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AIDS precautions in the '90s: prudence or paranoia?

The author, a close observer of the AIDS epidemic, reviews the effectiveness of Federal actions to control the spread of HIV infection.

By the winter of 1987 the AIDS outbreak in this country was reaching its peak momentum. With a 25% increase in new cases over the previous year, some public health experts were predicting that the deadly epidemic would continue to accelerate into the '90s and overwhelm our health care system. Fortunately, however, the increase in new cases declined earlier than expected, rising only 9% between 1989 and 1990. It will probably be in the same range when all the figures are in for 1991.

An appreciable decline in new cases has occurred among a major risk group, the gay community, as many of those previously infected have already developed AIDS and those who are uninfected increase their precautions to prevent its spread. Even IV drug users seem to be showing some precautionary behavior. While this apparent plateau is somewhat reassuring, we are seeing certain disturbing demographic shifts in the epidemiology, mainly the heterosexual spread to minority women and their newborns.

* Health care workers. Even in the face of ominous statistics that were emerging in late 1987, health care workers were being assured that their contact with the blood and tissues of AIDS patients posed no real threat to their safety. This sense of complacency was shattered by the Centers for Disease Control announcement in the May 18, 1987, issue of Morbidity and Mortality Weekly Report (MMWR) that three clinical laboratory workers had become infected with HIV through nonparenteral contact with blood specimens via nonintact skin and mucous membranes.[1]

It was this news that led the CDC to commission a task force, which that summer introduced the concept of universal precautions (UP). This was soon followed by the NCCLS's comprehensive M29 guidelines on protection of laboratory workers. During that same summer, largely in response to several municipal unions' petitions to insure the safety of their membership from occupational exposure to the AIDS virus, the Occupational Safety and Health Administration (OSHA) decided to get into the act. At that time OSHA began the long preparatory process leading to the recent publication of the final standard for the protection of workers from bloodborne diseases. As of March 6, 1992, this rule gave many Federal guidelines the bite of law.

Now, on the fifth anniversary of the MMWR report that gave rise to all this activity, it seems appropriate to reflect on the impact of the infection control strategies that resulted from it. Universal precautions and its offspring, body substance isolation (BSI), have been in wide use for four years. Have they been cost-effective? Although exact figures are still lacking, these codes have clearly added millions of dollars to the cost of doing business for hospitals faced with declining reimbursement from third-party payers.

Whether as a result of the promulgation of UP or despite it, there has been no evidence of significant hospital or laboratory workplace transmission of HIV in the last four years by either parenteral or nonparenteral routes. Largely as a consequence of the very low levels of viremia in infected blood, experience has shown a risk of only 0.3% that seroconversion will follow accidental needlestick injury with HIV-positive blood. The risk of nonparenteral exposure is presumably less by some orders of magnitude.

This low risk has led some public health critics to suggest that the three cases of nonparenteral transmission reported by the CDC in 1987 may have been aberrations. Critics also say that the present OSHA regulations, with their emphasis on hand and body barrier protection, may be overrestrictive, representing yet another example of Governmental regulatory excess. An example of the latter was the Medical Waste Tracking Act of 1988, hastily enacted in response to public pressure on state and Federal legislators following intense media coverage of beach washups of medical waste that summer. In the opinion of some experts, the debacle resulted in a set of regulations that have increased hospital costs extraordinarily while providing no clearly demonstrated benefit to the environment or public health.

Unfortunately, very few studies on UP efficacy have been published. Although these few have purported to show a net decrease in reported accidental exposures following the institution of UP, they rely on unverified self-reporting of exposures and suffer from the potential bias of underreporting. Of considerable interest are recent studies that reveal a shockingly poor compliance record by laboratory and nursing groups when carefully observed.[2]

Among the few surprises in the OSHA final standard was the removal of the local option for glove use by phlebotomists. It will now be mandatory that all phlebotomists in non-donor facilities wear gloves when performing their duties. This requirement will be stiffly resisted by many skilled phlebotomists who feel that gloves offer no protection from needlestick injuries and may impede their ability to perform difficult venipunctures.

* At greatest risk. It is this observer's feeling that the greatest potential risk of HIV seroconversion in the laboratory workplace is to the pathologist who must handle and dissect bulky and often bloody surgical and autopsy tissues. Although no cases of occupational seroconversions among this group have been reported to date, it is widely suspected that accidental exposures are vastly underreported. It is indeed unfortunate that we have no current information on the incidence of seroconversion among anatomic pathologists in otherwise non-risk groups.

Another unanswered question is the value of prophylactic treatment of occupational exposures with azidothymidine (AZT). Despite efforts by the CDC to collect prospective data on this question, no hard evidence has appeared that such treatment, with all its potential side effects, will protect against infection. At present, the burden of deciding whether to commence prophylactic treatment rests with the injured worker, who has little time or hard data available for guidance.

A preoccupation with HIV during the last few years has diverted attention from another major bloodborne infection, hepatitis B, which exacts a much higher toll of disease on the health care worker. The reported incidence of acute HBV in the general population increased by 37% from 1979 to 1989. The United States now includes an estimated 1.25 million carriers of HBV whose blood and tissues represent a significant danger to laboratory workers, probably more so than HIV. Perhaps, ironically, the greatest contribution of the new OSHA regulations to worker safety mill be not its strict mandate of universal precautions but its provision for employers to encourage, provide, and subsidize HBV immunization for all workers at risk.

[1.] Centers for Disease Control. Update: Human immunodeficiency virus infections in health care workers exposed to blood of infected patients. MMWR 36(19):285-289, 1987. [2.] Brown, J.W. Laboratorians: On the front lines of exposure (lab-related findings from the 7th International Conference on AIDS). MLO 23(8):54-60, August 1991.

General References

Brown, J., and Haider, M. The risk of AIDS to laboratorians: An update. MLO 22(4): 43-48, April 1990.

Gershon, R.; Carbow, B.; Vlahov, D.; et al. Low compliance with universal precautions among hospital employees despite high perceived risk. Presented at the 7th International Conference on AIDS, Florence, Italy, June 19, 1991.

Has AIDS peaked? (editorial). Sci. Am. 265: 302, September 1991.

Rutola, W.; and Weber, D. Infectious waste - mismatch between science and policy (Sounding Board). N. Engl. J. Med. 321:529, 1991.

Wong, E., and Stotka, J. Are universal precautions effective in reducing the number of occupational exposures among health care workers? JAMA 265: 1123-1128, 1991.

The author, director of laboratories and nuclear medicine at Northern Westchester Hospital Center, Mount Kisco, N.Y., is a member of the CAP Committee on AIDS and of the NCCLS Subcommittee on Protection of Laboratory Workers from Bloodborne infections. The views expressed in this article are his own.
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Article Details
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Author:Alpert, Laurence I.
Publication:Medical Laboratory Observer
Article Type:Cover Story
Date:Apr 1, 1992
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