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Percutaneous Injuries Among Health Care Workers: The Real Value of Human Immunodeficiency Virus Testing of 'Donor' Blood

Percutaneous Injuries Among Health Care Workers: The Real Value of Human Immunodeficiency Virus... Abstract A decision analysis was conducted to examine whether health care workers should receive short-term (42 days) zidovudine treatment following percutaneous exposure to blood, as well as to determine the value of testing "donor" (patient's) blood. Three alternative options were analyzed: treat all, treat none, and test. In the treat all option, all health care workers receive short-term zidovudine therapy immediately after exposure; in the treat none option, no one receives zidovudine; and in the test option, donor blood is tested, and if it is human immunodeficiency virus (HIV) positive, zidovudine is given. Baseline variables were obtained from the literature. Each outcome was expressed as a utility; this is a method of quantifying the values that persons place on different health states. The results showed that the test option was preferred. Sensitivity analyses indicated that even if the risk of seroconversion were zero or the effectiveness of zidovudine were zero or the drug were withheld, this option was preferred, thus indicating some value of testing other than merely identifying health care workers who should receive zidovudine. In the baseline analysis, this was derived from the fact that approximately 95% of the health care workers would be reassured by a negative test; ie, only approximately 5% of donors are HIV positive. If the prevalence of HIV seropositivity exceeded 42%, the treat none option was preferred. This was found to be due to the fact that increased numbers of health care workers would be told that they were exposed to HIV-positive blood. The "worrying factor" associated with such an exposure was such that above 42% HIV seropositivity, the treat none option was preferred overall. Thus, the real value of testing donor blood is in identifying those persons (>95%) who could be told that they were exposed to HIV-negative blood, that is, reducing their worrying factor to zero. Because acquired immunodeficiency syndrome is a fatal disease, and given that zidovudine is the only available therapeutic option at present, the drug has an important role to play if its effectiveness is greater than zero. (Arch Intern Med. 1991;151:2033-2040) References 1. Henderson DK. HIV-1 in the health care setting . In: Mandell GF, Douglas RG Jr, Bennett JE, eds. Principles and Practice of Infectious Diseases. 3rd ed. New York, NY: John Wiley & Sons Inc; 1989:2221-2236. 2. Henderson DK, Fahey BJ, Willy M, et al. Risk of occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures: a prospective evaluation . Ann Intern Med. 1990;113:740-746.Crossref 3. Centers for Disease Control. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings . MMWR. 1988;37:377-388. 4. Hayward RA, Shapiro MF. A national study of AIDS and residency training: experiences, concerns, and consequences . Ann Intern Med. 1991;114:23-32.Crossref 5. Centers for Disease Control. Public health service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine post-exposure use . MMWR. 1990;39:1-14. 6. Furman PA, St Clair M, Weinhold K, et al. Selective inhibition of HTLV-111 by BW A509U . In: Program and abstracts of the 25th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1985; Minneapolis, Minn. Abstract 440. 7. St Clair MH, Weinhold K, Richards CA, et al. Characterization of HTLV-111 reverse transcriptase and inhibition by the triphosphate of BW A509U . In: Program and abstracts of the 25th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1985; Minneapolis, Minn. Abstract. 8. Mitsuya H, Weinhold KJ, Furman PA, et al. 3′-azido-3′-deoxythymidine (BW A509U): an antiviral agent that inhibits the infectivity and cytopathic effect of human T-lymphotrophic virus type 111/lymphadenopathy-associated virus in vitro . Proc Natl Acad Sci U S A. 1985;82:7096-7100.Crossref 9. Ruprecht RM, O'Brien LG, Rossoni LD, Nusinoff-Lehrman S. Suppression of mouse viraemia and retroviral disease by 3′-azido-3′deoxythymidine . Nature. 1986;323:467-469.Crossref 10. Tavares L, Roneker C, Johnston K, Nusinoff-Lehrman SN, de Noronha F. 3′Azido-3′deoxythymidine in feline leukemia virus-infected cats: a model for therapy and prophylaxis of AIDS . Cancer Res. 1987;47:3190-3194. 11. Shih CC, Kaneshima H, Rabin L, et al. Post-exposure prophylaxis with zidovudine suppresses human immunodeficiency virus type 1 infection in SCID-hu mice in a timedependent manner . J Infect Dis. 1991;163:625-627.Crossref 12. Imagawa DT, Moon HL, Wolinsky SM, et al. Human immunodeficiency virus type-1 infection in homosexual men who remain seronegative for prolonged periods . N Engl J Med. 1989;320:1458-1462.Crossref 13. Jackson JB, Balfour HH. Practical diagnostic testing for human immunodeficiency virus . Clin Microbiol Rev. 1988;1:124-138. 14. Centers for Disease Control. Update: serologic testing for antibody to human immunodeficiency virus . MMWR. 1988;36:833-845. 15. Richman DD, Fischl MA, Grieco MH, et al. The toxicity of azidothymidine in the treatment of patients with AIDS and AIDS-related complex . N Engl Med. 1987;317:192-197.Crossref 16. Pizzo PA, Eddy J, Falloon J, et al. Effect of continuous intravenous infusion of zidovudine (AZT) in children with symptomatic HIV infection . N Engl J Med. 1988;319:889-896.Crossref 17. Creagh-Kirk T, Doi P, Andrews E, et al. Survival experience among patients with AIDS receiving zidovudine: follow-up of patients in a compassionate plea program . JAMA. 1988;260:3009-3015.Crossref 18. Dournon E, Rozenbaum W, Michon C, et al. Effects of zidovudine in 365 consecutive patients with AIDS or AIDS-related complex . Lancet. 1988;1:1297-1302.Crossref 19. Richman DD, Andrews J, AZT Collaborative Working Group. Results of continued monitoring of participants in the placebo-controlled trial of zidovudine for serious human immunodeficiency virus Infection . Am J Med. 1988;85( (suppl) ):208-213. 20. Lane HC, Falloon J, Walker RE, et al. Zidovudine in patients with human immunodeficiency virus (HIV) infection and Kaposi sarcoma: a phase 11 randomized, placebocontrolled trial . Ann Intern Med. 1989;111:41-50.Crossref 21. Kelen GD, Fritz S, Qaqish B, et al. Unrecognized human immunodeficiency virus infection in emergency department patients . N Engl J Med. 1988;318:1645-1650.Crossref 22. Landesman S, Minkoff H, Holman S, McCalla S, Sijin O. Serosurvey of human immunodeficiency virus infection in parturients: implications for human immunodeficiency virus testing programs of pregnant women . JAMA. 1987;258:2701-2703.Crossref 23. Eyster ME, Gail MH, Ballard JO, Al-Mondhiry H, Goedert JJ. Natural history of human immunodeficiency virus infections in hemophiliacs: effects of T-cell subsets, platelet counts, and age . Ann Intern Med. 1987;107:1-6.Crossref 24. Gordin FM, Gibert C, Hawley HP, Willoughby A. Prevalence of human immunodeficiency virus and hepatitis B virus in unselected hospital admissions: implications for mandatory testing and universal precautions . J Infect Dis. 1990;161:14-17.Crossref 25. St Louis ME, Raugh KJ, Petersen LR, et al. Seroprevalence rates of human immunodeficiency virus infection at sentinel hospitals in the United States . N Engl J Med. 1990;323:213-218.Crossref 26. Lafon SW, Mooney BD, McMullen JP, et al. A doubleblind, placebo-controlled study of the safety and efficacy of Retrovir (zidovudine) as a chemoprophylaxis agent in health care workers . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy ; (October) 1990; Atlanta, Ga. Abstract 489. 27. Tokars JI, Marcus RA, Culver DH, McKibbern PS, Bell DM, Needlestick Surveillance Group. Zidovudine (AZT) use after occupational exposure to HIV-infected blood . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1990; Atlanta, Ga. Abstract 490. 28. Fahey BJ, Beekmann SE, Schmitt J, Fedio J, Henderson DK. Assessment of risk for occupational HIV-1 infection in health care workers (HCW) and safety of zidovudine (AZT) administered as post-exposure chemoprophylaxis for occupational exposures . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1990; Atlanta, Ga. Abstract 460. 29. Gerberding JL, Wugofski L, Berkvan G, et al. Facilitated surveillance and post-exposure AZT prophylaxis for health care workers: The San Francisco General Hospital model . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1990; Atlanta, Ga. Abstract 961. 30. Fischl MA, Richman DD, Grieco MH, et al. The efficacy of 3′-azido3′deoxythymidine (azidothymidine) in the treatment of patients with AIDS and AIDS-related complex: a doubleblind placebo-controlled trial . N Engl J Med. 1987;317:185-191.Crossref 31. Burke DS, Brandt BL, Redfield RR, et al. Diagnosis of human immunodeficiency virus infection by immunoassay using a molecularly cloned and expressed virus envelope polypeptide . Ann Intern Med. 1977;106:671-676.Crossref 32. von Neumann J, Morganstern O. Theory of Games and Economic Behavior . 3rd ed. New York, NY: John Wiley & Sons Inc; 1953. 33. Holloway CA. Decision Making Under Uncertainty: Models and Choices . Englewood Cliffs, NJ: Prentice-Hall International Inc; 1979. 34. Torrance GW. Utility approach to measuring healthrelated quality of life . J Chronic Dis. 1987;40:593-600.Crossref 35. Wong N. Classical psychoanalysis . In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry . 5th ed. Baltimore, Md: Williams & Wilkins; 1989:375. 36. Harmony BH. Underreporting of needlestick injuries in a university hospital . Am J Infect Control. 1983;11:174-177.Crossref 37. Lange JMA, Boucher CAB, Hollak CEM, et al. Failure of zidovudine prophylaxis after accidental exposure to HIV-1 . N Engl J Med. 1990;322:1375-1377.Crossref 38. Looke DFM, Grove DI. Failed prophylaxis zidovudine after needlestick injury . Lancet. 1990;335:1280.Crossref 39. Sacks HS, Rose DN. Zidovudine prophylaxis for needlestick exposure to human immunodeficiency virus . J Gen Intern Med. 1990;5:132-137.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Percutaneous Injuries Among Health Care Workers: The Real Value of Human Immunodeficiency Virus Testing of 'Donor' Blood

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American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1991.00400100107018
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Abstract

Abstract A decision analysis was conducted to examine whether health care workers should receive short-term (42 days) zidovudine treatment following percutaneous exposure to blood, as well as to determine the value of testing "donor" (patient's) blood. Three alternative options were analyzed: treat all, treat none, and test. In the treat all option, all health care workers receive short-term zidovudine therapy immediately after exposure; in the treat none option, no one receives zidovudine; and in the test option, donor blood is tested, and if it is human immunodeficiency virus (HIV) positive, zidovudine is given. Baseline variables were obtained from the literature. Each outcome was expressed as a utility; this is a method of quantifying the values that persons place on different health states. The results showed that the test option was preferred. Sensitivity analyses indicated that even if the risk of seroconversion were zero or the effectiveness of zidovudine were zero or the drug were withheld, this option was preferred, thus indicating some value of testing other than merely identifying health care workers who should receive zidovudine. In the baseline analysis, this was derived from the fact that approximately 95% of the health care workers would be reassured by a negative test; ie, only approximately 5% of donors are HIV positive. If the prevalence of HIV seropositivity exceeded 42%, the treat none option was preferred. This was found to be due to the fact that increased numbers of health care workers would be told that they were exposed to HIV-positive blood. The "worrying factor" associated with such an exposure was such that above 42% HIV seropositivity, the treat none option was preferred overall. Thus, the real value of testing donor blood is in identifying those persons (>95%) who could be told that they were exposed to HIV-negative blood, that is, reducing their worrying factor to zero. Because acquired immunodeficiency syndrome is a fatal disease, and given that zidovudine is the only available therapeutic option at present, the drug has an important role to play if its effectiveness is greater than zero. (Arch Intern Med. 1991;151:2033-2040) References 1. Henderson DK. HIV-1 in the health care setting . In: Mandell GF, Douglas RG Jr, Bennett JE, eds. Principles and Practice of Infectious Diseases. 3rd ed. New York, NY: John Wiley & Sons Inc; 1989:2221-2236. 2. Henderson DK, Fahey BJ, Willy M, et al. Risk of occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures: a prospective evaluation . Ann Intern Med. 1990;113:740-746.Crossref 3. Centers for Disease Control. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings . MMWR. 1988;37:377-388. 4. Hayward RA, Shapiro MF. A national study of AIDS and residency training: experiences, concerns, and consequences . Ann Intern Med. 1991;114:23-32.Crossref 5. Centers for Disease Control. Public health service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine post-exposure use . MMWR. 1990;39:1-14. 6. Furman PA, St Clair M, Weinhold K, et al. Selective inhibition of HTLV-111 by BW A509U . In: Program and abstracts of the 25th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1985; Minneapolis, Minn. Abstract 440. 7. St Clair MH, Weinhold K, Richards CA, et al. Characterization of HTLV-111 reverse transcriptase and inhibition by the triphosphate of BW A509U . In: Program and abstracts of the 25th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1985; Minneapolis, Minn. Abstract. 8. Mitsuya H, Weinhold KJ, Furman PA, et al. 3′-azido-3′-deoxythymidine (BW A509U): an antiviral agent that inhibits the infectivity and cytopathic effect of human T-lymphotrophic virus type 111/lymphadenopathy-associated virus in vitro . Proc Natl Acad Sci U S A. 1985;82:7096-7100.Crossref 9. Ruprecht RM, O'Brien LG, Rossoni LD, Nusinoff-Lehrman S. Suppression of mouse viraemia and retroviral disease by 3′-azido-3′deoxythymidine . Nature. 1986;323:467-469.Crossref 10. Tavares L, Roneker C, Johnston K, Nusinoff-Lehrman SN, de Noronha F. 3′Azido-3′deoxythymidine in feline leukemia virus-infected cats: a model for therapy and prophylaxis of AIDS . Cancer Res. 1987;47:3190-3194. 11. Shih CC, Kaneshima H, Rabin L, et al. Post-exposure prophylaxis with zidovudine suppresses human immunodeficiency virus type 1 infection in SCID-hu mice in a timedependent manner . J Infect Dis. 1991;163:625-627.Crossref 12. Imagawa DT, Moon HL, Wolinsky SM, et al. Human immunodeficiency virus type-1 infection in homosexual men who remain seronegative for prolonged periods . N Engl J Med. 1989;320:1458-1462.Crossref 13. Jackson JB, Balfour HH. Practical diagnostic testing for human immunodeficiency virus . Clin Microbiol Rev. 1988;1:124-138. 14. Centers for Disease Control. Update: serologic testing for antibody to human immunodeficiency virus . MMWR. 1988;36:833-845. 15. Richman DD, Fischl MA, Grieco MH, et al. The toxicity of azidothymidine in the treatment of patients with AIDS and AIDS-related complex . N Engl Med. 1987;317:192-197.Crossref 16. Pizzo PA, Eddy J, Falloon J, et al. Effect of continuous intravenous infusion of zidovudine (AZT) in children with symptomatic HIV infection . N Engl J Med. 1988;319:889-896.Crossref 17. Creagh-Kirk T, Doi P, Andrews E, et al. Survival experience among patients with AIDS receiving zidovudine: follow-up of patients in a compassionate plea program . JAMA. 1988;260:3009-3015.Crossref 18. Dournon E, Rozenbaum W, Michon C, et al. Effects of zidovudine in 365 consecutive patients with AIDS or AIDS-related complex . Lancet. 1988;1:1297-1302.Crossref 19. Richman DD, Andrews J, AZT Collaborative Working Group. Results of continued monitoring of participants in the placebo-controlled trial of zidovudine for serious human immunodeficiency virus Infection . Am J Med. 1988;85( (suppl) ):208-213. 20. Lane HC, Falloon J, Walker RE, et al. Zidovudine in patients with human immunodeficiency virus (HIV) infection and Kaposi sarcoma: a phase 11 randomized, placebocontrolled trial . Ann Intern Med. 1989;111:41-50.Crossref 21. Kelen GD, Fritz S, Qaqish B, et al. Unrecognized human immunodeficiency virus infection in emergency department patients . N Engl J Med. 1988;318:1645-1650.Crossref 22. Landesman S, Minkoff H, Holman S, McCalla S, Sijin O. Serosurvey of human immunodeficiency virus infection in parturients: implications for human immunodeficiency virus testing programs of pregnant women . JAMA. 1987;258:2701-2703.Crossref 23. Eyster ME, Gail MH, Ballard JO, Al-Mondhiry H, Goedert JJ. Natural history of human immunodeficiency virus infections in hemophiliacs: effects of T-cell subsets, platelet counts, and age . Ann Intern Med. 1987;107:1-6.Crossref 24. Gordin FM, Gibert C, Hawley HP, Willoughby A. Prevalence of human immunodeficiency virus and hepatitis B virus in unselected hospital admissions: implications for mandatory testing and universal precautions . J Infect Dis. 1990;161:14-17.Crossref 25. St Louis ME, Raugh KJ, Petersen LR, et al. Seroprevalence rates of human immunodeficiency virus infection at sentinel hospitals in the United States . N Engl J Med. 1990;323:213-218.Crossref 26. Lafon SW, Mooney BD, McMullen JP, et al. A doubleblind, placebo-controlled study of the safety and efficacy of Retrovir (zidovudine) as a chemoprophylaxis agent in health care workers . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy ; (October) 1990; Atlanta, Ga. Abstract 489. 27. Tokars JI, Marcus RA, Culver DH, McKibbern PS, Bell DM, Needlestick Surveillance Group. Zidovudine (AZT) use after occupational exposure to HIV-infected blood . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1990; Atlanta, Ga. Abstract 490. 28. Fahey BJ, Beekmann SE, Schmitt J, Fedio J, Henderson DK. Assessment of risk for occupational HIV-1 infection in health care workers (HCW) and safety of zidovudine (AZT) administered as post-exposure chemoprophylaxis for occupational exposures . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1990; Atlanta, Ga. Abstract 460. 29. Gerberding JL, Wugofski L, Berkvan G, et al. Facilitated surveillance and post-exposure AZT prophylaxis for health care workers: The San Francisco General Hospital model . In: Program and abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 1990; Atlanta, Ga. Abstract 961. 30. Fischl MA, Richman DD, Grieco MH, et al. The efficacy of 3′-azido3′deoxythymidine (azidothymidine) in the treatment of patients with AIDS and AIDS-related complex: a doubleblind placebo-controlled trial . N Engl J Med. 1987;317:185-191.Crossref 31. Burke DS, Brandt BL, Redfield RR, et al. Diagnosis of human immunodeficiency virus infection by immunoassay using a molecularly cloned and expressed virus envelope polypeptide . Ann Intern Med. 1977;106:671-676.Crossref 32. von Neumann J, Morganstern O. Theory of Games and Economic Behavior . 3rd ed. New York, NY: John Wiley & Sons Inc; 1953. 33. Holloway CA. Decision Making Under Uncertainty: Models and Choices . Englewood Cliffs, NJ: Prentice-Hall International Inc; 1979. 34. Torrance GW. Utility approach to measuring healthrelated quality of life . J Chronic Dis. 1987;40:593-600.Crossref 35. Wong N. Classical psychoanalysis . In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry . 5th ed. Baltimore, Md: Williams & Wilkins; 1989:375. 36. Harmony BH. Underreporting of needlestick injuries in a university hospital . Am J Infect Control. 1983;11:174-177.Crossref 37. Lange JMA, Boucher CAB, Hollak CEM, et al. Failure of zidovudine prophylaxis after accidental exposure to HIV-1 . N Engl J Med. 1990;322:1375-1377.Crossref 38. Looke DFM, Grove DI. Failed prophylaxis zidovudine after needlestick injury . Lancet. 1990;335:1280.Crossref 39. Sacks HS, Rose DN. Zidovudine prophylaxis for needlestick exposure to human immunodeficiency virus . J Gen Intern Med. 1990;5:132-137.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 1, 1991

References