"Why Weren't You Just More Careful?"

"Why Weren't You Just More Careful?" What Does It Take to Avoid Occupational Exposure to HIV?

By Kristin White

Healthcare workers can become infected with HIV in a variety of ways, but, according to the CDC, 80% of exposures occur through needle stick injuries. A worker stuck by a hollowbore needle contaminated with blood from an HIV-infected patient runs a 0.05% risk of becoming infected with the virus. "The risk isn't high for all health care workers, or significant for all health care workers—but for health care workers who are exposed to many HIV-infected patients, and/or have many percutaneous exposures, the problem is a very significant one," says James T. Curran, M.D., chief of CDC's AIDS Task Force. Getting stuck with a used needle is painful, frightening, and expensive. At the University of Virgina School of Medicine, Charlottesville, which has a comprehensive follow-up system, the average cost is $405. That is if the blood involved is HIVnegative. If it's HIV-positive, and the worker requires prophylactic AZT, cost begins to skyrocket. The physical and emotional costs are, of course, incalculable. The Prego Case In March 1990, Veronica Prego, M.D., who has AIDS, settled for $1,350,000 in a lawsuit brought against a New York City hospital where she had been an unpaid externe, with no medical insurance. Dr. Prego attributed her disease to exposure to HIV-contaminated needles and blamed the hospital and a physician co-worker who had, she said, left one contaminated needle in a heap of bed linen. Defense lawyers for the institution and the other physician argued that the carelessness was Dr. Prego's. Originally, the 32-year old Argentinean woman asked for a total of $175 million but accepted the smaller amount because payment of a higher judgment would have been delayed by appeals. Dr. Prego is not
expected to live longer than a year. Nineteen other HIV-infected health care workers around the country have been waiting for the outcome of the Prego case to initiate similar lawsuits against their institutions. Authorities in the field believe as many as 200 workers have been infected
on the job.

Universal Precautions:

A Partial Answer

In this climate, preventing needle sticks is becoming a major occupational health priority for health care workers, but hospital rules, universal blood and body fluid precautions, and common sense are only partly effective. "Universal precautions would have prevented 40% of the 1500 needle stick injuries reported to us since 1983," says Jacquelyn Polder, R.N., M.P.H., coordinator of CDC's continuing study of occupational exposures to HIV. Universal precautions were not instituted nationwide until 1987, and even today, they are not followed consistently. For that matter, needle sticks are not reported consistently either, and therefore estimates of occupational exposures are probably low.

What Studies Indicate

"Even within hospitals, needle sticks are underreported," says Ms. Polder. "People forget to report incidents, or don't want to be bothered with the paperwork, " she notes. Even so, the CDC's voluntary, passive study mirrors smaller and more rigorous studies at the University of California, San Francisco, where about 500 such injuries are reported yearly, and elsewhere. The statistics tell a consistent story. "Blood, in the health care setting, is risk. Period," David Henderson, M.D., of the National Institutes of Health told The New York Times in an interview on March 9, 1990. Dr.Henderson is in overall charge of infection control at the NIH Clinical Center in Bethesda. Marguerite Jackson, R.N., M.S., at the University of California, San Diego, has also studied occupational risks of HIV infection. "It's almost always associated with puncture wounds, " she says, "rather than the mucous membrane. When the numbers and the follow-up are complete, 1 person in 200 becomes infected, and will seroconvert within 6 months of the exposure." But many questions remain open such as the minimum amount of virus needed for infection. Looking at specific episodes is not necessarily very helpful, at this stage of the epidemic. "In a case report, there's no de-nominator," explains Ms. Jackson. "The individual may attribute HIV infection to the workplace in order to collect benefits for which they wouldn't be eligible if the infection came from sex or IV drug use. In evaluating a case report, you have to ask yourself whether the person's telling the truth, or is there another reason they don't want to share?

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