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OSHA puts teeth into AIDS prevention guidelines.

After receiving pressure from Congress and several labor unions, the Occupational Safety and Health Administration has started to put the bite on any health care institution that fails to comply with Federal guidelines designed to prevent the spread of the AIDS virus.

Any institution lax in implementing the guidelines, recently updated by the Centers for Disease Control, could now face fines of up to $10,000. And it appears that a clinical laboratory will be the first such facility to feel the pinch.

An OSHA spokesperson confirmed at press time that one laboratory has been cited for failure to comply. He said the first fine was "not very large," but he was unable to supply additional details because the agency has not yet determined whether to publicize such specifics (anticipated filings under the Freedom of Information Act, however, were expected to force OSHA's hand this fall).

OSHA told Congress it would begin its enforcement with on-site inspections on an "as needed" basis, primarily to follow up on worker complaints to the agency. A more formal oversight policy has not yet been finalized, according to the OSHA spokesperson.

As it currently stands, the fines could range from a mild slap on the wrist to a total of $10,000 per infraction if the Labor Department agency's investigations turn up evidence of "willful violations."

According to the most recent CDC data, 5.8 per cent of the 32,000 adults with AIDS, for whom occupational information was available, are employed in a health care setting. In comparison, 6.8 million persons-representing 5.6 per cent of the U.S. Labor force-are employed in health services.

Of the infected health care workers, 95 per cent were reported as exhibiting high-risk behavior such as homosexual contact or intravenous drug use. But the cause of infection for the remainder was undetermined.

Cases involving three clinicallaboratory technicians were included in that "undetermined" category, as were five physicians, three nurses, nine nursing assistants, seven housekeeping or maintenance workers, one dentist, and one therapist.

In late summer, CDC issued a special 18-page AIDS advisory' that essentially updated and combined previous recommendations on preventive measures for health care workers.

The new guidelines emphasize universal use of such protective gear as gloves, masks, shields, eyewear, gowns, and aprons. Separate sections address concerns for clinical laboratories as well as for persons involved with invasive procedures, autopsies, and dialysis.

Blood and other body fluids from all patients should be considered infective, according to the latest guidelines. Here are the other specific precautions for clinical labs from the CDC:

* All specimens of blood and body fluids should be put in a well-constructed container with a secure lid to prevent leakage during transport. Care should be taken when collecting each specimen to avoid contaminating the outside of the container and the laboratory form accompanying the specimen.

* Everyone processing blood and body-fluid specimens (e.g., removing tops from vacuum tubes) should wear gloves. Masks and protective eyewear should be worn if mucous-membrane contact with blood or body fluids is anticipated. Gloves should be changed and hands washed after specimen processing.

* For routine procedures, such as histologic and pathologic studies or microbiologic culturing, a biological safety cabinet is not necessary. However, biological safety cabinets (Class I or II) should be used whenever procedures are conducted that have a high potential for generating droplets. These include activities such as blending, sonicating, and vigorous mixing.

* Mechanical pipetting devices should be used for manipulating all liquids in the lab. Mouth pipetting must not be done.

* Use of needles and syringes should be limited to situations in which there is no alternative, and the recommendations for preventing injuries with needles outlined under universal precautions should be followed (needles should not be manipulated by hand and should be disposed of in puncture-resistant containers).

* Laboratory work surfaces should be decontaminated with an appropriate chemical germicide after a spill of blood or other fluids and when work activities are completed.

* Contaminated materials used in laboratory tests should be decontaminated before reprocessing or be placed in bags and disposed of in accordance with institutional policies for disposal of infective waste.

* Scientific equipment that has been contaminated with blood or other body fluids should be decontaminated and cleaned before being repaired in the laboratory or transported to the manufacturer.

* All persons should wash their hands after completing laboratory activities and should remove protective clothing before leaving the laboratory.

The guidelines further note that implementation of blood and body-fluid precautions for all patients eliminates the need for warning labels on specimens, since all specimens would be considered infective.

CDC itself has no enforcement mechanism pertaining to the AIDS guidelines, and OSHA, the Federal agency charged with protecting employees from all workbased dangers, had previously been reluctant to assert itself into the AIDS crisis.

That changed dramatically following recent hearings by the House Government Operations Subcommittee on Employment and Housing. In those hearings, Chairman Tom Lantos (D. -Calif.) said he considered all health care workers to be the "front-line troops in the fight against AIDS."

Lantos further stated: "We cannot afford to let this lackadaisical compliance with guidelines for the protection of health care workers go on. It is nothing short of Russian roulette played with the lives of nurses, lab technicians, physicians, housekeeping staff, and other professional and support personnel."

During the hearings, lawmakers also heard the testimonyof Peggy Connerton, chief economist with the Service Employees International Union, which represents more than 300,000 U.S. health care workers. Connerton commented that although AIDS is "much less contagious than hepatitis B, it has more severe consequences for those exposed, since it has no cure. . . .The only cure for AIDS is preventing exposure to the virus."

The Labor representative further testified that nurses at one Los Angeles blood collection facility were forbidden to wear gloves during drawing procedures because donors might be "frightend away." She reported that some of the nurses resorted to self-inflicted scratches to force management's permission to wear gloves for the day.

Other unions called on the Government to issue emergency temporary standards for employee protection. OSHA ultimately rejected that idea but did agree to begin the enforcement of updated CDC guidelines. And now that the word is out, Washington's bite could well be worse than its bark.

1. Recommendations for prevention of HIV transmission in health care settings. MMWR 36: 3S-18S, Aug 21, 1987, Supplement.

Competitive bidding still on hold

It appears the much-debated competitive bidding trial for clinical laboratory services purchased by Medicare will be put on hold again by Congress.

In its version of the fall budget package, the powerful House Ways and Means Committee extended a moratorium on the experiment until Jan. 1, 1989.

The lab industry has lobbied hard-and, it would appear, effectively-against the Health Care Financing Administration project on the grounds that it would decrease competition by excluding many laboratories from Medicare business, and thus cause beneficiary out-of-pocket expenses to rise.

HCFA's main contractor on the program, Boston-based Abt Associates, has essentially completed the design phase and is left awaiting further direction from Washington.

The competitive bidding proposal, as well as all other lab-related measures, awaits further attention in Congress's overall budget reconciliation process. Everyone on the Hill is hopeful the process will be completed by the holiday recess in December, but no one is ready to make any predictions.
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Title Annotation:Occupational Safety and Health Administration
Publication:Medical Laboratory Observer
Date:Nov 1, 1987
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