Annals of the Royal College of Surgeons of England (1992) vol. 74, 5-8
Prevention of occupational transmission of HIV in the ENT clinic Julian M Rowe-Jones
MB BS
Senior House Officer
Michael B Pringle
FRCS
Registrar
Royal National Throat, Nose and Ear Hospital, London Key words: Human immunodeficiency virus; Occupational transmission; Otolaryngology
Much attention has been focused on the risks of inoculation with the human immune deficiency virus in the operating theatre. However, less emphasis has been placed on infection resulting from outpatient exposure to this pathogen. A survey of current protective measures undertaken by ENT consultants in the outpatient clinic in the United Kingdom is presented. The precautions employed by the majority of these subjects are inadequate and non-universal. A review of the risk factors and subsequent safety recommendations is detailed.
The acquired immune deficiency syndrome (AIDS) was first recognised in 1981. Since then 26 health care workers have been infected with the human immunodeficiency virus (HIV) after probable occupational transmission (1). Collated data from prospective studies has demonstrated a low risk of infection from a single needlestick injury of 0.36% (1). However, the consequences are devastating. Current estimates are that within 10 years 50% of infected persons will develop AIDS. This has an almost 100% mortality after 3 years. Specific guidelines on protection for surgeons in the operating theatre and for dentists have been produced (2-4). The otolaryngologist faces similar risks of nosocomial infection in the outpatient clinic to the latter group, but this situation has received less attention.
Materials and methods A questionnaire was sent to all United Kingdom ENT Consultants listed in The Directory of Operating
Correspondence
to: Dr J M Rowe-Jones, Registrar to Department of Otolaryngology, St George's Hospital, Blackshaw Road, London SW17 OQT
Theatres and Departments of Surgery for 1989 (5). Details were collected of precautions taken to prevent nosocomial infection with HIV in the outpatient clinic during certain procedures. These were aural toilet, anterior rhinoscopy, intra-oral examination, indirect laryngopharyngoscopy, flexible nasendoscopy and the management of acute epistaxis. Surgeons were asked about the use of gloves, eye protection and masks and as to whether these measures were undertaken always, for high-risk cases only, or never. When eye protection was evident we asked if this was by prescription spectacles, plain lenses, plain lenses with side-shields or any other forms, which the respondent was asked to describe.
Results A total of 482 questionnaires were sent out, and 314 were returned, of which five were discarded because the recipient had retired or, as in one case, was undecided on his own policy without compulsory AIDS testing of patients. Of the responses, 12 arrived too late, leaving 297 for analysis. The use of face masks is shown in Table I. Approximately two-thirds (mean = 64%) of surgeons used such protection for high-risk patients, the remainder predominantly never wearing a mask. More surgeons wore gloves for protection than any other measures, as illustrated in Table II. Again, however, their use was predominantly for high-risk patients only. Management of epistaxis attracted the greatest degree of protection: 91% of respondents used gloves for some patients in this situation and 40% of these always did so. Intra-oral examination also attracted an high prevalence for glove use of 88%, with similarly 40% of these always wearing them.
6
J M Rowe-Jones and M B Pringle
Table I. Use of face masks during outpatient procedures (n = 297) Aural toilet
Always High-risk only Never
Anterior
Acute
Intra-oral
Indirect
rhiniscopy
examination
laryngoscopy
Nasendoscopy
epistaxis
n
%
n
%
n
%
n
%
n
%
n
%
6 177 114
2 60 38
6 188 103
2 63 35
8 192 97
3 65 32
11 203 83
4 68 28
12 186 99
4 63 33
23 193 81
8 65 27
Table II. Use of gloves during outpatient procedures (n = 297) Aural toilet
Always High-risk only Never
Anterior rhinoscopy
Intra-oral examination
Indirect laryngoscopy
Acute epistaxis
Nasendoscopy
n
%
n
%
n
%
n
%
n
%
n
%
6 233 58
2 78 20
3 222 72
1 75 24
108 153 36
36 52 12
8 235 54
3 79 18
33 212 52
11 71 15
115 154 28
39 52 9
Table III. Use of eye protection during outpatient procedures (n = 171) (surgeons always wearing prescription spectacles for visual disorders have been excluded (n = 126)) Anterior rhinoscopy
Aural toilet
Always High-risk only Never
Intra-oral examination
n
%
n
%
n
%
2 88 81
1 52 47
2 88 81
1 52 47
2 90 79
1
53 46
Table IV. Types of eye protection worn Prescription spectacles Plain lenses Lenses with side-shields Protection worn-type not indicated Visor Goggles Voroscope
126 26 38 40 3 1 1
Prescription spectacles were worn by 126 surgeons, and none of these made additional efforts to protect their eyes. Of the remaining 171 subjects, more never used eye protection (mean =45%) as a precautionary measure, than never used face masks or gloves. The distribution of use is shown in Table III. The types of eye protection employed are listed in Table IV.
Discussion While routinely examining and investigating patients in clinic, the ENT surgeon may potentially come into
Indirect laryngoscopy
Acute epistaxis
Nasendoscopy
%
n
%
n
%
2
1
95
56 43
3 89 79
2 52 46
10 99 62
58 36
n
74
6
contact with a wide range of body fluids. These may also be contaminated by blood. Subjects seen may include asymptomatic carriers of HIV or demonstrate one of the many head and neck manifestations of infection with this virus (6).
Ears HIV and its antibody have been isolated from middle ear effusions and the antibody also from cerumen (7); no cases of transmission have been reported, however. Aural toilet may produce bleeding and thus handling of instruments such as sucker tips or sharp probes presents a risk of inoculation.
Nose No virus has as yet been identified in nasal mucus. Lymphocytes and monocytes, though, may be infected (8) and carry HIV in secretions of rhinosinusitis. The virus has been cultured from tears (9) and cerebrospinal fluid (CSF) (10). In both cases the patients had developed AIDS. Theoretically, therefore, the nasal cavities may be secondarily contaminated by drainage via the lacrimal
Transmission of HIV in the ENT clinic
ducts into the inferior meati, or by CSF rhinorrhoea presenting as rhinitis (11). Management of acute epistaxis presents the greatest risk of contamination with infected blood. Contact may be not only directly onto the hands but also from aerosolisation as the patient coughs and sneezes blood. This presents the skin of the face, mucous membranes of the lips, mouth and nose, the respiratory tract and the conjunctiva as potential portals of entry for infection with HIV.
Oral cavity HIV has been isolated from the saliva of healthy seropositive subjects, those with AIDS-related complex and those with AIDS (12). Saliva may also be contaminated with blood in patients with oral pathology. However saliva alone, like tears, has low numbers of virus particles and no epidemiological data have shown an association between exposure to these fluids and infection with HIV
(13). Larynx and pharynx Indirect examination again poses risk of exposure to infected saliva, exacerbated by patients gagging and coughing. In the latter situation the clinician may also be exposed to bronchial secretions. HIV has been cultured from bronchoalveolar lavage fluid (14). These patients all had AIDS and respiratory disease. Direct examination with a nasendoscope also provides a route for transferring virus in secretions. Pharyngeal and laryngeal mucosa may be damaged and result in contamination of the instrument with infected blood and tissue with further risk to the operator.
Precautions Studies have suggested that dentists are a high-risk group for acquisition of infection from the hepatitis B virus (15). Similar routes of transmission exist for HIV. As a result, recommendations of protection for health care workers have included specific guidelines for this group (2-4). A survey in North America in 1987 (16) revealed that 98% of dentists used gloves, 96% protective eyewear, and 90% masks. Another the following year found that over 75% always used gloves and/or eyewear (17). Otolaryngologists face similar risks. Our survey has revealed that for examining patients, in some instances 83% used gloves, 65% masks and only 54% eye protection. The comparison is even less favourable for use with all patients: 2% for eyewear, 15% for gloves and 4% for masks. Cases of seroconversion in health care workers, negative for other risk factors, are caused by percutaneous inoculation and, to a much lesser extent, broken skin and mucous membrane exposure (2,18,19). One example did involve blood being spattered on the face and in the mouth (18). However, although hepatitis B virus may have caused nosocomial infection via the respiratory and
7
conjunctival routes (20,21), only one case of HIV infection via the eye mucous membrane has been reported (22). More worrying are suggestions that infection may occur through intact skin as the Langerhans' target cell, which has receptors for HIV, is actually found within the epidermal and mucosal barriers (23,24). We would like to reiterate the recent recommendations of the Expert Advisory Group on Aids (4). The group advises protection of the skin and mucous membranes of eyes, mouth and nose. Protective measures should be used for all patients with regard to blood and other specific body fluids such as CSF and saliva in dentistry. We feel saliva in association with otolaryngology should also be included. The extent of these measures is related to three task categorisations which depend on blood exposure risk. Category 1 concerns probable contact with blood and high-risk fluids when there is also potential for uncontrolled bleeding or spattering. In this situation a full range of protective clothing including headwear, eyewear and masks should be used. We would include management of acute epistaxis in this category. Ideally a protective faceshield including a head mirror (25) should be employed. Category 2 applies to probable contact with high-risk fluids but unlikely spattering. In these circumstances gloves should be worn and masks and protective eyewear should be available. The third category arises when the probability of contact is low. In such cases gloves should be available. Otolaryngologists should alter their present practices as observed in our survey. Gloves should be worn in all cases when there is a high probability of contact with blood or saliva. Similarly, when there is a risk of spattering of these fluids, such as during acute epistaxis or examinations provoking coughing and gagging, the skin and mucous membranes of the face should also be protected. We would like to thank Mr C M Bailey for his help and advice in the preparation of this paper.
References I Henderson DK. HIV-1 in the health care care setting. In: Mandell GF, Douglas RG Jr, Benett JE, eds. Principles and Practice of Infectious Diseases. New York: Churchill Livingstone, 1989:2221-36. 2 Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(Suppl. No. 2S): 3-18. 3 Department of Health and Social Security. Guidance for surgeons, anaesthetists, dentists, and their teams in dealing with patients infected with HTLV III. Acquired immune deficiency syndrome. Booklet 3, 1986. 4 Department of Health. Recommendations of the Expert Advisory Group on AIDS. Guidance for clinical health care workers: Protection against infection with HIV and Hepatitis
Viruses. London: Her Majesty's Stationery Office, January 1990.
8
J M Rowe-Jones and M B Pringle
S The Directory of Operating Theatres and Departments of Surgery. CMA Medical Data Ltd, Cambridge, 1989. 6 Weng BM, Kuruvilla A, Goldrich MS, Heffner DK, Tuur S. Pathologic manifestations of acquired immunodeficiency syndrome in the head and neck. Ear Nose Throat J 1990;69:406-15. 7 Sooy C, Gerberding JL, Kaplan MJ. The risk for otolaryngologists who treat patients with AIDS and AIDS virus infection: Report of an in-process study. Laryngoscope 1987;97:430-4. 8 Levy JA. The transmission of AIDS: the case of the infected cell. JAMA 1988;259: 3037-8. 9 Fujikawa LS, Salahuddin SZ, Palestine AG, Masur H, Nussenblatt RB, Galo RC. Isolation of human T-lymphotropic virus type III from the tears of a patient with acquired immunodeficiency syndrome. Lancet 1985; 2:529-30. 10 Ho DD, Rota TR, Schooley RT. Isolation of HTLV-III from cerebrospinal fluid and neural tissue of patients with neurologic syndrome related to the acquired immunodeficiency syndrome. N Engl Jf Med 1985;313:1493-7. 11 Brockbank MJ, Veitch DY, Thomson HG. Cerebrospinal fluid in the rhinitis clinic. J Laryngol Otol 1989;103:281-3. 12 Groopman JE, Salahuddin SZ, Sarngadharan MG et al. HTLV III in saliva of people with AIDS related complex and healthy homosexual men at risk for AIDS. Science 1984;226:447-8. 13 Levy JA. Human immunodeficiency viruses and the pathogenesis of AIDS. JAMA 1989;261:2997-3006. 14 Dean NC, Golden JA, Evans LA et al. Human Immunodeficiency Virus recovery from bronchoalveolar lavage fluid in patients with AIDS. Chest 1988;93: 1176-9. 15 Mosley JW, Edwards VM, Casey G, Redeker AG, White E.
16 17 18 19
20 21
22
23 24
25
Hepatitis B virus infection in dentists. N Engl J Med 1975;293: 729-34. Academy of General Dentistry (AGD). AGD 1987 membership survey results, members express satisfaction with AGD's services. AGD Impact 1988;16:21. Neidle EA. AIDS-related changes in dental practice. J Dent Educ 1989;53:525-8. Centers for Disease Control. Update: Human immunodeficiency virus infections in health-care workers exposed to blood of infected patients. MMWR 1987;36(19):285-9. Sim AJW. HIV as an occupational hazard to surgeons. A UK perspective. In: Sim AJW, Jeffries DJ, eds. AIDS and Surgery. Oxford: Blackwell Scientific Publications, 1990: 49-51. Almeida JD, Chisholm GD, Kulatilake AE et al. Possible airborne spread of serum hepatitis virus within a haemodialysis unit. Lancet 1971;2;849-50. Kew MC. Possible transmission of serum hepatitis by conjunctiva. Infect Immun 1973;7:823-4. Gioannini P, Sinicco A, Cariti G, Lucchini A, Paggi G, Giachino 0. HIV infection acquired by a nurse. Eur J Epidemniol 1988;4: 119-20. Niedecken H, Lutz G, Bauer R, Kreysel HW. Langerhans' cell as primary target and vehicle for transmission of HIV. Lancet 1987;2:519-20. Braathen LR, Ramirez G, Kunze RO, Gelderblom H. Langerhans' cells as primary target cells for HIV infection. Lancet 1987;2:1094. Thal B, Johns ME. Drug/device capsules. Protective face shield attaches to head mirror. Otolaryngol Head Neck Surg 1990;103: 131-2.
Received 25 April 1991
Assessor's comment In otolaryngology, and presumably in other specialties, there has been a somewhat irritating burgeoning of questionnaires as the basis of publications. Many of these are so imprecise that the final value of the publication must be close to zero. Apart from the question about intra-oral examination, which seems to have been misinterpreted by many, this one was satisfactory so that the responses can be considered to be meaningful. Prevention of HIV infection has become an important issue in the practice of medicine and surgery. We all hear warnings of the risks and the methods of reducing or eliminating them. Sometimes we heed these warnings and sometimes we scoff at them. However, by and large we are influenced by those around us, and our tendency to take precautions tends to be similar to those with whom we work. But too often we do not know what is happening in other departments. This paper tries to fill that gap in our knowledge and many of us will be surprised at the findings. Personally, I find it amazing that anyone would deal with an acute
epistaxis in a high-risk patient without wearing gloves, and yet 9% of those who replied do not take this precaution, and even fewer use a mask or eye protection. Perhaps one of the most significant things about this paper is that it will, in the future, provide a reference point of practice in 1990. Future generations may well be surprised at our naivity and carelessness. We do not know what developments to expect, but we know now that many of us seem to be less than careful in the way in which we expose ourselves to potentially infected body fluids. If surgeons, for whatever reason, fail to take precautions in the presence of potential infection, should we be surprised that others, purely for pleasure, take similar risks! ALAN G KERR MB FRCS Consultant Otolaryngologist Royal Victoria Infirmary Belfast
Prevention of occupational transmission of HIV in the ENT clinic Julian M Rowe-Jones
MB BS
Senior House Officer
Michael B Pringle
FRCS
Registrar
Royal National Throat, Nose and Ear Hospital, London Key words: Human immunodeficiency virus; Occupational transmission; Otolaryngology
Much attention has been focused on the risks of inoculation with the human immune deficiency virus in the operating theatre. However, less emphasis has been placed on infection resulting from outpatient exposure to this pathogen. A survey of current protective measures undertaken by ENT consultants in the outpatient clinic in the United Kingdom is presented. The precautions employed by the majority of these subjects are inadequate and non-universal. A review of the risk factors and subsequent safety recommendations is detailed.
The acquired immune deficiency syndrome (AIDS) was first recognised in 1981. Since then 26 health care workers have been infected with the human immunodeficiency virus (HIV) after probable occupational transmission (1). Collated data from prospective studies has demonstrated a low risk of infection from a single needlestick injury of 0.36% (1). However, the consequences are devastating. Current estimates are that within 10 years 50% of infected persons will develop AIDS. This has an almost 100% mortality after 3 years. Specific guidelines on protection for surgeons in the operating theatre and for dentists have been produced (2-4). The otolaryngologist faces similar risks of nosocomial infection in the outpatient clinic to the latter group, but this situation has received less attention.
Materials and methods A questionnaire was sent to all United Kingdom ENT Consultants listed in The Directory of Operating
Correspondence
to: Dr J M Rowe-Jones, Registrar to Department of Otolaryngology, St George's Hospital, Blackshaw Road, London SW17 OQT
Theatres and Departments of Surgery for 1989 (5). Details were collected of precautions taken to prevent nosocomial infection with HIV in the outpatient clinic during certain procedures. These were aural toilet, anterior rhinoscopy, intra-oral examination, indirect laryngopharyngoscopy, flexible nasendoscopy and the management of acute epistaxis. Surgeons were asked about the use of gloves, eye protection and masks and as to whether these measures were undertaken always, for high-risk cases only, or never. When eye protection was evident we asked if this was by prescription spectacles, plain lenses, plain lenses with side-shields or any other forms, which the respondent was asked to describe.
Results A total of 482 questionnaires were sent out, and 314 were returned, of which five were discarded because the recipient had retired or, as in one case, was undecided on his own policy without compulsory AIDS testing of patients. Of the responses, 12 arrived too late, leaving 297 for analysis. The use of face masks is shown in Table I. Approximately two-thirds (mean = 64%) of surgeons used such protection for high-risk patients, the remainder predominantly never wearing a mask. More surgeons wore gloves for protection than any other measures, as illustrated in Table II. Again, however, their use was predominantly for high-risk patients only. Management of epistaxis attracted the greatest degree of protection: 91% of respondents used gloves for some patients in this situation and 40% of these always did so. Intra-oral examination also attracted an high prevalence for glove use of 88%, with similarly 40% of these always wearing them.
6
J M Rowe-Jones and M B Pringle
Table I. Use of face masks during outpatient procedures (n = 297) Aural toilet
Always High-risk only Never
Anterior
Acute
Intra-oral
Indirect
rhiniscopy
examination
laryngoscopy
Nasendoscopy
epistaxis
n
%
n
%
n
%
n
%
n
%
n
%
6 177 114
2 60 38
6 188 103
2 63 35
8 192 97
3 65 32
11 203 83
4 68 28
12 186 99
4 63 33
23 193 81
8 65 27
Table II. Use of gloves during outpatient procedures (n = 297) Aural toilet
Always High-risk only Never
Anterior rhinoscopy
Intra-oral examination
Indirect laryngoscopy
Acute epistaxis
Nasendoscopy
n
%
n
%
n
%
n
%
n
%
n
%
6 233 58
2 78 20
3 222 72
1 75 24
108 153 36
36 52 12
8 235 54
3 79 18
33 212 52
11 71 15
115 154 28
39 52 9
Table III. Use of eye protection during outpatient procedures (n = 171) (surgeons always wearing prescription spectacles for visual disorders have been excluded (n = 126)) Anterior rhinoscopy
Aural toilet
Always High-risk only Never
Intra-oral examination
n
%
n
%
n
%
2 88 81
1 52 47
2 88 81
1 52 47
2 90 79
1
53 46
Table IV. Types of eye protection worn Prescription spectacles Plain lenses Lenses with side-shields Protection worn-type not indicated Visor Goggles Voroscope
126 26 38 40 3 1 1
Prescription spectacles were worn by 126 surgeons, and none of these made additional efforts to protect their eyes. Of the remaining 171 subjects, more never used eye protection (mean =45%) as a precautionary measure, than never used face masks or gloves. The distribution of use is shown in Table III. The types of eye protection employed are listed in Table IV.
Discussion While routinely examining and investigating patients in clinic, the ENT surgeon may potentially come into
Indirect laryngoscopy
Acute epistaxis
Nasendoscopy
%
n
%
n
%
2
1
95
56 43
3 89 79
2 52 46
10 99 62
58 36
n
74
6
contact with a wide range of body fluids. These may also be contaminated by blood. Subjects seen may include asymptomatic carriers of HIV or demonstrate one of the many head and neck manifestations of infection with this virus (6).
Ears HIV and its antibody have been isolated from middle ear effusions and the antibody also from cerumen (7); no cases of transmission have been reported, however. Aural toilet may produce bleeding and thus handling of instruments such as sucker tips or sharp probes presents a risk of inoculation.
Nose No virus has as yet been identified in nasal mucus. Lymphocytes and monocytes, though, may be infected (8) and carry HIV in secretions of rhinosinusitis. The virus has been cultured from tears (9) and cerebrospinal fluid (CSF) (10). In both cases the patients had developed AIDS. Theoretically, therefore, the nasal cavities may be secondarily contaminated by drainage via the lacrimal
Transmission of HIV in the ENT clinic
ducts into the inferior meati, or by CSF rhinorrhoea presenting as rhinitis (11). Management of acute epistaxis presents the greatest risk of contamination with infected blood. Contact may be not only directly onto the hands but also from aerosolisation as the patient coughs and sneezes blood. This presents the skin of the face, mucous membranes of the lips, mouth and nose, the respiratory tract and the conjunctiva as potential portals of entry for infection with HIV.
Oral cavity HIV has been isolated from the saliva of healthy seropositive subjects, those with AIDS-related complex and those with AIDS (12). Saliva may also be contaminated with blood in patients with oral pathology. However saliva alone, like tears, has low numbers of virus particles and no epidemiological data have shown an association between exposure to these fluids and infection with HIV
(13). Larynx and pharynx Indirect examination again poses risk of exposure to infected saliva, exacerbated by patients gagging and coughing. In the latter situation the clinician may also be exposed to bronchial secretions. HIV has been cultured from bronchoalveolar lavage fluid (14). These patients all had AIDS and respiratory disease. Direct examination with a nasendoscope also provides a route for transferring virus in secretions. Pharyngeal and laryngeal mucosa may be damaged and result in contamination of the instrument with infected blood and tissue with further risk to the operator.
Precautions Studies have suggested that dentists are a high-risk group for acquisition of infection from the hepatitis B virus (15). Similar routes of transmission exist for HIV. As a result, recommendations of protection for health care workers have included specific guidelines for this group (2-4). A survey in North America in 1987 (16) revealed that 98% of dentists used gloves, 96% protective eyewear, and 90% masks. Another the following year found that over 75% always used gloves and/or eyewear (17). Otolaryngologists face similar risks. Our survey has revealed that for examining patients, in some instances 83% used gloves, 65% masks and only 54% eye protection. The comparison is even less favourable for use with all patients: 2% for eyewear, 15% for gloves and 4% for masks. Cases of seroconversion in health care workers, negative for other risk factors, are caused by percutaneous inoculation and, to a much lesser extent, broken skin and mucous membrane exposure (2,18,19). One example did involve blood being spattered on the face and in the mouth (18). However, although hepatitis B virus may have caused nosocomial infection via the respiratory and
7
conjunctival routes (20,21), only one case of HIV infection via the eye mucous membrane has been reported (22). More worrying are suggestions that infection may occur through intact skin as the Langerhans' target cell, which has receptors for HIV, is actually found within the epidermal and mucosal barriers (23,24). We would like to reiterate the recent recommendations of the Expert Advisory Group on Aids (4). The group advises protection of the skin and mucous membranes of eyes, mouth and nose. Protective measures should be used for all patients with regard to blood and other specific body fluids such as CSF and saliva in dentistry. We feel saliva in association with otolaryngology should also be included. The extent of these measures is related to three task categorisations which depend on blood exposure risk. Category 1 concerns probable contact with blood and high-risk fluids when there is also potential for uncontrolled bleeding or spattering. In this situation a full range of protective clothing including headwear, eyewear and masks should be used. We would include management of acute epistaxis in this category. Ideally a protective faceshield including a head mirror (25) should be employed. Category 2 applies to probable contact with high-risk fluids but unlikely spattering. In these circumstances gloves should be worn and masks and protective eyewear should be available. The third category arises when the probability of contact is low. In such cases gloves should be available. Otolaryngologists should alter their present practices as observed in our survey. Gloves should be worn in all cases when there is a high probability of contact with blood or saliva. Similarly, when there is a risk of spattering of these fluids, such as during acute epistaxis or examinations provoking coughing and gagging, the skin and mucous membranes of the face should also be protected. We would like to thank Mr C M Bailey for his help and advice in the preparation of this paper.
References I Henderson DK. HIV-1 in the health care care setting. In: Mandell GF, Douglas RG Jr, Benett JE, eds. Principles and Practice of Infectious Diseases. New York: Churchill Livingstone, 1989:2221-36. 2 Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(Suppl. No. 2S): 3-18. 3 Department of Health and Social Security. Guidance for surgeons, anaesthetists, dentists, and their teams in dealing with patients infected with HTLV III. Acquired immune deficiency syndrome. Booklet 3, 1986. 4 Department of Health. Recommendations of the Expert Advisory Group on AIDS. Guidance for clinical health care workers: Protection against infection with HIV and Hepatitis
Viruses. London: Her Majesty's Stationery Office, January 1990.
8
J M Rowe-Jones and M B Pringle
S The Directory of Operating Theatres and Departments of Surgery. CMA Medical Data Ltd, Cambridge, 1989. 6 Weng BM, Kuruvilla A, Goldrich MS, Heffner DK, Tuur S. Pathologic manifestations of acquired immunodeficiency syndrome in the head and neck. Ear Nose Throat J 1990;69:406-15. 7 Sooy C, Gerberding JL, Kaplan MJ. The risk for otolaryngologists who treat patients with AIDS and AIDS virus infection: Report of an in-process study. Laryngoscope 1987;97:430-4. 8 Levy JA. The transmission of AIDS: the case of the infected cell. JAMA 1988;259: 3037-8. 9 Fujikawa LS, Salahuddin SZ, Palestine AG, Masur H, Nussenblatt RB, Galo RC. Isolation of human T-lymphotropic virus type III from the tears of a patient with acquired immunodeficiency syndrome. Lancet 1985; 2:529-30. 10 Ho DD, Rota TR, Schooley RT. Isolation of HTLV-III from cerebrospinal fluid and neural tissue of patients with neurologic syndrome related to the acquired immunodeficiency syndrome. N Engl Jf Med 1985;313:1493-7. 11 Brockbank MJ, Veitch DY, Thomson HG. Cerebrospinal fluid in the rhinitis clinic. J Laryngol Otol 1989;103:281-3. 12 Groopman JE, Salahuddin SZ, Sarngadharan MG et al. HTLV III in saliva of people with AIDS related complex and healthy homosexual men at risk for AIDS. Science 1984;226:447-8. 13 Levy JA. Human immunodeficiency viruses and the pathogenesis of AIDS. JAMA 1989;261:2997-3006. 14 Dean NC, Golden JA, Evans LA et al. Human Immunodeficiency Virus recovery from bronchoalveolar lavage fluid in patients with AIDS. Chest 1988;93: 1176-9. 15 Mosley JW, Edwards VM, Casey G, Redeker AG, White E.
16 17 18 19
20 21
22
23 24
25
Hepatitis B virus infection in dentists. N Engl J Med 1975;293: 729-34. Academy of General Dentistry (AGD). AGD 1987 membership survey results, members express satisfaction with AGD's services. AGD Impact 1988;16:21. Neidle EA. AIDS-related changes in dental practice. J Dent Educ 1989;53:525-8. Centers for Disease Control. Update: Human immunodeficiency virus infections in health-care workers exposed to blood of infected patients. MMWR 1987;36(19):285-9. Sim AJW. HIV as an occupational hazard to surgeons. A UK perspective. In: Sim AJW, Jeffries DJ, eds. AIDS and Surgery. Oxford: Blackwell Scientific Publications, 1990: 49-51. Almeida JD, Chisholm GD, Kulatilake AE et al. Possible airborne spread of serum hepatitis virus within a haemodialysis unit. Lancet 1971;2;849-50. Kew MC. Possible transmission of serum hepatitis by conjunctiva. Infect Immun 1973;7:823-4. Gioannini P, Sinicco A, Cariti G, Lucchini A, Paggi G, Giachino 0. HIV infection acquired by a nurse. Eur J Epidemniol 1988;4: 119-20. Niedecken H, Lutz G, Bauer R, Kreysel HW. Langerhans' cell as primary target and vehicle for transmission of HIV. Lancet 1987;2:519-20. Braathen LR, Ramirez G, Kunze RO, Gelderblom H. Langerhans' cells as primary target cells for HIV infection. Lancet 1987;2:1094. Thal B, Johns ME. Drug/device capsules. Protective face shield attaches to head mirror. Otolaryngol Head Neck Surg 1990;103: 131-2.
Received 25 April 1991
Assessor's comment In otolaryngology, and presumably in other specialties, there has been a somewhat irritating burgeoning of questionnaires as the basis of publications. Many of these are so imprecise that the final value of the publication must be close to zero. Apart from the question about intra-oral examination, which seems to have been misinterpreted by many, this one was satisfactory so that the responses can be considered to be meaningful. Prevention of HIV infection has become an important issue in the practice of medicine and surgery. We all hear warnings of the risks and the methods of reducing or eliminating them. Sometimes we heed these warnings and sometimes we scoff at them. However, by and large we are influenced by those around us, and our tendency to take precautions tends to be similar to those with whom we work. But too often we do not know what is happening in other departments. This paper tries to fill that gap in our knowledge and many of us will be surprised at the findings. Personally, I find it amazing that anyone would deal with an acute
epistaxis in a high-risk patient without wearing gloves, and yet 9% of those who replied do not take this precaution, and even fewer use a mask or eye protection. Perhaps one of the most significant things about this paper is that it will, in the future, provide a reference point of practice in 1990. Future generations may well be surprised at our naivity and carelessness. We do not know what developments to expect, but we know now that many of us seem to be less than careful in the way in which we expose ourselves to potentially infected body fluids. If surgeons, for whatever reason, fail to take precautions in the presence of potential infection, should we be surprised that others, purely for pleasure, take similar risks! ALAN G KERR MB FRCS Consultant Otolaryngologist Royal Victoria Infirmary Belfast
