This article was downloaded by: ["Queen's University Libraries, Kingston"] On: 04 February 2015, At: 03:16 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Health care workers J. Elford
a
a
Lecturer in Epidemiology, Department of Public Health and Primary Care , Royal Free Hospital School of Medicine , London, NW3, UK Published online: 25 Sep 2007.
To cite this article: J. Elford (1991) Health care workers, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 399-404, DOI: 10.1080/09540129108251598 To link to this article: http://dx.doi.org/10.1080/09540129108251598
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
399
AIDS CARE, VOL. 3, NO. 4, 1991
Health care workers
Downloaded by ["Queen's University Libraries, Kingston"] at 03:16 04 February 2015
J. ELFORD Lecturer in Epidemiology, Department of Public Health and A . i m a y Care, Royal Free Hospital School of Medicine, London NW3, UK
Several clear messages emerged from the 1991 international conference on AIDS. Universal precautions are being universally ignored. The use of prophylactic zidovudine (AZT) after occupational exposure to HIV is increasing. And health care workers remain anxious about HIV infection in the workplace. But the most controversial issue to emerge at the Florence meeting was the risk a health care worker with HIV infection presents to his or her patients. In the past the chief concern has been the transmission of HIV from patient to health care worker; now the boot is on the other foot. Occupational transmission of HIV Health care worker to patient In Florida five people were apparently infected with HIV while being treated by a dentist with AIDS (Jaffe, ThDllO). Proviral DNA amplification showed that the viruses of the five patients, none of whom reported behavioural risk factors, were closely related to that of the dentist. The viruses were clearly distinct, however, from the isolates of control patients with HIV who did not attend the dental practice and from those of two other patients in the practice, also with Present address: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 376 Victoria Street, Sydney, NSW 2010, Australia.
HIV but who reported behavioural risk factors. The mode of transmission from the dentist to his patients remains unclear-was it through direct exposure or contaminated instruments? Apparently there was no written policy nor training programme for infection control in the dental practice and no protocol for reporting percutaneous injuries. Poor compliance with recommended infection control procedures may have facilitated transmission (Marianos, MC3071). There have been no other reported cases of HIV transmission from health care workers to their patients. However, two papers presented the estimated risk of transmission as a result of percutaneous injury during an invasive procedure. They reached strikingly different conclusions. Bell (MD59) from CDC, Atlanta, estimated the probability of HIV transmission from an infected surgeon to a patient during an operation as lying between 1 in 5,000 and 1 in 500. This estimate was based on the probability of the surgeon injuring himself, the probability that the sharp object causing the injury recontacted the patient and the probability of HIV transmission after recontact. Data from a variety of sources were used to derive the probabilities of each of these events. The authors suggested that between 1980 and 1990 up to 129 patients in the United States may have acquired HIV infection in this way. Lowenfels and Worm-
Downloaded by ["Queen's University Libraries, Kingston"] at 03:16 04 February 2015
400
FLORENCE SUMMARIES: J. ELFORD
ser (MD60), however, using a similar after occupational exposure to HIV (Ippomethod of estimation put the risk of loto, MD61). Needlesticks accounted for transmission from an infected surgeon to his 56% of the injuries. Two seroconversions or her patient at a much lower level-1 in occurred (0.15%, 95% confidence interval 133,000 per hour of surgery (95% confi- 0.018-0.54%). In Genoa 190 occupational dence interval 1 in 2 million to 1 in 26,000). exposures of HIV had been reported by the Concern was expressed about the relia- end of 1990, 68% of which were needlestick bility of these estimates and their underlying injuries. No seroconversions occurred (Di assumptions. Indeed the discrepancy be- Vito, WD4172). In Paris 186 health care tween the two sets of estimates highlighted workers exposed to patients’ blood were their fallibility. Yet these estimates could be tested for HIV, 78 of the source patients used to formulate employment policies for were known to be HIV positive. None seroworkers with HIV, a prospect which caused converted during a 12 month follow up (Abiteboul, WD4174). In France there did some anxiety. Have health care employers developed not appear to be an excess of health care formal guidelines for staff with HIV? An workers among people with AIDS; 4.3% of Italian working party recommended that the French working population were emhealth care workers with HIV involved in ployed in the health services, as were 4.0% invasive procedures should be made respon- of economically active people with AIDS sible for their own health status. They (Lot, WD4152). By the end of 1990 AIDS should be offered the choice of voluntary had been reported in 360 French health care and anonymous (sic) testing; be counselled workers. All but 22 (6.1%) had a known drug-related or via blood on ways of reducing the risk of transmission; risk-sexual, and be informed about the possibility of transfusions and products. While it may be restructuring their job (Cattorini, MD4175). tempting to ascribe occupational transmisAccording to this working party the respon- sion to the 22 health care workers without an sibility clearly lay with the health care established risk it is important to note that a worker rather than the employer. Yet US similar proportion of AIDS patients who lawyers Closen and Issacman (WD4180) ar- were not health care workers also had an gued that the health care profession needed indeterminate risk (5.9%). The risk of occupationally acquired to act quickly in developing a comprehensive policy for HIV infected health care workers tuberculosis for health care workers assumed which protected both patients and staff. If importance this year because of the high they did not do so the legal profession may prevalence of T B among AIDS patients. In have to formulate a policy by default, should Italy, AIDS service health care workers and a control group from other divisions were a case ever come to court. screened for TB with the Mantoux skin test when they joined the hospital and after a mean follow up of 16 months (Cadeo, Patient to health care worker WD4160). Of the 11 AIDS service workers, Less controversy surrounds the risk of HIV 3 had a positive skin test on enrolment while transmission from patients to health care by the end of the study all 11 were positive. workers nowadays. In the USA, CDC esti- Three developed pulmonary tuberculosis! mates the risk of transmission following a Among the 102 workers in other divisions 32 percutaneous injury as being 0.31% (Tokars, were positive on entry, 48 at the end of the WD4184). This reflects seroconversion rates study. None developed pulmonary tubercuin other countries. In Italy, by the end of losis. The relative risk of developing TB 1990, 1,340 health care workers had been among the AIDS service staff was 4.4. Similar findings came from Puerto followed up for an average of 10 months
Downloaded by ["Queen's University Libraries, Kingston"] at 03:16 04 February 2015
HEALTH CARE WORKERS
Rico. Between December 1987 and August 1989, 10% of the 154 patients on the AIDS unit of Puerto Rico hospital had TB. After adjusting for age and community exposure, a higher proportion of AIDS unit nurses had positive TB skin tests in 1989 than clerical personnel or nursing staff on other floors acting as controls (56% vs 17%,p
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Health care workers J. Elford
a
a
Lecturer in Epidemiology, Department of Public Health and Primary Care , Royal Free Hospital School of Medicine , London, NW3, UK Published online: 25 Sep 2007.
To cite this article: J. Elford (1991) Health care workers, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 399-404, DOI: 10.1080/09540129108251598 To link to this article: http://dx.doi.org/10.1080/09540129108251598
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
399
AIDS CARE, VOL. 3, NO. 4, 1991
Health care workers
Downloaded by ["Queen's University Libraries, Kingston"] at 03:16 04 February 2015
J. ELFORD Lecturer in Epidemiology, Department of Public Health and A . i m a y Care, Royal Free Hospital School of Medicine, London NW3, UK
Several clear messages emerged from the 1991 international conference on AIDS. Universal precautions are being universally ignored. The use of prophylactic zidovudine (AZT) after occupational exposure to HIV is increasing. And health care workers remain anxious about HIV infection in the workplace. But the most controversial issue to emerge at the Florence meeting was the risk a health care worker with HIV infection presents to his or her patients. In the past the chief concern has been the transmission of HIV from patient to health care worker; now the boot is on the other foot. Occupational transmission of HIV Health care worker to patient In Florida five people were apparently infected with HIV while being treated by a dentist with AIDS (Jaffe, ThDllO). Proviral DNA amplification showed that the viruses of the five patients, none of whom reported behavioural risk factors, were closely related to that of the dentist. The viruses were clearly distinct, however, from the isolates of control patients with HIV who did not attend the dental practice and from those of two other patients in the practice, also with Present address: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 376 Victoria Street, Sydney, NSW 2010, Australia.
HIV but who reported behavioural risk factors. The mode of transmission from the dentist to his patients remains unclear-was it through direct exposure or contaminated instruments? Apparently there was no written policy nor training programme for infection control in the dental practice and no protocol for reporting percutaneous injuries. Poor compliance with recommended infection control procedures may have facilitated transmission (Marianos, MC3071). There have been no other reported cases of HIV transmission from health care workers to their patients. However, two papers presented the estimated risk of transmission as a result of percutaneous injury during an invasive procedure. They reached strikingly different conclusions. Bell (MD59) from CDC, Atlanta, estimated the probability of HIV transmission from an infected surgeon to a patient during an operation as lying between 1 in 5,000 and 1 in 500. This estimate was based on the probability of the surgeon injuring himself, the probability that the sharp object causing the injury recontacted the patient and the probability of HIV transmission after recontact. Data from a variety of sources were used to derive the probabilities of each of these events. The authors suggested that between 1980 and 1990 up to 129 patients in the United States may have acquired HIV infection in this way. Lowenfels and Worm-
Downloaded by ["Queen's University Libraries, Kingston"] at 03:16 04 February 2015
400
FLORENCE SUMMARIES: J. ELFORD
ser (MD60), however, using a similar after occupational exposure to HIV (Ippomethod of estimation put the risk of loto, MD61). Needlesticks accounted for transmission from an infected surgeon to his 56% of the injuries. Two seroconversions or her patient at a much lower level-1 in occurred (0.15%, 95% confidence interval 133,000 per hour of surgery (95% confi- 0.018-0.54%). In Genoa 190 occupational dence interval 1 in 2 million to 1 in 26,000). exposures of HIV had been reported by the Concern was expressed about the relia- end of 1990, 68% of which were needlestick bility of these estimates and their underlying injuries. No seroconversions occurred (Di assumptions. Indeed the discrepancy be- Vito, WD4172). In Paris 186 health care tween the two sets of estimates highlighted workers exposed to patients’ blood were their fallibility. Yet these estimates could be tested for HIV, 78 of the source patients used to formulate employment policies for were known to be HIV positive. None seroworkers with HIV, a prospect which caused converted during a 12 month follow up (Abiteboul, WD4174). In France there did some anxiety. Have health care employers developed not appear to be an excess of health care formal guidelines for staff with HIV? An workers among people with AIDS; 4.3% of Italian working party recommended that the French working population were emhealth care workers with HIV involved in ployed in the health services, as were 4.0% invasive procedures should be made respon- of economically active people with AIDS sible for their own health status. They (Lot, WD4152). By the end of 1990 AIDS should be offered the choice of voluntary had been reported in 360 French health care and anonymous (sic) testing; be counselled workers. All but 22 (6.1%) had a known drug-related or via blood on ways of reducing the risk of transmission; risk-sexual, and be informed about the possibility of transfusions and products. While it may be restructuring their job (Cattorini, MD4175). tempting to ascribe occupational transmisAccording to this working party the respon- sion to the 22 health care workers without an sibility clearly lay with the health care established risk it is important to note that a worker rather than the employer. Yet US similar proportion of AIDS patients who lawyers Closen and Issacman (WD4180) ar- were not health care workers also had an gued that the health care profession needed indeterminate risk (5.9%). The risk of occupationally acquired to act quickly in developing a comprehensive policy for HIV infected health care workers tuberculosis for health care workers assumed which protected both patients and staff. If importance this year because of the high they did not do so the legal profession may prevalence of T B among AIDS patients. In have to formulate a policy by default, should Italy, AIDS service health care workers and a control group from other divisions were a case ever come to court. screened for TB with the Mantoux skin test when they joined the hospital and after a mean follow up of 16 months (Cadeo, Patient to health care worker WD4160). Of the 11 AIDS service workers, Less controversy surrounds the risk of HIV 3 had a positive skin test on enrolment while transmission from patients to health care by the end of the study all 11 were positive. workers nowadays. In the USA, CDC esti- Three developed pulmonary tuberculosis! mates the risk of transmission following a Among the 102 workers in other divisions 32 percutaneous injury as being 0.31% (Tokars, were positive on entry, 48 at the end of the WD4184). This reflects seroconversion rates study. None developed pulmonary tubercuin other countries. In Italy, by the end of losis. The relative risk of developing TB 1990, 1,340 health care workers had been among the AIDS service staff was 4.4. Similar findings came from Puerto followed up for an average of 10 months
Downloaded by ["Queen's University Libraries, Kingston"] at 03:16 04 February 2015
HEALTH CARE WORKERS
Rico. Between December 1987 and August 1989, 10% of the 154 patients on the AIDS unit of Puerto Rico hospital had TB. After adjusting for age and community exposure, a higher proportion of AIDS unit nurses had positive TB skin tests in 1989 than clerical personnel or nursing staff on other floors acting as controls (56% vs 17%,p
