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Nosocomial acquired immunodeficiency syndrome and human T-cell leukaemia lymphoma virus associated disease
jhmal
of flospital
Isjmtion
(1984) 5, 3 6
LEADING
ARTICLE
Nosocomial acquired immunodeficiency syndrome and human T-cell leukaemia lymphoma virus associated disease Over 1500 cases of acquired immunodeficiency syndrome (AIDS) have been reported in the LJSA since it was first recognized in 1981 [Centers for Disease Control (CDC), 1981.--831 and cases have been observed in other countries including 20 from Britain and 70 from France (October 1983). The exact aetiology of AIDS is unknown but an infective causative agent, spread particularly during homosexual contact and via blood, appear virtually certain. There is intense speculation about the possible role of retroviruses especially human T-cell leukaemia lymphoma virus (HTI,V) or related viruses (I
6701~84'010003
04 $02 OO;O
C
3
1984Thr
IIospital
Infection
Socwty
4
D. C. Shanson
from blood products the CDC, Atlanta, has requested that ‘at iisk’ groups, including male homosexuals with many partners and intravenous drug abusers, should voluntarily refrain from donating blood. A similar request has also been made in Britain. ‘l’here is no firm evidence that any health care personnel have acquired AIDS from hospitalized patients so far although accidental ‘sharps’ injuries occasionally occur (CDC reports, 1982 1983). A study has been started by the Hospital Infections Program, CDC, of staff who have had documented parenteral or mucous membrane exposure to blood of definite or suspected AIDS patients (Update: Aids-United States, 1983). In the meantime it appears prudent for hospital staff to take some extra precautionary measures while caring for AIDS patients. In practice many patients with AIDS, or suspected prodromal AIDS, are serum HBsAg positive and HB ‘e’ antigen positive: precautions are therefore required in any case with the handling of blood and body fluids to prevent the acquisition of hepatitis B. It simplifies matters that the chances of acquiring the AIDS agent are likely to be reduced by taking similar precautions to those already recommended for hepatitis B virus since both infective agents are liable to spread to staff via blood or serum. Along these lines valuable detailed recommendations, to prevent the transmission of AIDS to clinical and laboratory staff, appeared in a series of Morbidity and Mortality Weekly Reports (MMWR) in the USA. ‘I’he first of these appeared in the issue of 5 Sovember 1982 and copies are available in Britain from the Communicable Disease Surveillance Centre, Colindale; a supplementary report was included in the issue of 4 March 1983. These reports suggested precautions for persons and specimens from persons with opportunistic infections, such as pneumocystis pneumonia, that arc not associated with underlying immunosuppressive disease, or therapy; Kaposi’s sarcoma (patients under 60 years of age); chronic generalized lymphadenopathy, unexplained weight loss and/or prolonged or unexplained fever in persons who belong to groups with apparently increased risk of AIDS. These groups include (a) homosexual or bisexual males (b) intravenous drug abusers (c) Ilaitian emigrants (d) haemophiliacs and (e) possible AIDS patients hospitalized for evaluation as well as definite AIDS patients. The precautions recommended include: (1) ‘I’he need to avoid accidental wounds from sharp instruments and to avoid contact of open skin lesions with serum or bodily secretions from AIDS patients. (2) The wearing of gloves when handling blood specimens and body fluids as well as soiled items. (3) The wearing of gowns when clothing may be soiled. (4) Handwashing immediately and thoroughly if they become contaminated with blood: also after removing gowns and gloves before leaving the room of a patient with known or suspected AIDS. (5) Adequate labelling and bagging of specimens.
AIDS
and
HTLV
associated
disease
5
(6) Use of hypochlorite (10,000 ppm available chlorine) to clean up blood spills promptly. (7) Adequate disposal of soiled articles and of disposable syringes and needles. (8) Single room isolation of patients with suspected or known AIDS especially when there is an increased risk of exposure to blood (bleeding, iv drips) and body fluids (diarrhoea or vomiting) or loss of other body secretions. (9) Additional precautions mentioned for laboratories include the use of plastic rather than glass Pasteur pipettes, and the carrying out of certain laboratory procedures such as the crushing of tissues, under the hood of a safety cabinet. A further report in the MMVVII issue of 2 September 1983 suggested precautions for dental care personnel and for those carrying out postmortems. In both these situations the use of gloves, gowns, masks and protective eye wear were suggested along with other procedures currently recommended to prevent the transmission of hepatitis 13. recognized During the same period that AIDS h as become increasingly the role of the oncogenic virus, IITLV, in causing acute adult ‘I’-41 leukaemia lymphomas has become more clearly defined in American (Poiesz et ul., 1980), Japanese (Hanaoka, ‘l’akatsuki and Shimogama, 1982) and black West Indian patients in London (Catovsky et al., 1982; Shanson et al., 1983) and in Jamaica (Rlattner et al., 1983). The West Indian patients characteristically develop an aggressive malignant disease with onset in young adulthood, hypercalcacmia, an enlarged liver and/or spleen, lymphadenopathy and cutaneous manifestations. However, these patients may also present clinically with fever and what appears to be an acute viral infection affecting one particular site such as the central nervous system (Shanson et al., 1983). H’1’I.V is another agent which is probably mainly transmitted by sexual contact and via blood (I,ancet editorial, 19836); its possible relationship with AIDS has already been mentioned. Patients with known or suspected acute adult T-cell leukaemia lymphoma and specimens from these patients, as well as from others with serological evidence of H’I’1.V infection, should probably be managed in the same way outlined above for AIDS. D. C. Shanson
St Stephen’s i/ospitaL F&ham Road London SW10 91’1/
References Ammann, A. J., Cowan, M. J., Wara, I>. W., Weintrub, I’., I>ritz, S., Goldman, II. &Perkins, II. (1983). Acquired immunodeficiency in an infant: possible transmission by means of blood products. Lancet 1, 956 958. Blattner, W. A., Gibbs, W. S., Saxinger, C., Robert-Gut-off, M., Clark, J., Lafters, W.,
6
D. C. Shanson
Hanchard, II., Campbell, M. & Gallo, Ii. (1983). Human ‘T-cell leukaemia-lymphoma virus-associated lymphoreticular neoplasis in Jamaica. Lmcet 2, 61-64. Catovsky, D., Greaves, M. F., Rose, M., Galton, D. .4., <>oolden, A. W., McCluskey, D. R. White, J. M., I,ampert, I., Bourikas, Cr., Ireland, R., Brownell, A. I., Bridges, J. M., Blattner, W. A. & Gallo, R. C. (1982). Adult T-cell lymphoma-leukaemia in blacks from the West Indies. Loncet 2, 639-643. Centers for Disease Control (CIX) (1982). Acquired immuno-deficiency syndrome AIDS: precautions for clinical and laboratory staffs. Morbidity and N/ortu/ity Weekly Report (MzVIWRj 5 Xor:ember, 31, 577 580. CIX (1983). Acquired immunodeficiency syndrome: precautions for health-care workers and allied professionals MMWR 2 September 32, 450-451. CDC (1983). An evaluation of the acquired immunodeficiency syndrome reported in healthcare personnel--United States. zVIMWR 32, 35X- 360. CI>C (1983). Prevention of acquired immune deficiency syndrome: report of interagency recommendations. &l.VTWR 32, 101-l 03. CDC (1981). Kaposi’s sarcoma and I’neumocystis pneumonia among homosexual men Sew York City and California. M!QfWR 30, 305 308. CDC (1981). Pneumocy& pneumonia--I,os Angeles. MIV~WR 30, 230-252. CI>C (1983). IIuman T-cell lcukaemia virus infection in patients with AII>S: preliminary observations. MMWR 32, 233 234. Communicable Disease Report (1983). Surveillance of AIDS in the United Kingdom, January 19X2-July 1983, PHIS. CDR 83 29 July, 30, 34. Editorial (19830). Acquired Immunodeficiency in I Iaemophilia. Lancetl, 745. Editorial (1983b). H’J’I,V-related disease. Lamet 2, 319. 321. Essex, XI., McI,ane, M. F., Lee, ‘I’. II., Falk, L., Ilowe, C. W. S. & Mullins, J. I,. (1983). Antibodies to cell membrane antigens associated with Human ‘I’-cell leukaemia virus in patients with AIDS. Scie?zce 220, 859-862. Evatt, B. I,., Stein, S. I:., Francis, D. I’., Lawrence, I). S., McI,ane, M., McDougal, J. S., I,ee, T. Ii., Spira, 1‘. J., Carhradilla, C., Mullens, J. I. & Essex, M. (1983). Antibodies to Human T-cell leukaemia virus-associated memhranc antigens in haemophiliacs: evidence for infection before 1980. Lancet 3, 698-700. Gallo, R. C., Sarin, I’. S., Gelmann, E. I’., Robert-Guroff, M., Richardson, E., Kalyanaram, V. S., Mann, ID., Sidhu, G. L)., Stahl, R. E., I,olla-Parner, S., I,eihowitch, J. & Popovic, M. (1983). Isolation of IIuman T-cell leukaemia virus is acquired immune deficiency syndrome (AIDS) Science 220, 868. 870. Hanaoka, M., Takatsuki, K. & Shimogama, M. (eds) (1982). Adult ‘I.-cell leukaemia and related diseases. &zn~ i~onogruph, 28, 1 -237. Plenum Press, New York. Poiesz, B. J., Ruscetti, 1;. W., Gazdar, A. I;., Bunn, A., Minna, J. D. & Gallo, R. C. (1980). Detection and isolation of type c retrovirus particles from fresh cultured lymphocytes of a patient with cutaneous T-cell lymphoma. Proceedings of the ,Vational fJcademy of Science 77, 7415-7419. Shanson, D. C., Kyle, P. W., Harcourt-Webster, J. S., Sagy, K. & Weiss, 1~. A. (1983). Fulminant Human T-cell leukaemia-lymphoma in a Jamaican, masquerading as acute viral infection of the nervous system. British Medical Journal 287, 1764-1765. Update: AIDS -United States (1983). Jozrvnal of American Medical Associution 250, 1016. White, G. C. & I,escsne, II. 1~. (1983). Ilaemophilia, hepatitis, and the acquired immunodeficiency syndrome. AmIals of Internal Medicine 98, 403-404.
of flospital
Isjmtion
(1984) 5, 3 6
LEADING
ARTICLE
Nosocomial acquired immunodeficiency syndrome and human T-cell leukaemia lymphoma virus associated disease Over 1500 cases of acquired immunodeficiency syndrome (AIDS) have been reported in the LJSA since it was first recognized in 1981 [Centers for Disease Control (CDC), 1981.--831 and cases have been observed in other countries including 20 from Britain and 70 from France (October 1983). The exact aetiology of AIDS is unknown but an infective causative agent, spread particularly during homosexual contact and via blood, appear virtually certain. There is intense speculation about the possible role of retroviruses especially human T-cell leukaemia lymphoma virus (HTI,V) or related viruses (I
6701~84'010003
04 $02 OO;O
C
3
1984Thr
IIospital
Infection
Socwty
4
D. C. Shanson
from blood products the CDC, Atlanta, has requested that ‘at iisk’ groups, including male homosexuals with many partners and intravenous drug abusers, should voluntarily refrain from donating blood. A similar request has also been made in Britain. ‘l’here is no firm evidence that any health care personnel have acquired AIDS from hospitalized patients so far although accidental ‘sharps’ injuries occasionally occur (CDC reports, 1982 1983). A study has been started by the Hospital Infections Program, CDC, of staff who have had documented parenteral or mucous membrane exposure to blood of definite or suspected AIDS patients (Update: Aids-United States, 1983). In the meantime it appears prudent for hospital staff to take some extra precautionary measures while caring for AIDS patients. In practice many patients with AIDS, or suspected prodromal AIDS, are serum HBsAg positive and HB ‘e’ antigen positive: precautions are therefore required in any case with the handling of blood and body fluids to prevent the acquisition of hepatitis B. It simplifies matters that the chances of acquiring the AIDS agent are likely to be reduced by taking similar precautions to those already recommended for hepatitis B virus since both infective agents are liable to spread to staff via blood or serum. Along these lines valuable detailed recommendations, to prevent the transmission of AIDS to clinical and laboratory staff, appeared in a series of Morbidity and Mortality Weekly Reports (MMWR) in the USA. ‘I’he first of these appeared in the issue of 5 Sovember 1982 and copies are available in Britain from the Communicable Disease Surveillance Centre, Colindale; a supplementary report was included in the issue of 4 March 1983. These reports suggested precautions for persons and specimens from persons with opportunistic infections, such as pneumocystis pneumonia, that arc not associated with underlying immunosuppressive disease, or therapy; Kaposi’s sarcoma (patients under 60 years of age); chronic generalized lymphadenopathy, unexplained weight loss and/or prolonged or unexplained fever in persons who belong to groups with apparently increased risk of AIDS. These groups include (a) homosexual or bisexual males (b) intravenous drug abusers (c) Ilaitian emigrants (d) haemophiliacs and (e) possible AIDS patients hospitalized for evaluation as well as definite AIDS patients. The precautions recommended include: (1) ‘I’he need to avoid accidental wounds from sharp instruments and to avoid contact of open skin lesions with serum or bodily secretions from AIDS patients. (2) The wearing of gloves when handling blood specimens and body fluids as well as soiled items. (3) The wearing of gowns when clothing may be soiled. (4) Handwashing immediately and thoroughly if they become contaminated with blood: also after removing gowns and gloves before leaving the room of a patient with known or suspected AIDS. (5) Adequate labelling and bagging of specimens.
AIDS
and
HTLV
associated
disease
5
(6) Use of hypochlorite (10,000 ppm available chlorine) to clean up blood spills promptly. (7) Adequate disposal of soiled articles and of disposable syringes and needles. (8) Single room isolation of patients with suspected or known AIDS especially when there is an increased risk of exposure to blood (bleeding, iv drips) and body fluids (diarrhoea or vomiting) or loss of other body secretions. (9) Additional precautions mentioned for laboratories include the use of plastic rather than glass Pasteur pipettes, and the carrying out of certain laboratory procedures such as the crushing of tissues, under the hood of a safety cabinet. A further report in the MMVVII issue of 2 September 1983 suggested precautions for dental care personnel and for those carrying out postmortems. In both these situations the use of gloves, gowns, masks and protective eye wear were suggested along with other procedures currently recommended to prevent the transmission of hepatitis 13. recognized During the same period that AIDS h as become increasingly the role of the oncogenic virus, IITLV, in causing acute adult ‘I’-41 leukaemia lymphomas has become more clearly defined in American (Poiesz et ul., 1980), Japanese (Hanaoka, ‘l’akatsuki and Shimogama, 1982) and black West Indian patients in London (Catovsky et al., 1982; Shanson et al., 1983) and in Jamaica (Rlattner et al., 1983). The West Indian patients characteristically develop an aggressive malignant disease with onset in young adulthood, hypercalcacmia, an enlarged liver and/or spleen, lymphadenopathy and cutaneous manifestations. However, these patients may also present clinically with fever and what appears to be an acute viral infection affecting one particular site such as the central nervous system (Shanson et al., 1983). H’1’I.V is another agent which is probably mainly transmitted by sexual contact and via blood (I,ancet editorial, 19836); its possible relationship with AIDS has already been mentioned. Patients with known or suspected acute adult T-cell leukaemia lymphoma and specimens from these patients, as well as from others with serological evidence of H’I’1.V infection, should probably be managed in the same way outlined above for AIDS. D. C. Shanson
St Stephen’s i/ospitaL F&ham Road London SW10 91’1/
References Ammann, A. J., Cowan, M. J., Wara, I>. W., Weintrub, I’., I>ritz, S., Goldman, II. &Perkins, II. (1983). Acquired immunodeficiency in an infant: possible transmission by means of blood products. Lancet 1, 956 958. Blattner, W. A., Gibbs, W. S., Saxinger, C., Robert-Gut-off, M., Clark, J., Lafters, W.,
6
D. C. Shanson
Hanchard, II., Campbell, M. & Gallo, Ii. (1983). Human ‘T-cell leukaemia-lymphoma virus-associated lymphoreticular neoplasis in Jamaica. Lmcet 2, 61-64. Catovsky, D., Greaves, M. F., Rose, M., Galton, D. .4., <>oolden, A. W., McCluskey, D. R. White, J. M., I,ampert, I., Bourikas, Cr., Ireland, R., Brownell, A. I., Bridges, J. M., Blattner, W. A. & Gallo, R. C. (1982). Adult T-cell lymphoma-leukaemia in blacks from the West Indies. Loncet 2, 639-643. Centers for Disease Control (CIX) (1982). Acquired immuno-deficiency syndrome AIDS: precautions for clinical and laboratory staffs. Morbidity and N/ortu/ity Weekly Report (MzVIWRj 5 Xor:ember, 31, 577 580. CIX (1983). Acquired immunodeficiency syndrome: precautions for health-care workers and allied professionals MMWR 2 September 32, 450-451. CDC (1983). An evaluation of the acquired immunodeficiency syndrome reported in healthcare personnel--United States. zVIMWR 32, 35X- 360. CI>C (1983). Prevention of acquired immune deficiency syndrome: report of interagency recommendations. &l.VTWR 32, 101-l 03. CDC (1981). Kaposi’s sarcoma and I’neumocystis pneumonia among homosexual men Sew York City and California. M!QfWR 30, 305 308. CDC (1981). Pneumocy& pneumonia--I,os Angeles. MIV~WR 30, 230-252. CI>C (1983). IIuman T-cell lcukaemia virus infection in patients with AII>S: preliminary observations. MMWR 32, 233 234. Communicable Disease Report (1983). Surveillance of AIDS in the United Kingdom, January 19X2-July 1983, PHIS. CDR 83 29 July, 30, 34. Editorial (19830). Acquired Immunodeficiency in I Iaemophilia. Lancetl, 745. Editorial (1983b). H’J’I,V-related disease. Lamet 2, 319. 321. Essex, XI., McI,ane, M. F., Lee, ‘I’. II., Falk, L., Ilowe, C. W. S. & Mullins, J. I,. (1983). Antibodies to cell membrane antigens associated with Human ‘I’-cell leukaemia virus in patients with AIDS. Scie?zce 220, 859-862. Evatt, B. I,., Stein, S. I:., Francis, D. I’., Lawrence, I). S., McI,ane, M., McDougal, J. S., I,ee, T. Ii., Spira, 1‘. J., Carhradilla, C., Mullens, J. I. & Essex, M. (1983). Antibodies to Human T-cell leukaemia virus-associated memhranc antigens in haemophiliacs: evidence for infection before 1980. Lancet 3, 698-700. Gallo, R. C., Sarin, I’. S., Gelmann, E. I’., Robert-Guroff, M., Richardson, E., Kalyanaram, V. S., Mann, ID., Sidhu, G. L)., Stahl, R. E., I,olla-Parner, S., I,eihowitch, J. & Popovic, M. (1983). Isolation of IIuman T-cell leukaemia virus is acquired immune deficiency syndrome (AIDS) Science 220, 868. 870. Hanaoka, M., Takatsuki, K. & Shimogama, M. (eds) (1982). Adult ‘I.-cell leukaemia and related diseases. &zn~ i~onogruph, 28, 1 -237. Plenum Press, New York. Poiesz, B. J., Ruscetti, 1;. W., Gazdar, A. I;., Bunn, A., Minna, J. D. & Gallo, R. C. (1980). Detection and isolation of type c retrovirus particles from fresh cultured lymphocytes of a patient with cutaneous T-cell lymphoma. Proceedings of the ,Vational fJcademy of Science 77, 7415-7419. Shanson, D. C., Kyle, P. W., Harcourt-Webster, J. S., Sagy, K. & Weiss, 1~. A. (1983). Fulminant Human T-cell leukaemia-lymphoma in a Jamaican, masquerading as acute viral infection of the nervous system. British Medical Journal 287, 1764-1765. Update: AIDS -United States (1983). Jozrvnal of American Medical Associution 250, 1016. White, G. C. & I,escsne, II. 1~. (1983). Ilaemophilia, hepatitis, and the acquired immunodeficiency syndrome. AmIals of Internal Medicine 98, 403-404.