The first reaction of most health care workers (HCWs) exposed to bloodborne pathogens in the workplace (such as a needlestick) is concern about their suddenly acquired risk of infection (Figure 1 ). This acute anxiety is usually focused on the risk of infection with human immunodeficiency virus (HIV). However, HBV infection is transmitted from infected patients much more frequently than is HIV. One in 20 exposures to HBV-containing body fluid leads to infection in the recipient, compared to one infection per 200 to 300 exposures to HIVcontaining body fluid [Marcus, 1988).
The scene is familiar. The incoming shift is in report. You have worked hard on your tour of duty. You have successfully juggled bed baths, medications, and charting. You are tired and you are looking forward to your 2 days off. You have an appointment in 20 minutes with your child's teacher. You hurry down the hallway to answer Mr. Jones' call light for the last time today; he has slid down in bed once again. As you reach behind Mr. Jones to reposition him in bed, your finger is stuck by something sharp. You discover a used syringe /needle combination in the bed. Time seems to stop. Your heart is pounding; your palms are sweating. You feel immobilized. Questions fill your head.
What was the needle used for? Does Mr. Jones have any risk factors for hepatitis B virus (HBV) infection? Have you completed your HBV immunization series? Is Mr. Jones at risk for AIDS? Were you wearing gloves? Was there visible blood on the needle? Did you bleed spontaneously? Will you survive this minor injury? Will you live to see your child grow up?
This natural anxiety reaction is mediated by several important factors. HCWs already immunized against HBV have virtually eliminated that risk and its associated concern. Even if the source patient has a positive hepatitis B surface antigen (HBsAg), the immunized HCW is not susceptible. With the introduction of the federal Bloodborne Pathogen Standard in December 1991, all workers with potential exposure to human blood and the body fluids to which universal precautions apply are now eligible to receive free HBV vaccinations from their employers.
Recombinant - rather than serumderived - HBV vaccine is used in the United States to immunize HCWs. It is administered intramuscularly in the deltoid in three doses over a 6month period. More than 90% of healthy adults produce an adequate antibody response to this regimen. Up to half of the 10% nonresponders will develop antibody with one to three more injections. While 30% to 50% of vaccinated individuals lose their measurable antibody in 7 years, their protection against infection appears to continue. The parameters for booster doses are still being defined (Centers for Disease Control, 1990).
Figure . Immediately after an exposure incident, a patient previously assessed as "low risk" seems anything but "low risk" to the exposed health care worker.
THE POSTEXPOSURE MANAGEMENT PROGRAM
The other important mediator of exposure anxiety is the availability of a confidential, comprehensive, postexposure management program (PEMP) (Centers for Disease Control, 1990b). A formal PEMP provides the following:
* An education of the risk of infection and risk-reduction techniques;
* A mechanism for assessment of the source patient's risk factors and for obtaining source patient HBV and HIV serologic status;
* A setting in which the HCW can be periodically and confidentially tested for HIV antibody, usually at baseline; 6 weeks; and 3, 6, and 12 months following the exposure; and
* A formal assessment of the HCW for AZT chemoprophylaxis.
This information does not alter the outcome of the exposure. It does, however, provide the HCW with some intellectual tools to help manage the acute emotional response.
Under any circumstances, testing for HTV antibody is anxiety producing. Postexposure testing causes even greater concern, because the exposure makes the risk of infection clear and immediate. However, the overwhelming likelihood is that the results will be negative. The power of objective evidence against infection is without measure; the relief is as profound as the concern.
Many PEMPs also offer zidovudine/azidothymidine (AZT) to workers potentially exposed to HIV (Henderson, 1989). Since there is no scientific evidence that AZT will prevent infection, HCWs must be prepared to decide for themselves about its use after an occupational exposure (Lange, 1990). Because of the pathophysiology of HTV, it is crucial that AZT be administered within a few minutes following the exposure for it to have a theoretical chance of working. Often, this decision must be made without the availability of the source patient's HIV serologic status. Concerned HCWs may start taking AZT pending the source patient's HIV test results and risk factor assessment. Many HCWs opting to take AZT discontinue the medication when the source patient's HIV test is found to be negative and no risk factors are identified. Others complete the course regardless of the outcome of the source patient assessment.
AZT side effects are well documented. They include headache, dysphoria, sleep disturbances, nausea, and peripheral neuropathy. The most frequent AZT side effect, gastrointestinal symptoms, is often severe enough to preclude completion of the 4-week course of therapy.
The major risk factors for source patient infection with HBV and HIV are similar, and well known. They include sexual intercourse with an infected partner, infected blood or blood products transfusion, and intravenous drug use. Unfortunately, there is little epidemiologic and clinical information available on bloodborne pathogen infections specifically in older populations (Ferro, 1992).
Data from the Centers for Disease Control (CDC) indicate that more than 10% of AIDS cases in the United States occur in individuals over 50 years of age and 2.5% in those over 60. Approximately 2.9% of total reported AIDS cases have occurred in these age groups for a rate of 2.5 per 100,000 (Boudes, 1991). In 1990, out of a total of 43,339 reported cases of AIDS, 4,303 were in persons over 50 (CDC, 1991).
Analysis of the risk factors for the 1,450 cases of AIDS in individuals over age 50 reported in 1987 (Catania, 1989) shows that 65.8% were due to homosexual/bisexual activity. Transfusions accounted for 17.3% of cases, intravenous drug use for 8.3%, heterosexual transmission for 4.6%, homosexual/bisexual/ intravenous drug use for 1.9%, and hemophiliacs for 2.0%. While male/ male sexual exposure accounts for the majority of cases, infection via blood transfusion is the second largest risk category in this age group. In younger populations, intravenous drug use is the second largest risk category (about 20%).
Often, HIV infection in the elderly is unrecognized and may not be diagnosed until full-blown AIDS is present (Boudes, 1991). The incubation period may be longer and symptoms may be masked by other conditions in the older patient. Progression to AIDS, however, is more rapid than in younger individuals. This slightly atypical presentation may be influenced by a low index of suspicion on the part of caregivers, and could lead to needless HIV exposure of unaware sexual partners (O'Neill, 1992). It also could engender a false sense of security in HCWs providing elder care.
Attempting to proactively identify elder patients at risk for bloodborne pathogens is difficult at best - and it is confounded by the atypical presentation of HTV infection in this population. In addition, a patient assessed as "low risk" before an incident suddenly seems anything but "low risk" after an HCW is exposed. As in other areas of nursing practice, it is possible to be exposed to potentially infectious body fluids when caring for older patients. It is important that health care providers protect themselves with hepatitis B immunization and decrease exposure risk by the rigorous practice of universal precautions with patients in all age groups.
- Boudes, P. HIV infection in the elderly. Compr Ther 1991; 17(9):39-42.
- Catania, I, Turner, H., Kegeies, S.M., Stall, R., Pollack, L., Coates, T.J. Older Americans and AIDS: Transmission risks and primary prevention research needs. Gerontologist 1989; 29(3):373-381.
- Centers for Disease Control. Public health service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR 1990a; 39(RR-I ):1-14.
- Centers for Disease Control. Protection against viral hepatitis. MMWR 1990b; 39(suppl 2):125.
- Centers for Disease Control. The HIV/AIDS epidemic The first 10 years. MMWR 1991; 4022):357-365.
- Department of Labor. Occupational exposure to bloodborne pathogens: Final rule. Federal Register. December 6, 1991; 56:64004-64182.
- Ferro, S., Salit, I.E. HIV infection in patients over 55 years of age. j Acquir Immune Defic Syndr 1992; 5:348-355.
- Henderson, D.K., Gerberding, J.L. Prophylactic zidovudine after occupational exposure to the human immunodeficiency virus: An interim analysis. j Inject Dis 1989; 160-321-327.
- Lange, J.M.A., Boucher, CAB., Hollak, C.E.M., Wiltink, E.H.H., Reiss, R, Van Royen, E.A., et al. Failure of zidovudine prophylaxis after accidental exposure to HIV-I. N Engl J Med 1990; 322:1375-1377.
- Marcus, R., the CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med 1988; 319:11181122.
- O'Neill, D. HIV and the elderly. J R Soc Med 1992; 85:712.