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HIV/AIDS in Healthcare Workers

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Rizgar Mohammed-Ameen

on 27 April 2010

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Transcript of HIV/AIDS in Healthcare Workers

Occupationally Acquired HIV/AIDS

April 27th, 2010

Rizgar Mohammed-Ameen Investigation of cases of HIV infection in healthcare workers has been

conducted since early in the AIDS epidemic, but it was not until 1991 that a

standardized investigation protocol was developed and implemented by CDC.

(CDC website)

Acquired immune deficiency syndrome (AIDS) is

a disease of the human immune system caused

by the human immunodeficiency virus (HIV).

(Sepkowitz, 2001) Through sophisticated genetic analysis it is possible

to trace the origin of HIV back to approximately 1930,

when a common ancestor was transferred from

chimpanzee to man.

(Korber et. al., 2000) Where did HIV come from? Early in the HIV epidemic, occupationally acquired HIV

infection was recognized as a risk to healthcare workers,

leading to numerous efforts to collect data on occupational

HIV exposures and infections in the United States.

(Do AN et al, 2003) Early studies of HIV-exposed healthcarer workers focused on

defining and quantifying the risk for HIV infection associated with

different types of occupational exposures (eg, percutaneous or


(Marcus et al, 1988) In the 1980s, national surveillance data on AIDS were reviewed in an initial attempt to identify potentially unrecognized cases of occupationally acquired HIV infection.

No specific occupational exposures could be implicated as the source of infection for any of the healthcare workers with AIDS reported at that time.

(Lifson et al, 1986) Healthcare workers, defined as individuals employed in

healthcare or laboratory settings (including students

and trainees), who are infected with HIV.

(Do AN et. al., 2003) Due to the immune deficiency, patients are prone to various fungi, parasites, bacteria and viruses.

Prone to develop certain tumors (such as Kaposi's sarcoma and non-Hodgkin's lymphoma)

(Kallings, 2008) Some of these infections may have caused a primary infection,

especially in childhood, but then dwelling latently in the body.

-Mycobacterium tuberculosis is the most common killer of HIV infected

people in the world.

(Kallings, 2008) HIV is transmitted through direct contact of a mucous membrane or the blood stream

with a bodily fluid containing HIV, such as

- blood,


-vaginal fluid,

-preseminal fluid, and

-breast milk

(Kallings, 2008)
AIDS took the world by surprise.

AIDS is a viral disease, yet no vaccination is available

AIDS is different in many ways

Has no rapid rise, obvious peak, or rapid decline

Targets people in productive ages (25-44)

100% fatal

25 million fatal cases so far, and

another 33 million infected
(Kallings, 2008) Such infections are called “opportunistic infections” as many of these

microorganisms and viruses are ubiquitous and generally harmless to

immunocompetent individuals, often dwelling in our

bodies lifelong without causing damage.

(Kallings, 2008) It has been estimated that approximately 500,000 percutaneous blood

exposures may occur annually among hospital-based HCWs in the United States.

Of these, approximately 5,000 may involve exposures to blood that is known to

be HIV-infected.

(Bell, 1997) The average risk of HIV transmission after percutanoous

exposure to HIV-infected blood is 0.3%

(1 in every 250 needle stick exposures)

(Bell, 1997) Given 5,000 exposures to needlestick injuries from HIV-infected patients and a

transmission rate of 0.3%, then about 15 HCWs can be estimated to become

infected per year from occupational exposures.

How does that compare with reports to CDC?

(Bell, 1997) Approximately 5 -10 cases (documented plus possible) of occupationally

acquired HIV infection are reported each year in the United States.

The numbers are within the same order of magnitude.

(Bell, 1997) The CDC distinguishes between "documented" and "possible"

occupational transmission of HIV.

(Sepkowitz, 2001)

"documented" case of occupational HIV infection:

The HCW had no identifiable behavioral or transfusion risk , had occupational expsoure for which serocenversion was documented.

"possible" case of occuptaional HIV infection:

The HCW had no identifiable behavioral or transfusion risk, had occupational exposure for which seroconversion specifically resulting from an occupational exposure was not documented (ie, a baseline, postexposure test for HIV was not performed)

(Sepkowitz, 2001) In the United States, data on HIV infection and AIDS among healthcare workers have been collected through two major surveillance mechanisms:

-The HIV/AIDS Reporting System

- The National Surveillance for Occupationally Acquired HIV Infection

(Do AN et al, 2003)

The HIV/AIDS Reporting System

-The current policies require that AIDS cases be reported from state and local health departments to the CDC without names or other identifying information.

-Currently, the CDC receives AIDS case reports from all 50 states, the District of Columbia, and U.S. trusts and territories.

(Do AN et al, 2003)
-Unlike AIDS reporting, the reporting of HIV infection (without AIDS) has

not yet been fully implemented in all areas in the United States

-Recognizing the importance of timely HIV surveillance data to ongoing

prevention efforts, the CDC has published guidelines for conducting case

surveillance for HIV infection.

(Do AN et al, 2003)

The National Surveillance for Occupationally Acquired HIV Infection

-Healthcare workers with AIDS who are reported without any known risk for HIV infection are investigated

by state and local health departments using standardized protocol, which was developed and

implemented in 1991.

(Do AN et al, 2003)
-In addition, the Centers for Disease Control requested that health departments also

investigate other reports (eg, from physicians or from published sources of

information) of healthcare workers who may have occupationally acquired HIV

infection even if they did not meet the criteria of the AIDS surveillance case

definition and the state does not have formal requirements for HIV infection


(Do AN et al, 2003)
The protocol includes

- a review of medical records,

- discussions with the worker's healthcare providers, and

-an interview with the worker by health department staff.

(CDC, 1992) The objectives of the interview are

- to obtain information about possible exposures to HIV, including behavioral and transfusion risks, and to evaluate past occupational exposures.

-Information regarding previous serologic testing for HIV antibodies; details about the source patient;

- history of an illness compatible with primary HIV infection and of antiretroviral prophylaxis; and

- details about the circumstances of the occupational exposure, including type of device and procedure being performed, are also collected.

-Incident reports and employee health records are reviewed when available.

(CDC, 1992)

Increasing knowledge of how HIV is transmitted and

how exposures occur has led to improvements in

healthcare worker safety.

(Mendelson et al, 1998)

Improvements in postexposure management, including the use

of PEP (Post Exposure Prophylaxis) with combination antiretroviral

regimens, may also have added to the preventive effect for

healthcare workers

(CDC, 2001) Highly active combination antiretroviral therapy (ie, HAART) regimens have

dramatically improved the health and survival of HIV-infected individuals, thus

altering the HIV epidemic in the US

(McNaghten et al, 1999) HAART can suppress the plasma viral titer to undetectable levels in the blood of HIV-infected

patients, which would also result in exposures to lower concentrations of HIV, if occupational

blood exposures were to occur.

(McNaghten et al, 1999) However, although the number of high-risk occupational exposures may have decreased, the

frequency of the healthcare worker's contact with HIV-infected patients may have increased as

the number of individuals living with HIV infection and requiring long-term medical care

increases, particularly in outpatient settings.

(CDC, 2002) Among the documented cases of occupationally acquired HIV infection, information on viral

titers at the time of occupational exposures was not generally available.

However, 11% of the cases involved a source patient with asymptomatic HIV infection,

which is associated with lower plasma viral titers.

(Do AN et al, 2003) These observations suggest that even in the era of HAART, sustained

primary prevention efforts remain central to minimizing the risk for

occupationally acquired HIV infection.

(Do AN et al, 2003)

Risks of Occupationally Acquired

HIV to HCWs in Developing

Countries The Risks in Developing Countries

-Protection of health care workers does not appear on any list of health care priorities

- Clearly, health care workers in developing countries are at serious risk of infection from bloodborne

pathogens — particularly HBV, hepatitis C virus (HCV), and HIV — because of the high prevalence of

such pathogens in many poorer regions of the world.

(Goodnough, 2001)
Although the prevalence of blood-borne pathogens in many developing countries is high, documentation of infections caused by occupational exposure in these countries is scarce.

Seventy percent of the world’s HIV-infected population lives in sub-Saharan Africa, but only 4 percent of worldwide cases of occupational HIV infection are reported from this region.

By contrast, 4 percent of the world’s HIV-infected population lives in North America and western Europe, yet 90 percent of documented occupational HIV infections are reported from these areas.

(Goodnough, 2001)
Excessive handling of contaminated needles that results from some common, unsafe practices. These include:

-The administration of unnecessary injections on demand,

-the reuse of nonsterile needles when supplies are low, and

-the unregulated disposal of hazardous waste.

(Goodnough, 2001) Belief that injections are more effective than other forms of treatment. Thus, higher demand for injection use.

-In Ghana, 80 to 90 percent of the patients who visited a health center received one or more injections per visit.

-Similar findings have been reported in Uganda and Indonesia.

(Goodnough, 2001)
-Routine use of hazardous diagnostic equipment (such as nonretracting finger-stick lancets and glass capillary tubes) to test for common tropical diseases such as malaria and filariasis.

-both "nonretracting finger-stick lancets" and "glass capillary tubes" have been associated with the occupational transmission of HIV

-More than 100 million tests for malaria are performed each year.

(Goodnough, 2001)
-Lack of gloves, gowns, masks, and goggles to protect HCWs from contact with blood.

It was recently reported in Tanzania that birth attendants cover their hands with plastic bags to protect themselves from exposure to HIV during deliveries because there are no gloves available.

(Goodnough, 2001)


In industrialized countries, the cost of protective devices and equipment that reduce blood exposure may be offset by lower expenditures associated with postexposure testing and prophylaxis, medical treatment of infected workers, institutional insurance premiums, and workers’ compensation payments.

In most developing countries, however, similar economic incentives do not exist; there is little reason for postexposure follow-up in countries that cannot afford prophylaxis, treatment, and compensation benefits.

(Goodnough, 2001) Cost of Failing to Protect HCWs in Developing Countries:

-Can be devastating to the financial security of the worker’s family.

-Can have a disproportionate effect on the fragile health care infrastructure of developing countries, where trained health professionals are scarce in relation to the overall populations they serve.

Statistics from the World Health Organization (WHO) indicate that there are fewer than 10 physicians per 100,000 population in 15 sub-Saharan countries, as compared with nearly 250 physicians per 100,000 population in the United States.

-Similar discrepancies exist between the numbers of nurses in these countries and the number of nurses in the United States.

-Possibly the largest unrecognized cost is the loss of the national investment in the training of workers whose careers are cut short by occupationally acquired infections.

(Goodnough, 2001)
-Because HIV is a blood-borne pathogen, avoiding exposure to blood remains the primary means of preventing occupational HIV transmission.

-Although it is important to minimize all modes of occupational blood exposures, prevention efforts are especially needed to reduce the frequency of percutaneous injuries. (percutaneous injury accounted for 88% of healthcare workers with documented occupationally acquired
HIV infection)

(Do AN et al, 2003)
In 1985, the Centers for Disease Control (CDC) developed the strategy of "universal blood and body fluid precautions" to address concerns regarding the transmission of HIV in the health care setting.

This concept, which stresses that all patients be assumed to be infectious for HIV or other blood-borne pathogens, applies to exposure to blood, any other body fluid visibly contaminated with blood, and other specific body fluids

(CDC) 1. Barrier precautions should be used (eg, gloves, masks, gowns, eye protection).

2. Hand washing immediately and thoroughly upon contamination with blood or body fluids and after removal of gloves.

3. No recapping of needles, and disposal in puncture resistant containers.

4. Refrain from patient care when having exudative lesions or weeping dermatitis.

Engineering control measures for unexpected circumstances because such circumstances are difficult to anticipate with specific work practices or administrative measures

(unexpected movements by patients or coworkers account for 20% of the percutaneous exposures associated with documented occupationally acquired HIV infection)

(Do AN et al, 2003)
Concern over the need for engineering control measures led to the passage of the

Needlestick Safety and Prevention Act, a federal law mandating that safety-engineered

medical devices be evaluated and made available for use in healthcare workplaces.

(Do AN et al, 2003) The Needlestick Safety and Prevention Act has 5 sections






The act was signed into law by President Clinton 11/6/00

The bloodborne pathogens standard published at 29 CFR 1910.1030 shall be revised as follows:
(1) The definition of ‘Engineering Controls’ (at 29 CFR 1910.1030(b)) shall include as additional examples of controls the following: ‘safer medical devices, such as sharps with engineered sharps injury protections and needleless systems.’ (3) The term ‘Needleless Systems’ shall be added to the definitions (at 29 CFR 1910.1030(b)) and defined as ‘a device that does not use needles for:

(A) the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established;

(B) the administration of medication or fluids; or

(C) any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.’ DEPARTMENT OF LABOR
Occupational Safety and Health Administration
29 CFR Part 1910
[Docket No. H370A]
RIN 1218-AB85
Occupational Exposure to Bloodborne Pathogens; Needlestick and Other Sharps Injuries; Final Rule
The Occupational Safety and Health Administration revised the Bloodborne Pathogens standard in conformance with the requirements of the Needlestick Safety and Prevention Act.

This Act directs OSHA to revise the Bloodborne Pathogens standard to include new examples in the definition of engineering controls along with two new definitions;

-to require that Exposure Control Plans reflect how employers implement new developments in control technology;

-to require employers to solicit input from employees responsible for direct patient care in the identification, evaluation, and selection of engineering and work practice controls; and to require certain employers to establish and maintain a log of percutaneous injuries from contaminated sharps.

-the combination of all administrative and engineering control measures, together

with the consistent use of protective equipment (eg, gloves or eyewear) and safer

personal work practices.

(Zafar et al, 1997) Limitations of Surveillance Data on

Occupationally Acquired HIV Infection -The surveillance system relies on the willingness of healthcare workers and their healthcare providers to report potential cases.

-The actual number of healthcare workers with occupationally acquired HIV infection is probably underestimated, because healthcare workers do not always seek care following exposures.

-Individuals with occupationally acquired infection are not always reported to health departments, possibly due to confidentiality concerns.
(Do AN et al, 2003)
Delayed reporting may further add to the limitations of the surveillance system.

Potential cases of occupationally acquired HIV infection are investigated retrospectively; therefore, details regarding risks, circumstances, and test results at the time of occupational exposure may be difficult or impossible to document among those who have already progressed to AIDS or who have died.

(Do AN et al, 2003) The lack of timeliness may explain why most (88%) of the cases of possible occupationally acquired HIV infection, in which it is difficult to establish the time of infection and obtain details about specific occupational exposures, are seen among healthcare workers already reported as having AIDS rather than with more recently diagnosed HIV infection.

(Do AN et al, 2003) -a surveillance approach that relies solely on facility-based HIV/AIDS reporting may not be sufficient, because healthcare workers may follow up with their private physician rather than with their facility of employment after an occupational exposure.

(Do AN et al, 2003) Conclusions

Healthcare workers must continue to be educated about

-their risks of acquiring infections with blood-borne pathogens,

-ways to effectively reduce those risks, and

-the benefit of timely, confidential reporting and follow-up of occupational exposures.

(Do AN et al, 2003) Employers also have an important role by

-demonstrating a concern for the safety of healthcare workers,

-actively monitoring for work-related injuries and exposures to blood-borne pathogens, and

-continually assessing the need for preventive measures.

(Do AN et al, 2003) (Kallings, 2008) (Do AN et al, 2003) (CDC Website) (Do AN et al, 2003) (Do AN et al, 2003) (Do AN et al, 2003) (Do AN et al, 2003) Prevention of Cccupational HIV Transmission in Healthcare Settings What do you think the most effective approach to preventing occupational HIV exposure and infection is? (Do AN et al, 2003) AIDS Stigmatization

Who is Ryan White? And why is he so famous? Barack Obama signs the Ryan White HIV/Aids Treatment Extension Act at the White House overturning the US travel ban against people infected with the HIV virus. The ban has been in place for more than 20 years. Photograph: Gerald Herbert/AP Thank You

Questions? Reference List
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Sepkowitz K. AIDS--the first 20 years. The New England Journal Of Medicine [serial online]. June 7, 2001;344(23):1764-1772. Available from: MEDLINE with Full Text, Ipswich, MA.

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Bell, D. M. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am. J. Med. 1997; 102: 9–14.

Mendelson MH, Short IJ, Schechter CB, et al. Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes. Infect Control Hosp Epidemiol 1998;19:401-406

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Goodnough C. Risks to health care workers in developing countries. The New England Journal Of Medicine [serial online]. December 27, 2001;345(26):1916. Available from: MEDLINE with Full Text, Ipswich, MA.

Pub L No. 106-430, Needlestick Safety and Prevention Act. (November 6, 2000).

Zafar AB, Butler RC, Podgorny JM, Mennonna PA, Gaydos LA, Sandiford JA. Effect of a comprehensive program to reduce needlestick injuries. Infect Control Hosp Epidemiol 1997;18:712-715

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