Current Trends Recommendations for Preventing Transmission
of Infection with Human T-Lymphotropic Virus Type III/
Lymphadenopathy-Associated Virus during Invasive Procedures
BACKGROUND
On November 15, 1985, "Recommendations for Preventing
Transmission
of Infection with Human T-Lymphotropic Virus Type
III/Lymphadenopathy-Associated Virus in the Workplace," was
published
(1). That document gave particular emphasis to health-care
settings
and indicated that formulation of further specific recommendations
for
preventing human T-lymphotropic virus type
III/lymphadenopathy-associated virus (HTLV-III/LAV) transmission
applicable to health-care workers (HCWs) who perform invasive
procedures was in progress.
Toward that end, a 2-day meeting was held at CDC to discuss
draft
recommendations applicable to individuals who perform or assist in
invasive procedures.* Following the meeting, revised draft
recommendations for HCWs who have contact with tissues or mucous
membranes while performing or assisting in operative, obstetric, or
dental invasive procedures were sent to participants for comment.
In
addition, 10 physicians with expertise in infectious diseases and
the
epidemiology of HTLV-III/LAV infection were consulted to determine
whether they felt additional measures or precautions beyond those
recommended below were indicated. These 10 experts did not feel
that
additional recommendations or precautions were indicated.
DEFINITIONS
In this document, an operative procedure is defined as surgical
entry into tissues, cavities, or organs or repair of major
traumatic
injuries in an operating or delivery room, emergency department, or
outpatient setting, including both physicians' and dentists'
offices.
An obstetric procedure is defined as a vaginal or cesarean delivery
or
other invasive obstetric procedure where bleeding may occur. A
dental
procedure is defined as the manipulation, cutting, or removal of
any
oral or perioral tissues, including tooth structure, where bleeding
occurs or the potential for bleeding exists.
RECOMMENDATIONS
There have been no reports of HTLV-III/LAV transmission from an
HCW to a patient or from a patient to an HCW during operative,
obstetric, or dental invasive procedures. Nevertheless, special
emphasis should be placed on the following precautions to prevent
transmission of bloodborne agents between all patients and all HCWs
who perform or assist in invasive procedures.
All HCWs who perform or assist in operative, obstetric, or
dental invasive procedures must be educated regarding the
epidemiology, modes of transmission, and prevention of
HTLV-III/LAV infection and the need for routine use of
appropriate barrier precautions during procedures and when
handling instruments contaminated with blood after
procedures.
All HCWs who perform or assist in invasive procedures must
wear gloves when touching mucous membranes or nonintact
skin
of all patients and use other appropriate barrier
precautions
when indicated (e.g., masks, eye coverings, and gowns, if
aerosolization or splashes are likely to occur). In the
dental setting, as in the operative and obstetric setting,
gloves must be worn for touching all mucous membranes and
changed between all patient contacts. If a glove is torn
or
a needlestick or other injury occurs, the glove must be
changed as promptly as safety permits and the needle or
instrument removed from the sterile field.
All HCWs who perform or assist in vaginal or cesarean
deliveries must use appropriate barrier precautions (e.g.,
gloves and gowns) when handling the placenta or the infant
until blood and amniotic fluid have been removed from the
infant's skin. Recommendations for assisting in the
prevention of perinatal transmission of HTLV-III/LAV have
been published (2).
All HCWs who perform or assist in invasive procedures must
use extraordinary care to prevent injuries to hands caused
by
needles, scalpels, and other sharp instruments or devices
during procedures; when cleaning used instruments; during
disposal of used needles; and when handling sharp
instruments
following procedures. After use, disposable syringes and
needles, scalpel blades, and other sharp items must be
placed
in puncture-resistant containers for disposal. To prevent
needlestick injuries, needles should not be recapped;
purposefully bent or broken; removed from disposable
syringes; or otherwise manipulated by hand. No data are
currently available from controlled studies examining the
effect, if any, of the use of needle-cutting devices on
the
incidence of needlestick injuries.
If an incident occurs during an invasive procedure that
results in exposure of a patient to the blood of an HCW,
the
patient should be informed of the incident, and previous
recommendations for management of such exposures (1)
should
be followed.
No HCW who has exudative lesions or weeping dermatitis
should
perform or assist in invasive procedures or other direct
patient-care activities or handle equipment used for
patient
care.
All HCWs with evidence of any illness that may compromise
their ability to adequately and safely perform invasive
procedures should be evaluated medically to determine
whether
they are physically and mentally competent to perform
invasive procedures.
Routine serologic testing for evidence of HTLV-III/LAV
infection is not necessary for HCWs who perform or assist
in
invasive procedures or for patients undergoing invasive
procedures, since the risk of transmission in this setting
is
so low. Results of such routine testing would not
practically supplement the precautions recommended above
in
further reducing the negligible risk of transmission
during
operative, obstetric, or dental invasive procedures.
Previous recommendations (1,3,4) should be consulted for: (1)
preventing transmission of HTLV-III/LAV infection from HCWs to
patients and patients to HCWs in health-care settings other than
those
described in this document; (2) preventing transmission from
patient
to patient; (3) sterilizing, disinfecting, housekeeping, and
disposing
of waste; and (4) managing parenteral and mucous-membrane exposures
of
HCWs and patients. Previously recommended precautions (1) are also
applicable to HCWs performing or assisting in invasive procedures.
References
CDC. Recommendations for preventing transmission of infection
with human T-lymphotropic virus type
III/lymphadenopathy-associated virus in the workplace. MMWR
1985;34:682-6, 691-5.
CDC. Recommendations for assisting in the prevention of
perinatal
transmission of human T-lymphotropic virus type
III/lymphadenopathy-associated virus and acquired
immunodeficiency
syndrome. MMWR 1985;34:721-6, 731-2.
CDC. Acquired immune deficiency syndrome (AIDS): precautions
for
clinical and laboratory staffs. MMWR 1982;31:577-80.
CDC. Acquired immunodeficiency syndrome (AIDS): precautions
for
health-care workers and allied professionals. MMWR
1983;32:450-1.
*The following organizations were represented at the meeting:
American Academy of Family Physicians; American Academy of
Periodontology; American Association of Dental Schools; American
Association of Medical Colleges; American Association of Oral and
Maxillofacial Surgeons; American Association of Physicians for
Human
Rights; American College of Emergency Physicians; American College
of
Nurse Midwives; American College of Obstetricians and
Gynecologists;
American College of Surgeons; American Dental Association; American
Dental Hygienists Association; American Hospital Association;
American
Medical Association; American Nurses' Association; American Public
Health Association; Association for Practitioners in Infection
Control; Association of Operating Room Nurses; Association of State
and Territorial Health Officials; Conference of State and
Territorial
Epidemiologists; U.S. Food and Drug Administration; Infectious
Diseases Society of America; National Association of County Health
Officials; National Dental Association; National Institutes of
Health;
National Medical Association; Nurses Association of the American
College of Obstetricians and Gynecologists; Society of Hospital
Epidemiologists of America; Surgical Infection Society; and United
States Conference of Local Health Officers. In addition, a
hospital
administrator, a hospital medical director, and representatives
from
CDC participated in the meeting. These recommendations may not
reflect the views of all individual consultants or the
organizations
they represented.
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