June 23, 1989 / 38(S-6);3-37
Guidelines for
Prevention of Transmission of Human
Immunodeficiency Virus and Hepatitis B Virus to
Health-Care and Public-Safety Workers A Response to
P.L. 100-607 The Health Omnibus Programs Extension
Act of 1988
The material in this report
was developed by the National Institute for Occupational Safety and Health in
collaboration with the
Center for Infe ctious Diseases, Centers for Disease Control.
Introduction
A.Background This document is a response to recently enacted legislation, Public Law
100-607, The Health Omnibus
Programs Extension Act of 1988, Title II, Programs with Respect to Acquired Immune
Deficiency Syndrome ("AIDS
Amendments of 1988"). Subtitle E, General Provisions, Section 253(a) of Title II
specifies that "the Secretary of Health
and Human Services, acting through the Director of the Centers for Disease Control, shall
develop, issue, and
disseminate guidelines to all health workers, public safety workers (including emergency
response employees) in the
United States concerning-- (1) methods to reduce the risk in the workplace of
becoming infected with the etiologic agent for acquired immune deficiency syndrome; and
(2) circumstances under which
exposure to such
etiologic agent may occur." It is further noted that "The Secretary Õof Health
and Human Serviceså shall transmit the guidelines
issued under subsection (a) to the Secretary of Labor for use by the Secretary of Labor in
the development of standards to be
issued under the Occupational Safety and Health Act of 1970," and that "the
Secretary, acting through the Director of the
Centers for Disease Control, shall develop a model curriculum for emergency response
employees with respect to the
prevention of exposure to the etiologic agent for acquired immune deficiency syndrome
during the process of responding to
emergencies." Following development of these guidelines and curriculum, "Õtåhe
Secretary shall-- (A) transmit to State public
health officers copies of the guidelines and the model curriculum developed under
paragraph (1) with the request that such
officers disseminate such copies as appropriate throughout the State; and (B) make such
copies available to the public." B.
Purpose and Organization of Document The purpose of this document is to provide an
overview of the modes of transmission
of human immunodeficiency virus (HIV) in the workplace, an assessment of the risk of
transmission under various assumptions,
principles underlying the control of risk, and specific risk-control recommendations for
employers and workers. This document
also includes information on medical management of persons who have sustained an exposure
at the workplace to these viruses
(e.g., an emergency medical technicians who incur a needle-stick injury while performing
professional duties). These guidelines
are intended for use by a technically informed audience. As noted above, a separate model
curriculum based on the principles
and practices discussed in this document is being developed for use in training workers
and will contain less technical wording.
Information concerning the protection of workers against acquisition of the human
immunodeficiency virus (HIV) while
performing job duties, the virus that causes AIDS, is presented here. Information on
hepatitis B virus (HBV) is also presented
in this document on the basis of the following assumptions: the modes of transmission for
hepatitis B virus (HBV) are similar to
those of HIV, the potential for HBV transmission in the occupational setting is greater
than for HIV, there is a larger body of
experience relating to controlling transmission of HBV in the workplace, and general
practices to prevent the transmission of
HBV will also minimize
the risk of transmission of HIV. Blood-borne transmission of other pathogens not
specifically addressed here will be interrupted
by adherence to the precautions noted below. It is important to note that the
implementation of control measures for HIV and
HBV does not obviate the need for continued adherence to general infection-control
principles and general hygiene measures
(e.g., hand washing) for preventing transmission of other infectious diseases to both
worker and client. General guidelines for
control of these diseases have been published (1,2,3). This document was developed
primarily to provide guidelines for
fire-service personnel, emergency medical technicians, paramedics, and law-enforcement and
correctional-facility personnel.
Throughout the report, paramedics and emergency medical technicians are called
"emergency medical workers" and
fire-service, law-enforcement, and correctional-facility personnel, "public-safety
workers." Previously issued guidelines address
the needs of hospital-, laboratory-, and clinic-based health-care workers (4,5). A
condensation of general guidelines for
protection of workers from transmission of blood-borne pathogens, derived from the Joint
Advisory Notice of the Departments
of Labor and Health and Human Services (6), is provided in section III. C. Modes and Risk
of Virus Transmission in the
Workplace Although the potential for HBV transmission in the workplace setting is greater
than for HIV, the modes of
transmission for these two viruses are similar. Both have been transmitted in occupational
settings only by percutaneous
inoculation or contact with an open wound, nonintact (e.g., chapped, abraded, weeping, or
dermatitic) skin, or mucous
membranes to blood, blood-contaminated body fluids, or concentrated virus. Blood is the
single most important source of HIV
and HBV in the workplace setting. Protection measures against HIV and HBV for workers
should focus primarily on
preventing these types of exposures to blood as well as on delivery of HBV vaccination.
The risk of hepatitis B infection
following a parenteral (i.e., needle stick or cut) exposure to blood is directly
proportional to the probability that the blood
contains hepatitis B surface antigen (HBsAg), the immunity status of the recipient, and on
the efficiency of transmission (7).The
probability of the source of the blood being HBsAg positive from 1 to 3 per thousand in
the general population to 5%-15% in
groups at high risk for HBV infection, such as immigrants from areas of high endemicity
(China and Southeast Asia,
sub-Saharan Africa, most Pacific islands, and the Amazon Basin); clients in institutions
for the mentally retarded; intravenous
drug users; homosexually active males; and household (sexual and non-sexual) contacts of
HBV carriers. Of persons who have
not had prior hepatitis B vaccination or postexposure prophylaxis, 6%-30% of persons who
receive a needle-stick exposure
from an HBsAg-positive individual will become infected (7). The risk of infection with HIV
following one needle-stick exposure
to blood from a patient known to be infected with HIV is approximately 0.5% (4,5). This
rate of transmission is considerably
lower than that for HBV, probably as a result of the significantly lower concentrations of
virus in the blood of HIV-infected
persons. Table 1 presents theoretical data concerning the likelihood of infection given
repeated needle-stick injuries involving
patients whose HIV serostatus is unknown. Though inadequately quantified, the risk from
exposure of nonintact skin or mucous
membranes is likely to be far less than that from percutaneous inoculation. D.
Transmission of Hepatitis B Virus to Workers
1.Health-care workers In 1987, the CDC estimated the total number of HBV infections in the
United States to be
300,000 per year, with approximately 75,000 (25%) of infected persons developing acute
hepatitis. Of these infected
individuals, 18,000-30,000 (6%-10%) will become HBV carriers, at risk of developing
chronic liver disease (chronic
active hepatitis, cirrhosis, and primary liver cancer), and infectious to others. CDC has
estimated that 12,000 health-care
workers whose jobs entail exposure to blood become infected with HBV each year, that
500-600 of them are
hospitalized as a result of that infection, and that 700-1,200 of those infected become
HBV carriers. Of the infected
workers, approximately 250 will die (12-15 from fulminant hepatitis, 170-200 from
cirrhosis, and 40-50 from liver
cancer). Studies indicate that 10%-30% of health-care or dental workers show serologic
evidence of past or present
HBV infection. 2. Emergency medical and public-safety workers Emergency medical workers
have an increased risk for
hepatitis B infection (8,9,10). The degree of risk correlates with the frequency and
extent of blood exposure during the
conduct of work activities. A few studies are available concerning risk of HBV infection
for other groups of public-safety
workers (law-enforcement personnel and correctional-facility workers), but reports that
have been published do not
document any increased risk for HBV infection (11,12,13). Nevertheless, in occupational
settings in which workers may
be routinely exposed to blood or other body fluids as described below, an increased risk
for occupational acquisition of
HBV infection must be assumed to be present.
2.Vaccination for hepatitis B virus A safe and effective vaccine to prevent hepatitis B
has been available since 1982.
Vaccination has been recommended for health-care workers regularly exposed to blood and
other body fluids
potentially contaminated with HBV (7,14,15). In 1987, the Department of Health and Human
Services and the
Department of Labor stated that hepatitis B vaccine should be provided to all such workers
at no charge to the worker
(6). Available vaccines stimulate active immunity against HBV infection and provide over
90% protection against
hepatitis B for 7 or more years following vaccination (7). Hepatitis B vaccines also are
70%-88% effective when given
within 1 week after HBV exposure. Hepatitis B immune globulin (HBIG), a preparation of
immunoglobulin with high
levels of antibody to HBV (anti-HBs), provides temporary passive protection following
exposure to HBV. Combination
treatment with hepatitis B vaccine and HBIG is over 90% effective in preventing hepatitis
B following a documented
exposure (7). E. Transmission of Human Immunodeficiency Virus to Workers
3.Health-care workers with AIDS As of September 19, 1988, a total of 3,182 (5.1%) of
61,929 adults with AIDS, who
had been reported to the CDC national surveillance system and for whom occupational
information was available,
reported being employed in a health-care setting. Of the health-care workers with AIDS,
95% reported high-risk
behavior; for the remaining 5% (169 workers), the means of HIV acquisition was
undetermined. Of these 169
health-care workers with AIDS with undetermined risk, information is incomplete for 28
(17%) because of death or
refusal to be interviewed; 97 (57%) are still being investigated. The remaining 44 (26%)
health-care workers were
interviewed directly or had other follow-up information available. The occupations of
these 44 were nine nursing
assistants (20%); eight physicians (18%), four of whom were surgeons; eight housekeeping
or maintenance workers
(18%); six nurses (14%); four clinical laboratory technicians (9%); two respiratory
therapists (5%); one dentist (2%);
one paramedic (2%); one embalmer (2%); and four others who did not have contact with
patients (9%). Eighteen of
these 44 health-care workers reported parenteral and/or other non-needle-stick exposure to
blood or other body fluids
from patients in the 10 years preceding their diagnosis of AIDS. None of these exposures
involved a patient with AIDS
or known HIV infection, and HIV seroconversion of the health-care worker was not
documented following a specific
exposure. 2.Human immunodeficiency virus transmission in the workplace As of July 31,
1988, 1,201 health-care
workers had been enrolled and tested for HIV antibody in ongoing CDC surveillance of
health-care workers exposed
via needle stick or splashes to skin or mucous membranes to blood from patients known to
be HIV-infected (16). Of
860 workers who had received needle-stick injuries or cuts with sharp objects (i.e.,
parenteral exposures) and whose
serum had been tested for HIV antibody at least 180 days after exposure, 4 were positive,
yielding a seroprevalence
rate of 0.47%. Three of these individuals experienced an acute retroviral syndrome
associated with documented
seroconversion. Investigation revealed no nonoccupational risk factors for these three
workers. Serum collected within
30 days of exposure was not available from the fourth person. This worker had an
HIV-seropositive sexual partner, and
heterosexual acquisition of infection cannot be excluded. None of the 103 workers who had
contamination of mucous
membranes or nonintact skin and whose serum had been tested at least 180 days after
exposure developed serologic
evidence of HIV infection. Two other ongoing prospective studies assess the risk of
nosocomial acquisition of HIV
infection among health-care workers in the United States. As of April 1988, the National
Institutes of Health had tested
983 health-care workers, 137 with documented needle-stick injuries and 345 health-care
workers who had sustained
mucousmembrane exposures to blood or other body fluids of HIV-infected patients; none had
seroconverted (17) (one
health-care worker who subsequently experienced an occupational HIV seroconversion has
since been reported from
NIH Õ18å). As of March 15, 1988, a similar study at the University of California of 212
health-care workers with 625
documented accidental parenteral exposures involving HIV-infected patients had identified
one seroconversion following
a needle stick (19). Prospective studies in the United Kingdom and Canada show no evidence
of HIV transmission
among 220 health-care workers with parenteral, mucous-membrane, or cutaneous exposures
(20,21). In addition to the
health-care workers enrolled in these longitudinal surveillance studies, case histories
have been published in the scientific
literature for 19 HIV-infected health-care workers (13 with documented seroconversion and
6 without documented
seroconversion). None of these workers reported nonoccupational risk factors.
4.Emergency medical service and public-safety workers In addition to the one paramedic
with undetermined risk
discussed above, three public-safety workers (law-enforcement officers) are classified in
the undetermined risk group.
Follow-up investigations of these workers could not determine conclusively if HIV
infection was acquired during the
performance of job duties. II.Principles of Infection Control and Their Application to
Emergency and Public-Safety
Workers
A.General Infection Control Within the health-care setting, general infection control
procedures have been developed to
minimize the risk of patient acquisition of infection from contact with contaminated
devices, objects, or surfaces or of
transmission of an infectious agent from health-care workers to patients (1,2,3). Such
procedures also protect workers
from the risk of becoming infected. General infection-control procedures are designed to
prevent transmission of a wide
range of microbiological agents and to provide a wide margin of safety in the varied
situations encountered in the
health-care environment. General infection-control principles are applicable to other work
environments where workers
contact other individuals and where transmission of infectious agents may occur. The modes
of transmission noted in the
hospital and medical office environment are observed in the work situations of emergency
and public-safety workers, as
well. Therefore, the principles of infection control developed for hospital and other
health-care settings are also
applicable to these work situations. Use of general infection control measures, as adapted
to the work environments of
emergency and public-safety workers, is important to protect both workers and individuals
with whom they work from a
variety of infectious agents, not just HIV and HBV. Because emergency and public-safety
workers work in
environments that provide inherently unpredictable risks of exposures, general
infection-control procedures should be
adapted to these work situations. Exposures are unpredictable, and protective measures may
often be used in situations
that do not appear to present risk. Emergency and public-safety workers perform their
duties in the community under
extremely variable conditions; thus, control measures that are simple and uniform across
all situations have the greatest
likelihood of worker compliance. Administrative procedures to ensure compliance also can
be more readily developed
than when procedures are complex and highly variable. B.Universal Blood and Body Fluid
Precautions to Prevent
Occupational HIV and HBV Transmission In 1985, CDC developed the strategy of
"universal blood and body fluid
precautions" to address concerns regarding transmission of HIV in the health-care
setting (4). The concept, now referred
to simply as "universal precautions" stresses that all patients should be
assumed to be infectious for HIV and other
blood-borne pathogens. In the hospital and other health-care setting, "universal
precautions" should be followed when
workers are exposed to blood, certain other body fluids (amniotic fluid, pericardial
fluid, peritoneal fluid, pleural fluid,
synovial fluid, cerebrospinal fluid, semen, and vaginal secretions), or any body fluid
visibly contaminated with blood.
Since HIV and HBV transmission has not been documented from exposure to other body fluids
(feces, nasal secretions,
sputum, sweat, tears, urine, and vomitus), "universal precautions" do not apply
to these fluids. Universal precautions also
do not apply to saliva, except in the dental setting, where saliva is likely to be
contaminated with blood (7). For the
purpose of this document, human "exposure" is defined as contact with blood or
other body fluids to which universal
precautions apply through percutaneous inoculation or contact with an open wound,
nonintact skin, or mucous
membrane during the performance of normal job duties. An "exposed worker" is
defined, for the purposes of this
document, as an individual exposed, as described above, while performing normal job
duties. The unpredictable and
emergent nature of exposures encountered by emergency and public-safety workers may make
differentiation between
hazardous body fluids and those which are not hazardous very difficult and often
impossible. For example, poor lighting
may limit the worker's ability to detect visible blood in vomitus or feces. Therefore,
when emergency medical and
public-safety workers encounter body fluids under uncontrolled, emergency circumstances in
which differentiation
between fluid types is difficult, if not impossible, they should treat all body fluids as
potentially hazardous. The application
of the principles of universal precautions to the situations encountered by these workers
results in the development of
guidelines (listed below) for work practices, use of personal protective equipment, and
other protective measures. To
minimize the risks of acquiring HIV and HBV during performance of job duties, emergency
and public-safety workers
should be protected from exposure to blood and other body fluids as circumstances dictate.
Protection can be achieved
through adherence to work ractices designed to minimize or eliminate exposure and through
use of personal protective
equipment (i.e., gloves, masks, and protective clothing), which provide a barrier between
the worker and the exposure
source. In some situations, redesign of selected aspects of the job through equipment
modifications or environmental
control can further reduce risk. These approaches to primary prevention should be used
together to achieve maximal
reduction of the risk of exposure. If exposure of an individual worker occurs, medical
management, consisting of
collection of pertinent medical and occupational history, provision of treatment, and
counseling regarding future work and
personal behaviors, may reduce risk of developing disease as a result of the exposure
episode (22). Following episodic
(or continuous) exposure, decontamination and disinfection of the work environment,
devices, equipment, and clothing or
other forms of personal protective equipment can reduce subsequent risk of exposures.
Proper disposal of contaminated
waste has similar benefits. III. Employer Responsibilities
B.General Detailed recommendations for employer responsibilities in protecting workers
from acquisition of blood-borne
diseases in the workplace have been published in the Department of Labor and Department of
Health and Human
Services Joint Advisory Notice and are summarized here (6). In developing programs to
protect workers, employers
should follow a series of steps: 1) classification of work activity, 2) development of
standard operating procedures, 3)
provision of training and education, 4) development of procedures to ensure and monitor
compliance, and 5) workplace
redesign. As a first step, every employer should classify work activities into one of
three categories of potential exposure
(Table 3). Employers should make protective equipment available to all workers when they
are engaged in Category I or
II activities. Employers should ensure that the appropriate protective equipment is used
by workers when they perform
Category I activities. As a second step, employers should establish a detailed work
practices program that includes
standard operating procedures (SOPs) for all activities having the potential for exposure.
Once these SOPs are
developed, an initial and periodic worker education program to assure familiarity with
work practices should be
provided to potentially exposed workers. No worker should engage in such tasks or
activities before receiving training
pertaining to the SOPs, work practices, and protective equipment required for that task.
Examples of personal
protective equipment for the prehospital setting (defined as a setting where delivery of
emergency health care takes place
away from a hospital or other health-care setting) are provided in Table 4. (A curriculum
for such training programs is
being developed in conjunction with these guidelines and should be consulted for further
information concerning such
training programs.) To facilitate and monitor compliance with SOPs, administrative
procedures should be developed and
records kept as described in the Joint Advisory Notice (6). Employers should monitor the
workplace to ensure that
required work practices are observed and that protective clothing and equipment are
provided and properly used. The
employer should maintain records documenting the administrative procedures used to
classify job activities and copies of
all SOPs for tasks or activities involving predictable or unpredictable exposure to blood
or other body fluids to which
universal precautions apply. In addition, training records, indicating the dates of
training sessions, the content of those
training sessions along with the names of all persons conducting the training, and the
names of all those receiving training
should also be maintained. Whenever possible, the employer should identify devices and
other approaches to modifying
the work environment which will reduce exposure risk. Such approaches are desirable, since
they don't require individual
worker action or management activity. For example, jails and correctional facilities
should have classification procedures
that require the segregation of offenders who indicate through their actions or words that
they intend to attack
correctional-facility staff with the intent of transmitting HIV or HBV.
C.Medical In addition to the general responsibilities noted above, the employer has the
specific responsibility to make
available to the worker a program of medical management. This program is designed to
provide for the reduction of risk
of infection by HBV and for counseling workers concerning issues regarding HIV and HBV.
These services should be
provided by a licensed health professional. All phases of medical management and
counseling should ensure that the
confidentiality of the worker's and client's medical data is protected.
1.Hepatitis B vaccination All workers whose jobs involve participation in tasks or
activities with exposure to blood
or other body fluids to which universal precautions apply (as defined above on page )
should be vaccinated with
hepatitis B vaccine. 2.Management of percutaneous exposure to blood and other infectious
body fluids Once an
exposure has occurred (as defined above), a blood sample should be drawn after consent is
obtained from the
individual from whom exposure occurred and tested for hepatitis B surface antigen (HBsAg)
and antibody to
human immunodeficiency virus (HIV antibody). Local laws regarding consent for testing
source individuals should
be followed. Policies should be available for testing source individuals in situations
where consent cannot be
obtained (e.g., an unconscious patient). Testing of the source individual should be done
at a location where
appropriate pretest counseling is available; posttest counseling and referral for
treatment should be provided. It is
extremely important that all individuals who seek consultation for any HIV-related
concerns receive counseling as
outlined in the "Public Health Service Guidelines for Counseling and Antibody Testing
to Prevent HIV Infection
and AIDS" (22).
a.Hepatitis B virus postexposure management
For an exposure to a source individual found to be positive for HBsAg, the worker who has
not previously been
given hepatitis B vaccine should receive the vaccine series. A single dose of hepatitis B
immune globulin (HBIG) is
also recommended, if this can be given within 7 days of exposure. For exposures from an
HBsAg-positive source
to workers who have previously received vaccine, the exposed worker should be tested for
antibody to hepatitis
B surface antigen (anti-HBs), and given one dose of vaccine and one dose of HBIG if the
antibody level in the
worker's blood sample is inadequate (i.e., 10 SRU by RIA, negative by EIA) (7). If the
source individual is
negative for HBsAg and the worker has not been vaccinated, this opportunity should be
taken to provide hepatitis
B vaccination. If the source individual refuses testing or he/she cannot be identified,
the unvaccinated worker
should receive the hepatitis B vaccine series. HBIG administration should be considered on
an individual basis
when the source individual is known or suspected to be at high risk of HBV infection.
Management and treatment,
if any, of previously vaccinated workers who receive an exposure from a source who refuses
testing or is not
identifiable should be individualized (7). b.Human immunodeficiency virus postexposure
management For any
exposure to a source individual who has AIDS, who is found to be positive for HIV
infection (4), or who refuses
testing, the 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. In view of the evolving
nature of HIV
postexposure management, the health-care provider should be well informed of current PHS
guidelines on this
subject. The 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 characterized
by fever, rash, or
lymphadenopathy, may be indicative of recent HIV infection. Following the initial test at
the time of exposure,
seronegative workers should be retested 6 weeks, 12 weeks, and 6 months after exposure to
determine whether
transmission has occurred. During this follow-up period (especially the first 6-12 weeks
after exposure, when
most infected persons are expected to seroconvert), exposed workers should follow U.S.
Public Health Service
(PHS) recommendations for preventing transmission of HIV (22). These include refraining
from blood donation
and using appropriate protection during sexual intercourse (23). During all phases of
follow-up, it is vital that
worker confidentiality be protected. If the source individual was tested and found to be
seronegative, baseline
testing of the exposed worker with follow-up testing 12 weeks later may be performed if
desired by the worker
or recommended by the health-care provider. If the source individual cannot be identified,
decisions regarding
appropriate follow-up should be individualized. Serologic testing should be made available
by the employer to all
workers who may be concerned they have been infected with HIV through an occupational
exposure as defined
above.
2.Management of human bites On occasion, police and correctional-facility officers are
intentionally bitten by
suspects or prisoners. When such bites occur, routine medical and surgical therapy
(including an assessment of
tetanus vaccination status) should be implemented as soon as possible, since such bites
frequently result in
infection with organisms other than HIV and HBV. Victims of bites should be evaluated as
described above for
exposure to blood or other infectious body fluids. Saliva of some persons infected with
HBV has been shown to
contain HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected
person's serum (5,24).
HbsAg-positive saliva has been shown to be infectious when injected into experimental
animals and in human bite
exposures (25-27). However, HBsAg-positive saliva has not been shown to be infectious when
applied to oral
mucous membranes in experimental primate studies (27) or through contamination of musical
instruments or
cardiopulmonary resuscitation dummies used by HBV carriers (28,29). 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 potential for salivary transmission of HIV is
remote (5,30-33). One case
report from Germany has suggested the possibility of transmission of HIV in a household
setting from an infected
child to a sibling through a human bite (34). The bite did not break the skin or result in
bleeding. Since the date of
seroconversion to HIV was not known for either child in this case, evidence for the role
of saliva in the
transmission of virus is unclear (34).)
3.Documentation of exposure and reporting As part of the confidential medical record, the
circumstances of
exposure should be recorded. Relevant information includes the activity in which the
worker was engaged at the
time of exposure, the extent to which appropriate work practices and protective equipment
were used, and a
description of the source of exposure. Employers have a responsibility under various
federal and state laws and
regulations to report occupational illnesses and injuries. Existing programs in the
National Institute for
Occupational Safety and Health (NIOSH), Department of Health and Human Services; the
Bureau of Labor
Statistics, Department of Labor (DOL); and the Occupational Safety and Health
Administration (DOL) receive
such information for the purposes of surveillance and other objectives. Cases of
infectious disease, including AIDS
and HBV infection, are reported to the Centers for Disease Control through State health
departments.
4.Management of HBV- or HIV-infected workers Transmission of HBV from health-care workers
to patients has
been documented. Such transmission has occurred during certain types of invasive
procedures (e.g., oral and
gynecologic surgery) in which health-care workers, when tested, had very high
concentrations of HBV in their
blood (at least 100 million infectious virus particles per milliliter, a concentration
much higher than occurs with HIV
infection), and the health-care workers sustained a puncture wound while performing
invasive procedures or had
exudative or weeping lesions or microlacerations that allowed virus to contaminate
instruments or open wounds of
patients (35,36). A worker who is HBsAg positive and who has transmitted hepatitis B virus
to another individual
during the performance of his or her job duties should be excluded from the performance of
those job duties
which place other indi viduals at risk for acquisition of hepatitis B infection. Workers
with impaired immune
systems resulting from HIV infection or other causes are at increased risk of acquiring or
experiencing serious
complications of infectious disease. Of particular concern is the risk of severe infection
following exposure to other
persons with infectious diseases that are easily transmitted if appropriate precautions
are not taken (e.g., measles,
varicella). Any worker with an impaired immune system should be counseled about the
potential risk associated
with providing health care to persons with any transmissible infection and should continue
to follow existing
recommendations for infection control to minimize risk of exposure to other infectious
agents (2,3).
Recommendations of the Immunization Practices Advisory Committee (ACIP) and institutional
policies concerning
requirements for vaccinating workers with live-virus vaccines (e.g., measles, rubella)
should also be considered.
The question of whether workers infected with HIV can adequately and safely be allowed to
perform patient-care
duties or whether their work assignments should be changed must be determined on an
individual basis. These
decisions should be made by the worker's personal physician(s) in conjunction with the
employer's medical
advisors. C. Disinfection, Decontamination, and Disposal As described in Section I.C., the
only documented
occupational risks of HIV and HBV infection are associated with parenteral (including open
wound) and mucous
membrane exposure to blood and other potentially infectious body fluids. Nevertheless, the
precautions described
below should be routinely followed.
5.Needle and sharps disposal All workers should take precautions to prevent injuries
caused by needles, scalpel
blades, and other sharp instruments or devices during procedures; when cleaning used
instruments; during disposal
of used needles; and when handling sharp instruments after procedures. To prevent
needle-stick 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, scalpel blades,
and other sharp items
should be placed in puncture-resistant containers for disposal; the puncture-resistant
containers should be located
as close as practical to the use area (e.g., in the ambulance or, if sharps are carried to
the scene of victim
assistance from the ambulance, a small puncture-resistant container should be carried to
the scene, as well).
Reusable needles should be left on the syringe body and should be placed in a
puncture-resistant container for
transport to the reprocessing area.
6.Hand washing Hands and other skin surfaces should be washed immediately and thoroughly
if contaminated with
blood, other body fluids to which universal precautions apply, or potentially contaminated
articles. Hands should
always be washed after gloves are removed, even if the gloves appear to be intact. Hand
washing should be
completed using the appropriate facilities, such as utility or restroom sinks. Waterless
antiseptic hand cleanser
should be provided on responding units to use when hand-washing facilities are not
available. When hand-washing
facilities are available, wash hands with warm water and soap. When hand-washing
facilities are not available, use
a waterless antiseptic hand cleanser. The manufacturer's recommendations for the product
should be followed.
3. Cleaning, disinfecting, and sterilizing Table 5 presents the methods and applications
for cleaning, disinfecting, and sterilizing
equipment and surfaces in the prehospital setting. These methods also apply to
housekeeping and other cleaning tasks.
Previously issued guidelines for health-care workers contain more
detailed descriptions (4). 4. Cleaning and decontaminating spills of blood All spills of
blood and blood-contaminated fluids
should be promptly cleaned up using an EPA-approved germicide or a 1:100 solution of
household bleach in the following
manner while wearing gloves. Visible material should first be removed with disposable
towels or other appropriate means that
will ensure against direct contact with blood. If splashing is anticipated, protective
eyewear should be worn along with an
impervious gown or apron which provides an effective barrier to splashes. The area should
then be decontaminated with an
appropriate germicide. Hands should be washed following removal of gloves. Soiled cleaning
equipment should be cleaned and
decontaminated or placed in an appropriate container and disposed of according to agency
policy. Plastic bags should be
available for removal of contaminated items from the site of the spill. Shoes and boots
can become contaminated with blood in
certain instances. Where there is massive blood contamination on floors, the use of
disposable impervious shoe coverings
should be considered. Protective gloves should be worn to remove contaminated shoe
coverings. The coverings and gloves
should be disposed of in plastic bags. A plastic bag should be included in the crime scene
kit or the car which is to be used for
the disposal of contaminated items. Extra plastic bags should be stored in the police
cruiser or emergency vehicle. 5. Laundry
Although soiled linen may be contaminated with pathogenic microorganisms, the risk of
actual disease transmission is negligible.
Rather than rigid procedures and specifications, hygienic storage and processing of clean
and soiled linen are recommended.
Laundry facilities and/or services should be made routinely available by the employer.
Soiled linen should be handled as little as
possible 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. Linen soiled with blood
should be placed and transported in
bags that prevent leakage. Normal laundry cycles should be used according to the washer
and detergent manufacturers'
recommendations. 6. Decontamination and laundering of protective clothing Protective work
clothing contaminated with blood
or other body fluids to which universal precautions apply should be placed and transported
in bags or containers that prevent
leakage. Personnel involved in the bagging, transport, and laundering of contaminated
clothing should wear gloves. Protective
clothing and station and work uniforms should be washed and dried according to the
manufacturer's instructions. Boots and
leather goods may be brush-scrubbed with soap and hot water to remove contamination. 7.
Infective waste The selection of
procedures for disposal of infective waste is determined by the relative risk of disease
transmission and application of local
regulations, which vary widely. In all cases, local regulations should be consulted prior
to disposal procedures and followed.
Infective waste, in general, should either be incinerated or should be decontaminated
before disposal in a sanitary landfill. Bulk
blood, suctioned fluids, excretions, and secretions may be carefully poured down a drain
connected to a sanitary sewer, where
permitted. Sanitary sewers may also be used to dispose of other infectious wastes capable
of being ground and flushed into the
sewer, where permitted. Sharp items should be placed in puncture-proof containers and
other blood-contaminated items
should be placed in leak-proof plastic bags for transport to an appropriate disposal
location. Prior to the removal of protective
equipment, personnel remaining on the scene after the patient has been cared for should
carefully search for and remove
contaminated materials. Debris should be disposed of as noted above. IV. Fire and
Emergency Medical Services The
guidelines that appear in this section apply to fire and emergency medical services. This
includes structural fire fighters,
paramedics, emergency medical technicians, and advanced life support personnel. Fire
fighters often provide emergency
medical services and therefore encounter the exposures common to paramedics and emergency
medical technicians. Job duties
are often performed in uncontrolled environments, which, due to a lack of time and other
factors, do not allow for application of
a complex decision-making process to the emergency at hand. The general principles
presented here have been developed
from existing principles of occupational safety and health in Šconjunction with data
from studies of health-care workers in
hospital settings. The basic premise is that workers must be protected from exposure to
blood and other potentially infectious
body fluids in the course of their work activities. There is a paucity of data concerning
the risks these worker groups face,
however, which complicates development of control principles. Thus, the guidelines
presented below are based on principles of
prudent public health practice. Fire and emergency medical service personnel are engaged
in delivery of medical care in the
prehospital setting. The following guidelines are intended to assist these personnel in
making decisions concerning use of
personal protective equipment and resuscitation equipment, as well as for decontamination,
disinfection, and disposal
procedures.
A.Personal Protective Equipment Appropriate personal protective equipment should be made
available routinely by the
employer to reduce the risk of exposure as defined above. For many situations, the chance
that the rescuer will be
exposed to blood and other body fluids to which universal precautions apply can be
determined in advance. Therefore, if
the chances of being exposed to blood is high (e.g., CPR, IV insertion, trauma, delivering
babies), the worker should put
on protective attire before beginning patient care. Table 4 sets forth examples of
recommendations for personal
protective equipment in the prehospital setting; the list is not intended to be
all-inclusive.
1.Gloves Disposable gloves should be a standard component of emergency response equipment,
and should be
donned by all personnel prior to initiating any emergency patient care tasks involving
exposure to blood or other
body fluids to which universal precautions apply. Extra pairs should always be available.
Considerations in the
choice of disposable gloves should include dexterity, durability, fit, and the task being
performed. Thus, there is no
single type or thickness of glove appropriate for protection in all situations. For
situations where large amounts of
blood are likely to be encountered, it is important that gloves fit tightly at the wrist
to prevent blood contamination
of hands around the cuff. For multiple trauma victims, gloves should be changed between
patient contacts, if the
emergency situation allows. Greater personal protective equipment measures are indicated
for situations where
broken glass and sharp edges are likely to be encountered, such as extricating a person
from an automobile
wreck. Structural fire-fighting gloves that meet the Federal OSHA requirements for
fire-fighters gloves (as
contained in 29 CFR 1910.156 or National Fire Protection Association Standard 1973, Gloves
for Structural
Fire Fighters) should be worn in any situation where sharp or rough surfaces are likely to
be encountered (37).
While wearing gloves, avoid handling personal items, such as combs and pens, that could
become soiled or
contaminated. Gloves that have become contaminated with blood or other body fluids to
which universal
precautions apply should be removed as soon as possible, taking care to avoid skin contact
with the exterior
surface. Contaminated gloves should be placed and transported in bags that prevent leakage
and should be
disposed of or, in the case of reusable gloves, cleaned and disinfected properly.
2.Masks, eyewear, and gowns Masks, eyewear, and gowns should be present on all emergency
vehicles that
respond or potentially respond to medical emergencies or victim rescues. These protective
barriers should be
used in accordance with the level of exposure encountered. Minor lacerations or small
amounts of blood do not
merit the same extent of barrier use as required for exsanguinating victims or massive
arterial bleeding.
Management of the patient who is not bleeding, and who has no bloody body fluids present,
should not routinely
require use of barrier precautions. Masks and eyewear (e.g., safety glasses) should be
worn together, or a
faceshield should be used by all personnel prior to any situation where splashes of blood
or other body fluids to
which universal precautions apply are likely to occur. Gowns or aprons should be worn to
protect clothing from
splashes with blood. If large splashes or quantities of blood are present or anticipated,
impervious gowns or
aprons should be worn. An e xtra change of work clothing should be available at all times.
3.Resuscitation equipment No transmission of HBV or HIV infection during mouth-to-mouth
resuscitation has been
documented. However, because of the risk of salivary transmission of other infectious
diseases (e.g., herpes
simplex and Neisseria meningitidis) and the theoretical risk of HIV and HBV transmission
during artificial
ventilation of trauma victims, disposable airway equipment or resuscitation bags should be
used. Disposable
resuscitation equipment and devices should be used once and disposed of or, if
reusable,thoroughly cleaned and
disinfected after each use according to the manufacturer's recommendations. Mechanical
respiratory assist devices
(e.g., bag-valve masks, oxygen demand valve resuscitators) should be available on all
emergency vehicles and to
all emergency response personnel that respond or potentially respond to medical
emergencies or victim rescues.
Pocket mouth-to-mouth resuscitation masks designed to isolate emergency response personnel
(i.e., double lumen
systems) from contact with victims' blood and blood-contaminated saliva, respiratory
secretions, and vomitus
should be provided to all personnel who provide or potential ly provide emergency
treatment. V.
Law-Enforcement and Correctional-Facility Officers Law-enforcement and
correctional-facility officers may face
the risk of exposure to blood during the conduct of their duties. For example, at the
crime scene or during
processing of suspects, law-enforcement officers may encounter blood-contaminated
hypodermic needles or
weapons, or be called upon to assist with body removal. Correctional-facility officers may
similarly be required to
search prisoners or their cells for hypodermic needles or weapons, or subdue violent and
combative inmates. The
following section presents information for reducing the risk of acquiring HIV and HBV
infection by
law-enforcement and correctional-facility officers as a consequence of carrying out their
duties. However, there is
an extremely diverse range of potential situations which may occur in the control of
persons with unpredictable,
violent, or psychotic behavior. Therefore, informed judgment of the individual officer is
paramount when unusual
circumstances or events arise. These recommendations should serve as an adjunct to
rational decision making in
those situations where specific guidelines do not exist, particularly where immediate
action is required to preserve
life or prevent significant injury. The following guidelines are arranged into three
sections: a section addressing
concerns shared by both law-enforcement and correctional-facility officers, and two
sections dealing separately
with law-enforcement officers and correctional-facility officers, respectively. Table 4
contains selected examples
of personal protective equipment that may be employed by law-enforcement and
correctional-facility officers.
A.Law-Enforcement and Correctional-Facilities Considerations
1.Fights and assaults Law-enforcement and correctional-facility officers are exposed to a
range of assaultive
and disruptive behavior through which they may potentially become exposed to blood or
other body fluids
containing blood. Behaviors of particular concern are biting, attacks resulting in blood
exposure, and
attacks with sharp objects. Such behaviors may occur in a range of law-enforcement
situations including
arrests, routine interrogations, domestic disputes, and lockup operations, as well as in
correctional-facility
activities. Hand-to-hand combat may result in bleeding and may thus incur a greater chance
for
blood-to-blood exposure, which increases the chances for blood-borne disease transmission.
Whenever
the possibility for exposure to blood or blood-contaminated body fluids exists, the
appropriate protection
should be worn, if feasible under the circumstances. In all cases, extreme caution must be
used in dealing
with the suspect or prisoner if there is any indication of assaultive or combative
behavior. When blood is
present and a suspect or an inmate is combative or threatening to staff, gloves should
always be put on as
soon as conditions permit. In case of blood contamination of clothing, an extra change of
clothing should be
available at all times.
2.Cardiopulmonary resuscitation Law-enforcement and correctional personnel are also
concerned about
infection with HIV and HBV through administration of cardiopulmonary resuscitation (CPR).
Although
there have been no documented cases of HIV transmission through this mechanism, the
possibility of
transmission of other infectious diseases exists. Therefore, agencies should make
protective masks or
airways available to officers and provide training in their proper use. Devices with
one-way valves to
prevent the patients' saliva or vomitus from entering the caregiver's mouth are
preferable. B.
Law-Enforcement Considerations
3.Searches and evidence handling Criminal justice personnel have potential risks of
acquiring HBV or HIV
infection through exposures which occur during searches and evidence handling. Penetrating
injuries are
known to occur, and puncture wounds or needle sticks in particular pose a hazard during
searches of
persons, vehicles, or cells, and during evidence handling. The following precautionary
measures will help to
reduce the risk of infection: An officer should use great caution in searching the
clothing of suspects.
Individual discretion, based on the circumstances at hand, should determine if a suspect
or prisoner should
empty his own pockets or if the officer should use his own skills in determining the
contents of a suspect's
clothing. A safe distance should always be maintained between the officer and the
suspect. Wear protective gloves if exposure to blood is likely to be encountered. Wear
protective gloves for all body cavity
searches. If cotton gloves are to be worn when working with evidence of potential latent
fingerprint value at the crime scene,
they can be worn over protective disposable gloves when exposure to blood may occur.
Always carry a flashlight, even during
daylight shifts, to search hidden areas. Whenever possible, use long-handled mirrors and
flashlights to search such areas (e.g.,
under car seats). If searching a purse, carefully empty contents directly from purse, by
turning it upside down over a table. Use
puncture-proof containers to store sharp instruments and clearly marked plastic bags to
store other possibly contaminated
items. To avoid tearing gloves, use evidence tape instead of metal staples to seal
evidence.Local procedures for evidence
handling should be followed. In general, items should be air dried before sealing in
plastic. Not all types of gloves are suitable
for conducting searches. Vinyl or latex rubber gloves provide little protection against
sharp instruments, and they are not
puncture-proof. There is a direct trade-off between level of protection and
manipulability. In other words, the thicker the
gloves, the more protection they provide, but the less effective they are in locating
objects. Thus, there is no single type or
thickness of glove appropriate for protection in all situations. Officers should select
the type and thickness of glove which
provides the best balance of protection and search efficiency. Officers and crime scene
technicians may confront unusual
hazards, especially when the crime scene involves violent behavior, such as a homicide
where large amounts of blood are
present. Protective gloves should be available and worn in this setting. In addition, for
very large spills, consideration should be
given to other protective clothing, such as overalls, aprons, boots, or protective shoe
covers. They should be changed if torn or
soiled, and always removed prior to leaving the scene. While wearing gloves, avoid
handling personal items,
such as combs and pens, that could become soiled or contaminated. Face masks and eye
protection or a face shield are
required for laboratory and evidence technicians whose jobs which entail potential
exposures to blood via a splash to the face,
mouth, nose, or eyes. Airborne particles
of dried blood may be generated when a stain is scraped. It is recommended that protective
masks and eyewear or face shields
be worn by laboratory or evidence technicians when removing the blood stain for laboratory
analyses. While processing the
crime scene, personnel should be alert for the presence of sharp objects such as
hypodermic needles, knives, razors, broken
glass, nails, or other sharp objects. 2. Handling deceased persons and body removal For
detectives, investigators, evidence
technicians, and others who may have to touch or remove a body, the response should be the
same as for situations requiring
CPR or first aid: wear gloves and cover all cuts and abrasions to create a barrier and
carefully wash all exposed areas after any
contact with blood. The precautions to be used with blood and deceased persons should also
be used when handling
amputated limbs, hands, or other body parts. Such procedures should be followed after
contact with the blood of anyone,
regardless of whether they are known or suspected to be infected with HIV or HBV. 3.
Autopsies Protective masks and
eyewear (or face shields), laboratory coats, gloves, and waterproof aprons should be worn
when performing or attending all
autopsies. All autopsy material should be considered infectious for both HIV and HBV.
Onlookers with an opportunity for
exposure to blood splashes should be similarly protected. Instruments and surfaces
contaminated during postmortem
procedures should be decontaminated with an appropriate chemical germicide (4). Many
laboratories have more detailed
standard operating procedures for conducting autopsies; where available, these should be
followed. More detailed
recommendations for health-care workers in this setting have been published (4). 4.
Forensic laboratories Blood from all
individuals should be considered infective. To supplement other worksite precautions, the
following precautions are
recommended for workers in forensic laboratories. a.All specimens of blood should be put
in a well-constructed, appropriately
labelled 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. b.All persons
processing blood specimens should wear gloves. Masks and protective eyewear or face
shields should be worn if
mucous-membrane contact with blood is anticipated (e.g., removing tops from vacuum tubes).
Hands should be washed after
completion of specimen
processing. c.For routine procedures, such as histologic and pathologic studies or
microbiological 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. d.Mechanical pipetting devices should be used for manipulating all liquids in the
laboratory. Mouth pipetting must not be
done. e.Use of needles and syringes should be limited to situations in which there is no
alternative, and the recommendations for
preventing injuries with needles outlined under universal precautions should be followed.
f.Laboratory work surfaces should be
cleaned of visible materials and then decontaminated with an appropriate chemical
germicide after a spill of blood, semen, or
blood-contaminated body fluid and when work activities are completed. g.Contaminated
materials used in laboratory tests
should be decontaminated before reprocessing or be placed in bags and disposed of in
accordance with institutional and local
regulatory policies for disposal of infective waste. h. Scientific equipment that has been
contaminated with blood should be
cleaned and then decontaminated before being repaired in the laboratory or transported to
the manufacturer. i.All persons
should wash their hands after completing laboratory activities and should remove
protective clothing before leaving the
laboratory. j.Area posting of warning signs should be considered to remind employees of
continuing hazard of infectious disease
transmission in the laboratory setting. C. Correctional-Facility Considerations
1.Searches Penetrating injuries are known to occur in the correctional-facility setting,
and puncture wounds or needle
sticks in particular pose a hazard during searches of prisoners or their cells. The
following precautionary measures will
help to reduce the risk of infection: A correctional-facility officer should use great
caution in searching the clothing of
prisoners. Individual discretion, based on the circumstances at hand, should determine if
a prisoner should empty his own
pockets or if the officer should use his own skills in determining the contents of a
prisoner's clothing. A safe distance
should always be maintained between the officer and the prisoner. Always carry a
flashlight, even during daylight shifts,
to search hidden areas. Whenever possible, use long-handled mirrors and flashlights to
search such areas (e.g., under
commodes, bunks, and in vents in jail cells). Wear protective gloves if exposure to blood
is likely to be encountered.
Wear protective gloves for all body cavity searches. Not all types of gloves are suitable
for conducting searches. Vinyl
or latex rubber gloves can provide little, if any, protection against sharp instruments,
and they are not puncture-proof.
There is a direct trade-off between level of protection and manipulability. In other
words, the thicker the gloves, the
more protection they provide, but the less effective they are in locating objects. Thus,
there is no single type or thickness
of glove appropriate for protection in all situations. Officers should select the type and
thickness of glove which provides
the best balance of protection and sea rch efficiency.
2.Decontamination and disposal Prisoners may spit at officers and throw feces; sometimes
these substances have been
purposefully contaminated with blood. Although there are no documented cases of HIV or HBV
transmission in this
manner and transmission by this route would not be expected to occur, other diseases could
be transmitted. These
materials should be removed with a paper towel after donning gloves, and the area then
decontaminated with an
appropriate germicide. Following clean-up, soiled towels and gloves should be disposed of
properly. VI. References
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