Health care workers with AIDS. National surveillance update.

OBJECTIVES--To characterize health care workers with the acquired immunodeficiency syndrome (AIDS) in the United States and to evaluate the role of occupational transmission of the human immunodeficiency virus (HIV). DATA SOURCE--National AIDS surveillance data. METHODS--Health care workers with AIDS are reported to the Centers for Disease Control by state and local health departments. Health care workers who do not report a nonoccupational risk for HIV infection are termed undetermined risk cases and are investigated by health departments using a standard protocol. RESULTS--Through June 30, 1990, there were 5425 cases of AIDS in health care workers reported in the United States. Three of these workers developed AIDS following well-documented occupational exposure to HIV-infected blood. Of the 539 health care workers initially reported without a nonoccupational risk, follow-up investigations were completed for 303. Nonoccupational risk factors were established for 237 (78.2%) of the 303 investigated health care workers; 66 workers (21.8%) remained in the undetermined category. Follow-up information was incomplete for 236 health care workers who also remained in the undetermined category, resulting in 5120 health care workers (94.4%) with AIDS with nonoccupational risks for HIV infection. Overall, health care workers were more likely than non-health care workers with AIDS to have an undetermined risk for HIV infection (5.6% vs 2.8%; P less than .001). While many of the 66 investigated health care workers had jobs involving contact with patients and/or potential contact with blood, none reported percutaneous, mucous membrane, or cutaneous exposures to blood or body fluids known to be infected with HIV. CONCLUSION--Surveillance data suggest that most health care workers with AIDS acquired their HIV infection through a nonoccupational route.     

HTLV-III infection among health care workers. Association with needle-stick injuries

Health care workers are caring for an increasing number of persons infected with human T-cell lymphotropic virus type III (HTLV-III), the primary etiologic agent of the acquired immunodeficiency syndrome (AIDS). We studied 361 health care and clinical laboratory personnel from institutions in several metropolitan areas with both high and moderate levels of HTLV-III infection among high-risk group members to evaluate routes of exposure to and seropositivity for HTLV-III. Protection of the privacy of subjects and prospective determination of risk factors were integral components of the study design. Six (26%) of 23 health care workers with recognized risk factors for AIDS had HTLV-III antibodies. Thirty-nine (14%) of 278 workers at one institution as well as a total of five workers from other institutions reported possible percutaneous exposure to HTLV-III, usually injuries with needles that had been used on AIDS patients. There were three HTLV-III seropositive subjects who reported possible parenteral exposure to HTLV-III but no recognized AIDS risk factors. One was a symptomatic female, subject A, and her apparent sources of HTLV-III exposure were two puncture wounds, without injection of blood, made with needles used on AIDS patients. Human T-cell lymphotropic virus type III was cultured from her asymptomatic, seronegative long-term sexual partner, apparently representing female-to-male transmission. For the two other seropositive workers (subjects B and C) with nosocomial parenteral exposure, we could not rule out heterosexual transmission as a possible source of HTLV-III exposure. These latter two cases as well as the identification of seropositive health care providers from known risk groups point to the need for thorough case investigation to identify routes of exposure in health care workers. The risk of nosocomial HTLV-III transmission appears to be low and related to percutaneous exposure. Medical personnel should be trained systematically in the proper techniques and handling of instruments for phlebotomy and similar procedures to decrease occupational exposure to HTLV-III.     

A recommended approach to the evaluation of human rabies exposure in an acute-care hospital

It is important to minimize the costs and risks associated with unnecessary prophylaxis of health care workers. We studied the process of providing rabies postexposure prophylaxis following the 24-day hospitalization of a rabies-infected patient. Of 209 persons who cared for the patient, only 12 (6%) reported high-risk contact, and treatment was recommended for them. Unnecessary prophylaxis was limited to 35 persons (18%) who did not report high-risk contacts but who requested treatment because of their uncertainty about the degree of exposure. These persons, however, spent significantly more time with the patient compared with persons who did not request treatment. Maintaining strict isolation precautions when rabies is being considered, educating employees about the risks of transmission in this setting, carefully documenting exposures, and adhering to the guidelines for postexposure prophylaxis may help reduce excessive prophylaxis of health care workers.     

Investigations of AIDS patients with no previously identified risk factors

Through Sept 30, 1987, two thousand fifty-nine patients with acquired immunodeficiency syndrome (AIDS) and no recognized risk factors were reported to the Centers for Disease Control. Risk history was incomplete or unobtainable for 921 (45%) of them. Risk factors were ultimately identified for 825 (72%) of the remaining 1138. Another 32 persons (3%) did not meet the case definition for AIDS. Risk factors could not be identified for the remaining 281 patients (25%), despite additional information. Of these, 178 (63%) were interviewed with standard questionnaires; 38% reported sexually transmitted diseases and 34% of the men reported sexual contact with prostitutes. There was no evidence for new transmission modes. Although the proportion of AIDS patients with undetermined risk factors has increased significantly during the past year, the adjusted proportion shows no significant change over time. Thus, follow-up of AIDS patients with no apparent risk factors suggests that modes of transmission for human immunodeficiency virus have remained stable.     

A surgeon with AIDS. Lack of evidence of transmission to patients

In January 1989 [corrected], the media reported the identity of a surgeon who was recently diagnosed with the acquired immunodeficiency syndrome (AIDS). Concern about surgeon-to-patient transmission of human immunodeficiency virus (HIV) persisted despite reassurances from health authorities. Therefore, HIV antibody testing was offered to the surgeon's patients. We identified 2160 patients operated on since 1982; none had been reported to Tennessee's AIDS registry. A total of 264 had already died; none were reported to have died of AIDS or other HIV-related diseases. Of the 1896 patients remaining, we contacted 1652; 616 (37%) were tested. Only one (an intravenous drug user) was HIV antibody positive, and his medical history suggested that he may already have had AIDS at the time of his surgery. These results support the concept that the risks to patients operated on by HIV-infected surgeons are most likely quite low and support recommendations for the individualized assessment of HIV-infected health care workers.     

Absence of antibodies to HTLV-III in health workers after hepatitis B vaccination

A proportion of the plasma for the triply inactivated, plasma-derived hepatitis B vaccine produced in the United States is obtained from homosexual men. Because homosexual men are a high-risk group for the acquired immunodeficiency syndrome (AIDS), concern has emerged that the vaccine could harbor the AIDS agent. To evaluate this risk, we tested 15-month postvaccination serum samples for antibodies to human T-cell lymphotropic virus type III in 100 health care workers who had received inactivated hepatitis B vaccine lots made from plasma collected between 1977 and 1979 and 100 who had received placebo injections. None of the 200 health workers had serological evidence of human T-cell lymphotropic virus type III infection. These serological findings lend additional support to earlier epidemiologic and immunologic observations suggesting that hepatitis B vaccine does not transmit infection with an AIDS virus.     

Prospective study of clinical, laboratory, and ancillary staff with accidental exposures to blood or body fluids from patients infected with HIV

In a prospective study of 150 health care workers in the United Kingdom who had been accidentally exposed to the human immunodeficiency virus no evidence of transmission was found. Larger studies in the United States and anecdotal accounts in publications from other countries confirm that the risk of occupational infection is very low. Health care workers must adopt safe procedures at all times, however, to avoid exposure to infection.     

Transfusion-associated acquired immunodeficiency syndrome in the United States

By Aug 15, 1985, one hundred ninety-four cases of possible transfusion-associated acquired immunodeficiency syndrome (AIDS) had been reported to the Centers for Disease Control. Cases received their transfusions in 30 states. Infants account for 10% of the cases, suggesting an increased susceptibility to developing AIDS. Investigations one to six years after the transfusions have identified high-risk donors to 47 cases. Of 47 high-risk donors tested, 40 had a reactive serology for human T-cell lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) antibody, including five with no risk for AIDS by history. The HTLV-III/LAV was isolated from 23 of 26 seroreactive high-risk donors, most of whom remained asymptomatic. Blood components that transmitted HTLV-III/LAV included red cells, platelets, plasma, and whole blood. The time from transfusion to diagnosis of AIDS ranged from four to 84 months. The risk of developing AIDS after a blood transfusion has been low and will be lowered further by using both self-deferral and antibody screening.     

Infection with HTLV-III/LAV and transfusion-associated acquired immunodeficiency syndrome. Serologic evidence of an association

We studied patients with transfusion-associated acquired immunodeficiency syndrome (AIDS) and their blood donors for serologic evidence of infection with human T-cell lymphotropic virus type III/lymphadenopathy-associated virus with two enzyme-linked immunosorbent assays and a Western blot assay. All 19 patients with AIDS were seropositive by at least one test. In all 28 donor sets containing "high-risk" donors, at least one donor was seropositive by one or more tests. Of 255 donors not considered high risk, two (0.8%) were seropositive by all three tests. When 30 seropositive high-risk donors were evaluated a median of 29 months after donation, four (13%) had developed AIDS and eight (27%) had lymphadenopathy. Our findings support the hypothesis that human T-cell lymphotropic virus type III/lymphadenopathy-associated virus causes AIDS and indicate that seropositive high-risk donors may be at relatively high risk for developing AIDS or related conditions themselves.     

Why fear persists: health care professionals and AIDS

Three reasons for the continuing fear of AIDS among health care professionals are suggested: the real risk of occupational exposure to the human immunodeficiency virus (HIV), the inadequacy of infection control measures to guarantee against HIV transmission, and the breakdown of communication between health care authorities and professionals because of differences in the two groups' values and goals. In order to address this fear without denying the problem or allowing it to compromise the quality of care, scientific and administrative authorities are urged to cultivate their credibility as experts by interpreting data conservatively while acknowledging inconsistencies, and small discussion groups are recommended as a mechanism for encouraging health professionals to voice their concerns and to recognize differing viewpoints.     

Needlestick transmission of hepatitis C

Hepatitis C virus (HCV) transmission following a needlestick is an important threat to health care workers. We present the case of a 29-year-old medical intern who sustained a needlestick injury from a source patient known to be infected with both human immunodeficiency virus and HCV. The case patient subsequently developed acute HCV infection. The optimal strategy for diagnosing HCV infection after occupational exposures has not been defined. At a minimum, HCV antibody and alanine aminotransferase testing should be done within several days of exposure (to assess if the health care worker is already infected with HCV) and 6 months after percutaneous, mucosal, or nonintact skin exposure to blood or infectious body fluids from an HCV-infected patient. Currently, it is not possible to prevent HCV infection after exposure. However, recent data suggest that early treatment of acute HCV infection with interferon alpha may be highly effective in preventing chronic HCV infection. These data underscore the importance of identifying persons with acute HCV infection and promptly referring them to experienced clinicians who can provide updated counseling and treatment.     

Knowledge of AIDS among health care students

To assess the level of understanding about AIDS among future health care professionals, we developed and administered a 31-item test covering five AIDS-related knowledge domains to selected undergraduate students, medical school applicants, medical students and pre-clinical nursing students. The percentage of correct answers ranged from 74% for questions about mechanisms of transmission to 59% for items related to testing and interpretation. Seventy-two percent of questions on clinical illness and disease were answered correctly. The number of questions answered correctly was a function of educational level. The students were generally knowledgeable about the risk factors related to sexual transmission, interpretation of the AIDS antibody test, and symptoms of AIDS. They were less informed about issues related to occupational acquisition of human immunodeficiency virus (HIV) and clinical details. Medical educators need to develop educational programs providing accurate and up-to-date knowledge about this disease.     

云南省省、县两级医护人员HIV职业暴露现状分析

目的调查云南省省、县两级医务人员HIV/AIDS职业暴露现状,探讨自我保护意识和潜在的危险因素,提高对职业暴露防护能力.方法采用自行设计问卷对245名云南省省/县两级医务人员进行问卷调查.内容包括一般个人情况、艾滋病和职业暴露相关知识知晓程度、针刺伤情况及对职业暴露态度、发生职业暴露的频率等.结果云南省省、县两级医务人员对HIV传播途径等相关知识知晓率达92.68%,对职业暴露相关知识知晓率为72.10%,自我保护意识也基本形成,但仍普遍存在以针刺伤或锐器伤为主要职业暴露问题.结论基层医务人员职业暴露防护还存在潜在的危险,应进一步加强职业安全教育及技能培训,尽可能地减少职业暴露的风险.     

Residents' experiences in, and attitudes toward, the care of persons with AIDS in Canada, France, and the United States.

OBJECTIVE--To evaluate resident physicians' experiences in, and attitudes toward, the care of persons with the acquired immunodeficiency syndrome (AIDS) in Canada, France, and the United States. DESIGN--Cross-sectional survey, using a self-administered, mailed questionnaire to residents in 10 American states, three French regions, and all 10 Canadian provinces, with follow-up surveys of nonresponders in France and the United States. SUBJECTS--Systematic samples of residents in the last year of internal medicine or family medicine residencies prior to subspecialization or entry into medical practice. RESULTS--While the majority of residents had provided inpatient and outpatient care to persons with AIDS, most believed that their training in ambulatory care of persons with AIDS had been deficient. The rate of blood-contaminated needle-sticks from human immunodeficiency virus-infected patients ranged from 4% for internal medicine residents in Canada to 14% in the United States (P less than .05). The majority recognized an ethical obligation to treat AIDS, but 4% in France, 14% in Canada, and 23% in the United States indicated that they would not care for persons with AIDS if they had a choice (P less than .001). A substantial minority of US physicians reported that a patient of theirs had been refused care by a medical specialist (19%) or a surgeon (39%), but less than 10% of French physicians reported such refusals (P less than .001). CONCLUSION--Concerns about caring for AIDS patients were common and many physicians reported that patients were refused care. While most residents acknowledged an obligation to treat human immunodeficiency virus infection, many did not, and viewpoints varied considerably across the countries studied. The lower level of reluctance to treat AIDS patients in France and Canada makes it clear that the higher rate in the United States is far from optimal and needs to be addressed.     

A survey of occupational blood contact and HIV infection among orthopedic surgeons. The American Academy of Orthopaedic Surgeons Serosurvey Study Committee.

OBJECTIVE--To study the seroprevalence of human immunodeficiency virus (HIV) among orthopedic surgeons, and correlate the results with occupational and nonoccupational risk factors. Orthopedic surgeons are one of several groups of health care workers at risk for occupationally acquired HIV infection; however, few HIV seroprevalence studies in health care workers, and none in surgeons, have been performed to assist in estimating the extent of occupational risk. DESIGN--A voluntary, anonymous HIV serosurvey at an annual meeting. To assess the representativeness of participants, a mail survey of orthopedic surgeons was conducted 5 months prior to the annual meeting. SETTING--The 1991 annual meeting of the American Academy of Orthopaedic Surgeons held in Anaheim, Calif. PARTICIPANTS--United States or Canadian orthopedic surgeons in training, in practice, or retired from practice who attended the annual meeting. MAIN OUTCOME MEASURES--Participants' HIV serostatus and reporting of occupational and nonoccupational risk factors for HIV infection. RESULTS--Of 7147 eligible orthopedists at the annual meeting, 3420 (47.9%) participated. Compared with the 10,411 orthopedic surgeons responding to the mail survey, serosurvey participants had at least as many opportunities for occupational contact with blood and with HIV-infected patients. Among participants, 87.4% reported a blood-skin contact and 39.2% reported a percutaneous blood contact in the previous month. Among 3267 participants without reported nonoccupational risk factors for HIV infection, none was positive for HIV antibody (0%; upper limit of the 95% confidence interval [CI] = 0.09%); among 108 participants with reported nonoccupational HIV risk factors, two were positive for HIV antibody (1.9%; upper limit of the 95% CI = 5.7%). CONCLUSION--Although these findings may not be generalizable to all orthopedic surgeons, we found no evidence of HIV infection among serosurvey participants without nonoccupational risk factors. The high rates of self-reported blood contact underscore the importance of compliance with infection control precautions and of development of new techniques and equipment to minimize the risk of exposures to blood during surgical procedures.     

A proposed national policy on health care workers living with HIV/AIDS and other blood-borne pathogens

In 1991, scientific uncertainty about the risk of transmission of human immunodeficiency virus or hepatitis B virus (hepatitis B e antigen [HBeAg]-positive) led the Centers for Disease Control and Prevention to recommend that infected health care workers (HCWs) be reviewed by an expert panel and inform patients of their serologic status before engaging in exposure-prone procedures. The data demonstrate that risks of transmission in the health care setting are exceedingly low, suggesting that the national policy should be reformed. Implementation of the current national policy at the local level poses significant human rights burdens on HCWs, but does not improve patient safety. A new national policy should focus on the management of the workplace environment and injury prevention by creating a program to prevent blood-borne pathogen transmission; by encouraging infected HCWs to promote their own health and well-being; by discontinuing expert review panels and special restrictions for exposure-prone procedures, which stigmatize HCWs; by discontinuing mandatory disclosure of a HCW's infection status in low-level risk procedures; and by imposing practice restrictions to avert significant risks to patients. Inclusion of these principles would achieve high levels of patient safety without discrimination and invasion of privacy. JAMA. 2000;284:1965-1970.     

AIDS: the HIV epidemic. A time of transition

The surveillance of clinical cases of acquired immune deficiency syndrome (AIDS) in the United States began in June 1981 when the first case was reported. Since then, state and federal public health officials have continuously monitored progression of the epidemic by the number of persons reported with diagnosed clinical AIDS. The human immunodeficiency virus (HIV) that causes AIDS was identified in 1983 and an antibody test was licensed by the Food and Drug Administration in 1985. Recent studies have shown that the time from HIV infection to development of clinical AIDS is an average of seven or more years. Consequently, the reported cases of clinical AIDS reflect the severity of the epidemic an average of seven years ago or more, not now, and certainly not in the future. The AIDS epidemic is in reality an HIV epidemic. The number of persons with HIV infections is a better measure of the present status and future course of the disease. This paper discusses the development of HIV prevalence and incidence studies and illustrates the use of these data to predict the future number of persons with clinical AIDS and the economic impact of the epidemic.     

Universal precautions to prevent HIV transmission to health care workers: an economic analysis.

The universal precautions recommended by the US Centers for Disease Control (CDC), Atlanta, for the prevention of HIV (human immunodeficiency virus) transmission to health care workers are widely accepted, despite little documentation of their effectiveness and efficiency. We reviewed the evidence on the risk of HIV transmission to hospital workers and the effectiveness of the universal precautions. We also evaluated the costs of implementing the recommendations in a 450-bed acute care teaching hospital in Hamilton, Ont. On the basis of aggregated results from six prospective studies the risk of HIV seroconversion among hospital workers after a needlestick injury involving a patient known to have AIDS (acquired immune deficiency syndrome) is 0.36% (upper 95% confidence limit 0.67%); the risk after skin and mucous membrane exposure to blood or other body fluids of AIDS patients is 0% (upper 95% confidence limit 0.38%). We estimated that 0.038 cases of HIV seroconversion would be prevented annually in the study hospital if the CDC recommendations were followed. The incremental cost of implementing the universal precautions was estimated to be about $315,000 per year, or over $8 million per case of HIV seroconversion prevented. If all HIV-infected workers were assumed to have AIDS within 10 years of infection the of the program would be about $565,000 per life-year saved. When less conservative, more probable assumptions were applied the best estimate of the implementation cost was $128,862,000 per case of HIV seroconversion prevented. The universal precautions implemented in the study hospital were not found to be efficacious or cost-effective. To minimize the already small risk of HIV transmission in hospitals the sources of risk of percutaneous injury should be better defined and the design of percutaneous lines, needles and surgical equipment as well as techniques improved. Preventive measures recommended on the basis of demonstrated efficacy and aimed at routes of exposure that represent true risk are needed.     

Screening test for HTLV-III (AIDS agent) antibodies. Specificity, sensitivity, and applications

The third member of the human T-cell leukemia (lymphotropic) retrovirus family (HTLV-III) is a newly discovered retrovirus that has been closely associated with the acquired immunodeficiency syndrome (AIDS). In our application of an enzyme-linked immunosorbent assay (ELISA) for HTLV-III antibodies, 72 (82%) of 88 patients with AIDS were positive, 14 (16%) were borderline, and two (2%) were negative. In contrast, only 1% of 297 volunteer blood donors were positive, 6% were borderline, and 93% were negative, demonstrating that this ELISA for HTLV-III antibodies is highly specific and sensitive for AIDS (excluding borderline results, 98.6% and 97.3%, respectively). Among persons at high risk for AIDS, 8% had borderline results, with positive and negative results readily distinguished as bimodal distributions that paralleled the temporal and geographic trends in AIDS. None of the 188 laboratory and health care employees working with patients with AIDS or their specimens were positive for HTLV-III antibodies, indicating that current precautions for health care workers appear adequate. This ELISA for HTLV-III antibodies will be a useful screening test among blood donors and populations at risk for AIDS, will aid in the diagnosis of suspected AIDS, and will help in defining the spectrum of diseases that are etiologically related to HTLV-III.     

The impact of the "grim reaper" national AIDS educational campaign on the Albion Street (AIDS) Centre and the AIDS Hotline

The national educational programme on the acquired immunodeficiency syndrome (AIDS) caused a dramatic increase in the number of heterosexual persons who presented for human immunodeficiency virus (HIV) antibody testing at the Albion Street (AIDS) Centre. There was also a marked increase in the number of intravenous drugs abusers who presented, although the proportion of this high-risk group that has been tested remains low. There was no increase in the number of homosexual men who presented for testing. The increase in the number of telephone calls that were received by the Centre's AIDS Hotline was due to an interest in HIV-antibody testing, rather than an interest in information about safer sexual practices. The campaign was seen to have achieved its primary objective, namely, to alert sexually-active persons of the potential spread of the virus from the high-risk groups. However, it is clear that future educational campaigns need to target specific high-risk groups such as intravenous drug abusers.