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Perspectives in Disease Prevention
and Health Promotion Update:
Universal Precautions for
Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B
Virus, and Other Bloodborne Pathogens in Health-Care Settings
Introduction The
purpose of this report is to clarify and supplement the CDC publication
entitled "Recommendations for Prevention of HIV Transmission in
Health-Care Settings" (1).* In
1983, CDC published a document entitled "Guideline for Isolation
Precautions in Hospitals" (2) that contained a section entitled
"Blood and Body Fluid Precautions." The recommendations in this
section called for blood and body fluid precautions when a patient was known
or suspected to be infected with bloodborne pathogens. In August 1987, CDC
published a document entitled "Recommendations for Prevention of HIV
Transmission in Health-Care Settings" (1). In contrast to the 1983
document, the 1987 document recommended that blood and body fluid precautions
be consistently used for all patients regardless of their bloodborne
infection status. This extension of blood and body fluid precautions to all
patients is referred to as "Universal Blood and Body Fluid
Precautions" or "Universal Precautions." Under universal
precautions, blood and certain body fluids of all patients are considered
potentially infectious for human immunodeficiency virus (HIV), hepatitis B
virus (HBV), and other bloodborne pathogens. Universal
precautions are intended to prevent parenteral, mucous membrane, and
nonintact skin exposures of health-care workers to bloodborne pathogens. In
addition, immunization with HBV vaccine is recommended as an important
adjunct to universal precautions for health-care workers who have exposures
to blood (3,4). Since
the recommendations for universal precautions were published in August 1987,
CDC and the Food and Drug Administration (FDA) have received requests for
clarification of the following issues: 1) body fluids to which universal
precautions apply, 2) use of protective barriers, 3) use of gloves for
phlebotomy, 4) selection of gloves for use while observing universal
precautions, and 5) need for making changes in waste management programs as a
result of adopting universal precautions. Body
Fluids to Which Universal Precautions Apply Universal
precautions apply to blood and to other body fluids containing visible blood.
Occupational transmission of HIV and HBV to health-care workers by blood is
documented (4,5). Blood is the single most important source of HIV, HBV, and
other bloodborne pathogens in the occupational setting. Infection control
efforts for HIV, HBV, and other bloodborne pathogens must focus on preventing
exposures to blood as well as on delivery of HBV immunization. Universal
precautions also apply to semen and vaginal secretions. Although both of
these fluids have been implicated in the sexual transmission of HIV and HBV,
they have not been implicated in occupational transmission from patient to
health-care worker. This observation is not unexpected, since exposure to
semen in the usual health-care setting is limited, and the routine practice of
wearing gloves for performing vaginal examinations protects health-care
workers from exposure to potentially infectious vaginal secretions. Universal
precautions also apply to tissues and to the following fluids: cerebrospinal
fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial
fluid, and amniotic fluid. The risk of transmission of HIV and HBV from these
fluids is unknown; epidemiologic studies in the health-care and community
setting are currently inadequate to assess the potential risk to health-care
workers from occupational exposures to them. However, HIV has been isolated
from CSF, synovial, and amniotic fluid (6-8), and HBsAg has been detected in
synovial fluid, amniotic fluid, and peritoneal fluid (9-11). One case of HIV
transmission was reported after a percutaneous exposure to bloody pleural
fluid obtained by needle aspiration (12). Whereas aseptic procedures used to
obtain these fluids for diagnostic or therapeutic purposes protect
health-care workers from skin exposures, they cannot prevent penetrating
injuries due to contaminated needles or other sharp instruments. Body
Fluids to Which Universal Precautions Do Not Apply Universal
precautions do not apply to feces, nasal secretions, sputum, sweat, tears,
urine, and vomitus unless they contain visible blood. The risk of
transmission of HIV and HBV from these fluids and materials is extremely low
or nonexistent. HIV has been isolated and HBsAg has been demonstrated in some
of these fluids; however, epidemiologic studies in the health-care and
community setting have not implicated these fluids or materials in the
transmission of HIV and HBV infections (13,14). Some of the above fluids and
excretions represent a potential source for nosocomial and community-acquired
infections with other pathogens, and recommendations for preventing the
transmission of nonbloodborne pathogens have been published (2). Precautions
for Other Body Fluids in Special Settings Human
breast milk has been implicated in perinatal transmission of HIV, and HBsAg
has been found in the milk of mothers infected with HBV (10,13). However,
occupational exposure to human breast milk has not been implicated in the
transmission of HIV nor HBV infection to health-care workers. Moreover, the
health-care worker will not have the same type of intensive exposure to
breast milk as the nursing neonate. Whereas universal precautions do not
apply to human breast milk, gloves may be worn by health-care workers in
situations where exposures to breast milk might be frequent, for example, in
breast milk banking. Saliva
of some persons infected with HBV has been shown to contain HBV-DNA at
concentrations 1/1,000 to 1/10,000 of that found in the infected person's
serum (15). HBsAg-positive saliva has been shown to be infectious when
injected into experimental animals and in human bite exposures (16-18). However,
HBsAg-positive saliva has not been shown to be infectious when applied to
oral mucous membranes in experimental primate studies (18) or through
contamination of musical instruments or cardiopulmonary resuscitation dummies
used by HBV carriers (19,20). Epidemiologic studies of nonsexual household
contacts of HIV-infected patients, including several small series in which
HIV transmission failed to occur after bites or after percutaneous
inoculation or contamination of cuts and open wounds with saliva from
HIV-infected patients, suggest that the potential for salivary transmission
of HIV is remote (5,13,14,21,22). One case report from Germany has suggested
the possibility of transmission of HIV in a household setting from an
infected child to a sibling through a human bite (23). The bite did not break
the skin or result in bleeding. Since the date of seroconversion to HIV was
not known for either child in this case, evidence for the role of saliva in
the transmission of virus is unclear (23). Another case report suggested the
possibility of transmission of HIV from husband to wife by contact with
saliva during kissing (24). However, follow-up studies did not confirm HIV
infection in the wife (21). Universal
precautions do not apply to saliva. General infection control practices
already in existence -- including the use of gloves for digital examination
of mucous membranes and endotracheal suctioning, and handwashing after
exposure to saliva -- should further minimize the minute risk, if any, for
salivary transmission of HIV and HBV (1,25). Gloves need not be worn when
feeding patients and when wiping saliva from skin. Special
precautions, however, are recommended for dentistry (1). Occupationally
acquired infection with HBV in dental workers has been documented (4), and
two possible cases of occupationally acquired HIV infection involving
dentists have been reported (5,26). During dental procedures, contamination
of saliva with blood is predictable, trauma to health-care workers' hands is
common, and blood spattering may occur. Infection control precautions for
dentistry minimize the potential for nonintact skin and mucous membrane
contact of dental health-care workers to blood-contaminated saliva of
patients. In addition, the use of gloves for oral examinations and treatment
in the dental setting may also protect the patient's oral mucous membranes
from exposures to blood, which may occur from breaks in the skin of dental
workers' hands. Use
of Protective Barriers Protective
barriers reduce the risk of exposure of the health-care worker's skin or
mucous membranes to potentially infective materials. For universal
precautions, protective barriers reduce the risk of exposure to blood, body
fluids containing visible blood, and other fluids to which universal
precautions apply. Examples of protective barriers include gloves, gowns,
masks, and protective eyewear. Gloves should reduce the incidence of
contamination of hands, but they cannot prevent penetrating injuries due to
needles or other sharp instruments. Masks and protective eyewear or face
shields should reduce the incidence of contamination of mucous membranes of
the mouth, nose, and eyes. Universal
precautions are intended to supplement rather than replace recommendations
for routine infection control, such as handwashing and using gloves to
prevent gross microbial contamination of hands (27). Because specifying the
types of barriers needed for every possible clinical situation is
impractical, some judgment must be exercised. The
risk of nosocomial transmission of HIV, HBV, and other bloodborne pathogens
can be minimized if health-care workers use the following general
guidelines:** 1.
Take
care to prevent injuries when using needles, scalpels, and other sharp
instruments or devices; when handling sharp instruments after procedures;
when cleaning used instruments; and when disposing of used needles. Do not
recap used needles by hand; do not remove used needles from disposable
syringes by hand; and do not bend, break, or otherwise manipulate used
needles by hand. Place used disposable syringes and needles, scalpel blades,
and other sharp items in puncture-resistant containers for disposal. Locate
the puncture-resistant containers as close to the use area as is practical. 2.
Use
protective barriers to prevent exposure to blood, body fluids containing
visible blood, and other fluids to which universal precautions apply. The
type of protective barrier(s) should be appropriate for the procedure being
performed and the type of exposure anticipated. 3.
Immediately
and thoroughly wash hands and other skin surfaces that are contaminated with
blood, body fluids containing visible blood, or other body fluids to which
universal precautions apply. Glove Use for Phlebotomy Gloves should reduce the incidence of blood
contamination of hands during phlebotomy (drawing blood samples), but they
cannot prevent penetrating injuries caused by needles or other sharp instruments.
The likelihood of hand contamination with blood containing HIV, HBV, or other
bloodborne pathogens during phlebotomy depends on several factors: 1) the
skill and technique of the health-care worker, 2) the frequency with which
the health-care worker performs the procedure (other factors being equal, the
cumulative risk of blood exposure is higher for a health-care worker who
performs more procedures), 3) whether the procedure occurs in a routine or
emergency situation (where blood contact may be more likely), and 4) the
prevalence of infection with bloodborne pathogens in the patient population. The
likelihood of infection after skin exposure to blood containing HIV or HBV
will depend on the concentration of virus (viral concentration is much higher
for hepatitis B than for HIV), the duration of contact, the presence of skin
lesions on the hands of the health-care worker, and -- for HBV -- the immune
status of the health-care worker. Although not accurately quantified, the
risk of HIV infection following intact skin contact with infective blood is
certainly much less than the 0.5% risk following percutaneous needlestick
exposures (5). In universal precautions, all blood is assumed to be
potentially infective for bloodborne pathogens, but in certain settings
(e.g., volunteer blood-donation centers) the prevalence of infection with
some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some
institutions have relaxed recommendations for using gloves for phlebotomy
procedures by skilled phlebotomists in settings where the prevalence of
bloodborne pathogens is known to be very low. Institutions that judge that routine gloving
for all phlebotomies is not necessary should periodically reevaluate their
policy. Gloves should always be available to health-care workers who wish to
use them for phlebotomy. In addition, the following general guidelines apply:
4.
Use
gloves for performing phlebotomy when the health-care worker has cuts,
scratches, or other breaks in his/her skin. 5.
Use
gloves in situations where the health-care worker judges that hand
contamination with blood may occur, for example, when performing phlebotomy
on an uncooperative patient. 6.
Use
gloves for performing finger and/or heel sticks on infants and children. 7.
Use
gloves when persons are receiving training in phlebotomy. Selection of Gloves
The Center for Devices and Radiological
Health, FDA, has responsibility for regulating the medical glove industry. Medical
gloves include those marketed as sterile surgical or nonsterile examination gloves
made of vinyl or latex. General purpose utility ("rubber") gloves
are also used in the health-care setting, but they are not regulated by FDA
since they are not promoted for medical use. There are no reported
differences in barrier effectiveness between intact latex and intact vinyl
used to manufacture gloves. Thus, the type of gloves selected should be
appropriate for the task being performed. The following general guidelines are
recommended: 8.
Use
sterile gloves for procedures involving contact with normally sterile areas
of the body. 9.
Use
examination gloves for procedures involving contact with mucous membranes,
unless otherwise indicated, and for other patient care or diagnostic
procedures that do not require the use of sterile gloves. 10.
Change
gloves between patient contacts. 11.
Do
not wash or disinfect surgical or examination gloves for reuse. Washing with
surfactants may cause "wicking," i.e., the enhanced penetration of
liquids through undetected holes in the glove. Disinfecting agents may cause
deterioration. 12.
Use
general-purpose utility gloves (e.g., rubber household gloves) for
housekeeping chores involving potential blood contact and for instrument
cleaning and decontamination procedures. Utility gloves may be decontaminated
and reused but should be discarded if they are peeling, cracked, or
discolored, or if they have punctures, tears, or other evidence of
deterioration. Waste Management Universal precautions are not intended to
change waste management programs previously recommended by CDC for
health-care settings (1). Policies for defining, collecting, storing,
decontaminating, and disposing of infective waste are generally determined by
institutions in accordance with state and local regulations. Information
regarding waste management regulations in health-care settings may be
obtained from state or local health departments or agencies responsible for
waste management. Reported by: Center for Devices and Radiological Health,
Food and Drug Administration. Hospital Infections Program, AIDS Program, and
Hepatitis Br, Div of Viral Diseases, Center for Infectious Diseases, National
Institute for Occupational Safety and Health, CDC. Editorial Note:
Implementation of universal precautions does not eliminate the need for other
category- or disease-specific isolation precautions, such as enteric
precautions for infectious diarrhea or isolation for pulmonary tuberculosis
(1,2). In addition to universal precautions, detailed precautions have been
developed for the following procedures and/or settings in which prolonged or
intensive exposures to blood occur: invasive procedures, dentistry, autopsies
or morticians' services, dialysis, and the clinical laboratory. These
detailed precautions are found in the August 21, 1987, "Recommendations
for Prevention of HIV Transmission in Health-Care Settings" (1). In
addition, specific precautions have been developed for research laboratories
(28). References 13.
Centers
for Disease Control. Recommendations for prevention of HIV transmission in
health-care settings. MMWR 1987;36(suppl no. 2S). 14.
Garner
JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect
Control 1983:4;245-325. 15.
Immunization
Practices Advisory Committee. Recommendations for protection against viral
hepatitis. MMWR 1985;34:313-24,329-35. 16.
Department
of Labor, Department of Health and Human Services. Joint advisory notice:
protection against occupational exposure to hepatitis B virus (HBV) and human
immunodeficiency virus (HIV). Washington, DC:US Department of Labor, US
Department of Health and Human Services, 1987. 17.
Centers
for Disease Control. Update: Acquired immunodeficiency syndrome and human
immunodeficiency virus infection among health-care workers. MMWR 1988;37:229-34,239. 18.
Hollander
H, Levy JA. Neurologic
abnormalities and recovery of human immunodeficiency virus from cerebrospinal
fluid. Ann Intern Med
1987;106:692-5. 19.
Wirthrington
RH, Cornes P, Harris JRW, et al. Isolation of human immunodeficiency virus
from synovial fluid of a patient with reactive arthritis. Br Med J
1987;294:484. 20.
Mundy DC,
Schinazi RF, Gerber AR, Nahmias AJ, Randall HW. Human immunodeficiency virus isolated from
amniotic fluid. Lancet 1987;2:459-60. 21.
Onion
DK, Crumpacker CS, Gilliland BC. Arthritis of hepatitis associated with
Australia antigen. Ann
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Lee
AKY, Ip HMH, Wong VCW. Mechanisms of maternal-fetal transmission of hepatitis
B virus. J Infect Dis
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Bond
WW, Petersen NJ, Gravelle CR, Favero MS. Hepatitis B virus in peritoneal
dialysis fluid: A potential hazard. Dialysis and Transplantation
1982;11:592-600. 24.
Oskenhendler
E, Harzic M, Le Roux J-M, Rabian C, Clauvel JP. HIV infection with
seroconversion after a superficial needlestick injury to the finger (Letter).
N Engl J Med 1986;315:582. 25.
Lifson
AR. Do alternate modes for transmission of human immunodeficiency virus
exist? A review. JAMA 1988;259:1353-6. 26.
Friedland
GH, Saltzman BR, Rogers MF, et al. Lack of transmission of HTLV-III/LAV
infection to household contacts of patients with AIDS or AIDS-related complex
with oral candidiasis. N Engl J Med 1986;314:344-9. 27.
Jenison
SA, Lemon SM, Baker LN, Newbold JE. Quantitative analysis of hepatitis B virus DNA in saliva and semen of
chronically infected homosexual men. J Infect Dis 1987;156:299-306. 28.
Cancio-Bello TP, de Medina M, Shorey J, Valledor MD,
Schiff ER. An institutional
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RM, Snitbhan R, Bancroft WH, Alter HJ, Tingpalapong M. Experimental
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Glaser JB,
Nadler JP. Hepatitis
B virus in a cardiopulmonary resuscitation training course: Risk of transmission
from a surface antigen-positive participant. Arch Intern Med 1985;145:1653-5. 32.
Osterholm
MT, Bravo ER, Crosson JT, et al. Lack of transmission of viral hepatitis type B after oral exposure to
HBsAg-positive saliva. Br Med J 1979;2:1263-4. 33.
Curran
JW, Jaffe HW, Hardy AM, et al. Epidemiology of HIV infection and AIDS in the
United States. Science
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Jason JM,
McDougal JS, Dixon G, et al. HTLV-III/LAV antibody and immune status of household contacts and
sexual partners of persons with hemophilia. JAMA 1986;255:212-5. 35.
Wahn
V, Kramer HH, Voit T, Bruster HT, Scrampical B, Scheid A. Horizontal
transmission of HIV infection between two siblings (Letter). Lancet 1986;2:694. 36.
Salahuddin
SZ, Groopman JE, Markham PD, et al. HTLV-III in symptom-free seronegative persons. Lancet 1984;2:1418-20. 37.
Simmons
BP, Wong ES. Guideline for prevention of nosocomial pneumonia. Atlanta: US
Department of Health and Human Services, Public Health Service, Centers for
Disease Control, 1982. 38.
Klein RS,
Phelan JA, Freeman K, et al. Low occupational risk of human immunodeficiency virus infection among
dental professionals. N Engl J Med 1988;318:86-90. 39.
Garner
JS, Favero MS. Guideline for handwashing and hospital environmental control,
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Centers
for Disease Control. 1988 Agent summary statement for human immunodeficiency
virus and report on laboratory-acquired infection with human immunodeficiency
virus. MMWR 1988;37(suppl no. S4:1S-22S). *The August 1987 publication should
be consulted for general information and specific recommendations not
addressed in this update. **The August 1987 publication should be consulted
for general information and specific recommendations not addressed in this
update. Copies of this report and of the MMWR supplement entitled
Recommendations for Prevention of HIV Transmission in Health-Care Settings
published in August 1987 are available through the National AIDS Information
Clearinghouse, P.O. Box 6003, Rockville, MD 20850. All MMWR HTML
documents published before January 1993 electronic conversions from ASCII
text into HTML. This conversion may have resulted in character translation or
format errors in the HTML version. Users should not rely on this HTML
document, but are referred to the original MMWR paper copy for the
official text, figures, and tables. An original paper copy of this issue can
be obtained from the Superintendent of Documents, U.S. Government Printing
Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact
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