) found that the most significant predictors of burnout were time pressure, feelings of reduced personal accomplishment and stress. They suggested that in order to reduce burnout more emphasis needs to be placed on organizational development and the improvement of working conditions themselves. However, Canadian medical practitioners with a high caseload of HIV disease reported positive as well as negative aspects of their work which may provide critical information to assist those attempting to encourage more physicians to work in HIV disease (Taylor & White, PoB3437). Indeed, several studies reported successful strategies to attract more health care workers to HIV medicine (e.g. Jones et al., PoB3527; Ho ec al., PoB3526).


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Knowledge, attitudes and behaviour Studies continue to document su’boptimal levels of knowledge, attitude and behaviour (Shapiro et al., PoD5729; Bowman et al., PoD5853; Viau et al., PoD5739; Sampaio & Figueiredo, PoD5762; Vasco et al., PoD5863; Lie et al., PoD5735; Godin et al., PoD5728). A recurring theme was that many medical practitioners did not feel that they had the skills necessary to treat HIV infected persons, emphasising the need for intervention to improve knowledge and confidence (Vasco et al., PoD5863; Taylor & White, PoD5856; Bosio et al., PoD5720). These suboptimal responses on attitude highlight the need for ongoing training of health care workers to improve the quality of care delivered to persons with HIV disease. Several studies reported positive changes in attitude and behaviour reported following such intervention (Parris, PoD5104; Tersigni et al., PoB3544; McGivern et al., PoB3538; Kaplowitz et al., PoB3529; McCoy et al., PoB3531; Frank & Macher, PoD5758; Karp & Newitt, PoD5759; Rips & Sharp, PoD5467; Katsufrakis, PoB3530). Such intervention should ideally begin early in medical education (Friedman et al., PoB3535).

Conclusion Occupational transmission of HIV infection continues to be a rare event, and one which is largely preventable. It is now time to move beyond defining the precise small risk of infection in the health care setting. More research is urgently indicated to define and evaluate mechanisms of preventing the few cases that do occur, to maximize health care worker involvement in HIV disease, and to appropriately protect the rights of HIV-infected health care workers. B. TINDALL Senior Project Scientist, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, and Research Fellow Centre for Immunology, St Vincent’s Hospital, Sydney, Australia

Staff stress in HIV health care workers There is presently a dangerous misconception that the phenomenon of health worker burnout or even of staff stress is fully understood and is also adequately managed in organizations of carers for people with HIV. The I992 Amsterdam conference very effectively demonstrated that, in the context of HIV staff stress, our current understanding is at best fledgling and models of effective staff support are urgently required.

Burnout and stag stress Presentations on staff stress were made in posters and in complementary oral sessions: One a satellite symposium on “Burnout in Health Care Related to HIV and AIDS”, one on “Care for Care-Providers, and one on “HIV Multiple Losses: Personal, Social and Ritual Solutions”. Each of these fora involved suggestions for overcoming or minimising staff stress. These will be summarised later. The first issue to be covered concerns what we know of HIV staff stress. In the first instance, a clarification of terms is necessary. Many presentations referred to ‘burnout’ in HIV/AIDS health care workers (HCWs) as though this was a given phrase. They imposed a definition which they then sought to confirm by looking only for the phenomena that the definition demands if it is to be appropriate. A paper from Germany by Kleiber et al. (PoB3433) did also, however, draw an

Amsterdam AIDS Conference review.

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