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CDC updates precautions against AIDS.

The Centers for Disease Control has updated its precautions against AIDS infection in health care settings. Portions of the new guidelines' appear to be somewhat less stringent than previous recommendations.

On a related matter, the Occupational Safety and Health Administration is advancing work on AIDS prevention regulations that health care facilities must adhere to under threat of fines. At least one product manufacturer has encouraged the agency to include standards for protective apparel such as gowns and gloves.

CDC first published a document in 1983 entitled "Guidelines for Isolation Precautions in Hospitals," which contained a section on blood and body fluid precautions. Recommendations in that section called for preventive measures when a patient was known or suspected to be infected with bloodborne pathogens.

In August 1987, the Centers published "Recommendations for Prevention of HIV Transmission in Health-Care Settings." 2 In contrast to the 1983 guidelines, this document suggested that blood and body fluid precautions be consistently used for all patients, regardless of their bloodborne infection status. The extension, which became known as "Universal Precautions," stated that blood and body fluids of all patients should be considered potentially infectious for HIV, hepatitis B virus, and other bloodborne pathogens.

The Universal Precautions were designed to prevent parenteral, mucous membrane, and nonintact skin exposure to pathogens among health care workers. Further, immunization with hepatitis B vaccine was recommended as an important adjunct to worker safety.

Since those precautions were issued, CDC and the Food and Drug Administration have received numerous requests or clarification on body fluids to which the guidelines apply, use of protective barriers, use of gloves for phlebotomy, selection of glove types, and the need for changes in waste management programs as a result of complying with the precautions.

While the 1987 guidelines stressed the universal use of protective apparel, the Centers for Disease Control update issued in June seems less adamant about glovewear during phlebotomy.

According to the update, the risk of hand contamination from infected blood depends on the skill and technique of the worker, the frequency with which the procedure is performed, whether the procedure is done during an emergency situation, and the prevalence of infection in the patient population.

The update repeats that all blood is assumed to be potentially infective. But, it states, "in certain settings (e.g., volunteer blood donation centers), the prevalence of infection with some bloodborne pathogens is known to be very low."

While not explicitly condoning the nonuse of gloves, one carefully worded passage of the CDC update says: "Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health care workers who wish to use them for phlebotomy.

In addition, CDC specifies that gloves should be worn:

* For performing phlebotomy when the health care worker has cuts, scratches, or other breaks in the skin.

*In situations where the worker judges that hand contamination with blood may occur; for example, when performing phlebotomy on an uncooperative patient.

* For performing finger sticks and/ or heel sticks on infants and children.

* When persons are receiving training in phlebotomy.

FDA has responsibility for regulating the medical glove industry, with the exception of general purpose utility or "rubber" gloves, also used in health care settings. But as CDC explains, "There are no reported differences in barrier effectiveness between intact latex and intact vinyl used to manufacture gloves. Thus the type of gloves selected should be appropriate for the task being performed. "

The following general guidelines are recommended for glove selection:

* Use sterile gloves for proce

dures involving contact with normally sterile areas of the body.

* Use examination gloves for procedures involving contact with mucous membranes, unless otherwise indicated, and for other patient care or diagnostic procedures that do not require sterile gloves.

* Change gloves between patient contacts.

*Do not wash or disinfect surgical or examination gloves for reuse. Washing with surfactants may cause "wicking," the enhanced penetration of liquids through undetected holes in the glove. Disinfecting agents may cause deterioration.

* Use general purpose gloves for housekeeping chores involving potential blood contact and instrument cleaning and decontamination procedures. Utility gloves may be decontaminated and reused, but they should be discarded if they are peeling, cracked, or discolored, or if they have punctures, tears, or other signs of deterioration.

On related topics, CDC now says that Universal Precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, or vomitus unless they contain visible blood. "The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent," the agency states.

Further, the precautions do not apply to saliva. According to the update, chances of infection from the secretion are remote, and "general infection control practices already in existence-including the use of gloves for digital examination of mucous membranes and endotracheal suctioning and handwashing after exposure-should further minimize the minute risk, if any, for salivary transmission of HIV and HBV." Officials add that gloves need not be worn when feeding patients and when wiping saliva from the skin.

Portions of the update on protective barriers are substantially similar to the previous guidelines. For example, CDC continues to state that needles should not be recapped by hand, nor should they be bent, broken, or otherwise manually manipulated.

Officials explain that the Universal Precautions are intended to supplement rather than replace recommendations for routine infection control. The clarification states: "Because specifying the types of barriers needed for every possible clinical situation is impractical, some judgment must be exercised."

Beyond exercising care with needles, scalpels, and other sharp objects, CDC says to use protective barriers to prevent exposure to blood, body fluids containing visible blood, and other fluids to which the precautions apply. The type of barrier selected should be appropriate to the procedure being performed. Officials also say workers should immediately and thoroughly wash hands and other skin contaminated by materials cited by the precautions.

Finally, CDC notes that its 1987 guidelines are not intended to change waste management programs previously recommended for health care settings. Policies for defining, collecting, storing, decontaminating, and disposing of infective wastes are generally determined by institutions in accordance with state and local regulations. Information regarding waste management regulations in health care settings may be obtained from state or local health departments or from agencies responsible for waste management.

As CDC disseminates its information update, OSHA officials continue to advance a standard to protect workers against bloodborne infectious diseases.

The effort began last fall at about the same time the Labor Department agency began enforcing CDC guidelines under existing regulatory authority. Any health facility that is lax in implementing the guidelines faces possible fines of up to $10,000. Clinical laboratories and other health care providers are subject to on-site inspections conducted on an asneeded basis.

As that enforcement continues, OSHA is drafting a more formal standard in conjunction with CDC and industry officials.

Submitting public comment, product supplier Kimberly Clark has urged OSHA to make standards on barrier resistance of protective apparel part of the new rules. The manufacturer has developed a test for measuring the resistance of such items as gowns and gloves. Company officials suggest the test could have wide application for judging the effectiveness of products from various manufacturers.

An OSHA spokesperson declined to comment on that possibility, nor could she predict when the overall standard might be finalized. A draft, however, is expected to go to the Office of Management and Budget for analysis sometime this fall.
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Title Annotation:Centers for Disease Control
Publication:Medical Laboratory Observer
Date:Sep 1, 1988
Previous Article:What technologist shortage?
Next Article:Regulation of physicians' office laboratories.

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