The Response of Hospital Infection Control Programs to the AIDS Epidemic

Patients with the acquired immunodeficiency syndrome (AIDS) have provided hospital infection control programs in the United States with their greatest challenge since these programs became established some 20 years ago. When cases first appeared in 1981, AIDS was a dramatically new and mysterious illness. It was characterized by unusual tumors and opportunistic infections which were unknown to the public and were outside the experience of many nurses and physicians. The disease struck selectively; the majority of cases occurred among individuals who had engaged in activities which were either illicit (intravenous drug abuse) or with which society was uncomfortable (homosexual men). The patients' profound immunosuppression was easily demonstrated, but was unprecedented. The rapidly increasing tally of AIDS cases strongly suggested an epidemic of a communicable disease and it was speculated to have a vague link with the distant tropics. In those early days the cause and mode of transmission of AIDS were an enigma, but its high fatality rate was evident and frightening. These features of AIDS, quite understandably, produced considerable anxiety among hospital personnel who were assigned to care for AIDS patients. Unfortunately, these fears resulted in many regrettable episodes which were inconsistent with the mission of the health professions to provide sympathetic comfort and care to the sick. Some hospitals refused admission to patients who might have AIDS. Once admitted, patients often were severely isolated and were considered virtual pariahs. Food service workers would not enter patients' rooms, slipping food trays in on the floor; housekeepers avoided cleaning rooms; certain laboratories would not accept specimens from AIDS patients; mattresses and bed linens were incinerated after use; instruments used to examine AIDS patients were thrown out rather than have them resterilized; and elaborate disinfection rituals were applied to rooms and furniture after patients had been discharged from the hospital. Even more ominously, some nurses falsified recordings of vital signs rather than touch AIDS patients and physicians occasionally refused to accept responsibility for their medical care or to perform necessary surgery. Thus, all elements of the hospital were compromised by fear. The basic ability of hospitals to care for these very sick patients was threatened, as was the samaritan philosophy of the health professions. Effective infection control measures provided the resolution of this crisis. Epidemiologic investigations soon determined that AIDS transmission required either the inoculation of blood or blood products or intimate sexual contact. There was no evidence that casual contact put one at risk or that airborne or foodborne transmission occurred. Because this mode of transmission was entirely similar to that of hepatitis B, infection control personnel were able to respond rapidly. Guidelines for the safe care of AIDS patients were published quickly by the Centers for Disease Control (CDC) (1, 2), a consortium in San Francisco with extensive experience in the care of these patients (3), the American Hospital Association (4), and other professional organizations. Although the guidelines were conceptually simple, their implementation proved arduous. Because of the widespread fear of AIDS, hospital infection control teams discovered that they had to conduct intensive educational programs for all hospital personnel in order to be effective (5). This included not only physicians and nurses, but also administrators, food service workers, housekeepers, laboratory technicians, and even plumbers, electricians, telephone repairmen and the like. Personnel working on all three shifts and on weekends could not be overlooked. After the initial educational effort was concluded, it became necessary to establish a continuing educational mechanism to reach newly-hired employees, to remind those who had forgotten, and to answer questions which were raised by new developments which were widely reported in the news media. These efforts were successful; the occurrence of inappropriate incidents in the care of AIDS patients was greatly reduced. Another concern was health-care workers who had documented parenteral or mucous-membrane exposure to potentially infectious body fluids from patients with AIDS. Several groups of investigators have initiated prospective studies of such incidents. Their preliminary results indicate that when the health-care workers were not themselves members of a risk group, neither serologic evidence of HTLV-III infection nor decrease in the helper/ suppressor T-lymphocyte ratios occurred during the follow-up period (6-8). Although these results are generally reassuring, it is recognized that a nurse in England is thought to have developed HTLV-III antibody following an injury with a needle contaminated with the blood of an AIDS patient (9). Hepatitis B and cryptococcosis have been acquired similarly (10, 11), Initially, AIDS cases were concentrated in a few major urban centers in the United States. However, as the epidemic grew, patients with AIDS were admitted to hospitals throughout the country, often to hospitals in communities remote from a major medical center. Infection con-