Comprehensive prevention of occupational blood exposures: lessons from other countries.

Occupational exposures to blood and bloodborne viruses (ie, hepatitis B virus [HBV], hepatitis C virus [HCV], and human immunodeficiency virus [HIV]) have been a concern in the United States for more than a decade. Several studies have been conducted to assess the magnitude of the problem and to evaluate prevention strategies. The risk of occupational exposure to bloodborne pathogens is influenced by the prevalence of infection in the patient population and the nature and frequency of blood exposure, whereas the likelihood of acquiring infection after a single blood exposure event from an infected patient is influenced by the severity of the exposure (ie, route of entry and inoculum size) and viral type. The surveys conducted in Brazil and Mexico by Ribeiro et al1 and Kato-Maeda et al,2 respectively, showed that the prevalence of all three bloodborne viruses—HBV, HCV, and HIV—in patients admitted to emergency departments was higher than in the general population, as represented by blood donors. Studies in the United States have reported similar results. The prevalence of each bloodborne virus in the two surveys differed, reflecting expected geographic differences; however, patients with more than one bloodborne virus infection, particularly HIV and HCV, were frequent in both surveys. In the study conducted by Kato-Maeda et al in Mexico City, 32% of HIV-infected patients were unaware of their HIV status, and several did not report a risk factor for HIV infection. The results from these reports reinforce two important prevention concepts. One is the importance of following Universal or Standard Precautions with any patient during interactions when there is a potential for blood exposure, an approach that does not require knowledge of the patient’s bloodborne infection status on the part of either the patient or healthcare provider. The other is the importance of testing source patients for all three bloodborne viruses after an occupational exposure, for optimal postexposure management. Rabaud et al3 conducted a survey in six nursing schools and six hospitals in Lorraine, France, to assess reasons for not reporting a blood exposure, to describe the behavior of French nurses after occupational exposure to blood, and to explore links between personality traits and exposures to blood. The rate of underreporting in this survey was similar to other studies. Underreporting of rates in US hospitals has ranged from 40% to 80%, depending on the institution and the occupational group. In annual surveys conducted in 1996 to 1998 in hospitals participating in the Centers for Disease Control and Prevention (CDC) surveillance system for occupational exposures and infections, the National Surveillance System for Healthcare Workers, the average rate of underreporting among nurses was 51% (P. Srivastava, MS, CDC, oral communication, March 2000). One reason for not reporting exposures to blood in Rabaud’s paper was “fear of being judged.” Reports on the epidemiology of needlestick injuries in the United States from the 1970s and early 1980s often attributed the injury causation to “personal carelessness.” The pervasiveness of this blame-the-worker attitude likely contributed to underreporting in the United States and is suggested as a contributing factor in Rabaud’s report. Another reason for underreporting in Rabaud’s paper is the most frequent reason for underreporting in US hospitals: the perception that the source of exposure is associated with low risk of infection. In some US hospitals, reporting of blood exposures increased after the publication of the 1996 CDC recommendations for HIV postexposure prophylaxis.4 Since Rabaud’s survey was conducted before publication of these