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A three-pronged attack against AIDS infection in the lab.

Education, protective supplies, and a formal policy of precautions against blood-borne infection eased employee fears of AIDS.

The author is a medical technologist and client service representative at Methodist South Hospital in Memphis.

As in many clinical laboratories throughout the country, our staff grew somewhat paranoid when the Centers for Disease Control reported human immunodeficiency virus infection of three health care workers through breaks in the skin or contact with mucous membrane.

Even our small suburban hospital (200 beds) had begun to see HIV-positive patients, and the CDC report confirmed staff fears. Despite the minimal risk of HIV infection on the job, many of the 30 laboratory employees were afraid to handle patient specimens. Some were reluctant to provide services for HIV-positive patients; a few even considered a career change.

Fortunately, the laboratory manager promptly recognized early signs of panic. In an informal survey, he asked laboratory clerks, specimen collectors, technologists, and supervisors what could be done to reduce the risk of infection. The recommendations led to introduction of a program last spring that addresses AIDS issues through education, protective su lies, and a policy to guard against blood-bome infection (Figure I).

Since we cannot identify HIVpositive patients prior to testing, and since patients may have other infectious diseases, our program emphasizes universal precautions. A study at Walter Reed Army Hospital underscored the need to take such precautions. HIV antibody testing was performed on more than 1 ,600 serum specimens submitted for chemistry profiles. Specimens from two out of 536 inpatients and two out of 1,100 outpatients were positive for the antibody.

Here is our safety program in detail:

* Education. Lectures by the department's pathologists and guest speakers, along with reading materials, covered the causes and transmission of AIDS; high-risk groups; clinical manifestations, diagnosis, and treatment; interpretation of ELISA and Western blot results; and precautions to take when handling specimens and needles. Besides reassuring employees, the sessions demonstrated management's concern about their well-being and its willingness to confront issues associated with AIDS. Lectures were videotaped for those who missed the original presentation.

*Protective materials. Providing protective supplies further demonstrated the organization's dedication to employee safety. Not only was management willing to discuss AIDS, but it also backed its words with financial resources.

Needle drop boxes and gloves (in small, medium, and large sizes) were placed in all work areas. Masks, goggles, and gowns were also made available, and containers of 10 per cent bleach were placed throughout the laboratory in case of spills.

Employees are encouraged to use safeguards when coming into contact with specimens. They always replace gloves soiled by blood or other body fluids; commonly, glove changes also take place after test runs, although the frequency is left up to each person. Glove supplies fall to low levels from time to time, but the laboratory has never run out completely.

Gloves might have prevented two of the work-related HIV infections reported by the CDC. In one case, an emergency room nurse applied pressure with an ungloved hand while attempting to resuscitate a patient in cardiac arrest. The hand was chapped and exposed to blood for about 20 minutes. In the other case, a medical technologist spilled blood on her forearms and ungloved hands. She possibly touched an ear that had dermatitis (gloves might have reminded the technologist to avoid such contact).

*Precautions policy. Our new policy stressed prevention of infection first but also furnished guidance in instances when employees contract an infectious disease. In developing the policy, management listened to employee concerns, consulted legal experts, and met with human resources representatives.

Figure I presents the entire policy. Its components include:

Purpose. The policy explains the need for protection from jobrelated infections, including HIV and hepatitis, and outlines how the organization will respond to these health concerns.

Definition of HIV. Employees are told what AIDS is and how the virus is transmitted.

AIDS testing and screening. Interpretation of test results is discussed. The policy states that prospective employees will be screened for AIDS prior to employment and describes the testing of blood, tissue, and organ donors, as well as employees who may have been exposed to HIV.

Employees with AIDS. The policy states that the director of laboratories will evaluate the ability of employees with AIDS to perform work responsibilities. It notes that such cases will be handied on an individual basis.

Precautions against infectious diseases. Methods to avoid workrelated infection-including the use of gloves, gowns, and goggles-are described. Guidelines advise what steps to take following accidental spills and accidental exposure.

Management instructions. The policy calls for counseling and disciplinary action when employees fail to comply with AIDS precautions or refuse to care for AIDS patients.

Other labs may wish to consider additional provisions that were not made part of our policy:

Referral to support agencies. Employees would be informed about personnel available in the organization to give advice and make referrals.

Insurance coverage. Coverage of AIDS-related medical expenses under health benefits would be defined.

Changes in policy. A statement would note that policy changes may be made as more is learned about AIDS.

Employee rights to privacy. Confidentiality of information about employees' health and of test results *Is guaranteed.

Many employers have been reluctant to establish an AIDS policy for fear of losing flexibility or because they believe AIDS should be treated like any other disease. Many others, however, feel a policy is advisable to insure that all employees are treated fairly and consistently and to inform employees of the organization's position in dealing with this major health problem.

Although the risk of HIV transmission from close non-sexual contact with an AIDS patient is very small, it does exist. Dedicated employees should not have to take unnecessary chances with a virus as deadly as HIV.

It has been estimated that five million Americans will carry the AIDS virus by 1991. As the "Incidence of HIV-positive patients increases, so will the potential for transmission to health care workers. The keys to preventing exposure to AIDS and all other infectious diseases are education and the availability of protective materials.

Our program has eased the stress of working with AIDS specimens. Before it was implemented, the lab staff would panic whenever a patient tested positive for HIV. Some employees put on gloves before touching so much as a pencil; others used up gallons of bleach disinfecting the lab. Today we act more responsibly. We have become more cautious with all specimens and feel we now know enough about AIDS to protect ourselves.

Through responsible management and employee compliance with established guidelines, we can all win the fight against AIDS in the workplace.

Figure I

Policy on precautions against blood-borne


This policy was developed by Medical Express Laboratories, Memphis.

In the laboratory setting, personnel are becoming more and more exposed to acquired immunodeficiency syndrome and hepatitis. Since the laboratory handles such large amounts of blood and body fluid specimens, Methodist South Hospital Laboratory has chosen the approach that we should treat all specimens as if they were from an AIDS or hepatitis patient.

On July 23, 1988, the Occupational Safety and Health Administration issued an expanded interpretation of an existing standard that addresses the issue of protecting health care emoloyees from job-related infection with the hepatitis virus and human immunodeficiency virus (AIDS virus). The "general duty clause" by OSHA has been extended to include AIDS. This requires all employers to provide employees a work environment that is safe, healthy, and free of hazardous conditions. OSHA has also adopted Centers for Disease Control precautionary guidelines to cover AIDS until a specific standard is available.

The ultimate responsibility for insuring that employees are complying with CDC precautionary guidelines lies with the employers. Employers who fail to mandate compliance to employees are subject to fines up to $10,000 for each offense.

Laboratory's position

Methodist South Hospital Laboratory is complying with the OSHA interpretation relative to AIDS precautions for health care employees. This position will be accomplished through a set of expectations for management and employees, and areas that have not begun to adopt the precautions should do so now.

Expectations of management

1. To personally adopt the guidelines set forth in this policy relative to HIV (AIDS), including the proper handling of all blood and body fluids as though contaminated with HIV and hepatitis virus.

2. To meet with all employees and review the mandatory precautions and supporting information.

3. To insure that necessary protective barriers that fit are available to employees at all times.

4. To counsel and discipline employees, as indicated, for failure to comply.

Expectations of employees

1 . To personally adopt precautionary guidelines for health care employees relative to HIV and hepatitis virus,

2. To consult with the manager on any concerns or situations relative to HIV and hepatitis virus.


Acquired immunodeficiency syndrome (AIDS) is a disease of the immune system caused by the human immunodeficiency virus (HIV, formerly called HTLV-III). Transmission of the virus occurs by: 1) exposure to blood products, whether through a transfusion, intravenous drug abuse, or an accidental exposure to blood from an infected person; 2) perinatal transmission; or 3) sexual contact with the exchange of blood, semen, or vaginal secretions.

In the laboratory setting, personnelare becoming more and more exposed to AIDS and specimens from AIDS patients. It has been estimated that less than 2 per cent of all HIV-infected persons have AIDS. Thus it is not possible to identify the large majority of persons with HIV infection.

Methodist South Hospital Laboratory has set the following guidelines to prevent the accidental exposure of laboratory personnel to the AIDS virus. Since the laboratory handles a large amount of blood and body fluid specimens, an industrial approach to all patients must be initiated. This approach will consider all patients and patient specimens as contaminated with the AIDS virus.

Non-A, non-B hepatitis in the United States has epidemiologic characteristics similar to those of hepatitis B, occurring most commonly after blood transfusions and parenteral drug abuse. Multiple episodes of non-A, non-B hepatitis have been observed in the same persons and may be due to different agents. Chronic hepatitis following acute non-A, non-B hepatitis infection varies in frequency from 20 per cent to 70 percent. Experimental studies in chimpanzees have confirmed the existence of a carrier state, which may be present in up to 8 per cent of the population.

Although several studies have attempted to assess the value of prophylaxis with IG against non-A, non-B hepatitis, the results have been equivocal, and no specific recommendations can be made. However, for persons with percutaneous exposure to blood from a patient with non-A, non-B hepatitis, it may be reasonable to administer IG (0.06 ml/ky) as soon as possible after exposure.

1. Serologic screening

Routine screening for HIV infection and hepatitis B infection will be offered free with the donation of a unit of blood through the Methodist South Hospital Blood Program.

If an employee desires HIV infection testing without participating in the blood program, it can be provided at the standard laboratory discount rate.

II. Donors of tissue, organs, and blood

The donors of all tissue, organs, and blood will be screened for blood-borne disease, including HIV, prior to transplantation or transfusion. Living donors will be informed of the testing.

III. Laboratory personnel

A. Employee exposure and testing

Laboratory personnel should report all exposures to blood or body fluid to their manager.

If the exposure has caused the transmission of blood or body fluid into the health care worker: 1) A baseline for HIV should be run on both the employee and the patient, if a specimen is available. 2) The following testing procedure will be used for health care and laboratory employees who have been exposed. 3) An incident report will be completed and if necessary, an IG and tetanus injection for hepatitis exposure will be administered by the employee health clinic nurse.

Testing procedure:

EIA- Western blot IFA Antigen Code

- 1

+ + 2

+ - - - 3

+ - + + 4

+ Indeterminate - - 5

+ Indeterminate + + 6

1: Negative for HIV infection at this time.

2: Positive for HIV antibody confirmed by Western blot.

3: No serological evidence for HIV infection at this time.

4: Positive for HIV infection.

5: Indeterminate-results inconclusive-. repeat at suggested interval.

6: Positive serological evidence for HIV infection.

B. Employees who test positive for HIV infection

The ability of the individual who has AIDS or tests positive for HIV infection to perform work responsibilities should be evaluated on an individual basis by the director of laboratories,

C. Patient care

Laboratory employees' refusal to render care to patients with evidence of HIV infection or to work with employees with HIV infection should be handled via current work rules and disciplinary procedures for the laboratory.

D. Pregnant employees

CDC guidelines clearly state that pregnant women are no more susceptible than non-pregnant women to AIDS and other blood-borne infections.

IV. Preventive measures for transmission of AIDS and hepatitis in the laboratory

1. All work bench areas will be decontaminated at either the beginning or end of every work shift with a 10 per cent Clorox solution or a 3 per cent phenolic solution. Both solutions should have a minimum contact time of 10 minutes.

2. All laboratory specimens should be treated as contaminated with the HIV or hepatitis B virus. Any specimen taken from a known AIDS patient should be clearly marked with BLOOD/BODY FLUID PRECAUTION labels and transported in a leak-proot container. All BLOOD/BODY FLUID PRECAUTION labels should be attached to secondary specimen until discarded.

3. Specimens leaking from their container will be handled as contaminated, and disposable gloves will be worn. If at all possible, decontamination with a 10 per cent Clorox solution on the outside of the container should occur before handling.

4. Every laboratorian who comes in contact with any specimen would take the proper precautions. If hands have open cuts or abrasions, disposable gloves should be worn. If a laboratory coat is worn, it should be removed before one goes to non-patient areas (e.g., cafeteria, gift shop, etc.). This is not only out of concern for transmission of infectious disease but also to uphold professional image.

5. All initial specimens in microbiology should be cultured under a biohazard or laminar flow hood. Protective gloves and protective outer garments should also be worn when initial culturing is performed. Pre-processing manipulation of all other types of laboratory specimens in this area should also be performed under a biohazard hood.

6. Specimens that must be centrifuged should be placed in capped tubes, Centrifuge equipment should be sanitized daily with a 10 per cent Clorox solution with a contact time of 10 minutes,

7. To prevent needlestick injuries, needles should never be recapped, separated from the syringes, or otherwise manipulated. Place needles intact into a puncture-resistant container. The same procedure applies to all sharps utilized in the laboratory.

8. Reusable devices such as pipettes should be placed in a suitable container with an appropriate germicide added, If subject to contamination, phones and CRT keyboards should be decontaminated after use.

9. Mouth pipetting is strictly prohibited in all areas of the laboratory.

10. All laboratory disposables should be placed into biohazard autoclave bags for processing prior to disposal.

11. Accidental spillage of specimens should be cleaned up promptly with a suitable germicide. A 10 per cent solution of Clorox or a 3 per cent phenolic solution may be utilized to clean up biological spills.

12. If accidental exposure to the skin occurs, wash area with a good germicidal soap. Rinse area well with water and apply a 10 per cent Clorox solution to the area for approximately 1 minute before rinsing again with water.

13. Before employees leave the work area, all protective clothing should be removed and appropriate hand-washing procedures initiated.

V. Oral secretions

Oral secretions have not been asssociated with HIV or hepatitis B transmission. The CDC guidelines related to invasive procedures very explicitly urge the use of additional barriers such as masks and eye coverings only when appropriate. This is sensible if more extensive contact with blood is anticipated, such as during autopsy, dental, or endoscopic procedures.

VI. Patient isolation

Patients known to be positive for HIV, but with no other clinical symptoms requiring additional barriers, do not require isolation setups beyond BLOOD/BODY FLUID PRECAUTIONS. The decision to provide additional barriers should be based primarily on clinical presentation rather than on known or proven diagnosis. This will allow all employees to better protect themselves and others before diagnostic tests are completed.

VII. Gloves and gowns

Gloves, gowns, and other appropriate protective barriers will be made available where indicated for gross contamination of blood or body fluids. Gloves and a laboratory coat-gown should be worn when collecting bloodspecimens.

VIII. Pre-employment

1. On all pre-employment physicals, tests for blood-borne diseases including HIV will be performed.

2. If a candidate is positive for HIV infection-HIV antibody confirmed by Western blot or positive serological evidence for HIV infection-his or her application should be reviewed by the director of laboratories and the human resources department.

3. A candidate who has tested positive must also be informed to see his or her private physician for further testing due to abnormal test results.
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Title Annotation:includes policy statement on precautions against blood-borne infection
Author:LeSueur, Carol L.
Publication:Medical Laboratory Observer
Date:Feb 1, 1989
Previous Article:AIDS: how to protect your lab on legal issues.
Next Article:A supervisor's view: AIDS safety policies are impractical.

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