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Prevention of HIV and Hepatitis B Transmission in the Chiropractic Setting

Elizabeth Olsen, RN, DC

An article appeared in the February 14, 1992 issue of the Motion Palpation Institute's Dynamic Chiropractic, "Hygiene Protocol for Treating AIDS Patients." The authors of the article presented a list of infection control procedures and several of the procedures mentioned were inappropriate with respect to what is known about transmission of HIV infection. The Center for Disease Control recommended guidelines for preventing HIV and hepatitis B transmission in the health care setting are summarized at the end of this article.

Whenever infection control is discussed, it is essential to remember that there are different routes of transmission for communicable diseases. Each route is associated with a unique pattern as the disease spreads in a community and studying these patterns helps epidemiologists determine which method of transmission is associated with any given infectious disease.^1,2

Airborne or droplet spread is associated with coughing, sneezing and direct contact. The common cold and influenza are examples of illnesses spread in this manner.

Contact spread (direct skin to skin or indirect through a contaminated object) is the method of transmission associated with athlete's foot, scabies, and lice. The common cold and influenza can also be transmitted by contact spread.

Fecal-oral transmission occurs most classically when hands are not washed after defecation. Hepatitis A and many diarrheal illnesses like salmonellosis and shigellosis are transmitted in this manner.

Note: No cases of HIV infection have been associated with the above three routes of transmission and studies of non-sexual household contacts of HIV infected persons do not reveal HIV transmission by such casual contact.^3,4,5

Blood to blood or semen to blood transmission is the route associated with hepatitis B and HIV infection. These infections can be transmitted when "high-risk" body fluids like the blood, semen, or vaginal/cervical secretions of an infected person get into the blood of an uninfected person.

There are rare but documented cases of transmission via splashes of blood to mucous membrane surfaces and abraded skin.6 The degree of risk with any particular exposure depends on many factors including the viral load of the infected person, the amount and type of body fluid involved in the incident, the virulence of the virus (HIV is a "wimpy" virus outside the host compared to hepatitis B virus), and the susceptibility of the host.

HIV infection may be passed to an unborn child from an infected mother. Not all children, however, are infected with the virus even though they will test positive for HIV antibody (maternal) in their first months of life.² Breast feeding may also transmit HIV.

Urine, feces, saliva and sweat are considered "low risk" body fluids and although they may contain small amounts of HIV, no documented case of transmission has been associated with these fluids.⁷ Risk would increase if these "low risk" body fluids were contaminated with blood.

Sexual contact and sharing contaminated needles represent the most common modes of HIV transmission and heterosexual contact is the single most common method of transmission in the world.⁸

There are many unknowns in the war against HIV infection, particularly with regard to effective treatment and the search for a cure. There are other areas, however, where much is known and the knowledge about how HIV is transmitted is solid. The long track record that infection control professionals have with hepatitis B has contributed much to our understanding of how to prevent transmission of HIV. Hepatitis B still presents a much higher threat to health care workers than HIV.⁹ Occupationally acquired hepatitis B results in more morbidity and mortality than HIV. The good news about hepatitis B prophylaxis is that health care workers who are at high risk of exposure to body fluids (e.g., blood during invasive procedures or in the delivery of emergency care) can be protected with a hepatitis B vaccine.

The Occupational Safety and Health Administration (OSHA) has recently adopted rules regarding the protection of workers at risk for blood borne infections. The rules apply to employees who can "reasonably anticipate" to contact blood and other potentially infectious materials on the job and all employers including chiropractors in private practice are required to have written guidelines for infection control.¹⁰

Since chiropractic care rarely involves "invasive" procedures, the chiropractor's office is generally not considered a high risk setting for transmission of blood borne diseases like hepatitis B and HIV. Some chiropractors do perform intraoral, intravaginal, and intrarectal examinations, and phlebotomy is allowed and practiced in some states. Any chiropractor or the staff in any chiropractic office could be confronted with a surprise accident, a patient with a bloody nose or weeping wound, so it is essential that all DCs and staff understand universal blood and body fluid precautions. Such practices to reduce risks or exposure in the workplace are mandatory under the new OSHA rules.

The term "universal" refers to the fact that we are often unaware of who is and is not infected with HIV and hepatitis B so precautions must be taken universally in any situation where an individual may contact the body fluids of another person.

The following summary is reprinted from Mosby's 1991 text, Infectious Disease by Deanna E. Grimes.

Universal Blood and Body Fluid Precautions

All health care workers should use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or body fluids of any patient is anticipated.
Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Gloves should be changed after contact with each patient.
Hands and other surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed.
Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids.
Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids.
Needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After use, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal; the containers should be located as close as practical to the use area. Large-bore reusable needles should be placed in a puncture-resistant container for transport to the re-processing area.
Although saliva has not been implicated in HIV transmission, mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable.
Health care workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until the condition resolves.
Pregnant health care workers are not known to be at greater risk of contracting HIV infection than non-pregnant workers; however, if a pregnant worker develops HIV infection, the infant is at risk from perinatal transmission. Pregnant health care workers should strictly adhere to precautions.
Invasive procedures (surgical entry into tissues, cavities, or organs) or repair of major traumatic injuries carry a risk of splattering of blood and fluids and require the use of gloves, masks, protective eyewear or face shield, and gowns or aprons made of some materials that provide an effective fluid barrier.
During an invasive procedure, if a glove is torn or a needlestick or other injury occurs, the glove should be removed and a new glove used as promptly as patient safety permits; the needle or instrument involved in the incident should be removed from the sterile field.

[Source: Centers for Disease Control (Aug. 21, 1987). Recommendations for Prevention of HIV transmission in health care settings. MMWR, 36 (2S).]

Guidelines

Procedure	Wash Hands	Gloves	Gown	Mask	Eyewear
Talking with patients, shaking hands
Adjusting IV fluid rate or noninvasive equipment
Examining patient without touching blood, body fluid, mucous membranes	X
Examining patient with significant cough	X	X
Examining patient including contact with blood, body fluids, mucous membranes, drainage	X	X
Drawing blood	X	X
Inserting venous access	X	X
Suctioning	X	X	Use gown, mask, eyewear if bloody fluid spattering is likely
Inserting catheters	X	X	Use gown, mask, eyewear if bloody fluid spattering is likely
Handling soiled waste, linen, other materials	X	X	Use gown, mask, eyewear if bloody fluid spattering is likely
Intubation	X	X	X	X	X
Inserting arterial access	X	X	X	X	X
Endoscopy, bronchoscopy	X	X	X	X	X
Operative and other procedures that produce extensive spattering of blood or body fluids and are likely to soil clothes	X	X	X	X	X
Handling placenta or infant following vaginal or cesarean delivery	X	X	X
Postpartum care of umbilical cord	X	X

(Courtesy The Johns Hopkins Health System, Baltimore, MD.)

References

Lewis JE: History of the AIDS Epidemic. In Hopp JW, Rogers EA (eds): AIDS and the Allied Health Professions. Philadelphia: FA Davis Company, 1989.
Elder HA: Transmission of HIV and Prevention of AIDS. In Hopp JW, Rogers EA (eds): AIDS and the Allied Health Professions. Philadelphia: FA Davis Company, 1989.
Friedland GH, Klein RS: 101 Non-sexual household contacts. N Engl J Med, 317:1125, 1987.
Lifson AR: Do alternate modes for transmission of human immunodeficiency virus exist? JAMA, 259:1353, 1988.
Grimes DE, Grimes RM: Acquired immune deficiency syndrome (AIDS) and HIV infection. In Grimes DE: Infectious Disease. St. Louis; Mosby-Year Book Inc., 1991.
Update: Acquired immunodeficiency syndrome and HIV infection among health care workers. MMWR, 37:229, 1988.
Henderson DK, et al: Risk for occupational transmission of human immunodeficiency virus (HIV-1) associated with clinical exposures: a prospective evaluation. Ann Intern Med., 113:10, 1990.
Mann JM: Status of the pandemic - priorities for the 1990's. Virginia S. DeHann lecture, Emory University, 26 November 1990.
Office of Epidemiology and Health Statistics, Oregon State Health Division: Prevention of HIV Transmission in the Health Care Setting. Communicable Disease Summary, 37:2, 1988.
Office of Epidemiology and Health Statistics, Oregon State Health Division: New OSHA Requirements to Protect Workers from Bloodborne Infections. Communicable Disease Summary, 41: 1, 1992.

Elizabeth Olsen, B.S.N., D.C.
Portland, Oregon

April 1992