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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

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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.

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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%~.

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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

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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).

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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).

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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 (78C-80C (172.4F-176.0F)) 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.

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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

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APPENDIX C used, linen should be washed with detergent in water atleast 71 C (160F) 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

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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%.

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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

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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

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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.

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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.

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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~.

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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

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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.

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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

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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.

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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.