Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions

Recovery of HIV Antigen in Peritoneal Dialysis Fluid

We investigated the presence of HIV antigen in dialysis fluid of patients with end-stage renal disease (ESRD) undergoing continuous ambulatory peritoneal dialysis (CAPD), previously known to be infected with this virus. Sixteen adult patients and 6 adult volunteers were included in the study in 4 groups as follows: Group A: 3 patients on CAPD, previously known to be positive for serum HIV antibodies; Group B: 7 patients on CAPD, serum HIV negative; Group C: 6 AIDS patients without renal disease; and Group D: 6 healthy volunteers.

Of the 3 patients of Group A, the HIV-1 Ag was positive in dialysis fluid in only 2. In 1, serum Ab and Ag were present, while in the others only serum Ab was detected. The samples from Group B were all negative for the viral antigen in dialysis fluid.

We conclude that dialysis fluid of HIV-infected patients may contain the Ag and is therefore potentially infective. The presence of the HIV antigen was not constant, and was not related to antigenemia. It is possible that the presence of the Ag depends on local factors that influence viral replication or to alterations in the permeability of the peritoneal membrane. We discuss other possible factors that could influence the presence of viral Ag in peritoneal dialysis fluid.

The California HIV/AIDS Research Program: History, Impact, and HIV Cure Initiative

This Special Issue of AIDS Research and Human Retroviruses features results from the HIV Cure Initiative, funded by the California HIV/AIDS Research Program (CHRP). As a publicly funded grant maker, CHRP has served for more than three decades as a unique resource for innovative researchers in California, whose work seeks to address all aspects of the HIV epidemic and the communities affected by it. Early initiatives at CHRP pioneered what would become enduring cornerstones of HIV science: isolation of the virus; efficacy and toxicities of the first HIV treatments; the emergence of drug resistance; the first biospecimen banks for HIV-related research; the first community-based laboratory service for HIV diagnostic serology; and the first longitudinal case-control study of progression from HIV to AIDS-The San Francisco General Hospital Cohort. More recently, CHRP-funded conceptual studies of zinc-finger nuclease-mediated disruption of CCR5 genomic sequences and the safety of solid organ transplantation for HIV-positive patients have progressed from brilliant ideas to clinical realities, and CHRP is currently funding the first multisite trial of HIV preexposure prophylaxis for transgender persons in the United States. The present article outlines the founding of CHRP, our current grantmaking process, and our impact on HIV research over time. In 2013, CHRP launched a new initiative aimed at moving the then nascent frontier of HIV cure science forward: the CHRP HIV Cure Initiative provided over $1.4 million to multiple basic biomedical research projects, and selected results are presented in this Special Issue.

Nosocomial Transmission of HIV in Africa: What Tribute Is Paid to Contaminated Blood Transfusions and Medical Injections?

We reviewed the published data on the possible impact of medical injections and blood transfusions on the spread of human immunodeficiency virus (HIV) in Africa. We also compared these results to our experience in Rwanda, central Africa. The importance of medical injections in the epidemic of HIV infection seems to differ from one area to another. The excess of injections experienced by HIV seropositive subjects in Zaire could be secondary to the parenteral treatment of early HIV-related illness or to the treatment of sexually transmitted diseases, rather than being the cause of HIV infection, as suggested by Rwandese studies. In contrast, blood transfusions have been shown to represent an important source of nosocomial HIV infection in many African countries. Effective and relatively inexpensive measures to diminish the iatrogenic spread of HIV infection in developing countries are summarized.

Factors Promoting Consistent Adherence to Safe Needle Precautions Among Hospital Workers

Objective:

To examine organizational factors and occupational characteristics associated with adherence to occupational safety guidelines recommending never recapping needles.

Design:

Mail surveys were conducted with healthcare workers (HCWs) and infection control professionals (ICPs).

Setting:

The surveys were conducted at all non-federal general hospitals in Iowa, except one tertiary-care hospital. Survey data were linked to annual survey data of the American Hospital Association (AHA).

Participants:

HCWs were sampled from statewide rosters of physicians, nurses, and laboratory workers in Iowa. Eligible HCWs worked in a setting and position in which they were likely to routinely handle needles. ICPs at all hospitals in the state were surveyed.

Results:

Ninety-nine ICPs responded (79% response rate). AHA data were available for all variables from 84 (85%) of the hospitals. Analyses were based on 1,454 HCWs who identified one of these hospitals as their primary hospital (70% response rate). Analyses were conducted using multiple logistic regression. Positive predictors of consistent adherence included infection control personnel hours per full-time–equivalent employee (odds ratio [OR], 1.03), frequency of standard precautions education (OR, 1.11), facilities providing personal protective equipment (OR, 1.82), facilities using needleless intravenous systems (OR, 1.42), and management support for safety (OR, 1.05). Negative predictors were use of “blood and body fluid precautions” isolation category (OR, 0.74) and increased job demands (OR, 0.90).

Conclusion:

Healthcare organizations can improve staff safety by investing wisely in educational programs regarding approaches to minimize these risks, providing protective equipment, and eliminating the use of blood and body fluid precautions as an isolation policy.

A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: true picture or tip of iceberg

OBJECTIVES

Health care workers (HCWs) face constant risk of exposure to cuts and splashes as occupational hazard. Hence, a prospective observational study was conducted to observe the exposure of HCWs to various sharp injuries and splashes during health care and to work up a baseline injury rate among HCWs for future comparison in trauma care set ups.

METHODS

A 2 year and 5 month study was conducted among the voluntarily reported exposed HCWs of the APEX trauma centre. Such reported cases were actively followed for 6 months after testing for viral markers and counselled. The outcomes of such exposed HCWs and rate of seroconversion was noted. To form a future reference point, the injury rate in trauma care HCWs based on certain defined parameters along with the rate of under reporting were also analysed in this study.

RESULTS

In our study, doctors were found to have the highest exposure (129, 36.2%), followed by nurses (52, 14.6%) and hospital waste disposal staff (27, 7.6%). Of the source patients, a high number of them were HBV positive (11, 3.1%), followed by HIV positive patients (8, 2.2%). No seroconversion was seen in any of the exposed HCWs. Injuries by sharps (303, 85.1%) outnumber those due to splashes (53, 14.9%) which were much higher in those working in pressing situations. Underreporting was common, being maximally prevalent in hospital waste disposal staff (182, 51.1%).

CONCLUSIONS

High rates of exposure to sharp injuries and splashes among HCWs call for proper safety protocols. Proper methods to prevent it, encouraging voluntary reporting and an active surveillance team are the need of the hour.

Factors affecting occupational exposure to needlestick and sharps injuries among dentists in Taiwan: a nationwide survey

Background

Although the risks of needlestick and sharps injuries (NSIs) for dentists are well recognized, most papers published only described the frequency of occupational exposure to NSIs. Less has been reported assessing factors contributing to exposure to NSIs. The purpose of this study was to update the epidemiology of NSIs among dentists in Taiwan and identify factors affecting NSIs in order to find preventive strategies.

Methodology/Principal Findings

A nationwide survey was conducted in dentists at 60 hospitals and 340 clinics in Taiwan. The survey included questions about factors supposedly affecting exposure to NSIs, such as dentist and facility characteristics, knowledge and attitudes about infectious diseases, and practices related to infection control. Univariate and multivariate logistic regression analyses were conducted to determine the association between risk factors and exposure to NSIs. In total, 434 (74.8%) of 580 dentists returned the survey questionnaires, and 100 (23.0%) reported that they had experienced more than one NSI per week. Our data showed that the risk of occupational NSIs is similarly heightened by an older age (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.62–6.25), more years in practice (OR, 2.57; 95% CI, 1.41–4.69), working in clinics (OR, 1.73; 95% CI, 1.08–2.77), exhibiting less compliance with infection-control procedures (OR, 1.82; 95% CI, 1.04–3.18), having insufficient knowledge of blood-borne pathogens (OR, 1.67; 95% CI, 1.04–2.67), and being more worried about being infected by blood-borne pathogens (OR, 1.82; 95% CI, 1.05–3.13).

Conclusions/Significance

High rates of NSIs and low compliance with infection-control procedures highly contribute to the chance of acquiring a blood-borne pathogen infection and threaten occupational safety. This study reveals the possible affecting factors and helps in designing prevention strategies for occupational exposure to NSIs.

Hepatitis B vaccination in correctional health care workers

BACKGROUND

Data on bloodborne pathogen risk among health care workers (HCWs) employed in the correctional setting are sparse, even though the prevalence of bloodborne infections, including hepatitis B virus (HBV), among inmates is high. To address this, we determined prevalence and correlates of hepatitis B virus vaccination status in correctional health care workers (CHCWs) employed in 3 state correctional health care facilities.

METHODS

A confidential, self-administered cross-sectional survey was performed.

RESULTS

Four hundred eleven (69.8%) of 588 eligible participants completed the survey. Of these, 264 (64.2%) reported receiving a primary hepatitis B (HB) vaccine series. Vaccination rates varied by state and by job category. Parenteral exposures were not uncommon; 8.6% (n = 24) of clinical CHCWs and 2.0% (n = 7) of nonclinical CHCWs reported one or more needlesticks in the 6-month period prior to the study. Among clinical staff, vaccination correlated with licensure (RN or MD) and race (white) and in nonclinical staff with history of close contact with HBV infected inmates and with needlestick injury.

CONCLUSION

Although the HB vaccination rate among CHCWs was generally high, given their potential risk of exposure to HBV, universal vaccination should be encouraged and should include those nonclinicians with job duties that may involve potential exposure to blood/body fluids.

Standard precautions and post exposure prophylaxis for preventing infections

In health care set up, risk of acquiring infection by both patients and health care worker (HCW) from each other is fairly high. Despite progress, hospital acquired infections (HAI) are a problem in both developed and developing countries and are an important cause of death. Many different microbes cause HAI in both patients and HCW; these include various commensals, pathogenic bacteria, viruses, parasites, and fungi. Among these HIV, hepatitis B, and hepatitis C are of major significance to HCW. 'Standard precautions' have now replaced the term 'universal precautions', and are designed to reduce the risk of transmission of microorganisms in health care set-up from both recognized and unrecognized sources. Ultimate aim is to reduce the risk of disease transmission in the healthcare setting, both to the patient and the provider, and thus reduce morbidity. This applies to all patients, regardless of their diagnosis and expands the coverage of universal precautions by recognizing that any body fluid may contain contagious and harmful microorganisms. This article reviews the standard precautions and discusses current guidelines on post exposure prophylaxis (PEP).

Infection of patients by bloodborne viruses

BACKGROUND

Despite taking precautions, healthcare workers performing invasive procedures run a small risk of infection by bloodborne viruses. When injury occurs, the viral status of the patient is often unknown and testing requires informed consent, which may be refused. On the other hand, although the chance of transmission of infection from a healthcare worker to a patient is extremely small, such personnel have an obligation of disclosure and, if seropositive, are barred from performing invasive procedures.

METHODS

The medical literature on bloodborne virus transmission between carers and patients was reviewed, and the UK Department of Health, General Medical Council and Royal College of Surgeons of England guidelines on the risk management of these infections were read, along with secondary references from all sources.

RESULTS AND CONCLUSION

Patients have complete protection of confidentiality and the right to refuse testing, but these rights do not apply to the healthcare worker. When injured in circumstances in which the patient cannot or will not permit testing, carers can only submit to the risks of prophylactic treatment or go into denial. Infection may have devastating professional, personal and financial implications to carers and their dependants. Ways to re-establish a just balance between the legitimate rights of patients and healthcare workers are discussed.

Repair type I aortic dissection in a patient with human immunodeficiency virus infection

A 57-year-old man with human immunodeficiency virus (HIV) infection was evaluated in October 1997 with complaints of weakness of the right lower extremity. A chest computerized axial tomographic scan revealed a type I aortic dissection. He underwent surgical repair including resuspension of the aortic valve and placement of a 32-mm interposition graft between the aortic root and the transverse arch. Postoperatively he required abdominal aorta fenestration and stenting for ischemia of the left lower extremity. Follow-up magnetic resonance imaging 3(1)/(2) years postoperatively showed a normal-sized ascending and transverse aorta and the residual dissection in the descending thoracic and abdominal aorta. The thoracic and abdominal aorta diameters have remained stable. Select patients with type I aortic dissection and HIV infection are candidates for surgical repair.

Health and safety at necropsy

The postmortem room is a source of potential hazards and risks, not only to the pathologist and anatomical pathology technician, but also to visitors to the mortuary and those handling the body after necropsy. Postmortem staff have a legal responsibility to make themselves aware of, and to minimise, these dangers. This review focuses specifically on those hazards and risks associated with the necropsy of infected patients, with foreign objects present in the body, and with bodies that have been contaminated by chemicals or radioactive sources.

Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States

OBJECTIVE

To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States.

DESIGN

National surveillance systems, based on voluntary case reporting.

SETTING

Healthcare or laboratory (clinical or research) settings.

PATIENTS

Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV.

METHODS

Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection.

RESULTS

Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circumstances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring during a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the healthcare workers were infected despite receiving postexposure prophylaxis (PEP).

CONCLUSIONS

Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace.

Surgical care of the HIV-infected patient: a moral imperative

An increasing number of HIV-infected patients require surgical care. Many surgeons, regardless of their venue of practice, would prefer not to treat HIV-infected patients. The reasons for this attitude differ from individual to individual but include the fear of contracting an incurable fatal illness, a desire to avoid interaction with homosexuals and intravenous drug users, and fears that occupationally acquired HIV infection would result in restriction of clinical privileges and loss of income. At the same time, many individuals, institutions, and professional organizations have affirmed the obligation of all healthcare workers, including surgeons, to care for patients without regard to their HIV status. This article explores the nature of this obligation from the perspective of a clinical surgeon working in an inner city hospital.

Hospital bloodborne pathogens programs: program characteristics and blood and body fluid exposure rates

OBJECTIVE

To describe hospital practices and policies relating to bloodborne pathogens and current rates of occupational exposure among healthcare workers.

PARTICIPANTS AND METHODS

Hospitals in Iowa and Virginia were surveyed in 1996 and 1997 about Standard Precautions training programs and compliance. The primary outcome measures were rates of percutaneous injuries and mucocutaneous exposures.

RESULTS

153 (64%) of 240 hospitals responded. New employee training was offered no more than twice per year by nearly one third. Most (79%-80%) facilities monitored compliance of nurses, housekeepers, and laboratory technicians; physicians rarely were trained or monitored. Implementation of needlestick prevention devices was the most common action taken to decrease sharps injuries. Over one half of hospitals used needleless intravenous systems; larger hospitals used these significantly more often. Protected devices for phlebotomy or intravenous placement were purchased by only one third. Most (89% of large and 80% of small) hospitals met the recommended infection control personnel-to-bed ratio of 1:250. Eleven percent did not have access to postexposure care during all working hours. Percutaneous injury surveillance relied on incident reports (99% of facilities) and employee health records (61%). The annual reported percutaneous injury incidence rate from 106 hospitals was 5.3 injuries per 100 personnel. Compared to single tertiary-referral institution rates determined more than 5 years previously, current injury rates remain elevated in community hospitals.

CONCLUSIONS

Healthcare institutions need to commit sufficient resources to Standard Precautions training and monitoring and to infection control programs to meet the needs of all workers, including physicians. Healthcare workers clearly remain at risk for injury. Further effective interventions are needed for employee training, improving adherence, and providing needlestick prevention devices.

Hospital safety climate and its relationship with safe work practices and workplace exposure incidents

BACKGROUND

In the industrial setting, employee perceptions regarding their organization's commitment to safety (i.e., safety climate) have been shown to be important correlates to both the adoption and maintenance of safe work practices and to workplace injury rates. However, safety climate measures specific to the hospital setting have rarely been evaluated. This study was designed to develop a short and effective tool to measure hospital safety climate with respect to institutional commitment to bloodborne pathogen risk management programs and to assess the relationship between hospital safety climate and (1) employee compliance with safe work practices and (2) incidents of workplace exposure to blood and other body fluids.

METHODS

A questionnaire, which included 46 safety climate items, was developed and tested on a sample of 789 hospital-based health care workers at risk for bloodborne pathogen exposure incidents.

RESULTS

A 20-item hospital safety climate scale that measures hospitals' commitment to bloodborne pathogen risk management programs was extracted through factor analysis from the 46 safety climate items. This new hospital safety climate scale subfactored into 6 different organizational dimensions: (1) senior management support for safety programs, (2) absence of workplace barriers to safe work practices, (3) cleanliness and orderliness of the work site, (4) minimal conflict and good communication among staff members, (5) frequent safety-related feedback/training by supervisors, and (6) availability of personal protective equipment and engineering controls. Of these, senior management support for safety programs, absence of workplace barriers to safe work practices, and cleanliness/orderliness of the work site were significantly related to compliance (P<.05). In addition, both senior management support for safety programs and frequent safety-related feedback/training were significantly related to workplace exposure incidents (P<.05). Thus the most significant finding in terms of enhancing compliance and reducing exposure incidents was the importance of the perception that senior management was supportive of the bloodborne pathogen safety program.

CONCLUSIONS

Hospital safety climate with regards to bloodborne pathogens can be measured by using a short, 20-question scale that measures 6 separate dimensions. Whereas all 6 dimensions are essential elements of overall safety climate, 3 dimensions are significantly correlated with compliance, and 1 dimension (senior management support) is especially significant with regard to both compliance and exposure incidents. This short safety climate scale can be a useful tool for evaluating hospital employees' perceptions regarding their organization's bloodborne pathogens management program. In addition, because this scale measures specific dimensions of the safety climate, it can be used to target problem areas and guide the development of intervention strategies to reduce occupational exposure incidents to blood and other body fluids.

An overview of HIV infection and AIDS: etiology, pathogenesis, diagnosis, epidemiology, and occupational exposure

Thanks to a worldwide collaborative effort among health care providers, academia, governments, and industry, our knowledge base about infection caused by the human immunodeficiency virus (HIV) has expanded exponentially. During the past 2 decades, we have learned about its pathogenesis, virology, immunology, epidemiology and treatment. In the developed world, the approach to persons with HIV disease has evolved from palliative disease care to use of a chronic disease model, where survival is measured by decades, not months or years. More and more, clinical decision-making for HIV-infected patients is driven by comorbidities, including cardiothoracic disease. Thus, our clinically stable HIV population is increasingly accessing those health care services required by any maturing population, including the usual services of cardiothoracic surgeons. In this article, we review the basic facts of HIV disease, with an emphasis on occupational risks and infection control procedures.

Decreased splatter in dermabrasion

OBJECTIVE

To compare a new dermabrasion instrument equipped with a metal shield and hydration-suction apparatus with the standard instrument, with specific attention to the exposure of operating room personnel to potentially hazardous particles.

DESIGN

A surgical trial with each of the instruments was performed with a skin model. The splatter caused by the 2 instruments was evaluated and compared statistically and graphically.

SUBJECTS

Female hairless guinea pigs (450 g) were used as a skin model.

INTERVENTIONS

Ten guinea pigs were treated with the standard dermabrading instrument, and 10 were treated with a shielded suction-irrigating dermabrader. The splatter was analyzed by counting the number of particles landing on strategically placed glass slides. Evaluations of histologic cross-sections of the dermabraded skin were compared in a blinded fashion.

RESULTS

Statistical and graphic analysis showed the number of potentially hazardous particles generated by the suction dermabrader to be significantly less than that generated by the standard dermabrader. Histologic sections showed no difference between the 2 subsets.

CONCLUSION

The new shielded suction-irrigating dermabrader provides comparable surgical results while significantly decreasing exposure to potentially hazardous splatter particles. Arch Facial Plast Surg. 2000;2:23-26

The impact of multifocused interventions on sharps injury rates at an acute-care hospital

OBJECTIVE

To determine the impact of a multifocused interventional program on sharps injury rates.

DESIGN

Sharps injury data were collected prospectively over a 9-year period (1990-1998). Pre- and postinterventional rates were compared after the implementation of sharps injury prevention interventions, which consisted of administrative, work-practice, and engineering controls (ie, the introduction of an anti-needlestick intravenous catheter and a new sharps disposal system).

SETTING

Sharps injury data were collected from healthcare workers employed by a mid-sized, acute-care community hospital.

RESULTS

Preinterventional annual sharps injury incidence rates decreased significantly from 82 sharps injuries/1,000 worked full-time-equivalent employees (WFTE) to 24 sharps injuries/1,000 WFTE employees postintervention (P<.0001), representing a 70% decline in incidence rate overall. Over the course of the study, the incidence rate for sharps injuries related to intravenous lines declined by 93%, hollow-bore needlesticks decreased by 75%, and non-hollow-bore injuries decreased by 25%.

CONCLUSION

The implementation of a multifocused interventional program led to a significant and sustained decrease in the overall rate of sharps injuries in hospital-based healthcare workers.

Enhanced secretory leukocyte protease inhibitor in human immunodeficiency virus type 1-infected patients

Secretory leukocyte protease inhibitor (SLPI) has been found to possess activity against the human immunodeficiency virus type 1 (HIV-1) in vitro at physiological concentrations. A study was undertaken to evaluate SLPI levels in human saliva and plasma among HIV-positive (HIV(+)) patients with various HIV-1 viral loads in comparison to uninfected controls. Whole blood in EDTA and unstimulated saliva samples were collected from 37 HIV(+) patients, of whom 20 had a history of intravenous drug abuse (IVDA). Control samples were collected from 20 appropriate age- and sex-matched HIV-1-negative individuals. SLPI was estimated from both saliva and serum samples by an enzyme-linked immunosorbent assay. HIV viral load was determined using a quantitative reverse transcription-PCR. SLPI levels were increased 16.7% in plasma and 10.3% in saliva among HIV(+) patients in comparison to uninfected controls. SLPI levels were increased 5.9% in saliva and 3.9% in plasma among HIV(+) patients with a high viral load (>10,000 copies/ml) as compared to patients with a low viral load (<400 copies/ml). Only 23% of patients with a high viral load used combination therapy with protease inhibitor drugs, whereas 92.9% of HIV(+) patients with a low viral load used protease inhibitors. SLPI levels did not differ significantly among the IVDA patients, patients with different viral loads, or patients using protease inhibitor drugs. There was a statistically significant increase in SLPI levels in saliva among HIV patients in comparison to non-HIV-infected controls. An increase in SLPI levels among HIV(+) patients may be a natural consequence of HIV pathogenesis and an important factor in preventing oral transmission of HIV, but this increase may not be evident during plasma viremia in patients with a high viral load.

Factors associated with occupational exposure and compliance with universal precautions in an urban school district

Factors associated with occupational exposure and universal precautions (UP) compliance were assessed among employees in one urban school district. Half of the employees surveyed reported responding to bleeding injuries and cleaning blood or other body fluids (e.g., vomit, urine) during the previous school year. Also, 1 in 4 custodians and 1 in 10 teachers/teacher's aides had direct contact with blood or body fluids without protection. In multivariate logistic regression analyses, direct contact was most likely among secondary school employees in unpredictable situations who did not have protective equipment or comply with UP. UP compliance was greater among those who had protective equipment available and felt self-confident. Self-confidence was associated with having received training or protective equipment. Routine communications between administrators and employees, staff training, provision of protective equipment, and exposure incident monitoring are essential to effective implementation of UP policies in schools and work settings where occupational exposure could occur.

Issues related to human immunodeficiency virus transmission in schools, child care, medical settings, the home, and community. American Academy of Pediatrics. Committee of Pediatric AIDS and Committee on Infectious Diseases

Current recommendations of the American Academy of Pediatrics (AAP) for infection control practices to prevent transmission of blood-borne pathogens, including human immunodeficiency virus (HIV) in hospitals, other medical settings, schools, and child care facilities, are reviewed and explained. Hand-washing is essential, whether or not gloves are used, and gloves should be used when contact with blood or blood-containing body fluids may occur. In hospitalized children, the 1996 recommendations of the Centers for Disease Control and Prevention (CDC) should be implemented as modified in the 1997 Red Book. The generic principles of Standard Precautions in the CDC guidelines generally are applicable to children in all health care settings, schools, child care facilities, and the home. However, gloves are not required for routine changing of diapers or for wiping nasal secretions of children in most circumstances. This AAP recommendation differs from that in the CDC guidelines. Current US Public Health Service guidelines for the management of potential occupational exposures of health care workers to HIV are summarized. As previously recommended by the AAP, HIV-infected children should be admitted without restriction to child care centers and schools and allowed to participate in all activities to the extent that their health and other recommendations for management of contagious diseases permit. Because it is not required that the school be notified of HIV infection, it may be helpful if the pediatrician notify the school that he or she is operating under a policy of nondisclosure of infection with blood-borne pathogens. Thus, it is possible that the pediatrician will not report the presence of such infections on the form. Because HIV infection occurs in persons throughout the United States, these recommendations for prevention of HIV transmission should be applied universally.

Exposure of medical students to body fluids

Three hundred forty-two students at 3 Florida medical schools were surveyed concerning occupational exposures to blood and body fluids during their 3rd-year clerkship. The 16-item questionnaire was anonymously returned by 150 students, and differences among groups were assessed at p < .05. Most of the students complied with universal precautions guidelines (UVPG); 62 reported 101 exposures, including 9 with HIV-positive blood and body fluids. Most of the exposed students knew about the guidelines but regarded the incidents as irrelevant to their safety or supervision training. Noncompliant students reported significantly more exposures than compliant students. Time constraints, inconvenience of using gloves during procedures, and belief that patients were at low HIV risk discouraged adherence to the guidelines. Common practices following exposure were "no action" or "washed area only" without medical follow-up. Medical students' UVPG adherence should be increased by workload modification, user-friendly safety products, and supervised practice training in clinical exposure settings.

The influence of dental unit design on percutaneous injury

The handpiece receptacle of a European, buggy-whip-style dental unit is in a different location than that of a conventional dental unit. This study investigated whether this difference affects the incidence of percutaneous injuries among dental professionals. The researchers asked dental professionals to record descriptions of percutaneous injuries they sustained during a period of 30 workdays. Findings indicated that most injuries were bur-related and that there was no statistically significant difference between the European and the conventional dental units with respect to the incidence of percutaneous injury.

Compliance with universal precautions: knowledge and behavior of residents and students in a department of obstetrics and gynecology

OBJECTIVES

To assess the knowledge of universal precautions for the delivery and operating rooms by residents and students and to evaluate their use of universal precautions.

STUDY DESIGN

Obstetrics and gynecology (ob/gyn) residents (n = 30) and students (n = 31) from an inner-city, teaching hospital were polled by anonymous questionnaire to assess their knowledge of the appropriate barrier equipment for certain ob/gyn procedures. To determine actual compliance with universal precautions, 459 ob/gyn procedures were observed. We noted the use of appropriate barrier equipment for each procedure: gloves for pelvic exam and face shields, gowns, gloves, and booties for vaginal delivery, cesarean delivery, and dilation and curettage. The True Epistat statistical software program was used to perform simple regression analysis.

RESULTS

Thirty residents (100%) knew the appropriate barrier equipment required for each type of procedure performed. One student (< 1%) did not know that booties were appropriate for the surgical procedures. Rationale for lack of compliance with universal precautions elicited by the questionnaire included time constraints (64%), inconvenience (52%), and presumption that patient was not infected (34%). The observed rate of compliance with universal precautions by participants indicates that individual compliance was inversely related to the years of experience (overall compliance rate of students was 96%; for first-year residents, 92%, second-year residents, 89%, third-year residents, 84%, fourth-year residents, 78%; r = -0.9918, P = 0.0009).

CONCLUSIONS

Knowledge regarding universal precautions was nearly 100%, while overall observed compliance was only 89%. Compliance with universal precautions was better among students (96%) than among residents (88%). Compliance with universal precautions was inversely related to years of experience.

Do Sonographers Practice Proper Infection Control Techniques?

The Occupational Safety and Health Administration has established guidelines to help prevent the spread of infection in health care environments. Although there are no guidelines established specifically for ultrasound departments, general infection control protocols exist. In previous studies, researchers evaluated the compliance with infection control techniques among health care professionals, yet few researchers have focused on the field of ultrasound. Therefore, the authors sent 100 surveys to ultrasound departments located within the five boroughs of New York. Specific questions were asked regarding practiced infection control technique, including hand washing, glove use, transducer cleaning, disinfection and sterilization, wearing of additional protective clothing when necessary, and examination room maintenance. A 51% response rate was obtained. A number of statistically significant correlations were found between the personal characteristics of the sonographer and the adherence to universal precautions. With strict adherence to Occupational Safety and Health Administration guidelines, and with proper support and enforcement by ultrasound departments, sonographers should be able to provide a clean, infection-controlled environment.

Surgical risk assessment and management in patients with HIV disease

Determining the perioperative risks associated with surgical procedures performed in patients with HIV disease is a difficult and complex task. Because HIV is a contagious, blood-borne pathogen, it threatens the health and well-being of both patient and health care provider. Despite poor early results, there is now convincing evidence that HIV infection is not a significant, independent risk factor for major surgical procedures. In practice, the authors evaluate the risk of surgery in patients with HIV infection using the same basic tools and guidelines applied to the uninfected, with the best predictors of surgical morbidity and mortality stemming from a careful and accurate assessment of the patient's cardiopulmonary, renal, endocrine, and nutritional reserve. Although HIV disease provides a unique constellation of diagnoses and challenges to the health care provider, the risk of major surgery in this population is not unlike that for other immunocompromised or malnourished patients. The authors believe that members of the surgical team have a professional, moral, and ethical responsibility to provide the highest possible quality of care for their patients, regardless of their HIV status. If after weighing the risks and benefits to the patient the surgeon believes the procedure will have a positive effect on the patient's life, the surgeon must offer surgical treatment. To do less does a disservice to the patient, the provider, and the profession as a whole.

Secretory leukocyte protease inhibitor (SLPI) in mucosal fluids inhibits HIV-I

Despite the presence of HIV-1 in the oral cavity, transmission of the virus through saliva has not been proven. Consistent with these observations, we recently identified an endogenous 12 kD protein, secretory leukocyte protease inhibitor (SLPI), in saliva which blocks HIV-1 infection in vitro. Whereas other salivary proteins tested were inactive, purified native or recombinant SLPI inhibited HIV-1 infection of human monocytes at 100 ng ml-1. Levels of SLPI quantitated by ELISA in saliva from control and HIV-1 infected individuals exceeded this level, consistent with in vivo antiviral activity. As in saliva, levels of SLPI mRNA determined by Northern hybridization, and protein as assessed by immunohistochemistry in the salivary glands of control and infected populations were comparable. In contrast to adults, oral transmission occurs in infants, possibly due to their lack of fully developed salivary glands. To determine whether the inadequate antiviral protection might be compensated for by maternal sources, we evaluated breast milk samples obtained 6 months postpartum. Levels of SLPI were significantly lower than in saliva and not sufficient to provide antiviral protection in contrast to colostrum samples in which SLPI levels were equivalent to those in saliva and able to inhibit HIV-1 infection when tested in vitro. These data suggest that breast milk may provide transient antiviral activity in the newborn, but that this maternal source of SLPI is of insufficient duration to maintain protection against mucosal transmission of the virus over time. The high functional levels of SLPI in saliva and the low levels in mature breast milk correlate with negligible rates of HIV-1 transmission by saliva and higher rates by breast feeding.

Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation

Recently, a reluctance of lay and medical personnel to perform mouth-to-mouth resuscitation (MMR) in hospital and community settings has been documented, with 45% of respondents declining to perform MMR on a stranger. In the present study, we examined whether the perceived risk and fear of contracting infectious diseases diminishes the willingness of paramedics and emergency medical technicians (EMTs) to perform MMR. Seventy-seven EMTs and 27 paramedics responded to a questionnaire, administered by one of two physicians, containing mock cardiac arrest scenarios that were designed to assess willingness to perform MMR as a citizen responder. Faced with a situation in which an adult stranger required MMR, 57% of the participating EMTs and all of the paramedics stated that they would refuse to perform MMR. None of the paramedics and only 32.5% of the EMTs stated that they would perform MMR on a man in a gay neighborhood. In addition, 23% of the EMTs and 37% of the paramedics indicated that they would refuse to perform MMR on a child. White respondents were more willing than nonwhite respondents to perform MMR. Twenty-nine percent of the prehospital-care providers had been in situations requiring MMR in the community, and 40% either had walked away or did only external compression. Of those participating paramedics and EMTs who had performed MMR in emergency situations, only 45% indicated that they would do so again. The respondents indicated that they would not be willing to administer MMR because of the fear of contracting infectious agents, especially the human immunodeficiency virus. Despite the proven effectiveness of MMR in saving lives, paramedics and EMTs are highly reluctant to perform MMR as citizen responders. Their perceived risks of contracting infectious agents during MMR are high, despite the low actual risks. We recommend that instruction in cardiopulmonary resuscitation for providers of pre-hospital care, the medical community, and the general public should emphasize the benefits of providing MMR, the actual low risks of contracting infectious diseases during administration of MMR, and the use of widely available and effective barrier masks to minimize any risks due to administration of MMR.

Risks and issues for the health care worker in the human immunodeficiency virus era

The perception of degree of risk can vary markedly from actual risk. About 5% of the cases of AIDS and HIV infection in the United States have occurred in health care workers, a percentage that has remained stable over time. Nearly all of these infections are related to lifestyle factors, not occupational risk. The rise of occupational transmission is greatest with parenteral injuries. If there is an HIV risk to patients, it appears to be very much smaller than the risk to workers although it has received even more publicity. Apprehension exists concerning the future framework of the medical care delivery system and who will care for whom. The sensitive handling of legitimate fears and the balancing of conflicting risks will continue to be a challenging task in the decades ahead.

Rural nurses' use of universal precautions in relation to perceived knowledge of patient's HIV status

The increased incidence of AIDS in rural areas of the United States has called attention to the practice of universal precautions by rural nurses. The purpose of this research was to determine protective barrier use by 555 nurses living in rural counties in Pennsylvania and New York State and the effect on this use of their knowledge of their patients' HIV status. Findings suggest that nurses increased their use of protection if they knew their patients were HIV-positive. However, if they thought that their patients were HIV-negative or if they did not know their patients' HIV status, they did not always use adequate protection. Findings are discussed as they relate to the context of rural nursing practice.

Simultaneous human immunodeficiency virus and Hepatitis C infection following a needlestick injury

Needlestick injuries to health professionals at the Hospital del Mar, Barcelona since 1987 have been prospectively studied; a total of 296 such accidents in 286 subjects have been registered. We report the first case to our knowledge of simultaneous human immunodeficiency virus (HIV) and hepatitis C (HCV) infection in a nurse who suffered a needlestick injury after a blood sampling. Forty-four days after the accident she had symptoms and laboratory findings of acute hepatitis. Subsequent laboratory tests showed elevation in the aminotransferases and antibodies against HIV. The seroconversion to HCV was not detected until 109 days after the injury. The precise sequence of clinical and biological events of this case of simultaneous HIV and HCV infection is reported.

HIV nephropathy in children

The evaluation and management of children with HIV nephropathy provide a great challenge to the pediatric nephrologist caring for patients with this tragic illness, of which the nephropathy is only part of their problem and extends beyond the patient to the family and all of the supportive team involved. Care decisions should be based on a multi-disciplinary approach in which the infectious disease component is included. There are many areas that require a better understanding, particularly the pathogenesis of HIV nephropathy and the approach to treatment of the nephropathy with specific drugs. Early identification of children affected with this condition and an aggressive approach to management seem essential to the improvement of the outcome of these patients.

Compliance with universal precautions among health care workers at three regional hospitals

OBJECTIVE

To assess and characterize self-reported levels of compliance with universal precautions among hospital-based health care workers and to determine correlates of compliance.

DESIGN

Confidential questionnaire survey of 1716 hospital-based health care workers.

PARTICIPANTS

Participants were recruited from three geographically distinct hospitals. A stratified convenience sample of physicians, nurses, technicians, and phlebotomists working in emergency, surgery, critical care, and laboratory departments was selected from employment lists to receive the survey instrument. All participants had direct contact with either patients or patient specimens.

RESULTS

For this study, overall compliance was defined as "always" or "often" adhering to the desired protective behavior. Eleven different items composed the overall compliance scale. Compliance rates varied among the 11 items, from extremely high for certain activities (e.g., glove use, 97%; disposal of sharps, 95%) to low for others (e.g., wearing protective outer clothing, 62%; wearing eye protection, 63%). Compliance was strongly correlated with several key factors: (1) perceived organizational commitment to safety, (2) perceived conflict of interest between workers' need to protect themselves and their need to provide medical care to patients; (3) risk-taking personality; (4) perception of risk; (5) knowledge regarding routes of HIV transmission; and (6) training in universal precautions. Compliance rates were associated with some demographic characteristics: female workers had higher overall compliance scores than did male workers (25% of female and 19% of male respondents circled "always" or "often" on each of the 11 items, p < 0.05); and overall compliance scores were highest for nurses, intermediate for technicians, and lowest for physicians. Overall compliance scores were higher for the mid-Atlantic respondents (28%) than for those from the Southwest (20%) or Midwest (20%, p = 0.001).

CONCLUSIONS

This study supports earlier findings regarding several compliance correlates (perception of risk, knowledge of universal precautions), but it also identifies important new variables, such as the organizational safety climate and perceived conflict of interest. Several modifiable variables were identified, and intervention programs that address as many of these factors as possible will probably succeed in facilitating employee compliance.

Secretory leukocyte protease inhibitor: a human saliva protein exhibiting anti-human immunodeficiency virus 1 activity in vitro

Infection of adherent primary monocytes with HIV-1Ba-L is significantly suppressed in the presence of human saliva. By reverse transcriptase (RT) levels, saliva, although present for only 1 h during monocyte viral exposure, inhibited HIV-1 infectivity for 3 wk after infection, whereas human plasma and synovial fluid failed to inhibit HIV-1 infectivity. Antiviral activity was identified in the saliva soluble fraction, and to determine the factor(s) responsible, individual saliva proteins were examined. Of those proteins examined, only secretory leukocyte protease inhibitor (SLPI) was found to possess anti-HIV-1 activity at physiological concentrations. SLPI anti-HIV-1 activity was dose dependent, with maximal inhibition at 1-10 micrograms/ml (> 90% inhibition of RT activity). SLPI also partially inhibited HIV-1IIIB infection in proliferating human T cells. SLPI appears to target a host cell-associated molecule, since no interaction with viral proteins could be demonstrated. However, SLPI anti-HIV-1 activity was not due to direct interaction with or downregulation of the CD4 antigen. Partial depletion of SLPI in whole saliva resulted in decreased anti-HIV-1 activity of saliva. These data indicate that SLPI has antiretroviral activity and may contribute to the important antiviral activity of saliva associated with the infrequent oral transmission of HIV-1.

Nurses: at special risk

Nurses are at occupational risk for many infections, but it was not until human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) was recognized that a work-acquired infection was uniformly fatal. Other work-acquired infections, including tuberculosis, rubella, measles, varicella, and the viral hepatitides, may cause morbidity for the nurse and his/her family. Although the number of nurses who acquire occupational infections is small, each has a unique personal story, and all will have their productivity affected. A few will lose their lives to infections acquired on the job. Although all occupational infections cannot be prevented, understanding the chain of infection and how to break the links can go a long way in reducing risks and maintaining health for all health care workers.

The Management of Sinusitis in Patients Infected with the Human Immunodeficiency Virus (HIV)

As the Human Immunodeficiency Virus (HIV) has extended its influence across the United States, otolaryngologists have been increasingly called upon to manage its various head and neck manifestations. Sinusitis is a very prevalent, yet difficult, management problem in this patient population. The pathophysiology of sinusitis in this setting relates to altered helper T-lymphocyte function, an abnormal inflammatory response as well as increased IgE-mediated inflammation. Chronic HIV-related sinusitis is often due to Pseudomonas aeruginosa, Staphylococcus aureus, or anaerobic bacteria, and empiric antibiotic therapy must include these potential pathogens. Early cultures can facilitate organism-specific antibiotic therapy. Aggressive treatment with decongestants, topical nasal steroids, mucoevacuants and occasionally antihistamines should be included at maximal tolerated doses. When medical therapy fails, surgical drainage can be a safe and effective management option.

Appropriately directed medical, and occasionally surgical, therapy can lead to a dramatic clinical response and provide an improved quality of life in this patient population.