There are additional factors making it unlikely that every specimen and test receives the same attention, as required by universal precautions: the pressure to produce rapid test results for very sick patients (particularly in emergency situations), sensitivity to clinical needs, the demands from clinicians and relatives to get autopsy information quickly and the understandable desire that funeral arrangements not be delayed. All these situations require professional judgement. Precautions, if they are to be applied, should facilitate rather than hinder. There is a need for a detailed review of hospital activities to establish what aspects of universal precautions are not being followed and why. If any activities are shown to be impractical in the application of these precautions, consideration must be given as to what should be done. I thank Valerie Dalgetty for her help in the preparation of this letter and Dr. Ingrid Luchsinger for her challenging questions and for her criticisms. Matthew J. McQueen, MB, ChB, PhD, FCACB, FRCPC Chief Department of Laboratory Medicine Hamilton General Division Hamilton Civic Hospitals Hamilton, Ont.
References 1. Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MMWR 1988; 37: 377387 2. National Committee for Clinical Laboratory Standards: Protection of Laboratory Workers from Instrument Biohazards: Proposed Guideline (publ I 17-P), NCCLS, Villanova, Pa, 1991 3. Idem: Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Tentative Guideline (publ M29-T2), NCCLS, Villanova, Pa, 1991 4. McQueen MJ: Conflicting rights of patients and health care workers exposed to blood-borne infection. Can Med Assoc J 1992; 147: 299-302 1116
CAN MED ASSOC J 1992; 147 (8)
Universal precautions not justified
Numerous policies and procedures are being subjected to an analysis of cost-effectivene-s. According to a 1990 study by Stock, I disagree with the conclusion Gafni and Bloch4 the economic of Dr. Marie Louie and asso- validity of universal precautions ciates in "Prevalence of is questionable, and there is minibloodborne infective agents mal documentation of their effecamong people admitted to a Can- tiveness. Therefore, the assumpadian hospital" (Can Med Assoc J tion made by Louie and associates 1992; 146: 1331-1334) that the perpetuates but does not substanuse of universal precautions is tiate the perception that universal justified by prevalence rates of precautions are justified. 2.1% for hepatitis B surface antigen and 0.6% and 0.5% for anti- John Hardie, BDS, FRCDC, FICDC bodies to the human immunodefi- Head of Dentistry ciency virus (HIV) and the hepati- Department British Columbia's Health Sciences Centre tis C virus (HCV) respectively. Vancouver, BC Such an inference would be possible if the use of universal precau- References tions were the only reason for infective agents not being trans- 1. National Surveillance of Occupational Exposure to the Human Immunodefimitted to health care workers. The ciencv Virus, Federal Centre for AIDS, investigation failed to show this. Ottawa, 1992 The surveillance study' of the 2. Kiyosawa K, Sodeyama T, Tanaka E et al: Hepatitis C in hospital employees Federal Centre for AIDS demonwith needlestick injuries. Ann Intern strated that health care workers Med 1991; 115: 367-369 were exposed to HIV-infected 3. Universal precautions for prevention of transmission of human immunodefiblood no matter what form of ciency virus, hepatitis B virus, and protection was worn but that such other bloodborne pathogens in healthexposure did not result in serocare settings. MMWR 1988; 37: 377conversion. This should not be 388 surprising, since HIV transmis- 4. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transsion does not occur through the mission to health care workers: an ecoroutes protected by barrier technomic analysis. Can Med Assoc J 1990; niques. These findings weaken 142: 937-946 rather than support the use of universal precautions to avoid the occupational spread of HIV. Inexperience with HCV explains the uncertainty regarding Program evaluation its transmission to health care in health care workers. However, gloves would not have protected the 1 10 workhis article by the Health ers mentioned by Louie and assServices Research Group ociates from exposure through (Can Med Assoc J 1992; needlestick injuries.2 146: 1301-1304) describes the Finally, the authors fail to field as it was about 25 years ago. indicate that the most effective Program evaluation continues method of avoiding occupational to be viewed by some of its practitransmission of the hepatitis B tioners as a method of systemativirus is vaccination. The Centers cally collecting and analysing data for Disease Control, Atlanta, do about a specific program in order not include this among their uni- to summarize or improve its overversal precautions3 but consider it all performance. Over the past few to be an important adjunct to decades, however, this insular persuch preventive techniques. spective on the purposes of evaluLE
15 OCTOBRE 1992
References 1. Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MMWR 1988; 37: 377387 2. National Committee for Clinical Laboratory Standards: Protection of Laboratory Workers from Instrument Biohazards: Proposed Guideline (publ I 17-P), NCCLS, Villanova, Pa, 1991 3. Idem: Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Tentative Guideline (publ M29-T2), NCCLS, Villanova, Pa, 1991 4. McQueen MJ: Conflicting rights of patients and health care workers exposed to blood-borne infection. Can Med Assoc J 1992; 147: 299-302 1116
CAN MED ASSOC J 1992; 147 (8)
Universal precautions not justified
Numerous policies and procedures are being subjected to an analysis of cost-effectivene-s. According to a 1990 study by Stock, I disagree with the conclusion Gafni and Bloch4 the economic of Dr. Marie Louie and asso- validity of universal precautions ciates in "Prevalence of is questionable, and there is minibloodborne infective agents mal documentation of their effecamong people admitted to a Can- tiveness. Therefore, the assumpadian hospital" (Can Med Assoc J tion made by Louie and associates 1992; 146: 1331-1334) that the perpetuates but does not substanuse of universal precautions is tiate the perception that universal justified by prevalence rates of precautions are justified. 2.1% for hepatitis B surface antigen and 0.6% and 0.5% for anti- John Hardie, BDS, FRCDC, FICDC bodies to the human immunodefi- Head of Dentistry ciency virus (HIV) and the hepati- Department British Columbia's Health Sciences Centre tis C virus (HCV) respectively. Vancouver, BC Such an inference would be possible if the use of universal precau- References tions were the only reason for infective agents not being trans- 1. National Surveillance of Occupational Exposure to the Human Immunodefimitted to health care workers. The ciencv Virus, Federal Centre for AIDS, investigation failed to show this. Ottawa, 1992 The surveillance study' of the 2. Kiyosawa K, Sodeyama T, Tanaka E et al: Hepatitis C in hospital employees Federal Centre for AIDS demonwith needlestick injuries. Ann Intern strated that health care workers Med 1991; 115: 367-369 were exposed to HIV-infected 3. Universal precautions for prevention of transmission of human immunodefiblood no matter what form of ciency virus, hepatitis B virus, and protection was worn but that such other bloodborne pathogens in healthexposure did not result in serocare settings. MMWR 1988; 37: 377conversion. This should not be 388 surprising, since HIV transmis- 4. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transsion does not occur through the mission to health care workers: an ecoroutes protected by barrier technomic analysis. Can Med Assoc J 1990; niques. These findings weaken 142: 937-946 rather than support the use of universal precautions to avoid the occupational spread of HIV. Inexperience with HCV explains the uncertainty regarding Program evaluation its transmission to health care in health care workers. However, gloves would not have protected the 1 10 workhis article by the Health ers mentioned by Louie and assServices Research Group ociates from exposure through (Can Med Assoc J 1992; needlestick injuries.2 146: 1301-1304) describes the Finally, the authors fail to field as it was about 25 years ago. indicate that the most effective Program evaluation continues method of avoiding occupational to be viewed by some of its practitransmission of the hepatitis B tioners as a method of systemativirus is vaccination. The Centers cally collecting and analysing data for Disease Control, Atlanta, do about a specific program in order not include this among their uni- to summarize or improve its overversal precautions3 but consider it all performance. Over the past few to be an important adjunct to decades, however, this insular persuch preventive techniques. spective on the purposes of evaluLE
15 OCTOBRE 1992
