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The risk of AIDS to laboratorians: an update.

The risk of AIDS to laboratorians: An update

A leading AIDS epedemiologist from the Centers for Disease Control in Atlanta has called for all health care workers to deal with the risk of occupational exposure to HIV based on current data and on logic. James W. Curan, M.D., M.P.H., director of the division of HIV/AIDS at the CDC, made this challenge as part of his presentation to the Fifth International AIDS Conference held last summer in Montreal.

In his opening remarks on "HIV Transmission in the Health Care Setting," Dr, Curran noted that the debate over tha occupational risk of AIDS tends to be more passion than data and more emotion than logic. Indeed, he charged that if there is a gap iin America's ability to deal with HIV and AIDS, it is that we have toofew good workers involved in the clinical management of AIDS patients. To reach a balance between prudence and paranoia, we must be aware of employee concerns, better define the actual risk, and then do whatever we can to minimize the lifetime occupational threat of HIV exposure.

The hysteria over the occupational risk of AIDS erupted three years ago when the CDC announced that three health care workers had indeed become infected on the job. [1] The virus was transmitted through contact with non-intact skin or mucous membranes - there was no report of needlestick injury. This news triggered shock waves in the medical community and sent many workers scrambling for gloves and other methods of barrier protection. [2] For until May of 1987, the experts had assured us that HIV simply was not transmitted through casual contact. Yet many of us no doubt wondered whether the intense exposure common in certain health care professions could truly be considered casual contact.

Though the furor eventually subsided, the emotional debate continues, and the uncertainty is having a perceptible impact on the health care professions. * Defining the risks. The CDC began examining the risk of acquiring HIV from documented occupational exposure to blood and body fluids in 1983. The Cooperative Needlestick Surveillance Group has been monitoring on-the-job exposures of health care workers involving parenteral (needlestick), mucous membrane, or non-intack sking exposure. Subjects' blood is tested for HIV anitibody at six weeks and again at three, six, and 12 months following exposure and every six months thereafter. Specimens are tested by EIA to screen for the HIV antibody and by Western blot, a confirmatory test for the antibody. Investigators also look at exactly how each exposure occurred to gain valuable insight for preventive strategies.

As of December 31, 1989, more than 1,500 health care workers had been tested for the HIV antibody. (This number in no way reflects the number of HIV exposures among health care workers but merely those referred to the project.) Most of the participants came from such states as California, New York, New Jersey, and Florida, where AIDS is most prevalent.

Exposure in the majority of cases (80 per cent) resulted from needlesticks. Eight per cent of the subjects were cut with a sharp object, 7 per cent contaminated an open wound, and 5 per cent suffered splashes on a mucous membrane. More than 22 per cent of the needlestick injuries occurred duting recapping and thus were considered preventable. Most of the exposures due to blood entering an open wound could also have been prevented - simply by wearing gloves. [3]

The degree of patient contact was the overriding factor when considering job category - the more invasive the procedure performed, the greater the possibility of needlestick injury. Sixty-three per cent of those infected were nurses, 14 percent were physicians or medical students, and 10 per cent were laboratorians. The remaining 13 per cent included such health care personnerl as housekeepers. The degree of patient contact was also the determinant in assessing where the exposure occurred - 64 per cent happened in the patient's room or in a clinic. An additional 13 per cent occurred in the intensive care unit, 7 per cent in the operating room, and 7 per cent in the laboratory. The remaining 9 per cent covered all other areas, including the morgue.

Only four of these more than 1,500 health care workers subsequently seroconverted. All four were exposed via needlestick injury; none of those exposed by blood contamination of mucous membranes or broken skin have seroconverted. One of these four subjects did not have a baseline specimen available for testing and consequently could not be considered "documented."

Of the remaining three health care subjects, one suffered a deep needlestick, inflicted accidentally by a coworker during a resuscitation procedure. Two weeks later this person experienced an acute retroviral illness characterized by fever, shaking chills, arthralgia, and myalgia. the test for HIV anitbody was negative at day nine, but turned up positive at three months.

The second health care worker contracted the virus in almost exactly the same manner. Initial testing one day after exposure was negative for HIV antibody. One month later, however, the worker developed fever, shaking chills, night sweats, lymphadenopathy, and malaise. Both EIA and Western blot tests were positive at four months.

The third health care worker had two needlestick injuries 10 days apart. the baseline sera were negative, but four weeks later this person experienced fever, shaking chills, nausea, malaise, lymphadenopathy, dehydration, and a weight loss of more than 4.5 kilograms (nearly 10 pounds). At four months, the worker tested sero-positive by EIA and Western blot.

Since no other risk factors for HIV infection could be identified for any of these four health care workers, the infections were considered to be occupationally acquired. At the time of the conference last summer - and up to this artticle's publication - none of these four had developed overt AIDS. One of them, however, has gone on to develop sustained lymphadenopathy.

Health care workers in the survey who had received a needlestick injury or other exposure were counseled locally - either at their institutions or by their personal physicians - and advised to follow the somewhat vague Public Health Service guidelines. Specifically, they were advised to refrain from sexual intercourse or to use a condom for approximately six months. They were also asked to postpone pregnancy and not to donate blood during the first six to 12 weeks following exposure - the time when seroconversion is most likely to occur.

This study concluded that the risk of HIV infection following a known exposure is less than 1 per cent - 0.42 per cent in this particular study. The rate of AIDS infection is low, especially when compared with the likelihood of hepatitis B viral infection in health care workers. Even so, the study did emphasize that many of these exposures could have been prevented by following universal precautions.

Since October 1988, the CDC has been collecting information on the prophylactic use of such chemotherapeutic agents as zidovudine (AZT). Of the 13 health care workers who have received treatment, none had seroconverted by early this year. (4) Although this was encouraging news, no real conclusions could be drawn, given the small number of subjects and restricted follow-up time. The CDC has also started to stratify data with respect to severity of exposure - for example, a superficial needlestick injury versus a moderate or deep injury.

Additionally, in view of the current reports of individuals infected for substantial lengths of time before seroconversion, blood cells are now collected in the most severe exposures and will be monitored by the polymerase chain reaction (PCR). This makes it possible to detect AIDS viral nucleic acid within the cell duting the dormant state. Nationwide, about 100 health care workers testing negative for the HIV antibody have also tested negative for PCR, which is very reassuring in light of recent reports of individuals seroconverting long after having been infected with HIV. (3) * Health care workers who have AIDS. All AIDS cases reported to the CDC are categorized by exposure based on the specific mode of transmission. As of March 31, 1989, nearly 115,000 adult cases of AIDS had been reported in the United States. Five per cent of these patients were identified as health care workers, yet 5.7 per cent of the nation's work force is employed in health services. Thus, as a group, health care workers are not overrepresented in terms of full-blown AIDS cases. More than 94 per cent of the infected health care workers reported behavioral risks unrelated to their occupation. [5]

Health care workers who develop AIDS and have no identifiable risk factors (such as intravenous drug use or anal intercourse) get top priority for immediate follow-up by a local health department or agency to determine whether there was an occupational expoxsure, such as a needlestick or a cut with a contaminted object. After a complete and extensive follow-up non-work-related risk factors were established for 72 per cent of the 175 subjects.

Although no risk factors were identified for the remaining 49 individuals 58 per cent reported that their jobs involved potential contact with blood. Fifty-three per cent remembered one or more specific injuries from needlesticks or other sharp objects, while 36 per cent recalled mucous membrane exposure to blood or other body fluids. Some had multiple risk factors.

Unfortunately, the potential exposures they described had not been documented at the time, and it is almost impossible to go back months or years later and determine whether the exposure involved HIV-positive blood or body fluids. Conversely, there was a disproportionate number of males in this group and a disproportionate incidence of sexually transmitted diseases. Thus, one could argue for a sexual rather than occupational mode of transmission. One health care worker with AIDS did undergo well-documented seroconversion to HIV following a needlestick with blood from an AIDS patient. (4)

A major limitation of such a surveillance study is that it gathers information only on health care workers who progress all the way to full-blown AIDS. There is a considerable time lapse from exposure and seroconversion until the patient manifests overt symptoms of AIDS. That is, seroconversion usually occurs within six months, but it may take a year or more to develop full-blown AIDS. These individuals are termed "HIV positive." There were many anecdotal reports of health care workers who had, in fact, seroconverted byt had not yet developed AIDS. One such report dealt with 10 orthopedic surgeons who had become infected with HIV and then seroconverted.

A study performed by the Walter Reed Retrovirus Research Group at the Walter Reed Army Institute of Research in Washington, D.C., examined the association between employment in health care professions and HIV infection among U.S. Army Reserve personnel. Inverstigators found a higher prevelence of HIV-positive subjects among the health care personnel - mostly unmarried males. This study did not support a hypothesis of an occupational risk but probably reflected a higher than expected percentage of homosexuals in the military who did not admit to such risk behavior for fear of retaliation. * Significant exposure to blood and body fluids. Gabor Kelen, M.D., of the Johns Hopkins University School of Medicine in Baltimore, evaluated compliance with universal precautions at the hspital's emergency department - a pioneer with respect to barrier protection and biosafety procedures. [6] In the emergency unit, located in inner-city Baltimore, the blood of a surprisingly high 6 per cent of patients contains HIV antibody.

Dr. Kelen acknoledged that universal precautions and barrier protection are the only way to minimize exposure and protect the staff. Yet compliance with hospital policies and CDC guidelines remains poor, despite the high prevalence of HIV positivity among the patient population and a comprehensive educational awareness program. The investigators observed 129 health care workers during 1,274 interventions ranging from minor to major exposures to blood and body fluids. Overall adherence was deemed "adequate" only 57.4 per cent of the time during minor interventions and fell to a mere 16.5 per cent during major interventions. Adherence plummeted to an abysmal 0.8 per cent in major non-trauma procedures. (5)

Compliance was best among the housekeeping staff, who took adequate precautions 91 per cent of the time. Paramedics had the worst showing, with a compliance rate of only 8 per cent. Physicians complied 38 per cent of the time, and nurses, 44 per cent.

When precautions fell short, health care workers were most likely not to wear surgical masks. Indeed, masks were used in only 22.4 per cent of the cases where the investigators deemed them to have been necessary. Compliance was 45 per cent for eye protection and 49.6 per cent for gowns. Health care personner did better with gloves, which they wore in 73.7 per cent of appropriate situations.

Overall, it was an inordinately poor showing. A follow-up questionnaire helped explain why these workers had chosen to ignore commonsense measures. Forty-seven per cent noted that it simply took too much time to suit up in protective garb. Another 33 per cent commented that the protective gear either got in the way or was just plain uncomfortable.

Yet despite such protestations, the same health care workers stated that they still considered universal precautions necessary. Since the hospital's intensive training program hadn't convinced staff members to take adequate precautions, the investigators suggested pursuing such strategies as strictly enforcing biosafety measures as part of performance evaluations; implementing disciplinary measures, such as suspension or even termination for noncompliance; and altering the physical design and placement of protective materials. * Attitudes about AIDS. The conference focused much attention on health care workers' attitudes, concerns, stress, knowledge, and behavior when dealing with AIDS. This is where the profession's battle of AIDS begins, and there is a long way to go. In a Zairian study [7] of 3,500 health care workers, for example, more than one-third of the professionals polled recommended isolating AIDS patients. Three per cent actually advocated killing them.

Despite such extreme views as expressed by a few, the vast majority of health care workers are compassionate and dedicated and accept the risk as part of their jobs. That is not to say the impact is not being felt, particularly in the lab. Joan Dworkin of the University of Illinois, Chicago, reports that areas in which the population has a high incidence of AIDS are experiencing employee loss, a reluctance to work in certain hospitals or specialties, and considerable stress among those remaining on staff. [8] * Impact on lab workers. Medical technologists, medical technicians, phlebotomists, and other laboratorians are on the front lines when it comes to occupational risk and stress. Not surprisingly, one study found that needlestick injuries have an adverse emotional impact on staff members. Participants worried about developing an infection or possibly infecting family members. They also lost both sleep and appetite. Forty per cent of the 54 health care workers reporting a needlestick injury experienced anxiety over the possibility of contracting AIDS. Eighteen per cent lost sleep, and 9 per cent noted a loss of appetite. [9]

These concerns will ultimately have an even greater impact on the medical technology profession. An anecdotal report underlined just how devastating an accidental needlestick can be. The victim, a nurse, received no counseling from her New Jersey hospital after the accident. Her spouse left her. This health care worker eventually left the profession entirely.

A brand-new case report involves a 28-year-old medical technologist who developed AIDS. [10] Careful investigation ruled out the typical methods of transmission. The investigators concluded that she may have become infected following direct inoculation with HIV-contaminated blood. The mode of transmission: weeping lesions on the technologist's hands.

Only one study presented at the conference addressed the level of concern among technologists. A survey conducted at the 1988 meeting of the New Jersey Society for Medical Technology found a high degree of concern about occupational exposure, which may, in turn, contribute to the chronic staff shortage in the laboratory. [11]

Indeed, 85.4 per cent of the 283 technologists surveyed admitted that friend or family members worried about the routine contact with HIV-positive specimens. The technologists also worry, and 25.9 per cent are considering a career change because of their own fear or because of pressure from home. Nearly half (45.2 per cent) said that if they had known before what they know now, they never would have become medical technologists in the first place. The findings are particularly ominous given that New Jersey has one of the highest incidence rates of AIDS. This study, however, simply reflects what has already been observed in other health care professions in high-incidence areas: Fear is prompting many people to consider leaving the lab. * Combating fear. Several studies underscored the need for better educational programs and demonstrated how incredibly misinformed "knowledgeable" health care professionals can be when it comes to AIDS. Ironically, half of the employees at the renowned Centers for Disease Control could not correctly identify what the HIV antibody test actually represents. [12] Those attending the CDC educational conference (583 employees, representing 93 per cent of the staff) agreed that biosafety education for employees must go beyond a simply lecture and a few posters.

Julie L. Gerberding, M.D., of San Francisco General Hospital, advocates combating this fear with intensive, ongoing, on-site education. [13] This effort should include such basics of biosafety as where the protective devices are kept and how often the disinfectant solutions should be changed and by whom.

The Occupational Safety and Health Administration (OSHA) has responded to such risks in the workplace by issuing proposed regulations governing occupational exposure to bloodborne pathogens. The proposed regs were issued on May 30, 1989. When they are published in final form, possibly not until early next year, they will be mandatory, unlike the CDC and Public Health Service guidelines, which are only recomendations. (See the related article in this issue, "OSHA: New Player in the Battle Against AIDS.") * Risk low, but take care. The take-home lesson from the AIDS conference was that the occupational risk of contracting AIDS is low and many exposures can be prevented by taking simple precautions. Since clinical laboratorians are at risk of exposure to HIV, OSHA will give employers no choice but to take a more pro-active stance in implementing biosafety policies.

The greatest obstacle with AIDS is fear, and this fear must be met head on. We must educate staff members and provide both protection and guidance. Since the time of Louis Pasteur, laboratorians have accepted the occupational risk of being exposed to many potentially fatal infectious diseases.

Laboratorians must also set an example for others. We must demonstrate how to work safely, despite the many risks. Finally, laboratorians must assume a leadership role in the fight to dispel the fear and hysteria so closely linked to AIDS. The issues raised at last year's conference will no doubt be examined more closely at the Sixth International Conference on AIDS, to be held June 20-24 in San Francisco.

[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, B.L., and Brown, J.W. The Third International Conference on AIDS: Risk of AIDS in health care workers. Nurs. Management 19(3): 33-35, 1988.

[3.] Marcus, R. Health care workers exposed to patients infected with human immunodeficiency virus (HIV), United States. Abstract #W.A.O.1, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[4.] Centers for Disease Control. Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR 39(RR-1): 1-14, 1990.

[5.] Chamberland, M.; Conley, L.; Bush, T; et al. Surveillance update: Health care workers with AIDS. Abstract #W.A.O.2, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[6.] Kelen, G.; DiGiovanna, T.; Kalainov, D.; et al. Experience with AIDS among 3,500 Zairian health workers, 1987-1989. Abstract #M.D.P.49, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[7.] Moore, M.; Hassig, S.E.; Lusakulira, N.; et al. Experience with AIDS maong 3,500 Zairian health workers, 1987-1988 . Abstract #E.745, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[8.] Dworkin, J.; Albrecht, G.; and Cooksey, J. Health professionals' knowledge, experience, and attitudes concerning AIDS in relation to anxiety about caring for infected persons. Abstract #E.745, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[9.] Marrie, T.; MacIntosh, N.; Streight, R.; et al. The emotional impact of needlestick injuries on health care workers. Abstract #E.743, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[10.] Haley, C.E.; Reff, V.J.; and Murphy, F.K. Report of a possible laboratory-acquired HIV infection. Abstract #Th.A.P.48, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[11.] Brown, J.W.; Feeney, K.B.; and Gauch, R. Attitudes of medical technologists toward the acquired immunodeficiency syndrome. Abstract #E.746, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[12.] Rugg, D.; Kidd, S.; Brownell, D.; et al. Workplace AIDS education: An evaluation of CDC employees. Abstract #M.E.P.30, presented at the Fifth International AIDS Conference, Montreal, June 1989.

[13.] Gerberding, J.L. Effecting behavior change through policy and training. Abstract #M.E.P.26, presented at the Fifth International AIDS Conference, Montreal, June 1989.

Dr. Brown is director of microbiology and health and environmental affairs and Dr. Haider is assistant vice president, Roche Biomedical Laboratories, Raritan, N.J.
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Author:Brown, James W.; Haider, Masood
Publication:Medical Laboratory Observer
Date:Apr 1, 1990
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