Prevention of HIV transmission in the health-care setting

Prevention of HIV transmission in the health-care setting Cathryn Murphy MPH • Senior Policy Analyst, NSW Health Department

Abstract Preventing the transmission of the human immunodeficiency virus (HIV) in the health-care setting is a principal aim of infection control programs in New South Wales. Key stakeholders have adopted a number of approaches to this problem, including education, redesign of equipment, change of work practices, policy implementation and surveillance. This paper will discuss some of the main strategies for preventing occupational and iatrogenic transmission of HIV

Background Before the advent of acquired immune deficiency syndrome (AIDS), the primary role of infection control practitioners in New South Wales (NSW) was to prevent the transmission of staphylococcal surgical site infections I. Limited surveillance involved identifying and counting cases of 'golden staph' or performing 'environmental audits' and swabbings. When a patient with an infectious condition was identified infection control measures were implemented. Routine use of protective apparel was uncommon. The NSW infection control community embraced the problem

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education;

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changing work practice;

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engineering out;

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surveillance;

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policy, guidelines and regulations;

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health department initiatives, and

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networking.

Education

of human immunodeficiency virus (HIV) in the late 1980s,

Educating mainstream health-care workers in the epidemiol-

with prevention of its transmission in the health-care setting

ogy of HIY, its routes of transmission and the appropriate preventive measures has been a fundamental feature of all

now a major tenet of infection control practice in that state '. Preventing the transmission of HIV has meant a major shift in the thinking of health-care workers, requiring them to acknowledge both their occupational risks and risk-taking behaviours. Assuming ownership of the HIV problem and adopting safer working practices are integral to reducing transmission in the health-care setting 3 . Not only were longheld infection control beliefs reviewed and overturned but practices deemed safe and suitable for generations were now considered risky 4. In NSW, obstacles to changing practice and developing safe health-care settings continue. Justifying the cost of preventative measures is difficult in a country where HIV prevalence is comparatively low and occupational transmission uncommon 5, 6. This paper will outline and comment on the success of the various approaches to preventing HIV transmission in NSW health-care settings. Such strategies have included:

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infection control programs since the mid-1980s 7. Staff undertake orientation on the use of protective apparel, prevention and management of occupational exposures and the safe use, handling and disposal of sharps ". The use of ongoing campaigns such as 'Sharps Safety Awareness' and educational updates on the treatment and management of occupational exposures is widespread. These campaigns are important for maintaining mainstream health-care workers' understanding of, and ongoing responsibility for, minimising transmission risks. Modified versions of these sessions, available for nonclinical staff, are useful in allaying fear and enabling such staff to appropriately assess the actual risks of their work and identify actions to eliminate those risks. The introduction of 'safety equipment' poses a special challenge for infection control staff. Used incorrectly or without proper training, such equipment can be ineffective and has the potential to cause injury 3.

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In 1990 the NSW government developed a comprehensive,

Nevertheless, effective ways of changing behaviour continue

statewide 'Train the Trainer' program, with a training kit

to elude Australian infection control staff.

designed to assist those responsible for health-care worker

used needles, inappropriate disposal of sharps and under-

Recapping of

education. The kit provided a framework for appropriate

reporting of occupational exposures continue, despite edu-

local training, to equip health-care workers with the know-

cation and policy initiatives 13, 14. The search for successful

ledge and skills necessary to meet the challenges of HIV in the

strategies for changing practice in these areas will continue to

health-care setting'.

challenge modern infection control practitioners and anyone

Sydney'S Albion Street Centre plays a key role in providing

should share their findings with the international infection

health-care training and offers a variety of courses in HIV prevention and management. These and other infection con-

who can identify long-term solutions to these problems control community.

trol courses are available to local, interstate and international

Engineering out

health-care workers.

The NSW medical industry has been relentless in developing

Another key training initiative undertaken by the NSW

able protective apparel and 'sharps safety equipment'.

Health Department in 1997 was the release and distribution of the 'Infection Control Training and Information Kit' to all hospitals in the state 10 . NSW Health developed the kit to educate health-care workers on their regulatory requirements and responsibilities.

and refining such safety products as functional and comfortManufacturers have developed needleless systems, sharps containers and self-sheathing needles that some hospitals have adopted in an attempt to reduce the 'life' of a sharp and subsequently the possibility of injury 15. 'Point of use' placement of sharps containers is routine in NSW and dentists and surgeons have adopted 'neutral zones' for safer handling and

Changing practices Health-care workers need a comprehenSive understanding of

passing of sharps.

the possible risks of acquiring HIV in the health-care setting

NSW infection control practitioners consider the review of

if they are to change their practice. The ability to identify and

new products to be one of their core roles 7 - they assess new

assess individual risk-taking behaviour in relation to HIV

products and their potential to cause or reduce occupational

transmission continues to be a principal objective of training

exposure. Further, infection control practitioners recommend

programs. In NSW, the inability of staff to see themselves as

the most appropriate methods of cleaning and reprocessing

actually being at risk limits the extent to which they adopt or

reusable equipment and instruments,

comply with recommended risk-reduction measures '.

SUNeillance

There is scant literature evaluating the impact of Australian

In 1995 Becton DickinsonAustralia initiated the development

infection control measures 11 and this limits the development,

of a national occupational exposure surveillance system to

implementation and evaluation of local, state and federal

standardise reporting and establish baseline rates 16, Australia

policy and training initiatives to minimise HIV transmission

adopted a modified version of the EPINet™ surveillance

in the health-care setting.

system 17, with the National Centre in HIV Epidemiology and

A number of hospitals have adopted the use of 'satellite infection control groups' to assist with policy implementation and review 11. Such groups generally consist of ward/unitbased staff informally identified as opinion leaders capable of influenCing their peers at ward level. Hospitals established the groups so that these opinion leaders could assist the facility's infection control staff in the development and implementation of local policy. The role of the groups is to act

Clinical Research (NCHECR) coordinating the program. Presently, over 35 sites across Australia collect detailed data on local incidents. The NCHECR analyses and reports deidentified aggregate data, with particular emphasis on the epidemiology of the exposure and the risk and incidence of transmission of HIV 18,19. The EPINet'M surveillance system is a valuable tool for identifying local problems and facilitates the development of evidence-based strategies,

as intermediaries for infection control and ward-based staff.

Policy and regulation

A number of countries have documented the positive in-

Key state and federal infection control policies address the

fluence of such groups in expediting compliance with local

prevention of HIV transmission in the health-care setting 20-21 .

policy 12 .

In 1995 the NSW government promulgated infection control

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regulations for six professional groups 24 - medical practition-

and referral to persons sustaining actual or potential occu-

ers, dentists, nurses, dental technicians, physiotherapists and

pational exposure to HIV and other blood-borne viruses.

podiatrists.

These regulations stipulate the minimum

infection control standard for practitioners, regardless of the practice setting. Areas addressed in the document include:

Collaboration and networking In NSW, the involvement of professional associations, key stakeholders and opinion leaders has been useful in maxi-

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aseptic technique;

mising the outcome of HIV prevention strategies.

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hand and skin washing;

Conclusion

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protective gowns and aprons;

Cases of occupational transmission have occurred in Aust-

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gloves;

transmission 25. In addition, reported patient-to-patient trans-

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masks and protective eye wear;

mission 26 demonstrated very clearly the need for all of us to

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sharps;

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management of waste, and

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processing of instruments and equipment.

ralia, despite the very proactive approach to preventing HIV

maintain our vigilance in providing safer working conditions. Regular reviews of prevention strategies, work practices and equipment, in line with international best practice, is crucial and many challenges remain, including the need to:

The NSW Health Department involved key stakeholders from each of the affected professional groups in the drafting of the regulations and the standard required equates with international best practice. Despite this, there is widespread opposition to the regulations, stemming from two main areas:

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maintain a rational and sensible approach to the problem;

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initiate local infection control research and apply findings;

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assess the impact of safety equipment;

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improve and monitor compliance with regulations/ recommendations, and

firstly, the significant costs involved in compliance and, secondly, the high standard of reprocessing. The requirement for sterilisation of critical items has reduced surgeons' ability to

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the problem.

perform minor procedures in their private consulting rooms, while the inability of manufacturers to develop specialised surgical equipment capable of withstanding sterilisation has resulted in frustration and confusion at a clinical level. The lack of a formal system of measuring or monitoring compliance with the regulatory requirements could also be

maintain health-care worker awareness and ownership of

While our work in NSW to date illustrates partial success, our future efforts must achieve a greater guarantee that both staff and clients in NSW can provide and consume health care without the risk of acquiring HIV.

reducing compliance.

References

Initiatives

1.

Health Commission of New South Wales. Role of the infection control sister in the hospital setting. Circular No: 80/82.

2.

New South Wales Health Department. Report on the findings of the NSW nosocomial infection taskforce. Sydney, 1997.

3.

Ippolito G et al. Prevention, Management and Chemoprophylaxis of Occupational Exposure to HIY. Virginia: International Health Care Worker Safety Center, University of Virginia, 1997.

4.

Jagger J. Reducing occupational exposure to blood-borne pathogens: where do we stand a decade later? Infect Control Hosp Epidemiol 1996; 17:573-75.

5.

Evans M. Taking responsibility for sharps safety. Meeting report: First National EPINeFM Meeting. Becton Dickinson Australia.

6.

Dore G, Kaldor JM, Ungchusak K & Mertens TE. Epidemiology of HIV and AIDS in the Asia-Pacific region. Med J Aust. 1996; 165:494-98.

Other key initiatives in NSW include the NSW Infection Control Resource Centre and the NSW 24-Hour Needlestick Injury Hotline. In 1995, the NSW Infection Control Resource Centre was set up. A government-funded facility, its primary aim is to provide NSW health-care workers with practical and up-to-date resources, advice and educational services. Also in 1995, the Albion Street Centre established the NSW 24-Hour Needlestick Injury Hotline, a 'round the clock and immediate response service available to health-care workers and at-risk professional groups. The team of clinical experts staffing the Hotline provides assessment, advise, counselling

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7.

Albera G, Gold J & Murphy C. Reflections on the Beginnings of Infection Control in NSW. Sydney: New South Wales Health Department Public Health Bulletin 1994; 7:75-76.

8. Murphy C. Infection control in the Australia health care setting.

(PhD work in progress.)

9.

Berenger S (ed). HIV and AIDS: Health Care Worker Education Kit. Sydney: NSW Health Department, 1992.

10. NSW Health. Infection Control Training and Information Resources Kit. Sydney, 1997.

11. NSW Health Infection Control Practice Group.

cussion, September 1997.)

(lnfonnal dis-

12. Seto WH, Ching TV, Yuen KY, Chu YB & Seto WL. The enhancement of infection control in-service education by ward opinion leaders. Am J Infect Control 1991; 19:86-91.

Keep up to date with infection control issues as we approach the new millennium at our

13. Murphy C & Resnik S. Get to the point: a comparison of needlestick injuries at Manly Hospital and Sutherland Hospital. Infection Control Journal 1992; November:lO-11.

Annual State Conference

14. NSW Health Department, AIDS & Infectious Diseases Unit. Report on Health Care Worker Exposure to Blood and Body Fluids: Results of a 1993 Survey of NSW Health Care Facilities. Sydney, July 1994.

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Burswood Resort Casino.,'" Convention Centre •• .....w ..;.·• . : #' 9,. .. 8 October 1999 : "i. j :

15. Sharp K. A trial of the Safety-Lok Syringe. Presented at NSW EPINet'" User Meeting. Sydney, May 1997.

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16. Murphy C, MacDonald M, Drury M, Effler P & Weekes P. EPINEt"': Version 3 - User Manual, Sydney.

if" ..,"

-•• b,(,

.~

17. Jagger J. EPlNet: Exposure Prevention Information Network. Health Care Worker Safety Project, University of Virginia, 1992.

.".

18. MacDonald M. National surveillance for occupational exposure

to blood-borne viruses in health-care workers. Australian HIV Surveillance Report 1996; 12(2):1-5.

19. MacDonald M. Occupational exposures to blood and body fluids among health-care workers in Australia. Abstract -11th National Conference of the Australian infection Control Association. Melbourne, May 7-9,1997.

iary of events 13-17 September 1998

20. National Health and Medical Research Council. Infection control

in the health care setting: guidelines for the prevention of transmission of infectious diseases. Canberra, 1996.

21. NSW Health Department. 95/13. Sydney, 1995.

Infection Control Policy. Circular

22. NSW Health Department. Blood borne infections - management of health-care workers potentially exposed to HIY, hepatitis B and hepatitis C. Circular 97/12. Sydney, 1997. -

23. NSW Health Department. HIV and hepatitis B infected healthcare workers. Circular 95/8. Sydney, 1995. 24. NSW Health. Medical Practice Act - Regulation (relating to infection control standards). NSW, 1995. 25. National Centre in HlV Epidemiology and Clinical Research.

HIV Surveillance Report 1997; 13(2)17.

26. Chant K, Lowe D, Rubin G, Manning W, O'Donoughue R, Lyle D et al. Patient-to-patient transmission of HIV in private surgical consulting rooms. The Lancet 1993; 342:1548-49.

Hospital Infection Society Fourth Internatiollal Conference: 'Effective Infection Control: Ahead of Change' Edinburgh International Conference Centre Edinburgh, Scotland Website:

9-11 September 1999

The Second Joint Conference of the Infection Control Practitioners Association of Queensland and the Queensland Wound Care Association 'COlllltry to Coast: A United Approach' Capricorn In ternational Resort, Yeppoon, Queensland For further information, please contact: Judy L d rle or uzanne Best Tel: (07) 3369 0477 Fax: (07) 3369 1512 E-mail: .

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Australian Infection Control

Volume 3

Issue 3

Spring

1998