Low occupational risk of human immunodeficiency virus infection among dental professionals

Multicenter HIV and hepatitis B seroprevalence study

Prior single institutional investigations have found unrecognized HIV seroprevalence in emergency department (ED) patients to range from 0.38% to 4%. A prospective, anonymous study of HIV and hepatitis B (HB) seroprevalence was performed on excess serum of all ED patients over two 48-hour periods in May and August, 1988, from 7 hospitals in the Portland metropolitan area. Demographics were known for 338/444 (76%) of patients. Forty-six percent were male, 85% white, with a median age group of 30-39 years. Ambulance transport, trauma, external blood, presentations requiring ED procedure(s), and acuity resulting in ICU admission were present on 21%, 7%, 10%, 34%, and 14% of patients, respectively. Two of 444 (.45%) patients were HIV +, one previously undiagnosed. Fifty-five of the 444 (12%) and 3 of 444 (0.6%) samples were positive for HBcAB and HBsAG respectively. Risk factor assessment was possible on 180/444 (40%) patients. HBcAB seroprevalence correlated with race (P less than 0.01), IV drug use (P less than 0.0001), and hospital location, (P less than 0.006) but were sensitive in detecting only 14%, 18%, and 38%, respectively, of HBcAB+ patients. HBcAB was not associated with the following factors: sex, area of residence, presence of blood externally, trauma, acuity of illness, ED procedures, or mode of transport. This data strongly support the use of universal body fluid precautions. Hepatitis B poses a significant and distinct risk to all emergency care providers. HB vaccination should be strongly advocated for all ED health care workers (HCWs). Emergency medicine multicenter studies are both desirable and feasible.

Use of non-sterile gloves in clinical practice

This paper reviews the use of non-sterile gloves in dental practice. It is now considered to be normal practice to wear gloves for all dental procedures and although there is considerable controversy regarding patterns of glove use, there is increasing evidence to the effect that single patient use is indicated. Careful use of gloves and proper hand care are key components to effective cross-infection control in clinical practice.

Occupational exposures to blood and risk of HIV transmission in a general hospital (1986-88)

We conducted a study on occupational exposure to blood in a 1500-bed General Hospital in order to define incidence, type and circumstance of each exposure and to assess the risk of HIV transmission. From 1986 to 1988 a total of 548 cases of accidental blood exposure were reported, with an average of 15 accidents/month. The health care workers exposed included 376 nurses (68.6%), 91 manual workers (16.6%), 54 surgeons (9.8%), 14 physicians (2.5%) and 13 laboratory technicians (2.4%). There were 206 (37.6%) incidents related to recapping of needles. Other types of needle-stick injuries accounted for 191 cases (34.8%), cuts with sharp objects for 110 (20%) and skin or mucous membrane exposure for 41 (7.5%). The highest incidence of exposure per month of work (in a total of 85,932 persons/month of work) and employment category was observed in nurses (.008) and the lowest in physicians (.001). Fifty-three (9.7%) employees were exposed to blood from patients with HIV infection: 36 nurses, 16 surgeons and 1 physician. No cases of seroconversion have been observed after a mean follow-up of 9 months (range: 2-18). The highest rate of HIV at-risk exposure per month of work was observed in surgeons (.001) and the lowest in physicians (.00008). Careful adherence to the universal infection-control guidelines published by international health authorities (W.H.O., C.D.C.) is recommended to prevent most at-risk incidents in health-care settings.

Attitudes of BCLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic

We surveyed 5,823 American Heart Association Virginia Affiliate basic cardiac life support (BCLS) instructors to assess the impact that the acquired immunodeficiency syndrome (AIDS) epidemic has had on their attitudes, beliefs, and behaviors with respect to the training and performance of mouth-to-mouth (MTM) ventilation. The response rate by those whose mail survey could be delivered to a valid address was 41% (women, 63%; men, 37%; mean age, 38 +/- 1 years; health care providers, 87%; laypersons, 11%; and public safety workers, 2%). Of those surveyed, 49% had performed CPR within the past three years. Of these, 40% reported having hesitated to provide MTM ventilation at least once. Of those who had hesitated, more than one half identified fear of exposure to disease as the reason for their hesitation. Forty percent of all respondents had witnessed another provider hesitate to provide MTM ventilation. When presented with mock rescue scenarios, the majority of respondents indicated that they would not perform or would hesitate to perform MTM ventilation on most adult strangers. More than half felt that there was some risk of contracting AIDS from ventilating a manikin, and 71% said that their attitudes about providing CPR to strangers had changed as a result of the AIDS epidemic. We conclude that concern about AIDS appears to be adversely affecting the attitudes, beliefs, and self-reported behaviors of BCLS instructors in Virginia regarding the use of MTM ventilation on strangers.

HIV infection and dental care: views and experiences among HIV-seropositive patients

This study reports the views and experiences of HIV-seropositive individuals within the Danish Dental Care System. One hundred and thirty-five consecutive HIV-seropositive outpatients visiting the infectious departments at three Danish hospitals completed a structured questionnaire anonymously; participation rate was 96%. Refusal of dental treatment due to HIV-seropositivity had been experienced by 10.4% of the sample (95% CI: 7.1-20.3%), although more (24.4%) knew someone who had been rejected at a dental clinic. Rejection was seen more often among those who had informed a dentist of HIV-seropositivity than among those who had not; 17.8% compared to 3% (P = 0.06). Only 25.4% (18.3-33.6%) favoured the idea of special dental units for referral for routine treatment. Negative attitudes and behaviour against HIV-infected people were characterized as discriminatory by 83.5% (76.0-89.3%). Most of the participants seemed to have established an open and confident relationship with their attending dentist with regard to their HIV-seropositivity and to a lesser extent, their sexuality. When patients told their dentists about their HIV-seropositivity, this was clearly reflected in increased infection control.

Detection of HIV in the dental pulp of a patient with AIDS

Dental pulp tissue from a patient with acquired immune deficiency syndrome (AIDS) was examined to determine the presence of the human immunodeficiency virus (HIV). The results found a high concentration of proviral HIV DNA.

The reaction of dentists to members of groups at risk of AIDS

An experimental field study examined dentists' attitudes and actual behaviors toward men who belong to groups at great risk of AIDS. A total of 102 randomly selected dentists were uninformed subjects who examined an actor in need of dental care and who played three roles as a patient: one who is heterosexual, homosexual, and an intravenous drug user. After each examination, the actor/patient completed a questionnaire about his experience and the dentists were interviewed about homosexuality and AIDS. The dentists were then debriefed and told that they were part of an experiment. Despite negative feelings toward homosexuality, only one dentist refused to treat the actor when he was perceived to be homosexual. One dentist also rejected him when he played the part of an intravenous drug user.

Dental care experience of HIV-infected men in Chicago

Press reports and surveys of dentists in the United States suggest that HIV-infected persons may have considerable difficulty in securing dental care. To determine the actual experience of HIV-infected people, a personal interview survey of 125 HIV-infected patients at three HIV/AIDS clinics in Chicago was conducted. The 61 subjects who sought dental care after learning that they were HIV positive were generally successful. Those who concealed their status encountered no difficulty, but one of 32 who disclosed it was refused care. Twenty-five of 26 dentists who knew their patients had HIV infection chose to treat them. Informed, nonrandom selection of dentists by the persons surveyed may partially explain the apparent discrepancy between their experience and that predicted by formal random surveys of dentists.

AIDS and the lung. 1--AIDS, aprons, and elbow grease: preventing the nosocomial spread of human immunodeficiency virus and associated organisms

Epidemiological evidence indicates that transmission of human immunodeficiency virus (HIV) other than by direct inoculation or sexual contact is extremely rare. HIV has, however, been found on fibreoptic bronchoscopes used on patients with AIDS and there is a clear theoretical risk of transmission by bronchoscopy. Applied experiments have underlined the importance of cleaning equipment thoroughly and have shown the limitations of disinfection. Infection control policies should be revised to meet the following four basic requirements: (1) all precautions should apply to all patients alike--that is, whether infectious or not; (2) equipment should be cleaned thoroughly in detergent immediately after use to remove body secretions and reduce contamination; (3) staff who may be exposed to body secretions should wear simple barrier clothing routinely; and (4) contaminated bronchoscopes should be disinfected for 20 minutes in 2% alkaline glutaraldehyde after cleaning.

Norwegian dentists' knowledge, attitudes, and behavior concerning the HIV

Knowledge about routes of HIV transmission and attitudes to HIV antibody testing was studied in a group of Norwegian dentists. Personal protection by gloves was also recorded. Eighty-three of 120 (69%) dentists in Bergen (private practitioners) completed a postal questionnaire. More than half of these considered themselves to be in potentially infectious situations daily. Overall knowledge was good, although one fifth gave wrong answers about the relation between antibody status and infectivity. About half the respondents had attitudes to antibody testing not consistent with Centers for Disease Control (CDC) guidelines. These dentists scored significantly lower on the knowledge questions. Seventy-five (92%) reported consequent use of gloves. A low knowledge score was found among non-users. The present study indicates that lack of knowledge is related to non-recommended attitudes and behavior. The study underlines the need for continuous education and information about HIV.

Dental care of HIV-infected patients: attitudes and behavior among Danish dentists

The aims of the study were to study Danish dentists' attitudes and behavior with regard to providing dental care to HIV-infected persons and to look for explanatory variables for the dentists' attitudes and behavior. Two hundred and twenty-eight Danish dentists responded to a questionnaire on dental treatment of HIV-infected patients and related problems (response rate: 91.2%). The dentists' attitudes differed a great deal from the current national policy as to where HIV-infected patients should be treated and with regard to the possibility of being tested for HIV anonymously. 64% of the dentists favored the idea of referral of HIV-infected patients to special dental clinics for routine dental treatment, and 93% disapproved of the idea that infected individuals themselves should decide whether they wish to inform their dentist or doctor of seropositivity. Older dentists were more reluctant to treat HIV-infected individuals than younger. Other differences with regard to a number of demographic variables were not found. No difference in attitude towards HIV-infected persons was found when compared to that towards HBV-infected individuals. The reluctance towards treatment of HIV-infected persons was present irrespective of any subsidy for an extra cost for treatment of HIV-infected patients.

The dentist and infectious diseases: a national survey of attitudes and behavior

Two national surveys of infection control practices in 1986 and 1988 suggest several trends. A massive educational effort has brought about impressive acceptance and use of the hepatitis vaccine. Dramatic changes have occurred in respect to use of gloves and other barrier techniques. However, increased understanding of HIV infection has not, in the years surveyed, totally eradicated irrational fears about this disease.

AIDS and HIV-1 infection: clinical entities in geriatric dentistry

The number of AIDS cases in individuals 50 years of age or older in the United States is reported to exceed 9000. Contaminated blood and blood transfusions are major contributors to HIV-1 infection in this age group. Sexual transmission and infection through intravenous drug abuse are also potential avenues of HIV-1 transmission in the older population. AIDS presents with a variety of clinical manifestations, including dementia, frequently seen in non-HIV-1-infected older people. Neurological deficiencies associated with AIDS are very common and may lead to misdiagnosis in the elderly. The observed incubation period of HIV-1 infection is longer than previously estimated, increasing the risk of older individuals exposed to HIV-1 in the past to develop AIDS. Oral manifestations may present as one of the early clinical signs of AIDS. Little is known concerning AIDS in the geriatric population. It demands consideration by dental professionals treating older individuals belonging to one of the exposure categories of the disease.

Risk of transmission of the human immunodeficiency virus to health care workers exposed to HIV-infected patients: a review

The possibility of transmission of the human immunodeficiency virus (HIV) to health care workers with occupational exposure to infected patients has caused concern since the beginning of the AIDS crisis. This report summarizes both national surveillance data for AIDS among health care workers and the results of prospective studies on the risk of HIV transmission in the health care professions. All the available evidence indicates that HIV infection in health care workers in the United States results primarily from exposure outside the health care setting, and is acquired by one of the conventional routes of transmission. A small number of health care workers have been infected with HIV through occupational exposure. Prospective surveillance studies indicate that the risk of seroconversion after needlestick exposure to HIV-infected blood is about 0.5%. The level of risk associated with exposure of mucous membranes or nonintact skin is far less.

Development of the Occupational Safety and Health Administration's proposed standard to protect workers from contracting bloodborne diseases in the workplace

The Occupational Safety and Health Administration (OSHA) is in the process of developing a health standard to protect workers by reducing occupational exposure to hepatitis B virus, human immunodeficiency virus, and other bloodborne pathogens. This article reviews the history of the standard, the steps involved in OSHA standard development, and--most specifically--how the dental professional can participate in this process.

Infection control practices of Minnesota dentists: changes during 1 year

In 1986, a survey of all licensed Minnesota dentists (N = 2,752) was conducted to determine current infection control practices. In 1987, the survey was repeated with a 45% random sample of all Minnesota dentists (N = 1,357) to monitor changes in such practices during 1 year. The findings indicate that dentists made dramatic changes in their routine use of barrier techniques and also, that rates of vaccination against hepatitis B increased decidedly. Younger dentists had higher vaccination rates and use of routine barrier techniques. Although dentists' reluctance to treat patients with AIDS decreased in frequency, some dentists still refuse to treat these patients. However, a substantial majority will treat patients with other infectious diseases.

HIV protocol for the pediatric otolaryngology office

With the increasing awareness and concern over the transmission of human immunodeficiency virus (HIV) to health care providers, the development of a reasonable approach to patient care is necessary with those suspected of or documented as being HIV-positive. Children are all too frequently the innocent victims of this deadly disease and will often require the services of the otolaryngologist for evaluation, diagnosis, and treatment. In order to provide appropriate care for these children and reduce the risk of possible contamination of health care professionals or other patients a protocol was established for the Pediatric Otolaryngology Division of Children's Hospital at Washington University. This protocol is discussed in detail with explanation of rationale and alternatives.

HIV and hepatitis B infection in an international cohort of dental hygienists

The risk for dental hygienists to contract HIV and hepatitis B infection at work was studied in an international cohort of 167 dental hygienists from 13 countries. A significant proportion of the hygienists had taken care of HIV-positive patients or patients known to be at risk for contracting HIV infection. None of the hygienists had antibodies to HIV. Five hygienists who came from or worked in high-endemic areas for hepatitis B infection had antibodies to hepatitis B core antigen, consistent with previous infection with hepatitis B virus. The study is in agreement with previous reports on blood-borne infections among health care workers, concluding that the risk for dental hygienists of contracting HIV and hepatitis B infection is minimal.

Assessment of the effectiveness of glove use as a barrier technique in the dental operatory

To assess the effectiveness of routine glove use as a barrier technique in the dental operatory, the relationship between frequency of glove use and hepatitis B infection was examined. Hepatitis B screening results and information on infection control practices of 1,109 dentists who attended the 1985 annual session were compiled and statistically analyzed. The results showed that 18% of the dentists wore gloves routinely, 65% wore gloves intermittently, and 17% never wore gloves. Frequency of glove use was related to hepatitis B infection (P less than .01), with dentists who never wore gloves being infected more than twice as often as dentists who wore gloves routinely. Dentists with less frequent glove use and more years in practice had a higher incidence of hepatitis B infection (P less than .0001).

What is the occupational risk to emergency care providers from the human immunodeficiency virus?

The risk to health care providers of acquiring human immunodeficiency virus (HIV) infection through occupational exposure is very low, but the consequences of becoming infected are obviously severe. The magnitude of this risk has been debated extensively in the medical literature, but the majority of these discussions have focused on providers of surgical, orthopedic, and obstetric care, none of whom have ever been documented to have become infected with HIV through occupational exposure. In contrast, there has been very little information published regarding the degree of risk to emergency care providers, several of whom have been confirmed as having acquired HIV infection through occupational exposures. This report addresses the extent and nature of risk of HIV infection to emergency care providers and reviews the current management of significant exposures.