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Epidemiologic Notes and Reports Update: Human Immunodeficiency Virus Infections in Health-Care Workers Exposed to Blood of Infected Patients

Six persons who provided health care to patients with human immunodeficiency virus (HIV) infection and who denied other risk factors have previously been reported to have HIV infection. Four of these cases followed needle-stick exposures to blood from patients infected with HIV (1-4). The two additional cases involved persons who provided nursing care to persons with HIV infection. Although neither of these two persons sustained needle-stick injuries, both had extensive contact with blood or body fluids of the infected patient, and neither observed routinely recommended barrier precautions (5,6).

CDC has received reports of HIV infection in three additional health-care workers following non-needle-stick exposures to blood from infected patients. The exposures occurred during 1986 in three different geographic areas. Although these three cases represent rare events, they reemphasize the need for health-care workers to adhere rigorously to existing infection control recommendations for minimizing the risk of exposure to blood and body fluids of all patients (7-9).

Health-Care Worker 1: A female health-care worker assisting with an unsuccessful attempt to insert an arterial catheter in a patient suffering a cardiac arrest in an emergency room applied pressure to the insertion site to stop the bleeding. During the procedure, she may have had a small amount of blood on her index finger for about 20 minutes before washing her hands. Afterwards, she may also have assisted in cleaning the room but did not recall any other exposures to the patient's blood or body fluids. She had no open wounds, but her hands were chapped. Although she often wore gloves when anticipating exposure to blood, she was not wearing gloves during this incident.

The patient with the cardiac arrest died. A postmortem examination identified Pneumocystis carinii pneumonia, and a blood sample was positive for HIV antibody by enzyme immunoassay (EIA) and Western blot methods. Twenty days after the incident, the health-care worker became ill with fever, myalgia, extreme fatigue, sore throat, nausea, vomiting, diarrhea, a 14-pound weight loss, and generalized lymphadenopathy which her physician diagnosed as a viral syndrome. That illness lasted 3 weeks. She felt much better 9 weeks after the incident, and, when she was examined 6 months after the incident, all signs and symptoms had resolved. She had donated blood 8 months before the incident and was negative for HIV antibody by EIA. She donated again 16 weeks after the incident and was positive for HIV by EIA and Western blot (bands p24 and gp41). Serum samples obtained 20 and 23 weeks after the incident were also positive for HIV antibody. She stated that for over 8 years her only sexual partner had been her husband, who denied risk factors for HIV and was seronegative for HIV antibody. She denied ever receiving a blood transfusion, ever using intravenous drugs, or having any needle sticks or other significant exposures to blood or body fluids in the past 8 years. Her serologic test for syphilis was negative. Fifteen other employees who assisted in the care of the patient were seronegative at least 4 months after the exposure.

Health-Care Worker 2: A female phlebotomist was filling a 10 ml vacuum blood collection tube with blood from an outpatient with a suspected HIV infection when the top of the tube flew off and blood splattered around the room, on her face, and in her mouth. She was wearing gloves to protect her hands and was wearing eyeglasses so she did not think she got any blood in her eyes. She had facial acne but no open wounds. She washed the blood off immediately after the exposure. The outpatient's blood sample was positive for HIV antibody by EIA and Western blot, and a hepatitis B surface antigen test was negative. The phlebotomist's EIA was negative the day after the incident and again 8 weeks later. When she donated blood 9 months after the exposure, she was positive for HIV antibody by EIA and Western blot (bands p24 and gp41). She has had no symptoms. She denied having any sexual contact during the previous 2 years,ever using drugs intravenously, or ever receiving a transfusion. Two months after the incident, she scratched the back of her hand with a needle used to draw blood from an intravenous drug abuser of unknown HIV-antibody status. She did not bleed as a result of the scratch and has not had any needle-stick injuries in over 2 years. Her serologic tests for syphilis and hepatitis B were negative. A coworker who was splattered with blood on the face and in the mouth during the same incident remains seronegative 1 year after the incident.

Health-Care Worker 3: A female medical technologist was manipulating an apheresis machine (a device to separate blood components) to correct a problem that developed during an outpatient procedure when blood spilled, covering most of her hands and forearms. She was not wearing gloves. She does not recall having any open wounds on her hands or any mucous-membrane exposure. However, she had dermatitis on one ear and may have touched it. She washed the blood off herself and the machine several minutes after the spill. The patient undergoing the apheresis had denied risk factors for HIV infection. However, a blood sample from the patient was positive for HIV antibody by EIA and Western blot methods and negative for hepatitis B surface antigen the next day. The technologist's HIV-antibody tests were negative 5 days after the exposure and again 6 weeks later. Eight weeks after the exposure, she had an influenza-like illness with fever, myalgia, diarrhea, hives, and a pruritic red macular rash on her arms and legs. The illness resolved after a few weeks, and her physician thought the illness was probably a viral syndrome. Three months after the incident, she was positive for HIV antibody by EIA and Western blot methods (band p24 alone). Four months after the incident, a Western blot was positive (bands p24 and gp41). She indicated that for more than 8 years her only sexual partner had been her husband, who denied risk factors for HIV infection and was seronegative for HIV antibody. She denied ever receiving a transfusion, ever using intravenous drugs, or having any needle-stick injuries in over 2 years. Her serologic tests for syphilis and hepatitis B were negative. She has an immunologic disorder which had been treated with corticosteroids in the past, but she had not taken any immunosuppressive medication for the past year. A coworker with a similar exposure during the same procedure remains seronegative after 3 months. Reported by: Hospital Infections Program and AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:Three instances of health-care workers with HIV infections associated with skin or mucous-membrane exposure to blood from HIV-infected patients are reported above. Careful investigation of these three cases did not identify other risk factors for HIV infection, although unrecognized or forgotten needle-stick exposures to other infected patients cannot be totally excluded. The exact route of transmission in these three cases is not known. Health-Care Worker 1 had chapped hands, and the duration of contact with the blood of the patient experiencing a cardiac arrest may have been as long as 20 minutes. Health-Care Worker 2 sustained contamination of oral mucous membranes. This individual also had acne but did not recall having open lesions. In addition, she had sustained a scratch from a needle used to draw blood from an intravenous drug abuser of unknown HIV-infection status. Health-Care Worker 3 had a history of dermatitis involving an ear. Health-Care Workers 1 and 3 were not wearing gloves when direct contact with blood occurred. Health-Care Worker 2 was wearing gloves, but blood contaminated her face and mouth.

Three ongoing prospective studies provide data on the magnitude of the risk of HIV infection incurred when health-care workers are exposed to blood of infected patients through needle-stick wounds or contamination of an open wound or mucous membrane. In a CDC cooperative surveillance project (10), a total of 1,097 health-care workers with parenteral or mucous-membrane exposure to the blood of patients with AIDS or other manifestations of HIV infection had been enrolled as of March 31, 1987. Needle-stick injuries and cuts with sharp objects accounted for 969 (89%) of the exposures to blood; 298 of these had paired serum samples tested for HIV antibody. One (0.3%) seroconverted (2), indicating that the risk of transmission during these exposures is very low. In addition, 70 health-care workers had open wounds exposed to blood, and 58 had mucous membrane exposed to blood. Postexposure serum samples from 82 of these 128 workers have been tested for antibody to HIV; none was seropositive.

In a study at the National Institutes of Health (11) through April 30, 1987, none of the 103 workers with percutaneous exposures and none of the 229 workers with mucous-membrane exposures to blood or body fluids of patients with AIDS was seropositive. At the University of California (12), none of 63 workers with open wounds or mucous

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