UNIVERSAL PRECAUTIONS FOR PREVENTION OF TRANSMISSION OF HIV AND OTHER BLOODBORNE INFECTIONS

"Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens.

Universal precautions took the place of and eliminated the need for the isolation category "Blood and Body Fluid Precautions" in the 1983 CDC Guidelines for Isolation Precautions in Hospitals. However, implementing universal precautions does not eliminate the need for other isolation precautions, such as droplet precautions for influenza, airborne isolation for pulmonary tuberculosis, or contact isolation for methicillin-resistant Staphylococcus aureus.

Universal precautions differ from the system of Body Substance Isolation (BSI) used in some institutions. For information about BSI, refer to the following articles:

Lynch P, et al. Rethinking the role of isolation precautions in the prevention of nosocomial infections. Annals of Internal Medicine 1987;107:243-246.
Lynch P, et al. Implementing and evaluating a system of generic infection precautions: Body substance isolation. American Journal of Infection Control 1990;18:1-12.

In 1996, CDC published new guidelines (standard precautions) for isolation precautions in hospitals. Standard precautions synthesize the major features of BSI and universal precautions to prevent transmission of a variety of organisms. Standard precautions were developed for use in hospitals and may not necessarily be indicated in other settings where universal precautions are used, such as child care settings and schools.

Universal precautions apply to blood, other body fluids containing visible blood, semen, and vaginal secretions. Universal precautions also apply to tissues and to the following fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable.

Universal precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infective materials. In addition, under universal precautions, it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.

Pregnant health care workers are not known to be at greater risk of contracting HIV infection than are health care workers who are not pregnant; however, if a health care worker develops HIV infection during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Because of this risk, pregnant health care workers should be especially familiar with, and strictly adhere to, precautions to minimize the risk of HIV transmission.

WRITTEN GUIDELINES: UNIVERSAL PRECAUTIONS

In addition, the Occupational Safety and Health Administration (OSHA) has published a standard on "bloodborne pathogens." For information about this document, call 202-219-7157.

For information on infection control in dental practice, call 1-800-458-5231 to obtain "The Infection Control File." For further questions on dental practice, call the Division of Oral Health, CDC, telephone 770-488-3034.

GLOVING, GOWNING, MASKING, AND OTHER PROTECTIVE BARRIERS AS PART OF UNIVERSAL PRECAUTIONS

All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure during contact with any patient's blood or body fluids that require universal precautions.

Recommendations for the use of gloves are presented in detail in the Morbidity and Mortality Weekly Report dated June 24, 1988, which is available by calling the National AIDS Information Hotline at 1-800-342-2437 or the National AIDS Information Clearinghouse at 1-800-458-5231.

Gloves should be worn:

for touching blood and body fluids requiring universal precautions, mucous membranes, or nonintact skin of all patients, and
for handling items or surfaces soiled with blood or body fluids to which universal precautions apply.

Gloves should be changed after contact with each patient. Hands and other skin surfaces should be washed immediately or as soon as patient safety permits if contaminated with blood or body fluids requiring universal precautions. Hands should be washed immediately after gloves are removed. Gloves should reduce the incidence of blood contamination of hands during phlebotomy, but they cannot prevent penetrating injuries caused by needles or other sharp instruments. Institutions that judge 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:

Use gloves for performing phlebotomy when the health care worker has cuts, scratches, or other breaks in his/her skin.
Use gloves in situations where the health care worker judges that hand contamination with blood may occur, e.g., when performing phlebotomy on an uncooperative patient.
Use gloves for performing finger and/or heel sticks on infants and children.
Use gloves when persons are receiving training in phlebotomy.

The Center for Devices and Radiological Health, Food and Drug Administration (FDA), has responsibility for regulating the medical glove industry. For more information about selection of gloves, call FDA at 301-443-8913.

Masks and protective eyewear or face shields should be worn by health care workers to prevent exposure of mucous membranes of the mouth, nose, and eyes during procedures that are likely to generate droplets of blood or body fluids requiring universal precautions. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or body fluids requiring universal precautions.

All health care workers should take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needlestick injuries, needles should not be recapped by hand, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal. The puncture-resistant containers should be located as close as practical to the use area. All reusable needles should be placed in a puncture-resistant container for transport to the reprocessing area.

General infection control practices should further minimize the already minute risk for salivary transmission of HIV. These infection control practices include the use of gloves for digital examination of mucous membranes and endotracheal suctioning, handwashing after exposure to saliva, and minimizing the need for emergency mouth-to-mouth resuscitation by making mouthpieces and other ventilation devices available for use in areas where the need for resuscitation is predictable.

Although 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, e.g., in breast milk banking.