Given the magnitude of the current and future impact of AIDS on health care services, current and future costs associ- ated with the epidemic, and the current economic difficulties experienced by many countries, it is obvious that politi- cal and financial commitment by each and every country will be essential in or- der to deal with AIDS and attract external funds for AIDS prevention and control.
Some countries are already beginning to feel the impact of AIDS on their health care delivery systems. Those countries which have yet to feel that impact must prepare for the inevitable consequences of a relatively broad epidemic of HIV in- fection. PAHO will continue in a united effort with its Member Countries in the fight to stop AIDS.
PAHO Guidelines for AIDS
These guidelines were originally pre- pared in 1985 by an ad hoc expert advi- sory group brought together by PAHO. The group, made up of scientists, epide- miologists, and disease control specialists from several of the Region’s countries, met again in December 1986 to review and update the document. The current guidelines are a result of a subsequent review by the WHO Global Program on AIDS, and eventually will be replaced by guidelines prepared by that program.
The guidelines comprise an introduc- tion and six sections, which deal with the development of national AIDS programs, recommendations for health care work- ers, prevention, psychosocial aspects, le- gal aspects, and the socioeconomic and health aspects of AIDS; four appendices contain additional information on AIDS. This abstract presents a condensed ver- sion of the section on recommendations for health care workers.
Source: Pan American Health Organization, Guidelines for Acquired Immunodeficiency Syndrome (AIDS), Washington, D.C., October 1987. A copy of the complete document can be obtained from’the Pan American Health Oraanization. Health Situa- tion and Trend AssessGent Pro&am, 525 23rd Street, N.W., Washington, D.C., 20037.
A condensed version of the original guidelines appeared in Spanish in the October 1986 Boletin de la Oficina Sanitaria Panamericana.
RECOMMENDATIONS
FOR
HEALTH CARE WORKERS
Since HIV infection and hepatitis B virus infection share a similar epidemiology-the modes of transmis- sion for both viruses are by sexual con- tact, by parenteral exposure to contami- nated blood or blood products, and from infected mother to child by exposure be- fore, during, or shortly after birth- knowledge gathered about the risk of ac- quiring hepatitis B in the workplace can effectively be used to understand the risk of HIV transmission to health care workers.
Obviously, for health care workers, ex- posure to blood, blood products, other specimens, or blood-contaminated nee- dles or instruments from persons at high risk for HIV infection presents a particu- lar risk. However, it should be noted that several studies suggest that the actual risk of occupational transmission is very low, that even among thousands of health care workers with documented
parenteral exposure to contaminated blood, only very few have had evidence of HlV seroconversion to date. Further- more, transmission of HIV in the work- place by casual contact, contaminated I food or water, insect vectors, or airborne
routes has not been documented.
In any case, patient-care and laboratory personnel should take precautions to avoid bringing their skin and mucous membranes in direct contact with blood, blood products, excretions, secretions, and tissues of AIDS patients or persons likely to be infected with I-TN The pre- cautions outlined below should be rou- tinely enforced, as should other standard infection-control precautions-regardless of whether the HIV-infected person is a patient or a health care worker. All health care workers, including students and hospital staff, should be informed of these precautions and should also study the epidemiology, clinicaI manifestations, modes of transmission, and prevention of HIV infection. Finally, hospitals and laboratories should tailor these recom- mendations to their particular circum- stances, implementing additional precau- tions if they consider it necessary.
Precautions Advised in providing
Hospital and Outpatient Clinic Care
to HIV-Infected Patients
1. Care must be taken to prevent acci- dental wounds from sharp instruments such as needles, scalpels, and razor blades that have been contaminated with potentially infectious material and to avoid having open skin lesions come into contact with material from infected patients.
2. Disposable syringes and needles, scalpel blades, and other sharp instru- ments should be discarded in puncture- resistant containers placed within easy reach. To prevent punctures, needles
should not be recapped, bent, broken, or removed from disposable syringes, or otherwise manipulated by hand.
3. Precautions should be taken when- ever there is potential exposure to blood or other body fluids. When handling blood-soiled items or equipment contam- inated with blood or other body fluids, gloves should be used. If the procedure involves more extensive contact with blood or potentially infected body fluids-for example, when performing certain dental or endoscopic procedures or postmortem examinations-gowns, masks, and eye coverings may also be re- quired. If hands accidentally become con- taminated with blood, they should be washed thoroughly.
4. Blood and other specimens should display prominent warning labels, such as “Blood Precautions,” and if the out- side of the container is visibly contami- nated with blood, it should be cleaned with a disinfectant such as a 1:lO dilution of 5.25% sodium hypochlorite (house- hold bleach) in cold water. When trans- porting blood specimens, they should be placed in a second container such as an impervious bag; this second container should be examined carefully for leaks or cracks.
5. Blood and body-fluid spills should be cleaned quickly with a disinfectant solution (see item 4).
6. Before reprocessing or disposing of articles contaminated with blood, they should be placed in impervious bags prominently labeled “Blood Precau- tions, ” or placed in plastic bags of a color that the hospital has designated exclu- sively for the disposal of infectious wastes.
7. Disposable items should be inciner- ated or autoclaved and discarded accord- ing to hospital policies; reusable items should be reprocessed according to hos- pital policies regarding items contami-
nated with hepatitis B virus; and instru- ments with lenses should be sterilized after use on infected patients.
8. Disposable syringes and needles are preferable; if reusable syringes are used, they should be sterilized before repro- cessing. Only needle locking syringes or one-piece needle syringe units should be used to aspirate fluids from patients, so that collected fluid can be discharged safely through the needle when desired.
9. In most countries it is common prac- tice to isolate any patient with a severe, undiagnosed infection in a single room. However, this practice, or special admis- sion policies, are not recommended for HIV-infected persons-including those with AIDS, except: (a) when a particular superinfection such as tuberculosis re- quires special isolation precautions; (b) when protective isolation is deemed nec- essary; (c) when maintaining hygiene standards becomes difficult, such as in circumstances when there is profuse di- arrhea, fecal incontinence, uncontrolled bleeding, or altered behavior as a result of central nervous system involvement; and (d) when the severity or terminal nature of the illness requires care in a sin- gle room.
10. To avoid mouth-to-mouth contact during emergency resuscitation at- tempts, mouth pieces, resuscitation bags, or other ventilation devices should be strategically located.
Precautions Advised for Persons
Performing Laboratory Tests or
Studies
These precautions are intended for both clinical and research laboratories. Since clinical laboratories may not always have biological safety cabinets and other safety equipment, assistance should be sought from microbiology laboratories as needed, to assure that available contain-
ment facilities permit safe laboratory tests.
Guidelines for studies involving exper- imental animals inoculated with tissues or other potentially infectious materials from individuals with known or sus- pected HIV infection were published in 1982 by the Centers for Disease Control in volume 31 of their Morbidity and Mor- tality Weekly Report, pages 577-580.
1. Mechanical pipetting devices should be used to handle all liquids in the labora- tory. Mouth pipetting should not be allowed.
2. Needles and syringes should be handled as stipulated above.
3. Laboratory coats, gowns, or uni- forms should be worn while working with potentially infectious materials.
4. Gloves should be worn to avoid skin
contact with blood, specimens containing blood, blood-contaminated items, body fluids, excretions, and secretions, as well as with surfaces, materials, and objects exposed to them.
5. Potentially infectious material should be processed and manipulated carefully to minimize creation of aerosols.
6. When conducting procedures likely to create aerosols, including centrifuging, blending, sonicating, vigorous mixing, and harvesting infected tissues from ani- mals or embryonated eggs, biological safety cabinets (Class I or II) and other primary containment devices such as centrifuge safety cups are recommended.
7. Since fluorescent activated cell sort- ers generate droplets that could result in aerosols, translucent plastic shielding should be used between the droplet col- lecting area and the equipment operator to reduce this risk. Primary containment devices should also be used in handling materials that might contain greater quantities of concentrated infectious
agents or organisms than those expected in clinical specimens.
8. Following any spill of potentially in- fectious material and upon work comple- tion, laboratory work surfaces should be cleaned with a disinfectant such as so- dium hypochlorite (see item 4 in the pre- vious section).
9. All potentially contaminated materi- als used in laboratory tests should be sterilized, preferably by autoclaving, be- fore they are disposed of or reprocessed.
10. All personnel should wash their hands after removing protective clothing and before leaving the laboratory.
Precautions for Dental Care Personnel
1. Personnel should wear gloves, masks, and protective eyewear when performing dental procedures or oral sur- gery. Personnel should wash their hands before and after attending each patient.
2. Dental instruments used for a pa- tient should be sterilized before reuse on another patient.
3. lke and
care of
ultrasonic scalers, hand- pieces, and dental units. Routine steriliza- tion of handpieces is desirable between patients. However, given the configura- tions of most handpieces, not all lend themselves to high-level disinfection of both internal and external surfaces (see following paragraph). Therefore, when using handpieces that cannot be steril- ized, the following cleaning and disinfec- tion procedures should be conducted be- tween each patient: After use, the handpiece should be flushed (see follow- ing paragraph) and then thoroughly scrubbed with a detergent and water to remove adherent material. Then it should be thoroughly wiped with an ab- sorbent material saturated with a chemi- cal germicide that is known to inactivate HIV virus and that is mycobactericidal at use-dilution. This disinfecting solution should remain in contact with the hand-piece for the time specified by the solu- tion’s manufacturer. Ultrasonic scalers and air/water syringes should also be treated this way between patients. After disinfection, any chemical residue should be rinsed off with sterile water.
Water retraction valves within dental units may aspirate infective materials into the handpiece and water line; there- fore, check valves should be installed to reduce this risk. Even though the magni- tude of this risk is unknown, it is prudent to run water-cooled handpieces and dis- charge the water into a sink or container for 20 to 30 seconds after completing care on each patient. This is designed to flush any patient material that may have been aspirated into the handpiece or water line. In addition, there is some evidence that shows that overnight bacterial accu- mulation can be significantly reduced by allowing water-cooled handpieces to run and to discharge water into a sink or con- tainer for several minutes at the begin- ning of the workday. Sterile saline or sterile water should be used as a coolant/ irrigator when performing surgical proce- dures involving the cutting of bone or soft tissue.
Precautions for Operative and
Obstetric Procedures
1. All health care workers who per- form or assist in vaginal or cesarean de- liveries must use appropriate barrier pre- cautions, such as gloves and gowns, when handling the placenta or the infant until blood and amniotic fluid have been removed from the infant’s skin.
2. Guidelines for HIV disinfection are sufficient and should be followed when disinfecting instruments (endoscopes, bronchoscopes, cytoscopes, fiberoptic scopes) used during invasive procedures in HIV-infected patients. When properly disinfected, these instruments can be safely reused in persons without HIV in- fection.
