rournal
of Hospital
Infection
(1991)
18, 313-318
INFECTION
CONTROL
IN PRACTICE
Phlebotomy in inoculation risk patients: a questionnaire survey of knowledge and practices hospital doctors in Liverpool C. M. Parry, Regional Liverpool
A. D. Harries,
Infectious L9 7AL
N. J. Beeching
of
and M. M. Rothburn*
Diseases
Unit, Fazakerley Hospital, Longmoor Lane, Health Laboratory, Fazakerley Hospital, Longmoor Lane, Liverpool L9 7AL
and “Public
Accepted foforpublication
18 June 1991
Summary:
To assess the knowledge of hospital doctors about patients at increased risk of infection with human immunodeficiency virus (HIV) or hepatitis B virus, and the precautions they took during phlebotomy in such patients, an anonymous postal questionnaire was sent to all 307 hospital doctors working at two District General Hospitals in Liverpool, UK. Two hundred and thirty-eight (77.5%) of the questionnaires were returned. More than 90% of respondents considered a history of male homosexuality, intravenous drug abuse, prostitution or a child of a prostitute to indicate an inoculation risk. There was uncertainty about a previous prison sentence in the 198Os, residence in a home for the mentally handicapped, previous residence in the tropics and hospital treatment in the tropics. Thirty-eight percent of doctors would never enquire about sexual preference, 54.1% about a previous prison sentence and 15.7% about intravenous drug abuse in their clinical history. Although 97.4% of doctors would sometimes or always wear gloves during phlebotomy of an inoculation risk patient, 25.5% always resheathed the needle after phlebotomy and 20.8% would never take the sharps box to the patient. More effort is required to identify accurately inoculation risk patients and greater care is needed in phlebotomy techniques. Keywords: deficiency
Inoculation risk assessment; virus; hepatitis B virus.
phlebotomy;
human
immuno-
Introduction Needlestick accidents during phlebotomy involving patients infected with human immunodeficiency virus (HIV) or hepatitis B virus (HBV) carry a substantial risk of virus transmission to the health care worker. The risks are estimated to be up to 20% for HBV (to a non-immune recipient) and 0.5% for HIV as a result of a single, contaminated ‘sharp’ injury.’ The Correspondence to: Dr C. M. Parry, Department Liverpool Hospital, Liverpool L69 3BX.
of Medical
0195-6701/91/080313+06S03.00/0
Microbiology,
Duncan
Building,
0 1991 The Hcqxtal
313
Infection
Royal
Society
314
C. M. Parry
et al.
precautions required to prevent transmission of HIV and HBV during phlebotomy have been the subject of debate, and guidelines have been proposed.‘-’ Some have argued for a policy of universal precautions for all patients whereas others have proposed special care only for those patients known to be infected or at high risk of infection. The first approach (one-tier system) is appropriate where the prevalence of HIV and HBV in the population is high. A two-tier system may be more appropriate where the prevalence of HIV and HBV is low. In the UK, guidelines from the Hospital Infection Society Working Party’ propose a two-tier system and enumerate sixteen ‘inoculation risk’ categories of patients for whom precautions should be taken. In our hospitals a two-tier system is used, but inoculation risk categories are not defined in detail in the procedure. We decided to assess knowledge of inoculation risk categories among hospital doctors, to discover whether relevant questions to assess inoculation risk were routinely asked in the clinical history-taking and to find out what precautions were taken during phlebotomy of inoculation risk patients. Methods
In May 1990 we conducted an anonymous questionnaire survey of all hospital doctors (excluding pathologists) in Walton and Fazakerley District Each doctor was asked to complete a General Hospitals, Liverpool. two-page questionnaire (see Table I) to assess knowledge of inoculation risk
Table
I. Responses of hospital staff concerning
the ‘inoculation risk’ status of different patients
‘Correct’ answer6 1. 60-year-old 2. 30-year-old 3. S&year-old transfusion 4. 30-year-old in prison 5. 30-year-old injecting 6. 14-year-old mentally 7. 35-year-old treatment Kenya 8. 2-month-old 9. 35-year-old childhood 10. 40-year-old
male homosexual female homosexual female who was given a blood six months ago for a fractured femur married man who spent six months in 1983 intravenous drug abuser who stopped drugs 3 years ago boy in residential home for the handicapped British man who received hospital for pneumonia while on holiday in baby born to a prostitute British woman who spent her in Uganda female prostitute
No. of respondents giving correct answer/ no. answering the question (% correct)
Yes No
2281236 (96.6) 166/237 (70.0)
No
217/236 (91.9)
Yes
11 l/236 (47.0)
Yes
2271237 (95%)
Yes
87/236 (36.9)
Yes Yes
137/234 (58.5) 214/236 (90.7)
Yes Yes
SO/236 (21.2) 226/236 (958)
Inoculation
risk
315
questionnaire
patient categories and to determine whether hospitalized patients were routinely asked about risk categories and whether specified precautions were used when taking blood from high risk patients. of reminder numbered to allow one set Questionnaires were questionnaires to be sent to non-responders and to allow analysis of the results according to grade and speciality. The ‘correct’ answer to the question was derived from the Hospital Infection Society guidelines.’ The data were analysed using a computer database (EPIINFO 5). Statistical analysis was with x2 tests.
Results
Questionnaires were returned by 238 of 307 doctors (response rate 77.5%). registrars/registrars These included 86 consultants (79.6%), 47 senior (78.3%), 86 senior house officers/house officers (74.8%) and 19 clinical assistants (79.2%). Table I shows the response of hospital staff concerning the risk of HIV/HBV transmission posed by certain categories of hospitalized patients. More than 90% of doctors gave the correct answer for categories 1, 3, 5, 8 and 10. Approximately one-third (30-40%) gave incorrect answers for categories 2 and 7, while over 50% gave incorrect answers for categories 4, 6 and 9. The frequency of asking about HIV/HBV inoculation risk categories in clinical history taking is shown in Table II. The majority of respondents always or sometimes asked about travel abroad, intravenous drug abuse and previous residence overseas. Over one-third never asked about sexual preference and more than one-half never asked about time spent in prison. The precautions taken during phlebotomy of a high-risk patient are shown in Table III. The majority of doctors always or sometimes wore gloves, but one-quarter always resheathed the needle and one-fifth never took the sharps box to the patient. No significant differences in results were found among the responses of different hospital grades or medical/surgical specialities.
Table
II.
Question
Questions
in routine
clinical
Travel abroad Previous overseas residence Sexual preference Intravenous drug abuse Time spent in prison
taking
No. (%) respondents who ask the question (IV= 235) Always
1. 2. 3. 4. 5.
history
59 39 31 57 21
(25.1) (16.6) (13.2) (24.3) ( 8.9)
Sometimes 144 140 112 141 86
(61.3) (59.6) (47.7) (60.0) (36.6)
Never 32 56 92 37 128
(13.6) (23.8) (39.1) (15-7) (54.5)
316
C. M. Parry Table
III.
Precautions
Precaution
et al.
taken during phlebotomy
of inoculation
No. (%) of respondents taking (N= 232) Always
1. 2. 3. 4. 5. 6.
Wear gloves Wear eye protection Wear mask Wear gown Take sharps box to patient Resheath needle
risk patients
207 56 34 20 130 59
(89.2) (24.1) (14.7) ( 8.6) (56.0) (25.4)
Sometimes 19 55 45 43 53 19
( 8.2) (23.7) (19.4) (18.5) (22.8) ( 8.2)
precaution Never 6 121 153 169 49 154
( 2.6) (52.2) (65.9) (72.9) (21.2) (66.4)
Discussion The results of this survey are disturbing. There was considerable agreement about the need for extra precautions for certain patients (male homosexuals, intravenous drug abusers, prostitutes and children of prostitutes) who fulfilled the inoculation risk criteria enumerated in the Hospital Infection Society guidelines.6 There was uncertainty, however, concerning other patients also included in the guidelines. A significant proportion of doctors did not consider a history of previous time in prison in the 1980s childhood spent in the tropics, recent hospital treatment in the tropics and residence in long-stay homes for the mentally handicapped as indicating the need for extra precautions. There is good evidence that these patients should be included in the guidelines. The prevalence of HBV in the tropics has always been high and the level of HIV in many areas is increasing. Hepatitis B continues to occur in institutions for the mentally handicapped.’ The extent of drug abuse and homosexuality in the prison system is not known, but the constraints of prison life may lead to unsafe sexual practices and needle sharing.” Our study shows a reluctance on the part of hospital doctors to ask important questions about sexual preference or time spent in prison. It is recognized that some patients may deliberately conceal high risk behaviour from medical attendants, and that such patients are more likely to have undetected blood-borne infections. i1 Despite this, c. two-thirds of infected patients can be identified by routine clinical questions about possible high risk behaviour.‘* It is encouraging that over 95% of doctors always or sometimes wear gloves during phlebotomy of inoculation risk patients. Gloves, however, are not always reliable and provide no protection against needlestick injury.13 Doctors are at a high risk of needlestick injuries,14 c. half of which are of concern that a associated with recapping needles. 15,16 It is therefore quarter of doctors in our survey always resheathed the needle after taking blood from such patients. Similar findings were reported in a survey of measures and procedures to control infection by general practitioners.17
Inoculation
risk
questionnaire
317
Although resheathing devices are available on most wards it is our observation that in practice these are rarely used by medical staff. The guidelines recommend that instead of being resheathed the needle is disposed of immediately into a sharps box beside the patient. One-fifth of our surveyed doctors would never have taken a sharps box to the patient. This study reveals uncertainty among hospital doctors of all grades and speciality about inoculation risk categories, a reluctance to ask questions to assess risk status and the adoption of unsafe practices during phlebotomy. Should a one-tier system of universal precautions be applied in the UK? The implications of this for phlebotomy are not great with the recognition of the importance of wearing gloves, not resheathing needles and taking the sharps box to the patient in every case. In other areas the adoption of a one-tier system would have more far reaching implications.‘*,t9 In orthopaedic surgery, for example, more involved and extensive precautions, including a change in operative technique would be required.20 If the two-tier system of precautions is to be continued more effort is needed to ensure that the guidelines become a part of daily clinical practice. A new section in routine clinical history taking is required of ‘inoculation risk’ when appropriate questions can be asked and a risk assessment made before invasive procedures are performed. Safe practices for phlebotomy should be adopted. Wards should have a phlebotomy trolley with all the necessary equipment, including a sharps box, which can be taken from patient to patient. The education of hospital staff concerning ways of minimizing infection risk from blood, and the assessment and improvement of infection control procedures should be a subject for clinical audit in all hospitals. We thank
all our colleagues
who participated
in this study.
References 1. Department of Health. Guidance for clinical health care workers: Protection against infection with HIV and Hepatitis B viruses. Recommendations of the expert advisory group on AIDS. London: HMSO. January 1990. 2. Centers for Disease Control. Recommendations for prevention of HIV transmission in health care settings. MMWR 1987; 36(2S): 3S-18s. 3. Centers for Disease Control. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MhfWR 1988; 37: 377-388. 4. Centers for Disease Control. Guidelines for prevention of transmission of HIV and HBV to health care and public safety workers. MMWR 1989; 38: S6. 5. Advisory Committee on Dangerous Pathogens. HIV-The causative agent of AIDS and related conditions. Second revision of guidelines. London: HMSO January 1990. 6. Acquired immunodeficiency syndrome: recommendations of a Working Party of the Hospital Infection Society. J Hosp Infect 1990; 15: 7-34. 7. British Medical Association. A code of practice for sterilisation of instruments and control of cross infection. London: BMA 1989. 8. British Medical Association. A code of practice for the safe use and disposal of sharps. London: BMA 1990. 9. Polakoff S. Acute viral hepatitis B reported to the Public Health Laboratory Service.
J Infect 1990; 20: 163-168.
318
C. M. Parry
et al.
Hart GJ. Risk behaviours for HIV infection among drug users in prison. 10. Carve11 ALM, Br MedJ 1990; 300: 1383-1384. HL, Holman S, Beller E, Delke I, Fishbone A, Landesman S. Routinely 11. Minkoff offered prenatal HIV testing. N Engl J Med 1988; 319: 1018. 12. Gordin FM, Gibert C, Harold HP, Willoughby A. 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. 13. Yangco BG, Yangco r\rF. What is leaky can be risky: a study of the integrity of hospital gloves. Infect Control Hasp Epidemiol 1989; 10: 553-556. risks in hospital staff from blood: hazardous injury rates 14. Astbury C, Baxter PJ. Infection and acceptance of hepatitis B immunisation. J Sot Occup Med 1990; 40: 92-93. J, Pearson RD. Rates of needle-stick injury caused 15. Jagger J, Hunt EH, Brand-Elnagger by various devices in a university hospital. N Engl J Med 1988; 319: 284288. 16. McGeer A, Simor AE, Low DE. Epidemiology of needlestick injuries in house officers. J Infect Dis 1990; 162: 961-964. 17. Fov C. Gallagher M. Rhodes T et al. HIV and measures to control infection in general practice. Br &led J i990; 300: 1048-1049. 18. Gazzard BG, Waste11 C. HIV and surgeons. The risks are small. Br MedJ 1990; 301: 1003-1004. infection among anaesthetists. Lancet 1990; 336: 1103. 19. Anon. Occupational practices of and precautions taken by orthopaedic surgeons 20. Porteous MJ LeF. Operating to avoid infection with HIV and hepatitis B virus during surgery. BY Med J 1990; 301: 1677169.
of Hospital
Infection
(1991)
18, 313-318
INFECTION
CONTROL
IN PRACTICE
Phlebotomy in inoculation risk patients: a questionnaire survey of knowledge and practices hospital doctors in Liverpool C. M. Parry, Regional Liverpool
A. D. Harries,
Infectious L9 7AL
N. J. Beeching
of
and M. M. Rothburn*
Diseases
Unit, Fazakerley Hospital, Longmoor Lane, Health Laboratory, Fazakerley Hospital, Longmoor Lane, Liverpool L9 7AL
and “Public
Accepted foforpublication
18 June 1991
Summary:
To assess the knowledge of hospital doctors about patients at increased risk of infection with human immunodeficiency virus (HIV) or hepatitis B virus, and the precautions they took during phlebotomy in such patients, an anonymous postal questionnaire was sent to all 307 hospital doctors working at two District General Hospitals in Liverpool, UK. Two hundred and thirty-eight (77.5%) of the questionnaires were returned. More than 90% of respondents considered a history of male homosexuality, intravenous drug abuse, prostitution or a child of a prostitute to indicate an inoculation risk. There was uncertainty about a previous prison sentence in the 198Os, residence in a home for the mentally handicapped, previous residence in the tropics and hospital treatment in the tropics. Thirty-eight percent of doctors would never enquire about sexual preference, 54.1% about a previous prison sentence and 15.7% about intravenous drug abuse in their clinical history. Although 97.4% of doctors would sometimes or always wear gloves during phlebotomy of an inoculation risk patient, 25.5% always resheathed the needle after phlebotomy and 20.8% would never take the sharps box to the patient. More effort is required to identify accurately inoculation risk patients and greater care is needed in phlebotomy techniques. Keywords: deficiency
Inoculation risk assessment; virus; hepatitis B virus.
phlebotomy;
human
immuno-
Introduction Needlestick accidents during phlebotomy involving patients infected with human immunodeficiency virus (HIV) or hepatitis B virus (HBV) carry a substantial risk of virus transmission to the health care worker. The risks are estimated to be up to 20% for HBV (to a non-immune recipient) and 0.5% for HIV as a result of a single, contaminated ‘sharp’ injury.’ The Correspondence to: Dr C. M. Parry, Department Liverpool Hospital, Liverpool L69 3BX.
of Medical
0195-6701/91/080313+06S03.00/0
Microbiology,
Duncan
Building,
0 1991 The Hcqxtal
313
Infection
Royal
Society
314
C. M. Parry
et al.
precautions required to prevent transmission of HIV and HBV during phlebotomy have been the subject of debate, and guidelines have been proposed.‘-’ Some have argued for a policy of universal precautions for all patients whereas others have proposed special care only for those patients known to be infected or at high risk of infection. The first approach (one-tier system) is appropriate where the prevalence of HIV and HBV in the population is high. A two-tier system may be more appropriate where the prevalence of HIV and HBV is low. In the UK, guidelines from the Hospital Infection Society Working Party’ propose a two-tier system and enumerate sixteen ‘inoculation risk’ categories of patients for whom precautions should be taken. In our hospitals a two-tier system is used, but inoculation risk categories are not defined in detail in the procedure. We decided to assess knowledge of inoculation risk categories among hospital doctors, to discover whether relevant questions to assess inoculation risk were routinely asked in the clinical history-taking and to find out what precautions were taken during phlebotomy of inoculation risk patients. Methods
In May 1990 we conducted an anonymous questionnaire survey of all hospital doctors (excluding pathologists) in Walton and Fazakerley District Each doctor was asked to complete a General Hospitals, Liverpool. two-page questionnaire (see Table I) to assess knowledge of inoculation risk
Table
I. Responses of hospital staff concerning
the ‘inoculation risk’ status of different patients
‘Correct’ answer6 1. 60-year-old 2. 30-year-old 3. S&year-old transfusion 4. 30-year-old in prison 5. 30-year-old injecting 6. 14-year-old mentally 7. 35-year-old treatment Kenya 8. 2-month-old 9. 35-year-old childhood 10. 40-year-old
male homosexual female homosexual female who was given a blood six months ago for a fractured femur married man who spent six months in 1983 intravenous drug abuser who stopped drugs 3 years ago boy in residential home for the handicapped British man who received hospital for pneumonia while on holiday in baby born to a prostitute British woman who spent her in Uganda female prostitute
No. of respondents giving correct answer/ no. answering the question (% correct)
Yes No
2281236 (96.6) 166/237 (70.0)
No
217/236 (91.9)
Yes
11 l/236 (47.0)
Yes
2271237 (95%)
Yes
87/236 (36.9)
Yes Yes
137/234 (58.5) 214/236 (90.7)
Yes Yes
SO/236 (21.2) 226/236 (958)
Inoculation
risk
315
questionnaire
patient categories and to determine whether hospitalized patients were routinely asked about risk categories and whether specified precautions were used when taking blood from high risk patients. of reminder numbered to allow one set Questionnaires were questionnaires to be sent to non-responders and to allow analysis of the results according to grade and speciality. The ‘correct’ answer to the question was derived from the Hospital Infection Society guidelines.’ The data were analysed using a computer database (EPIINFO 5). Statistical analysis was with x2 tests.
Results
Questionnaires were returned by 238 of 307 doctors (response rate 77.5%). registrars/registrars These included 86 consultants (79.6%), 47 senior (78.3%), 86 senior house officers/house officers (74.8%) and 19 clinical assistants (79.2%). Table I shows the response of hospital staff concerning the risk of HIV/HBV transmission posed by certain categories of hospitalized patients. More than 90% of doctors gave the correct answer for categories 1, 3, 5, 8 and 10. Approximately one-third (30-40%) gave incorrect answers for categories 2 and 7, while over 50% gave incorrect answers for categories 4, 6 and 9. The frequency of asking about HIV/HBV inoculation risk categories in clinical history taking is shown in Table II. The majority of respondents always or sometimes asked about travel abroad, intravenous drug abuse and previous residence overseas. Over one-third never asked about sexual preference and more than one-half never asked about time spent in prison. The precautions taken during phlebotomy of a high-risk patient are shown in Table III. The majority of doctors always or sometimes wore gloves, but one-quarter always resheathed the needle and one-fifth never took the sharps box to the patient. No significant differences in results were found among the responses of different hospital grades or medical/surgical specialities.
Table
II.
Question
Questions
in routine
clinical
Travel abroad Previous overseas residence Sexual preference Intravenous drug abuse Time spent in prison
taking
No. (%) respondents who ask the question (IV= 235) Always
1. 2. 3. 4. 5.
history
59 39 31 57 21
(25.1) (16.6) (13.2) (24.3) ( 8.9)
Sometimes 144 140 112 141 86
(61.3) (59.6) (47.7) (60.0) (36.6)
Never 32 56 92 37 128
(13.6) (23.8) (39.1) (15-7) (54.5)
316
C. M. Parry Table
III.
Precautions
Precaution
et al.
taken during phlebotomy
of inoculation
No. (%) of respondents taking (N= 232) Always
1. 2. 3. 4. 5. 6.
Wear gloves Wear eye protection Wear mask Wear gown Take sharps box to patient Resheath needle
risk patients
207 56 34 20 130 59
(89.2) (24.1) (14.7) ( 8.6) (56.0) (25.4)
Sometimes 19 55 45 43 53 19
( 8.2) (23.7) (19.4) (18.5) (22.8) ( 8.2)
precaution Never 6 121 153 169 49 154
( 2.6) (52.2) (65.9) (72.9) (21.2) (66.4)
Discussion The results of this survey are disturbing. There was considerable agreement about the need for extra precautions for certain patients (male homosexuals, intravenous drug abusers, prostitutes and children of prostitutes) who fulfilled the inoculation risk criteria enumerated in the Hospital Infection Society guidelines.6 There was uncertainty, however, concerning other patients also included in the guidelines. A significant proportion of doctors did not consider a history of previous time in prison in the 1980s childhood spent in the tropics, recent hospital treatment in the tropics and residence in long-stay homes for the mentally handicapped as indicating the need for extra precautions. There is good evidence that these patients should be included in the guidelines. The prevalence of HBV in the tropics has always been high and the level of HIV in many areas is increasing. Hepatitis B continues to occur in institutions for the mentally handicapped.’ The extent of drug abuse and homosexuality in the prison system is not known, but the constraints of prison life may lead to unsafe sexual practices and needle sharing.” Our study shows a reluctance on the part of hospital doctors to ask important questions about sexual preference or time spent in prison. It is recognized that some patients may deliberately conceal high risk behaviour from medical attendants, and that such patients are more likely to have undetected blood-borne infections. i1 Despite this, c. two-thirds of infected patients can be identified by routine clinical questions about possible high risk behaviour.‘* It is encouraging that over 95% of doctors always or sometimes wear gloves during phlebotomy of inoculation risk patients. Gloves, however, are not always reliable and provide no protection against needlestick injury.13 Doctors are at a high risk of needlestick injuries,14 c. half of which are of concern that a associated with recapping needles. 15,16 It is therefore quarter of doctors in our survey always resheathed the needle after taking blood from such patients. Similar findings were reported in a survey of measures and procedures to control infection by general practitioners.17
Inoculation
risk
questionnaire
317
Although resheathing devices are available on most wards it is our observation that in practice these are rarely used by medical staff. The guidelines recommend that instead of being resheathed the needle is disposed of immediately into a sharps box beside the patient. One-fifth of our surveyed doctors would never have taken a sharps box to the patient. This study reveals uncertainty among hospital doctors of all grades and speciality about inoculation risk categories, a reluctance to ask questions to assess risk status and the adoption of unsafe practices during phlebotomy. Should a one-tier system of universal precautions be applied in the UK? The implications of this for phlebotomy are not great with the recognition of the importance of wearing gloves, not resheathing needles and taking the sharps box to the patient in every case. In other areas the adoption of a one-tier system would have more far reaching implications.‘*,t9 In orthopaedic surgery, for example, more involved and extensive precautions, including a change in operative technique would be required.20 If the two-tier system of precautions is to be continued more effort is needed to ensure that the guidelines become a part of daily clinical practice. A new section in routine clinical history taking is required of ‘inoculation risk’ when appropriate questions can be asked and a risk assessment made before invasive procedures are performed. Safe practices for phlebotomy should be adopted. Wards should have a phlebotomy trolley with all the necessary equipment, including a sharps box, which can be taken from patient to patient. The education of hospital staff concerning ways of minimizing infection risk from blood, and the assessment and improvement of infection control procedures should be a subject for clinical audit in all hospitals. We thank
all our colleagues
who participated
in this study.
References 1. Department of Health. Guidance for clinical health care workers: Protection against infection with HIV and Hepatitis B viruses. Recommendations of the expert advisory group on AIDS. London: HMSO. January 1990. 2. Centers for Disease Control. Recommendations for prevention of HIV transmission in health care settings. MMWR 1987; 36(2S): 3S-18s. 3. Centers for Disease Control. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MhfWR 1988; 37: 377-388. 4. Centers for Disease Control. Guidelines for prevention of transmission of HIV and HBV to health care and public safety workers. MMWR 1989; 38: S6. 5. Advisory Committee on Dangerous Pathogens. HIV-The causative agent of AIDS and related conditions. Second revision of guidelines. London: HMSO January 1990. 6. Acquired immunodeficiency syndrome: recommendations of a Working Party of the Hospital Infection Society. J Hosp Infect 1990; 15: 7-34. 7. British Medical Association. A code of practice for sterilisation of instruments and control of cross infection. London: BMA 1989. 8. British Medical Association. A code of practice for the safe use and disposal of sharps. London: BMA 1990. 9. Polakoff S. Acute viral hepatitis B reported to the Public Health Laboratory Service.
J Infect 1990; 20: 163-168.
318
C. M. Parry
et al.
Hart GJ. Risk behaviours for HIV infection among drug users in prison. 10. Carve11 ALM, Br MedJ 1990; 300: 1383-1384. HL, Holman S, Beller E, Delke I, Fishbone A, Landesman S. Routinely 11. Minkoff offered prenatal HIV testing. N Engl J Med 1988; 319: 1018. 12. Gordin FM, Gibert C, Harold HP, Willoughby A. 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. 13. Yangco BG, Yangco r\rF. What is leaky can be risky: a study of the integrity of hospital gloves. Infect Control Hasp Epidemiol 1989; 10: 553-556. risks in hospital staff from blood: hazardous injury rates 14. Astbury C, Baxter PJ. Infection and acceptance of hepatitis B immunisation. J Sot Occup Med 1990; 40: 92-93. J, Pearson RD. Rates of needle-stick injury caused 15. Jagger J, Hunt EH, Brand-Elnagger by various devices in a university hospital. N Engl J Med 1988; 319: 284288. 16. McGeer A, Simor AE, Low DE. Epidemiology of needlestick injuries in house officers. J Infect Dis 1990; 162: 961-964. 17. Fov C. Gallagher M. Rhodes T et al. HIV and measures to control infection in general practice. Br &led J i990; 300: 1048-1049. 18. Gazzard BG, Waste11 C. HIV and surgeons. The risks are small. Br MedJ 1990; 301: 1003-1004. infection among anaesthetists. Lancet 1990; 336: 1103. 19. Anon. Occupational practices of and precautions taken by orthopaedic surgeons 20. Porteous MJ LeF. Operating to avoid infection with HIV and hepatitis B virus during surgery. BY Med J 1990; 301: 1677169.
