How're we doin'? Preventing occupational infections with blood-borne pathogens in healthcare.

Ed Koch was the 105th Mayor of New York City and served in this capacity for three terms from 1978 to 1989. During his time as mayor, he was recognized for restoring financial stability and accountability to the “Big Apple,” but was nearly equally as famous for walking the streets of New York and asking of random constituents, “How’m I doin’?” In many, if not most, respects, I believe his “walking-thetalk” behavior should be a paradigm for the healthcare industry in the 21st century. The arrival of acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) infection into the healthcare milieu in the early 1980s provided perhaps the single greatest thrust to improve the safety of healthcare practices regarding occupational risks for exposure to, and infection with, blood-borne pathogens. In this issue of Infection Control and Hospital Epidemiology, four articles address issues relating to healthcare workers’ risks for, and prevention of, occupational infections with bloodborne pathogens.1-4 As we approach the 25th anniversary of the identification of AIDS and HIV infection, we may all gain from taking a careful, thorough, and thoughtful look at how we’re doin’ regarding preventing exposures to and infections with blood-borne pathogens in the healthcare setting—ultimately, with an eye toward the development of new, and even more effective, prevention strategies. The creation by the Centers for Disease Control of the so-called universal precautions guidelines5 (now broadened to encompass the concepts associated with standard precautions)6 represented the first giant step toward reducing risks for occupational infections of healthcare workers with blood-borne pathogens. These guidelines focused principally on primary prevention (ie, preventing occupational exposures to blood and thereby preventing infection with all blood-borne pathogens) and emphasized—because testing can never provide 100% accuracy—that blood from all patients should be assumed to represent occupational risk. This concept, which arrived on the healthcare scene only with the implementation of the universal precautions guidelines in 1987, should have long since permeated the healthcare workplace, beginning in the late 1940s, when the occupational risks for hepatitis B infection were initially identified and characterized.7 Since the publication of the universal precautions guidelines, we have learned a great deal about primary prevention of occupational exposures (Table). In my view, thoughtful adherence to these precautions likely has contributed more to the reduction of occupational risk than any other single intervention. These guidelines effectively put the healthcare worker in the “driver’s seat” regarding risk management. If, in the healthcare worker’s view, a specific procedure is associated with a risk for getting blood on his or her hands, the healthcare worker should elect to wear gloves. If a risk for spattering or splattering is present, the healthcare worker could decide to protect his or her mucous membranes. That it took until the late 1980s for these guidelines to appear is problematic. Nonetheless, the major message of these guidelines—that blood equals risk in the healthcare environment—is both precisely correct and entirely reasonable. Prospective evaluation of procedures and work practices associated with recurring risk is another area rife with potential for reducing occupational risk. In my institution, a multidisciplinary team effectively mines all of our exposure data, looking for common circumstances of exposure. In instances in which a specific procedure is identified as being associated with recurring risk, we propose and test modifications to the procedure in an attempt to prevent exposures. Use of this approach during the past 15 years