Hygiene Protocol for Treating AIDS Patients

The authors: Robert Pokras, Ph.D., research director at Cleveland Chiropractic College, Los Angeles; Kathleen Wells, D.C., CCCLA's AIDS task force director; and Courtney Cooke, M.T., L.V.N., D.C., also of CCCLA. Acknowledgements go to CCCLA faculty members for contributing ideas: C. Calimag, M.D., L. Iler, M.S., G. Khare, Ph.D., D. Lennartz, Ph.D., and Dr. Grace Jacobs, academic dean and microbiologist. The authors also wish to thank CCCLA interns Gregory Sabol, Robert Xanthos, Randolf Enos, Phillip Gillet, and Tracy Diner for their input.

With the uncertainty associated with the AIDS virus, the authors state: "We fall short of recommending this 17 step protocol as an established portion of the chiropractic compendium for 'standards of care.'"

The original title of this article was "Suggested Hygiene Measures for Treating Patients Suspected of Harboring the HIV-1 Virus."

 

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Chiropractic is now absorbing patients from the larger health care community who may have contracted the AIDS virus, or are at risk for doing so. We need to consider those steps which may be necessary to protect these particular patients, other patients, the doctor, and associated workers within the chiropractic clinic setting. Since chiropractors make contact with a large area of a patient's skin surface, we must be more diligent than the average MD with respect to the common sense rules of hygiene. What follows are some recommendations based on information presented at the American Public Health Association Conference (Atlanta, November 1991); a consensus of ideas from many of the faculty at CCCLA; and a more generalized protocol CCCLA adopted for treating patients with contagious diseases.

Many of these new recommendations will be adopted by the CCCLA college clinic. The protocol however will be subject to repeated modification as more facts related to the etiology and transmission of the disease become available (chiefly via updates from the Center for Disease Control in Atlanta).

None of the ideas discussed here are hard facts, especially given the opposing opinion by a few scientists that the HIV-1 virus may not be the certain causal agent inducing AIDS. Even so, the suggestions that we have proposed are consistent with established guidelines for controlling the spread of pathogens within the clinical setting.

Diagnosis

Certain signs and symptoms may make you suspect that your patient may have been infected with the AIDS/HIV-1 virus. Within 2-4 weeks after exposure with the virus, some patients exhibit a 3-14 day acute nonspecific viral syndrome which may include fever, sweats, malaise, rash, arthralgias, and generalized lymphadenopathy. These symptoms then disappear and the patient becomes an asymptomatic carrier. The AIDS related complex (ARC) is characterized by generalized lymphadenopathy; weight loss; intermittent fever; malaise and lethargy; chronic diarrhea; rectal condylomata; anemia; idiopathic thrombocytopenia; and oral thrush (candidiasis). The full blown AIDS syndrome may consists of any of the above signs and symptoms along with opportunistic infections (e.g., Pneumocystis carinii) and certain secondary cancers (Kaposi's sarcoma, non-Hodgkin's lymphoma, or primary lymphoma of the brain). The most common motor and behavioral abnormalities include gait unsteadiness, weakness, apathy, social withdrawal, and depression. Peripheral nerve disorders are associated with all stages of HIV infection. Painful dysesthesias, numbness, paresthesias, and weakness are evidence of peripheral nerve involvement.

Taking a good patient history may also alert you to consider the potential for contamination with the AIDS virus. High risk behaviors include casual and multiple partner oriented sexual encounters; IV drug abuse; anal sex; and recreational use of aliphatic nitrites ("poppers"). Confirmation of HIV-1 infection must be made via enzymatic immunoassay (EIA) and then Western Blot. Note that serologic diagnosis must be done in a way to insure patient confidentiality.

Protocols for Suspected HIV-1 Infected Patients

1. Theoretically, all patients and clinicians would be tested for evidence of exposure to the AIDS virus. Consensus among chiropractors at present falls short of this drastic measure and instead to apply rigorous protocols of hygiene within the clinic setting, so as to minimize the potential for the transmission of the virus. The political and social ramifications of testing are beyond the political and ethical scope of the chiropractor's services to the patient. When the doctor suspects infection with the HIV-1 virus (based on the above mentioned criteria), the following steps might be incorporated into the treatment regime.

    

2. Use a separate room for these patients. Scrub the floor of this room with strong detergent or bleach solution (10%) at least once per day. Patients will need to wear disposable paper "scuffs" for their feet.

    

3. Clean surfaces properly. Counter tops, adjusting tables, P.T. equipment (i.e., ultrasound transducers, muscle stimulator pads), and environmental surfaces would be routinely, thoroughly, and carefully cleaned with a solution of household bleach (1:10 dilution, prepared daily). All foam pads must be soaked in the same bleach solution. After completion of the chiropractic transaction, contaminated surfaces should be cleaned with a 1:10 dilution of sodium hypochlorite solution. Tables or any surfaces that may have come in contact with any bodily fluids (e.g., blood, saliva, nasal effluent, urine, or excrement) should be wiped with paper towels and then disinfected in the same manner. Use disposable pads/leads and covers for EKG and physiotherapy equipment. Disinfection also extends to the stethescope and blood pressure cuff. Disposable crystal thermometers might be used in place of glass or digital instruments.

    

4. All x-ray equipment in direct contact with the patient should be cleaned with a 1:10 dilution of sodium hypochlorite solution.

    

5. Use face paper and either disposable table paper or washable sheets to cover the entire adjusting table surface.

    

6. Wash sheets, towels, and hydroculator covers in bleach and water heated above 71^oC. for a period of at least 25 minutes.

    

7. Clinicians must thoroughly wash hands before and after treating the patient (see references 3 and 4). One may use germicidal soap for hand washing (e.g., Phisohex/Physoderm, see reference 2).

    

8. The chiropractor should wear latex gloves when handling the patient (e.g., adjustments/palpation, touching mucus membranes or non-intact skin) or cleaning up after the patient (step 3). Change gloves every 10 minutes; when gloves tear; when moving from one skin area to another (e.g., face to torso to legs); or when glove comes in contact with an open lesion (i.e., burst pimple, or weeping area of Kaposi's sarcoma). Wash hands after removing gloves each time. Unless there is overt blood to blood contact, you may have about a three to five minute safety lag period for the had washing step. (Cost of gloves must not be an issue here.)

    

9. The doctor should wear a new disposable paper gown above normal clothing, which protects the skin surface of the arms. One may also wear surgical paper boots over the shoes, but remove and dispose of them with gloved hands before leaving the isolation room each time. If the patient or doctor is sneezing, one should consider the use of a surgical face mask and protective eyewear. The patient should also wear a disposable gown and should remain in that gown during the entire chiropractic treatment.

    

10. Dispose of waste in special infectious waste containers. Waste may be incinerated. Washable sheets etc., should be decontaminated (step 6) in batches separate from those of the other patients.

     

11. No health care worker who is experiencing exudative/superative lesions or dermatitis should perform or assist in any direct patient care procedure.

     

12. Keep all open cuts and abrasions (both patient and clinician) covered with adhesive bandages with repel liquid (i.e., Band-Aids).

     

13. Examine the patient for associated dermatological lesions such as excessive seborrheic dermatitis, herpes simplex and zoster, persistent folliculitis, tinea capitis/pedis, candidiasis, open sores (including in the mouth), and Kaposi's sarcoma. Presentation with such lesions requires referral to the MD. As a conservative approach, many chiropractors may exclude HIV-1 patients from treatment. Most chiropractors will treat these patients for spine specific correlates to their condition such as back pain. Note however that the presence of skin lesions increases the risk to the chiropractor of being infected with the AIDS virus as well as the opportunistic pathogens which may have induced the specific lesion. One must avoid touching the skin lesions (even with gloves; use a disposable tongue depressor). If the lesions manifest themselves on the skin above specific vertebra to be adjusted, these maneuvers would not be performed. Aside from the potential of infecting the doctor, there is some concern that mechanical pressure on a lesion could disseminate the infective pathogen.

     

14. Do not touch the patient's clothes and use gloved hands when disposing of waste material (including that of the doctor) which has come in contact with the patient. Educate and supervise chiropractic assistants and cleaning personnel as to the details of these hygiene regulations.

     

15. Before each chiropractic transaction, always obtain the vital signs in the suspect HIV patient. One must look for the evidence of systemic infection: increased heart rate/blood pressure/temperature/respiration, swelling of lymph nodes, and diarrhea. With cervical lymph gland swelling, one should not adjust the neck as there is the possibility of spreading the infection through the lymphatic drainage. Infection in general may exacerbate tissue inflammation secondary to a traumatic adjustment. Many chiropractors would delay adjustments until signs of the infection disappear. Again, consult with an MD is advisable when systemic infection is identified. Diarrhea may make adjustments to the abdomen impossible. With infection one must also screen for meningitis, especially if there is cervical lymphadenopathy and headache. One must also consider vertebral osteomyelitis in suspect HIV-1 patients who present with back pain and fever.

     

16. It is recommended that an MD be part of the health care team to deal with HIV-1 components independent of back pathology. To this end, it is more practical to perform phlebotomy on such patients within the hospital setting.

     

17. Remind and reassure the patient that these hygiene measures are for their own protection as well as for the doctor. Their immunosuppressed state would make them more vulnerable to pathogens which could be transmitted to them by the clinician if there was a less rigorous level of hygiene.

Note: The Center for Disease Control in Atlanta publishes updates on the type of protocol that we have described. You may contact them directly for information at 1-800-458-5231 or 1-800-342-2437. One such reprint that is available is "Health Care Worker Precautions."

References

1. Abrams DI: Clinical manifestations of HIV infection. J Am Acad Dermatol, 22:1217-22, 1990.

    

2. Iler L, Pokras R: Headrest paper as a physical barrier to bacterial contamination on the adjusting table. Aus. J. of Chiropractic Association, 20(3):85-89, 1990.

    

3. Spore S: Did you wash your hands? Journal of Chiropractic Education, 2(1):6-8, 1988.

    

4. Pokras R, Iler L, Leland MT, Cooke C: Recommendations for a hand and arm washing protocol specific to the chiropractic treatment session. Am Chiro, 13(4):24-28, and 47.

    

5. Pokras R, Cooke C, Graham L: Draping the patient without the need for hemostats or towel clips. Advances in Therapy, 8(4): 172-175.

    

6. Recommendations for prevention of HIV transmission in health care settings. ACA J Chiro. 25(1):36-46, January 1988.