|Caring with Confidence - Practical information for health workers who prevent and treat HIV infection in children (AHRTAG, 1997, 60 p.)|
|Section 4. Issues for health workers|
Health personnel, especially nurses and midwives, are often worried about the risk of HIV infection at work. There have been reports of health workers refusing to deal with infants and young children with HIV and of laboratories refusing to handle specimens.
The risk of transmission from an infected child or mother to a health worker is very low if sensible precautions are taken/especially methods to reduce the risk of injuries from needles and other sharp instruments, and safe procedures for sterilisation, decontamination and handling specimens.
But even where it is not possible to follow recommended procedures, the risk of an infected mother transmitting HIV to a birth attendant or of an infected infant transmitting HIV to a health worker is still low. The risk of infection through needle-stick injury is estimated at 1 in 300.
There is a risk of HIV infection if health workers come into contact with blood or other body fluids through:
· open cuts or sores on their skin
· accidents such as needle pricks or blood splashes
· carelessness such as dangerously discarded needles or blades
· poor practices such as reuse of equipment without sterilisation or disinfection.
Factors increasing risk include:
· poor lighting
· emergency situations
· lack of gloves and other protective barriers
· lack of disinfectants.
It is especially important to provide midwives, birth attendants and surgical staff with gloves and protective clothing as they may be at higher risk, because there is a large amount of blood at delivery and during operations.
These precautions minimise the risk of transmission of HIV (as well as of hepatitis and other blood-borne diseases) and should be used when dealing with all patients regardless of their HIV status:
· careful handling, cleaning and disposal of sharps (needles, scalpels, blades), including properly placed puncture-resistant sharps disposal containers that are readily accessible, disposal of needles without recapping, without removing from the syringe and without breaking or bending by hand
· handwashing with soap before and after procedures
· using protective barriers such as gloves, gowns and eye masks to prevent direct contact with blood and other body fluids
· disposing safely of waste contaminated with blood and body fluids
· careful handling of soiled linen
· cleaning up spills of blood and body fluids with disinfectants
· covering broken skin, sores or cuts with a waterproof plaster or dressing before contact with patients. It is especially important that midwives and birth attendants cover insect bites, open wounds, sores and cuts on their hands and arms before attending a delivery.
In settings where resources are limited - for example, where gloves are in short supply - supplies should be used rationally. Gloves should be kept for activities where there is the greatest risk of exposure, such as delivery, rather than for other procedures such as giving injections. Gloves should be changed between patients. If they are reused, only reuse intact gloves and wash and sterilise between uses.
Tuberculosis (TB) is spread as infectious particles through the air, either directly from person to person via coughing, or indirectly from dust on bedding, dressings, floors. For this reason, it is crucial to identify, isolate and treat people with TB to minimise risks to others. Proper ventilation, increased sunlight, and good working practices can also help to reduce the risk of infection.
The rise in clinic and hospital patients with HIV is mirrored by a rise in patients with TB. In many countries, one in three or one in two patients with HIV infection also have TB. These infections interact. Patients with pulmonary TB are infectious to others, especially to those with HIV. People who have a latent TB infection have a high chance of that infection being reactivated if they are also infected with HIV.
Health workers should take the following precautions:
· isolating infectious patients
When a person is suspected of or diagnosed with TB, he or she should be isolated from other patients who do not have the disease. He or she should also be isolated from patients and staff known to have HIV infection during the initial phase of their treatment. Patients suspected of having TB who are known to be infected with HIV or to have AIDS should not be admitted to a TB ward until their TB treatment has been started.
· making the environment safer
Accommodation for people with TB should be kept well ventilated with doors closed and windows to the outside open, to reduce the chance of airborne infection. Exhaust fans are useful for moving air from tuberculosis wards and isolation rooms to the outside. In colder climates it may be necessary to keep windows closed, but fans blowing air outside may be useful.
Sunlight is a cheap source of ultraviolet light which kills airborne TB micro-organisms. If possible, patient rooms should have large, uncurtained windows.
· safer working practices
Working methods should avoid creating dust which may contain TB micro-organisms. Carers should keep the patient's room aired and should avoid dry sweeping and shaking out soiled bedding and clothing indoors. Soiled bedding and clothing should be washed immediately using soap and hot water.
Out-patient clinics where people are screened for TB should be well ventilated, and sputum specimens should be collected in an area away from general waiting rooms and other people.
Infectious patients with uncontrolled cough should wear masks when being moved around the hospital or clinic. Alternatively, patients can use a clean handkerchief or cloth tied over their nose and mouth. Surgical or other masks will reduce infection risk from coughs and sneezes when worn by patients with pulmonary TB but are no help in stopping infection when worn by anyone else. For this reason it is not normally recommended that masks are worn by staff and visitors.
If possible, health workers with open cuts and sores should avoid working where direct contact with patient's blood or body fluids is likely.
Risk of HIV and hepatitis transmission can also be reduced by eliminating unnecessary injections, episiotomies, and laboratory tests. In Uganda there is evidence that the main risk of occupational transmission is needle-stick injury to midwives performing stitching after episiotomies in conditions of poor lighting.
After delivery the placenta should be handled as little as possible and burned or buried.
It may also be possible for health workers to obtain more regular or additional supplies by finding out what is available through government and non-governmental sources, seeing if patients and their families can contribute, improving procurement, ordering and storage systems.
Care after exposure
If a health worker has been exposed to blood or body fluids through splashing, he or she should wash the area immediately with soap and water. Splashes to the eyes or mouth should be flushed clean with water or saline solution.
Wounds from needle-stick injuries should be cleaned with soap and water.
WHO recommends that incidents where health workers have been exposed to potentially infected blood and body fluids should be reported to the supervisor or manager, and that health workers be offered testing and counselling. In some countries, health workers are offered post-exposure prophylactic treatment with antiretroviral drugs, but this is not available in many places. There are also questions about the effectiveness of post-exposure prophylaxis.