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Northern Territory Department of Health Library Services Historical Collection
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DL HIST 616 .9792
ROY 1990
ROYAL DARWIN HOSPITAL
INFECTION CONTROL GUILDELINES
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HISTORICAL COLLECTION ·
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-~HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION
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NT DEPARTMENT OF HEAL TH~ AND COMMUNITY SERVICES
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ROYAL DARWIN HOSPITAL INFECTION CONI'ROL GUIDELINES
HUMAN IMMUNODEFICIENCY VIRUS ( HIV) INFECTION
1.0 INrRODUcrION
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1.1 Guidelines have been developed by the National AIDS task force for use by Health Care Workers and other personnel including ambulance attendants, dentists, orderlies, mortuary attendants and 'handlers' of contaminated waste, whose work may require contact with patients who are HIV positive or have developed AIDS or AIDS related conditions.
1.2 Sections of the AIDS Task Force Guidelines and Australian Hospital Association Draft Policy have been used to prepare this booklet for easy reference for staff.
2. 0 THE HUMAN IMMUNODEFICIENCY VIRUS: (HIV)
2. 1 This virus causes HIV infection, which includes Acquired Immune Deficiency Syndrome (AIDS) , is a member of a family of Retroviruses.
2.2 Present evidence indicates that approximately 35% of HIV infected individuals will progress to AIDS over the next 5-7 years while another 35% will develop one or more symptoms characteristic of HIV infection but not fulfilling the criteria for a diagnosis of AIDS.
2.3 The remaining people who are infected with HIV and have antibodies to the virus may not develop any symptoms during that period. ie asymptomatic infection.
3.0 TRANSMISSION OF H.I.V.
3.1 HIV is transmitted through infected blood, tissues, secretions or excretions that may contain the virus, such as semen, vaginal fluid and breast milk.
3. 2 Lower concentrations of virus have been isolated from urine, faeces, saliva and tears. Precautions should be directed at reducing exposure to these body fluids.
3.3 The risk of HIV infection in health care workers due to occupational exposure is very low.
3. 4 There is evidence that transmission of HIV following a needle stick injury or cutanaeous exposure occurs at least 10 to 100 times less readily than it does with Hepatitis B virus.
3 . 5 There is no evidence of person to person transmission of HIV through casual contact.
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4.0 CLASSIFICATION OF HIV INFECTION 4. 1 Group I - Acute HIV Infection
An acute illness can occur on initial infection with HIV in about 50% of cases. The illness is characterized by a self-limited mononucleosis (glandular fever) - like syndrome which may include an aseptic meningitis.
Patients in this group may be antilx:dy negative at onset but viral core antigen (P24) is often detectable in the serum early and
transiently following primary infection.with HIV.
4.2 Group II Asymptomatic HIV Infection
This group corresponds to the previous Category C (no evidence of deficient cell mediated inununi ty) and includes people who are usually well, but infected and HIV antilx:dy positive.
4.3 Group III- Persistent generalized (lymphadenopathy)
This group is characterised by the presence of lympth node enlargement (more than 1cm) at 2 or more extra - inguinal sites for 3 months or longer, without any other explanations of lymphadenopathy. Most of the conditions included in the previous Category B classification fall into this group.
This group will also have a positive test for HIV antil:x:xiy.
4.4 Group IV - AIDS and related conditions
This group is subdivided into subgroup A to E and includes all serious illness attributes to HIV infection: i.e.
5. 0 PRECAUTIONS.
Constitutional illnesses Neurological complications Opportunistic Infections
Secondary cancers- e.g. Kaposi sarcoma
Patients in all groups (I-IV) are a potential source of infection with HIV. Any person who has antilx:dies to HIV is considered infectious.
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5.1 Universal Blood and Body Substance Precautions
Universal precautions are intended to prevent parental, mucous membrane, and non-intact skin exposure of health care workers to blood borne pathogens. Under universal precautions, blood and certain 1:x:dy fluids of all patients are considered potentially infective for Hiv, Hep B Virus and other blood borne pathogens, hence the use of gloves and/or other appropriate protective barriers are mandatory whenever exposure to blood and the following (5.3) 1:x:dy substances is likely to take place.
5.2 Universal Precautions are intended to supplement rather than replace reconunendations for routine infection control principles.
Implementation of these precautions does not obviate the need for continued adherence to general infection control principles and general hygiene measures (e.g. hand washing) for prevention of other infectious diseases to health worker and patient .
5.3 Body Substances to which Universal Precautions apply . Blood
. Semen
. Vaginal Secretions . Tissues
. Cerebrospinal fluid (C.S.F.) Synovial fluid
. Plueral fluid . Pericardia! fluid . .Amniotic fluid and
. Other 1:x:dy fluids containing visible bloc:xl.
Blood is the most important source of HIV, HBV, and other blood borne pathogens in the occupational setting.
5.4 The risk of HIV transmission from the following 1:x:dy substances is extremely low or non existent, (*Breast milk has been implicated in perinatal transmission, but), epidemiology studies in the health care setting have not implicated these fluids in the transmission of HIV infection:
Faeces
Nasal secretions Sputum
Sweat Tears Urine Vomitus Saliva
Breast Milk*
Unless they contain visible blood.
However, routine infection-control and hygiene measures should be observed when handling these substances.
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6.0 Needles and Syringes
NEEDLE STICK INJURY IS THE SINGLE ?-DST COMrvDN CAUSE OF C:X:CUPATIONAL HIV TRANSMISSION AMJtJmST HEALTH ~RKERS.
IT IS THE INDIVIDUAL HEALTH 'MJRKER'S RESPONSIBILITY 'IO PROIECT THEMSELVES AND arHERS FROM BEING PROI'ENTIALLY INFECTED.
6. 1 Needles should never be re-sheathed after use. Needles and syrings should be disposed of as 'one unit' wherever possible into an approved rigid wall, puncture resistant container.
6.2 The injury should be washed with soap and water until all traces of blood have disappeared as soon as posssible.
6.3 Employees with needle stick injury should report to the Accident and Emergency Medical Officer and be treated according to Biohazard Injury Guidelines.
6.4 If necessary, the health care worker should be counselled on the risk associated with the injury and refer to 20.0 on AZT prophylaxis following needlestick injury.
7.0 PROI'ECTIVE BARRIERS 7.1
7.2
7.3
7.4
7.5
Gloves should be worn by health workers who may come in contact with blood and body fluids or moist surfaces potentially contaminated by them. Gloves protect health workers with unnoticed cuts from contact with blood and body fluids.
Workers with frank exudati ve lesions or weeping dermatitis must avoid direct patient care until the lesions heal.
The type of protective barrier(s) should be appropriate for the procedure being perfonned and the type of exposure anticipated.
Inunediately and thoroughly wash hands and other skin surfaces that are contaminated with blood, or other body fluids to which universal precautions apply.
Protective Eyewear
Protective eyewear should be worn in situations in which splattering with blood and body fluids is expected.
Protective eyewear is available in all clinical areas in this hospital .
7.6 Hand Washing
Thorough hand washing with soap and water before and after contact with patients is mandatory.
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"8.0 OUTPATIENTS/CASUALT':l DEPARTMENT
For Outpatients, separate examination rooms are not necessary, although direct contact between patients with HIV infection and other inununosuppressed patients should be av~ided.
Outpatients infected with HIV may use the conunon waiting and bathroom facilities.
8.1 Single Boom or Isolation
The provision of a single room for patients with HIV infection (Gp
I-III) is usually unnecessary, if they are cooperative, do not have a productive cough and can be adequately instructed in the necessary elements of personal hygiene. In AIDS patients (Gp IV) with Pneumocystis Carinii pneumonia (PCP), dry cough is conunon and non-infectious to inununo-competent patients and staff.
8.2 Ensure that patients sharing rooms with patients who have developed AIDS are not themselves immunosuppressed or infected with organisms that could endanger the patient with AIDS.
Similarly, immunosuppressed patients with other medical conditions should not be placed adjacent to a patient with AIDS.
8.3 AIDS patients with active bleeding and open wounds or suspected of having infectious related conditions, e.g. Pulmonary tuberculosis, herpes zoster (shingles), severe diarrhoea should be isolated according to hospital protocols until determined non- infectious.
8.4 Invasive Procedures
Gloves, surgical masks and protective eyewear should always be worn during procedures that may result in splashing of blood and body fluids.
8.5 Disposable Items
All used items should be bagged as potentially infectious material and incinerated.
8.6 Linen
Contaminated linen should be bagged and sent to Hospital laundry.
Laundry procedures provide adequate decontamination.
Gloves and protective clothing should be worn when handling and bagging infectious linen .
8.7 Sterilization and Disinfection Refer to Royal Darwin Hospital.
and Cleaning Policy .
Sterilization, Decontamination
-· 9.0 STAFF CONSIDERATIONS
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9. 1 There is no scientific reason for healthy people to be excused from providing care to patients infected with HIV.
9.2 Pregnant staff should be given the option of caring for HIV infected patients as Cytomegalovirus (CMV) may be shed in blood, urine, saliva, semen, breast milk, tears and faeces.
9.3 Transmission recommended observed.
of CMV infection, is very low blood and body fluid precautions
provided the are strictly
9.4 Health Workers with HIV Infection, who have exudative lesions or weeping dermatitis should avoid all direct patient care and handling patient equipment until the condition resolves.
9.5 Health Workers with asymptomatic HIV Infection should be counselled by their physician to avoid direct patient care in clinical situations where biohazard injury is likely to occur.
10.0 EMERG~ RESUSCITATION
10.1 There is no reason to withold resuscitation from anyone who is in a high risk group for HIV Infection.
10.2 The decision to withold direct mouth to mouth resuscitation from a patient with HIV Infection when CPR device is not available is that of the individual health care worker.
10.3 Resuscitation bags are readily available in all clinical areas.
11.0 AU'IOPSY AND MORTUARY PROCEDURES
Autopsy procedures for HIV Infections do not differ from those that would apply in cases of Hepatitis B e.g. Gloves, gowns, plastic aprons and boots should be used.
11. 1 Protective eyewear should be used when operating on the body or engaging in other activities that could result in risks from splashes or spraying.
11.2 Extrao.rdinary attempts to disinfect walls and other surfaces are not necessary as the virus is easily destroyed.
12. 0 HIV ANrIBODY TESTING
12.1 Laws in the Territory require testing for HIV antibodies for all donors of blood, blood fractions, organ and other tissue transplantation and for donors of semen and ova collected for artificial insemination and in vitro fertilisation. Patients undergoing transplantation, cardio-pulmonary by-pass and haemodialysis should be tested.
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12.2 HIV antibody testing should, except in carefully defined circumstances, be carried out only with a patient's consent and in accordance with the nationally agreed protocol for HIV testing developed by the Australian National Council on AIDS (ANCA). 'lllis protocol reconunends counselling before and after the test.
However, the patient has the right to decline counselling and
should not be denied testing. Testing may also be deferred if patient ~s deemed psychologically unfit to deal with a positive result. Patient should be offered a referral for further counselling.
12. 3 The criteria for a valid consent are that: the consent is voluntary; and the person has the mental capacity to consent;
the consent is informed; and the person consents to the particular procedure that is being performed.
12. 4 Procedures are necessary for maintaining confidentiality of the results of HIV testing for ooth patients and health care workers.
13.0 EDUCATION
13.1 Current knowledge of HIV infection and AIDS is incomplete and new information is being discovered all the time. Health care workers (HCW) require continuing education on HIV infection and AIDS ooth for their own safety and in the interests of good patient care.
13.2 Fducation programs should include the most current clinical information regarding HIV infection and methods of transmission;
instruction on the hospital's policies and procedures to prevent the transmission of infection and the importance of following those procedures; education on the psycho-social needs of HIV/AIDS patients; the need for protecting confidentiality of all medical information balanced against the need to prevent spread of the HIV infection; sensitizing and providing staff support in resolving legal/ethical issues.
14.0 ZIOOVUDINE (AZT) PROPHYLAXIS FOR NEEDLESTICK INJURY
14.1 All parental exposures of staff to blood or other oody fluids of patients should be reported according to Infection Control Protocol.
14.2 Each needlestick injury should be evaluated as soon as possible by the Director, Accident & Emergency in consultation with a Hospital Specialist Physician with regard to the potential risk of transmission of blood oorne viruses, including Hepa ti tis B and
HIV .
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14.3 Should the risk of transmission be regarded to be significant and
the exposure be known to involve HIV infected blood or it is assessed to be highly likely in event that definite infection cannot be established, the staff member should be counselled and
AZT prophylaxis offered. Counselling should include the adverse effects of AZT and yet unproven effectiveness of prophylaxis in humans. The effectiveness of AZT prophylazis has only been established in experimental animals to date.
14. 4 Should the HIV status of the exposure be unknown, permission to test the patient should be requested from the patient and if granted, a test for HIV antil:x:>dy should be performed as soon as possible.
14.5 Should the pennission to test not be granted, the patient should not be forced to have the test nor testing of blood already held in laboratory is advisible. Legal opinions are being sought to clarify situations of testing without consent.
14.6 The effectiveness of AZT is likely to be related to the interval following exposure, prophylaxis, if accepted, should commence as soon as possible, ideally within 72 hours, and according to the Royal Darwin Hospital. Protocol on Zidovudine (AZT) Prophylasis following Needlestick Injury.
Compfled by Communicable Diseases Unit,
endorsed by ROH Infection Control Committee March 1990
