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Risk of human immunodeficiency virus infection among emergency department workers
REVIEWS
Literature Is the use of boxed gloves care unit safe?
In an intensive
Rossoff W, Lam S, Hilton E, Borenstein M, lsenberg HD. Am J Med 1993;94:602-7. Reprint requests to Leonard J. Rossoff, MD, Division of Pulmonary and Critical Care Medicine, Room C20, Long Island Jewish Medical Center, 270-05 76th Ave., New Hyde Park, NY 11042.
The use of gloves in hospitals has dramatically increased in response to perceived benefits in the reduction of nosocomial infections and the recommendations for universal precautions by the Centers for Disease Control and Prevention. Investigators at Long Island Jewish Medical Center designed a study to identify the type, rate, burden, and pattern of contamination of boxed, clean, nonsterile gloves in their intensive care unit. The researchers found that 16 of 29 (55%) first pairs of gloves removed aseptically from boxes were contaminated, with a mean bioburden of 1.8 colony-forming units (cfu). The percentage contamination and bioburden did not change significantly with the glove’s position in the box. There was only an 11% increase in the rate of contamination when gloves were removed without special precautions (compared with gloves that had been removed according to strict aseptic technique). The length of time that boxes were open and being used was unrelated to whether the final, aseptically removed pair was sterile or contaminated. The predominate organisms recovered from contaminated gloves were coagulase-negative staphylococci. This investigation shows that half of the pairs of latex examination gloves in an intensive care unit setting remain sterile despite repeated barehanded access to boxes. Those gloves that were contaminated had an extremely small bioburden, consisting of with organisms of low pathogenic potential. No patterns of contamination or unsafe durations of box use were observed. The authors conclude that boxed, clean, nonsterile gloves appear to be safe for routine use in the intensive care setting. AJIC
AM J INFECT CONTROL
Copyright Control,
0 1993 Inc.
0196-6553/93
334
1993;22:334-6
by the Association
$01.00
+ 0.10
for Practitioners
17/51/50455
in infection
Risk of human immunodeficiency Infection among emergency department workers
virus
Marcus PI, Culver DH, Bell DM, et al. Am J Med 1993;94:363-70. Reprint requests: Ruthanne Marcus, MPH, HIV Infections Branch, Mailstop A-07, Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta, GA 30333.
Investigators at the Centers for Disease Control and Prevention and several other centers conducted a prospective study to estimate the prevalence of HIV infection in emergency department patients, the frequency of blood contact among emergency department personnel, the efficacy of gloves in preventing cutaneous blood contact, and the risk of HIV infection in emergency department workers as a result of blood contact. The study was carried out over an g-month period in three pairs of inner-city and suburban hospital emergency departments in areas of high AIDS incidence in the United States. At each hospital, blood specimens from approximately 3400 patients were tested for HIV antibody. Observers monitored blood contact and glove use by emergency department workers. The HIV seroprevalence rate was 4.1 to 8.9 per 100 patient visits in the three inner-city emergency departments; it was 6.1 in one suburban emergency department and 0.2 and 0.7 in the other two. HIV infection status was unknown to the emergency department staff in 69% of the patients who were shown to be seropositive through the study protocol. Seroprevalence rates were highest among patients aged 15 to 44 years, male patients, blacks and Hispanics, and patients with pneumonia. Blood contact was observed in 379 (3.9%) of 9793 procedures. Of these, 362 contacts (95%) were on skin, 11 (3%) were on mucous membranes, and six (2%) were percutaneous. From these data, the authors calculated that one in every 40 full-time emergency department physicians in areas with high HIV seroprevalence could expect an HIV-seropositive percutaneous blood contact annually. In the emergency departments studied with low HIV seroprevalence, one in every 575 could expect an HIV-positive percutaneous blood contact. The annual occupational risk of HIV infection for an individual emergency department physician or nurse performing procedures observed in this study was estimated as
AJIC Volume 21, Number 6
Reviews
0.008% to 0.026% (1 in 13,100 to 1 in 3,800) in areas of high HIV seroprevalence and 0.0005% to 0.002% (1 in 187,000 to 1 in 55,000) in areas of low HIV seroprevalence. As might have been anticipated, this investigation showed that patient HIV seroprevalence varies with patient demographics and clinical presentation. Accordingly, the risk to an emergency department worker of occupationally acquiring HIV infection varies by emergency department location and the nature and frequency of blood contacts. This study also points out the fact that the infection status of most HIV-seropositive patients is unknown to the emergency department staff at the time of treatment. This information should be made known to hospital workers who may not be aware of these statistics to motivate them to adhere strictly to the principles of universal precautions.
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Hoffman-Terry M, Rhodes LV 3rd Reed JF, 3rd. Arch intern Med 1992;152:1788-95. Reprint requests: Dr. Luther V. Rhodes, 1210 S Cedar Crest Blvd., Suite 2700, Allentown, PA 18103.
Previous surveys of resident physicians on issues pertaining to HIV or AIDS have tended to focus on urban programs serving a patient population with an expected high prevalence of HIV infection. The authors of this report focus their efforts on surveying residents from a community hospital training program in a nonurban area with a perceived low HIV seroprevalence. They developed a 32-question survey that was sent to all 74 members of a multidisciplinary resident physician cohort at a two-campus, university-affiliated program in southeastern Pennsylvania in May 199 1. The residents who were surveyed in this study perceived their patient population’s HIV seroprevalence rate as low. However, they believed their personal risk of occupational exposure to blood-borne exposure was moderate to high. House staff most often complied with universal precautions out of fear of acquiring a blood-borne illness. The most frequently cited reason for lack of compliance was time constraints. The primary reason for not reporting possible exposures to blood-borne pathogens was because the resident did not perceive the exposure as a health risk. The majority of house staff wanted improved HIV patient management training, as well as life and disability insurance to protect them in case they
335
acquired HIV from a workplace exposure. Most were unfamiliar with HIV legislation. This report shows that, even in a low seroprevalence environment, residents fear acquiring HIV infection from occupational exposure. There is a great need for improved training in universal precautions in these settings, similar to the need for this type of training in areas where there is a higher seroprevalence of HIV infection. In addition, house staff in low seroprevalence areas must be educated thoroughly regarding the clinical, ethical, and legal issues involved with the management of HIV-infected patients.
Tokars JI, Marcus R, Culver DH, et al. Ann Intern f&xl 1993;118: 913-9. Reprint requests: Dr. Jerome Tokars, Hospital Infections Program, Division HIV/AIDS National Center for Infectious Diseases, Center for Disease Control and Prevention, Atlanta, GA 30333.
In 1983, the Centers for Disease Control and Prevention began a national voluntary surveillance project to estimate the risk of HIV transmission after a single exposure to HIV-infected blood. In October 1988, the project was expanded to collect information describing the use of postexposure zidovudine prophylaxis among enrolled workers. This report is an update of the ongoing surveillance project that focuses on the patterns of use and associated toxicity of postexposure zidovudine prophylaxis. From August 1983 through June 1992, a total of 1245 workers from 3 12 institutions were enrolled in the project. Of these, 1103 had baseline negative serologic studies. Four of the 1103 enrolled workers with percutaneous exposures to HIV-infected blood had seroconversion, for an HIV seroconversion rate of 0.36%. No enrolled workers with mucous membrane (n = 75) or skin (n = 67) contact had seroconversion. From October 1988 to June 1992, 31% of 848 enrolled workers used zidovudine after exposure. This proportion increased from 5% during October through December 1988 to 43% during January through June 1992. Despite use of zidovudine after exposure, one worker became infected with a strain of HIV that was apparently sensitive to zidovudine. Adverse symptoms, including nausea, malaise or fatigue, and headache, were reported by 75% of workers who used zidovudine; 3 1% of workers did
Literature Is the use of boxed gloves care unit safe?
In an intensive
Rossoff W, Lam S, Hilton E, Borenstein M, lsenberg HD. Am J Med 1993;94:602-7. Reprint requests to Leonard J. Rossoff, MD, Division of Pulmonary and Critical Care Medicine, Room C20, Long Island Jewish Medical Center, 270-05 76th Ave., New Hyde Park, NY 11042.
The use of gloves in hospitals has dramatically increased in response to perceived benefits in the reduction of nosocomial infections and the recommendations for universal precautions by the Centers for Disease Control and Prevention. Investigators at Long Island Jewish Medical Center designed a study to identify the type, rate, burden, and pattern of contamination of boxed, clean, nonsterile gloves in their intensive care unit. The researchers found that 16 of 29 (55%) first pairs of gloves removed aseptically from boxes were contaminated, with a mean bioburden of 1.8 colony-forming units (cfu). The percentage contamination and bioburden did not change significantly with the glove’s position in the box. There was only an 11% increase in the rate of contamination when gloves were removed without special precautions (compared with gloves that had been removed according to strict aseptic technique). The length of time that boxes were open and being used was unrelated to whether the final, aseptically removed pair was sterile or contaminated. The predominate organisms recovered from contaminated gloves were coagulase-negative staphylococci. This investigation shows that half of the pairs of latex examination gloves in an intensive care unit setting remain sterile despite repeated barehanded access to boxes. Those gloves that were contaminated had an extremely small bioburden, consisting of with organisms of low pathogenic potential. No patterns of contamination or unsafe durations of box use were observed. The authors conclude that boxed, clean, nonsterile gloves appear to be safe for routine use in the intensive care setting. AJIC
AM J INFECT CONTROL
Copyright Control,
0 1993 Inc.
0196-6553/93
334
1993;22:334-6
by the Association
$01.00
+ 0.10
for Practitioners
17/51/50455
in infection
Risk of human immunodeficiency Infection among emergency department workers
virus
Marcus PI, Culver DH, Bell DM, et al. Am J Med 1993;94:363-70. Reprint requests: Ruthanne Marcus, MPH, HIV Infections Branch, Mailstop A-07, Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta, GA 30333.
Investigators at the Centers for Disease Control and Prevention and several other centers conducted a prospective study to estimate the prevalence of HIV infection in emergency department patients, the frequency of blood contact among emergency department personnel, the efficacy of gloves in preventing cutaneous blood contact, and the risk of HIV infection in emergency department workers as a result of blood contact. The study was carried out over an g-month period in three pairs of inner-city and suburban hospital emergency departments in areas of high AIDS incidence in the United States. At each hospital, blood specimens from approximately 3400 patients were tested for HIV antibody. Observers monitored blood contact and glove use by emergency department workers. The HIV seroprevalence rate was 4.1 to 8.9 per 100 patient visits in the three inner-city emergency departments; it was 6.1 in one suburban emergency department and 0.2 and 0.7 in the other two. HIV infection status was unknown to the emergency department staff in 69% of the patients who were shown to be seropositive through the study protocol. Seroprevalence rates were highest among patients aged 15 to 44 years, male patients, blacks and Hispanics, and patients with pneumonia. Blood contact was observed in 379 (3.9%) of 9793 procedures. Of these, 362 contacts (95%) were on skin, 11 (3%) were on mucous membranes, and six (2%) were percutaneous. From these data, the authors calculated that one in every 40 full-time emergency department physicians in areas with high HIV seroprevalence could expect an HIV-seropositive percutaneous blood contact annually. In the emergency departments studied with low HIV seroprevalence, one in every 575 could expect an HIV-positive percutaneous blood contact. The annual occupational risk of HIV infection for an individual emergency department physician or nurse performing procedures observed in this study was estimated as
AJIC Volume 21, Number 6
Reviews
0.008% to 0.026% (1 in 13,100 to 1 in 3,800) in areas of high HIV seroprevalence and 0.0005% to 0.002% (1 in 187,000 to 1 in 55,000) in areas of low HIV seroprevalence. As might have been anticipated, this investigation showed that patient HIV seroprevalence varies with patient demographics and clinical presentation. Accordingly, the risk to an emergency department worker of occupationally acquiring HIV infection varies by emergency department location and the nature and frequency of blood contacts. This study also points out the fact that the infection status of most HIV-seropositive patients is unknown to the emergency department staff at the time of treatment. This information should be made known to hospital workers who may not be aware of these statistics to motivate them to adhere strictly to the principles of universal precautions.
Imp66t of hummb m6dfod6nd6uqjb8lfdd6nt6
immu~kncy
virur
on
Hoffman-Terry M, Rhodes LV 3rd Reed JF, 3rd. Arch intern Med 1992;152:1788-95. Reprint requests: Dr. Luther V. Rhodes, 1210 S Cedar Crest Blvd., Suite 2700, Allentown, PA 18103.
Previous surveys of resident physicians on issues pertaining to HIV or AIDS have tended to focus on urban programs serving a patient population with an expected high prevalence of HIV infection. The authors of this report focus their efforts on surveying residents from a community hospital training program in a nonurban area with a perceived low HIV seroprevalence. They developed a 32-question survey that was sent to all 74 members of a multidisciplinary resident physician cohort at a two-campus, university-affiliated program in southeastern Pennsylvania in May 199 1. The residents who were surveyed in this study perceived their patient population’s HIV seroprevalence rate as low. However, they believed their personal risk of occupational exposure to blood-borne exposure was moderate to high. House staff most often complied with universal precautions out of fear of acquiring a blood-borne illness. The most frequently cited reason for lack of compliance was time constraints. The primary reason for not reporting possible exposures to blood-borne pathogens was because the resident did not perceive the exposure as a health risk. The majority of house staff wanted improved HIV patient management training, as well as life and disability insurance to protect them in case they
335
acquired HIV from a workplace exposure. Most were unfamiliar with HIV legislation. This report shows that, even in a low seroprevalence environment, residents fear acquiring HIV infection from occupational exposure. There is a great need for improved training in universal precautions in these settings, similar to the need for this type of training in areas where there is a higher seroprevalence of HIV infection. In addition, house staff in low seroprevalence areas must be educated thoroughly regarding the clinical, ethical, and legal issues involved with the management of HIV-infected patients.
Tokars JI, Marcus R, Culver DH, et al. Ann Intern f&xl 1993;118: 913-9. Reprint requests: Dr. Jerome Tokars, Hospital Infections Program, Division HIV/AIDS National Center for Infectious Diseases, Center for Disease Control and Prevention, Atlanta, GA 30333.
In 1983, the Centers for Disease Control and Prevention began a national voluntary surveillance project to estimate the risk of HIV transmission after a single exposure to HIV-infected blood. In October 1988, the project was expanded to collect information describing the use of postexposure zidovudine prophylaxis among enrolled workers. This report is an update of the ongoing surveillance project that focuses on the patterns of use and associated toxicity of postexposure zidovudine prophylaxis. From August 1983 through June 1992, a total of 1245 workers from 3 12 institutions were enrolled in the project. Of these, 1103 had baseline negative serologic studies. Four of the 1103 enrolled workers with percutaneous exposures to HIV-infected blood had seroconversion, for an HIV seroconversion rate of 0.36%. No enrolled workers with mucous membrane (n = 75) or skin (n = 67) contact had seroconversion. From October 1988 to June 1992, 31% of 848 enrolled workers used zidovudine after exposure. This proportion increased from 5% during October through December 1988 to 43% during January through June 1992. Despite use of zidovudine after exposure, one worker became infected with a strain of HIV that was apparently sensitive to zidovudine. Adverse symptoms, including nausea, malaise or fatigue, and headache, were reported by 75% of workers who used zidovudine; 3 1% of workers did