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OCR for page 155
Appendix C
Recommendations for
Prevention of HIV Transmission in
Health-Care Settings
C O N T EbrrS
I. Recommendations for Prevention
of HIV Transmission
in Health-Care Settings*
Introduction
156
Definition of Health-Care Workers 156
Health-Care Workers with AIDS
157
Risk to Health-Care Workers of
Acquiring REV in Health-Care
Settings 157
Precautions to Prevent Transmission
of HIV
158
Universal~cautions 158
Precautions for Invasive Procedures 159
159
Precautions for Dentistry..............
Precautions for AUtDDRi~R or Morticinn.~'
Environmental Considerations for
H]VTransmi~ion 161
Sterilization and Disinfection 161
Survival of HIV in the Environment 162
Housekeeping 162
Cleaning and Decontaminating Spills of
Blood or Other Bodv Fluids
162
Laundry 162
InfectiveWaste 163
Implementation of Recommended
Precautions ..................
Seriologic Testing for HIV Infection
R~.lr~rn~mfl
63
163
_ ~ ~_ 163
64
65
-
Testing of Patients ............
Testing of Health~are Workers .
Management of Infected Health-Care
Workers
165
Services 160 Management of Exposures 166
Precautions for Dialysis 160
Precautions for Labo~tories 160 References 166
* Reprinted from Morbidity and Mortality Weeldy Report, 1987; 36 (2S):3S-18S.
NOTE: Tables and page numbers in these repents have been renumbered to avoid confusion.
155
OCR for page 156
156
II. Update: Universal Precautions for
Prevention of Transmission of Human
Immunodeficiency Virus, Hepatitis B Virus,
and Other Bloodborne Pathogens in
Health-Care Settings**
Introduction bee e~eeeeeeeeeeeeee 168
Body Fluids to Which Universal
Precautions Apply ...............
Body Fluids to Which Universal
Precautions Do Not Apply e e e e e
...... 169
e e e e e e e e 169
I. RECOMMENDATIONS FOR
PREVENTION OF HIV TRANSMISSION
IN HEALTH-CARE SETTINGS
INTRODUCTION
Human immunodeficiency virus (HIV), the vi-
rus Hat causes acquired immunodef~ciency syndrome
(AIDS), is transmitted Trough sexual contact and
exposure to infected blood or blood components and
perinatally from mower to neonate. HIV has been
isolated from blood, semen, vaginal secretions, sa-
liva, tears, breast mills, cerebrospinal fluid, amniotic
fluid, and urine and is likely to be isolated from other
body fluids, secretions, and excretions. However,
epidemiologic evidence has implicated only blood,
semen, vaginal secretions, and possibly breast milk
· · -
in transmission.
The increasing prevalence of HIV increases the
risk that health-care workers will be exposed to blood
from patients infected with HIV, especially when
blood and body-fluid precautions are not followed
for all patients. Thus, this document emphasizes the
need for health-care workers to consider all patients
as potentially infected with HIV and/or other blood-
borne pathogens and to adhere rigorously to infec-
tion-control precautions for minimizing the risk of
exposure to blood and body fluids of all patients.
** Repnnted from Morbidity and Mortality Weekly Report, 1988; 37(24):377+.
APPENDIX C
Precautions for Other Body Fluids in
Special Settings
Use of Protective Barriers
170
170
Glove Use for Phlebotomy 171
Selection of Games 171
Waste Management ....
MMWR Editorial Note
References ............
- 172
-.... 172
......... 172
The recommendations contained in this docu-
ment consolidate and update CDC recommendations
published earlier for preventing HIV transmission in
health-care settings: precautions for clinical and labo-
ratory staffs (1) and precautions for health-care work-
ers and allied professionals (2~; recommendations
for preventing HIV transmission in the workplace (3)
and during invasive procedures (4~; recommenda-
tions for preventing possible transmission of HIV
from tears (5~; and recommendations for providing
dialysis meaunent for HIV-infected patients (63. These
recommendations also update portions of the "Guide-
line for Isolation Precautions in Hospitals" (7) and
reemphasize some of the recommendations contained
in "Infection Control Practices for Dentistry" Air.
The recommendations contained in this document
have been developed for use in health-care settings
and emphasize the need to treat blood and other body
fluids from all patients as potentially infective. These
same prudent precautions also should be taken in
other settings in which persons may be exposed to
blood or other body fluids.
DEFINITION OF HEALTH-CARE WORKERS
Health-care workers are deemed as persons, in-
cluding students and trainees, whose activities in-
volve contact with patients or with blood or other
body fluids from patients in a health-care setting.
OCR for page 157
AIPPEND~ C
HEALTH-CARE WORKERS WITH AIDS
As of July 10, 1987, a total of 1,875 (5.8%) of
32,395 adults with AIDS, who had been reported to
the CDC national surveillance system and for whom
occupational information was available, repot
being employed in a health-care or clinical labora-
tory setting. In comparison, 6.8 million persons-
representing 5.6% of the U.S. labor force-were
employed in health services. Of the health-care work-
ers with AIDS, 95% have been reported to exhibit
high-risk behavior; for the remaining 5%, the means
of HIV acquisition was undetermined. Health-care
workers with AIDS were significantly more likely
than other workers to have an undetermined risk (5%
versus 3%, respectively). For both health-care work-
ers and non-health-care workers with AIDS, the pro-
portion with an undetermined risk has not increased
since 1982.
AIDS patients initially reported as not belonging
to recognized risk groups are investigated by state
and local health departments to determine whether
possible risk factors exist. Of all health-care workers
with AIDS reported to CDC who were initially char-
acterized as not having an identified risk and for
whom follow-up information was available, 66% have
been reclassified because risk factors were identified
or because the patient was found not to meet the
surveillance case definition for AIDS.
Of the 87 health-care workers currently catego-
rized as having no identifiable risk, information is
incomplete on 16 (18%) because of death or refusal
to be interviewed; 38 (44%) are still being investi-
gated.
The remaining 33 (38%) health-care workers
were interviewed or had other follow-up information
available. The occupations of these 33 were as fol-
lows:
· .
nine nursing assistants
seven housekeeping or
maintenance workers
five physicians, three of
whom were surgeons
three nurses
three clinical laboratory
technicians
one dentist
one therapist
four others who did not
have contact with patients
157
Although 15 of these 33 health~are workers reported
parenteral and/or over non-needleshck exposure to
blood or body fluids from patients in the 10 years
preceding their diagnosis of AIDS, none of these
exposures involved a padent win AIDS or known
HIV infection.
RISK TO HEALTH-CARE WORKERS OF
ACQUIRING HIV IN HEALTH-CARE
SETTINGS
Heal~-care workers with documented percuta-
neous or mucous-membrane exposures to blood or
body fluids of HIV-infected patients have been pro-
spectively evaluated to determine the risk of infec-
tion after such exposures. As of June 30, 1987, SS3
health-care workers have been tested for antibody to
HIV in an ongoing surveillance project conducted by
CDC (9~. Of these, 708 (80%) had percutaneous
exposures to blood, and 175 (20%) had a mucous
membrane or open wound contaminated by blood or
body fluid. Of 396 health-care workers, each of whom
had only a cs~nvalescent-phase serum sample ob-
tained and tested 2 90 days postexposure, one-for
whom heterosexual transmission could not be ruled
out was seropositive for HIV antibody. For 425
additional health-care workers, both acute- and con-
valescent-phase serum samples were obtained and
tested; none of 74 health-care workers with nonper-
cutaneous exposures seroconverted, and three (0.9%)
of 351 with percutaneous exposures seroconverted.
None of these three health-care workers had other
documented risk factors for infection.
Two other prospective studies to assess the risk
of nosocomial acquisition of HIV infection for health-
care workers are ongoing in the United States. As of
April 30, 1987, 332 health-care workers with a total
of 453 needlestick or mucous-membrane exposures
to the blood or other body fluids of HIV-infected
patients were tested for HIV antibody at the National
Institutes of Health (103. These exposed workers in-
cluded 103 with needlestick injuries and 229 with
mucous-membrane exposures; none had serocon-
verted.
A similar study at the University of California of
129 health-care workers with documented needle-
stick injuries or mucous-membrane exposures to blood
or other body fluids from patients with HIV infection
has not identified any seroconversions (11). Results
of a prospective study in the United Kingdom identi-
D~ed no evidence of transmission among 150 health
(27%~;
(21%~;
(15%~;
(9%~;
(9%~;
(3%~;
(3%~; and
(12%~.
OCR for page 158
158
care workers with parenteral or mucous-membrane
exposures to blood or other body fluids, secretions,
or excretions from patients with HIV infection (121.
In addition to health4are workers enrolled in
prospective studies, eight persons who provided care
to infected patients and denied other risk factors have
been reported to have acquired HIV infection. Three
of these health-care workers had needlestick expo-
sures to blood from infected patients (13-15~. Two
were persons who provided nursing care to infected
persons; although neither sustained a ne~lestick,
both had extensive contact with blood or other body
fluids, and neither observed recommended barrier
precautions (16,17~. The other three were health-care
workers with non-needlestick exposures to blood from
infected patients (18~. Although the exact route of
transmission for these last three infections is not
known, all three persons had direct contact of their
skin with blood from infected patients, all had skin
lesions that may have been contaminated by blood,
and one also had a mucous-membrane exposure.
A total of 1,231 dentists and hygienists, many of
whom practiced in areas with many AIDS cases,
participated in a study to determine the prevalence of
antibody to HIV; one dentist (0.1%) had HIV anti-
body. Although no exposure to a known HIV-in-
fected person could be documented, epidemiologic
investigation did not identify any other risk factor for
infection. The infected dentist, who also had a his-
tory of sustaining needlestick injuries and trauma to
his hands, did not routinely wear gloves when pro-
viding dental care (19~.
PRECAU IRONS TO PREVENT
TRANSMISSION OF HIV
Universal Precautions
Since medical history and examination cannot
reliably identify all patients infected with HIV or
other blood-borne pathogens, blood and body-fluid
precautions should be consistently used for all pa-
tients. This approach, previously recommended by
CDC (3,4), and referred to as "universal blood and
body-fluid precautions" or "universal precautions,"
should be used in the care of all patients, especially
including those in emergency-care settings in which
the risk of blood exposure is increased and the infec-
tion status of the patient is usually unknown (20~.
APPENDIX C
1. All health-care workers should routinely use
appropriate barrier precautions to prevent skin and
mucous-membrane exposure when contact with blood
or other body fluids of any patient is anticipated
Gloves should be worn for touching blood and body
fluids, mucous membranes, or non-intact skin of all
patients, for handling items or surfaces soiled with
blood or body fluids, and for performing venipunc-
ture and other vascular access procedures. Gloves
should be changed after contact with each patient.
Masks and protective eye wear or face shields should
be worn during procedures that are likely to generate
droplets of blood or other body fluids to prevent
exposure of mucous membranes of the mouth, nose,
and eyes. Gowns or aprons should be worn during
procedures that are likely to generate splashes of
blood or other body fluids.
2. Hands and other skin surfaces should be
washed immediately and thoroughly if contaminated
with blood or other body fluids. Hands should be
washed immediately after gloves are removed.
3. All health-care workers should take precau-
tions to prevent injuries caused by needles, scalpels,
and other sharp instruments or devices during proce-
dures; when cleaning used instruments; during dis-
posal of used needles; and when handling sharp in-
struments after procedures. To prevent needlestick
injuries, needles should not be recapped, purposely
bent or broken by hand, removed from disposable
syringes, or otherwise manipulated by hand. After
they are used, disposable syringes and needles, scal-
pel blades, and other sharp items should be placed in
puncture-resistant containers for disposal; the punc-
ture-resistant containers should be located as close as
practical to the use area. Large-bore reusable needles
should be placed in a puncture-resistant container for
transport to the reprocessing area
4. Although saliva has not been implicated in
HIV transmission, to minimize the need for emer-
gency mouth-to-mouth resuscitation, mouthpieces,
resuscitation bags, or other ventilation devices should
be available for use in areas in which the need for re-
suscitation is predictable.
5. Health-care workers who have exudative
lesions or weeping dermatitis should refrain from all
direct patient care and from handling patient-care
equipment until the condition resolves.
6. Pregnant health-care workers are not known
to be at greater risk of contracting HIV infection than
OCR for page 159
APPENDIX C
health-care workers who are not pregnant; however,
if a health-care worker develops HIV infection dur-
ing pregnancy, the infant is at risk of infection result-
ing from perinatal transmission. Because of this risk,
pregnant health-care workers should be especially
familiar with and strictly adhere to precautions to
minimize the risk of HIV transmission.
Implementation of universal blood and body-
fluid precautions for all patients eliminates the need
for use of the isolation category of "Blood and Body
Fluid Precautions" previously recommended by CDC
(7) for patients known or suspected to be infected
with blood-bome pathogens. Isolation precautions
(e.g., enteric, AFB (7~) should be used as necessary
if associated conditions, such as infectious diarrhea
or tuberculosis, are diagnosed or suspected.
Precautions for Invasive Procedures
In this document, an invasive procedure is de-
f~ned as surgical entry into tissues, cavities, or organs
or repair of major traumatic injuries 1) in an operat-
ing or delivery room, emergency department, or
outpatient setting, including both physicians' and den-
tists' offices; 2) cardiac catheterization and angi-
ographic procedures; 3) a vaginal or cesarean deliv-
ery or other invasive obstetric procedure during which
bleeding may occur; or 4) the manipulation, cutting,
or removal of any oral or perioral tissues, including
tooth structure, during which bleeding occurs or the
potential for bleeding exists. The universal blood
and body-fluid precautions listed above, combined
with the precautions listed below, should be the mini-
mum precautions for all such invasive procedures.
1. All health-care workers who participate in
invasive procedures must routinely use appropriate
barrier precautions to prevent skin and mucous-mem-
brane contact with blood and other body fluids of all
patients. Gloves and surgical masks must be worn
for all invasive procedures. Protective eye wear or
face shields should be worn for procedures that com-
monly result in the generation of droplets, splashing
of blood or other body fluids, or the generation of
bone chips. Gowns or aprons made of materials that
provide an effective barrier should be worn during
159
invasive procedures that are likely to result in the
splashing of blood or other body fluids. All health-
care workers who perform or assist in vaginal or
cesarean deliveries should wear gloves and gowns
when handling the placenta or the infant until blood
and amniotic fluid have been removed from the in-
fant's skin and should wear gloves during post-deliv-
ery care of the umbilical cord.
2. If a glove is torn or a ne~lestick or other
injury occurs, the glove should be removed and a
new glove used as promptly as patient safety per-
mits; the needle or instrument involved in the inci-
dent should also be removed from the sterile field.
Precautions for Dentistry***
Blood, saliva, and gingival fluid from all dental
patients should be considered infective. Special em-
phasis should be placed on the following precautions
for preventing transmission of blood-borne patho-
gens in dental practice in both institutional and non-
institutional settings.
1. In addition to wearing gloves for contact
with oral mucous membranes of all patients, all den-
tal workers should wear surgical masks and protec-
tive eye wear or chin-length plastic face shields
during dental procedures in which splashing or spat-
tering of blood, saliva, or gingival fluids is likely.
Rubber dams, high-speed evacuation, and proper
patient positioning, when appropriate, should be util-
ized to minimize generation of droplets and spatter.
2. Handpieces should be sterilized after use with
each patient, since blood, saliva, or gingival fluid of
patients may be aspirated into the handpiece or wa-
terline. Handpieces that cannot be sterilized should
at least be flushed, the outside surface cleaned and
wiped with a suitable chemical germicide, and then
rinsed. Handpieces should be flushed at the begin-
ning of the day and after use with each patient. Manu-
facturers' recommendations should be followed for
use and maintenance of waterlines and check valves
and for flushing of handpieces. The same precau-
tions should be used for ultrasonic scalers and air/
water syringes.
3. Blood and saliva should be thoroughly and
carefully cleaned from material that has been used in
***Gala~1 infemon-contm1 precautions are more specifically addressed in previous lecanmendanans for infection control practices for
denus~y (8).
OCR for page 160
160
the mouth (e.g., impression materials, bite registra-
tion), especially before polishing and grinding intra-
oral devices. Contaminated materials, impressions,
and intra-oral devices should also be cleaned and dis-
infected before being handled in the dental labora-
tory and before they are placed in the patient's mouth.
Because of the increasing variety of dental materials
used intra-orally, dental workers should consult with
manufacturers as to the stability of specific materials
when using disinfection procedures.
4. Dental equipment and surfaces that are diffi-
cult to disinfect (e.g., light handles or X-ray-unit
heads) and that may become contaminated should be
wrapped with impervious-backed paper, aluminum
foil, or clear plastic wrap. The coverings should be
removed and discarded, and clean coverings should
be put in place after use with each patient.
Precautions for Autopsies or Morticians' Services
In addition to the universal blood and body-fluid
precautions listed above, the following precautions
should be used by persons performing post-mortem
procedures:
1. All persons performing or assisting in post-
mortem procedures should wear gloves, masks, pro-
tective eye wear, gowns, and waterproof aprons.
2. Instruments and surfaces contaminated dur-
ing post-mortem procedures should be decontami-
nated with an appropriate chemical germicide.
Precautions for Dialysis
Patients with end-stage renal disease who are
undergoing maintenance dialysis and who have HIV
infection can be dialyzed in hospital-based or free-
standing dialysis units using conventional infection-
control precautions (21~. Universal blood and body-
fluid precautions should be used when dialyzing all
patients.
Strategies for disinfecting the dialysis fluid path-
ways of the hemodialysis machine are targeted to
control bacterial contamination and generally consist
of using 500-750 parts per million (ppm) of sodium
hypochlorite (household bleach) for 3040 minutes
or 1.5%-2.0% formaldehyde overnight. In addition,
APPENDIX C
several chemical germicides formulated to disinfect
dialysis machines are commercially available. None
of these protocols or procedures need to be changed
for dialyzing patients infected with HIV.
Patients infected with HIV can be dialyzed by
either hemodialysis or peritoneal dialysis and do not
need to be isolated from other patients. The type of
dialysis treatment (i.e., hemodialysis or peritoneal
dialysis) should be based on the needs of the patient.
The dialyzer may be discarded after each use. Alter-
natively, centers that reuse dialyzer~i.e., a specific
single-use dialyzer is issued to a specific patient,
removed, clea - , disinfected, and reused several
times on the same patient only-may include HIV-
infected padents in the dialyzer-reuse program. An
individual dialyzer must never be used on more than
one patient.
Precautions for Laboratories****
Blood and other body fluids from all patients
should be considered infective. To supplement the
universal blood and body-fluid precautions listed
above, the following precautions are recommended
for health care personnel:
1. All specimens of blood and body fluids
should be put in a well-constructed container with a
secure lid to prevent leaking during transport. Care
should be taken when collecting each specimen to
avoid contaminating the outside of the container and
of the laboratory form accompanying the specimen.
2. All persons processing blood and body-fluid
specimens (e.g., removing tops from vacuum tubes)
should wear gloves. Masks and protective eye wear
should be worn if mucous-membrane contact with
blood or body fluids is anticipated. Gloves should be
changed and hands washed after completion of speci-
men processing.
3. 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.
***Additional precautions for research and indust~1 labo~tones are addressed elsewhere (2:2,23).
OCR for page 161
APPENDIX C
161
4. Mechanical pipetting devices should be used other items contaminated with blood or other body
for manipulating all liquids in the laboratory. Mouth fluids from persons infected with blood-bome patho
pipetting must not be done.
5. Use of needles and syringes should be lim
ited to situations in which there is no alternative, and
the recommendations for preventing injuries with
needles outlined under universal precautions should
be followed.
6. Laboratory work surfaces should be decon
taminated with an appropriate chemical germicide
after a spill of blood or other body fluids and when
work activities are completed.
7. 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 (24~.
8. Scientific equipment that has been contami
nated with blood or other body fluids should be de
contaminated and cleaned before being repaired in
the laboratory or transported to the manufacturer.
9. All persons should wash their hands after
completing laboratory activities and should remove
protective clothing before leaving the laboratory.
Implementation of universal blood and body
fluid precautions for all patients eliminates the need
for warning labels on specimens since blood and
other body fluids from all patients should be consid
ered infective.
ENVIRONMENTAL CONSIDERATIONS FOR
HIV TRANSMISSION
No environmentally mediated mode of HIV trans
mission has been documented. Nevertheless, the pre
cautions described below should be taken routinely
in the care of all patients.
Sterilization and Disinfection
Standard sterilization and disinfection procedures
for patient-care equipment currently recommended
for use (25,26) in a variety of health-care settings-
including hospitals, medical and dental clinics and
offices, hemodialysis centers, emergency-care facili
ties, and long-term nursing-care facilities-are ade
quate to sterilize or disinfect instruments, devices, or
yens including HIV (21,23~.
Instruments or devices that enter sterile tissue o
the vascular system of any patient or through which
blood flows should be sterilized before reuse. De-
vices or items that contact intact mucous membranes
should be sterilized or receive high-level disinfec-
tion, a procedure that kills vegetative organisms and
viruses but not necessarily large numbers of bacterial
spores. Chemical germicides that are registered with
the U.S. Environmental Protection Agency (EPA) as
"sterilants" may be used either for sterilization or for
high-level disinfection depending on contact time.
Contact lenses used in trial Sttings should be
disinfected after each String by using a hydrogen
peroxide contact lens disinfecting system or, if com-
patible, with heat (78°C-80°C (172.4°F-176.0°F)) for
10 minutes.
Medical devices or instruments that require ster-
ilization or disinfection should be thoroughly cleaned
before being exposed to the germicide, and the manu-
facturer's instructions for the use of the germicide
should be followed. Further, it is important that the
manufacturer's specifications for compatibility of the
medical device with chemical germicides be closely
followed. Information on specific label claims of
commercial germicides can be obtained by writing to
Disinfectants Branch, Office of Pesticides, Environ-
mental Protection Agency, 401 M Street, SW, Wash-
ington, D.C. 20460.
Studies have shown that HIV is inactivated rap-
idly after being exposed to commonly used chemical
germicides at concentrations that are much lower
than used in practice (27-30~. Embalming fluids are
similar to the types of chemical germicides that have
been tested and found to completely inactivate HIV.
In addition to commercially available chemical ger-
micides, a solution of sodium hypochlorite (house-
hold bleach) prepared daily is an inexpensive and
effective germicide. Concentrations ranging from
approximately 500 ppm (1:100 dilution of household
bleach) sodium hypochlorite to 5,000 ppm (1:10 di-
lution of household bleach) are effective depending
on the amount of organic material (e.g., blood, mu-
cus) present on the surface to be cleaned and disin-
fected. Commercially available chemical germicides
may be more compatible with certain medical de-
vices that might be corroded by repeated exposure to
sodium hypochlorite, especially to the 1:10 dilution.
OCR for page 162
162
Survival of HIV in the Environment
The most extensive study on the survival of HIV
after drying involved greatly concentrated REV
samples, i.e., 10 million tissue-culture infectious doses
per milliliter (31~. This concenbmion is at least
100,000 times greater than that typically found in the
blood or serum of patients with HIV infection. HIV
was detectable by tissue-culture techniques 1-3 days
after drying, but the me of inactivation was raDid.
Studies performed at CDC have also shown that
drying HIV causes a rapid (within several hours) 1-2
log (90%-99%) reduction in HIV concentration. In
tissue-culture fluid, cell-free HIV could be detected
for up to 15 days at room temperature, up to 11 days
at 37 C (98.6.F), and up to 1 day if the HIV was cell-
associated.
When considered in the context of environmental
conditions in health-care facilities, these results do
not require any changes in currently recommended
sterilization, disinfection, or housekeeping strategies.
When medical devices are contaminated with blood
or other body fluids, existing recommendations in-
clude the cleaning of these instruments, followed by
disinfection or sterilization, depending on the type of
medical device. These protocols assume "worst-case"
conditions of extreme virologic and microbiologic
contamination, and whether viruses have been
inactivated after drying plays no role in formulating
these strategies. Consequently, no changes in pub
fished procedures for cleaning, disinfecting, or steril-
izing need to be made.
Housekeeping
Environmental surfaces such as walls, floors,
and other surfaces are not associated with transmis-
sion of infections to patients or health-care workers.
Therefore, extraordinary attempts to disinfect or ster-
ilize these environmental surfaces are not necessary.
However, cleaning and removal of soil should be
done routinely.
Cleaning schedules and methods vary according
to the area of the hospital or institution, type of
surface to be cleaned, and the amount and type of
soil present. Horizontal surfaces (e.g., bedside tables
and hard-surfaced flooring) in patient-care areas are
usually cleaned on a regular basis, when soiling or
spills occur, and when a patient is discharged. Clean-
ing of walls, blinds, and curtains is recommended
APPENDIX C
only if they are visibly soiled. Disinfectant fogging is
an unsatisfactory method of decontaminating air and
surfaces and is not recommended.
Disinfectant~e~ent formulations registered by
EPA can be used for cleaning environmental sur-
faces, but the actual physical removal of microorgan-
isms by scrubbing is probably at least as important as
any antimicrobial effect of the cleaning agent used.
Therefore, cost, safety, and acceptability by house-
keepers can be the main criteria for selecting any
such registered agent. The manufacturers' instn~c-
tions for appropriate use should be followed.
Cleaning and Decontaminating Spills of Blood or
Other Body Fluids
Chemical germicides that are approved for use
as "hospital disinfectants" and are tuberculocidal when
used at recommended dilutions can be used to decon-
taminate spills of blood and other body fluids. Strate-
gies for decontaminating spills of blood and other
body fluids in a patient-care setting are different
from those for spills of cultures or other materials in
clinical, public health, or research laboratories. In
patient-care areas, visible material should first be
removed and then the area should be decontami-
nated. With large spills of cultured or concentrated
infectious agents in the laboratory, the contaminated
area should be flooded with a liquid germicide be-
fore cleaning, then decontaminated with fresh germi-
cidal chemical. In both settings, gloves should be
worn during the cleaning and decontaminating pan
cedures.
Laundry
Although soiled linen has been identified as a
source of large numbers of certain pathogenic micro
organisms, the risk of actual disease transmission is
negligible. Rather than rigid procedures and specifi-
cations, hygienic and common-sense storage and
processing of clean and soiled linen are recommended
(26~. Soiled linen should be handled as little as pos-
sible and with minimum agitation to prevent gross
microbial contamination of the air and of persons
handling the linen. All soiled linen should be bagged
at the location where it was used; it should not be
sorted or rinsed in patient-care areas. Linen soiled
with blood or body fluids should be placed and trans-
ported in bags that prevent leakage. If hot water is
OCR for page 163
APPENDIX C
used, linen should be washed with detergent in water
atleast 71 C (160°F) for25 minutes. If low-tempera-
ture (<70 C (158 F) laundry cycles are used, chemi-
cals suitable for low-temperature washing at proper
use concentration should be used.
Infective Waste
There is no epidemiologic evidence to suggest
that most hospital waste is any more infective than
residential waste. Moreover, there is no epidemiol-
ogic evidence that hospital waste has caused disease
in the community as a result of improper disposal.
Therefore, identifying wastes for which special pre-
cautions are indicated is largely a matter of judgment
about the relative risk of disease transmission. The
most practical approach to the management of infec-
tive waste is to identify those wastes with the poten-
tial for causing infection during handling and dis-
posal and for which some special precautions appear
prudent. Hospital wastes for which special precau-
tions appear prudent include microbiology labora-
tory waste, pathology waste, and blood specimens or
blood products.
While any item that has had contact with blood,
exudates, or secretions may be potentially infective,
it is not usually considered practical or necessary to
treat all such waste as infective (23,26~. Infective
waste, in general, should either be incinerated or
should be autoclaved before disposal in a sanitary
landfall. Bulk blood, suctioned fluids, excretions, and
secretions may be carefully poured down a drain
connected to a sanitary sewer. Sanitary sewers may
also be used to dispose of other infectious wastes
capable of being ground and flushed into the sewer.
IMPLEMENTATION OF RECOMMENDED
PRECAUTIONS
Employers of health-care workers should ensure
that policies exist for:
1. Initial orientation and continuing education
and training of all health-care workers-including
students and trainees-on the epidemiology, modes
of transmission, and prevention of HIV and other
blood-borne infections and the need for routine use
of universal blood and body-fluid precautions for all
patients.
163
2. Provision of equipment and supplies neces-
sary to minimize the risk of infection with HIV and
other blood-borne pathogens.
3. Monitoring adherence to recommended pros
tective measures. When monitoring reveals a failure
to follow recommended precautions, counseling,
education, and/or restraining should be provided, and,
if necessary, appropriate disciplinary action should
be considered.
Professional associations and labor organizations,
through continuing education efforts, should empha-
size the need for health care workers to follow rec-
ommended precautions.
SEROLOGIC TESTING FOR HIV INFECTION
Background
A person is identified as infected with HIV when
a sequence of tests, starting with repeated enzyme
immunoassays (EIAs) and including a Western blot
or similar, more Specific assay, are repeatedly reac-
tive. Persons infected with HIV usually develop anti-
body against the virus within 6-12 weeks after infec-
tion.
The sensitivity of the currently licensed EIA
tests is at least 99% when they are performed under
optimal laboratory conditions on serum specimens
from persons infected for >12 weeks. Optimal labo-
ratory conditions include the use of reliable reagents,
provision of continuing education of personnel, qual-
ity control of procedures, and participation in per-
formance-evaluation programs. Given this per-
formance, the probability of a false-negative test is
remote except during the first several weeks after in-
fection, before detectable antibody is present. The
proportion of infected persons with a false-negadve
test attributed to absence of antibody in He early
stages of infection is dependent on both the inci-
dence and prevalence of HIV infection in a popula-
tion (Table Cal.
The specificity of the currently licensed EIA
tests is approximately 99% when repeatedly reactive
tests are considered. Repeat testing of initially reac-
tive specimens by EIA is required to reduce the like-
lihood of laboratory error. To increase further the
specificity of serologic tests, laboratories must use a
supplemental test, most often the Western blot, to
validate repeatedly reactive EIA results. Under opti
OCR for page 164
164
mat laboratory conditions, the sensitivity of the West-
ern blot test is comparable to or greater than that of a
repeatedly reactive EIA, and the Westem blot is highly
specific when strict criteria are used to interpret the
test results.
The testing sequence of a repeal reactive
EIA and a positive Western blot test is highly predic-
tive of HIV infection, even in a population with a
low prevalence of infection (Table C.2~. If the West-
em blot test result is indeterminant, the testing se-
quence is considered equivocal for HIV infection.
When this occurs, the Westem blot test should be
repeated on the same serum sample, and, if still inde-
terminant, the testing sequence should be repeated
on a sample collected 3-6 months later. Use of other
supplemental tests may aid in interpreting of results
on samples that are persistently indeterminant by
Western blot.
TABLE C.1 Estimated Annual Number of Patients Infected
with HIV not Detected by HIV-Antibody Testing in a Hypothetical
Hospital with 10,000 Admissions/Year*
Approximate
Beginning Annual number of
prevalence of incidence of HIV-infected
HIV infection HIV infection patients
Approximate
number of
HIV-infected
patients
not detected
5.0~o
5.0%
1.0%
1.0%
0.1%
0.1%
1.0%
0.5%
0.2%
0.1%
0.02%
0.01%
550
525
110
105
11
11
17-18
1 1-12
3-4
2-3
0-1
0-1
*The estimates are based on the following assumptions: 1) the
sensitivity of the screwing test is 99% (i.e., 99% of HIV-infected
persons with antibody will be detected); 2) persons infected with
HIV will not develop detectable antibody (seroconvert) until 6
weeks (1.S months) after infection; 3) new infections occur at an
equal rate throughout the year, 4) calculations of the number of
HIV-infected persons in the patient population are based on the
mid-year prevalence, which is the beginning prevalence plus half
the annual incidence of infections.
APPENDIX C
Testing of Patients
Previous CDC recommendations have empha-
sized the value of HIV serologic testing of patients
for:
1) management of parenteral or mucous-mem-
brane exposures of health-care workers,
2) patient diagnosis and management, and
3) counseling and serologic testing to prevent
and control HIV transmission in the community.
In addition, more recent recommendations have
stated that hospitals, in conjunction with state and
local health departments, should periodically deter-
mine the prevalence of HIV infection among patients
from age groups at highest risk of infection (32~.
Adherence to universal blood and body-fluid
precautions recommended for the care of all patients
will minimize the risk of transmission of HIV and
other blood-borne pathogens from patients to health-
care workers. The utility of routine HIV serologic
testing of patients as an adjunct to universal precau-
tions is unknown. Results of such testing may not be
available in emergency or outpatient settings. In ad-
dition, some recently infected patients will not have
detectable antibody to HIV (Table Cal.
TABLE C.2 Predictive Value of Positive HIV-Antibody Tests
in Hypothetical Populations with Different Prevalences of
Infection
Prevalence Predictive value
of infection of positive test*
Repeatedly reactive enzyme
immunoassay (EIA)t
Repeatedly reactive EIA
followed by positive
Western Blot (WB)§
0.2%
2.0%
20.0~o
0.2%
2.0%
20.0%
28.41%
80.16%
98.02%
99.75%
99.97%
99.99%
*Potion of persons with positive tests who are actually in
fected with HIV.
tAssume5 EIA sensitivity of 99.0% and specificity of 99.5%.
§Assumes WB sensitivity of 99.04,0 and specificity of 99.9%.
OCR for page 165
APPENDIX C
Personnel in some hospitals have advocated se-
rologic testing of patients in settings in which expo-
sure of health-care workers to large amounts of pa-
tients' blood may be anticipate. Specific patients
for whom serologic testing has been advocated in-
clude those undergoing major operative procedures
and those undergoing treatment in critical-care units,
especially if they have conditions involving uncon-
trolled bleeding. Decisions regarding the need to es-
tablish testing programs for patients should be made
by physicians or individual institutions. In addition,
when deemed appropriate, testing of individual pa-
tients may be performed on agreement between the
patient and the physician providing care.
In addition to the universal precautions recom-
mended for all patients, certain additional precau-
tions for the care of HIV-infected patients undergo-
ing mapr surgical operations have been proposed by
personnel in some hospitals. For example, surgical
procedures on an HIV-infected patient might be al-
tered so that hand-to-hand passing of sharp instru-
ments would be eliminated; stapling instruments
rather than hand-suturing equipment might be used
to perform tissue approximation; electrocautery de-
vices rather than scalpels might be used as cutting
instruments; and, even though uncomfortable, gowns
that totally prevent seepage of blood onto the skin of
members of the operative team might be worn. While
such modifications might further minimize the risk
of REV infection for members of the operative team,
some of these techniques could result in prolonga-
tion of operative time and could potentially have an
adverse effect on the patient.
Testing programs, if developed, should include
the following principles:
· Obtaining consent for testing.
· Informing patients of test results, and pro-
viding counseling for seropositive patients by prop-
erly trained persons.
· Assuring that confidentiality safeguards are
in place to limit knowledge of test results to those
directly involved in the care of infected patients or as
required by law.
· Assuring that identification of infected pa-
tients will not result in denial of needed care or
provision of suboptimal care.
Evaluating prospectively: 1) the efficacy of
the program in reducing the incidence of parenteral,
mucous-membrane, or significant cutaneous expo
165
sures of health care workers to the blood or other
body fluids of HIV-infected patients and 2) the effect
of modified procedures on patients.
Testing of Health-Care Workers
Although transmission of HIV from infected
health-care workers to patients has not been reported,
transmission during invasive procedures remains a
possibility. Transmission of hepatitis B virus
(REV - a blood-borne agent with a considerably
greater potential for nosocomial spread-from health-
care workers to patients has been documented. Such
transmission has occurred in situations (e.g., oral and
gynecologic surgery in which health-care workers,
when tested, had very high concentrations of BV in
their blood (at least 100 million infectious virus par-
ticles per milliliter, a concentration much higher than
occurs with HIV infection), and the health-care work-
ers sustained a puncture wound while performing
invasive procedures or had exudative or weeping
lesions or microlacerations that allowed virus to con-
taminate instruments or open wounds of patients
(33,34~.
The hepatitis B experience indicates that only
those health care workers who perform certain types
of invasive procedures have transmitted HBV to pa-
tients. Adherence to recommendations in this docu-
ment will minimize the risk of transmission of HIV
and other blood-borne pathogens from health-care
workers to patients during invasive procedures. Since
transmission of HIV from infected health-care work-
ers performing invasive procedures to their patients
has not been reported and would be expected to
occur only very rarely, if at all, the utility of routine
testing of such health-care workers to prevent trans-
mission of HIV cannot be assessed. If consideration
is given to developing a serologic testing program
for health-care workers who perform invasive proce-
dures, the frequency of testing, as well as the issues
of consent and confidentiality, and consequences of
test results previously outlined for testing pro-
grams for patients-must be addressed.
MANAGEMENT OF INFECTED HEALTH
CARE WORKERS
Health-care workers with impaired immune sys-
tems resulting from HIV infection or other causes are
at increased risk of acquiring or experiencing serious
OCR for page 166
166
complications of infectious disease. Of particular
concern is the risk of severe infection following ex-
posure to patients with infectious diseases that are
easily transmitted if appropriate precautions are not
taken (e.g., measles, varicella). Any health-care
worker with an impaired immune system should be
counseled about the potential risk associated with
taking care of patients with any transmissible infec-
tion and should continue to follow existing recom-
mendations for infection control to minimize risk of
exposure to other infectious agents (7,35~. Recom-
mendations of the Immunization Practices Advisory
Committee BACH and institutional policies concern-
ing requirements for vaccinating health care workers
with live-virus vaccines (e.g., measles, rubella) should
also be considered.
The question of whether workers infected with
HIV especially those who perform invasive proce-
dures can adequately and safely be allowed to per-
form patient-care duties or whether their work as-
signments should be changed must be determined on
an individual basis. These decisions should be made
by the health-care worker's personal physicians) in
conjunction with the medical directors and personnel
health service staff of the employing institution or
hospital.
MANAGEMENT OF EXPOSURES
If a health-care worker has a parenteral (e.g.,
needlestick or cut) or mucous-membrane (e.g., splash
to the eye or mouth) exposure to blood or other body
fluids or has a cutaneous exposure involving large
amounts of blood or prolonged contact with blood
especially when the exposed skin is chapped, abraded,
or afflicted with dermatit~the source patient should
be informed of the incident and tested for serologic
evidence of HIV infection after consent is obtained.
Policies should be developed for testing source pa-
tients in situations in which consent cannot be ob-
tained (e.g., an unconscious patient).
If the source patient has AIDS, is positive for
HIV antibody, or refuses the test, the health-care
worker should be counseled regarding the risk of
infection and evaluated clinically and serologically
for evidence of HIV infection as soon as possible
after the exposure. The health-care worker should be
advised to report and seek medical evaluation for any
acute febrile illness that occurs within 12 weeks after
the exposure. Such an illness-particularly one char
APPENDIX C
acterized by fever, rash, or lymphadenopathy-may
be indicative of recent HIV infection. Seronegative
health-care workers should be retested 6 weeks post-
exposure and on a periodic basis thereafter (e.g., 12
weeks and 6 months after exposure) to determine
whether transmission has occurred. During this fol-
low-up period-especially the first 6-12 weeks after
exposure, when most infected persons are expected
to seroconvert-exposed health-care workers should
follow U.S. Public Health Service (PHS) recommen-
dations for preventing transmission of HIV (36,37~.
No furler follow-up of a health care worker
exposed to infection as described above is necessary
if the source patient is seronegative unless the source
patient is at high risk of HIV infection. In the latter
case, a subsequent specimen (e.g., 12 weeks follow-
ing exposure) may be obtained from the health-care
worker for antibody testing. If the source patient
cannot be identified, decisions regarding appropriate
follow-up should be individualized. Serologic test-
ing should be available to all health-care workers
who are concerned that they may have been infected
with HIV.
If a patient has a parenteral or mucous-mem-
brane exposure to blood or other body fluid of a
health-care worker, the patient should be informed of
the incident, and the same procedure outlined above
for management of exposures should be followed for
both the source health-care worker and the exposed
patient.
REFERENCES
1. CDC. Acquired immunodeficiency syndrome
(AIDS): Precautions for clinical and laboratory
staffs. MMWR 1982;31:577-80.
2. CDC. Acquired immunodeOlciency syndrome
(AIDS): Precautions for health-care workers
and allied professionals. MMWR 1983;32:450
1.
CDC. Recommendations for preventing
transmission of infection with human T-lym-
photropic virus type III/lymphadenopathy-
associated virus in the workplace. MMWR
1985;34:681-6~691-5.
4. CDC. Recommendations for preventing
transmission of infection with human T-lym
OCR for page 167
APPENDIX C
photropic vines type IIVIymphadenopathy-
associated virus during invasive procures.
MMWR 1986;35:221-3.
5. CDC. Recommendations for preventing pos-
sible transmission of human T-lymphotropic
virus type m/lymphadenopathy-associated vi-
rus from tears. MMWR 1985;34:5334.
6. CDC. Recommendations for providing dialysis
beahnent to patients infected with human T-
lymphotropic virus type mllymphadenopa~y-
associated virus infection. MMWR
1986;35:376-8, 383.
7. Gamer IS, Simmons BP. Guideline for isola-
tion precautions in hospitals. Infect Control
1983 ;4(suppl):245-325.
8. Cl:)C. Recommended infection control prac-
tices for dentistry. MMWR 1986;35:23742.
9. McCray E, The Cooperative Needlestick Sur-
veillance Group. Occupational risk of the ac-
quired immunodef~ciency syndrome among
health care workers. N Engl J Med
1986;314: 1127-32.
10. Henderson DK, Saah AT, Zak BJ, et al. Risk of
nosocomial infection with human T-cell lym-
photropic virus type IIIdymphadenopa~y-
associated virus in a large cohort of intensively
exposed heals care workers. Ann Intern Med
1986;104:644-7.
11. Gerberding JL, Bryant-LeBlanc CE, Nelson K,
et al. Risk of transmitting the human immu-
nodef~ciency vines, cytomegalovirus, and hepa-
titis B virus to health care workers exposed to
patients with AIDS and AIDS-related condi-
tions. J Infect Dis 1987;156:1-8.
McEvoy M, Porter K, Mortimer P. Simmons
N. Shanson D. Prospective study of clinical,
laboratory, and ancillary staff with accidental
exposures to blood or other body fluids from
patients infected with HIV. Br Med J
1987;294: 1595-7.
167
13. Anonymous. Needlestick transmission of
HTLV-m from a patient infected in Africa.
Lancet 1984;2:137~7.
14. Oksenhendler E, Hasidic M, Le Roux JM, Ra-
bian C, Clauvel JP. HIV infection with sero
conversion after a superficial needlestick in-
jury to the finger. N Engl J Med 1986;315:582.
15.
Neisson-Vernant C, Arfi S. Mathez D, Leibow-
itch J. Monplaisir N. Needlestick HIV serocon-
version in a nurse. Lancet 1986;2:814.
16. Grint P. McEvoy M. Two associated cases of
the acquired immune deficiency syndrome
(AIDS). PHLS Commun Dis Rep 1985;42:4.
18.
CDC. Apparent transmission of human T-lym-
photropic virus type IIVIymphadenopathy-
associated virus from a child to a mother pro
viding health care. MMWR 1986;35:7~9.
CDC. Update: Human immunodeficiency virus
infections in health-care workers exposed to
blood of infected patients. MMWR
1987;36:285-9.
19. Kline RS, Phelan J. Friedland GH, et al. Low
occupational risk for HIV infection for dental
professionals (Abstract). In: Abstracts from the
III International Conference on AIDS, 1-5 June
1985. Washington, DC: 155.
20. Baker JL, Kelen GD, Sivertson KT, Quinn W.
Unsuspected human immunodef~ciency virus
in critically ill emergency patients. JAMA
1987;257:2609-11.
21. Favero MS. Dialysis-associated diseases and
their control. In: Bennett JV, Brachman PS,
eds. Hospital infections. Boston: Little, Brown
and Company, 1985:267-84.
22.
Richardson JH, Barkley WE, eds. Biosafety in
microbiological and biomedical laboratories,
1984. Washington, DC: US Department of
Health and Human Services, Public Health
Service. AS publication no. (CDC) 84-8395.
OCR for page 168
168
CDC. Human T-lymphotropic virus type IIV
lymphadenopathy-associated virus: Agent
summary statement. MMWR 19X6;35:540-
2,547-9.
24. Environmental Protection Agency. EPA guide
for infectious waste management. Washington,
DC: US Environmental Protection Agency, May
1986 (Publication no. EPA/530-SW-86-014.
Favero MS. Sterilization, disinfection, and anti-
sepsis in the hospital. In: Manual of clinical
microbiology.4th ed. Washington, DC: Ameri-
can Society for Microbiology, 1985;129-37.
26. Gamer JS, Favero MS. Guideline for hand-
washing and hospital environmental control,
1985. Atlanta Public Health Service, Centers
for Disease Control, 1985. HHS publication
no.99-1117.
Spire B. Montagnier L, Barre-Sinoussi F. Ch-
ermann JC. Inactivation of lymphadenopathy
associated virus by chemical disinfectants.
Lancet 1984;2:899-901.
28. Martin LS, McDougal JS, Loskoski SL. Disin-
fection and inactivation of the human T lym-
photropic virus type IIVlymphadenopath
associated virus. J Infect Dis 1985;152:400-3.
29. McDougal JS, Martin LS, Cort SP, et al. Ther-
mal inactivation of the acquired immunodefi-
ciency syndrome virus-III/lymphadenopathy-
associated virus, with special reference to an-
tihemophilic factor. J Clin Invest 1985;76:X75-
7.
30. Spire B. Barre-Sinoussi F. Dormont D, Mon-
tagnier L, Chermann JC. Inactivation of lym-
phadenopathy-associated virus by heat, gamma
rays, and ultraviolet light. Lancet 1985;1:188-
9.
31. Resnik L, Veren K, Salahuddin SZ, Tondreau
S. Markham PD. Stability and inactivation of
27.
APPENDIX C
HTLV-IIVLAV under clinical and laboratory
environments. JAMA 1986;255:1887-91.
32. CDC. Public Health Service (PHS) guidelines
for counseling and antibody testing to prevent
HIV infection and AIDS. MMWR 1987;3:509-
15.
33. Kane MA, Lettau LA. Transmission of BV
from dental personnel to patients. J Am Dent
Assoc 1985;110:634-6.
34. Lettau LA, Smith JD, Williams D, et. al. Trans-
mission of hepatitis B with resultant restriction
of surgical practice. JAMA 1986;255:934-7.
35. Williams WW. Guideline for infection control
in hospital personnel. Infect Control 1983;
4(suppl):326~9.
36. CDC. Prevention of acquired immune defi-
ciency syndrome (AIDS): Report of inter-
agency recommendations. MMWR 1983;
32:101-3.
37. CDC. Provisional Public Health Service inter-
ager~y recommendations for screening donated
blood and plasma for antibody to the vi~us caus-
ing acquired immunodeficiency syndrome.
MMWR 19X5;34:1-5.
II. UPDATE: UNIVERSAL PRECAUTIONS
FOR PREVENTION OF TRANSMISSION OF
HUMAN IMMUNODEFICIENCY VIRUS,
HEPATITIS B VIRUS, AND OTHER
BLOODBORNE PATHOGENS IN HEALTH
CARE SETTINGS
INTRODUCTION
The purpose of this report is to clarify and sup-
plement the CDC publication entitled '`Recommen-
dations for Prevention of HIV Transmission in Health-
Care Setiings" (1~.*****
*****The August 1987 publication (see pages 155-168 of this report) should be consulted for general infonnanon and specific recommen-
daiions not addressed in this update.
OCR for page 169
APPENDIX C
In 1983, CDC published a document entitled
"Guideline for Isolation Precautions in Hospitals"
(2) that contained a section entitled "Blood and Body
Fluid Precautions." The recommendations in this
section called for blood and body fluid precautions
when a patient was known or suspected to be in-
fected with bloodborne pathogens. In August 1987,
CDC published a document entitled '`Recommenda-
tions for Prevention of HIV Transmission in Health-
Care Settings" (1~. In contrast to the 1983 document,
the 1987 document recommended that blood and
body fluid precautions be consistently used for all
patients regardless of their bloodb~ne infection status.
This extension of blood and body fluid precautions
to all patients is referred to as "Universal Blood and
Body Fluid Precautions" or "Universal Precautions.,'
Under universal precautions, blood and certain body
fluids of all patients are considered potentially infec-
tious for human immunodeficiency vines ~V), hepa-
titis B virus (HBV), and other bloodborne pathogens.
Universal precautions are intended to prevent
parenteral, mucous membrane, and nonintact skin
exposures of health-care workers to bloodborne pa-
thogens. In addition, immunization with HBV vac-
cine is recommended as an important adjunct to uni-
versal precautions for health-care workers who have
exposures to blood (3,41.
Since the recommendations for universal pre-
cautions were published in August 1987, CDC and
the Food and Doug Administration (FDA) have re-
ceived requests for clarification of the following is-
sues: 1) body fluids to which universal precautions
apply, 2) use of protective Earners, 3) use of gloves
for phlebotomy, 4) selection of gloves for use while
observing universal precautions, and 5) need for
making changes in waste management programs as a
result of adopting universal precautions.
BODY FLUIDS TO WHICH UNIVERSAL
PRECAUTIONS APPLY
Universal precautions apply to blood and to other
body fluids containing visible blood. Occupational
transmission of HIV and HBV to health-care work-
ers by blood is documented (4,5~. Blood is the single
most important source of HIV, HBV, and other bloo-
dborne pathogens in the occupational setting. Infec-
tion control efforts for HIV, HBV, and other bloo-
dborne pathogens must focus on preventing expo-
sures to blood as well as on delivery of HBV immuni-
zation.
16g
Universal precautions also apply to semen and
vaginal secretions. Although both of these fluids have
been implicated in He sexual transmission of HIV
and HBV, they have not been implicated in occupa-
tional transmission from patient to health care worker.
This observation is not unexpected, since exposure
to semen in He usual health-care setting is limited,
and the routine practice of wearing gloves for per-
forming vaginal examinations protects health care
workers from exposure to potentially infectious vagi-
nal secretions.
Universal precautions also apply to tissues and
to the following fluids: cerebrospinal fluid (CSF3,
synovial fluid, pleural fluid, peritoneal fluid, pericar-
dial fluid, and amniotic fluid. The risk of transmis-
sion of HIV and HBV from these fluids is unknown;
epidemiologic studies in the health-care and commu-
nity setting are currently inadequate to assess the
potential risk to health-care workers from occupa-
tional exposures to them. However, HIV has been
isolated from CSF, synovial, and amniotic fluid (~
8), and HBsAg has been detected in synovial fluid,
amniotic fluid, and peritoneal fluid (9-11~. One case
of HIV transmission was reported after a percutane-
ous exposure to bloody pleural fluid obtained by
needle aspiration (12~. Whereas aseptic procedures
used to obtain these fluids for diagnostic or therapeu-
tic purposes protect health-care workers from skin
exposures, they cannot prevent penetrating injuries
due to contaminated needles or other sharp instru-
ments.
BODY FLUIDS TO WHICH UNIVERSAL
PRECAUTIONS DO NOT APPLY
Universal precautions do not apply to feces, na-
sal secretions, sputum, sweat, tears, urine, and vomi-
tus unless they contain visible blood. The risk of
transmission of HIV and HBV from these fluids and
materials is extremely low or nonexistent. HIV has
been isolated and HBsAg has been demonstrated in
some of these fluids; however, epidemiologic studies
in the health-care and community setting have not
implicated these fluids or materials in the transmis-
sion of HIV and BY infections (13,14~. Some of
the above fluids and excretions represent a potential
source for nosocomial and community-acquired in-
fections with other pathogens, and recommendations
for preventing the transmission of non-bloodborne
pathogens have been published (2~.
OCR for page 170
170
PRECAUTIONS FOR OTHER BODY FLUIDS
IN SPECIAL SETTINGS
Human breast milk has been implicated in peri-
natal transmission of HIV, and BsAg has been
found in the milk of mothers infected with HBV
(10,13~. However, occupational exposure to human
breast milk has not been implicated in the transmis-
sion of HIV or HBV infection to health-care work-
ers. Moreover, the health-care worker will not have
the same type of intensive exposure to breast mild as
the nursing neonate. Whereas universal precautions
do not apply to human breast milk, gloves may be
worn by health-care workers in situations where ex-
posures to breast milk might be frequent, for ex-
ample, in breast milk barking.
Saliva of some persons infected with BV has
been shown to contain BY-DNA at concentrations
1/1,000 to 1/10,000 of that found in the infected
person's serum (15~. BsAg-positive saliva has been
shown to be infectious when injected into experi-
mental animals and in human bite exposures (1~18~.
However, HBsAg-positive saliva has not been shown
to be infectious when applied to oral mucous mem-
branes in experimental pinnate studies (1X3 or through
contamination of musical instruments or cardiopul-
monary resuscitation dummies used by HBV camers
(19,20~.
Epidemiologic studies of nonsexual household
contacts of HIV-infected patients, including several
small series in which HIV transmission failed to
occur after bites or after percutaneous inoculation or
contamination of cuts and open wounds with saliva
from HIV-infected patients, suggest that the poten-
tial for salivary transmission of HIV is remote
(5,13,14,21,22~. One case report from Germany has
suggested the possibility of transmission of HIV in a
household setting from an defected child to a sibling
through a human bite (23~. The bite did not break the
skin or result in bleeding. Since the date of serocon-
version to HIV was not known for either child in this
case, evidence for the role of saliva in the transmis-
sion of virus is unclear (23~. Another case repart
suggested the possibility of transmission of HIV from
husband to wife by contact with saliva during kissing
(24~. However, follow-up studies did not confab
HIV infection in the wife (21~.
Universal precautions do not apply to saliva.
General infection control practices already in exis-
tence-including the use of gloves for digital exami
APPENDIX C
nation of mucous membranes and endo~acheal suc-
tioning, and handwashing after exposure to saliva-
should further minimize the minute risk, if any, for
salivary ban~nission of HIV and HBV (1,25~. Gloves
need not be worn when feeding patients and when
wiping saliva from skin.
Special precautions, however, are recommended
for dentistry (1~. Occupationally acquired infection
with HBV in dental workers has been documented
(4), and two possible cases of occupationally ac-
quired HIV infection involving dentists have been
reported (5,26). During dental procedures, contami-
nation of saliva with blood is predictable, trauma to
health care workers' hands is common, and blood
spattering may occur. Infection control precautions
for dentistry minimize the potential for non-intact
skin and mucous membrane contact of dental health-
care workers to blood-contaminated saliva of pa-
tients. In addition, the use of gloves for oral exami-
nations and treatment in the dental setting may also
protect the patient's oral mucous membranes from
exposures to blood, which may occur from breaks in
the skin of dental workers' hands.
USE OF PROTECTIVE BARRIERS
Protective barriers reduce the risk of exposure of
the health-care worker's niacin or mucous membranes
to potentially infective materials. For universal pre-
cautions, protective barriers reduce the risk of expo-
sure to blood, body fluids containing visible blood,
and other fluids to which universal precautions ap-
ply.
Examples of protective barriers include gloves,
gowns, masks, and protective eyewear. Gloves should
reduce the incidence of contamination of hands, but
they cannot prevent peneHadng injuries due to needles
or other sharp instruments. Mask and protective
eyewear or face shields should reduce He incidence
of contamination of mucous membranes of the mouth,
nose, and eyes.
Universal precautions are intended to supple-
ment rather than replace recommendations for rou-
tine infection control, such as handwashing and us-
ing gloves to prevent gross microbial contamination
of hands (27~. Because specifying the types of barri-
ers needed for every possible clinical situation is
impractical, some judgment must be exercised.
The risk of nosocomial transmission of HIV,
HBV, and other bloodborne pathogens can be mini
OCR for page 171
APPENDIX C
mized if health-care workers use the following gen-
erad guidelines:* ** ***
1. Take care to prevent injures when using
needles, scalpels, and other sharp instruments or
devices; when handling sharp instruments after pro
cedures; when cleaning used instruments; and when
disposing of used needles. Do not recap used needles
by hand; do not remove used needles from dispos-
able syringes by hand; and do not bend, break, or
otherwise manipulate used needles by hand. Place
used disposable syringes and needles, scalpel blades,
and other sharp items in puncture-resistant contain-
ers for disposal. Locate the puncture-resistant con-
tainers as close to the use area as is practical.
2. Use protective barriers to prevent exposure
to blood, body fluids containing visible blood, and
other fluids to which universal precautions apply.
The Be of protective barrierts) should be appropri-
ate for the procedure being performed and the type of
exposure anticipated.
3. Immediately and thoroughly wash hands and
other skin surfaces that are contaminated with blood,
body fluids containing visible blood, or other body
fluids to which universal precautions apply.
GLOVE USE FOR PHLEBOTOMY
Gloves should reduce the incidence of blood
contamination of hands during phlebotomy (drawing
blood samples), but they cannot prevent penetrating
injuries caused by needles or other sharp instruments.
The likelihood of hand contamination with blood
containing HIV, BY, or other bloodborne patho-
gens during phlebotomy depends on several factors:
1) the skill and technique of the health-care
worker;
2) the frequency with which the health-care
worker performs the procedure (other factors being
equal, the cumulative risk of blood exposure is higher
for a health-care worker who performs more proce-
dures);
3) whether the procedure occurs in a routine or
emergency situation (where blood contact may be
more likely); and,
171
4) the prevalence of infection with bloodborne
pathogens in the patient population.
The likelihood of infection after skin exposure
to blood containing HIV or BV will depend on the
concentration of virus (viral concentration is much
higher for hepatitis B than for HIV), the duration of
contact, the presence of skin lesions on the hands of
the health-care worker, and for HBV the immune
status of the health-care worker. Although not accu-
rately quantified, the risk of HIV infection following
intact skin contact with infective blood is certainly
much less than the 0.5% risk following percutaneous
needle stick exposures (5~. In universal precautions,
all blood is assumed to be potentially infective for
bloodbome pathogens, but in certain settings (e.g.,
volunteer blood-donation centers) the prevalence of
infection with some bloodborne pathogens (e.g., HIV,
REV) is known to be very low. Some institutions
have relaxed recommendations for using gloves for
phlebotomy procedures by skilled phlebotomists in
settings where the prevalence of bloodborne patho-
gens is known to be very low.
Institutions that judge that routine gloving for all
phlebotomies is not necessary should periodically re-
evaluate their policy. Gloves should always be avail-
able to health-care workers who wish to use them for
phlebotomy. In addition, the following general guide-
lines apply:
1. Use gloves for performing phlebotomy when
the health care worker has cuts, scratches, or other
breaks in hisfher skin.
2. Use gloves in situations where the health-
care worker judges that hand contamination with
blood may occur, for example, when performing phle-
botomy on an uncooperative patient.
3. Use gloves for performing finger and/or heel
sticks on infants and children.
4. Use gloves when persons are receiving Paining in
phlebotomy.
SELECTION OF GLOVES
The Center for Devices and Radiological Health,
FDA, has responsibility for regulating He medical
******the August 1987 publication (see pages 155-168 of this report) should be consulted for general infonnanan and specific recom-
mendabons not addressed in this-update.
OCR for page 172
172
glove industry. Medical gloves include those mar-
keted as sterile surgical or nonsterile examination
gloves made of vinyl or latex. General purpose util-
ity ("rubbery gloves are also used in the health-care
setting, but they are not regulated by FDA since they
are not promoted for medical use. There are no re-
ported differences in barrier effectiveness between
intact latex and intact vinyl used to manufacture
gloves. Thus, the We of gloves selected should be
appropriate for the task being performed.
The following general guidelines are recommended:
1. Use sterile gloves for procedures involving
contact with normally sterile areas of the body.
2. Use examination gloves for procedures in-
volving contact with mucous membranes, unless oth-
erwise indicated, and for other patient care or diag-
nostic procedures that do not require the use of sterile
gloves.
3. Change gloves between patient contacts.
4. Do not wash or disinfect surgical or exami-
nation gloves for reuse. Washing with surfactants
may cause "winking," i.e., the enhanced penetration
of liquids through undetected holes in the glove.
Disinfecting agents may cause deterioration.
5. Use general-purpose utility gloves (e.g., rub-
ber household gloves) for housekeeping chores in-
volving potential blood contact and for instrument
cleaning and decontamination procedures. Utility
gloves may be decontaminated and reused but should
be discarded if they are peeling, cracked, or discol-
ored, or if they have punctures, tears, or other evi-
dence of deterioration.
WASTE MANAGEMENT
Universal precautions are not intended to change
waste management programs previously recom- 3.
mended by CDC for health-care settings (1~. Policies
for defining, collecting, storing, decontaminating, and
disposing of infective waste are generally determined
by institutions in accordance with state and local
regulations. Information regarding waste manage
ment regulations in health-care settings may be ob
tained from state or local health departments or agen
cies responsible for waste management.
APPENDIX C
Reported by:
Center for Devices and Radiological Health,
Food and Drug Administration.
Hospital Infections Program, AIDS Program,
and Hepatitis Branch, Division of Viral Diseases,
Center for Infectious Diseases, National Institute for
Occupational Safety and Health, CDC.
MMWR EDITORIAL NOTE
Implementation of universal precautions does
not eliminate the need for other category- or disease-
specific isolation precautions, such as enteric precau-
tions for infectious diarrhea orisol~on for pulmonary
tuberculosis (1,2~. In addition to universal precau-
tions, detailed precautions have been developed for
the following procedures and/or settings in which
prolonged or intensive exposures to blood occur
invasive procedures, dentistry, autopsies or morti-
cians' services, dialysis, and the clinical laboratory.
These detailed precautions are found in the August
21, 1987, "Recommendations for Prevention of HIV
Transmission in Health-Care Settings" (1~. In addi-
tion, specific precautions have been developed for
research laboratories (28~.
REFERENCES
1. Centers for Disease Control. Recommendations
for prevention of HIV transmission in health-
care settings. MMW1R 1987;36(suppl no.
2S),3S-18S.
2. Garner IS, Simmons BP. Guideline for isola-
tion precautions in hospitals. Infect Control
1983:4;245-325.
Immunization Practices Advisory Committee.
Recommendations for protection against viral
hepatitis. MEW R 1985;34:313-24,329-35.
Deparunent of Labor, Department of Health
and Human Services. Joint advisory notice:
protection against occupational exposure to
hepatitis B virus (HBV) and human immunode-
B~ciency vims (HIV). Washington, DC:US
OCR for page 173
APPENDIX C
Department of Labor, US Department of Health
and Human Services, 1987.
5.
Centers for Disease Control. Update: Acquired
immunodeficiency syndrome and human im-
munodeficiency virus infection among health-
care workers. MMWR 1988;37:229-34,239.
6. Hollander H. Levy JA. Neurologic abnormali-
ties and recovery of human immunodef~ciency
virus from cerebrospinal fluid. Ann Intern Med
1987;106:692-5.
Wirthrington RH, Comes P. Harris JRW, et al.
Isolation of human immunodef~ciency virus
from synovial fluid of a patient with reactive
arthritis. Br Med J 1987;294:484.
8. Mundy DC, Schinazi RF, Gerber AR, Nahmias
AT, Randall HW. Human immunodeficiency
virus isolated from amniotic fluid. Lancet
1987;2:459-60.
9.
Onion DK, Crumpacker CS, Gilliland BC. Ar-
thritis of hepatitis associated with Australia
antigen. AM Intern Med 1971;75:29-33.
10. Lee AKY, Ip HMH, Wong VCW. Mechanisms
of maternal-fetal transmission of hepatitis B
virus. J Infect Dis 1978;138:668-71.
11. Bond WW, Petersen NJ, Gravelle CR, Favero
MS. Hepatitis B virus in peritoneal dialysis
fluid: A pomntial hazard. Dialysis and Trans-
plantation 1982;11:592-600.
12. Oskenhendler E, Harzic M, Le Roux J-M, Ra-
bian C, Clauvel JP. HIV infection with sero-
conversion after a super6~cial needlestick in-
jury to the finger (Letter). N Engl J Med
1986;315:582.
13. Lifson AR. Do alternate modes for transmis-
sion of human immunodeficiency virus exist?
A review. JAMA 1988;259: 1353~.
14. Friedland GH, Saltzman BR, Rogers MF, et al.
Lack of transmission of HTLV-IIVLAV infec
173
tion to household contacts of patients with AIDS
or AIDS-related complex with oral candidiasis.
N Engl J Med 1986;314:344-9.
15. Jenison SA, Lemon SM, Baker LN, Newbold
JE. Quantitative analysis of hepatids B virus
DNA in saliva and semen of chronically in-
fected homosexual men. J Infect Dis 1987;
156:299-306.
16. Cancio-Bello TP, de Medina M, Shorey J. Val-
ledor MD, Schiff ER. An institutional outbreak
of hepatitis B related to a human biting carrier.
J Infect Dis 1982;146:652-6.
17. MacQuarrie MB, Forghani B. Wolochow DA.
Hepatitis B transmitted by a human bite. JAMA
1974;230:723-4.
18. Scott RM, Snitbhan R. Bancroft WH, Alter lIJ,
Tingpalapong M. Experimental transmission of
hepatids B virus by semen and saliva. J Infect
Dis 1980;142:67-71.
19. Glaser JB, Nadler JP. Hepatitis B virus in a
cardiopulmonary resuscitation ~aining course:
Risk of transmission from a surface antigen-
positive participant. Arch Intern Med 1985;
145: 1653-5.
20. Osterholm MT, Bravo ER, Crosson JT, et al.
Lack of transmission of viral hepatitis type B
after oral exposure to HBsAg-positive saliva.
Br Med J 1979;2: 1263-4.
21. Curran JW, Jaffe HW, Hardy AM, et al. Epi-
demiology of HIV infection and AIDS in the
United States. Science 1988;239:610-6.
22.
Jason JM, McDougal JS, Dixon G, et al. HTLV-
IIVLAV antibody and unmune status of house-
hold contacts and sexual partners of persons
wi~ hemophilia. JAMA 1986;255:212-5.
23. Wahn V, Kramer HH, Voit T, Bruster HT,
Scrampical B, Scheid A. Horizontal ~ansmis-
sion of HIV infection between two siblings
(Letter). Lancet 1986;2:694.
OCR for page 174
174
24. Salahuddin SZ, Groopman JE, Markham PD,
et al. HTLV-III in symptom-free seronegative
persons. Lancet 1984;2:1418-20.
25. Simmons BP, Wong ES. Guideline for preven-
tion of nosocomial pneumonia. Atlanta: US
Deparanent of Health and Human Services,
Public Health Service, Centers for Disease
Control, 1982.
26. Klein RS, Phelan JA, Freeman K, et al. Low
occupational risk of human immunodeficiency
virus infection among dental professionals.
N Engl J Med 1988;318:8~90.
APPENDIX C
27. Gamer IS, Favero MS. Guideline for hand-
washing and hospital environmental control,
1985. Atlanta: US Deparunent of Health and
Human Services, Public Health Service, Cen-
ters for Disease Control, 1985; HHS publica-
tion no. 99-1117.
28. Centers for Disease Control. 1988 Agent sum-
mary statement for human immunodeficiency
vines and report on laborat;ory-acquired infec-
tion with human immunodeE'ciency virus.
MMWR 1988;37(suppl no. Sib: lS-22S.
Representative terms from entire chapter:
universal precautions
