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

Can AIDS be prevented after injury with contaminated instruments?

Particulate matter comparable in size with that of human immunodeficiency virus was subcutaneously injected into experimental animals. Such matter remained at the inoculation site long enough to suggest the possibility that human immunodeficiency virus can be destroyed in loco before it invades the host's circulation. These findings may be useful in developing a method to prevent acquired immunodeficiency syndrome after accidental injury with human immunodeficiency virus-contaminated instruments.

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.

Human immunodeficiency virus and the emergency department: risks and risk protection for health care providers

The AIDS epidemic is having an increasing impact on the practice of emergency medicine. In inner-city emergency departments, significant numbers of patients have unrecognized human immunodeficiency virus (HIV) infection. Transmission of HIV in the health care setting has been predominantly from exposure to patients' infected blood, but most of the exposures (80%) are due to injuries from sharp instruments. There are only 18 documented cases of occupational HIV transmission worldwide. Four of these have occurred from nonparenteral exposures. Based on surveillance studies, the best estimate of seroconversion after exposure is about 0.5%. However, due to methodologic limitations, these figures may be underestimations. The effectiveness of azidothymidine for postexposure prophylaxis has not been shown. Currently, the best protection against HIV and other blood-borne pathogens remains use of universal precautions.

[Occupational accidents with possible HIV contamination]

From January 1st, 1984 until December 31st, 1988 586 employees of the University Clinic of Frankfurt, West-Germany, were treated after occupational accidents with potentially HIV-contaminated materials. The majority of the patients were admitted because of lacerations that occurred with used injection needles. Up to now the sero-conversion of a patient after this special kind of trauma has not been documented in West-Germany. In our clinic we found an infection in one employee, which is due to an occupationally acquired injury.

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.

Evaluation of an antimicrobial soap formula for virucidal efficacy in vitro against human immunodeficiency virus in a blood-virus mixture

The virucidal efficacy of a health care personnel hand wash product containing 0.5% parachlorometaxylenol in a sodium C14-16 olefin sulfonate formula was evaluated in in vitro tests with human immunodeficiency virus type 1 (HIV-1) in the presence of 50% whole human blood. The HTLV-IIIRF strain of HIV-1 was suspended in 50% medium-50% whole human blood and exposed to various dilutions of the hand wash product for 30 or 60 s. Following detoxification, residual infectivity was determined by a lytic cytopathogenic assay in MT2 cell cultures. No infectious HIV could be detected after a 30-s exposure to the hand wash product at dilutions of 1:5 and 1:10 and after a 60-s exposure at dilutions of 1:5, 1:10, 1:20, and 1:30. More than 99.9% of the virus was inactivated at these dilutions and exposure times.

Infection prevention and control in the era of the AIDS/HIV epidemic

The chronology of important events in the AIDS/HIV epidemic is presented in Table 2. Nurses are the largest group of health care workers and persons who provide direct care and handle sharp objects regularly. As the number of persons infected with HIV increases and as more infected persons become ill enough to require care, the opportunity for an individual nurse to have contact with an infected person will increase. Because many persons with HIV infection also have Kaposi's sarcoma and other malignancies, some oncology nurses may have more contact with HIV-infected individuals than nurses in general. However, it is well established that the major risk for HIV infection is from puncture injuries, and a number of strategies are available and are being developed to make needle and sharps handling safer. Nurses must take personal responsibility for knowing how to reduce their own risks for exposure to HIV and other infectious agents while keeping in mind the need not to increase risks of nosocomial infections in patients. Thus, all nurses need a comprehensive understanding of the purposes of barriers (eg, gloves, gowns, masks, handwashing, room assignment) and when and how to use them correctly. In addition, all nurses who have contact with blood and body fluids should take responsibility for their own immunity to hepatitis B by obtaining hepatitis B vaccination. By using all of these strategies in combination, many infection risks to nurses and patients will be minimized.

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.

Occupational exposure to human immunodeficiency virus (HIV) and hepatitis B virus (HBV) among embalmers: a pilot seroprevalence study

We performed a serosurvey of 133 embalmers in an urban area where human immunodeficiency virus (HIV) infection is prevalent. Although we found histories of needlesticks to be common, and the seropositivity rate of hepatitis B virus (HBV) (13%) was approximately twice that of a blood donor comparison group, HIV antibody was uniformly absent in 129 embalmers who denied HIV risk factors, and present in one of four with self-described risk behaviors. The risk of HBV infection was higher among embalmers who have worked more than 10 years, relative risk (RR) 16.2 (95% confidence interval 2.1, 126.5), did not routinely wear gloves, RR 9.8 (CI 3.4, 28.5), or are employed in the city of Boston, RR 4.7 (CI 1.8, 12.0).

The urological manifestations of the acquired immunodeficiency syndrome

Between 1984 and March 1987, 120 patients with either the acquired immunodeficiency syndrome or its related complex seen at our hospital were studied retrospectively for urological signs and/or symptoms. Autopsy findings also were reviewed. Of the patients 84 per cent had no complaints referable to the urinary system, 2 per cent had gross hematuria (all with a negative diagnostic evaluation) and 14 per cent had urinary infections. We conclude that only a small percentage of patients with the acquired immunodeficiency syndrome suffer from significant urological manifestations and that a full urological evaluation of such patients generally is not warranted. If the patient presents with gross hematuria excretory urography should be performed if there is no infectious etiology, and cytoscopy should be performed only if the hematuria is life-threatening or prolonged and possibly to confirm significant urographic findings.

[General insecurity, "false" and "real" security: arguments for the routine study of hospital patients for anti-HIV]

HIV infection has become an important risk for medical personal. Use of sufficient preventive measures with all patients and patient materials is time consuming, expensive and impracticable. In the present epidemiological situation anti-HIV testing of all hospital patients will give correct information on the presence or absence of HIV infection for 999 of 1000 patients. In addition to the increased safety of medical personal, testing will have several other advantages, some for the HIV infected persons: (1) In patients with HIV-related diseases time consuming delays in diagnosing the disease can be avoided. An earlier start of therapy will improve prognosis. (2) In HIV-infected persons a therapy can be chosen which exerts the least stress to the immune system. This may delay manifestation or progression of HIV-related diseases. (3) By medical surveillance of HIV-infected persons prophylaxis and immediate therapy of opportunistic infections is possible, which may prolong survival time. (4) Counselling of persons previously unaware of their HIV infection will slow down spread of HIV in the population. (5) Missing data on prevalence and incidence of HIV infection in different geographical areas will be available. Apart from the considerable cost reduction by reducing the use of extensive preventive measures to less than 10% of patients, routine screening of all patients is already economic if testing of 10,000 patients will prevent one single new infection by counselling of people with previously unknown HIV infection.

Exposure to and precautions for blood and body fluids among workers in the funeral home franchises of Fort Worth, Texas

In 1982 the Centers for Disease Control published a set of recommendations and measures to protect persons working in health care settings or performing mortician services from possible exposure to the human immunodeficiency virus. This study of a number of funeral homes in the Fort Worth area was designed to determine the level of exposure of funeral home workers to blood and other body fluids and also to assess existing protective measures and practices in the industry. Workers in 22 funeral home franchises were surveyed with a predesigned questionnaire. Eighty-five responses from 20 of the 22 establishments were received. All 85 respondents admitted exposure of varying degrees to blood and body fluids. Sixty persons (70%) admitted heavy exposure, that is, frequent splashes. Analysis of the responses showed that 81 of 85 (95.3%) persons consistently wore gloves while performing tasks that might expose them to blood or other body fluids. Of the 60 persons who were heavily exposed, 43 wore long-sleeved gowns, 27 wore waterproof aprons, 17 surgical masks, and 15 goggles. The study further revealed that 52.9% (45/85) of the respondents had sustained accidental cuts or puncture wounds on the job. In light of these findings it is important to target educational efforts to persons in this industry to help them minimize their risks of infection with blood and body fluid borne infections.

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.

Basal cell carcinoma in a patient with acquired immunodeficiency syndrome: treatment with Mohs micrographic surgery fixed-tissue technique

A case illustrating Mohs micrographic surgery fixed-tissue technique in the treatment of a large basal cell carcinoma of the left nasal alar groove in a patient with acquired immunodeficiency syndrome is described. Fixation of the tissue before excision and appropriate infectious disease precautions minimize exposure to the human immunodeficiency virus by the surgical and laboratory personnel, while Mohs micrographic mapping assures complete removal of a potentially life-threatening cancer in an immunocompromised patient.

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.

Life-sustaining treatment for patients with AIDS

Physicians increasingly are being called upon to make difficult decisions about intensive care for patients with the acquired immunodeficiency syndrome (AIDS). AIDS patients who require intensive care have a poor prognosis; the in-hospital mortality rate of those receiving mechanical ventilation for P carinii pneumonia is 86-100 percent in most studies. However, in the past year, two studies documenting improved outcome have been published. Physicians should understand these outcome data and use well-established ethical principles to allow informed competent patients with AIDS to express their preferences regarding intensive care. Patients should be encouraged to provide advanced directives regarding life-sustaining treatments or to designate surrogate decision-makers to be consulted should they lose mental competence. The health care system should provide alternatives to the ICU for compassionate terminal care. However, arbitrary policies denying intensive care to AIDS patients for whom it is medically indicated and desired are not warranted.

Human immunodeficiency virus and the cardiac surgeon: a survey of attitudes

The decision to operate on carriers of the human immunodeficiency virus (HIV) who need an urgent cardiac operation is difficult. There is a lack of knowledge about the effect of the presence of HIV on operative risk, about the effect of cardiopulmonary bypass on the progression of HIV infection to acquired immunodeficiency syndrome (AIDS), and about the risk to the cardiac surgical team of operating on 1 or more HIV carriers. This lack of knowledge is exacerbated by the strict regulations surrounding testing. We polled the board-certified cardiac surgeons in the United States on their willingness to perform open cardiac procedures on HIV carriers and AIDS patients. Fifty-three percent of the surgeons responded. Two thirds of them will operate on HIV carriers who need an urgent cardiac operation but regard the presence of AIDS as a contraindication to cardiopulmonary bypass. This is presumably a medical judgment. Those who will not operate on HIV carriers are apparently motivated by fear rather than moral judgments concerning the patients. Virtually all surgeons want to be able to test "high-risk" patients, and a substantial majority would test all patients.

Acquired immunodeficiency syndrome: a new population of children at risk

Cases of AIDS in children have been described since 1982. Diagnosis is more complex in children than in adults owing to the more varied clinical presentations and the difficulty in interpretation of laboratory tests. Our current understanding of HIV infection in children is reviewed, as well as the controversies regarding medical, psychosocial, and public health issues.

Nursing Students' Attitudes Toward AIDS

A study of 177 baccalaureate nursing students was conducted to explore their knowledge, fears, beliefs and other attitudes regarding AIDS. Lazarus' theory related to coping with threatening events provided the theoretical framework. Students with a high fear score were less willing to care for AIDS patients, had higher knowledge scores, and were more homophobic. While 96.6% of the students felt that AIDS patients are entitled to the same care as any other patient, 49% preferred not to care for AIDS patients. Thirty-six percent thought nursing students should not be assigned to care for AIDS patients. Most of the students (70.6%) got their information about AIDS from the media. Nursing faculty must respond by including current, correct information when instructing students about AIDS. Faculty also need to provide opportunities for students to ask questions and share their fears regarding AIDS.

Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus

Since 1983, we have conducted national surveillance of health care workers exposed to blood or body fluids from persons infected with the human immunodeficiency virus (HIV), to assess the risk of HIV transmission by such exposures. As of July 31, 1988, 1201 health care workers with blood exposures had been examined, including 751 nurses (63 percent), 164 physicians and medical students (14 percent), 134 laboratory workers (11 percent), and 90 phlebotomists (7 percent). The exposures resulted from needle-stick injuries (80 percent), cuts with sharp objects (8 percent), open-wound contamination (7 percent), and mucous-membrane exposure (5 percent). We concluded that 37 percent of the exposures might have been prevented. Of 963 health care workers whose serum has been tested for HIV antibody at least 180 days after exposure, 4 were positive, yielding a seroprevalence rate of 0.42 percent (upper limit of 95 percent confidence interval, 0.95 percent). Three subjects experienced an acute retroviral syndrome associated with documented seroconversion; serum collected within 30 days of exposure was not available from the fourth person. Two exposures that resulted in seroconversion were caused by coworkers during resuscitation procedures. We conclude that the risk of HIV infection after exposure to the blood of a patient infected with HIV is low, but at least six months of follow-up is recommended. Many exposures can be prevented by careful adherence to existing infection-control precautions, even during emergencies.

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.

Unrecognized human immunodeficiency virus infection in emergency department patients

To determine the extent of unrecognized human immunodeficiency virus (HIV) infection, we examined blood samples drawn from patients presenting to an inner-city emergency department. We found 119 of 2302 consecutive adult patients (5.2 percent) to be seropositive for HIV. Although 27 patients presented with known symptomatic HIV infection, 92 of the remaining 2275 patients (4.0 percent) had unrecognized HIV infection. The highest seroprevalence rate (11.4 percent) was found among black men 30 to 34 years of age. Blacks, other nonwhites, and patients under the age of 45 had high rates of unrecognized infection. The clinical team established risk-factor status in only 29.0 percent of the patients. Of the 276 patients with identified risk factors, 13.0 percent were seropositive, whereas 3.1 percent of the 1616 patients with unknown risk-factor status were seropositive. None of the 102 patients who reported no risk factors were seropositive. Although penetrating trauma (seroprevalence, 13.6 percent) was the only clinical presentation associated with an increased seroprevalence rate independent of other known predictors of infection (P = 0.02), seropositive patients were found in all categories of clinical condition. These data, although based on observations in one emergency department setting, support the concept of universal blood and body-fluid precautions by all health care workers whether or not HIV infection is known.