Appendix II. World Health Organization Guidelines on AIDS and first aid in the workplace

HIV transmission

HIV has been isolated from many body fluids of infected persons. However, only blood, semen, vaginal and cervical fluids, and breast milk have been implicated in transmission of the virus. Epidemiological studies throughout the world have shown that there are three modes of transmission of HIV:

· sexual intercourse (heterosexual or homosexual) and use of donated semen;

· exposure to blood, blood products, or donated organs; exposure to blood is principally through the transfusion of unscreened blood or the use of unsterilized contaminated syringes and needles by intravenous drug users;

· from infected mother to foetus or infant, before, during, or shortly after birth (perinatal transmission).

There is considerable evidence that HIV cannot be transmitted by the respiratory or gastrointestinal routes or by casual person-to-person contact in any setting (such as school, household, social, work, or prison). Nor is HIV transmitted via insects, food, water, toilets, swimming-pools, sweat, tears, shared eating and drinking utensils, or other agents such as clothing or telephones.

HIV has not been shown to be transmitted in the workplace except in health care or research laboratory settings. The few reported cases of HIV transmission to health care workers have resulted from exposure to the blood of an HIV-infected patient as a result of needlestick injury, blood on broken skin, or splashing of blood into the eyes or mouth (mucous membranes). Although accidents such as these occur with some frequency in health care settings, they have only rarely led to HIV infection of health care workers.

In addition to HIV, other serious infections, such as hepatitis B and non-A non-B hepatitis can be transmitted by blood.

HIV transmission and the first aider

In relation to HIV transmission, the major concerns in first aid are mouth-to-mouth resuscitation and the management of bleeding, two situations where contact with the body fluids of another person may occur.

Mouth-to-mouth resuscitation

A worker who is unconscious and no longer breathing spontaneously (for example because of a heart attack, an electric shock, or a blow to the head) may require mouth-to-mouth resuscitation. Resuscitation must be started immediately. Mouth-to-mouth resuscitation is a life-saving procedure and should not be withheld through fear of contracting HIV or other infection.

HIV transmission from mouth-to-mouth resuscitation has not been reported. Although HIV has been found in saliva, it is present in extremely small quantities and no cases have been reported in which transmission has been shown to have occurred through saliva.

Although it has never been substantiated, there is a theoretical risk that HIV could be transmitted if the person in need of resuscitation is bleeding from the mouth. First aiders should use a clean cloth or handkerchief, when available, to wipe away any blood from the person's mouth.

Mouth-pieces, resuscitation bags, or other ventilation devices should only be used by people specially trained to use them. They are not recommended for use by general first aiders as incorrect use may lead to further injury and bleeding. The absence of such equipment should not be used as a reason to withhold mouth-to-mouth resuscitation.

Bleeding

Workers who are bleeding require immediate attention. The first aider must not hesitate to help them as some wounds may be life-threatening (e.g. a spurting artery).

Whenever feasible, the first aider should instruct the person bleeding to apply pressure to the wound himself or herself, using a clean thick cloth. If he or she is unconscious or uncooperative, or if the wound is too large or is located in a place the person cannot reach, the first aider should apply pressure to the wound with a clean cloth or another barrier, avoiding direct contact with blood. Gloves should be used if available; if not available, another barrier such as a cloth or clothes should be used to prevent skin contact with blood. However, since bleeding may be life-threatening, the absence of gloves should not be used as a reason to withhold first aid.

Special care should be taken to prevent blood from coming into contact with broken skin or the mucous membranes of the first aider. If the first aider's hand are contaminated with blood, he or she should take care not to touch his or her own eyes or mouth.

Hands should always be washed with soap and water as soon as possible after administering first aid.

Cleaning up blood spills

Spilt blood should be soaked up with absorbent material such as a cloth, rag, paper towel or sawdust, direct skin contact with the blood being avoided. The blood-soaked absorbent material should then be disposed of in a plastic bag, burnt in an incinerator, or buried. The area contaminated with the blood should then be washed with a disinfectant (preferably sodium hypochlorite (household bleach) diluted 1:10 with water, to give 0.1-0.5 per cent available chlorine) to clean up remaining blood. Rubber household gloves should be worn if available when spilt blood is being cleaned up. If gloves are not available, another barrier such as a large wad of paper towels should be used to avoid direct skin contact with the blood. Hands should always be washed with soap and water after cleaning up blood or other body fluids.

Clothes or cloths that are visibly contaminated with blood should be handled as little as possible. Rubber household gloves should be worn if available, and the clothes or cloths should be placed in and transported in leakproof bags. They should be washed with detergent and hot water (at least 70°C (160°F) for 25 minutes; or if in cooler water (less than 70°C (160°F)), with a detergent suitable for cold water washing.

Additional measures

First aiders should be careful with broken glass and other sharp objects that may be in the accident area. They should also ensure that any open cuts or wounds they have are covered to prevent exposure to blood while they are providing first aid.

Workers who have been exposed to blood

If the guidelines give here are adhered to, the risk of acquiring bloodborne infection, including HIV, will be significantly reduced. Even so, it is not possible to guarantee that exposure will not occur. Workplaces should therefore develop policies to meet those situations where first aiders are injured or are exposed to blood while administering first aid.

If first aiders are exposed to blood on skin that is not intact, they should wash the affected area with soap and water as soon as possible. Exposed mucous membranes should be washed with water.

A first aider who is injured by a sharp object that is contaminated with blood (e.g. a used needle) should encourage bleeding, wash the wound thoroughly with soap and water and, if appropriate, apply a dressing. To determine whether further action is needed, the injury should be assessed for the type and severity of the wound - puncture, surface or deep laceration, contamination of non-intact skin or mucous membrane - and for the extent to which the wound may be contaminated with blood.

Obviously, the more severe the wound the greater the concern should be, not only for HIV infection but for all bloodborne infections. The decision whether additional evaluation is necessary should be made by the first aider jointly with the health care provider concerned.

In rare instances, a first aider may sustain injuries of sufficient severity to warrant further investigation, including assay of the first aider's blood for HIV and other infections such as hepatitis B.

If a first aider requests HIV antibody testing, this should be performed as soon as possible after the exposure. If the initial test is negative, follow-up testing should be performed three and six months later. In the interim, counselling should be available to the first aider and should deal with the low risk of acquiring infection as well as the first aider's concerns. He or she should be counselled on the need to prevent possible transmission of HIV during this period through, inter alia, sexual intercourse, the use of intravenous drugs, and pregnancy. If a worker becomes HIV antibody positive at any point, continuing counselling should be provided. If the test immediately after the exposure is positive, it cannot be a result of the exposure: the person must have been infected with HIV previously. He or she should be referred for counselling, which should include advice on how to prevent transmission of HIV.

Training in first aid

First aid training provides an opportunity to disseminate accurate information on HIV infection and AIDS to members of the community. People who receive training in first aid will subsequently be able further to disseminate accurate information within the community.

First aid training in the workplace should include clear instruction on the ways in which HIV is and is not transmitted. This is especially important, since the myths surrounding this topic may interfere with potentially life-saving first aid measures.

First aid training should emphasize that, even after parenteral exposure to HIV-infected blood, the risk of acquiring infection is extremely low, about one in 250 exposures. First aiders should be taught the precautions needed to avoid contact with blood or body flu ids, since such precautions significantly reduce the risk of bloodborne infection.

First aid is generally given to alleviate suffering and in a spirit of compassion. This should be stressed. The first aider should be urged to weigh the extremely small and so far theoretical risk of acquiring HIV infection in providing first aid against the benefit gained by the person receiving first aid.

A number of organizations in many countries train large numbers of first aiders both within and outside the workplace. Employers should be encouraged to utilize the expertise of those organizations in planning first aid training courses or first aid interventions within the workplace.