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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.

  1. 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.

  2. 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.

  3. 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).

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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

  1. 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.

  2. 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.

  3. CDC. Acquired immune deficiency syndrome (AIDS): precautions for clinical and laboratory staffs. MMWR 1982;31:577-80.

  4. 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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