HIV and Safety: Universal Precautions SHEILA A. MURPHEY, MD

hose who care for sick patients place themselves at risk for acquiring transmissible infection. This has been recognized for centuries. Agents that spread by the respiratory route such as influenza and pulmonary tuberculosis and those that spread by direct contact have long been known as occupational risks for health care providers. Recognition of the important role of bloodborne pathogens, however, is relatively recent. Not until the outbreaks of hepatitis B among hemodialysis unit staff were recognized in the 1970s did many health care workers think of blood contact as other than a routine event or a nuisance resulting primarily in unsightly stains.

T

Background The AIDS epidemic has changed the way in which health care workers think about blood and about their own risk of acquiring an occupational infection. Hepatitis B infection has been estimated to have infected approximately 12,000 health care workers annually who have occupational contact with blood.’ Much of this infection is probably occupationally acquired. Hepatitis B virus (HBV) causes about 3,000 cases of acute hepatitis B, about 500 hospitalizations, and about 200 deaths in health care workers each year.’ Deaths occur both from acute hepatic necrosis and from the complications of chronic HBV infection-chronic active hepatitis, cirrhosis, and hepatoma. In spite of these statistics, fewer than half of the health care workers at risk for occupational HBV infection have received the safe and effective hepatitis B vaccine.’

From the Department of Medicine, Jefferson Medical College, Thomas [efferson University, Philadelphia, Pennsylvania. Address correspondence to Sheila A. Murphey, M.D., Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Room 1410 Edison, 130 South 9th Street, Philadelphia, PA 19107.

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1991 by Elsevier

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0738-081x/92/$3.50

Health care workers are much less complacent about the risk of contracting occupational human immunodeficiency virus (HIV) infection and rightly so. Once acquired, HIV infection is lifelong and remains transmissible throughout the period of infection although infectivity, indirectly indicated by higher levels of HIV in blood late in the course of infection, probably increases over time.2,3 Progression of HIV infection to symptomatic illness can be expected in most, if not all, patients over a period of years.* Human immunodeficiency virus infection is presently incurable, although it is treatable at least for a while. There is no effective vaccine at present, nor is one likely to be available in the immediate future. The social stigma currently attached to human immunodeficiency virus infection can result in emotional, social, occupational, and financial discrimination against infected persons, even when infection is acquired as the result of occupational exposure.5 In the early years of the AIDS epidemic, appropriate precautions, identical to those used for patients with hepatitis B, were recommended for all patients known or suspected to have acquired immunodeficiency syndrome (AIDS).6 Identification of the human immunodeficiency virus and development of diagnostic serologic assays confirmed the epidemiologic suspicion that the majority of HIV-infected persons are currently asymptomatic and that recognizably ill patients represent only a modest fraction of all patients with HIV infection.’

Universal Precautions The size of the population estimated to have asymptomatic human immunodeficiency virus infection, the continuing transmission of HIV, recognition of the magnitude of risk of transmission to health care workers, and the anxiety of health care workers themselves have all combined to promote a major change in the recommended methods for preventing infection transmission in

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health care. Heretofore, official recommendations were aimed at patients with definite, recognizable, or at least suspected infection. In August of 1987, however, the Centers for Disease Control issued their “Recommendations for prevention of HIV transmission in health care settings” and applied these to all patients, at all times, in all care situations8 These “Universal Precautions” are to be followed even when a patient has no symptoms of infection, even when tests for detecting the presence of blood-borne pathogens are negative. This is a dramatic change in the philosophy of infection containment, but one which is, unfortunately, warranted by the prevalence data for HIV and for HBV infection. In 1987,5.2% of adult patients presenting to an urban emergency department were seropositive for HIV.9 In a study of consecutive admissions to an urban Veterans Administration Hospital, 3.7% of all patients were seropositive for HIV infection and 2.0% were positive for hepatitis B surface antigen. lo While the incidence of HIV infection varies geographically and by age and sex in the United States, these figures demonstrate that a sizeable pool of patients harboring blood-transmissible pathogens enter the health care system each year. Many of these patients are not readily identifiable as being at high-risk for a blood-transmissible infection.‘O Routine testing of all hospital admissions in order to identify HIV- and HBV-infected patients would be prohibitively expensive’O and would not identify all infectious patients, especially early in the course of infection when viremia can precede a diagnostic serologic response. “Universal Precautions,“ therefore, are a reasonable, logical, and costeffective response to the current HIV epidemic. They should be regarded as a permanent change in medical practice, necessary for the foreseeable future. The essence of “Universal Precautions” is the interposition of barriers between patient blood, body fluids, and mucous membranes and the health care provider. Barriers must be used whenever blood, body fluid, or mucosal contact is anticipated, in all patients and for all such contacts.s The most common barrier used will be gloves. Gloves may be vinyl or rubber.” The choice of sterile or nonsterile gloves will depend on the task being performed. The task should also determine whether well-fitted or looser gloves can be used. Hands must be washed when gloves are removed, as well as whenever inadvertently contaminated with blood or body fluids. The handwashing agent chosen will depend on the circumstances. Soap is quite satisfactory for routine use; disinfectant agents should be considered before invasive procedures and if inadvertent blood contamination of hands occurs. Gloves must be changed after each patient contact. Gloves should be changed whenever grossly contaminated and between tasks. Gloves should be dis-

carded after use and never washed or disinfected for reuse.” The utility of two pairs of gloves (double-gloving) for traumatic procedures has not been adequately studied. When invasive procedures are performed or when splash, splatter, or generation of aerosols of blood or body fluids are possible, additional barriers will be needed. The conjunctival, nasal, and oral mucosa should all be protected from blood splatter or aerosolization. This can be done by a combination of a surgical mask and protective eyewear. All three sites-eyes, nose, and mouth-must be protected simultaneously. A variety of devices are now available-full face shields, goggles of various types, disposable surgical masks with an upper eye shield. The choice of protective eye/face wear should be determined by the task(s) involved. The type and magnitude of splash or splatter, the length of time for which protection will be needed, the degree of visual acuity needed, and the relative comfort level of the protective device must each be considered. If the protective eyewear chosen is to be reused, it must be able to be disinfected after every use. Ordinary glasses are not adequate for eye protection from splash or splatter; blood can spurt under the lower rim or in at the side and reach the conjunctival mucosa. If prescription glasses must be worn, safety side pieces must be added. Protective eyewear used for personnel performing laser surgery must be both optically suitable and adequate in design to protect against splash or splatter. If splashing of clothing with blood or body fluids is likely to occur during an examination or an invasive procedure, protective gowns or aprons should be worn. The most recent OSHA compliance memorandum12 requires that protective gowns be fluid proof or fluid resistant. Technical standards for these descriptive terms have not yet been issued, however. Protective gowns or aprons should cover the entire area likely to be contaminated and should be selected for maximal resistance to fluid penetration. Both disposable and reusable cover garb of various designs is now available. Consider fluid-resistance characteristics, design (length, ease of putting on), comfort during lengthy procedures or in warm areas, frequency of likely use, and cost in selecting protective cover garb. Disposable gowns are convenient and will increase the bulk (and handling costs) of the biohazard waste generated in practice. Reusable gowns will not increase waste levels but require used linen storage and adequate available laundry facilities.

Penetrating

Injuries

Most documented occupationally acquired HIV infections have resulted from blood-contaminated needlesticks or other penetrating injury with blood-contami-

Clinics in Dermatology 1991;9:32 -38 nated sharp objects (shattered glass, scalpels, etc.).1,5,13 Proper handling of needles and other contaminated sharp objects and the proper disposal of used sharps are absolutely essential if occupational HIV infection is to be avoided.**8 J a gg er et al.” studied needle- stick injuries in a university hospital. They found that one-third of the reported injuries occurred during recapping of needles. Devices requiring disassembly or needle removal (intravenous lines with attached needles, prefilled cartridge syringes, vacuum tube phlebotomy devices) were more likely to be associated with needle-stick injury relative to their frequency of use in the hospital. More injuries occurred during the disposal process than while the devices were in use. The Centers for Disease Control has also noted high rates of health care worker injury due to recapping needles and improper disposal of contaminated sharps in their prospective study of health care personnel exposed to HIV-infected blood.13 While it has been estimated that at least one-third of blood-contaminated sharp injuries are preventable,13 many are not clearly so at present due to poor design of many devices used routinely in the hospital. Recapping of needles should always be avoided if possible. If needles or other sharp devices must be recapped or disassembled, it must be done as carefully and as safely as possible. One-handed use of fixed needle cap holders, use of needle disposal containers that will grip a bare needle and allow it to be twisted free, use of hand-protecting needle shields, automatically resheathing needle-syringe assemblies, and other such safety devices are already available. Not all devices are suitable for all needle-requiring activities, however, and some are cumbersome in use. Needle/ sharps disposal containers should be placed as near to the areas of use as possible. Many needle-sticks occur while gathering used materials for transport to a disposal unit or because items were inadvertently left in a room rather than being taken to a disposal unit outside the room. Needle disposal containers must be rigid, impervious to accidental extrusion of their contents, and clearly labeled. A wide variety of types, sizes, and shapes are currently available. Units can be wall mountable or portable. Desirable design features include ease of insertion of a fairly large needle-syringe unit, a visible indication of how close to full the unit is, and resistance to accidental removal of contents placed into the disposal unit. When full, units should be securely closed and disposed of as biohazard waste. Invasive procedures, of necessity, increase the risk of blood splash or aerosolization and of needle/sharp percutaneous injury and resulting blood exposure. Full protective garb should be worn for even minor office surgery, by all participating personnel. Gloves for invasive procedures should, of course, be sterile. Protection for the eyes

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HIV AND SAFETY: UNIVERSAL PRECAUTIONS

and for the respiratory tract mucosa is necessary the most minor procedures. Ordinary glasses are quate. The duration of the procedure, likelihood ter, and the visual acuity needs should determine of eye/face protection chosen.

for even not adeof splatthe type

Instruments All instruments, materials, and devices that come in contact with normally sterile tissues must be sterile themselves. Once used and contaminated with blood or body fluids, they must be disposed as biohazard waste or resterilized. Sterilization is a strictly defined process and must be monitored for compliance with standards.15 If materials are sterilized in an office or clinic rather than by a central hospital facility, the responsible individual must ensure that items are thoroughly cleaned before resterilization, that steam or ethylene oxide sterilizer-processed items are properly wrapped and loaded, that chemical indicators of the adequacy of sterilization are run with every load, and that biologic indicators are run at least weekly and with any implantable devices. The results of spore test monitoring should be recorded in a permanent log. If chemical sterilization is used, items must be thoroughly cleaned before sterilization and sterilely rinsed (to remove the sterilant) and packaged after sterilization. The most extensive experience with chemical sterilants is with gluteraldehyde preparations.15 The manufacturer’s directions for dilution and for acceptable duration of use should be strictly followed. Items that come into contact with mucosal surfaces but do not penetrate below to sterile tissues should receive sterilization if possible, or high-level disinfection before reuse. High-level disinfection is defined as a process that kills vegetative bacteria, mycobacteria, and certain viruses.15 A chemical disinfectant is usually used. Although most published experience in chemical disinfection is with gluteraldehyde preparations, other agents have also been approved by the Environmental Protection Agency (EPA). It should be noted that chemical disinfectants have not been tested by the EPA itself since 1982, that there is serious disagreement over the adequacy of the testing procedures used for the evaluation of disinfectants and published difficulties in reproducing some manufacturers’ claims for their disinfectant products.16 Standards for tuberculocidal activity have been subject to particular scrutiny.16 Chemical disinfection requires thorough cleaning of the instrument before disinfection, careful adherence to the manufacturer’s directions for dilution, temperature of use, duration of disinfection and for acceptable shelf-life of the product, and finally, careful rinsing and drying afterwards before clean storage of the instrument.

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Disinfection Fortunately, the human immunodeficiency virus has been shown to be susceptible to killing by a wide variety of physical and chemical agents.17**8 Because the virus is relatively protected from destruction while in a fluid suspension, blood spills and visible contamination should be cleaned up as quickly as possible. Agents used to clean up visible blood or body fluid spills or contamination should be EPA-registered disinfectants that have also been shown to be tuberculocidal.i6 Gloves must be worn while cleaning up blood or body fluid spills and materials used in the clean-up must be discarded as biohazard waste. Routine cleaning of contaminated equipment exteriors, environmental surfaces, furniture, etc. can be done with any EPA-registered germicide. The amount of small-particle splatter and short-distance spray during invasive procedures can be surprising. While such contaminated surfaces do not usually pose a direct danger to subsequent patients, they do provide a reservoir for the contamination of the hands of health care providers. Operating and procedure rooms where invasive procedures are performed should be cleaned between each patient use with attention directed to equipment health care personnel will be using and surfaces in direct patient contact. The use of disposable drapes and appropriate equipment covers can reduce the workload between each case. A thorough cleaning of the entire area should be part of the daily routine. Personnel doing the cleaning cleaning equipment should wear gloves. Reusable (clothes, mop-heads, etc.) is acceptable only if properly laundered after each use. If this is not feasible, then disposable, single-use items should be used.

Other Modalities Instruments intended for the therapy of multiple patients may pose hazards for the transmission of pathogens to health care professionals and to other patients. Electrodessication devices have been shown to splatter droplets of blood or of indicator dye over distances from 1 - 29 cm away from the lesion treated.*9,20 Sheretz et al. and Colver and Peutherer have shown that in-use current flow and generated heat are insufficient to sterilize needle electrodes contaminated with either Hepatitis B virus or Herpes simplex virus. 20,21If reusable needle electrodes are used, they should be removed and sterilized after every patient use. Alternately, sterile, disposable needle electrodes can be used. The use of infrared coagulators poses the same hazards of probe contamination and splatter of blood or tissue debris and requires the same precautions mentioned above. Other invasive therapeutic instruments such as dermabrasion fraises and brushes must also be sterilized if they are to be reused.

Cryotherapy is used in the management of a wide range of lesions. If delivered by a no-touch technique, then instrument-patient cross-contamination should not be a problem. Jones and Darville showed that an aliquot of liquid nitrogen could be contaminated by Herpes simplex virus and adenovirus and could transfer these agents to sterile swabs under conditions simulating multiplepatient use of a single aliquot.22 Liquid nitrogen is not virucidal under conditions of use and is actually used to store viral pathogens in the laboratory. Liquid nitrogen should, therefore, be used only with no-touch techniques or dispensed into small, single-patient-use aliquots with residual material discarded. Once empty, Dewar flasks should receive high-level disinfection before reuse.22 Silver nitrate and aluminum sulfate sticks have not been shown to successfully transmit viral or bacterial pathogens in conditions simulating multiple-patient use.** Only a small number of pathogens and potential use situations have been studied; it would be premature to assume that there is absolutely no risk of cross-infection from the use of these devices. The use of lasers in dermatologic therapy has paralleled the rapid increases in laser use in the rest of medicine. In addition to the very important issues of optical safety, electrical hazard, potential thermal injury, and ignition of flammable gases at certain sites, laser users must also be aware of the biologic risks of the laser plume. Although the composition of the laser plume varies with the target tissue and with laser-beam characteristics such as wavelength, pulse character, and power density, it is clear that laser plumes can contain whole cells, viable bacteria, and intact papillomavirus DNA.23-25 Low levels of toxic chemicals can also be found in the plume.26 Smoke evacuation systems should always be used during laser surgery. The collection nozzle should be within 2 cm of the surgical field, if possible. The nozzle should receive disinfection after each use unless a disposable tip is used. Personnel performing laser procedures should wear optically safe eye protection and masks capable of removing submicron-size particles (0.2 -0.3 PM), rather than regu lar surgical masks, as well as gowns and gloves.*’

Biohazardous

Waste

“Biohazard waste” is waste containing materials that pose a biologic hazard upon contact. It includes, but is not limited to, infectious wastes. Chemotherapeutic agent waste is also considered to be biohazard waste. The Environmental Protection Agency (EPA) defines infectious waste as any waste that is capable of producing infectious disease.28 While the exact definitions of infectious waste vary from the EPA to the CDC to those states that have already enacted or are presently drafting infectious waste

Clinics in Dermatology 1992;9:31-38 regulation programs, several major categories are accepted by all regulatory agencies. Cultures and stocks of infectious agents, human blood and blood products, contaminated sharps, and pathologic waste including body parts and tissue are generally accepted to be infectious waste. The EPA and at least some states also consider waste from patients in isolation for communicable disease to be infectious waste.2*-30 Infectious waste is generated not only by hospitals, but also by freestanding medical clinics, independent laboratories, and the private offices of physicians and dentists. Well-publicized episodes of improper medical waste disposal resulting in pictures of needles and syringes and tubes of blood washing up onto public beaches have resulted in public and legislative anxiety over the handling of medical waste. This is likely to increase the already extensive legislation in the handling and disposal of general medical and biohazard (including infectious) waste. Existing regulations all presently require several steps. First, infectious (and other biohazard) waste must be identified and separated from general waste, preferably at the time it is generated. Second, it must be appropriately contained and labeled. Usually, this means a leakproof can or holder. A covered container for infectious waste is recommended. Red plastic bags, with or without an imprinted label or added tag saying “infectious” or “biohazard’ are most commonly used for identifying infectious waste. The waste container for infectious waste should be available immediately where such waste is expectedin the treatment room, in the laboratory suite, etc. Third, infectious waste bags or containers must be securely closed when full and kept in temporary storage for the minimum time possible before final disposal. Local regulation on how long infectious waste can be held at room temperature before refrigeration or final disposal should be consulted. If the outside of a red bag or other waste container becomes contaminated, it should be double-bagged or otherwise safely contained. Access to waste storage areas should be restricted to authorized personnel; waste areas must be cleaned regularly and should not be used for any other purpose. Finally, infectious waste must be disposed of in a legally prescribed manner and records of proper disposal must be kept. Infectious waste can be sterilized, usually by steam autoclaving. Once sterility has been proved (cultures of sterilized waste and records of results are required by regulatory agencies), sterilized waste can usually be discarded as general waste; local regulations should be consulted. Most commonly, infectious waste is incinerated; this is the most satisfactory method for disposing of contaminated sharps. When a contractor is employed to dispose of infectious waste for private practices,

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clinics, or laboratories, the responsible physician or administrator should check the contractor’s credentials, references, and procedures, and should require written certification of the appropriate disposal of their infectious wastes. In October 1987, the Occupational Safety and Health Administration (OSHA) announced that, under the authority of its “general duty” clause of the Occupational Safety and Health Act of 1970 that requires employers to provide a safe work environment for their employees, compliance with the recently issued CDC recommendations for the prevention of HIV transmission in healthcare settings* would be required of all health care employers. The “Proposed Rule” on occupational exposure to bloodborne pathogens was issued in May, 1989.’ Publication of the final rule is expected in late 1990 or early 199 1. Since OSHA’s involvement in health-care workplaces had previously been limited largely to the regulation of hazardous materials such as ethylene oxide, asbestos, etc., many health care professionals are relatively unfamiliar with the implications of this addition to the regulatory overseers of health care. The OSHA rules, presently in the forms of compliance memoranda for inspectors and the 1989 proposed rule,‘J2 now apply to all health care employment settings, including outpatient clinics and private office practices. OSHA has the ability to enforce compliance with its rules by unannounced random inspections, by inspections in response to employee complaints, by imposing fines for violations of the rules, and by releasing to the news media the results of its inspections, the names of violators, and by imposing monetary penalties for noncompliance. While some points in the OSHA “Proposed Rules” may be clarified or changed, the following items will certainly continue to be required. First, appropriate equipment-gloves, eye and face protection, gowns, etc. -must be provided for all employees with blood or body fluid contact. Second, standard workplace safety practices such as avoiding needle recapping, avoiding mouth suctioning, preventing aerosol formation when handling blood by the use of safety cabinets, etc. will also be required. Appropriate disposal of biohazard waste is required. Education of all employees with blood, body fluid, or tissue contact on the modes of transmission of HIV and HBV and the procedures necessary to prevent transmission must be given at the time of hire and annually thereafter. Records of educational program attendance must be kept for several years. Finally, employers must provide hepatitis B vaccine without cost to all employees with blood, tissue, or body fluid contact.12 Salaried physicians must comply with the OSHA safety programs established by their employers and must assure that employees they supervise also comply. Physicians

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who employ their own staff must set up such programs for all of their employees with blood, tissue, or body fluid contact.

Accidental Exposure Procedures for the evaluation and management of all health care workers accidently exposed, by needlestick or other injury, to patient blood or body fluids are also required by the CDC and by OSHA.1,8 Health care providers must be encouraged to report all definite or potential blood and body fluid exposures for evaluation. The exposure should be documented and analyzed for the likelihood of pathogen transmission. The circumstances should be recorded and the employee instructed on how to avoid similar events in the future. The source patient, if identifiable, should be informed of the exposure and asked to permit testing for evidence of blood-transmissible infection such as HIV and HBV. HIV serologic testing of patients should be done only after adequate pre-test counseling has been done and written informed consent from the patient has been obtained. The patient must be informed of the test results and given post-test counseling as needed. The exposed employee should be evaluated for prior immunization history for HBV, history of prior hepatitis, and of HIV risk factors, and be asked to submit baseline sera for testing. Pre-test counseling before HIV testing should include the modes of transmission of HIV and HBV, the likelihood of infection from exposure (approximately 0.4% per needle-stick exposure in the CDC prospective study13), means of prevention of transmission of infection to others, and issues of test interpretation and confidentiality. Written consent for HIV serologic testing should be obtained. Employee sera for HIV testing should be sent under a code system to preserve confidentiality, if possible. If an employee decides not to be tested, this should be noted. However, counseling on how to prevent HIV transmission should still be provided. All counseling should be documented. If the source patient is shown to be HIV seronegative, the exposed employee may elect to forego follow-up testing. However, if the source patient is at high risk for HIV infection or there is a possibility of an inadequate risk history, then follow-up serologic testing as described below should be encouraged. If the source patient is shown to be HIV infected or refuses to be tested, the exposed employee should be followed prospectively for possible HIV seroconversion. An acute febrile illness within 1 - 6 months after exposure, especially if accompanied by lymphadenopathy, a rash, or symptoms of aseptic meningitis should be regarded with particular suspicion. Repeat serologic testing for HIV should be done at

least at 6 weeks, 3 months, 6 months, and 12 months after exposure. Most seroconversions will occur within 6 months of exposure. During the follow-up periods, exposed health care providers should follow the CDC and USPHS recommendations for preventing transmission of HIV.8,30

Occupational Exposure Concern over the risk of HIV infection after occupational exposure has led to consideration of the use of zidovudine, the only currently approved antiviral agent active against HIV, as possible post-exposure prophylaxis. The animal models of retrovirus infection used to first suggest the possible utility of zidovudine prophylaxis did not study HIV itself. 31,32A national, double-blind placebocontrolled trial was begun to evaluate the efficacy of zidovudine in health care workers occupationally exposed to HIV.33 Unfortunately, this study terminated enrollment in 1989. The number of health care workers enrolled was far too small to evaluate the efficacy of zidovudine. In January, 1990, the US Public Health Service (USPHS) released its “Statement on Management of Occupational Exposure to Human Immunodeficiency Virus, Including Consideration Regarding Zidovudine Post-exposure Use”.34 The USPHS concluded that “data from animal and human studies are inadequate to establish the efficacy or safety of zidovudine for prophylaxis after occupational exposure to HIV.” The arguments for and against the use of zidovudine as post-exposure prophylaxis and the protocols used at two institutions that offer zidovudine to HIV-exposed employees are described. In April, 1990, Lange et al. published their experience with a parenteral exposure to approximately 100 - 200 pl of HIV-infected blood in which zidovudine begun 45 minutes after exposure failed to prevent the development of HIV infection.35 What is the magnitude of the risk of acquiring HIV infection as the result of an occupational needlestick injury, accidental mucosal exposure to blood etc.? Prospective studies of health care personnel who report needlestick or other types of exposure to HIV-infected blood offer the most accurate assessment of risk. The Centers for Disease Control has been enrolling health-care workers exposed to HIV-infected blood since August, 1983;13 this study population totaled 1449 persons by 1989 of whom 1172 had agreed to HIV-antibody testing. 36 The HIV seroconversion rate for this group of exposed health care workers is 0.4%.36 All four seroconversions followed needlestick injury; no seroconversion has yet been reported in the 20% of this group exposed by other means.

Clinics in Dermatology 1992;9:31-38 Smaller prospective studies elsewhere have given comparable results. lr3’ Anecdotal reports of HIV seroconversion following both needlestick injuries and other types of exposure to HIV-infected blood and to bloody body fluids exist,1J3,34 but magnitude of risk cannot be calculated because of a lack of population-at-risk denominators. These cases vividly illustrate the need to prevent all possible blood exposures, especially those due to percutaneous inoculation. How often do health care professionals experience exposure to blood or body fluids? Though general rates cannot be calculated due to the difficulties of estimating numbers of potential exposure situations per person per unit time, it is clear that health care employees are often injured by needles or other sharp objects, occasionally report being splashed or splattered with blood or body fluids, and that such exposures are clearly underreported. 13~14,38 Invasive procedures pose greater risks. Estimates of the frequency of percutaneous injuries during surgery have been made; Lowenfels et al. found a median injury rate of 4.2 per 1000 operating hours among New York surgeons. 39 Eighty-six percent of the surgeons responding reported at least one percutaneous injury in the preceeding year and a small number report very frequent exposures that did not correlate with operative workload or specialty. Hands are not the only target at risk during invasive procedures. Breasley and Buist documented blood splashes on eyewear during 25% of general surgical procedures.40 The frequency of such potentially risky exposures during invasive procedures underscores the need for the appropriate barrier precautions at all times. Gloves, gowns, and protective eyewear will be needed by all scrubbed or other close-in assistants during invasive procedures, as well as for the surgeon. Conclusions Human immunodeficiency virus is a formidable pathogen, deserving of respect for its unique pathogenetic mechanisms and for its lethality. Its prevalence clearly mandates the use of “Universal Precautions” by all health care professionals. Nevertheless, it is an agent of relatively modest infectivity1*41,42 and should not provoke inappropriate levels of fear among health care workers. HIV transmission has been occurring in the United States at least since the late 1970s and probably earlier.43 In spite of this long interval of contact between HIV-infected patients and health care workers who were not using “Universal Precautions,” the number of cases of AIDS in health care workers is proportional to their representation in the general population. 44*45 Moreover, most of the health care workers reported to have AIDS have a history of nonoccupational risks. Health care workers with AIDS

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37

who deny nonoccupational risks are not representative of the entire class of health care workers; they are disproportionately male, members of minority population groups, and frequently have a history of prior sexually transmitted disease. Because screening of all patients for HIV infection prior to care provision is neither effective nor feasible, and fear is self-defeating, the consistent use of the barrier precautions called “Universal Precautions” in all health care encounters, along with the appropriate decontamination of disposal of contaminated materials, is and is likely to remain the most effective means of protection from occupational HIV infection.

References 1. Dept. of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens. Federal Register, May 30. 1989;54:23042-139.

2. Ho D, Moudgil T, Alam M. Quantitation of human immunodeficiency virus type 1 in the blood of infected persons. N Engl J Med 1989;321:1621-25.

3. Coombs R, Collier A, Allain J, et al. Plasma viremia in human immunodeficiency 1989;321:1626-31.

virus infection. N Engl J Med

4. Liu K, Darrow W, Rutherford G. A model-based estimate of the mean incubation period for AIDS in homosexual men. Science 1988;240:1333-35.

5. Aoun H. When a house officer gets AIDS. N Engl J Med 1989;321:693-36.

6. Centers for Disease Control. Acquired immunodeficiency syndrome (AIDS): precautions for health care workers and allied professionals. MMWR 1983;32:450-51.

7. Goedert J, Beggar R, Weiss S, et al. Three-year incidence of AIDS in five cohorts of HTLV-III-infected risk group members. Science 1986;231:992-95.

8. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings MMWR 1987;36:25- 18s.

9. Kelen G, Fritz S, Qaqish B, et al. Unrecognized human immunodeficiency virus infection in emergency department patients. N Engl J Med 1988;318:1645-50. 10. Gordin F, Gilbert C, Hawley H, et al. Prevalence of human immunodeficiency virus and hepatitis B virus in unselected hospital admissions: implications for mandatory testing and universal precautions. J Infect Dis 1990;161:14-17. 11. Centers for Disease Control. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-87. 12. OSHA. OSHA Instruction CPL 2-2.448 Washington, D.C., 1990. 13. Marcus R, CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to

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HIV and safety: universal precautions.

HIV and Safety: Universal Precautions SHEILA A. MURPHEY, MD hose who care for sick patients place themselves at risk for acquiring transmissible infe...
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