PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC HEALTH CARE WORKER SAFETY The Hearing was held at the Indiana University Executive Conference Center 850 West Michigan Street Indianapolis, Indiana Wednesday, May 11, 1988 COMMISSION MEMBER PRESENT: ADMIRAL JAMES D. WATKINS (RET.), CHAIRMAN COLLEEN CONWAY-WELCH, Ph.D. KRISTINE M. GEBBIE, R.N., M.N. BURTON JAMES LEE, III, M.D. FRANK LILLY, Ph.D. CORY SerVAAS, M.D. JOHN J. CREEDON THERESA L. CRENSHAW, M.D. RICHARD M. DeVOS BENY J. PRIMM, M.D. PENNY PULLEN POLLY L. GAULT, Executive Director COMMISSION MEMBERS NOT PRESENT: JOHN CARDINAL O’ CONNOR WILLIAM B. WALSH, M.D. I-N-D-E-X PAGE WELCOME Polly Gault, Executive Director 339 Richard DeVos, Hearing Chairman 339 PANEL ONE CURRENT STATUS OF THE EXTENT OF RISK OF HIV INFECTION TO THE HEALTH CARE PROVIDERS Dr. Henry Chambers, Medical Service, San 340 Francisco General Hospital, San Francisco, California Dr. David Henderson, Clinical Center Hospital 342 Epidemiology Services, National Institutes of Health, Bethesda, Maryland Dr. William J. Martone, Acting Director, 344 Hospital Infections Program, Centers for Disease Control, Atlanta, Georgia Dr. Thomas Kuhls, Department of Pediatrics, 347 Oklahoma Children's Hospital, Oklahoma City, Oklahoma PANEL TWO CONCERNS OF THE HEALTH CARE PROVIDER Norma Watson, R.N.; Hercules, California 369 Dr. Aurelio Rodriguez, Shock Trauma Unit, 374 University of Maryland, Baltimore, Maryland Dr. Joan Phelan, Department of Oral Medicine 375 and Pathology, New York University, New York, New York Harriett Olson, R.N.; Visiting Nurse Service, 379 Inc., Indianapolis, Indiana Bill Borwegen, M.P.H.; Director, Health and 382 Safety Department, Service Employees International Union, Washington, D.C. Julie Chamberlain, R.N.; Infection Control 385 Coordinator, Butterworth Hospital, Grand Rapids, Michigan I-N-D-E-X (continued) PAGE PANEL THREE POLICY DEVELOPMENT FOR PREVENTION OF TRANSMISSION IN THE HEALTH CARE SETTING Dr. Rober J. Mullan, Workplace AIDS 409 Coordinator, National Institute on Occupational Safety and Health, Centers for Disease Control Atlanta, Georgia Frank Chalmers, Occupational Safety and Health 411 Administration, Department of Labor, Washington, D.C. Patricia Lynch, R.N., M.B.A.; Infection Control 413 Coordinator, Harborview Medicine Center, Seattle, Washington (on behalf of the American Hospital Association) Dr. Harvey Bartnof, AIDS Virus Education and 416 Research Institute, San Francisco, California PANEL FOUR POLICY DEVELOPMENT FOR HEALTH CARE PROVIDERS WHO HAVE BECOME INFECTED John C. Petricciani, M.D., Deputy Director 440 National AIDS Program Office, Public Health Service, Washington, D.C. Dr. Agnes D. Lattimer, Medical Director 442 Cook County Hospital, Chicago Illinois Michelle Parker, R.N.; Chicago, Illinois, (on 444 behalf of the American Nurses Association), Chicago, Illinois Dr. Harvey Elder, Chief 447 Infectious Disease Section Jerry L. Lettis Memorial Veterans Hospital Loma Linda, California Dr. Phillip Pierce, Director, 449 AIDS Clinic Georgetown University Hospital Washington, D.C. APPENDIX - SUBMITTED TESTIMONY P-R-O-C-E-E-D-I-N-G-S 9:00 a.m. MS. GAULT: Good morning, ladies and gentlemen, distinguished witnesses, members of the President’s Commission, my name is Polly Gault. I am the designated federal official here today, and in that capacity it is my privilege to declare this meeting open. Mr. Chairman? MR. DeVOS: Good morning everybody. This is our third and final day here in Indianapolis. We began on Monday morning talking about the ovérall concerns in the workplace, and we reviewed that both from a standpoint of general as well as finally moving down to specific companies, and how they are coping with the HIV epidemic with some of those people from some companies that are doing a very fine job sharing that with us. Today we are narrowing our focus a little to a specific workplace setting, and especially to you young people who may be thinking of nursing careers, or medical careers, we’re going to be working today on workplace challenges in the medical field in hospital settings and so forth. So, we’re sure you will find that of interest. We have invited expert witnesses who represent a variety of health care professions, as well as other related fields, to tell us about their concerns as health care givers, and to share with us the latest research on the extent of risk of the HIV infection in the health care setting. We will also hear from representatives of government, health professional associations and hospital administrations about the policies that are being developed to deal with this important issue. I do have one word to both Commissioners and to our guests today, we are on a tight track today, and so, we would appreciate your help on that. If I find you wandering a little, I’m just going to say, thanks, that’s really good. We’11l take the rest of it up in discussion. That’s not to be unkind to you, it’s just to kind of bear in mind that this Commission has listened to, I think, the Admiral said 600 witnesses -- CHAIRMAN WATKINS: By the end of the time. MR. DeVOS: Yes, and each one wants to give us a little overview on all of the HIV epidemic. And so, sometimes it is not to be unkind to you, it’s just that we’re trying to move you down to the area where you are really working on. And so, we want to thank you all for coming this morning. 339 PANEL 1: CURRENT STATUS OF THE EXTENT OF RISK OF HIV INFECTION TO THE HEALTH CARE PROVIDERS MR. DevOS: Our first panel this morning is on the Current Status of the Extent of Risk of HIV Infection to the Health Care Providers. What’s the likelihood of picking that up if you work in that hospital setting. And having with us such experts as Doctor Henry Chambers, Medical Service, San Francisco General Hospital, from San Francisco, Doctor David Henderson, Clinical Center Hospital, Epidemiology Services, from NIH in Bethesda, Maryland, Doctor William J. Martone, Acting Director, Hospital Infectious Programs, Centers for Disease Control in Atlanta, and Doctor Thomas Kuhls, Department of Pediatrics, from Oklahoma Children’s Hospital, Oklahoma City, Oklahoma is a great pleasure. So, as you can see, young people and others, we have some highly qualified people here this morning. Doctor Chambers, we are going to begin with you for about a five-minute report, and you are going to have plenty of time to dialogue if you highlight what you have to say to us. DR. CHAMBERS: Thank you, Mr. Chairman, distinguished members of the President’s Commission. I’m pleased to be here teday to report the San Francisco General Hospital experience of am ongoing surveillance study of health care workers enrolled at San Francisco General Hospital. The study has been conducted by Doctor Julie Gerberding primarily, and involves over 600 health care workers who have been enrolled at San Francisco General Hospital. These health care workers have been intensively exposed to patients with acquired immunodeficiency syndrome and AIDS~-related-complex. San Francisco General Hospital takes care of over 1,600 AIDS and ARC patients presently. These 600 subjects were enrolled in an ongoing perspective surveillance study to determine the risk of contracting human immunodeficiency virus infection from occupational exposure. Exposure history and established risk factors for HIV are evaluated yearly by a confidential questionnaire, and serum is tested annually for HIV. 468 workers who have reported no non-occupational HIV risk factors have been tested prospectively. Approximately half are physicians, 57 are surgeons; 140 are nurses, about a third; 10 percent or 51 are laboratory technicians. 51 subjects worked solely in AIDS units or AIDS research laboratories, and about a quarter work in intensive care units, the emergency room and in the operating room, areas where blood exposure is especially frequent. Thus far, 212 subjects have reported 625 accidental exposures to HIV-infected blood. There have been 224 needlesticks and: 401 mucocutaneous splashes. 340 If I could have the first slide, please. I would like to draw your attention to the middle line under Doctor Gerberding’s study to show you the results. Thus far, there has been one seroconversion noted in, our subject population, out of 215 needlesticks, giving a frequency of seroconversion per needlestick of .5 percent, or 1 in 200, with an upper confidence limit of 1.4 percent. We have been able to document no seroconversions following mucocutaneous exposure. I have taken the liberty to show some data that are published from CDC and Doctor Henderson’s studies to put in perspective our findings. You can see that the sum of the needlestick exposures is approximately 1,200. There have been five seroconversions noted in those 1,200 patients, to give a frequency of .4 percent, and an upper confidence interval of .8 percent. There have been no seroconversions documented in these prospective studies following mucocutaneous exposure. If I could have the second slide, please. This slide is just to draw your attention to what I feel is the major risk to health care workers in terms of contracting HIV, and, that is, HIV infection as a result of needlestick injury. A typical surgeon, surveying our surgeons at San Francisco General, may have up to five needlesticks a year. Ina 30-year career, he will have well over 100 needlesticks. As you can see from this table plotting seroprevalence versus number of needlesticks, that as, the number of needlesticks rises to ten or 100, and the seroprevalence approaches one to ten percent, the risk of HIV seroconversion over a lifetime becomes substantial. This assumes a rate of seroconversion of .5 percent from each needlestick exposure. These are only estimates, and I caution the pane] from reading too much into this, but I think these estimates dramatize the strong relationship between needlesticks and risk to health care workers. Slide off, please. For intensively exposed health care worker’s, occupational transmission of HIV infection was detected only following needlestick exposure to HIV-infected blood. The risk of other exposures is low, probably less than .1 percent. Infection control procedures to protect health care workers from occupational HIV infection should emphasize prevention of needlesticks. Thank you. MR. DevVOS: Thank you very much for a concise report. MR. Devos: We’re going to go next to Doctor Henderson, from the Clinical Center Hospital at NIH. I’m going to skip that epidemiology stuff. 341 DR. HENDERSON: That’s fine with me. Admiral Watkins, Mr. Chairman, distinguished members of the Presidential Commission. The magnitude of risk for occupational transmission of the Human Immunodeficiency Virus (HIV) has now been measured in a number of longitudinal studies. Prospective evaluation of more than 800 health care workers sustaining an adverse exposure to a sharp object contaminated with blood or blood-contaminated body fluids have demonstrated that the risk for a health care worker becoming infected as a result of such exposures is approximately 0.4 - 0.5 percent (four to five infections per 1,000 injuries). Risks for infection as a result of other exposures (e.g., mucous membrane splashes, or cutaneous exposure, skin exposures to blood) are so small that they currently elude precise measurement. Whereas these latter exposures can (and have clearly been documented to) result in HIV infection, the actual risk for such an event is quite small. More than 600 health care workers who have sustained mucous membrane exposures to blood or blood-contaminated body fluids from HIV-infected patients have been evaluated in four longitudinal studies. These data are somewhat different from those that you heard from San Francisco, because they are qualified, in that all of these individuals are known to have had an injury from someone who is infected, all are known to be not infected at the time the injury occurred, and all have been followed for at least six months, those three qualifiers. None have developed antibody to HIV following these other sorts of exposures, that is, other than needlestick injuries. Additional evidence suggesting a low relative risk for transmission of HIV as a result of providing care for HIV- infected patients in the absence of one of these injuries come from the elegant studies of household contacts of HIV-infected patients. Exposures in this setting are likely to even be more intimate than would occur in the health care setting, and precautions are presumably more lax than for individuals providing direct patient care. To my knowledge, eight such studies of more than 500 household contacts of 260 AIDS patients are in progress. With the exception of sexual partners of infected individuals and children born to infected mothers (known routes for HIV transmission), none of the remaining 540 household contacts have acquired HIV infection. These data provide further evidence that the risk for occupational HIV transmission associated with routine patient care activities is quite small. These magnitudes of risk for occupational HIV infection compare favorably with other risks that health care workers have been taking in the workplace for years. For example, the risk for occupational infection with hepatitis B virus following a percutaneous injury with a needle or sharp object which has been used on a patient known to be infectious for hepatitis B is between 27 and 43 percent, that is, out of 1,000 such injuries we’d have 270 to 430 infections. The risk 342 for the person to develop clinical hepatitis ranges between 6 and 24 percent, so again, between 60 and 240 cases of clinical hepatitis. In fact, the Centers for Disease Control estimates that approximately 12,000 cases of occupationally-acquired hepatitis B occurred in U.S. health care workers in 1985. Although no deaths have yet been reported due to occupationally- acquired HIV infection, the Occupational Safety and Health Administration conservatively estimates that between 167 and 202 American health care workers died of occupationally-acquired hepatitis B infection last year. The reason for citing these data on occupational transmission of hepatitis B is not to suggest that the risk for occupational transmission of HIV is negligible, only to try to place these relative risks in perspective. Such data strongly support the implementation and continued use of "Universal Precautions" for all hospitalized patients. Universal Precautions were first recommended by the Centers for Disease Control in August of 1987. These recommendations and guidelines note simply that blood and blcood- containing body fluids represent risk to health care workers. Universal Precautions for all patients and specimens are, in my opinion, both prudent and appropriate. In a study from the University of Washington, either hepatitis B surface antigen or antibody to HIV was detected in 5.7 percent of samples sent to the clinical laboratory from patients not known to harbor any infectious disease. Thus, the sample that a health care worker thinks is not a risk for infection may well be the one that truly represents risk. Also, it seems likely that additional blood- borne viral infections will ultimately be identified. Fora variety of reasons, then, the use of Universal Precautions see prudent. In my own opinion, a major obstacle to the use of these precautions, and therefore to the protection of American health care workers, is that both training and tradition are standing in our way. In general, health care workers have been reasonably cavalier about cutaneous exposures to blood or blood-containing body fluids in the past. Ina study from a hospital in California, San Francisco General, that has a large HivV-infected patient population, compliance with recommended infection control precautions was marginal, at best, despite intensive educational efforts by the hospital infection control staff. Prior to the implementation of Universal Precautions in our own hospital, 442 health care workers participating in our longitudinal study, trying to measure the risk of HIV transmission, reported more than 10,000 cutaneous exposures to blood or other body fluids in a one-year period. For many years, such exposures have really been "business as usual" for the health care profession. Health care workers need to learn a new approach to handling blood and blood-containing body fluids in the health care setting. Percutaneous injuries, as you’ve already heard, also occur far 343 too commonly. Again, in our own hospital, despite intensive educational programs designed to minimize such exposures, an average of 300 percutaneous injuries are reported to our Occupational Medical Service each year. Training of health care workers (physicians, nurses, and other allied health care professionals) should include an emphasis on the risk for transmission of blood-borne infectious diseases in the health care setting. Such an emphasis has not been present in training programs in the past. Prevention should also be emphasized. Hepatitis B, for example, is now a preventable illness; a safe and effective vaccine is now marketed. Health care workers who have exposure to blood or blood-containing body fluids should be strongly encouraged to be immunized with this vaccine. Health care workers should be educated about techniques to be used to prevent percutaneous injuries and about appropriate disposal of needles and other contaminated sharp objects. In my view, protection of health care workers will be best accomplished through a program that includes all of the following: 1) intensive education of health care workers regarding the pathogenesis, routes of transmission and risks for transmission of all blood-borne infectious diseases; 2) intensive education regarding preventive strategies for health care workers, including use of Universal Precautions for all patients (not just those suspected of HIV infection), the use of appropriate barriers in the health care setting, the advisability of hepatitis B immunization, and techniques to be used to prevent needle puncture injuries and injuries from other sharp objects; 3) an active hepatitis B immunization program; 4) an active program that insures the provision and immediate availability of appropriate barriers for health care workers performing procedures associated with the likelihood of cutaneous exposure, Spray or spatter; and 5) a systematic program for follow-up of health care workers sustaining adverse exposures to blood or body fluids from all patients in the health care setting. Thank you. MR. DeVOS: Good. Thank you, Doctor Henderson. MR. DeVOS: Doctor Martone is the Acting Director, Hospital Infections Program, Centers for Disease Control in Atlanta. Doctor Martone? DR. MARTONE: Mr. Chairman, and members of the Committee, good morning. I appreciate this opportunity to appear before you today to discuss the occupational acquisition of human immunodeficiency virus (HIV) infection -- 344 MR. DeVOS: Why don’t you pull the microphone to you a little bit closer, the whole thing. You don’t have to lean. No, not that, just take the whole stand, or is it hung up someplace? DR. MARTONE: I1/’11 lean forward. MR. DeVOS: Well, it looks like you are leaning into this pretty heavy. DR. MARTONE: It’s a heavy topic. Epidemiologic information on this subject comes from several sources: the CDC nationwide AIDS surveillance system, case reports published in the medical literature, and prospective risk-assessment studies being conducted by CDC and others. The CDC nationwide AIDS surveillance system has provided information on AIDS cases with onset since 1978. AIDS cases are classified as health care workers if they have reported ‘employment in health care or clinical laboratory settings. As of March 14, 1988, 2,586 AIDS cases were classified as health care workers. Health care workers comprised 5.4 percent of the 47,532 adults with AIDS reported to CDC for whom occupation was reported. For comparison, about 5.7 percent of the U.S. labor force is employed in health care services. Like AIDS cases in non-health care workers, health care workers with AIDS had a median age of 35 years, were predominately male, the majority were white and 95 percent had one or more well-recognized non-occupational risk factors. The 5 percent of health care workers with AIDS who are not categorized into one of the previously recognized transmission categories are categorized as having "undetermined risk." This compares with 3 percent of non-health care workers with AIDS having "undetermined risk." The reasons for this difference are not known with certainty, but may include the occupational risk of HIV infection. Published reports provide information on 22 health care workers whose HIV infections have definitely or potentially been ascribed to occupational exposures. In 15 of these health care workers, occupationally-related HIV infection was documented by seroconversions. 13 health care workers had exposures to blood and one health care worker had exposure to bloody pleural fluid. One additional case followed exposure to concentrated virus in the laboratory. The remaining seven workers also had occupational exposures to HIV; they were seropositive when tested but the dates of their seroconversions are not known. 15 of the 22 cases developed infection following accidental injection of blood or concentrated virus through the skin. The remainder had exposures through breaks in their skin or mucous membranes. 345 The surveillance data and case reports discussed above are useful in documenting that risk exists. However, they do not provide information on the magnitude of the risk. In August, 1983, CDC initiated a prospective surveillance system to quantitate the risk of HIV infection to health care workers following specific occupational exposures to blood and body fluid of AIDS patients. To date, approximately, 1,400 health care workers have been enrolled from over 300 hospitals nationwide. Of these, 1,070 workers have had antibody testing at least three months after exposure; 870 had needlestick or other parenteral exposures to blood and 114 had mucous membrane or non-intact skin exposure to blood of HIV-infected patients. 96 had parenteral, mucous membrane, or non-intact skin exposures to saliva, urine or other substances. Four health care workers have tested positive for HIV antibody; all were from the group of 870 workers who had needlestick exposures to blood. Of these four health care workers, three had documented seroconversions clearly linked to the exposure. Thus, the risk of infection following a needlestick exposure to HIV-infected blood in this study is four of 870, or 0.5 percent. For non-needlestick exposures, such as mucous membrane or skin exposure to blood of HIV-infected patients, the risk is much lower than 0.5 percent, but we cannot define that risk at present. There have been no reports of transmission among health care workers being followed in prospective studies which resulted from contact with a body substance other than blood. Although the risk of infection following exposure to HIV-infected blood is low, the risk is not zero. With the increasing number of HIV-infected patients requiring medical care, the potential for occupational exposures will increase. For this reason, our current research effort is focused on 1) determining the risk of infection in health care workers who have frequent contact with blood, such as emergency room personnel and surgeons, and 2) identifying ways in which on-the-job exposures to blood can be prevented. For over 18 years, CDC has been active in developing guidelines and recommendations to prevent patient-to-patient, health care worker-to-patient, and patient-to-health care worker transmission of hospital infections. Guidelines and recommendations are developed in consultation with recognized authorities on nosocomial transmission. cCDC’s first recommendation dealing specifically with prevention of HIV transmission in the clinical setting were published in 1982. As new information became available, CDC periodically updated and expanded the recommendations. 346 In August, 1987, CDC published a comprehensive set of recommendations entitled, "Recommendations for Prevention of HIV Transmission in Health-Care Settings." These were developed in consultation with recognized authorities on HIV and HIV transmission and were reviewed by over 50 representatives of nursing, medical and dental organizations; other allied health professional organizations; State and local health departments; and labor. CDC will continue to periodically review these and other recommendations as new information becomes available. You will hear more about this process from Doctor Robert Mullan, of the National Institute for Occupational Safety and Health. Thank you. MR. DevOS: Good, thank you, Doctor Martone. MR. DevOS: Doctor Kuhls is next. Doctor Kuhls comes to us from the Department of Pediatrics, Oklahoma Children’s Hospital, in Oak City, Oklahoma. Doctor Kuhls, good morning. DR. KUHLS: Good morning, Mr. Chairman, other distinguished members of the Commission. I'd like to state that I just recently moved to the University of Oklahoma from UCLA, and am still deeply involved in the UCLA health care workers’ study, so that, the data that I will be presenting today will actually be from UCLA, and not from Oklahoma. I’m going to have my testimony done with slides, please. Can I have the first slide? Like the other speakers prior to me, we have also, at UCLA, been interested in the risk of HIV infection. We, however, have also been interested in another question and, that is, since AIDS patients have many opportunistic infections, are health care workers at risk for other AIDS-related infections since they could have possibly acquired them through occupational exposure? . Could I have the next slide? At UCLA, we decided to study female health care workers, and we've used in-depth, self- administered questionnaires, limited physical examinations and laboratory studies, and have repeated them yearly since 1984. Could I have the next slide, please? We started our study in March to November of 1984, and began with 292 health care workers. Right now we have evaluated 430 health care workers, and have follow-up of one to three years on 305 health care workers, or 71 percent of the original health care worker cohort. Can I have the next slide? In looking at these health care workers, we have then studied 506 health care worker years 347 of health care workers reporting very high exposure to AIDS specimens, and 941 health care worker years of health care workers with very low or no exposure to AIDS patients and their specimens. It was very important for us to also study health care workers with no or very low exposure to AIDS patients and their specimens, especially if we were going to look at CMV transmission, hepatitis B transmission and so on. We needed a baseline control group. We’ve studied now a total of 1,447 health care worker years of exposure. Can I have the next slide? This is the seroprevalence data of the health care workers at enrollment. And, aS you can see, to date, by only studying female health care workers, we have not found a seropositive female health care worker yet. For CMV, for hepatitis B virus, for herpes simplex virus type 2, and also for EBV, enrollment the health care worker group did not have any difference in seroprevalence rates. In fact, in all the viruses there were slightly higher seroprevalence rates, though, not significantly different, for the low exposure group. Could I have the next slide, please? This is the data looking at our prospective follow-up and our seroconversion data. Again, for health care workers for HIV, we have not found anybody to seroconvert. For CMV, we’ve found that the percent seroconversion per year are similar between the people working with AIDS patients and the people not. This is also true for hepatitis B virus, herpes simplex virus type 2 and, again, Epstein-Barr virus, although the number of seronegative people that we have studied are very, very low. The only one where the high exposure group is higher than the low exposure group is in the herpes simplex virus type 2 category. Again, that is not significantly different, by Fisher’s exact test is P=.18. Can I have the next slide? Also, during the same time period, we have studied now with pre and convalescent sera following percutaneous needlestick injuries and mucous membrane exposures another 64 health care workers. Again, we have not found a health care worker to HIV seroconvert at UCLA. Can I have the next slide? In summary, we have now studied female health care workers, and we have not found any seroconversion or any seropositive female health care workers to date. We’ve also studied 64 health care workers with percutaneous exposures, or mucous membrane exposures, and, again, found no seroconversion. And, probably most important for us, we found no differences in health care workers with or without high exposure to AIDS patients and their biological specimens with respect to CMV, hepatitis B, herpes simplex virus type 2, and Epstein-Barr virus acquisition. Can I have the slides off? The last thing, the only other thing I’d like to say is that, this study again was started in 1984, and this was even 348 prior to when Universal Precautions went into effect. So that, even in the situation where we were utilizing, basically, very good hand washing, and not really using Universal Precautions, in that situation we again still did not find any increased seroconversion in any of the other categories of different etiologic agents. Thank you. MR. DevVOS: Thank you for the high level of expertise out there. I want to commend you on condensed reports with highlights. We haven’t always had that, but that was very important and very well done. MR. DeVOS: I’m going to start with Doctor Lilly down at that end, and he’s our resident expert on all these things. DR. LILLY: I’m very interested in the Universal Precautions that you are recommending, and you went a little bit into what the difficulties are there. I wonder if you could summarize for us what these are, how difficult they are, indeed, to use, how annoying they are. Could you give us some measure of that, anyone who knows about them? DR. MARTONE: I can give you a basic overview of Universal Precautions, but I will defer to Doctor Henderson, who has experience in the clinical setting, for his observations. DR. LILLY: All right. DR. MARTONE: Basically, Universal Precautions, as defined in the Department of Labor/Department of Health and Human Services Joint Advisory notice, are a combination of prudent work practices, of barrier precautions, and of engineering controls, that are designed to prevent exposures, predominantly to blood, but also, other blood containing body substances, and body fluids obtained from normally sterile body cavities from all patients. The problem in interpretation of the Universal Precautions that we faced over the past year since the August ‘87 guideline, is that the term "body fluids" was not adequately defined in the previous CDC recommendations. So, to address that issue, we convened a panel of experts at CDC to look at the issues and to address the questions. And, basically, the thoughts are that the primary risk, as you’ve heard here, is blood. The major mode of transmission is percutaneous needlestick exposure, and this is the mode of transmission we have to keep stressing: this is the focus of our prevention efforts. We have to stop needlesticks. 349 DR. LILLY: But, the Universal Precautions don’t include needle impervious gloves, for example, do they, nor do I suspect that anyone knows how to do that easily and simply? DR. MARTONE: That’s correct. I mean, if they existed, they’d be great. DR. HENDERSON: I would agree entirely with Doctor Martone, that the major risk for transmission is by needlestick injury in terms of relative risk. The overall major risk may be for other types of exposure, cutaneous exposures currently, or mucous membrane exposures, because they occur so much more frequently. So, if in our own hospital there were 10,000 cutaneous exposures, every time that happens you, essentially, roll a very large die, with one chance, a long-shot chance, of getting infected. I think the reason this had been foreign for the health care profession is that we’re all old dogs who have to learn a new trick. I learned about this wrong when I was a third year medical student, walking into the operating room getting blood splashed on my greens. I didn’t have a professor who took me aside and said, "There is some risk associated with this. We have to keep something between us and the body fluids, or the blood-containing body fluids." Some aspects of these precautions are cumbersome, and involved relearning by the 5.7 million health care workers out there, and I think it is for that reason, because we’ve been doing this a long time, and I believe doing it incorrectly, will be a painful process of learning. Nonetheless, I believe that these are important precautions that will benefit the health care profession, not only in preventing HIV infection, but also a variety of other blood-borne infectious diseases that over the past several years we’ve really been quite cavalier about. DR. CHAMBERS: If I could add one other comment -- DR. LILLY: Sure. DR. CHAMBERS: -- to what I think is a major difference from the past and the present in terms of body substance precautions. In the old system, it required that you identify the patient and the specific infection, so you had to be able to tell what the patient had before you would implement appropriate infection control procedures. 350 AIDS has taught us that we really can’t identify everyone who is infected, much less with HIV, but with a number of pathogens, and that precautions universally applied are much more rational, given that understanding. DR. KUHLS: And, I’d like to also add that, although these precautions were made and were actually formulated because of HIV, although we don’t have any data as of yet, I believe that jt is a much more rational policy to treat everybody as if they were HIV seropositive. Infection control, even in the non-HIV seropositive individual, in the future will be improved. It’s just a matter of education and, again, teaching a dog new tricks. It’s going to be a long time, but I think overall it’s a more rational policy, even for non-AIDS or non-HIV seropositive individuals, by having one complete Universal Precautions set up for infection control. DR. LILLY: Do you have the feeling that -- I’m sure you don’t have data -- but do you have the feeling that, perhaps, people who are newly into the health care worker professions are accepting these guidelines more readily than they old dogs? DR. HENDERSON: Absolutely, and that’s one of the recommendations I would make, is I think that the Commission could recommend that this be included in health care training for physicians, nurses and other allied health care professionals. I don’t think this kind of training appears, or at least is not emphasized, to a significant extent, and I think that we could prevent infections with all of these viruses by emphasizing that training in medical school, nursing school and so on. DR. KUHLS: I can tell you froma practical aspect, since I am a pediatrician, I learned to draw blood on small babies, and when I learned to put intravenous lines in, I learned with my bare hands. I have a very difficult time now drawing blood and putting in IVs with gloves on. But, I can tell you that by pushing it with the interns now, by teaching them early on to use gloves, and to use that in the learning process, it’s actually done well. And, I’ve actually heard the statements from a few individuals that they cannot now put in IVs with their bare hands because they are so used to the gloves. So, I really think it’s a matter of teaching and a matter of, if you teach somebody to do things right in the beginning, then it is relatively easy. It’s just that we’ve been taught @ifferently. /MR. DeVOS: Admiral Watkins, I think, has a follow-up, Frank. 351 CHAIRMAN WATKINS: Maybe I missed it in your statement, Doctor Chambers, but do you have the data broken out within the statistics you gave us on the cases where health care workers were, in fact, using Universal Precautions and where they were not? Did you take that data down? You didn’t present it, I’m just wondering if you took it. DR. CHAMBERS: Yes. In San Francisco at the time the study was conducted, we did not have a formal policy of blood and body substance precautions. However, we were realizing that that was probably the way to go, and we were starting to implement that. In the survey, we found that the rule of thirds applied. A third were not adhering, a third were adhering to recommended guidelines, and a third were overdoing it. CHAIRMAN WATKINS: But, you didn’t know which ones. DR. CHAMBERS: No, we did not know which ones. It’s not been tabulated that way. CHAIRMAN WATKINS: Doctor Henderson, the same with you? DR. HENDERSON: In our study, the bulk of our study occurred prior to the August, '87 guideline recommendations. We collected, when we heard that these recommendations were going to come out, we collected baseline information from our study participants about these exposures, and those are the data that I gave you. We plan to submit the same questionnaire in a year to see if we can assess, in the same cohort, whether institution of Universal Precautions has had an impact on the number of cutaneous exposures, mucous membrane splashes and so on. So, although I can’t give you that information today, hopefully, in another six or eight months I will have that information. CHAIRMAN WATKINS: Would you also include training of volunteers who work in this field of HIV? DR. HENDERSON: Any one -- CHAIRMAN WATKINS: I mean, it seems to me, we forget them. That’s a large body of volunteers who deal with these issues, and every time we hear presentations, it is health care providers who fit the normal mold, and yet, we have thousands and thousands of volunteers -- 352 DR. HENDERSON: Absolutely. CHAIRMAN WATKINS: -- who are coming forward to handle this problem, because nobody else will. And, it seems to me that training is a key part of what we should be focusing on as well, and that takes some dollars, and people have to do that kind of training. DR. HENDERSON: I think that’s an excellent point. Doctor Martone’s point, that the risk is really blood, and percutaneous exposure is an important one, I have come to think of this in terms of an equal sign, blood equals risk. And, it is whoever has that kind of exposure, whether they are doctors, nurses, other health care providers, volunteers or anyone, is at risk, especially if they are not educated about that risk. MR. DeVOS: Gebbie, you are next. MRS. GEBBIE: I think I’m going to carry the same point a little bit further. You present, in a very logical, sensible way, some information that’s well founded, that comes primarily from the organized in-patient setting. We have heard from a number of people who fit the definition you just described, particularly, those I’m used to calling "first responders," policemen, firemen, EMTs, who, to put it gently, don’t believe a word you are saying. They really aren’t sure that this makes sense. They are quite convinced that in developing these precautions or doing these studies, you yourselves have never been on the front line, nor do you have the foggiest notion what goes on out there, and, therefore, are missing the boat. They believe the precautions you proposed are not quite doable, and they probably won’t protect them anyway. And, I’m slightly overstating, but we've heard a mix of that. I would appreciate some comments, therefore, on the extent to which those non-in-patient, broadly defined providers have been included in any studies, so that we can sensibly answer their concerns. And secondly, the extent to which the analysis of the precautions have included not just theoreticians, or bureaucrats or managers, which are some nicer pejorative labels on all of us, but folks who live and work in those front-line kinds of settings. DR. |HENDERSON: Well, let me respond first, but I know Doctor Martone will also want to respond to that regarding the recommendations. I would agree with the first responders, that they are, in my own view, in the population of health care providers who would be among the highest risks. That is a risk- 353 taking profession. Those people get in helicopters and fly to accidents, crawl through glass, and so on, and I think need to perceive that, as they are doing that, all of those actions are associated with risk. The recommendations are really both, in my view, cerebral and straightforward, in that, insofar as it’s possible, as a first responder, do what you can to keep a barrier between you and a patient’s body fluid. Now, if I am driving along the freeway, and I come upon an accident and someone has an arterial bleeder, and I don’t have a pair of gloves with me, I’m going to take the small risk and put my hand on a bleeding artery. I would rather not do that, but health care providers take risks. This isn’t a risk-free job. I think that those health care providers are at reasonable risk, but we can do some things with these precautions to minimize those risks for them as well. MRS. GEBBIE: Let me repeat my specific question, though. Have those health care workers been prospectively enrolled in the same kind of study you are doing with in-patient workers, in order to give them some data that they can really relate to on their relative risk? DR. HENDERSON: Our hospital has no emergency room or emergency providers, so there are none in my own study. Bill, do you know? DR. MARTONE: We have no clinical services at the Centers for Disease Control. All of our information comes from volunteer cooperating hospitals. We do have a study which has been approved, which will be implemented, I believe, this September, to look at first responders, emergency room health care providers, and others, in the same fashion, but more intensively, as in the types of prospective studies you’ve heard here. These will include observational studies as to what these people are actually doing in the field, and in the emergency room setting, what type of risks they are taking and how they can be prevented. DR. CHAMBERS: If I could respond to an implication of your question, I think. At San Francisco General, first of all, I do take care of patients, and I feel like I’m on the front line. So, I would exempt myself from the accusations that you just voiced. 354 Secondly, at San Francisco General, we have a trauma room, and we are studying individuals who have an incredibly intensive blood exposure in the emergency room. I would, with all respect, beg to differ, that people outside of that emergency room setting are liable to have a greater blood exposure than those individuals. So, we have a tremendous experience with people who are intensively exposed to blood. Now, people who have a risk like that, you can define what the situation is like. If you have a risk like that, I think you can draw some conclusions for these other individuals. We have no data, however, to answer your question directly, on EMTs, police officers, individuals in the field. MRS. GEBBIE: The perceived difference, as I hear it from those folks, is that, yes, you may have a lot of blood gushing around that trauma room, but you are in a situation where performing the precautions is simple. You’ve got the equipment, you are in control, and they do not in the field. I’m sharing with you what we are hearing, to see how you respond to that. DR. CHAMBERS: I think the need there is to find a way to help the people in the field make it easier to implement the precautions. MR. DevoOS: Thank you, Gebbie. Cory? DR. SerVAAS: I guess the first one might be answered by Doctor Kuhls, who is in "pede’s," but when you have a woman of child-bearing age, who is shedding -- I mean, a woman of child- bearing age, do you have these nurses taking care of CMV babies who are infected and shedding CMV virus? And then, I’d also like to know from anybody on the panel, we’ve talked about -- I don’t know how much you can tell us about air cell-borne TB and histoplasmosis with health care workers, and whether a human papilloma virus, 16 and 18, which now are found to cause cervical cancer, whether those viruses are also a danger with needlesticks. DR. KUHLS: I think the first question about CMV is a very important question, and let me answer that last so I don’t forget the other questions. As for TB, we have put skin tests and/or studied all the health care workers that were presented today each year by looking at their TB skin test, either in occupational health or 355 putting the skin test on ourselves, and we have not found anybody who became PPD positive to date in any of the health care workers in the high or the low exposure group. I think that’s the only data available on the subject. I don’t know, does San Francisco have any data on TB? But, we’ve looked at that, but again, it’s only a small number of health care workers with high exposure to AIDS patients, but we have not found anybody to be PPD positive. We don’t have any data at all on histoplasma at UCLA. I’ve thought about that, because I’ve seen more histoplasma in Oklahoma in AIDS patients than in California. Going back to the last question, though, I think it’s a very important question. And, that is, if you have a pregnant health care worker, do you allow that health care worker to work with AIDS patients, since most AIDS patients are excreting CMV, and usually in very high titre. And, the answer to that, I think, really goes back not only to the data that we’ve shown today, but also to data in pediatrics looking at, health care workers in the pediatric field who work with children who excrete CMV. Do they have a higher risk of having seroconversion than people in the regular public and so on? The answer to that question is there’s been many seroepidemiologic studies completed, probably the best is from the University of Alabama, which has shown no increase in seroconversion compared to the regular public in CMV seroconversion of health care workers. And, I think that complies with our data too, that we definitely let these health care workers work with AIDS patients. But, the important thing of is that, there probably is a theoretical increased risk of getting CMV, but, if you follow Universal Precautions, and when you are around bodily fluids and so on, if you wear gloves, and if you especially practice good hand washing, then in that situation, if you work with AIDS patients, and even if you are pregnant, you are at no increased risk of getting CMV. MR. DeVOS: Do you have a follow-up, Frank? Okay. DR. SerVAAS: Well, I guess, if I may, I’d just like to ask about the sewage worker, who, I don’t know if it was from a hospital or not, who is suing his city for many millions because he didn’t know, or evidently got AIDS. Do you know about that, and could you tell us how you handle training the sewage worker? MR. DevOS: They don’t work at that level, Cory. DR. SerVAAS: In the hospitals, your garbage, sewage, all that? 356 DR. HENDERSON: No. We have housekeepers who handle trash in our hospital, and they receive the same Universal Precautions training. I mean, it’s slightly different, but pretty much the same essential message, that our health care workers get. DR. SerVAAS: Thank you. MR. DeVOS: Thank you, Cory. Theresa? Blazing blue today. DR. CRENSHAW: Thank you. Could you tell me what the numbers were of any health care workers in your studies who converted but were attributed to other risk factors? DR. CHAMBERS: In our study, we did not follow individuals who had other risk factors. They were identified as being in a risk group, and we have followed only those without risk factors. DR. HENDERSON: We have, in our study, four individuals who were infected at the time they came into the study. All four acknowledged risk factors. None had needlestick injuries, none had mucosal exposures, and all four believe that they acquired their infection outside the hospital. None of those had adverse exposures. One of the four did not have patient contact. One, although a health care worker, did not have exposures to blood. We had no seroconversions among even risk-group people in that population. DR. MARTONE: None of the three seroconversions in our study had other risk factors. One individual was seropositive, I believe it was 90 or 100 days after the exposure, and that was the only blood specimen that was obtained, so we don’t know whether seropositivity was related to the occupational exposure. DR. KUHLS: When we developed our study protocol, we were really worried about risk factors and so on, so that’s the one reason why we studied only female health care workers, figuring that we could cut down on people with high-risk factors. In our questionnaires, though, we do ask about risk factors. We have a number of different female health care workers who have had risk factors, sexual partners with IV drug abuse, and so on, and so on. However, again, we found nobody to be seropositive in our study. DR. CRENSHAW: In one of the earlier San Francisco studies, there was a series of, I think, I don’t remember exactly, 1,200 or thereabouts, it might have been smaller, where 26 were reported to be HIV positive, but then that was reduced to 357 three when they eliminated the 23 as a result of risk factors. You are familiar with that study. And, I guess one of the questions that comes to my mind, that I don’t think has been answered and I took a close look at that study myself, is, how does one objectively determine which causes it? And, one of the things I think is very misleading is not to report all of the numbers and put one ina questionable zone, rather than to put that group in an absolutely separate category as though they don’t exist, because even if someone is using drugs, if they are not sharing needles, or if they are sharing with one partner who is not infected, it really makes a difference. And so, it seems to me that that builds in some bias. Also, in relation to the TB, if I understood you, there are none that you know of that are converted. But I mentioned yesterday, 13 nurses in Urbana, who got TB, who are caring for AIDS patients. This is an enormous number when, basically, we’re hearing zeroes. The one thing that I would say is, that the impression I’m getting is that all the answers are there, and it’s, basically, a quiet problem, and there is zero here and there is zero there. But, I’m not satisfied, not based on the issue of being unreasonably fearful, but based on the fact that there are some rather significant anecdotal and reported cases, like of 13 TB patients. I recently learned of an EMT man who became positive and this was found this on an insurance physical, and he had no idea. He wasn’t in any study group, and there are so many health care workers who aren’t, that aren’t perceived of or suspected to be even in high-risk settings, that we’re not going to find out in a systematic way. So, would you comment on the conclusiveness of your studies, and the, perhaps, open-mindedness or scope for leeway that exists for future considerations as more data comes in? DR. HENDERSON: I’m very comfortable with the conclusions drawn from the needlestick studies. I’d like to address the one issue you raised about excluding risk-group members from the studies. MR. CREEDON: Would you define what we mean by risk- group members, other than -- DR. HENDERSON: Well -- MR. CREEDON: -- I mean -- DR. HENDERSON: -~- it depends on the study. In the traditional risk-group populations, or transmission categories, 358 are male homosexuals and bisexuals, IV substance abusers, sexual partners of someone who is in one of the other risk groups, hemophiliacs, recipients of transfusions prior to March of 1985. MR. CREEDON: How about promiscuous heterosexuals? DR. HENDERSON: No, that would not be included in that. MR. CREEDON: Okay. I just wanted to clarify that. DR. HENDERSON: That would not be included as a traditional risk. On the other hand, there may be some risk there. For the purposes of trying to assess the magnitude of risk, the best way to measure that number precisely would be to have a pristine population that doesn’t have any of those risks, who have exposures in the health care setting, and then you’d be able to measure that precisely. DR. CRENSHAW: Not much hope of that. DR. HENDERSON: Well, I think that was the intent of some of the studies in limiting those. DR. CRENSHAW: Yes. DR. HENDERSON: In many of the studies, the number of people participating in risk behaviors, in our study, for example, it is not known, because we didn’t ask people up front. We took all comers. The only people we have found positive at the time of the interview, all acknowledge outside the hospital risks, they were all prevalent positives coming into the study. Of those individuals, several already knew about the infection. DR. CRENSHAW: By the way, that’s really helpful, and that’s nice to hear, that you are dealing with the risk group factors after finding out the positive, and then looking for, better understanding and more clues, as opposed to just tuning it out up front. DR. HENDERSON: Right. Of the remaining now 842 individuals, I can’t tell you precisely how many are risk-group individuals, or participants in risk behaviors, but I can tell you that all those people are seronegative, are being followed. And, I think that we do have some precision now for that number, that is, the risk for acquiring this infection as a result of percutaneous exposure, mucous membrane exposure, cutaneous exposures. We’re getting a clear feeling for what the range is, what that real number would be. 359 The issue about tuberculosis is a stickier wicket. I would like to emphasize that I don’t think we have any information that suggests that TB in an HIV-infected patient is any more transmissible than TB in anybody else. And, I think that because of an increased concern about tuberculosis in the United States, all health care providers need to look at pulmonary infiltrates with a jaundice eye, raise the TB question. If you don’t know the answer until the AFB sputum Samples come back, put the patient in respiratory precautions. That’s all very reasonable. Probably the largest risk comes from someone with cavitary pulmonary TB, and that would not, very likely, be an AIDS patient, because most often they don’t cavitate. DR. CRENSHAW: Now, one of the other factors that could influence your study conclusions is the Finnish study that suggests a very long window in time that could be well over a year and up to three years. I heard last night, from the head of the Department of Public Health in Hawaii, that there has been a study done in San Francisco to try to verify or disprove the conclusions drawn in that study, because it hasn’t been duplicated. They went back to blood in San Francisco that was in storage of up to three years, and that 18 percent of them were virus positive but didn’t seroconvert between one to three years, which seems to support some of the data that was in that Finnish study. He also indicated that that study would probably never be published, but I wasn’t -- we were rushed off to dinner, and I didn’t have occasion to find out why. Are any of you aware of this study, and if it turns out to be true that the window in time in some cases can be measured as a function of years, what impact would that have on the interpretation of your results? DR. HENDERSON: I’m not aware of the study, but that’s one of the reasons that our study is ongoing. DR. CRENSHAW: Right. DR. HENDERSON: The median follow-up now for our employees with needlestick injuries is a little over 34 months. So, we're getting into the right ball park, even for those individuals still in our study among the health care workers with no seroconversions. so, I’m more and more comfortable that the information from the paper in Lancet also was concerning to us, we’re trying to assess the -- 360 DR. CRENSHAW: Also was what? DR. HENDERSON: -- was of concern to us, because of the, perhaps, widened window of infectivity. We’re looking for newer technologies that may be able to address that question more directly. We’re hoping to study people with these adverse exposures using the new polymerase chain reaction technology, the gene amplification technique, and we may be able to answer that question more directly, should we be able to apply that technology. Again, with long follow-up in all of these studies, I’m as comfortable as one can be, given the median terms of follow- up, that the data we’re reporting are precise. DR. CHAMBERS: I would also be careful from drawing too many conclusions on banked blood, because the sample may have been obtained at a time when the rate of transmission was high in San Francisco. You don’t really know, I haven’t seen the study either, but I would want to know the relationship of that blood sample to other blood samples, and was it a failure to seroconvert, or was it a narrow interval of time when the rate of transmission was high, and was it within the three-month period that might be reasonable? DR. CRENSHAW: These are people they are stiil following, that they still have. They are not just going back to look at isolated blood samples. MR. DeVOS: Thank you everybody. We’re going to go to John Creedon. John? MR. CREEDON: With respect to the point about Universal Precautions, I don’t know how many hospitals there are in the United States, but I guess it must number in the, what, tens of thousands? Is there evidence that it’s cost effective to have Universal Precautions? It may or may not be, but whose job is it? Is it the individual hospital’s, is the American Medical Association doing anything about it, the American Hospital Association doing anything about it, and, if so, I guess what I’m looking for is, what should we be doing as a Commission? What should we be recommending in light of the different institutions that are involved, not only the CDC, but the hospitals themselves, the associations that deal with the different types of providers? | 361 DR. MARTONE: I think health promotion and education efforts are being accomplished by a wide variety of the professional organizations. As you are aware now, the Department of Labor has also issued a Joint Advisory notice with the Department of Health and Human Services. You’1l]l hear more about that this afternoon, but I imagine in terms of hospitals implementing Universal Precautions, and providing materials to do so, that the Occupational Safety and Health Administration will serve as a major impetus for that. MR. CREEDON: By requiring it. DR. HENDERSON: It would be very difficult this early on, since these precautions were not universally recommended until August of last year, to have a good handle yet on cost benefit analysis. It will be difficult to obtain those data even with 20 years of follow-up, but I don’t have a good way of approaching that issue, but I would certainly agree with Doctor Martone, that the educational efforts -- MR. CREEDON: Well, I think it’s going to be costly. I’m not suggesting that it shouldn’t be done, but if you are supplying people with equipment that’s to be used and throw away, and done in every case, it’s bound to be costly. I guess it’s a little surprising, maybe I misinterpreted what was said, but, if not shocking, that precautions were not being taken before in view of the experience with hepatitis B. DR. HENDERSON: It’s astounding to me, frankly, as I got into this, that we have tolerated having 160 to 200 -- MR. CREEDON: Right. DR. HENDERSON: -- American health care workers die every year of hepatitis B. MR. CREEDON: Exactly. DR. HENDERSON: That’s, essentially, been business as usual for many. MR. CREEDON: Yes, it’s really surprising and it’s a further evidence of what we have seen in a number of instances with this Commission, of the AIDS epidemic bringing to light some issues that need to have been examined in the health care system aside from AIDS. I think that there will be, unfortunate as it is, some positive impacts from the studies of the disease. Thank you. 362 DR. MARTONE: Could I respond to your cost effective question? ' MR. CREEDON: Yes. DR. MARTONE: I don’t know of any studies, but there is some anecdotal information I have. It will be very costly according to these studies, and it may be more expensive than the cost of a case of HIV infection in a health care worker. But, I think that would get concurrence among my panel members, that cost effectiveness studies, as they relate to health, are very difficult to interpret. MR. CREEDON: They are. Well, the reason I raise it is that we discussed in the last day or so, among other things, the sky-rocketing cost of health care generally, and the impact that it’s having in the country. We were talking about small business yesterday. I certainly am aware of it in big business. That’s one of the major concerns among chief executives in big companies, because it impacts the bottom line, the employee benefit costs. Do I have time for one more question, Mr. Chairman, or not? MR. DeVOS: Well, you probably are going to take it anyway. The voice of Metropolitan goes on. MR. CREEDON: The Indianapolis Star this morning, on the first page, had an article about how fast this virus is mutating, at a speed that is not typical of other viruses. And, I wonder to what extent that influences the kind of work you are doing. Are the tests that you are doing sufficiently refined to take care of the mutations and so forth? DR. HENDERSON: Yes. The serology is not influenced dramatically by the sorts of mutations that -- although I didn’t see that article -- that are generally discussed about mutations in the outer envelope of this virus. Other parts of the virus to which antibodies are directed, the gag protein, endonuclease, and other pieces of the virus remain relatively constant over time, and antibodies directed against one virus isolate that has almost a totally different outer membrane will cross over into that. MR. CREEDON: Thank you. MR. DeVOS: You get one comment and three head shakes, John. We’1ll go from the voice of Metropolitan to Sloan- Kettering. 363 DR. LEE: Thank you, the Honorable Mr. DeVos MR. DeVOS: The New York delegation here. DR. LEE: The most vocal people before us have been the surgeons who have been -- they are our highest paid colleagues, and they are screaming the loudest. What percentage of these accidents that are reported are surgical? Now, these people are gowned, and dressed, and going through the whole bit. What percentage relate to surgery? DR. CHAMBERS: I don’t have the breakdown of exposures by category before me, but we had 57 surgeons in our study that had one or more of those exposures. And, the individual who seroconverted was not a surgeon. I think that’s the most that I could say. DR. LEE: So, we have no surgeons. DR. CHAMBERS: In San Francisco. To my knowledge, there are four or five surgeons, possibly, that have been reported in the literature. Probably Doctor Martone has something else. DR. HENDERSON: We have only a few surgeons in our study at the Clinical Center, I think fewer than 20 the last time I added. None of them are currently infected. MR. DeVOS: Thank you. Theresa has a follow-up to John over here. DR. CRENSHAW: I understood that HIV-2, which is one of the newly related strains, was missed on the current tests by about 30 percent, which is a rather huge number. Is that not correct? DR. HENDERSON: That’s correct, but it’s a much different virus if you go back. I mean, it’s really very different. To my knowledge, and Bill probably can speak to this better than I, but, to my knowledge, there is only one individual in the United States among several thousand samples who has been found to be infected with HIV-2, and that was, I believe, an individual visiting here from Western Africa, which is not terrifically surprising. By the time there would be a significant prevalence of HIV-2 infection, there will be test kits, I would be certain, that will detect that virus as well. MR. DevOS: Okay. Admiral, you are next, wrap it up. 364 CHAIRMAN WATKINS: Everything we’ve heard to date suggests that the Universal Precautions has been a ho-hum sort of an issue with the medical profession for a long time, despite admonishment by CDC and others. We had a similar situation in the Navy for about 30 years, nobody paid any attention to damage control. It was expensive, and so forth, until people start shooting at you. We looked into the budget, and the R&D budget for damage control equipment, uniforms, protective devices and so forth, heat resistant materials, was virtually declining to minuscule figures. What do you know about the emphasis on research in Universal Precautions materials, equipment and so forth, and I don’t mean just for the doctors. I’m talking about those same people in the field, the people we heard from yesterday who are frightened to death out there, the police, reaching through broken windshields with blood all over the place. They are also worried, they are cutting their own hands and getting exposed to blood. How about for the firefighters? They are up to their eyes in it most of the time. How about the paramedics? So, who is doing the integrated research, who has the responsibility, Doctor Martone, for putting emphasis on this in a coordinated way to help all health care providers, volunteer people that work in this field, to really have the kinds of equipment they need for the future? Now, we’ve seen some evidence coming out of defense spinoff in research and development, where new impenetrable gloves are being developed. Some of those may be too difficult to use for surgery, but they may not be too inflexible for other health care workers. They can’t be cut with a scalpel, they can’t be penetrated with a needle, but how much emphasis has gone into this type of development, and who has the responsibility, primarily federal responsibility to really put a round turn half hitch on this thing and get going? DR. MARTONE: I think in the past much of this has really been left up to private enterprise and the laws of supply and demand. CHAIRMAN WATKINS: But, if you don’t demand it, private enterprise doesn’t want to build it. DR. MARTONE: I was just saying what was going on in the past. I don’t know who is responsible for applying this pressure today. 365 CHAIRMAN WATKINS: Now, FDA tells us that they are sitting there waiting to measure the efficacy of a glove, but do they just sit there and wait until it arrives, the new latex glove arrives on the scene, and they measure it, or do they have the responsibility to make sure someone is developing it? DR. HENDERSON: I don’t think they would have the primary responsibility. CHAIRMAN WATKINS: Does HHS have kind of a general responsibility? DR. MARTONE: I don’t believe so. CHAIRMAN WATKINS: Is this awash somewhere in the field, that if you ask for it, and there is a supply and demand, then the great American spirit will come forward and produce something? That seems to be pretty loose in terms of standards, guidelines, lessons learned, how do you get the best glove to the firemen. DR. MARTONE: I was addressing technology. I don’t know about the other issues. DR. HENDERSON: I don’t know either, but the -- CHAIRMAN WATKINS: Well, your answers are typical of what I would expect, and so, would you think that emphasis on research across the board on equipment, standardization, bringing the right people in so it is user friendly, and get this thing going in a much more coordinated way. DR. HENDERSON: I would concur with that entirely. CHAIRMAN WATKINS: Thank you. MRS. GEBBIE: Following -- MR. DevOS: Cory, do you have a quick one? Go ahead. I’ve got Cory next for a quick one, Mrs. Gebbie. She said a quick one. DR. SerVAAS: It was. I speak regularly with two doctors, who are HIV-positive and who have -- they are practicing, and they don’t divulge to their practice or anyone else. How do you know when you are doing this that the health Care workers who have gotten their needlesticks are telling you that they have seroconverted? What makes you think that the ones who are, are going to come and be in your study or whatever you are doing, that you are catching those? 366 DR. HENDERSON: Well, again, I’m fairly comfortable in our own study, because we did this prospectively. If you were a health care worker, we would enroll] you today and follow you periodically. We have a measure of how well we do in terms of needlestick reporting by our questionnaire, by comparing that to the people who go down to our Occupational Medical Service and report an injury. Actually, more injuries are reported on our questionnaire than are reported to the Occupational Medicine Service, and we’re following all those individuals. Nonetheless, I mean, it’s possible that some people may not report injuries, but in our large cohort we still are not seeing seroconversion. DR. SerVAAS: Thank you. DR. KUHLS: And also, as a sideline to that, I think it’s very important to point out that when you look in the literature for health care workers, that really what you should take seriously and what you really should evaluate the strongest is the literature where you show true seroconversion. In other words, health care workers that come right to the health facilities right away, and get tested, are seronegative, and then they seroconvert. In that situation, you can feel confident if there are no other risk factors that there is a seroconversion. In other words, those people came right as soon as they got the injury to the health care physician, they were seronegative and they seroconverted. If you look at that population, then you can feel pretty comfortable that for sure they are seroconverted. MR. DeVOS: Mrs. Gebbie, did you have something else you wanted to say? MRS. GEBBIE: Well, as a follow-up to the Admiral’s questions. If, just for a sense of this particular group, if this panel were to pursue the idea that someone in the federal structure ought to be responsible for stimulating and disseminating that technology, not just waiting for it, or not just monitoring it, what is your sense of to whom in that federal structure such an order ought to be directed. That is, what agency or sub-agency is in the leadership posture that would be relied upon to do that? Do you have any sense of what would be a good place to consider? DR. MARTONE: I really can’t give you much help on that, except that you would have to categorize the task, in terms 367 of whether it’s a research effort to develop new technologies, whether it is transfer of the technology, whether it is use of existing technologies of proven efficacy. In that case, you would rely on the Occupational Safety and Health Administration. DR. HENDERSON: I’m sure that you could get better advice from someone who is more bureaucratically inclined than most of the people at this table, to understand those efforts ought to be focused. I’m sure I’m the wrong person to try to answer that question. MRS. GEBBIE: Who would get you excited about? Where do you relate in the system to look for exciting new things? Who would you relate to? That’s really what I was after. DR. HENDERSON: Bill’s point is well made, and that’s that for scientific projects, one often finds either intramurally or extramurally NIH carrying the lead, for epidemiology, broad- based studies, CDC, and so on, but in terms of who one would direct the memo to, I’m not the right person to ask. MR. DeVOS: We want to thank this panel for what you’ve told us and what you haven’t told us. I say that because, some time the work of this Commission is to find out things that are talked about a lot in the country but may or may not be as major as they get talked about. And so, to try and sort that out, and reduce that fear level, is part of what we are trying to do. So, we thank you for your scientific support of where you are at, and what you’ve learned so far, and we’ll take it from there. So, thank you so much for joining us, and we’ll go right to our next panel. CHAIRMAN WATKINS: I’d like to also thank Doctor Henderson. He is a member of the Commission’s Physician Review Committee, and he’s one of our finest, most articulate members of that Physician Review Committee, which makes up about seven clinicians that work in the field. And, we thank you, Doctor Henderson, for continuing to work with us in that regard. PANEL 2: CONCERNS OF THE HEALTH CARE PROVIDER MR. DeVOS: Our next panel consists of Norma Watson, Julie Chamberlain, Bill Borwegen, Aurelio Rodriguez, Joan Phelan and Harriett Olson. Yesterday they snuck in and made a Mr. a Doctor. I bet you they you could make a Mr. into a Mrs. pretty quick. Either that, or you sure do look different than when I remember you. We have a document submitted by the Association of Operating Room Nurses to us. They are not here to testify in person, but I want to publicly, into the record, note that we 368 have their report, and it will become a part of the record that we're dealing with here. The panel that we are looking at now consists of Norma Watson, who is a Registered Nurse from Hercules, California, we have Doctor Rodriguez, who comes to us from the Shock Trauma Unit, the University of Maryland, Baltimore, Doctor Joan Phelan, Director of Oral Medicine and Pathology, from New York University. We have Ms. Olson, Harriett Olson, Visiting Nurse Service, Incorporated, all the way from Indianapolis, and we have Bill Borwegen, is that correct, Bill? MR. BORWEGEN: That’s correct. MR. DeVOS: Director of Health and Safety Department, Service Employees International Union, Washington, D.C., along with Julie Chamberlain, an R.N., who is Infection Control Coordinator at Butterworth Hospital in Grand Rapids. And, with that, we’ll begin with Norma Watson, comes from Hercules, California. Norma? MS. WATSON: Thank you. My name is Norma Watson. I have been -~- MR. DeVOS: Norma, would you please get into that mike a little better, just kind of swallow it for us a little bit, please. MS. WATSON: I have been a Registered Nurse since 1974, and was employed at San Francisco General Hospital since 1977. While I was the charge nurse caring for AIDS patients, I was denied the opportunity to know the diagnosis of these patients; and, when the diagnosis was known, I was specifically forbidden to wear protective gloves, masks, and gowns. When I attempted to do so, I was threatened with termination of employment by supervisors and attending physicians. The physicians, nursing supervisory personnel, and hospital administrators were presumably motivated by a desire to demonstrate that AIDS virus communicability and the danger of caring for AIDS patients was so low that infection control procedures were not necessary. To employ such measures would have indicated to a fearful public that there existed a real danger in coming in contact with or caring for persons infected with the AIDS virus. In a hospital environment constantly open to media scrutiny, the public’s observation that medical personnel were employing barrier techniques in the presence of their arguments claiming that no danger existed appeared dangerously hypocritical. . It is difficult to comprehend how medical personnel could rationalize any position so inconsistent with and 369 detrimental to time-honored hospital infection control procedures; but, when viewed in the context that a high percentage of key personnel are self-defined as homosexuals and gravitated to San Francisco General to participate in a disease process that, too, was associated with homosexual populations, it then clarifies to the uninitiated why this influential group of medical staff were willing to place their own philosophies precariously above the accepted standard of care. San Francisco’s liberal political and social climate during the 1960s and '70s attracted homosexuals from all over the nation and the world. The AIDS epidemic resulted in the migration of numerous homosexually biased health care workers, administrators, and physicians to work in what was seen as a medical, social, and personal survival situation. Over time, the hospital’s employee population became heavily peopled by homosexuals, many of whom were already infected themselves (Annals of Internal Medicine, 1985; 103:210-214 -- showing as many as 70 percent San Francisco homosexuals seropositive and accompanying death certificates) and eager to demonstrate, by example, that they themselves posed no risk to patients. I was forced to participate in this philosophy by being ordered to facilitate an abject abandonment of infection control procedures wherein nurses were ordered to "develop an effective approach, such as a contract with patients which: 1) acknowledges the patient’s sexual needs 2) stresses the need to protect nurses and staff from unnecessary disturbances 3) arranges for private place and time for sex 4) is noted in the Kardex file 5) is in cooperation with medical staff." These sexual practices, executed on a 24-hour per day basis, were particularly disturbing to me since they exposed assumed to be healthy visitors to AIDS, a known, sexually transmissible, fatal disease. I have witnesses incidents where gloves were not only removed from the wards, making them unavailable for use in code blue and bloody situations, but were ceremoniously burned by hospital personnel in an effort to preserve the psychological and emotional sensitivities of the infected. Unfortunately, but seemingly ignored, was the known reality that AIDS patients harbor, secrete, and are capable of transmitting to others numerous infectious agents including Tuberculosis, Cytomegalovirus (CMV) and a multitude of other infectious organisms capable of infecting persons with normal immune systems. It is my contention that while working at San Francisco General Hospital I was unnecessarily and negligently exposed to these organisms through an egregious abandonment of infection control procedures. This exposure resulted in my 370 acquiring Tuberculosis and Cytomegalovirus infections. The Cytomegalovirus infection then causing numerous congenital malformations in my only son including premature calcification of cranial sutures (which later resulted in an extensive neurosurgical procedure), prematurity, malformation and disease of the genitals and related structures, defects of the axial skeleton, bilateral hearing loss, infection of the retina with high risk of blindness, special high risk of retardation, developmental delays, special high risk of impairment of his future quality of life and earning ability. All the while that this tragedy was unfolding I attempted to use my administrative remedies to prevent this scenario from occurring and being repeated in other health care facilities to other health care workers. The enclosed publication Medical Malpractice, Verdicts, settlements, and Experts, contains a special report entitled: "The Anatomy of a Modern Medical Tragedy: The case of Watson v. SF General Hospital" by Doctor William T. O’Connor, M.D. which delineates the chronology of events leading up to the present time. Included but not amplified was the failure of a number of institutions that were charged with the responsibility to protect health care workers. The Service Employees International Union, Public Employees Local #790, City and County of San Francisco refused to adequately investigate health and safety violations of our closed union shop’s contract or prosecute a grievance and failed to adequately represent me ina binding arbitration proceeding. I filed complaints of health and safety violations with California Occupational Safety and Health Administration and The California Department of Labor. Despite overwhelming evidence to the contrary, the California Department of Labor issued a complete clearance of the hospital prior to Cal OSHA’s termination of the ongoing investigation. This was done, I believe, in a cover-up emanating from the State Capitol in Sacramento because if health and safety violations were found at a federally funded hospital (San Francisco General Hospital) millions of dollars of Federal funds could have been withheld. The California Nursing Association was also notified by myself regarding these health and safety violations. However, they failed to act upon them because I feel their concerns focused more on the confidentiality of the AIDS patients than the safety of health care workers. The inadequate addressing of these problems led toa demoralization of the nursing staff at San Francisco General resulting in numerous resignations, early retirements and medical 371 leaves of absence that culminated in a 40 percent reduction of nursing staff. This caused the loss of nearly 100 beds of hospital capacity due to inadequate staffing. As late as January of 1988, resulting from an unannounced State Department of Health investigation, San Francisco General Hospital was cited for 28 major discrepancies of health and safety violations including a breakdown of infection control policy directly attributable to staffing shortages, inadequate supervision, and failure to implement federal and state requirements in their infection control program. The hospital is still out of compliance as of this date largely due to the above mentioned existent problems and the stark reality that you cannot pay nurses enough to work under these conditions. I relate these occurrences because without intervention the same scenario will be repeated across the nation if the issues of health care worker protection and infection control go unaddressed. In the midst of a critical nursing shortage, as the AIDS problem grows in other cities, health care workers will be threatened by the same set of circumstances I have faced. As long as health care workers are denied their right to know the diagnoses of the patients by this current obsession with confidentiality and their right to wear protective gear continues to be impaired by a delusional misrepresentation that AIDS patients pose no threat to others in close contact with them, they can end up as I have become -- an innocent victim of this epidemic. My recommendations to prevent this and other tragedies are as follows: 1. Federal Legislation should not be motivated by a concern for risk group members’ confidentiality in deference to health care workers’ and the population’s safety. 2. Federal Legislation should be forthcoming that guarantees health care workers the right to test for the presence of the virus and to immediately know the diagnosis so that they can take the "extraordinary precautions" with AIDS patients advocated by the CDC guidelines. 3. The Department of Interior and the Department of Health and Human Services should immediately coordinate their efforts to find specific geographic locations, such as islands, (similar to a policy enacted by an enlightened Swedish Government with a health care system recognized as being superior to our own, innovated wherein those persons infected by the virus are being placed in a health care resort facility in Stockholm harbor) so that the virus and the associated infectious diseases will be prevented from spreading to the general population. 372 I cannot allow the suffering of myself, my family, and my only child to have served no purpose. Therefore, if no Federal Legislation or action is taken on those issues forthwith, it will be my recommendation to all health care workers to reject taking care of any patients who appear to be AIDS risk group members in order to protect themselves, their children, as well as other patients. I am also submitting for the record a copy of San Francisco General’s State Investigation Report, recommending total breakdown of infection control. It’s over here, as well as a California State Health Department Report of Failure to Report 25 Persons of AIDS Death in California, and publication of AIDS: The Alarming Reality, by William O’Connor, M.D., citing 123 document in the scientific literature. And further, in view of my multi-million dollar lawsuits against the State of California, and the advice of legal counsel, I cannot respond to Commission’s questions. MR. DeVOS: You cannot, you say? MS. WATSON: I cannot respond. MR. DevoS: Okay. We thank you very much for coming here to share this with us. MR. DeVOS: Would you care to introduce, is that your husband with you? MS. WATSON: Yes. MR. DeVOS: Would you like to introduce him to us, please? MS. WATSON: My husband is behind me. MR. DeVOS: Good, and that’s Doctor Watson, I believe? MS. WATSON: Yes. MR. DeVOS: Okay. Is that the correct way to say that, Doctor Watson, I believe. MS. WATSON: That’s correct. MR. DevoS: All right. Anyway, thank you for coming and sharing your experiences with us. We’re going to go next to Doctor Rodriguez, from the Shock Trauma Unit, University of Maryland in Baltimore. Doctor Rodriguez? 373 DR. RODRIGUEZ: Yes. I am a trauma surgeon, and I understand there are probably several hundreds of trauma surgeons in the United States. In my specialty, we dedicate exclusively to treatment of trauma victims. We do see an average of about 2,500 critical ill patients every year, from which about 1,000 are patients purely trauma victims. We are intimately involved with the patient’s blood, secretions, bloody secretions, et cetera, and I’m trying to represent the concern of the trauma surgeon in all this situation. We have talked about Universal Precautions, and I think one of my recommendations is to continue enforcing the Universal Precautions. However, it is my understanding, and as I can if you’1l be kind enough to pass this to the table, show an example of how good Universal Precaution is. This is a front-page -- there are several ones -- from The Sunday Capital, the capital of Maryland, Annapolis, which shows, unfortunately, myself after Universal Precautions, full of blood, and my shoes and my pants they are soaked, in other words, the blood soaked the gown, and goes through the shoe covers which are usually cheap because the administrators usually buy something that’s the cheaper thing they can buy. In conclusion, the Universal Precautions fails in my view, and so, I admire Admiral Watkins very intelligent thing, the research that he proposed, because in my view, despite that we are one of the most expensive and sophisticated trauma centers in the universe, Shock Trauma Unit of Maryland, I still, you can see there, Universal Precautions doesn’t work, and I encourage, tremendously, the investigation -- this is supposed to be an impermeable-gowns that protect only to your knees, and below your knees, it doesn’t protect it, and the shoe covers, as I repeat, they are supposed to be impermeable, but you can see all the shadows of blood, they are not impermeable. So, it’s a major concern of trauma surgeons despite, I am very aware of the low number of doctors who has been contaminated with blood in contact with the skin, it is of tremendous concern for us. All what I propose is the encouragement, education, maybe somehow -- I’m not an administrator -- how to encourage administrators in the hospital to buy better gowns, better goggles, better shoe covers, and no waiting, as we are doing sometimes, to buy something cheaper before to buy. Other than that, my last recommendation is reevaluation of the compensation and protection of the welfare of the trauma surgeons and their families. This is one of the major concerns. JI cannot stop taking care of trauma victims, but I am 374 very concerned what happens if despite my Universal Precautions I’m being infected. What’s going to happen to my family? Is my Chief going to let me do surgery anymore? I am going to continue working as a surgeon? It’s a real concern, and I don’t know, and I ask all the trauma surgeons in my institute, we have about 20, and it is a major concern, what is going to happen to our families if we get contaminated? We’re not going to stop treatment, but we are concerned. MR. DevoS: Thank you, Doctor Rodriguez. MR. DevOS: We’ll go to Doctor Phelan next. Doctor Phelan comes to us from the Department of Oral Medicine and Pathology at New York University in New York. DR. PHELAN: College of Dentistry. MR. DevVOS: Yes, get right up to the mike on that, would you? Thank you. DR. PHELAN: Mr. Chairman, and members of the -- MR. DevoS: Say that again, because I may have missed that. College of what? DR. PHELAN: College of Dentistry. MR. DevoS: Okay, fine. DR. PHELAN: Dental care considerations for patients with HIV infection and AIDS fall into four categories: fear of occupational transmission of HIV, resulting infection control concerns, the diagnosis, management and pathogenesis of oral lesions which occur as a result of HIV infection, and potential dental treatment complications which may occur in patients with HIV infection and AIDS. Studies in the United States have suggested that dentists are among the health care providers at greatest risk of acquisition of hepatitis B infection. The similarity of the routes of transmission between hepatitis B and HIV and the recognized occupation risk of hepatitis B infection among dental professionals led to the concern among dental health care workers that there might also be an occupational risk of the transmission of HIV. I was a co-investigator in one study designed to assess the risk of such infection to dental health care workers, and you have a copy of that study. Our study and others have consistently demonstrated that dentists and other dental health care workers are at low risk of occupational infection with HIV. Together, studies of dental health care workers in the United 375 States have included over 3,000 individuals. our study identified one HIV seropositive dentist for whom no other risk for infection could be identified. Other dental studies have not identified any seropositive dentists or other dental health care workers for whom there was no other identified risk. One dentist diagnosed with AIDS is included in the Centers for Disease Control (CDC) series of 41 health care workers with undetermined risk. Although the measured risk of HIV infection for dentists and other dental health care workers is low, the results of studies of other health care workers strongly suggests that there is a risk. Dental health care workers are at risk not only for accidental parenteral inoculation, but also for splashes with saliva containing blood. They are also likely to be exposed repeatedly to persons infected with HIV, often for months or years before those persons become ill or know that they have HIV infection. Moreover, as the prevalence of HIV infection increases in the United States, dental health care workers will treat more infected patients. Studies of the occupational risk of HIV infection among dental health care workers must be continued, new studies initiated, and these studies must be financially supported in order to further define the occupational risk of transmission of HIV to dental health care workers and to present dental health Care workers with the most accurate information possible in order for them to make rational decisions about their behavior. \ In the past, efforts to prevent transmission of \ infectious diseases during dental treatment were centered on the identification of infectious patients and on the use of special precautionary procedures. Emphasis has been placed on taking an accurate medical history before initiating dental treatment in order to identify medical conditions which would require special dental treatment management for medically compromised patients. The attempt at identification of infectious patients has been part of this process. Up to the beginning of the AIDS epidemic, recommendations for dental treatment of patients known to be carriers of the hepatitis B virus included special infection control procedures which were different from those used for routine patients. In the beginning of the AIDS epidemic these same guidelines were applied to the treatment of patients with AIDS. Not until more recently have universal infection control procedures been widely recommended for dental care. In their concern for identification of HIV infected individuals and referral of these patients to hospital dental clinics for dental treatment, dentists have been doing exactly what they were taught to do to prevent occupational exposure to hepatitis B. The experience of dentistry with hepatitis B illustrates that this method of infection control did not work 376 for hepatitis B and should not be expected to be an effective means for reducing the already low risk of occupational transmission of HIV. At the present time the most effective means of preventing transmission of HIV to dental health care workers is by the implementation of universal infection control procedures, i.e., the same procedures for all patients whether identified infectious or not. 1. Studies to confirm the effectiveness of infection control procedures should continue and new studies should be investigated. 2. New dental equipment should be redesigned in order to allow for optimum infection control. 3. Educational programs should be designed to teach the implementation of infection control procedures. These must be incorporated both into dental school curricula and into continuing education programs. 4. Studies to assess the success of education programs for implementation of infection control should be done. 5. Educational programs which provide accurate information to dental health care workers concerning HIV infection must continue and new programs be initiated. 6. Implementation of infection control procedures will add to the cost of providing dental treatment. Fees for dental treatment and third party reimbursement will have to be adjusted to cover this additional cost. Several studies and case reports have described the spectrum of oral lesions which occur in patients with AIDS and HIV infection. These include oral candidiasis, herpes simplex ulceration, herpes zoster, hairy leukoplakia, gingival and periodontal disease, severe aphthous-type ulceration, Kaposi’s sarcoma and several other unusual oral neoplasms and opportunistic infections. Information about the treatment of these lesions is included in several reports. Three oral lesions may fulfill the CDC surveillance definition for the diagnosis of AIDS: chronic Herpes simplex infection, oral Kaposi’s sarcoma and certain types of lymphoma. Although studies of the pathogenesis of these oral lesions and the relationship of these lesions to the natural history of HIV infection have been initiated and funded, additional studies are necessary. Studies to determine the most appropriate treatment of oral lesions will enhance the quality of life for patients with HIV infection. 377 There is no question that persons who are infected with HIV are entitled to dental treatment. Determining the appropriate location for the delivery of this treatment, ina private dental office or a special setting, has been the subject of controversy. The literature contains to date only one report of complications occurring in one AIDS patient following endodontic or root canal treatment. This lack of reports suggests that most dental treatment can be done without complications and, therefore, could be done within routine dental practice. However, there are no reports of studies of dental treatment of patients with HIV infection and AIDS. Therefore, we do not know whether this lack of complications is real. Personal communication with dentists and hygienists who treat many HIV Seropositive patients has confirmed this lack of complications. However, dentists who routinely treat HIV positive patients have developed a variety of different treatment techniques which may or may not be successful in preventing complications. Studies should be initiated which are designed to assess the response of HIV positive individuals to dental treatment procedures. In summary, the impact of AIDS on the practice of dentistry has been extensive. The Human Immunodeficiency Virus has finally forced dentistry to think rationally about infection control. Questions about several oral diseases are being answered in the context of HIV studies. In the final analysis, our profession as well as our society will be measured by the extent and quality of our care and concern for human beings. Thank you. MR. DevOS: Thank you, Doctor Phelan. MR. DevOS: Next is Harriett Olson, a Registered Nurse, from the Visiting Nurse Services, Incorporated, from good old Indiana. MS. OLSON: If I could take this down. You can use it this way. - DevOS: You may, if you like. OLSON: It’s a little easier for me. Sa 5 - DeVOS: Whatever you like -- MS. OLSON: Thank you. MR. DeVOS: -- just so everybody in the back can hear you, that’s the main thing, as well as the people up here. 378 MS. OLSON:' Thank you. I’m very pleased to be here today. I am representing the National Association for Home Care. In the United States, we have over 6,000 home health agencies, and we provide care to people in their homes throughout the entire United States, in every community in the United States. Our involvement with AIDS patients varies, dependent upon the prevalence of the disease within each of those communities, and dependent upon the expertise and the involvement of the agencies, home health agencies that are providing care to those individuals and to those families. The main risk that home health workers face is the risk of being infected with the AIDS virus in the course of caring for others who suffer from that disease. They can be exposed to many, many risk factors in the pursuit of caring for patients who have the disease. They are exposed to the virus as they draw blood, as they clean wounds, as they provide comfort measures to patients who have diarrhea and vomiting. They are exposed when they know that the patient is HIV positive, and they are also exposed when that same patient is undiagnosed. They deliver care in the patients’ homes, and sometimes these homes are less than ideal. The risk factors are multiple, and it just seems to go along with the job of home care. The question for us becomes, whose responsibility is it to safeguard those home caregivers? I believe the responsibility is shared. There are three responsible parties, and those responsibilities are interlocking and they are interdependent. Failure in one area causes the entire system of safeguarding health care workers to fail. The three responsible parties are (1) those who set the standards for protection and enforce those standards, based on the most current information, (2) those who employ health care workers, and (3) those who actually give the care. A fourth one I might also include is those who also receive the care. Let’s talk about those who set and enforce the standards. Research and communicating research findings is of paramount importance. Guidelines which are written and promulgated by the Centers for Disease Control are invaluable to the protection of health care workers. Standards need to be based on the most current information, and they need to be practical. Home care workers are practical people, and they follow directions that make sense to them. They balk at instructions that seem impractical to them. As one nurse said, 379 "It’s fine for CDC to tell us to wear gloves when starting IV’s, but they aren’t the ones out there palpating for the vein or getting the tape stuck to the gloves!" They know the danger of finger sticks, yet they know the needles can puncture latex gloves. Directives for OSHA are necessary, and so is their enforcement. As was reported in the April 23, 1988 edition of HEALTHWEEK, over 18 percent of the 38 health facilities inspected were cited for failure to adequately protect health care workers from AIDS. (That’s a sad indictment on our "caring" institutions.) Most of these citations were for failure to provide education to employees and failure to provide or require protective equipment for workers. The watchdog function is, unfortunately, extremely important. It may always be so, but it is especially important as we employers learn the rules. The next group who are responsible are those who employ health care workers. Certainly those who employ health care workers have a great responsibility to protect workers from the risk of infection. We’re responsible to be informed, and to read and discuss application of guidelines to our unique settings. Home care employers are responsible for setting policies regards AIDS care. The policy developed by Visiting Nurse Service of Indianapolis is straightforward; Whereas Visiting Nurse Service does not discriminate on the basis of other factors, neither does it discriminate on the basis of diagnosis. We give care to people with AIDS. Furthermore, the policy states that employees will follow precautions (and these precautions are written), and it also states which caregivers are prohibited from caring for persons with AIDS -- and these people are those who are pregnant, those who have an infection, and those who are immunosuppressed. Employers are also responsible for developing and implementing appropriate clinical procedures. This includes specific AIDS procedures, such as treatment of emesis with a 10 percent chlorine solution, double bagging of blood samples, and labeling wastes and seeing that they are incinerated. There are also general precautionary procedures and that falls under the rubric of Universal Management of Blood and Body Fluids. This system of infection control minimizes the health care worker's exposure to infection by creating a barrier between the blood or body fluids and the health care worker. The system is based on the premise that any patient may be infected, and therefore all blood and body fluids are considered potentially contaminated. So, gloves are worn whenever handling blood or giving enemas, for example. It’s not just the patient with a specific known diagnosis who is handled with these precautions. All patients are handled this way. 380 The benefit of Universal Management is apparent. No longer do we assume that a patient is not HIV positive because AIDS is not written as a diagnosis. If all blood is handled alike, then the nurse does not have to make judgment on such matters. “Always dispose of sharps immediately in a puncture- proof container" and "Never recap a needle" are easier to remember and do than "Sometimes do this and sometimes do that." There is more compliance with the Universal Precautions; everyone does know what is expected. Another critical responsibility of the employer is to educate, and teaching does not translate to learning, of course, anymore than dictating translates to compliance. Yet it is the responsibility of the employer to make every effort to assure that learning about AIDS and infection control can occur. It means money, and it means time. It means careful attention to the way adults learn. And it really is worth every minute and every penny that we spend. We did attempt to involve our staff initially in the development of the policies, procedures, precautions, et cetera, and yet, there was still non-compliance. It took an expert coming in, talking with them, giving them the facts and the information, and allowing them to come to their own conclusions, which, in fact, precipitated and facilitated compliance with the established policies and procedures. They really weren’t scared when they heard the facts, but they were sobered, and the request for gloves started to be what they should have been before, really understanding the components of AIDS. I relate this experience to underline that educating staff is not simple, and that what motivates one group may not motivate another. Yet it remains the employer’s responsibility to keep at it until it clicks. The other people who are responsible for assuring that health workers are as safe as they can be are those who actually give the care, and the health care worker has a responsibility that cannot be shirked. That responsibility includes using tools and procedures that are available. No one can relieve the health care worker of that responsibility. They must value themselves and they must recognize in a healthy balanced way that they are at risk, and they must be realistic about what they can actually and practically do to assure their own protection, and they must recognize that they have a value. I have several areas of concern related to health care workers in home care. As a health care administrator, I have a responsibility to assure the best possibility safety for the patients, employees, community and agency which have been placed under my care. 381 So, how do I handle an employee, a health care employee, who appears to have symptoms of AIDS? How do I protect that employee’s rights to employment, while balancing my responsibility to provide safe care to the patients and families we serve? At what point do I legally and humanely intervene and require an AIDS test and job accommodation for the direct service employee? I feel that national standards and guidelines should be developed to assist employers in dealing with direct service employees who have symptomatology of AIDS. The second concern is, as a health care administrator I must rely upon the health care professionals to use good judgment in all areas of practice. Agency specific policies have been developed to support universal management of blood and body fluids. But, this includes the increased use of disposable items, such as gloves, gowns and puncture-proof containers for used needles and syringes. There are increased costs, and they are associated with increased barrier protective supplies. Therefore, third party payers need to recognize the justified increased costs and to adjust maximum limits of dollar coverage accordingly. A third concern, in home health care, health workers teach families of AIDS patients to properly dispose of contaminated supplies, such as soiled dressings. Double bagging soiled dressings that have been treated with a bleach or Chlorox solution could result in breaks and leakage. A safer system for disposal of home supplies is indicated. Fourth, home care health workers are part of families, as are all other health workers in other areas of practice. Family members, particularly husbands, object to their family members caring for AIDS patients. In addition, staffing for private duty 24-hour care of AIDS patients in his or her own home can be a problen. Public education and objective, accurate information is crucial to decreasing apprehension about the care of AIDS patients. I thank you for listening to my testimony today. MR. DeVOS: Thank you, Ms. Olson. MR. DeVOS: We turn now to Mr. Borwegen, who is our next panelist here. He’s Director of the Health and Safety Department, Service Employees International Union, from Washington. Mr. Borwegen? MR. BORWEGEN: Thank you very much, and good morning. My job at the Service Employees International Union is to protect our 850,000 public and private sector workers, many of which have 382 exposure to blood and bodily fluids. About a third of our members are health care workers, and most of those are in blue collar positions. In addition, we represent people that are in non-health care jobs that have exposure to blood and bodily fluids, from janitors, to correction officers, to park workers that find IV drug user needles in rest rooms, in parks, to police officers that have to deal with violent individuals and other sources of exposures. On behalf of these workers, I appreciate the opportunity to appear before the AIDS Commission today. This Commission has a broad mandate to recommend the proper course of action on a host of public health issues surrounding the AIDS epidemic. It is important that this Commission add the considerable weight that it has to protect health care workers and others from occupational exposures to this deadly disease. Our union first became involved in this issue in 1984 when fear of transmission first arose among our membership. To assure that health care workers would be able to continue to provide care to their patients, it was critical that irrational fear be confronted with factual information and that adequate safety precautions be implemented. our first step was to develop some of the first educational material in the country for workers. Since then we've produced a publication called "The AIDS Book - Information for Workers," acclaimed by CDC as the best information available for workers, and also a two-page brochure "AIDS and the Health Care Worker," that’s available in both English and Spanish. We’ve distributed hundreds of thousands of both of these items to state health departments, local health departments, lots of health institutions across the country, and, of course, among our own membership. In addition, we’ve conducted scores of seminars across the country as well as Canada, training thousands of health care workers about AIDS and how to protect themselves. Our educational efforts have only served to reinforce the findings of our original research and to convince us that other critical actions must be taken in order to protect health care workers from occupational exposures to blood and bodily fluids. As you know, as you heard this morning many times, the mode of transmission of HIV is similar to hepatitis B -- an occupational illness referred to as "health care workers disease." It is killing hundreds of health care workers every year and striking thousands more. It’s responsible for 11 percent of all lost work days for health care workers. Clearly, this is the deadly evidence that you need to prove that 383 comprehensive infectious disease control programs are not working in this country. To address this lack of infectious disease control procedures we petitioned the Occupational Safety and Health Administration in September of 1986, to issue a permanent blood- borne disease standard to protect health care and other workers that had exposure to blood and bodily fluids on their job. Last summer, I’m glad to announce that OSHA has agreed to begin the standard-setting process and they solicited comments from the general public to help them in this rulemaking process. To assist them, we conducted our own survey of 100 different institutions across the country to evaluate infectious disease control practices. I have provided the Commission with a copy of that report and the comments that we did submit to OSHA that outlines both the survey results and also what we believe a standard should contain. One of the more significant findings in the study, which is particularly disturbing to our union, because we represent predominantly blue collar health care workers, is the comparison between occupations where people are most likely to be exposed to blood and bodily fluids, and those that are actually receiving the training and protective equipment. What we found is that, while 75 percent of the registered nurses in the facilities surveyed had received infectious disease control training, only 55 percent of nurses aides had received the same and 35 percent of laundry workers. Regarding provision of hepatitis B vaccine, while two-thirds of departments surveyed made them available to registered nurses, the vaccine was provided only to 40 percent of nurses aides and 27 percent of housekeeping personnel. Yet in one study that was published back in 1981 of needlestick injuries in the Journal of the American Medical Association the highest rate of injuries of needlesticks was among housekeeping personnel -- 127 needlesticks per thousand workers per year, compared to 92.6 needlesticks per thousand workers per year among registered nurses. This Commission could provide invaluable assistance to the many individual health care workers who are fighting for adequate work site protections against infectious disease, by acknowledging the contribution of health care workers who have responded to the AIDS epidemic responsibly and compassionately despite inadequate protections. Second, I urge you to include in your next report, a strong statement on the need for both adequate infectious disease d 384 controls and consideration of the stress of health care givers, involving AIDS patients. Specifically, I urge the Commission to endorse the OSHA efforts in your final report in regard to infectious disease control to call for the expeditious completion of a permanent infectious control standard as soon as possible, but under no circumstances to exceed one year. Such an endorsement would be a major boost towards the work site protections health care workers have long been denied, and will go a long way toward easing these caregivers’ fears of treating patients with infectious diseases. It’s said that AIDS can only be prevented exclusively through voluntary actions -- and for the so-called high risk groups, such as IV drug users, homosexuals, perhaps, promiscuous heterosexuals -- this is largely true. However, for the nation’s health care workers, and millions of other workers at potential risk, they have no choice. They are involuntarily exposed to blood-borne diseases as they struggle to earn a living and earn a pay check. This one specific action by the federal government to issue an OSHA standard can have a significant impact in stemming the morbidity and mortality caused by this national epidemic, as supported by substantial documentation and consensus on the need to act. I thank you for inviting us to speak, and believe our recommendations provide the Commission with a unique opportunity to act to provide health care workers and other workers with the protections they need and deserve. 4 Thank you. MR. DevoS: Thank you, Mr. Borwegen. MR. DevOS: We're going to go next to Julie Chamberlain, who is an R.N., Infection Control Coordinator at Butterworth Hospital, in Grand Rapids, Michigan. I don’t want to bug you, Julie, but you are next. MS. CHAMBERLAIN: Thank you. I am the Infection Control Coordinator, in charge of bugs (microorganisms). I really appreciate the opportunity to address you, Mr. Chairman, and also the rest of the panel, on the fear of health care workers. I would like to report on the reactions of staff from my experiences as Infection Control Coordinator at Butterworth Hospital. We are a 529-bed community teaching tertiary referral hospital in the conservative Midwestern city of Grand Rapids. I have submitted more extensive testimony to all of you, which you have, and I will be very brief in my summary. I am responsible for the education of the health care workers at Butterworth, and also, responsible, with a committee, for the implementation of infection control standards. 385 We now have in-house in treatment at least one or two AIDS patients all the time. In 1984, we first treated two male AIDS patients; now we treat about 20 a year, in every department of the hospital, from the ER to pediatrics, to adult intensive care. We/’ve had none in the nurseries. Education about AIDS has been ongoing since 1983. We’ve taught the use of universal barrier precautions to prevent staff exposure to blood since July, 1987; that’s in addition to the usual isolation precautions suggested by CDC. The equipment needed to practice Universal Precautions is easily accessible to our staff in all patient areas; and I must tell you all in answer to your questions that we also educate the volunteers, we educate the EMTs, we have programs for the house staff, the nurses, housekeeping, -- every department in our hospital. Reactions of health care workers at first varied from refusal to wear gloves to over-reaction; for instance, refusing to enter the room of an AIDS patient unless assured of an environment which was 100 percent safe. Staff at first refused to believe that we did not need extraordinary sterilization and disinfection measures to clean instruments, furniture or roons. A mortician threatened a lawsuit because he felt he needed to burn his new $300.00 suit, which he had worn into the room of an AIDS patient. He did not have contact with this patient. Staff with least exposure feared AIDS the most. Some staff also reflected a judgmental conservative, fundamentalist, religious approach, ‘believing AIDS to be God’s vengeance on homosexuals. Even after extensive education, one is uncertain and fearful the first time one cares for an AIDS patient. Usually, common sense prevails. Gloves are worn, and simple hand washing following glove removal allows the health care worker to provide appropriate, compassionate care without fear. However, practicality disappears when a doctor or a nurse accidentally pokes oneself with a needle from a patient with AIDS, or a hemophiliac who has infected blood. Instinctual terror and panic result, in spite of the low odds. Unrealistic fear, hostility and anger control the mind, as this minor exposure could cost one’s life. All staff require appropriate counseling as this extreme stress and anxiety must be lived with for at least six months until the usual time span for blood conversion expires, and one is no longer, we hope, at risk of conversion. This type of accident has persuaded our trauma doctors, ER doctors, OR doctors, nurses, respiratory therapists, for 386 example, to now wear gloves and glasses for all contact with blood or the possibility of blood splashes. Some patients, whether in the ER or intensive care, won’t tell the staff they have AIDS. One patient divulged his status three weeks after being on a ventilator. The staff felt exposed, angry and manipulated. Counseling assisted the staff to handle their hostility by understanding the psycho-social implications of the disease involving this patient’s children, mother and siblings. Another wouldn’t allow his blood to be tested, even though he was a hemophiliac at high risk, and a nurse had accidentally splattered blood in her eye. Staff empathized with the hemophiliac who stated, "I’m not one of those; I can’t let my neighbors know I have AIDS." The nurses made sure the five-year old hemophiliac was not isolated, but treated like other children. However, they did wear gloves if contacting his blood body fluids. We searched the city to find a dentist who would check this child’s teeth. In summary, staff are frightened but won’t refuse care or divulge the information about this patient inappropriately. Infected patients must inform their physicians. Mandatory screening, however, of all patients after informed consent is not appropriate unless a more exact lab test can be used. . ° Health care workers feel they have'a right to be protected from a knowing exposure to the contagious blood of this deadly disease, and expect the equipment to be available, which provides some protection. If an accident occurs, mandatory medical follow-up and counseling for at least six months to a year for the health care worker must be provided. I thank you for this opportunity. MR. DevOS: Thank you, Julie. MR. DevOS: John, we’re going to start with you on our next go around. I’m sure all the panelists know the rules of the game around here. They all get one shot, theoretically. Some of them have several follow-up questions always. We try to go through it once, and then come back, and we’ve never been able to get around twice. We’ve barely gotten around once. MR. CREEDON: I address this question to the panel generally. Obviously, from the standpoint of the health care provider, it’s desirable to know whether a patient has AIDS or not, or has the virus or not, so that, if there is a situation 387 where blood or other body fluids are involved that the provider knows about it. You know, there are supposed to be somewhere between 900,000 and 1.5 million people out there with the virus. How do you feel about -- I mean, how do you know whether a patient has it or not? Should there be, in the case of hospitalization, mandatory testing when someone comes in, or do you just rely on happenstance to decide whether someone has it? It seems to me there are two problems. One is, how do you know whether someone has the virus, and then, if they have the virus, how do you treat them? What should be the protocols in order to control this infectious disease? And, certain types of infectious diseases, I guess, in a hospital the patients are kept on a certain floor, and people wear masks and so forth. No, that’s not done? MS. CHAMBERLAIN: Well -- MR. CREEDON: Hepatitis, or other types of infectious diseases? MS. CHAMBERLAIN: -- there are definite guidelines published by the Centers for Disease Control, which all hospitals follow, called "Isolation Precaution Techniques," so thet the transmission of the spread of these contagious diseases from one person to another, from a patient to a staff member, doesn’t occur. As far as AIDS is concerned, you aren’t always going to know if the person is infected -- if the blood is contagious or not, because the symptoms aren’t always there. And, as you heard, the patient doesn’t always tell the physician in the history. MR. CREEDON: Well, the patient, him or herself may not know. MS. CHAMBERLAIN: The patient may not know, that’s correct. And so, the use of Universal Precautions makes a great deal of sense. MR. CREEDON: But, there is no clamor among the providers, the nurses and so forth, to have mandatory testing? MS. CHAMBERLAIN: Well, mandatory testing, with our current test system, is not accurate, because there is a window phase where you could test -- MR. CREEDON: Well, I understand that, but -- 388 MS. CHAMBERLAIN: -- you could test us, and there is a whole year -- MR. CREEDON: -- But at least it would identify those cases where the window phase has passed, and maybe, it’s not going to be 100 percent accurate in terms of picking up all the people who have the virus, but if someone has had the virus, or the window phase doesn’t apply for some reason, it would pick up those who have the virus, and who may not know that they have the virus. MS. CHAMBERLAIN: It would pick up some who have the antibody, but -- MR. CREEDON: Well, presumably most. MS. CHAMBERLAIN: -- it doesn’t pick up everybody. MR. CREEDON: Presumably most. MS. CHAMBERLAIN: We’ve had some patients who have not, who have been very ill and have died of AIDS-related complex, very documented AIDS-related complex. However, that man did not have the antibody. And, the people who come in through the ER, in the trauma areas, and when you are delivering a baby, sometimes there isn’t time to test. MR. CREEDON: Yes, well -- MS. CHAMBERLAIN: So that, the mandatory testing is going to leave a lot of people out. MR. CREEDON: It’s going to leave a lot of people out, but it’s going to bring more people in than now. MR. BORWEGEN: I’d like to respond to that. As the largest health care union in the country, our members call us all the time saying that they want to know whether or not someone is seropositive, or whether or not someone has the AIDS virus. And, the labor movement has fought for the last 15 years for chemical rights to know because we believe workers have a right to know about hazards that they face in the job. However, there is insufficient protections against discrimination for housing, for employment, for health care for people that test seropositive. And also, if Universal Precautions are strictly followed, then there is simply no need to know, because you are 389 treating everyone like they are potentially infectious. And also, you are not dealing with what’s killing more health care workers than anything else, hepatitis B. So, what are you going to do, are you going to screen for hepatitis B, are you are going to screen them for AIDS, you are going to screen for all the other blood-borne diseases, or, are you going to make sure -- MR. CREEDON: Maybe, maybe. MR. BORWEGEN: -- that they follow Universal Disease Precautions? What I’m saying, Mr. Creedon, if they follow Universal Disease Precautions, and that there is a system in place by the federal government through OSHA to make sure that that training and equipment is provided, then there is no need for health care workers to know this information that can have devastating consequences on the lives of afflicted individuals. MR. CREEDON: Well, I suspect the likelihood of everybody following Universal Precautions in every situation is less likely than people following precautions that should be taken where there’s a known risk factor. If you knew someone had hepatitis B, you would darn well follow the precautions that you should follow, or if you knew somebody had the virus, you would follow then. If you have to follow these precautions in all cases, every single hospitalization case or whatever, it seems to me the likelihood of people really following it, just as an enforcement matter, seems -- DR. PHELAN: The question you are asking I think is a very important question. There is a point at which we have to look at how we can make health care workers the safest possible. For many people this means to identify as many people as possible, and then treat those people differently. The question that has to be answered is, "Is there any way that that makes anybody safer?" And, if you look at dentistry, and you look at dentistry’s experience with hepatitis B, (and since that’s my field I know a little bit more about dentistry than others), that’s exactly what dentists have been working very, very hard to do. They take a very careful medical history in many instances. They identify people that have had hepatitis at all, and then they go about testing those people to see if they can identify the carriers. 390 Despite these attempts at identification, dentistry is one of the health care professions that is at very high risk for infection with the Hepatitis B virus. So, dentistry’s experience with Hepatitis B and this method of infection control has failed, and my concern with HIV is, if we put our emphasis on identifying a person who is infected, there are some people that are going to be very easy to identify. If we put the emphasis on trying to identify patients, we give health care workers a false sense of security when they use their infection control procedures for those patients, and then relax on others. Infection control isn’t easy, but the more it’s habit, the easier it becomes. MS. CHAMBERLAIN: I guess I’d like to also tell you that I just heard a study in an oral presentation by Doctor Wenzel from the University of Iowa, who was testing gloves, these latex gloves that it is suggested everybody wear in contact with -- to protect us from contact with blood, and the data is not in that the gloves are protecting you completely. Okay? You must also wash your hands, and, unfortunately, washing your hands with soap and water sounds like something your mother told you, and nobody -- I mean, we’re thinking, ah, it’s much too simple. But, it does get the viruses and the bacteria off your hands. And, the data is not in that gloves are going to protect you completely. . MS. OLSON: In home care, we’ve always worked with a population with an undiagnosed condition, and that’s always been a big problem in the community. The best protection is, as you’ve explained, just using good infection control procedures. The problem has been, in the past 20 years, there’s really been a lessening of emphasis on that, and a lessening of practice by the health care workers in the home care settings for that type of procedure. I think what the AIDS epidemic has done, has reinforced the need for good infection control practice, and as a result of that, professionals and health care workers are doing what they should have been doing to begin with. I do agree that if the diagnosis were known for those we care for in the home, we would work differently with families in terms of how they handle certain equipment and supplies, and some of their work load would be reduced significantly if it were not necessary to do that. 391 But, right now, we treat everything as potentially infectious and use good basic infection control procedures. DR. RODRIGUEZ: I would like to state in regard to trauma, that it is very difficult to convince people. By example, we have an Infection Disease Committee control, infection controls nurses, etc. But convincing them is difficult, there, because they are not there at 3:00 o’clock in the morning when the three or four people come, full of blood, they are not there. It is very difficult to convince them. It took me a year to convince that my shoes are full of blood all the time, there is no showers available, that the gowns are not impermeable, still it took me another year to convince the administrators in the hospital to buy something more reliable. MS. OLSON: Doctor Rodriguez, you can’t always find the equipment and supplies that you need. DR. RODRIGUEZ: Correct. MS. OLSON: You know, even if you want to, and you are willing to spend the dollars, the technology for some of the design is really not available. DR. RODRIGUEZ: That’s where I agree with Admiral Watkins. I never heard that, but I think it makes sense. I mean, aS an example, the technology we have now is not sufficient. : MR. DeVOS: We’re going to move on to Bert Lee here next. DR. LEE: Mr. Chairman, fellow Commissioners, we are hearing some amazing things with this panel. We are hearing that in the early ’80s, that this nurse that left was asked to enter into a contract to arrange for a private place and time for sex in the hospital. We are told, at the same time, that a assistant director of this hospital said that, "To wear gloves and masks at any time is wrong, misrepresentative and ignorant." I also read in the medical malpractice newspaper here, that she included as part of her testimony that one of our fellow physicians intentionally and maliciously sewed his estranged wife’s vagina shut during a hysterectomy, and was sued for $5 Million in punitive damages. I will have to say that we have to get our act together. The dentists are long overdue to improve their infection control. So, it gets back to Admiral Watkins’ admonition, I think we have to get our precautions together and make some minor improvements. Until that is done, we can all protect ourselves, though. I think we can double gown, protect 392 our feet, wear the proper glasses, even if the hospital doesn’t give them to us. In Memorial Hospital, we were using hepatitis precautions in 1981 for anybody with AIDS or ARC, and having single rooms. This was common knowledge as far as I knew. So, this is all unbelievable information to me, and I hope that we can write some very strict provisions in our Commission report. Thank you, Mr. Chairman. MR. DevOS: Thank you, Bert. We’re going to -- do you want to comment to that? MR. BORWEGEN: I’d just like to add that you have to realize that today health care workers have no legal right to demand either training, or protective equipment, or the free provision of the hepatitis B vaccine. We are talking about very basic rights. I get calls on a weekly basis from our members, that the infectious disease control programs simply are not working, and we have no legal rights, and that’s why we have taken this drastic step of petitioning the Occupational Safety and Health Administration for a standard in this area. MR. DevOS: Okay. We’1ll go to Admiral Watkins next. CHAIRMAN WATKINS: Doctor Phelan, we’ve had presentations before the Commission in the past from American Dental Association representatives and the like. There have also been surveys run, and we have significant anecdotal information reported to us by dentists who do work on AIDS patients. Along the lines of Ms. Chamberlain’s comments, you searched the town to find one. The recent conference of the American Dental Association, over 1,000 dentists indicated that four out of five would not serve an AIDS patient. And, while your approach addresses the medical side of things, it doesn’t mention the issue that the real impulse is economic. You lose your other patients. And so, I’m worried that if we jack everything up to get your equipment in line, and get all the other things for the dentist, and we determine the HIV positivity of your patient, and the patient is positive, that you are going to take advantage of the ADA ethics, which says you can refer them elsewhere. DR. PHELAN: That’s right. CHAIRMAN WATKINS: So, we have a social problem, it seems to me, among health care professionals, including the 393 dentists, that when we get all this stuff done they are not going to serve AIDS patients anyway for other purposes. So, I really think that we’ve got to be fair and honest about ourselves, and address this thing in its other context, which is probably a bigger bar to getting on to controlling this epidemic than the mechanics of the. things we’ve been talking about. I’m not a proponent of an ethical standard which would do other than what you’ve recommended, which is, they must serve the individual once that HIV positivity status has been determined. And, I’m not sure that’s the case. DR. PHELAN: I agree with you. I think that there has been a great deal of difficulty among HIV positive patients in getting dental care. In New York City at the present time, if I needed to find a dentist who would treat a person who was HIV positive, I would not have difficulty doing that, but that does not mean that I could send that patient to any dentist in the City. What tends to happen is, the more people treat HIV- positive patients, the more comfortable they become doing that. I think that one of the places that we have to start is within our dental schools. Dentists have believed in the past that they were at very little risk for anything, and the idea that they are at risk for Hepatitis B really never made a dent. Somehow HIV did, for all of the reasons that it’s also made a dent in the other health care professions, it made a dent in dentistry as well. Some of the reasons are discriminatory, but some of the reasons are also the tradition of dentistry. Dentists have believed that they could make their practice safe by doing something different. We have taught that right up to the present, that if you identify a Hepatitis B patient, you do something different. If you teach dentists that for Hepatitis B when an HIV-positive patient walks into their office, they are very likely to do exactly what they were taught. So, we have to change the way dentists are taught. CHAIRMAN WATKINS: Well, I appreciate your forthright statement in that regard, because I don’t think we’ve received it to date quite that way, and I appreciate your willingness to face the dual issues here. Because, the other issue is every bit as significant as a bar to getting on with good health practices, as the equipment and the protective devices. Thank you. 394 MR. DeVOS: Thank you, Admiral. We’re going to go down there to Frank. Frank is going to pass. Gebbie? Gebbie, do you want Frank’s time? MRS. GEBBIE: No. I promise I’ll try to follow your rules this time. I get too interested. I am at least as interested in the process by which we arrive at things, than in where we arrive. A piece of what we’ve heard in several forms from various people is the gap between policy-makers and practitioners, the gap in the middle of the night when you can’t find what you need, or the gap with blue collar workers who might not be as much involved in what’s going on as the infection control nurse in the institution. I would appreciate, then, hearing any ideas, insights, issues that you could raise on what it is we as a Commission could say or do that would move the process along so that those folks who are having to remember to put the gloves on, or remember to wash their hands, or find the gown at 4:00 a.m., will feel as much a part in the decision that that’s what they should do, as they, apparently, feel the burden of having to do it all by themselves out there on the front line. How do we break that we/they division, what is it we as a Commission could do that would break that we/they division and make this process work better for folks? MS. CHAMBERLAIN: I guess I/’1l1 try to answer you a little bit, in that you are hitting at the very basis of the educational process. As somebody mentioned earlier, you can teach all you want to, but unless you can get people to buy into that and change their behavior, they aren’t going to follow what you’ve taught them. And, HIV has made them stand up and be alert and be afraid, and to start following practices that we’ve been teaching all along but nobody’s followed. I don’t think that legislation alone is going to make people change their behavior. Somehow you must make sure that the actual facts, the actual scientifically-based facts, are appropriately marketed and sold to the general public, and to the health care people. For instance, Dr. Koop had a wonderful brochure out; however, I don’t think half the people in the United States saw that brochure. Certainly, everybody in the United States heard about Masters and Jonhnson’s study because of the difference in the marketing techniques; if you could help publicize appropriately these actual facts and protective measures, like the book publishers do, it would be very, very helpful. The new brochure that’s coming out to every single family will be helpful. This whole Commission meeting, I think will be helpful, your emphasis on the AIDS brochure, but it has to be publicized and marketed appropriately. Legislation and people- professionals particularly, we don’t like to be told what to do necessarily, or legislated what to do. We would like to 395 emphasize our professional judgment. If you could encourage discussions, if you can encourage group meetings to discuss this kind of thing, you could make a change in behavior. DR. PHELAN: I think also, as we design educational programs, we have to be careful not to give too much all at once, because I think some of our health care workers just get overwhelmed by being told that they have to do about 17 things different tomorrow. There is a priority -- you can prioritize some of the things that they need to do, and go one at a time, so that things become habit, maybe five at a time, rather than 17 at a time. But, I do think that some of the people that I’ve worked with have just gotten overwhelmed by the number of things they get taught in one educational session, so that, it sounds much more difficult than it actually is once procedures become habit. MRS. GEBBIE: That sounds like good advice to people teaching it. I’m asking what it is we as a Commission could do that would help in that kind of thing that you are pointing out. MR. BORWEGEN: We begrudgingly decided to petition OSHA for a standard after we spent years training people and talking to people all over the country, and producing educational materials, and we found out that infectious disease control programs simply are not working. I’m not going to continue to listen to the American Hospital Association’s argument, if you can call it an argument, that, yes, they admit that infectious disease control is terrible, but we think regulation is not necessary. Now, these seem to be contradictory statements, and we feel that regulation, while I agree with my colleague to my left, is not going to be the complete answer, that he’s going to move the agenda, it’s going to increase the adequacy of infectious disease control practices, because it is going to give workers the right to demand that they have training and they have equipment. And, right now they do not have that legal right. Again, as something as basic as free provision of the hepatitis B vaccine, this vaccine costs over $100.00, a significant proportion of our membership makes less than $5.00 an hour in these blue collar jobs in these health care facilities. These kind of basic things, yet the health care institutions have had years and years to deal with this situation because of the hepatitis B situation, and the fact that we have 12,000 to 15,000 health care workers a year getting hepatitis B is proof positive that infectious disease control practices in the current situation do not work, and that additional action is needed. 396 \ Therefore, we would urge the Commission to strongly urge OSHA to proceed with rulemaking. And, in addition, responding to a question from the first panel, the research branch of OSHA is called the National Institute of Occupational Safety and Health. This would be an agency that could do research on the efficacy of personal protective equipment, and I think that, again, the Commission could ask that NIOSH be given this mission to study the efficacy of personal protective equipment to make sure that it’s adequate. MS. OLSON: I think one of the major things you could do, that’s not possible right now, is to clarify the conflicting informational base. One of the problems that the health care workers have is that there is conflicting information about what safeguards to put into practice. For instance, on the West Coast, in our industry, they handle the care of AIDS patients in a very different way than they do on the East Coast and in the Midvest, and it has a lot to do with the way we are interpreting the data that’s coming out and the precautions that need to be in Biabe. | So, the one factor that would help aid and assist | health care professionals in buying into this process would be if the information could be clarified and be pretty consistent.! I think that is impossible right now, because our informational base is evolving as we learn more about the disease and about the process itself. But, that’s the one piece that has played a significant part in the process of health professionals buying into good practice. MS. CHAMBERLAIN: Excuse me. I’d like to respond to that a little bit. I agree with you that the data has to be clarified. However, I am in contact with colleagues from all over the country, and I have found that, perhaps, it’s some of the areas that are in the country areas, rather than in the suburban areas or the teaching centers, that are more confused about the appropriate practices. T think if you are in a university, or if you have access, if you are in a city area, that you have more appropriate guidance as far as scientific data, sometimes, okay? It depends on the interpretation; there is confusion, I agree with that. DR. RODRIGUEZ: I think that education should be emphasized, however, I don’t think it’s enough. In the trauma experience, our infection disease control lady has given 2,000 conferences to RNs, MSs, BSNs, CSRNs, they are intelligent 397 people. However, you can see after the meeting area where everybody is precautious with their patient, the patients goes to their regular floor, it is the same patient one hour later, for some magic thing they think the patient is cured. There is no contaminate, he is not contagious anymore. The precaution decreases 100 percent. So, who enforced that? We tell the infection disease control people, they say, "Well, we cannot take the hose to drink the water. We tell them to do it, but they don’t do it. What can we do?" So, in my view, education is not enough. There has to be something mandatory, it is mandatory that they have to have the precautions, and I don’t think that exists. I see breaks all the time in that mandatory precaution systen. MRS. GEBBIE: Ought it be a basis for disciplinary action of the person who doesn’t follow it? DR. RODRIGUEZ: My wife is a nurse, and I sometimes feel like that, because I am protecting myself, she is not protecting. What good is me protecting myself? MR. BORWEGEN: I would agree that disciplinary action has its place, as long as you have a comprehensive program in place. And, obviously, you can’t -- it would be unethical, I believe, to discipline a worker that was not adequately informed about the risk posed by blood-borne infectious diseases, nor provided with adequate equipment. So, I think discipline has its place ina comprehensive program, but, obviously, we would like to deal with these other factors. I think we really have to talk about changing the entire mind set of the health care institution, so that people have a tendency to -- you know, people have to make sure that they have the time necessary to also practice these preventive procedures. A lot of our nursing home workers don’t have time to wash their hands in between patients because of short staffing, and I think staffing is a major factor that is affecting the adequacy of workers practicing adequate infectious disease control practices, even though when they know what they are supposed to do there is a contradiction between what they can do because of time pressures and lack of staffing. DR. PHELAN: Can I make a comment? MR. DeVOS: Yes, go ahead. DR. PHELAN: I think one of the things that I think you could do is to make a decision, and I would hope that I would agree with your decision, about the separation of patients and 398 identification of patients in the area of infection control, because I think that’s an area that is going crossways in many areas. There are people that so desperately want this identification, and then there are those of us that are saying so strongly that that identification for infection control is not going to work. And, I think it would be very helpful if it would be possible for you to make some kind of statement about that. MRS. GEBBIE: You say that, I think I heard the whole panel say, if you were making that recommendation for us, you would say don’t distinguish, deal with the precaution control. DR. PHELAN: For infection control. MRS. GEBBIE: For infection control purposes. DR. PHELAN: That’s right. MR. DevoOS: Don’t or do? DR. PHELAN: For infection control purposes, and I make that very clear, because I think that for many other reasons, knowing information about patients would be important to predict the response to dental care. Ms. Olson made the comment about the difference in the management of families. So, I’m not saying that that information should not be available in certain circumstances, but for infection control, that piece of information is not likely to make people safer. MRS. GEBBIE: Thank you for that very clear distinction. I appreciate that. MR. Devos: Theresa? DR. CRENSHAW: I agree with the application of Universal Precautions in all circumstances where one can, and I think it’s long overdue in both dentistry and medicine, not just in relation to AIDS, but in relation to whatever the future holds in terms of new infections that we have to contend with. But, on the other hand, I don’t know of any example in medicine where not knowing something, or lack of knowledge, is an advantage. With the issue of Universal Precautions, I certainly wouldn’t want someone knowing that someone was infected, cause them to be cavalier or casual in caring for someone else. I think that needs to be reinforced over and over again. But, on the other hand, this issue often gets linked with, don’t test, don’t find out, don’t know, and I’m completely on the other side of that coin. So, I was very pleased to hear 399 you raise the issue that there are circumstances which, of course, I consider any time a physician or a nurse is caring for a patient, when they need to know the full scope of medical information about that particular patient to best manage their care, and I’m glad to see some nods and some agreement on that point. I think there is a problem that you are contending with. It was highlighted by Norma Watson’s testimony, and, that is that the authorities within the health care profession have done a 180° turn in recent years, where she had to go to court to take the very precautions that are now mandated by the CDc. So, the messages have been mixed. They are getting to a point where I think people are coming to consensus on these things, at least that’s my opinion. Then there are cases, such as Doctor Rodriguez, where the Universal Precautions, as best you try to apply them, and the firemen and the police, there are many times where that isn’t a possibility. The one area that I think has been constantly overlooked that I want to bring up is the psychological side of the opportunity to take precautions. With dentists, for example, who aren’t treating patients, I would suggest that if they were -- or, health care workers, such as the 40 nurses who resigned, if they had been even humored emotionally and allowed to take the precautions that made them feel safe, as long as they did no harm to anyone, then it seems to me we would maintain a lot more people in the profession and keep them treating sick patients. So, I’d like your comments on that, because I think that that’s a commonly neglected point. We are always trying to deal with the specifics of knowledge at a given moment in time, and not the feelings of the people that go along with it. MS. CHAMBERLAIN: I guess I could address that from the health care worker’s standpoint, in that we have found that everybody in our institution is much more comfortable now that everybody can wear gloves, and is supposed to be encouraged to wear gloves if they are going to touch anything wet. Okay? They just put on gloves. And then, they wash their hands. And, we do have the puncture-resistant needle boxes around, and we do have the resuscitation masks available for anybody to use whenever it is needed. It gives a sense of security, so that they feel sure of themselves. They feel technically proficient. The thing that we cannot seem to break people of doing is to change their habits. For years the medical profession, and the nurses also, if you 400 were going to be giving a shot, for instance, and you had a syringe with a needle on it, you gave the shot and then you very carefully broke that needle and put it away. Or, otherwise, you recapped that needle and then dumped it -- that behavior is very, very difficult to change, very difficult to change. We can have puncture-resistant boxes, and we can tell them, and we can practice with them. It’s their behavior that they have to remember to change. MS. OLSON: I think the psychological-emotional part is extremely important. Before we ever rendered care to AIDS patients, we talked with the staff in terms of, what are the items that they really were concerned about, afraid of, and what did we need to do to deal with those. It really came down to, essentially, the basic understanding of the disease and its process, and that understanding base for them allayed and diminished a significant amount of the fear. Also, we began to institute the supports that they felt were important in their practice. Our bigger problem, which we have difficulty dealing with, is the real concerns of their family members. And then, the bigger problem than that is the real concerns of the families of AIDS victims and how they are dealt with in the communities, and how they are unable, really, to be able to relate in the community that, in fact, they’ve got a son, or a husband, or a friend who has AIDS. That’s a really bigger problem that needs dealt with. The mothers of AIDS victims is of significance. DR. CRENSHAW: Do I understand that there is a fairly good consensus on the panel that testing should not be linked to infectious disease control prerequisites, but that it is encouraged for the medical management, and care and understanding of the patient? MS. OLSON: Yes. DR. PHELAN: Yes, very definitely. DR. CRENSHAW: Okay. Anybody else have a comment? MR. BORWEGEN: I was just going to say, we really have to look at the bigger picture regarding the supply of health care workers in this country, and if the federal government doesn’t give a signal to the health care workers of this country that it’s doing all it legally can do to protect these health care workers, it has long-term consequences regarding our ability to adequately staff our health care institutions. 401 DR. CRENSHAW: I might mention that there was a case this year, that shows our problems and troubles aren’t over, in San Diego, where a nurse found that USCD Hospital, University Hospital, was not following the current public health guide precautions for infection control, and tried to handle this through channels. And, they tried to fire her. So, she then went to the press, and this is so recent. Now, public health, I believe, has really tried, I think they’ve put a $10,000.00 fine on hospitals that don’t comply. So, we’re getting some progress, but cases like this illustrate the problems we still face. MR. BORWEGEN: I would just to point out a Clarification of that $10,000.00 fine. The problem is right now that they are just citing facilities under what’s called the General Duty Clause of the Occupational Safety and Health Act, and it’s a very vague clause. That simply says the employer will provide a safe and healthful workplace. We just met with OSHA officials last week, and it’s clear that they really can’t go in and cite facilities, for instance, for failure to provide free vaccine, failure for the hospital to provide written standard operating procedures, and that they really need to go ahead with the permanent rulemaking, where all affected parties will have an opportunity in a public forum to work with OSHA to develop the best standard that we can use in the health care facility. It will talk about where needle disposal containers need to be placed. It will be very prescriptive, but it will also give health care workers assurances that, in fact, the federal government is really doing something. Right now, OSHA is really treading on soft ground on trying to use this General Duty Clause. It’s just a matter of time before, we believe, it’s legally struck down in the courts. MR. DevOS: Thank you. I’m going to go back, Frank’s got a comment here. DR. LILLY: I’ve just been pre-associating here for a minute, and let me follow a line of thought that’s been going on up here somewhere. I’m going to assume that health care workers are pretty well covered with health insurance for themselves, and that infections that are acquired in the line of duty are covered. I get both yes shakes and no shakes of heads here, but the real answer to that is not what I’m getting at. So, on the assumption that that is true, I’11 proceed. 402 Then, we've heard from you recommendations that there should be mandatory regulations installed for health care workers to perform under in order to protect themselves. I’m wondering if that does happen, does that then invalidate any kind of health care that you might need as a result of occupational infection? Does that relieve the employer of responsibility for that? MR. BORWEGEN: The employer continues to have the sole responsibility for worker health and safety. If someone gets hurt on the job, employers and workers are covered by the exclusive remedy of Worker’s Compensation, so, therefore, if you develop AIDS on the job you can’t actually sue your employer, but you do get Worker’s Comp benefits. I would beg to differ, though, with your first statement. In fact, a large percentage of our nursing home employees do not have health insurance, and every time we negotiate a new contract with hospitals, they are trying to increase the co-payment that our members have to pay for health insurance. So, a lot of our members do not have health insurance, and they are health care workers. MR. DevOS: Thank you, Frank. We’ll go to John Creedon. MR. CREEDON: I just want to be sure that I understand Doctor Crenshaw’s position, but I have to get her attention first. I want to be sure that I understand your position in this area. You made a statement to the effect that as medical doctor you would, obviously, want to know the most that you could know about the condition of a particular patient. And, that goes back a little bit to the question of whether the patient has been tested. If the patient has been tested, and has the virus, you at least know about that in treating with that patient. The patient may have the virus and it doesn’t show up, because of the window problem or whatever, but that’s a situation where you can’t get that information. But, the principle is, get as much information as you can about a patient before you treat them, especially if it’s a surgery, or another situation where there is exposure to infectious disease. My reading of the panel is that, despite that, they would not favor testing everybody that comes into the hospital. 403 I’m not sure, Doctor Crenshaw, what your view is on that, and I would appreciate if you would expand a little bit on it. DR. CRENSHAW: I think that it’s of critical value in the care of someone who is HIV infected that the physician and the health care staff know, and I think it’s becoming more and more obvious and a more prevailing view among many health professionals. The ability, for example, to institute low-dose AZT to prevent the onset of developmental symptoms of AIDS and other drugs as they become available, covering someone more aggressively with antibiotics at the first blush of an infection, advising a patient of all those things to do that we heard yesterday, or what you shouldn’t do if you are infected, such as going to visit a friend with the flu, or various other, you know, simple things like that. So that, the issue of knowledge of the results of that test by health care workers is becoming more and more obviously critical to the care of the patient who is infected. I state on general principles, that not knowing something about your patient’s care as a physician or a health care worker or nurse has never been an issue in medicine before. When we’ve had an available test, we’ve used it, according to its usefulness. If it’s the TB test screening, which isn’t very precise or reliable, we interpret it in that context. If it’s HIV, which we’ve documented with the confirmatory tests, are very good, then we could make more use of that test. If it were up to me, I would like to see patients who entered hospitals, since they are usually either infected or bleeding, be tested automatically for their benefit, and for the comfort of all the health care workers. But, I think that if society isn’t ready for that yet, we ought to have the doctors, at their discretion, be able to test anyone they feel they need to in the course of their medical care. MR. CREEDON: Well, I don’t know whether society is ready for it or not. It surprises me, for example, especially Mr. Borwegen, who represents, the blue collar health care workers that are out there, it surprises me that your position would not be that we want people tested, that we would like to know whether a person has the virus or not. Not the virus only, hepatitis or whatever. In other words, if there is a higher degree of risk in dealing with that patient, then -- I try to put myself in the position of a health care worker -- if someone had a contagious disease or a disease that required special treatment, I would like to know it. It doesn’t mean that I wouldn’t follow all the Universal Precautions in every other case, but human nature being what it is, you can’t exercise this high standard for everybody that you would exercise for known cases where there was particular risk. 404 And, I find it a little hard to understand why the health care providers, and especially, the workers who are out there, wouldn’t want the protection of knowing whether or not a person has either the AIDS virus, or hepatitis B, or whatever. The discrimination problem is a different problem, and we have to deal with that as a Commission, but in terms of knowledge of a health care provider, I find it difficult to understand your position, frankly. MR. BORWEGEN: Believe me, you know, our own members disagree with our position, but what I’m saying is, if you want-- MR. CREEDON: Oh, then that’s different. MR. BORWEGEN: -- Universal Precautions to work, and you don’t want it to be a farce, then you have to enforce Universal Precautions regardless. Otherwise you are also not dealing with the window period where people may be positive, and not dealing with all these other blood-borne infectious diseases. So, if you want to weaken Universal Precautions, then I would say, then you should test, then you should tell workers. But, otherwise, you know, it’s just going to critically weaken -- MR. CREEDON: I think you can favor Universal Precautions, and I fully agree with you, that the Occupational Health and Safety Administration, and Washington, should come out with standards that are applicable, and those should be enforced, and it is up to OSHA to enforce them. If they adopt certain standards for a job, then they can legally enforce them and bring criminal action, I believe under OSHA, any hospital or administration that fails to protect the workers in that way. Having said that, I come back to where Doctor Crenshaw is. The more you know about a patient, the better off you are, regardless of the standards. The standards are great, you enforce them as best you can, recognizing that you don’t know everything about every patient no matter what. But, the more you do know, the better off you are to protect yourself and to protect the patient. MR. BORWEGEN: Well, I would draw a difference, for instance, with tuberculosis. In that case, then we should know so that people can practice respiratory isolation precautions. But, as long as it’s just a blood-borne disease, if you are following the Universal Disease Precautions, we do not believe that identification provides any higher level of protection to these workers. There is a study that was done in Seattle that was talked about in the first panel, where they labeled materials, 405 and what they found was that there was no correlation between what was labeled and what wasn’t labeled, whether or not it was hepatitis B or HIV positive. And, I think that study proves that labeling doesn’t really serve any purpose. MS. OLSON: Mr. Creedon -- MR. CREEDON: Well, labeling might not. Are you ready to interrupt me, Mr. Chairman? MR. DeVOS: Yes. We’re going to move on, John. They’ve established their position. MR. CREEDON: All right. MR. DeVOS: And, if they want to enlighten us a little, but we’re not a debating society and we tend to do that, because after listening to so many people you start to try and focus on things you can actually do, and recommendations, you know, hard ones that you make. And so, what we are gathering here is data, and I don’t want you to feel like you are threatened by John. He’s just saying, I want to make very sure I hear you right, so; don’t feel like that’s a debate. MR. BORWEGEN: Believe me, I’m familiar with this process, and, unfortunately, I may have come across in a hostile manner, but it’s, perhaps, my debating style. MR. DeVOS: Well, no, you were very clear, and that’s what I think John was seeking, was clarity. Ms. Olson is going to wrap up for you. MS. OLSON: Oh, I am? All of us, as health care professionals, function better with a base of knowledge. So, if we had the information and the diagnosis, we certainly could function more effectively. The practical aspect of it is that we don’t always have that information, and when you don’t have that information, you must employ certain practices. And, infection control procedures should be in place regardless. MR. DeVOS: We agree, believe me. MS. OLSON: That’s the premise. If I were practicing in a hospital setting where it were a possibility of doing this, then I would want the screening done. In the home care setting which I am addressing, that is not a possibility. And so, therefore, you function with what you have at hand, and you do the best job with what you can. But, trying to get as much knowledge and information as you possibly can certainly enhances whatever practice and care we can render. MR. DevoS: Well, I -- 406 DR. PHELAN: Can I have one lick? MR. DeVOS: Go ahead. Do you want to get one lick in here? DR. PHELAN: If you do one thing different when you identify an infectious patient than you do routinely, you are leaving yourself open for infection. And, that’s the reason that identifying patients becomes an issue that has to be faced in infection control, and it’s the reason I think most of us are saying that for infection control that’s not a reasonable way of reducing the risk of health care workers. MR. CREEDON: I think it’s good in theory, but in practice I have difficulty. MR. BORWEGEN: Let me just say one last thing. What you are suggesting is that you are going to tell the laundry workers, and you are going to tell the housekeeping workers that clean that patient’s room, and you are going to tell, basically, everybody that interfaces with that patient, that has potential contact with blood, bodily fluids, linens, sharps, needles, that that person is HIV positive. MR. CREEDON: I’m not really talking about HIV positive. I’m talking about the condition which is a threat to either the patient or to the people who deal with the patient. MR. BORWEGEN: So, how would you deal with it? MR. CREEDON: I would -- MR. DevoS: I’m going to shut you off, only because what we’re getting into are all the related issues, and we have other panels that we have dealt with on that. And, that doesn’t mean they are unimportant. We are trying to zero in here on the health care worker’s situation, what precautions they should take and how they should proceed. The other age old thing of what’s going to happen in the hospital, and the protection of the rights of privacy of these people, and whether the doctor has a right to know, and especially, if the patient and doctor agree. I think our findings here have found out that in most cases, the doctor and the patient do agree, and they just work it out between then, and they don’t care about law. You know, the temptation always on these kind of panels, is to get into law, and what we’re going to demand. You never have one demand without another demand. If you are going 407 to demand certain rights, then the other side is going to demand certain rights, and this country has worked primarily because people have agreed in one setting to work together out of mutual respect and love for each other, and that’s how this country runs. We need some laws to guide that, technical or not technical. I’m concerned in the overall of whether we have proper assurances for our health care workers, and as to whether we are going to run out of health care workers who get discouraged. If panic sets into that type of setting, then you are not going to have anybody, and your nurse shortage will just be exacerbated way beyond where it is today. You are also not going to have nurses if you don’t pay them adequately either, because they are going to be attracted to other places. And so, that all gets very complicated, and this is just one issue of safety in the workplace. How can I be assured that I’m working as safe as I can in my job, and then all the other things come with it. We want to thank you for the light you’ve shed on this subject for us, for your time, for your willingness to interchange with us. Doctor Rodriguez, we salute you for your courage and being on the front line of this. Ms Watson, we thank you for coming and sharing your story with us, and all the rest of you for carrying on the battle day to day right in the front pits of this whole thing, and we salute you for that, and we thank you for coming here today. Julie, nice seeing you today. - MS. CHAMBERLAIN: Thank you. MR. DeVOS: We will adjourn until 12:45. (Whereupon, the hearing was recessed at 12:05 p.m., to reconvene at 12:45 p.m., this same day.) 408 A-F-T-E-R-N-0-0O-N S-E-S-S-I-O-N 12:45 p.m. PANEL 3: POLICY DEVELOPMENT FOR PREVENTION OF TRANSMISSION IN THE HEALTH CARE SETTING DR. LEE: Welcome to this after lunch panel, which is entitled Policy Development for prevention of Transmission in the Health Care Setting. We have Doctor Robert J. Mullan to start off, Workplace AIDS Coordinator. Mr. Chalmers is taking Mr. Adkins place, but we have Doctor Robert Mullan here, right? DR. MULLAN: Yes. DR. LEE: And, we’re starting off with Doctor Robert Mullan, Workplace AIDS Coordinator, the National Institute for Occupational Safety and Health, CDC, Atlanta, Georgia. Doctor Mullan? DR. MULLAN: Good afternoon, Mr. Chairman and members of the President’s Commission. I appreciate the opportunity to appear before you today to discuss my Agency’s role in formulating policies for prevention of human immunodeficiency virus transmission in the health care workplace. As you may be aware, the Occupational Safety and Health Act of 1970 was enacted "to assure safe and healthful working conditions for working men and women." Under this Act, the National Institute for Occupational Safety and Health was established under the then Department of Health, Education and Welfare to "conduct research, experiments, and demonstrations relating to occupational safety and health" and to "make recommendations concerning new or improved occupational safety ana health standards" and convey these to OSHA. Simultaneously, the Occupational Safety and Health Administration (OSHA) was established under the Department of Labor to provide "for the development and promulgation of occupational safety and health standards" and to provide "an effective enforcement program" for these standards. I would now like to turn my attention to my Agency’s involvement in the ongoing epidemic of human immunodeficiency virus infection and disease. In late summer of 1986, several unions petitioned OSHA for an emergency temporary standard to prevent transmission of HIV in the health care setting, as well as to assure provision of 409 immunization of health care workers (HCWs) for hepatitis B. This petition for an emergency temporary standard was ultimately denied, but it served to alert officials in both Departments of the need for developing standards and policies to protect health care workers from acquisition of blood-borne diseases in the workplace. On July 23, 1987, the Assistant Secretary of OSHA, John Pendergrass, and the Assistant Secretary for Health, Robert E. Windom, discussed a four-point plan with Congress in a hearing before the Subcommittee on Employment ana Housing, Committee on Government Operations, U.S. House of Representatives. This plan provided a framework for collaborative work between the two Departments for protection of workers from exposure to blood- borne diseases in the health care workplace. One point, in particular, involves my Agency. That is that, the Department of Labor and the Department of Health and Human Services will issue a notice to ensure that hospitals and affected employees are fully aware of the applicable guidelines regarding blood-borne diseases. In collaboration with other Centers for Disease Control Centers involved in AIDS, we began to develop a joint Department of Health and Human Services, and Department of Labor advisory notice that would serve to expand upon the Centers for Disease Control’s "Recommendations for Prevention of HIV Transmission in Health Care Settings." This document is intended to present health-care employers with additional information to help them meet the responsibility to protect their workers from exposure to hepatitis B and HIV in the workplace. Work on this joint advisory notice began in August of last year. You will find this document in your information packet. It was written after extensive internal CDC scientific consultation with the Hospital Infections Program and the AIDS Program, both in the Center for Infectious Diseases, and the Center for Prevention Services. All of these are within the Centers for Disease Control. In addition, other U.S. Public Health Service agencies, including the Health Resources and Services Administration and the Health Care Financing Administration, were involved as well. This document was then reviewed extensively by numerous groups, including the American Medical Association, the American Hospital Association, the American Dental Association, the American Nurses Association, various labor representatives, and consultants from other professional organizations representing emergency medical technicians, blood banking, pathologists, funeral directors, state and local health officers, and a rather lengthy list of others. The intent of such an extensive review is to make sure that all parties with an interest in protecting health care workers from HIV and HBV transmission in the workplace had a 410 chance to provide input into this document. We strove to identify and involve a variety of knowledgeable groups and professions, whose input could serve to improve this document. This document was published and mailed to approximately 600,000 health-care employers last November. An accompanying cover letter noted that this document, in conjunction with the August 21, 1987 CDC guidelines, would form the basis for employers to institute protective measures for their employees. Finally, OSHA has issued an advanced notice of proposed rulemaking for blood-borne diseases in the workplace. I will leave the details of this process to Mr. Chalmers from OSHA, but I would like to note that NIOSH has been actively involved in review of this ANPR, and will continue to be involved as OSHA moves closer to setting standards for protecting health care workers against blood-borne diseases in the workplace. Thank you, and I’11]1 be happy to answer any questions that you may have when these presentations are finished. DR. LEE: Thank you, Doctor Mullan. DR. LEE: The next speaker is Mr. Frank Chalmers, Director of Policy, at the Occupational Safety and Health Administration, Department of Labor. Mr. Chalmers? MR. CHALMERS: Thank you, Mr. Chairman, and members of the Commission. I appreciate this opportunity to discuss with you the activities of the Occupational Safety and Health Administration (OSHA) to protect workers in health and supporting professions from exposure to blood-borne diseases, including the acquired immunodeficiency syndrome, AIDS. It is our belief that any consideration by OSHA -of risks to health care workers from contact with blood and body fluids from an individual who may have human immunodeficiency virus (HIV) must include the risks of other blood-borne pathogens, especially hepatitis B virus (HBV), which can cause serious and sometimes fatal liver disease. At present, the evidence indicates that both HBV and HIV pose occupational risks for health care and certain other workers who are exposed to blood and certain other body fluids. It is important in the discussion this afternoon to recognize that the work practice controls, engineering controls, and personal protective equipment that are available to protect workers: against HIV, also protect those workers against HBV. Our concern is to protect workers from significant risks of exposures to these viruses, and to do so in the most 411 effective manner consistent with the Agency’s other responsibilities. Given that the public health issues surrounding this decision are critical, the Department of Labor (DOL) and the Department of Health and Human Services (DHHS) formed a working group to develop an extensive and far-reaching plan regarding occupational exposure to both HIV and HBV. Pursuant to the plan of that working group, and in order to provide immediate protection in the health care workplace against exposure to these viruses, we have taken the following steps: * First, we implemented an inspection program under the Occupational Safety and Health Act to examine actual work practices in health care work sites, focusing on the extent of compliance with existing protective guidelines. We began inspections in August of 1987 in response to formal worker complaints. In January of this year, we began general schedule inspections in addition to those inspections on worker complaints. BY mid-May 1988, we had conducted some 60 of these inspections. * Second, the Department of Labor and Health and Human Services issued a Joint Advisory Notice to ensure that health care employers are fully aware of the applicable guidelines regarding blood-borne disease. The Joint Advisory Notice, which was mentioned earlier, and a brochure for workers were sent, with a cover letter signed by the Secretary of Labor and the Secretary of Health and Human Services, to more than 600,000 employers. * Third, the Department of Labor published an Advance Notice of Proposed Rulemaking (ANPR) on November 27, 1987. This ANPR raised a number of issues and solicited comments on the Scope and substance of the steps necessary to protect health care workers from the threat of infections from blood-borne diseases. This many-faceted program will furnish OSHA with valuable information on how best to accomplish its goals of ensuring that workers at significant risk are provided with appropriate protection and are trained in the need for safe work practices. OSHA will work with the Department of Health and Human Services to develop a stronger body of knowledge about actual practices in the workplace. We believe that in cooperation with HHS we have devised an effective approach which represents a workable solution to the complex and difficult problem of worker exposure to blood-borne infectious diseases among health care and support workers. Thank you. This concludes my prepared statement. I would be pleased to answer any questions. 412 DR. LEE: Thank you, Mr. Chalmers. DR. LEE: The next speaker is Ms. Patricia Lynch, Infection Control Coordinator at the Harborview Medicine Center in Seattle, Washington, and I believe you are speaking on behalf of the American Hospital Association. Thank you. MS. LYNCH: Thank you, Mr. Chairman, members of the Commission. On behalf of the AHA, I’m very pleased to have the opportunity to discuss the protection of health care workers from occupational transmission of blood-borne agents, such as HBV and HIV, and also to share my experience in implementing such a program at Harborview. Several previous speakers alluded to studies that were performed at Harborview, and as far as I know we are the only hospital in the country with a long program for using any form of Universal Precautions, and the only one that has conducted four years of evaluation. The potential for nosocomial or hospital-acquired infections among patients and personnel is well documented. It is estimated that about 5 to 6 percent of hospitalized patients develop nosocomial infections, and, of course, health care workers are now described to be at risk for nosocomial infections as well, particularly, the blood-borne agents. In the late 1970s and early 1980s, well before the appearance of AIDS was described, there were published reports of hepatitis B virus risk among health care workers and physicians in different job occupational categories, and these reports, the first one in 1978, the second in 1982, made it clear to all health care facilities that the precautions that we had been using were not protecting health care workers. There was a long gap between the first study and the second study, and this contributed, I think, to some of the confusion about whether the practices that we had been using in the past actually worked or not. It forced all health care facilities and personnel to rethink their entire strategy for prevention of transmission of infectious agents, both among the patients and among the personnel. The traditional routine had been to identify known infected cases, and to use particular precautions with them. This was the practice that led to the high failure rate, that led to high incidence of hepatitis B virus in health care workers in the late 1970s. This kind of "diagnosis-driven" approach has obvious flaws, which many of the previous panel members have already alluded to. In 1984 at Harborview, concerned about transmission of infectious agents among patients, particularly in the critical 413 care units, and also concerned about protecting personnel, we implemented a system of barrier precautions that was used for all patients. We revised the system somewhat in 1985, and have been trying to measure compliance and the effect of the system in reducing nosocomial colonization of patients, particularly in critical care units, ever since. We find the system of Universal Precautions to be efficacious in reducing risk of transmission of infectious agents among patients. It’s more difficult to answer the questions that some of you have asked regarding protection of health care workers. The underlying assumption of body substance isolation, which is what we have termed our practice of Universal Precautions, is that the moist body substances of all humans contain potentially infectious agents. We require personnel to put on clean gloves just before a health care worker touches mucous membranes, non-intact skin, and indwelling device insertion sites. This serves to protect the patients; infection risk for patients may be increased when health care workers do not use clean gloves for these activities. We further require that personnel glove their hands before contact with moist body substances of any patient. Those two things provide a fair amount of protection to the health care worker, and, in our studies quite a bit of protection to the patients. The rest of the precautions that we use, such as, hand washing, I think other panelists have already described fairly well. The use of barriers, such as, goggles, gowns, other additional attire, is fairly infrequent, but the supplies need to be available for all sorts of situations in all areas of the hospital to achieve good compliance. Many people have commented on the need for a better approach to sharps management in the hospital, and this is very true. Part of our system is to dispose of sharps in puncture- resistant containers. The problem with recapping is that the caps are too small. This is an engineering problem. The diameter of the cap on tubex syringes, for instance, is about 1/16 of an inch. The likelihood that you’1l puncture yourself in attempting to recap is very good. But, a study has shown that if the cap size is increased to about 5/8s of an inch, the risk is roughly one in 25,000. Those kinds of engineering strategies are needed to reduce transmission to Health Care Workers. Now, in order to achieve the goals of getting people to do it, there is a considerable time that must be spent in education and management strategies in getting performance up. There are barriers to compliance that are physical barriers, engineering barriers that need to be fixed, but there are behavioral barriers as well. 414 We have measured compliance with our recommendations in a structured observation study over approximately two years and several months now, and identified some factors that increased compliance in terms of behavioral information among personnel. We also have a fairly good idea now of the level of compliance necessary to achieve a reduction in nosocomial transmission of infectious agents among patients. We assume that a comparably high degree of compliance is necessary to reduce risk to the health care workers as well. Many hospitals are implementing these kinds of precautions, but most hospitals are not funded to do research. Our hospital is certainly not funded to do research either. And so, the studies that are being reported are with small numbers, and this makes interpretation very difficult. There are other obstacles to successful implementation, and these include the significant costs. Training programs, for example; we found that virtually everyone, in order to practice Universal Precautions correctly, needs about three iterations of information. That means that somehow you must schedule the educational delivery to allow for the knowledge that accrues and the experience that accrues in between these discussion periods; training is a major cost of implementation of Universal Precautions. There is also a shortage of supplies, which I mentioned in the testimony, particularly gloves, and they are of variable quality. There are a number of devices and doo-dads in hospitals that could be engineered to promote health care worker safety without a tremendous increase in cost, and these things need to be identified. There is a need to develop high quality educational resources for employees. We now have faculty who are out of date, and text books that are out of date. I teach students, medical students, nursing students and others, and much of what I teach them now is in direct conflict with their text books. It takes a great deal of time to change text books, and, thus, to change practices. ; \ \ \ The last thing I think we really need to consider is some of the social issues. We are dealing with anxiety and fear in personnel. Personnel are feeling safer the more clothing they wear now, and are looking for reasons to wear more clothing. One pair of gloves is not enough for a lot of people. They want to double glove, a gown, a double gown, other kinds of things. This increases expense. There is also, as Doctor Rodriguez mentioned this morning, a problem with quality in some of these supplies. 415 I think that systematic studies of the occupational risk of blood-borne agents in health care workers have not been adequately performed, and that this Commission could serve a great purpose in encouraging, funding or otherwise seeing that the appropriate studies in large populations are actually done, so that we’re not depending on tiny studies and generalizing from almost infinitely small numbers. Cooperative efforts among health care employers and federal and state regulatory agencies to standardize the requirements, while ensuring that appropriate flexibility is maintained, are really essential. I commend OSHA for their measured respond to the requests from unions and frightened health care workers for sufficient time to study what needs to be done before moving precipitously or in an uncoordinated fashion into developing standards that hospitals would have to tend to. I think there needs to be an increased recognition of the cost to health care facilities. Implementing a lot of these changes is expensive, and it’s expensive in time and labor, not only in supplies. It’s the increased training, the increased time, and the cost of changing health care worker practices over a lifetime of work activities. Ultimately, the hospital’s most important resource is its personnel, and so, hospitals will spend the funds that are necessary to do this, and I think are moving in a fairly careful fashion to try and get it accomplished. I think that’s all I can really say about that. I’d be glad to answer questions, either about our implementation, or about the studies that we’ve performed that other speakers have alluded to. DR. LEE: Thank you, Ms. Lynch. You will get your share of questions, I can assure you. DR. LEE: The next speaker is Doctor Harvey Bartnof, AIDS Virus Education and Research Institute, San Francisco, California. Doctor Bartnof? DR. BARTNOF: Yes, thank you, Doctor Lee. Mr. Chairman, and members of the Commission, as a course director for the AIDS elective, ("AIDS-HIV: Overview and Update,"), at U.c. San Francisco School of Medicine, I have taught over 600 medical, nursing and pharmacy students about AIDS and infection control. 173 health professional students enrolled in this course and completed the 19-hour, multidisciplinary requirement in 1988. I have a copy of the syllabus if anyone wants to look at it. As the Chief Physician of AVERI (AIDS Virus Education and Research Institute), I have taught hundreds of physicians, nurses, and other health providers about AIDS, HIV, and infection control, in the form of traditional continuing education seminars. I am also 416 responsible for the accurate and timely maintenance of the AVERI Infection Control Certification exam and AIDS Knowledge Certification exams. By using anonymous pre-seminar questionnaires, we have shown that 56 percent of health professionals do not comply with cpc guidelines for infection control. Their practices include inadequate and sometimes excessive behaviors. This problem will lead to the continual, unnecessary transmission of HIV and other blood-borne transmitted agents to health care professionals. In my experience, there are several reasons for the insufficient compliance. These reasons are not mutually exclusive, and they include: 1. Health care professionals are lacking knowledge of known infection control information. When compared to those who are knowledgeable of infection control information, those who are not knowledgeable tend to: (1) to overestimate the risk of contracting HIV in the workplace; (2) those who are not knowledgeable tend to have a lower score of AIDS-HIV knowledge; and (3) those who are not knowledgeable tend to acknowledge more fear of contracting HIV in the workplace. 2. No policy exists regarding the usage of existing standardized infection control examinations to document health professionals’ infection control knowledge. Such policies do exist for National Board certification and CPR certification by the American Heart Association. 3. Health care professionals engage in incorrect or outdated infection control practices "out of habit" and these "habits" are difficult to change. I think several speakers have alluded to this already. 4. In some health care institutions, there is a lack of availability in immediate care areas of devices and supplies which will enable compliance with infection control guidelines, something else that’s repeated. 5. Health care professionals are lacking knowledge of AIDS-HIV and of information within the broad scope of AIDS Medicine or "Aidsology." 6. No policy exists regarding the usage of existing standardized AIDS knowledge exams to document health care professionals’ AIDS knowledge. Such standardization does exist for National Board and CPR certification. HIV is a new human pathogen; it leads to clinical manifestations which are new and variable. Therefore, health professionals who have not have had very recent formal educational training about AIDS do have gaps 417 in their clinical knowledge. Standardized knowledge scales will bridge that gap in a uniform way, and will also lead to uniform non-conflicting health messages from health providers. 7. Health care professionals have AIDS fears, phobias and psychologic blocks which often inhibit assimilation of appropriate infection control practices and AIDS knowledge. These fears include: fear of contagion for themselves or loved ones, fear or disapproval of stigmatized behaviors, i.e., IV needle sharing and homosexual male activity, fear of death, fear of premature death, fear or discomfort of discussing sexuality, fear of perceived "societal decay" brought on by the AIDS epidemic, and fear of helplessness in the inability to do something for the patient with a life-threatening illness. 8. There is a lack of biomedical/bioengineering research as to which procedural and surgical techniques (including devices) will decrease the risk of transmitting HIV and other agents to surgeons and other health professionals. 9. There is a lack of psychosocial research as to what will enable health professionals to practice safe infection control guidelines. Specific Recommendations 1 and 2. The federal government should pass legislation requiring all health professionals to be certified in infection control knowledge, and to participate in an appropriate infection control education program, the type of which would be determined by the likelihood of contact with patients’ body fluids. An infection control certification exam already exists and is provided by the AIDS Virus Education and Research Institute. (Note: The Department of Labor has addressed the issue of infection control education of hospital employees, as has been discussed; the recently-passed Senate bill does mandate CDC to address the issue. However, neither discusses knowledge certification.) 3, 7, and 9. The National Institutes of Mental Health should offer Requests for Proposes (RFPs) to health education institutions for the purpose of researching the complex psychosocial issues which preclude assimilation of and compliance with CDC infection control guidelines. 4. The federal government should pass legislation to ensure that infection control devices and supplies are available in all patient care areas. Institutions should be required to document that adequate stocks and timely disposal of filled infectious waste containers are accomplished. 418 5 and 6. The federal government should pass legislation requiring all health professionals to be certified in AIDS knowledge, including health provider concerns. The federal government should require that all health professionals who participate in HRSA and AHEC AIDS-HIV training programs should complete a standardized AIDS-HIV knowledge exam. The AIDS Virus Education and Research Institute has developed and implemented three scales of AIDS knowledge for this purpose. The two tiers are specifically for health care providers. The AAPK and AAPKT sub-scales are used by San Francisco General Hospital’s AIDS Provider Education Experience Program, as a pre and post-course evaluation of knowledge gained. The AAPK was used as the final exam for the AIDS course at UCSF for medical students. Approximately 50 students are now AAPK certified. AIDS certification must be preceded by a comprehensive AIDS-HIV education, a topic which has been addressed in this Commission’s interim report. Recommendations in Education, Under-served and Psychosocial address AIDS-HIV education. However, none of these address AIDS knowledge documentation or certification. 8. The National Institutes of Allergy and Infectious Diseases should offer Requests for Proposals (RFPs) to health care institutions for the purpose of researching the biomedical and bioengineering aspects of which surgical procedures, medical techniques and devices will minimize the risk of transmitting HIV and other blood-borne transmitted agents to health professionals in the workplace, including pre-hospital personnel environment, as the question came up this morning, and to develop guidelines for so-called "Safer Surgery." These recommendations overlap somewhat, but when taken together will decrease HIV transmission in the health care environment. There are many benefits to the educational program and certifications which would lead to decreased risk of transmitting HIV in the workplace. We have shown in health professional students at UCSF that AIDS and infection control education also leads to a greater willingness to work with AIDS patients, also leads to decreased fears of AIDS, a better understanding of the psychosocial aspects of people infected with HIV, as well as increased AIDS knowledge and infection control knowledge. AVERI on-site AIDS continuing education programs for health professionals also have shown increased AIDS and infection control knowledge, as well as increased self-reported compliance with infection control guidelines, decreased fears of AIDS patients, increased willingness to work with AIDS patients, and improved attitudes essential for optimal care for people with AIDS or other HIV infection. 419 AVERI has also provided AIDS education for over 1,200 non-health care worksite employees throughout the United States and Canada. In a sample of 500 employees in 1987, AIDS knowledge increased and AIDS fears decreased significantly when comparing pre to post-knowledge and attitude scales. Those who had fear of AIDS in the workplace decreased from 50 percent to 24 percent of attendees. Most had less fear than prior to the seminar. If there are any questions, I’1ll be happy to take then. Thank you. DR. LEE: Thank you, Doctor Bartnof. DR. LEE: Doctor Lilly, do you want to start off the questioning? MRS. GEBBIE: That’s going to be hard. DR. LEE: I guess Doctor Lilly isn’t there, so we’ll go with Ms. Gebbie, who is our Public Health expert. MRS. GEBBIE: I’m sorry I missed the first part of the oral presentations. I tried to take a quick look at that. Two areas I’m going to combine into one question. I’d really appreciate comment from any or all of you, based partially on what you’ve said here, and partially on what we’ve been hearing from a number of other folks. There is a determined impression on the part of some people that folks like yourselves are living in a very cerebral and protected world, in which you can read studies and design policies that make logical sense but are not based in reality. And, even in infection control, persons such as Ms. Lynch are seen as remote from cleaning up dirty beds at 3:00 o’clock in the morning. How do you attempt to bridge that perceived gap between your roles and those folks who perceive themselves at the frontline? Related to that is, what is becoming clear to me as a potential problem in using that broad term "health care workers," which encompasses such a huge range from neurosurgeons and intensive care unit nurses to the food service worker who delivers meals, or the janitor on the night shift, what that whole range of people may need to know someone’s HIVs’ status for infection control gets mixed up with what portion of those people need to Know for illness treatment purposes. How do you deal with using such a huge term? Are you seeing that confusion, or are you satisfied with using the term? Would you elaborate on that? 420 MR. BARTNOF: 1I/’11 begin with that. In this epidemic, I have several hats, but I enjoy treating patients, so I am not only involved in policy and teaching, but I see AIDS patients and other patients every week. So, I’m out there, and I’m well aware of the issues involved in old behaviors. When I trained in putting IVs in, I didn’t wear gloves either, and it’s a lot harder to do it if you have to wear gloves. So, I think I’m on both sides of the fence, and I can understand the gap that often exists there. But when I’m teaching, or, certainly, in keeping the knowledge scales up to date, I’m thinking as a health provider who is out there in the front line taking care of patients. So, that’s how I would respond in that way. I think it better enables me to be a better teacher. Secondly, I think as the Department of Health and Human Services and Department of Labor, in their letter that went out to hospital employers, and it was in Federal Register last October, if I’m not mistaken, does designate three different categories of health providers, in terms of their risk of being in touch with patients or body fluids. Most of the individuals that we’re talking about are those that are going to be dealing with body fluids on a regular basis. You are talking about nurses, physicians, respiratory technicians, and including pre-hospital personnel, paramedics, emergency medical technicians, firefighters, police and so forth. And, in the infection control certification, for example, or in the AIDS knowledge questions, we have questions that follow people or patients throughout specific clinical vignettes, that in one question the respiratory therapist will be interacting with the patient, and two questions before that, the EMT would have treated the patient out in the field. I think that there are guidelines and precautions that really apply to every person who is going to he involved in patient care. Now, if you want to talk about the clerk on the ward who is not involved in direct patient care, who may be having to fill out lab slips, and maybe having to handle containers that have specimens, then that’s a little different level, and the knowledge that they need to have about infection control is a little bit different, although, they might have to be called upon to do CPR if a patient were to keel over right in front of the clerk’s desk on the ward, for example. 421 MRS. GEBBIE: Well, you went rather far in jumping to the clerk. I was pushing at that distinction between the folks who are directly involved in managing that individual patient’s very personalized care, the doctor, the nurse, the respiratory therapist, a couple of others you might name, from those workers who do something incidental to all patients, like mop all rooms, and pick up all dirty laundry, and deliver all trays, all of whom we have lumped under this term, health care worker. You don’t seem uncomfortable by using a term "health care worker" and having it covered. Now, I’d like to hear from some of the other people, I’m beginning to hear that that was causing confusion as I listened this morning. MS. LYNCH: I’m not sure that it’s causing confusion. We call everybody who comes near the front door a health care worker, recognizing that that includes the housekeepers and other people. I am not a front-line delivery person, and it would be completely inappropriate for me to develop department policies or procedures, for example, for respiratory therapy or other departments where the personnel do take care. It is essential in looking at the management of a new philosophy in the hospital, that you have to sit down with the people who own the practice. And, in my position, I can tell them the results of studies, I can tell them the results of our structured observation, and then I can say, "What does this mean in terms of your policies and procedures? What do you need to do in order to get this thing done right," whatever it is. They write the policies and procedures, I don’t, and that way they understand the knowledge which is important for them, and they also own the policy and procedure, which is important to me. I think none of us who are not front-line people should be seen as the people who own the policy and procedure that other people perform. That’s just, basically, a management strategy. There are some things that are broad that I can suggest as a result of our experience. One is that, in the system where you do special precautions for identified infected cases, and where everybody is diagnosis dependent, that compliance with Universal Precautions will be extremely low. We followed compliance for 18 months when we had an isolation system that identified infected cases, much as you were talking about this morning, and then measured compliance after we stopped identifying the infected cases. Now, this is not to say, aS you were mentioning, Doctor Crenshaw, that diagnosis is not essential for the caregivers. It is in terms of therapy. It is very poor as the basis for taking precautions. It should not be linked to precautions. The precautions should be linked to the interaction with the patient. 422 Once we remove diagnosis as the trigger for taking precautions, compliance soared; we could almost immediately see the results in patient colonization in the critical care units, where problems with transmission show up first, but we could also see it in confidence of the health care workers, because once they were not making that internal decision about precautions before they had contacts, they were much more comfortable in practicing precautions consistently. The teaching time, the training time for this, is very substantial. It doesn’t happen quickly. MRS. GEBBIE: I’d like to hear from Mr. Chalmers. MR. CHALMERS: We started from the left here, so I will answer for OSHA. On the question of academic versus pragmatic, that is very much a foremost question in the minds of those of us in the National Office at OSHA. The answer to that is, we do extensive field visits, and we do extensive field surveys to find out what others are thinking. Also, in the process of coming up with new regulations, the reason for having an advanced notice of proposed rulemaking is to solicit the thoughts of those in the trenches, those in the front lines, those who are exposed. We are concerned not only with just health care workers in the sense of those who have an immediate relationship to the patient. We are also concerned with all workers who may come in contact with those body fluids or those materials which could transmit these diseases. Now, if hypodermic needles are loose in the trash, and the janitorial person picks up a plastic bag and there is a needle that sticks in their hand, that is just as certainly a needle prick as if a needle happened to be still on a syringe adjacent to the patient. We are concerned about that also and equally so. And, it extends to the mortuary. There are other workers involved with those bodily fluids. I think that answer that bridging the gap, as you put it, or how to bridge the roles, is the process that we have for involving the public and the feedback from the public. MRS. GEBBIE: Did that involvement extend to what are commonly called "first responders," police, fire, EMT kinds of people? MR. CHALMERS: Oh, yes, absolutely. 423 MRS. GEBBIE: Because of the witnesses we have had -- MR. CHALMERS: We are quite concerned with first responders, not only -- MRS. GEBBIE: And, they were consulted in the process of developing their process? MR. CHALMERS: Yes and we at OSHA are also involved with first responders from their responses to other hazardous incidents. So, we have multiple contacts with them. The handling of potentially infected patients is only one of the many hazards that they face. DR. MULLAN: I would just like to echo what Mr. Chalmers said. When we go forth with developing some form of guidelines or our recently developed joint advisory notice, we strive very hard to identify those groups that have a need to provide input into any kind of planning for the document. We get them involved at an early stage, and try to get them to identify problem areas for us to consider. These people include not only the obvious, nurses, physicians and professional hospital persons, but we also strive to get the first response people, as you say, the emergency medical technicians, the firefighters, as well as the unions and labor representatives who will then represent the housekeeping and maintenance folks within the hospital, and we try to listen very carefully to what they have to say to us. With regard to your other question concerning the question of how broad do you want to define the health-care worker, I think the basic scientific premise which underlies the development of the joint advisory notice is that you can prevent transmission of both HBV and HIV in the workplace through the use of universal precautions, work practices, and so forth. The way that you implement those differing forms of protection may be different for varying populations, or sub- populations of health care workers. For instance, as you are aware, there is a whole set of very difficult problems, technological problems, that need to be overcome in talking about first response people, who would be dealing with shattered glass, or weapons, or similar items. Those kinds of very difficult issues, I think, are looming on the horizon for us to start to address systematically. MRS. GEBBIE: Just a comment as I move on to Mr. Chalmers and Doctor Mullan, that your comments sound very logical and thoughtful. I’m sorry we don’t have some of our 424 other witnesses here so we could start some dialogue, because there are a lot of folks who have testified to us that would say, we really weren’t heard and weren’t a part of the process. That’s part of the problem of now implementing it, because they don’t feel ownership, and they don’t feel like they’ve been in there. MR. CHALMERS: If I may, the process is far from complete. The process is only beginning. When an advanced notice of proposed rulemaking is issued, that is a beginning point to solicit comments from the public. We will go through that, we will go through the Notice of Proposed Rulemaking, we will have public hearings on both. There will be potentially hearings about the country as we’re having here today. So, what is past is prologue. MRS. GEBBIE: Yet, it is happening many months after people down at this end of the table are saying they are expecting those workers to already be following through on the things that you say are just in dialogue with the folks out there. I think this is part of the confusion that we’re hearing. MR. CHALMERS: Yes. That is the reason for the immediacy of enforcing the guidelines from CDC. The guidelines were published for the health care workers, and OSHA has started to enforce those guidelines. But we have a long, long way to go to get all of the feedback from all of the people who may be involved. This is not a short process. MRS. GEBBIE: If there’s time, I might have more questions. DR. LEE: Yes, I’1l come back to you, Kris, at the end if we have time. Doctor Lilly? DR. LILLY: I pass for the moment. DR. LEE: You are passing? Doctor Crenshaw? DR. CRENSHAW: Could you clarify something for me, Ms. Lynch? I understood that Universal Precautions involved little more than just the gloves on standard wards, and I think there’s been some change lately. So, please, bring me up to speed. 425 From your testimony, the conclusion I drew was that the definition of Universal Precautions are that all glove up when they are dealing with body fluids of any sort. Is that correct? And, that the other material is there and available should some need it or want it, like gowns and the rest. MS. LYNCH: Appropriate use of gloves at my hospital is a performance standard. That is, it is included in personnel evaluation, it’s presented in orientation, it’s part of acceptable performance. Inappropriate use of gloves, where personnel put on gloves and then do a lot of activities, and then have contact with the mucous membrane, non-intact skin or indwelling device Site, increases patient risk, and one of our major efforts is to decrease that risk. So, that’s why it’s a performance standard. It’s not entirely to protect personnel, but also to protect patients. Hand washing is also a performance standard, but it doesn’t get as good compliance. It’s not as observable, and I don’t know. Someone mentioned this morning that your mom teaches you how to wash your hands. I’m not sure that I’ve subsequently taught anyone or trained anyone on how to wash their hands or increased their frequency. The use of the other barrier precautions is important in certain situations -- Doctor Phelan this morning, for instance -- dentists and other personnel really need to protect their oral and nasal mucous membranes and their eyes. What I meant to imply was that the supplies need to be available in many clinical areas, but that the actual demand for them, except for gloves, is much less. DR. CRENSHAW: I’m really in favor of the Universal Precaution approaches, as you probably heard me Say earlier today, and yet, until you mentioned that I was under the impression that masks were included. Now, I want to ask the following: tuberculosis is more prevalent than HIV infection, and it has increased 20 percent in this last year. It seems logically inconsistent that if we’re talking about Universal Precautions, we are not considering airborne diseases, like tuberculosis and the other respiratory ones. Do you have any comment on that? MS. LYNCH: In my clinical setting, tuberculosis is not more common than AIDS, and, in fact, we see more HIV-infected people than we do people with tuberculosis. The efficacy of masks to reduce airborne transmission, that is, a truly airborne communicable disease, has not ever been demonstrated. You can 426 see that the studies to do so would be really difficult. There are anecdotal studies, though, that demonstrate almost introvertibly that if you are truly susceptible to an airborne communicable disease, like chicken pox, and you wear a mask to go in and take care of the patient, what you’1l get is chicken pox, because masks don’t adequately filter air. The use of a mask to protect you from splatter in the face -- DR. LEE: Did you say it gets through the mask, or it doesn’t get through the mask? MS. LYNCH: Air does get through the mask. If you were to tape a mask to your face, and then breathe normally, you’d find your air supply cut off fairly dramatically. A lot of air comes in around the edges of masks. That’s why they don’t serve as a real good barrier for true susceptible. Tuberculosis is not a readily transmitted disease, however, and neither is meningococcal meningitis, and we suggest that personnel wear masks in that setting even though there is no efficacy demonstrated. It doesn’t do any harm to have masks on people in that setting. It may not do any good. DR. CRENSHAW: Would you elaborate on some of the research studies that you were suggesting of the environment and the protective devices? You mentioned gloves, but what are some of the studies that you are recommending should be encouraged? MS. LYNCH: Engineering and design modifications for a lot of equipment: used needle caps as one example. There is no reason to have those teeny-weeny needle caps, anybody can see the problem. There are a lot of laboratory devices that require the laboratorians to hand wipe sharp pipettes. Those kinds of things can be engineered out of existence. They don’t need to continue to be hazards for health care workers. The problem with studies of health care workers is that, they aren’t studied in a population base usually that’s large enough to really clarify risk. In other words, even Gerberding’s nice study at San Francisco General only has one seroconversion in hundreds of exposures. What we need is large- base studies that probably wind up with thousands of people. These would, obviously, have to be collaborative studies that would require coordination and collaboration between facilities in order to accomplish the outcome of the study. No one knows, for example, in punctures, how many puncture events or puncture-prone events, a nurse may have had 427 before having that one. It might be that she got a puncture one out of a 1,000 needle-handling operations, it might be one in 10,000, it might be one in 200,000, those kinds of studies simply have not been developed. As far as I know, only one state in the United States actually attempts to retrieve hepatitis B infection in health care workers, and that’s Minnesota. These kinds of large studies really need to be done, but there are no funds available to do them. Minnesota is ina unique position, in having started. DR. CRENSHAW: I’ve heard concerns expressed by orthopedic surgeons and dental workers who aerosolize through their drilling processes, and saws, and what have you. And now, you are mentioning that me that even with airborne diseases that the masks have been demonstrated not to be sufficient protection. MS. LYNCH: But, for aerosols, masks are very good. It’s almost like putting a plastic bag in front of your face in terms of protection. They offer excellent protection from aerosols, because contact is the mode of transmission there. It’s not an airborne communicable disease where the tiny viral particle circulates in the air. DR. CRENSHAW: Are there published studies on that? MS. LYNCH: There are anecdotal reports, mostly in pediatric literature, relative to transmission of measles, rubella and chicken pox in true susceptibles who wore masks to try and prevent transmission, and transmission still occurred. The use of barrier precautions, I think, is fairly well outlined in several studies. I’d be glad to think about them and sort of pick out some of the ones that -- DR. CRENSHAW: I was thinking more particularly with relation to the aerosolized issues, because what you are saying is very reassuring. And then, they can simply be referred to the studies that exist that they may not be familiar with, and then if those published studies don’t exist, maybe that would be an area that we ought to document better. MS. LYNCH: There are, not to labor the issue too much, there are areas where studies would be very cost effective. For instance, biological safety cabinets with laminar clean air flow that are used in the laboratories, cost about $100,000.00 a piece. DR. CRENSHAW: Would you translate that for me? 428 MS. LYNCH: The cabinets that are used in laboratories, where the laboratorians actually do their set up of microbiology specimens, and some chemistry and hematology, cost about $100,000.00 a piece. They have laminar clean air flow that moves the air in a pattern away from the worker who is actually doing the operation. DR. CRENSHAW: Oh, I have seen those, yes. MS. LYNCH: It may be that a safety cabinet, similar to what you find on a salad bar, is really alli that’s necessary. In other words, the physical plastic barrier in front of the face, and it’s a whole lot less expensive, of course. But again, those are engineering studies. They haven’t been done. DR. CRENSHAW: Thank you very much. Do I have time for another? DR. LEE: Sure. DR. CRENSHAW: Mr. Chalmers, I happened to catch the Kennedy hearings on OSHA and watched them for a few hours. The suggestion during those hearings that came up over and over again was that there is a lot of bureaucratic red tape being intentionally put in the way of getting health care safety procedures implemented with the explanation that because of the costs and the paper work that there was disinclination to do so. I’d like to give you an opportunity to respond. MR. CHALMERS: Yes. You are certainly correct in your perception of what was said at the Kennedy hearings. It is not always in the public interest for regulations to move forward at a very rapid pace. We might say that the most efficient form of government would be a benevolent dictatorship, where someone makes a decision, enforces it, and that’s the end of it. There is no appeal. Some of the early things that were done by OSHA bordered on that. There was a paragraph in the original OSH Act which permitted the adoption of regulations from consensus standards within the first two years of the existence of the Agency, without public hearings, without feedback from the public, and we were a decade in getting rid of a number of those regulations which were great as consensus standards, but they never should have been made law, or have the effect of law. They were poor regulations. They were not in the public interest, and it took quite a bit of time and a great deal of effort to get them out of the Federal Register, or the CFR. 429 As a direct result of that, there was considerable interest on the part of the public. OSHA is now about 17 years old, 18 years old. The first ten years, a number of those regulations were forced on the public, and the public rebelled. Both the Congress and the President, in about 1980, came out with revised laws, the Paperwork Reduction Act, to which the Kennedy hearings referred in a number of cases, the Paperwork Reduction Act. Also there were Executive Orders from the Office of the President, requiring that the public have adequate opportunity to express their viewpoints. This is what we were talking about here a few minutes ago, in order to get all viewpoints into consideration for a new regulation. This does take more time, but it has been broadly demonstrated that it is well worth the extra time to get the correct regulations, not only where they address all of the problems, but are reasonable in the consequences of that addressing. If we were to require, for instance, some excessive amount of education on each and every one of a number of detailed areas, say in the medical profession, it might result in decreasing the number of people available to give that medical help. It would actually restrict the availability by increasing the burden to the point that people simply wouldn’t bother, they wouldn’t go that route. This is always a problem. DR. CRENSHAW: Thank you, that’s helpful. DR. LEE: Mr. Creedon? MR. CREEDON: To some extent, I’m building on Ms. Gebbie’s question, and also some of the questions this morning. I’m thinking out loud a little bit. I have the impression, and Doctor Lee and Doctor Lilly might be able to comment on it, that for many years the experience with infections in hospitals, not so much with employees, but with patients, has been such that many patients go into a hospital and come out with an infection they contracted in the hospital. There is a fairly high level of people, 6 percent -- DR. LEE: 5 to 6. MR. CREEDON: -~- of people going into hospitals. Is that percentage nationwide? MS. LYNCH: That’s a nationwide percentage and reflects an averaging of very low risk hospitals, such as small community hospitals, and then extremely higher risk hospitals, tertiary care centers, trauma centers and the like. 430 MR. CREEDON: So, in other words, there is a fairly good risk, five or six out of every 100 people who go into a hospital acquire some infection that they didn’t go in with. Three of the panelists here, are looking at this problem primarily, if not solely, from the standpoint of the worker. Whereas, Ms. Lynch, I think, commented both from the standpoint of the worker and the patient. To some extent, I would think that there would be a process in the hospitals of trying to find out what infections the various patients in the hospital have, just kind of as a matter of routine. Is that done? MS. LYNCH: Yes, that is done. All hospitals have infection control programs of various sorts. In some hospitals-- MR. CREEDON: Well, I’m not talking about infection control, but infection identification. Is an effort -- MS. LYNCH: Infection surveillance. MR. CREEDON: -~ made to identify what patients have what infections? MS. LYNCH: Surveillance is a part of infection control programs in virtually all hospitals, less so, I think, in skilled nursing facilities and community-based settings. MR. CREEDON: Is that done at the time someone enters the hospital? MS. LYNCH: No. It’s done at the time that a person acquires infection. Surveillance systems usually track the numerator, that is, the onset of infection, and then -- MR. CREEDON: So, you wait until the infection takes place? MS. LYNCH: Before you count it, yes. MR. CREEDON: Yes. MS. LYNCH: But, procedures -- MR. CREEDON: But, I mean -- MS. LYNCH: -- procedures to decrease risk for infections, of course, can be considered before patients get infected, but surveillance for infection can only take place after the infection occurs. 431 MR. CREEDON: -- if someone comes into the hospital and has hepatitis B, would you know when they come in that they have hepatitis B? MS. LYNCH: No. About two thirds of cases of hepatitis B are sub-clinical, and would not be clinically apparent. And so, we wouldn’t know about any of those cases. MR. CREEDON: So, there would be no tests taken. MS. LYNCH: On a routine basis, no, there would not. MR. CREEDON: I have the impression that when you go into a hospital they take a million tests. That’s not true, maybe they do, but they don’t test for infections? DR. LEE: No, they do. MR. CREEDON: I’m leading up to something here. It’s going to take a little while, but I am leading up to something. DR. LEE: You sound like a lawyer, John. We know almost everything, John. Occasionally something slips by. MR. CREEDON: But then, why are five or six out of every 100 people that go into the hospital coming out with an infection that they didn’t go in with? MS. LYNCH: Is that a question, or a rhetorical? MR. CREEDON: Well, I’m kind of responding to Doctor Lee’s boast. DR. LEE: He wants to know why. MS. LYNCH: A large -- DR. LEE: I’11 tell him later if you don’t want to tell him. MS. LYNCH: Fine. MR. CREEDON: What I’m really pointing toward, is whether the hospitals should be doing something different than they are doing, not only to protect the patients, but to protect the health care workers, by doing some tests that they don’t now do. If someone comes into the hospital with hepatitis B, or a strep infection, or tuberculosis, or whatever, and no attempt is made at the time the person comes in to determine whether or not they have an infectious disease, then it seems to me the 432 likelihood of that infectious disease spreading in the hospital is enhanced. Which gets back to the question, specifically, before the Commission, but it seems to me it is part of a larger question, and in the case of AIDS, probably a more difficult question because of the consequences of having AIDS. Should hospitals, not only from the standpoint of the health care worker, but from the standpoint of the patients, should be testing people for infectious diseases before they come in the hospital. DR. LEE: Ms. Lynch do you want to -- or, Doctor Bartnof, do you want to field that? DR. BARTNOF: I/’11 respond. I think that was discussed a little bit this morning. When you are talking about testing, I think my experience is that you have to ask three questions in terms of why you are doing the testing. Is it for the benefit of the patient, in terms of the type of health care or what decisions will be made in regard to that patient? MR. CREEDON: I would say, yes. DR. BARTNOF: Number two, are you looking at it from the standpoint of public health? MR. CREEDON: Yes. DR. BARTNOF: Because, being able to identify people who are infected with communicable diseases -- MR. CREEDON: Whatever, right. DR. BARTNOF: -- that’s a good place to identify then, presumably, and that you could take precautions to prevent transmission outside of that situation, whether it be to family members and so forth. And, the third that you need to look at, what the costs are, in terms of a risk/benefit ratio. Anything else, you look at what the risks are of doing it, making a decision on what the benefits are. When it comes to information for the patient, whether somebody who is HIV antibody positive should be starting on AZT if they already have a low number of T-helbra cells, or their P- 24 antigen is high, and so forth, whether you would want to give them a skin test for TB, because if they are positive you’d want to give them therapy. Those kinds of decisions need to be looked at. The other thing is, once you do an antibody test on someone, you are really incurring a tremendous responsibility, including the health care institution, the attending physician -- 433 MR. CREEDON: So, you’d rather not know, is that it? DR. BARTNOF: No. I’m just saying that you are incurring a tremendous responsibility, and if you do the test you have a responsibility to interpret that test and make sure that that person knows what the test means, positive or negative, and what false negatives, and false positives means. Counseling that person is a big part of the cost. The counseling cost is a tremendous cost. MR. CREEDON: I understand. Were you here this morning? DR. BARTNOF: I was outside, yes. MR. CREEDON: Okay. We’ve received data in the last day or so about the incidence of people getting either hepatitis B or AIDS, whether they were firefighters, or policemen, or sanitation workers, or prison guards, or, other people in the system, very, very low incidence, .5 of 1 percent, 1/2 of 1 percent, if they get stuck with a needle. And, we’re setting up a very, I would say, elaborate, maybe that’s not the right word, or, comprehensive occupational health and safety system, which I raise a question as to whether it is cost effective, but, presumably, to protect them against that very small risk. Now, here we have testimony that 5 to 6 percent of the people who go into a hospital, the patients, get an infection while they are in the hospital. What are we doing about that? DR. BARTNOF: Well, you may want to respond as well, but most of those are minor infections that are easily treatable with routine antibiotics. It might be a minor skin infection -- MR. CREEDON: It may be minor from the standpoint of the doctor. I don’t know if it’s minor from the standpoint of the patient. DR. BARTNOF: Well, certainly, any infection is a complication, I wouldn’t disagree with that, but on a relative scale as to how treatable the infection is, whether someone is going to get HIV in the hospital, because the patient in the next bed is infected with HIV, unless they are having sex or sharing needles, that’s not going to happen. There is the finite risk from a blood transfusion even today, and of the rare, rare incidence when, perhaps, a health provider might be infected and could, perhaps, expose a patient. DR. LEE: We only have about five minutes left to reassure Mr. Creedon. At your average academic institution, when a patient is admitted, he’s worked up for two to three hours by 434 an intern, for an hour and a half by a resident, for an hour and a half by a senior resident, for several hours by an attending ward physician, innumerable hours by his own attending physician. He’s seen by the charge nurse, the head nurse, the floor nurse, the nurse associated with him, and every Single one of these people is trying to find out what all of the diagnoses are on this patient when he is admitted. So, if it is conceivably possible, you have about a dozen brains working on that, when a patient is admitted. Now, despite that, because of procedures, because of contamination, because of operations, because of scoping, because of a million people seeing him, et cetera, et cetera, these types of infections occur at the 5 to 6 percent level. Don’t think that the medical profession isn’t terribly concerned about it. That’s why Ms. Lynch was as concerned as she is about it. MR. CREEDON: But, in this process that you’ve just described, do they test for the HIV virus? DR. LEE: If there is any suspicion whatsoever that this virus might be present, speaking for myself at our institution, that patient would be tested. If there’s any conceivable suspicion. That obviously varies from institution to institution. We’re going to run out of time, and I wanted to bring up a very important point. Chris Grady, one of our Commission staff people, has brought up a question I want answered for the record here. This morning we talked about some part of the government implementing what Ms. Lynch was talking about, and, that is, being responsible for improvement in engineering and design for this type of protective equipment across the board for all health care and health care-related workers, like our firemen, and policemen, and so forth. Now, is NIOSH going to take this under their belt? Is OSHA going to do it? Who is going to do it? DR. MULLAN: I would take a deep breath, and say that under the Occupational Safety and Health Act, clearly the responsibility for research that relates to worker protection rests with my Agency, NIOSH. DR. LEE: So, you, sir, are responsible for this. This is practically the point of the whole day as far as I can see, and there are innumerable improvements that can be made in all of this type of equipment and practices. 435 There is one other question I can’t let go. Doctor Bartnof, you are a teacher, educator in San Francisco, and some witnesses have given a frankly horrendous picture of what was happening in San Francisco in the early ’80s at your best hospitals. When did this educational process start? Why has it started so late in our most sophisticated medical environment? DR. BARTNOF: I can only speak for a couple of the hospitals. DR. LEE: I notice you are a Fellow in ’84 and ’85, so we can’t lay it at your door step, but it’s astounding that you only started in the mid-’80s with this kind of thing. DR. BARTNOF: Until there was, I think, an understanding that this could possibly be transmitted to health care providers, and the evidence of that started to come out, I think that there was a sense of denial as to what the real risk was. I know at San Francisco General, as was mentioned this morning, there is one case now of a nurse who acquired infection by a needlestick. That just happened in 1987. DR. LEE: We had a case of a nurse here who -- DR. BARTNOF: I’m saying, it’s -- DR. LEE: -- was drug into a train wreck here in the early ‘80s, at a time when every hospital I’m aware of on the East Coast was using standard hepatitis precautions for patients with AIDS. DR. BARTNOF: But, I think there’s a sense that until it comes to your own home institution, and one of your co- workers has had the accident, that it’s led to this seroconversion, that really brings it home. There are so many analogies to that, in terms of this epidemic. DR. LEE: Well, doctors have got to be smarter in that one. You are not going to let the train hit you. Anyway, I‘1l turn it back to Mr. Richard DeVos. MRS. GEBBIE: Rich, can I ask one question for a written answer, not to take up time? Of Mr. Chalmers, I think it would be really critical if you could very quickly, in a couple of days, get back to us some information about actually how your inspection and follow-up system works, what cycle, what level of 436 information goes to an institution that’s being checked for its compliance with OSHA standards, a health care institution, once these standards are set, and how that follow-up is going to happen? And, I’d be truly interested not just in how it applies to hospitals, which we've heard most about, but how it applies to long-term care facilities. Could we get that back in writing, because I know we don’t have much more time? MR. CHALMERS: Well, our inspection procedure, if I may, I think I can give it to you in a few seconds -- our inspection -~- MRS. GEBBIE: But, Rich is going to hit me if we take any more time with this answer. MR. DeVOS: Go ahead, you’ve got one minute. MR. CHALMERS: -- our inspection procedure is very straightforward and follows a definite pattern in all cases. There is an opening conference, the inspection takes place, people walk with the inspectors through the facility. Then at the end of the inspection there is a closing conference, following which there are citations written up specifically for violations of any regulations, large or small, and these are all transmitted back. This is the entire purpose of the way the thing is set up, is to feed back that information. MRS. GEBBIE: With or without prior notice to the institution? MR. CHAIMERS: The law prohibits OSHA from giving prior notice to anyone on any inspection. MRS. GEBBIE: Thank you. MR. DevOS: I presume after you get through with that report, you will also give an accommodation of the outstanding things they’ve done? MR. CHALMERS: You bet yes. MR. DevOS: That’s good. MR. CHALMERS: Sure. MR. DevOS: You know, we’ve got to have a little bit of that with the rest. MR. CREEDON: Mr. Chairman, could I add just one point? 437 MR. DeVOS: You too, huh? MRS. GEBBIE: I’m sorry, I set a bad example. MR. CREEDON: Well, Doctor Lee cut me off before I made my point. MR. DeVOS: I see. MR. CREEDON: But the point really is to the Occupational Safety and Health people, in looking at what should be done to protect the workers, and I think as Ms. Gebbie said, there are different types of health care providers, and maybe different standards should apply to different ones. i guess the question I have is whether it would be protective to the health care providers to know before someone comes into the hospital whether or not they have the HIV virus. In other words, in thinking of how do we protect the health care provider, should one of the standards be, determine what kinds of infections people have coming into the hospital? MR. DeVOS: He has a very simple question for you. You can vote yes or no. MR. CREEDON: No, they don’t have -- I’m not suggesting that you answer the question. I’m just posing a rhetorical question, which I think should influence the deliberations of OSHA. MR. CHALMERS: It certainly would be considered during the process, yes. MR. DevOS: You obviously did an outstanding job to provoke all this lively discussion, and we thank you for coming, and for sharing your insights with us today, and now you want a closing statement, I suppose. DR. BARTNOF: I just want to make a couple quick follow-up remarks to the questions and issues that came up this morning. First of all, Doctor Rodriguez gave a very heartening story about trauma surgeons and the problems that they have. At San Francisco General, trauma surgeons now will wear an impermeable thick plastic apron from here, that goes down to the knees, they will be wearing rubber boots that come up to the knees, the kind you wear when you are going fishing, and they will be wearing a thick plastic face shield, like what a welder would be wearing, to avoid contact with blood. Secondly, the issue has come up about tuberculosis. A number of people have asked something we tend to forget, that the 438 rate of tuberculosis amongst health care providers has always been higher than the general population. We’re talking about decades and even a few centuries that we know of. And, lastly, in terms of students, when I’m teaching the medical and nursing students, they are learning infection control practices right the first time. The problem that they face is that when they go out in the ward and start doing these things, that interns, residents and nurses, will be giving them negative feedback about overdoing it or undergoing it. Whether it’s the Doctor Macho syndrome, where, oh, you don’t need to wear the gloves at all, versus the space-suit syndrome, where you need to wear four pair of gloves and two caps and gowns and everything else. MR. DeVOS: I have dismissed some panelists. We are going to terminate this one. So, we thank you very much. We’1l go the next panel and we’1ll deal with some of the other things that you are already talking about or we have talked about. So, we thank you for your special section in here. PANEL 4: POLICY DEVELOPMENT FOR HEALTH CARE PROVIDERS WHO HAVE BECOME INFECTED MR. DeVOS: We’re going to move to our next panel, and our last one for the day, which deals with Policy Development for Health Care Providers Who Have Become Infected. I don’t know if you are Doctor Lattimer, Ms. Parker -- Ms. Parker, Doctor Lattimer, Pettricciani down on the end there. I think you’ve probably been sitting through some of this, and you know we try to run on time, not because what you say isn’t important, but the Commission has listened to hundreds of witnesses. So, we don’t expect you to cover the whole history of the HIV epidemic today. We just thank you for coming to share your special insights on this very special problem. We’re going to begin on this panel, which deals with, for our audience here, Policy Development for Health Care Providers Who Have Become Infected with the HIV, and we’re going to start with Doctor John Pettricciani, from the National AIDS Program Office, Public Health Service, in Washington, D.C., and we also have Doctor Agnes Lattimer, Medical Director, from Cook County in Chicago, Michelle Parker is an RN from Chicago on behalf of the American Nurses Association, Doctor Harvey Elder, Chief of Infectious Disease Section, Jerry L. Pettis Memorial Veterans Hospital, Loma Linda, California, and Doctor Phillip Pierce, Director, AIDS Clinic, Georgetown University Hospital, Washington. So, aS you can see, we have assembled a very high- powered group of experts, and with that we’re going to start with our Dutch friend on the left, Doctor John. 439 DR. PETTRICCIANI: Thank you, Mr. Chairman. I appreciate the opportunity to appear before you today to discuss the Public Health Service’s efforts in formulating policies to protect employees who may be at risk for HIV infection in their work with special emphasis on the laboratory worker, and in addition, I’11l touch upon a few of the unresolved issues in setting policies for health care providers who have become infected. In the previous panel, Doctor Robert Mullan presented a description of the policy developed jointly between the Department of Health and Human Services and the Department of Labor for the protection of health care workers. That document addressed the needs of health care workers, and was not specifically applicable to the needs of personnel who work with HIV in the research setting. In the HIV research area, individuals can be exposed to the AIDS virus in higher concentrations than is routinely possible in the clinical setting (up to 1000X higher concentration than in human serum) and they also have a more frequent opportunity for exposure, sometimes on a daily basis. Because of the importance of establishing a uniform system among the Public Health Service agencies, we developed a PHS-wide policy, the final version of which was signed recently by the Assistant Secretary for Health, and a copy of this document has been submitted with my written testimony. One essential aspect of this policy bears highlighting, and, that is, the establishment of a surveillance program. There are three basic reasons for wanting to know when someone has been infected: 1) to try to get an understanding of what went wrong and to correct it, so as to prevent infections in others in the laboratory setting; 2) to advise infected persons so that they can take steps to prevent passing HIV on to their sexual partners; and 3) to identify infected laboratory workers, so as useful new drugs become available, there is an opportunity for early medical intervention. PHS has chosen to institute this surveillance program in the laboratory setting on a voluntary basis. Experience to date at NIH, where a voluntary surveillance program has begun, indicates that a majority of eligible employees choose to participate. I’ve mentioned our development of a PHS policy for laboratory workers, not only because it’s an area in which we’ve had concern and have taken some positive action, but because there are several aspects of it that one could consider in the case of an infected health care provider. 440 The first issue is the identification of infected health care workers. As opposed to the research laboratory setting, the concentration of virus and the frequency for potential exposure are very much less in the health care setting. For those reasons, the joint Department of Labor/HHS Advisory Notice did not suggest routine serologic monitoring of health care workers. Instead, serologic follow-up of health care workers who are accidentally exposed to HIV-containing material would seem to be a more reasonable and cost-effective strategy. Such a system, of course, depends on the voluntary reporting of accidents by health care workers. Identifying health care workers who have been infected outside of the workplace is a difficult issue and one about which there is a great deal of discussion and debate and differences of opinion. But, knowing that a person is infected is the first and essential step in the consideration of any policy that attempts to deal with infected workers. Identification of health care workers infected with HIV outside of the work setting now depends on their voluntary reporting that fact to colleagues once they themselves find it out. We have not given serious consideration to a mandatory serosurveillance system for health care workers within the PHS. Instead, we believe it is important to impress upon our personnel their responsibility to consider whether they may have become infected by HIV, and to seek counseling and testing if they see themselves as having been at risk for HIV, whatever the reason. Once a health care worker is known to be infected, the next issue relates to their ability to continue professional activities. With the federal setting, the Office of Personnel Management (OPM) recently issued guidelines for handling HIV- infected employees. And in a general way, those guidelines apply equally well to health care workers. In essence, the OPM policy says that HIV-infected individuals should be treated no differently than one would treat individuals with other illnesses, and that job performance is really the critical issue. In the health care worker setting, however, there are specific situations that require close examination. In the large majority of clinical procedures there really is no risk of transmission of HIV from a health care worker to a patient because risk arises only from the exposure to blood, and in most cases blood is not really part of the procedure or a risk. That means that concern for patient safety is basically limited to, invasive procedures. An infected health care worker who participates in surgery, for example, creates at least a theoretical risk to the patient because of unavoidable injury that can occur with bleeding during some invasive procedures, such as surgery. We are now reviewing these kinds of situations at the PHS and are beginning to develop a policy which, like our laboratory worker policy that I mentioned previously, will apply 441 to all health care workers who are now within the Public Health Service system. Thank you, Mr. Chairman. MR. DeVOS: Thank you very much for that. MR. DeVOS: We’re going to go from Washington now to Chicago, and we’re going to hear from Doctor Agnes Lattimer, Medical Director, Cook County Hospital, Chicago. Doctor Lattimer, welcome. DR. LATTIMER: Good afternoon, panel members. I’m pleased to be here with you. MR. DevOS: Get a little closer to that, would you, please, Doctor? DR. LATTIMER: I’m pleased to be here with you to share some of our concerns at Cook County Hospital about the risks of HIV infection for employees who are infected. We had the occasion to have one of the early position providers with AIDS, and have to deal with that problen. Two things have come out of that controversy. One is, and the most compelling problem that we had to deal with, is the attitudes and behaviors of patients, and their worry and concern about the possible risk of having a health care provider with AIDS. Secondly, was the problem of the fact that the CDC guidelines at that time were not very clear on what constituted a risk in terms of an invasive procedure. We had to make a decision based on fairly superficial evidence of what constituted risk for that particular health care provider. And, the third problem we had was confidentiality and the maintenance of confidentiality in the monitoring process of employees who have HIV conversions, or, particularly, actually have the AIDS infection with clinical manifestations. You are dealing with a health care provider who has the potential for both physical as well as mental derangement, and, therefore, can pose a problem for both his fellow employees and patients on an almost daily basis. This requires a monitoring system which is quite different than simply monitoring employees for positive conversion of HIV antibody. As a result of this problem, we instituted a procedure that calls for voluntary reporting of HIV conversions, and/or any absence from work for a specified time has to be reported to Employee Health Service with a report from the physician. This constitutes voluntary compliance because of the fact that Illinois, as in most states, does not provide for routine testing 442 of health care workers for HIV antibody. When we were asked by our County Board of Trustees why we did not do routine testing, they couldn’t understand why we didn’t just test everybody, it became very clear that in addition to the fact that it’s against the law, one could, in fact, miss many of the employees at the time of testing because of the latent period. Our process for employees calls for voluntary reporting and monitoring by Employee Health Service, and once they have clinical evidence of AIDS, or ARC, then they are monitored on a specific basis by Employee Health Service, where they are required to return every two to three weeks, as well as they are monitored by their supervisor for any evidence of clinical infection. A third category of employee, that of non-provider, but a health care worker that does not deliver direct patient care, are other employees, such as, Environmental Health Service workers, nurses, nurses aides, transporters, and employees of that type whom we have been able to transfer from direct patient care activities while maintaining their employment at the hospital. A final concern we had was how we would treat patients who were admitted to the hospital in order to protect our employees, and there are two methods for doing this. One is routine screening of all patients, as was mentioned in the previous panel, and, of course, this is neither cost effective nor permissible, and, second, the implementation of Universal Precautions for all patients admitted. Employees can, in fact, be protected against possible exposure to patients admitted with HIV antibody infections. One of the problems, as you may be very familiar with, is that most patients who are admitted to the hospital, who have the capability of transmitting either HIV or hepatitis B, have not been identified. Most hospitals, like our’s, the isolation procedures are governed by the diagnosis. They are diagnosis- specific. And, if a diagnosis has not been made, then a specific isolation precaution is not implemented. One of the problems that that poses for employees is, they become very anxious about the possibility of being exposed to patients who have not been identified as having an infection. At our hospital, that has happened on several occasions, and it was the basis of our implementation of the Body Substance Isolation System of Universal Precautions, in order to relieve the anxiety of some of our employees. In addition to protecting the employees from the infection, one of the problems we have in dealing with patients 443 in the hospital with AIDS, as you may have already heard, is the difficulty some employees have in providing the caring component of medical care for the AIDS patients. To the extent that employees are relieved of anxiety, and feel that the risk of exposure is minimal, they are free to engage in more caring behavior. Thank you. MR. DeVOS: Thank you very much. Did you rehearse that or ad lib all that? That was very well done. MR. DeVOS: We/’re next going to hear from Ms. Parker. Michelle Parker is an RN from Chicago, on behalf of the American Nurses Association. Ms. Parker? MS. PARKER: Mr. Chairman, I am here today representing and as a member of the American Nurses’ Association’s Cabinet on Economic and General Welfare, and also aS a member of the Association of Critical Care Nurses, and I’d Like to thank you on behalf of their 188,000 members and their 58,000 members, respectively, for the opportunity to address this Commission. You have asked us to address nursing’s concerns regarding policy development for health care providers who have contracted Human Immunodeficiency Virus. ANA and AACN believe that the first and most important step is the education of health care workers about AIDS, its transmission and prevention. ANA and AACN have designated the occupational safety and health of critical care nurses a priority issue. Recently, AACN completed a publication on occupational safety and health hazards faced by critical care nurses entitled, AACN Occupational Hazards Handbook for the Critical Care Nurse. Recent media reports on health care workers who seroconverted after contact with the blood of HIV-positive patients have emphasized the need for increased vigilance with established procedures. The Centers for Disease Control have identified a significant number of registered nurses as at-risk to blood and body fluids infected with HIV. We are especially concerned, as studies show that AIDS patients require almost double the amount of nursing time as equally ill patients who do not have AIDS. We have urged the Occupational Safety and Health Administration to issue a final health standard on AIDS and hepatitis B, because CDC does not have the authority to enforce hospital compliance with its recommendations. 444 ANA and AACN advocate the implementation of the recommendations of the Centers for Disease Control on Universal Precautions in all health care settings as a standard of care; and also, the provision of continuous prevention education; and voluntary, anonymous HIV testing with informed consent and appropriate counseling. Studies of health care workers indicate that special infection control precautions for HIV-infected patients are not required to prevent occupational transmission of HIV. Nevertheless, it would seem prudent to implement and enforce standard infection control guidelines designed to reduce exposure to body fluids from all patients. Although we know that approximately 7 million health care workers have been exposed to HIV, less than 20 seroconversions have been reported. Investigation of the incidents have revealed that compliance with existing CDC recommendations would probably have reduced employee exposure. We believe that health care employers should develop prospective personnel policies for employees with occupational exposure to blood and body fluids, and those infected with HIV, to ensure consistent equitable treatment, appropriate medical surveillance and monitoring of such employees. Nurses must participate in the development of such policies, as the common denominator for HIV-occupational exposures is blood, needlesticks and nurses. As you are aware, both ANA and AACN oppose mandatory HIV testing of health care workers. However, we do recognize that testing may be appropriate in certain situations. Random or routine testing of all employees should not be permitted. All employee health information must be kept confidential because of hostile adverse insurance, employment and housing actions. We do support employer testing if it is done in accordance with the medical surveillance routine recommended by the CDC to document occupational exposure to HIV. Serologic testing after on-the-job exposure to HIV, follow-up tests, record keeping and access to records, confidentiality and medical and health counseling during medical surveillance must be addressed. There must not be any disincentives for health care workers to responsibly report occupational exposures. We have heard anecdotal reports that nurses who have experienced needlesticks have had difficulties with the insurance companies regarding coverage. 445 Likewise, policies must address the source patient of an occupational exposure. That patient must be afforded the same protections of confidentiality, privacy, informed consent and counseling as the employee. Follow-up testing of employees must be done with anonymity, counseling with informed consent, and assurances of confidentiality. When the source patient or the HIV status of a patient is unknown, the employee may have to postpone marital or family- planning decisions until seroconversion is ruled out. When health care workers are infected with HIV or have AIDS, their fitness for duty should be evaluated in conjunction with his/her family health provider and employee health. Confidentiality must be maintained throughout the process. Any changes in work assignment should be done in the same manner as for other medical conditions. Ideally, the goal of such policies is to return the employee to his or her assignment, utilizing the skills and talent of the employee. Employees infected with HIV should have access to the same sick, disability or vacation leave in the same manner as employees with other medical conditions. Employees must have a written policy regarding employee reluctance or refusal to work with HIV-infected employees, which incorporates appropriate education and counseling and corrective or disciplinary actions, and which also parallel non-AIDS-related personnel problems. The employer must ensure that employees infected with HIV are afforded the protections of Section 504 of the Rehabilitation Act of 1973. We recognize that employers cannot protect their workers from all harm. Employers must take reasonable precautionary steps to protect their employees. They must do more than caution. Employers should orient all employees on personnel policies regarding AIDS, and give them an opportunity to ask questions and receive informed responses from designated authorities. Employees must be monitored to ensure consistent and equitable compliance and enforcement with personnel and health and safety programs. Recently, ANA received a call from a nurse in Georgia, stating that her employer was giving educational programs on Universal Precautions. However, the employer asked the employees to sign forms absolving the employer from liability if the employees were exposed to HIV. Such a policy seems prohibitive and inconsistent with accepted occupational health concepts. We hope that our recommendations will aid the Commission in addressing occupational issues in AIDS. ANA and 446 AACN are sensitive to the difficulty and complexity of the issues addressed here today. Our commitment to the provision of nursing care to all patients is steadfast. However, the health and safety of health care workers must be ensured. We believe that scientific, logical, compassionate and prospective policies can balance the health and safety interests of health care workers and their patients. Thank you for the opportunity to present our concerns and recommendations. MR. DeVOS: Thank you very much. MR. DevVOS: We are going to go next to Doctor Harvey Elder, Chief, Infectious Disease Section, Jerry L. Pettis Memorial Veterans Hospital, from Loma Linda, California. Doctor Elder, thank you very much for coming. DR. ELDER: Thank you very much for inviting me from the VA to come and share some of what we’ve learned. I need to take a second first to point out a couple of typographical errors, since I am not a very good typist. On page 2, under Item 4, there is a negation that’s missed. I think it is obvious in the script, in about the fifth line down, it starts out, "is an easily prevented disease." MR. DevOS: What are you doing typing anyway? DR. ELDER: The VA is short of money. MR. DevOS: You are supposed to write prescriptions people can’t read. DR. ELDER: As we approach the epidemic, I have a couple of concerns and a couple of things that seem apparent. I’m concerned about what medicine will be like once the AIDS epidemic is over. It seems to me what you folks are discussing the last couple of days are very determinative, because American medicine may make Soviet psychiatric hospitals look hospitable if we aren’t careful about what we decide. I think that’s a crucial issue. Second, to date no really new problems have emerged with the HIV epidemic. What happened is that we have discovered that our previous blaseness covered up a lot that wasn’t working well. 1/’11 use a very specific example, confidentiality. Whether it is a Catholic nun for a pregnancy test, or a Mormon Bishop for a blood alcohol, or a person for an HIV, these are identical issues and they are issues of confidentiality. A radical improvement, not just minor, a radical improvement in confidentiality must occur, and if that occurs, then some of the 447 problems we’re trying to solve can be handled appropriately. Confidentiality is a medical issue. Finally, AIDS is far more than a disease. AIDS is a symbol. It’s a symbol of many things, and I’m not exactly certain what they all are, but unless we deal with it as an important symbol of the present era, probably we will make bigger messes than we now have, and they are already big enough. With those preliminaries, I will merely identify my conclusions and let the document speak for itself. I think that HIV-infected health workers, whether they be nurses, laboratorians, respiratory therapists of physicians, are relatively minor risk, and I outline that from some guesstimates that are in the document, for the transmission of HIV to patients. If HIV-infected workers were to double glove, and I think for their level of risk, double gloving is all that’s required, I think the issue would become zero. I don’t think there would be an added risk. I think what Doctor Rodriguez told us about a little bit ago is important. The trauma surgeon with their hand in the wound, with sharp spicules of bone, which are as sharp as glass, cutting the fingers, means the surgeon will bleed into the wound. That’s another order of magnitude. And, what was said earlier, I want to emphasize, I can’t imagine that a country that can land people on the moon can’t make gloves that will protect surgeons, and it strikes me that that should have a high level of priority. Let me point out that funding for health research has basically been limited to basic research. If it isn’t breaking new ground, no one is interested. But, we are talking about practical stuff that needs to be solved. It is solvable. I can’t accept that it is not. My third conclusion from looking at estimates of numbers is that broadly-based mandatory HIV testing program would be ineffective, and, I think, totally inappropriate. We need to expand present impairment programs. The problem of HIV is impairment, and that’s no different than alcohol, drugs, senescence, Alzheimer’s, and so forth. As Doctor Lattimer just talked about, it’s how well do they perform on the job? I think as far as the trauma surgeon is concerned, that locally, could I emphasize that word "locally" developed and administered programs will work far better than regulations from Washington. Finally, Doctor Lattimer mentioned, and I do want to focus on, the public believes that their health workers are free 448 of HIV, and as soon as you say that to them, they blink, because they know better. But, that’s a matter of fate. I think an important role that the Presidential Commission could do is to begin a discussion of the fact that there are HIV-infected physicians and health care workers out there, and they deserve and ought to stay in the workplace, because they will do a good job. Thank you. MR. DevOS: Thank you very much, Doctor Elder. MR. DeVOS: Doctor Pierce is next, and Doctor Pierce is one of the members of our Physicians Advisory Panel in Washington, to help us evaluate scientific or medical proposals that are sent to the Commission, so he has some special insights, and Doctor Phillip Pierce is the Director of the AIDS Clinic in Georgetown University Hospital in Washington. Doctor Pierce, welcome, and thank you. DR. PIERCE: Thank you. I’m here actually today just to give you our particular hospital’s response to the problem of the infected health care worker. Health care workers infected with HIV have posed very difficult problems for all hospitals. There are concerns over the transmission to patients, as you have heard, and public fears regarding contact with infected health care workers need to be balanced with the employee rights. The problem is not theoretical. Indeed, one estimate is that there are 5,000 infected physicians in the United States practicing medicine. The CDC has identified 1,875 health care workers with AIDS, not HIV infection, in the United States. That data is one-year old. As a private institution, Georgetown needed to be sensitive to public fears, which we have little control over, and realistically little ability to effect. Our patients have voiced fears of acquiring HIV infection in the hospitals, be it comments to the Medical Director of inquiring whether we have infected physicians working on the staff, et cetera. Even interviewing health care workers, whether they would be taken care of by an HIV-infected physician, or their families, they expressed reluctance to me in that. Those fears must be addressed. Indeed, though, in spite of our institution needing to be aware of these fears, we have gone forth and developed a very specific policy based on what we feel is the existing scientific information. 449 To our knowledge, no patient has been infected by a health care worker in the setting of the hospital. Routes of transmission for HIV are well established and our policy reflects possible exposures through the routes, that is, most specifically, through the risk of blood of the health care worker entering the body of the patient. Georgetown University Medical Center developed our first written policy in 1986. It has been revised in 1987. The policy was written by members of our Infection Control Committee, representatives from our administration, legal services, and as well our Employee Health Section. The CDC publication "Recommendations for Prevention of HIV Transmission in the Health Care Setting" was used as a reference. However, this publication devoted two paragraphs to this particular topic that we’re addressing presently. And, frankly, those were rather vague recommendations. It stated that decisions "must be determined on an individual basis," and that was the end of that statement. We feel that more specific guidelines are needed for institutions. Our policy provides a detailed list of procedures that HIV-positive employees can and cannot perforn. In general, routine examinations and blood drawing by an HIV-positive health care worker may be performed, but invasive procedures, such as, surgery, cardiac catheterization, vaginal deliveries, dental extractions and trauma care are not permitted by an HIV-positive health care worker. In our ‘policy, health care workers with AIDS are not involved in direct patient care and are reassigned to non-patient care areas. The latter has two purposes. One, it is designed to protect the health care worker with AIDS from infectious agents which are prevalent in our hospital environment, and also, it is designed to protect patients. No routine testing of health care workers is performed. It is the responsibility of the health care worker to confidentially inform the Employee Health Service, or ina physician’s case, to his or her department chairman, of their positive HIV status. I believe these policies are cautious policies. Our goal is to offer rigorous procedures to protect patients, while reasonably accommodating the infected health care worker. MR. DeVOS: Thank you, Doctor Pierce. 450 MR. DeVOS: With that, we’re going to go to the voice of Metropolitan, big John. MR. CREEDON: I’d like to continue to pursue a little bit the subject we’ve been discussing. MR. DeVOS: You and Theresa get a minute each, John, and I’m going to let you talk to each other after the meeting. MR. CREEDON: I’m looking at it in part from the standpoint of the hospital, and some of the representatives here are involved with the hospitals. Doctor Lee, a little while ago, described the process that they go through at Sloan-Kettering when someone enters the hospital. I don’t know whether you were here when he talked about it, but he described a very elaborate process of working up the patient and trying to determine exactly what his or her health situation is. I guess it’s not normal or common to take and do a test with respect to the AIDS virus unless there is some suspicion that it might be appropriate. One of the questions that went through my mind is whether, if a health care worker comes down with the AIDS virus as a result of an occupational situation, and the procedure of the hospital is not to test patients who are admitted to the hospital, and there is no specific warning given because you still have these Universal Precautions that presumably the health care worker uses, but if despite those he or she comes down with the virus, whether the hospital will be liable ina lawsuit for having failed to identify those patients with HIV and take special precautions. I suppose I should be asking this question of a lawyer rather than those on the panel, but Doctor Lattimer, should that be a matter of concern? Would you be concerned about having one of your employees come down with the virus, and claiming ina lawsuit that the hospital did not do everything it could reasonably have done to protect him or her against the possibility of getting the infection. DR. LATTIMER: We have looked at that situation, because we thought we had a situation where that had occurred. What we were reassured by our attorney, is that if we are in compliance as a hospital, with applicable CDC guidelines, and we are protecting our employees utilizing those guidelines, and we can document that we have, in fact, educated them and provided the equipment that they need, then we cannot be sued for negligence, which is what it will have to be in terms of the employee. 451 However, the most important thing to emphasize there is that even if we had tested that particular employee or group of patients on admission, and that employee was exposed to them, and they had a negative test, that doesn’t mean that a patient could not have transmitted the virus, which is one of the main reasons why, in addition to the confidentiality, that routine testing of all patients, as well as all employees, is not a good way to prevent transmission. DR. ELDER: Mr. Creedon, if I may make a couple of comments on that. One is, HIV testing is not without its cost. There is a cost to a patient who didn’t want to know the information, it’s one thing. See, you are a very reasonable person, you want to know, but a lot of people live under a great deal of denial, and it is a very difficult thing to be a physician to a patient who wants denial, very difficult. And, you may well be closing off hospital care to that person, at least delaying it. The second is that the number of dollars in health care is fixed, so that if the dollar goes for HIV testing, it doesn’t go for something else. Now, if the panel believes that HIV testing is the highest priority, then please identify it, but if it isn’t, remember that if it becomes -- if it is used much more broadly than it is now, it will take dollars away from something else. And, we have been going, in health care, through a wrenching experience, in terms of what things should be. The third comment is, clearly, lots of lawyers are going to get rich on this issue. I mean, that’s without question. And finally, if somebody’s been cheating on their wife, that’s the way to get out clean, and so, it’s going to happen. You know it’s going to. In fact, you can write the script right now. MR. CREEDON: Well, I agree. I think that there will be a lot of lawsvits about this subject. I think as Doctor Lattimer said, the fact that the OSHA does not require that as one of the conditions to protect the health worker should be helpful. But, if I were at OSHA, I would be thinking about that as whether it should be one of the conditions. In terms of what the patient wants to know and the denial and so forth, of course, as a doctor you would know that it’s better for the patient to know than not to know, and it’s better for you to know rather than not to know, in terms of treating that patient. DR. LATTIMER: I’d just like to say one other thing, because we had the experience recently of doing what Doctor Elder mentioned. The Illinois Legislature passed a requirement for 452 mandatory testing of HIV for all who were getting married. At the time we thought it was probably a good thing to do. Over the ensuing months, what we found is that a tremendous amount of money and resources had to be committed to that with very, very low yield in terms of the cost of diagnosing one patient with HIV positivity. But, it was taking away from us the opportunity to do really good AIDS testing, for example, for infants of mothers who had HIV, and other much more critical resources. And, what it did was actually penalize the poor, because they did not have the ability to get the test. So, not only did it not accomplish its purpose, it had a very negative impact overall. MR. CREEDON: Thank you. Just going back to Doctor Lee’s example of what’s done at Memorial, one of the difficulties I think you have in terms of a possible lawsuit is saying, well, they work a patient up for everything else but the AIDS virus. DR. LEE: No, no, no. MR. DevOS: Okay, Bert, you’re on. DR. LEE: No, no, no. MR. DevOS: Defend yourself. DR. LEE: No, no, no. I agree with Doctor Pierce and Doctor Elder’s positions. They seem to be very, very well taken. I have nothing to add at all on that. And, so far as what we do at Memorial, I’m sure every conscientious doctor does it. If there’s the slightest evidence that this patient might be HIV infected, we get an HIV test. We don’t get them randomly, just like we don’t get any other test randomly, but we get it if we have the slightest hint that that might be there. I deal with lymphomas, so all my cases have an HIV test. Was he putting me on here? MR. DevoS: He’s just pulling your leg. DR. LEE: I don’t have anything to add to what Doctor Pierce and Doctor Elder had to say, except one thing. So far, physicians have tended, in this epidemic, to let the customer dictate the rules. Just in the six months since we’ve been conducting these intensive hearings, I’ve noticed that attitude changing and I’m very, very happy about it. I think doctors and other health care professionals ought to get back in the driver’s seat on this one. MR. DeVOS: Thank you. We’re going back over here to Doctor Lilly. 453 DR. LILLY: I’d like to change the subject a little bit here. We’ve had testimony in previous hearings from a number of people who have pointed out that, the amount of discrimination that is experienced by gay men has increased since AIDS has come on the scene. Gay men are perceived as being HIV infected, if not having AIDS, and, therefore, are dangerous. I’m beginning to gather that health care workers may be perceived in that sense as being carriers of HIV virus, and I’m just wondering if, particularly Ms. Parker, you referred to AIDS- related discrimination in your talk, I’m wondering if that is actually occurring with health care workers, discrimination based on perceived HIV infection. MS. PARKER: If someone has had a HIV test ordered, or gone to employee health after a possible exposure to a patient, then there may be some experience on their behalf from an insurance company, or if they’ve related that story to other people, that that health care worker is at high risk for developing AIDS, and, therefore, we may not want them living around here anymore, et cetera. I don’t think it’s on any large- scale basis. The other experience I’ve had is when patients have been in the hospital, and you’ve been drawing their blood, for instance, and you wear gloves, they believe that you are protecting them, rather than the health care workers are protecting themselves. So, I think their perception of whose getting the most protection out of this is still themselves, and they don’t fully understand that the health care workers are wearing gloves primarily for protection of themselves. I think that the public doesn’t really totally understand this yet, and so, there is some thought that there may be discrimination against health care workers because they may have the virus, but in a large sense it’s the public still thinks that they are the ones that are being protected. DR. LILLY: Does anyone else have any comments on that? DR. ELDER: I think it’s tragic when health care policy is developed as a means of protecting insurability. That is a breakdown. It is a very serious breakdown. Insurability, I think, is fundamentally a civil right. I think that’s the way it is handled in this country, of an employed person. I think everybody’s got it, and I would applaud that. But, when we do health care so that somehow that’s kept different, we are messing up health care. They ought to be separate, and I think the Presidential Commission could do something very- valuable if they made statements -- I am embarrassed that the medical profession has not pushed stronger 454 that the insurability and whatever these people have be protected. That must be done. But, the mechanism is not by doing tests or not doing tests. It’s not even confidentiality which I talked about, with some passion. But, our choice of tests, I mean, it’s a tragic thing, and we’ve had the same sort of experience. A nurse has been stuck, and the insurance carrier finds out. That’s wrong, that’s really wrong. That’s not treating them right. MR. DevOS: Mrs. Gebbie? MRS. GEBBIE: This has been alluded to, but I don’t think it’s been well developed, and I’d like to hear some more discussion on it. The specific policies that have been cited, Doctor Lattimer’s, Doctor Pierce’s, I think some of the others, talk about the responsibility of the worker who seroconverts, to, essentially, turn him or herself in to the Employee Health Service for monitoring, and then for review of their capability to perform jobs, functional evaluation, which all sounds very nice. The majority, at least as I can best understand it, the majority of health care workers who seroconvert are going to seroconvert because of their sexual or needle-sharing activities off the job, as opposed to an on-the-job needlestick, which you would find about probably because they have to report those anyway. A lot of the folks aren’t real excited about coming in and telling their supervisor about their sexual life anyway. In this particular case, all of those overwhelming fears about discrimination start arising. So, I’d like some discussion about real experience with these policies, not just the policies as theory, but how forthcoming are people, how much experience have you had of demonstrating that you really can provide protection of confidentiality and supportive counseling and so on. What policies or experiences do you have with the worker who, because of fear, chooses not to self-disclose, but subsequently becomes ill with AIDS and can’t work? Does that worker than become fired for failing to be honest with you, lose insurance coverage, because of that failure to come forward and do what you wanted? How does all that fit together in the real world, not on a piece of paper? DR. LATTIMER: In our experience, the reason why we put into place the voluntary reporting, is because when we had the first case, we found it out quite accidentally, and then we were thrown into turmoil because the problem became public before we had any policy to deal with it. 455 So that, we did put it into place. Subsequently, because of confidentiality, we have had several employees voluntarily report it. Depending upon what their clinical privileges were, and assignments were, they have been changed or not as the case might be, but those patients who are clinically ill, that is, with AIDS or ARC, generally their assignments have been changed. But, there has been no other kind of sanctions against them, and as far as we know, no one else in the hospital knows about it except their own primary care physician and Employee Health. So, I would feel at this point that we have not had a problem as much with confidentiality in this process as I thought we would. I think with our first physician, we did have a problem with confidentiality, and that was part of the process that we changed since that time. MRS. GEBBIE: Before we move on to the other answers, were those workers that you’ve had experience with so far a mix, as far as level and type of employment? Were some of them licensed professionals, some of them blue collar workers, men, women, et cetera? DR. LATTIMER: No, that’s a group -- MRS. GEBBIE: Just, your reactions to it. DR. LATTIMER: -- of health care workers, non- professional, but providers of direct patient care, like transporters, nurses assistants, things of that nature, to nurse, no other positions. MRS. GEBBIE: And, you mentioned a physician. Okay, thank you. MS. PARKER: In terms of the response from ANA, they would not take steps that reporting must occur. If a person is just HIV infected and not ill, then we would not back the position that they must report that to their employer. What we would ask them to do, is do that ona voluntary basis, keeping in mind what they think the risk of relating that story to their employer are, and also, if they do become ill, i.e., if they get pneumonia, or have some disease that could affect a patient and be contagious to a patient, then we ask them to report it. But, just being positive HIV, we don’t believe is necessary. The institution I work in has the same type of policy. Just being HIV positive is not required to be reported. 456 MRS. GEBBIE: Because you don’t think there’s any need to consider job reassignment even if they are a surgeon or a trauma nurse in an ER or something. MS. PARKER: Right. MRS. GEBBIE: You don’t think that policy of Doctor Lattimer’s is appropriate? MS. PARKER: No. I think there is a theoretical risk in people who work in invasive procedures. It’s not been ever documented that that kind of transmission has occurred, and, for that reason, that’s why we don’t have restrictions on people. We have had several employees who voluntarily come forward when they knew they were HIV positive, and chose at that time to quit their jobs and do other things, not that they were asked to or were ill from any symptoms at that point. They just chose, in view of the fact that they had turned positive, that they wanted to leave and go do other things. DR. ELDER: Our experience isn’t as extensive as Doctor Lattimer’s is, and so, I will not answer it out of experience directly. The patient, the employee, the health care worker who suspects that they may be HIV positive, the thought brings incredible problems to their own thinking, and my guess is, real terror. What are they going to do, and how are they going to handle it? It seems to me, then, that the hospital has a marvelous opportunity, if they were thoughtful about this, of handling it in a manner which recognizes the problem. The problem is HIV, not the employee, in a friendly atmosphere, which is set up to solve problems. Now, that ought to be a medical atmosphere. I mean, that’s basically our idea of how health care should be provided. It would seem to me then that there is a period of time, if I can stay with our own cliches, with a window of time here, where hospitals can have experience developing employee health relationships, specifically, to handle this, where such people in terms of their job assignments, their own evaluations, they can say to the person that way, we’re going to watch you. We’re going to let you work just as long as you can. We are going to give your life -- we are going to allow you to have meaning in your life, even though you have a bad illness. And, in that kind of a friendly atmosphere, there would be reason to come forward and volunteer. 457 Now, if there is a public hysteria about this, and ny guess is there is going to be somewhere, sometime, about it, then there will be a track record of things that work, and I think under that setting we can appropriately resist mandatory regulations which would make an adversarial relationship which is going to be total disaster. DR. PIERCE: You’ve asked a very, very difficult question, and I think there are differences among us on this. Specifically, though, the model for infection control for AIDS, for HIV, is hepatitis B. Health care workers have transmitted hepatitis B to patients, and they have done that during invasive procedures. The most common example is dentists. I feel that if we are going to have credibility with our patients, that we must maintain that model, and tell health care workers if they are infected they are obligated, not through mandatory testing, but through the sense that we are in this business to take care of patients, to inform their supervisor of their status. And that, invasive procedures, at this point in time, until more information is available, should be prohibited from a physician who is HIV positive, a health care worker who is HIV positive. [I think that, again, is a cautious statement. We need more information. We need to revise those as time goes by, as more data comes in, but I think at some time there is going to be a risk of a patient, there is going to be an example of a patient having been infected in the health care setting, and we cannot afford that. MRS. GEBBIE: So, what is your real experience with your policy? DR. PIERCE: That gets more problematic. That’s, the reality comes back to what’s gone on. The feeling of the people who I’ve been aware of who have reported it have felt they've been punished, and I think that it goes back to very much what Doctor Elder says, you need to have that environment ironed out before you go out and start saying, I want to know, I want to know. It’s, what are you going to do, you have to foster that atmosphere that you will take care of that person, that you will not shun them, that you will not fire them, that you will take care of them as any other illness, and I think that is the atmosphere that must be created. Right now, we don’t have a great track record as far as the people I’m aware of that have reported that, have not been treated fairly. There are examples, certainly, from physicians who have been infected, even in the line of work, who do not feel they’ve been treated fairly at all by their hospitals. My recommendation is that hospitals, before they have to deal with this, and this is what Doctor Lattimer has said, 458 emphasized, I think, is you better get something ready to handle this problem, and get it ironed out so that there is true confidentiality for that person, and that there is going to have to be some track experience before people are willing to come forth and do that. Our record, again, would say that right now people have observed what’s happened and are not going to come forth voluntarily. They are going to -- and I think there will be problems arising from that. MRS. GEBBIE: So, how are you going to overcome that? DR. PIERCE: I think you’re going to have to have policies, and advertise those to them, and that has to be the start of this kind of problem, addressing this problem, is, clearly establishing, involving esthiusts with your hospital policy, and making sure there are no wrinkles in that policy where there is going to be a breach of confidentiality, or mistreatment of that person. Those policies, it’s through policies and procedures that protect that person. MRS. GEBBIE: I think Doctor Petricciani had something. DR. PETRICCIANI: As I mentioned, we’re in the final stages now of establishing our policy for health care workers, so we don’t have any experience with the implementation of that policy. However, we do have experience with three PHS laboratory workers who have seroconverted, and in those three cases confidentiality has been maintained very, very well, and those people continue to work within the laboratory setting. But, we don’t have any experience within the clinical setting. MRS. GEBBIE: With regard to this debate about whether the seroconverted individual should identify him or herself in order that accommodations in the work setting should be made, we’ve had one no and several yes. Where are you on that? DR. PETRICCIANI: Well, as I mentioned in my testimony, we’re moving in the direction of really suggesting very strongly to individual health care workers that they examine their own life situation. Here I’m talking now about other than exposures on the job. We’re talking about people who may have seroconverted outside of the work site, and suggesting that they look at their own life situation to see whether or not they may have been at risk for exposure. And, if they think that they are, to identify themselves after finding out that they are antibody positive. 459 MRS. GEBBIE: But, if they identify themselves, do you think you are heading in your policy toward the view that it really is irrelevant, because until they become ill their job doesn’t need changing, or toward the view that, if they’ve seroconverted they should at least be removed from invasive procedures? DR. PETRICCIANI: The question of whether or not to remove someone from invasive procedures in the health care setting is something that we’re debating internally right now. MRS. GEBBIE: So, you’re not -- DR. PETRICCIANI: Other than that, we see no reason generally to remove someone from whatever their responsibilities are. MRS. GEBBIE: Thank you. DR. LATTIMER: I’d just like to add one thing. We do make the decision on a case-by-case basis, determine by that employee’s supervisor, the employee, him or herself, has input into that decision, in terms of what they need to do, and what kind of activities they need to engage in. I think one of the situations we had with our physician is that, once a person seroconverts, that the time interval between clinical symptomatology, you don’t know, because you don’t know when they first seroconverted. And, one of the most important things, particularly for a physician, is the psychologic and mental derangement which can be very, very significant in terms of whether they can continue to function in an independent, unsupervised way, which physicians characteristically do. So that, while we still do it on a case-by-case basis, we feel that the seroconversion itself simply tells you that this person is at risk for the clinical symptomatology. It doesn’t tell you that they won’t become sick for a month, or two, or two years, and, therefore, the internal monitoring that has to go on to determine their competence to continue to work has to be in place, and that has to be given confidentiality too. MRS. GEBBIE: Although at least three people know in your institution, the individual, your health service, and their supervisor, your people haven’t reported feeling punished, the way Doctor Pierce’s people have when they’ve come forward? DR. LATTIMER: No, they have not. MRS. GEBBIE: Thank you. 460 MR. DeVOS: I am wondering if any of you know of a hospital or institution that has a complete policy that deals with this matter that you think is adequate. You are working on some. I hear encouraging steps, but is there a place, is there somebody who has a document, Doctor Lattimer, does your institution have such a document? DR. LATTIMER: We have in place policies and procedures which we are constantly monitoring. I feel at this point that, even from the point of view of myself as a health care worker who might seroconvert, I feel that the policy is in place. I think it’s a sensitive policy, and I think that so far, except for the first person who was a physician who was hurt when we didn’t have a policy, that none of the other subsequent employees have felt that they were either exposed or in any way unfairly treated. MR. DevOS: I’m looking, Doctor Elder, maybe you can tell me where we can go -- you know, we need a document right now you can recommend, say, here’s the ideal policy for an institution. DR. ELDER: Prior to -- in preparation for this testimony, I called about a half dozen hospitals that I thought most likely would have them. I got. the impression they assiduously avoided having them, almost as if that would be a problem. I have trouble with that, but I-.hear then. ~ MR. DevOS: Okay. DR. ELDER: They are probably wiser than I. MR. DeVOS: You guys are as bad as business, you know. They talk about business not educating their employees, but here you are in the middle of it, and all you are going to need is one case -- DR. ELDER: I know. MR. DeVOS: -- where one person gets AIDS from a hospital worker, and this whole thing is going to be in a panic. I don’t know what do we have to do to expedite that amongst the entire medical community to get them to deal with this ahead of time? They kept telling us in business, you’ve got to prepare your employees ahead of time. Now, we’re trying to do that. Now, you are going to have a much more tragic thing, you’re going to find people just avoiding your hospital and just panicking as to who they have to go see and where they’re going to go. DR. LATTIMER: I think that’s one of the reasons why we sort of catapulted into that situation, because, in fact, our patients were beginning to question whether they were safe in 461 coming to Cook County Hospital with a physician who had AIDS. So that, we had to develop a policy, under fire, so to speak, as well as implement it. And, over the last year and a half since we’ve developed that policy and dealt with many other issues relating to that, I think that we’re in a much better position from the point of view of our employees, as well as the community perception of what’s going on in order to deal with it. But, I would absolutely insist that failure to put a policy in place is not going to help. In fact, it undermines the employee’s confidence. It does not reassure them at all. Even if they have some conflict with it, and wonder about whether it is going to protect all of them, the absence of a policy does not reassure them. They need to have a policy in place, and if it is effectively and sensitively implemented, I think it is much better. In fact, everyone who has had to deal with this, the public schools, day care, everyone that has developed a policy, educated their people in advance, before they had to deal with it, has found that it is much better than finding themselves having to deal with it with nothing in place and no mechanism to handle it. MR. DeVOS: Would you be willing to give us a copy of that policy as a model policy, or is it already in your testimony? DR. LATTIMER: Yes. I already gave it to you. MR. DevOS: Okay, fine. Thank you. DR. LEE: What do you want, Mr. DeVos, that Doctor Pierce doesn’t have? MR. DeVOS: Well, I don’t know. There are differing views of what that policy should be and how should be implemented. It’s one thing what you do to protect the patient. It’s another thing how you counsel and handle the employee, what their disabilities are, how you are going to stage them. Ina corporation, we try to say these is the benefits you get, and we will supply this, and you have that documented. Now, I gather most hospitals don’t have that, according to Doctor Elder, and they are right in the middle of this. DR. PIERCE: There has been a lot of foot dragging, literally, in doing that. There are people who don’t want to assume a leadership role in this, because of attacks by different groups of people, that there is -- that’s why I hesitated when you asked for an ideal policy, in most of what you’ve heard about this disease, there is no ideal resolution to the problem. 462 ~~ MR. DevVOS: But, there is whatever resolution you have. It’s not ideal, but it’s all we’ve got right now. DR. PIERCE: Right. The hesitation was with the word "ideal," but our policy is also included in your notes. ; MR. DevOS: If I had my ideal right now, I’d develop a new test that gives instantaneous results the following morning as to whether you have it, and most of these other questions would disappear. And, we may get there some day, but, it’s the morning after test, they have things like that. MRS. GEBBIE: Rich, I have a related question. MR. DeVOS: Go ahead. MRS. GEBBIE: We spent some time earlier today on the role of OSHA in enforcing infection control policies. There are a number of other bodies that have at least as much, if not more, influence on institutional policies in health care. I’m thinking of the Joint Commission, I’m thinking of the Health Care Financing Administration, operating through its certification program, and I’m thinking of Hospital Licensure Programs operating at the state level. Have you been involved with any of those other bodies as to whether, either through legalistic enforcement, or their role as setting a standard for the industry, they could be helpful in getting institutions farther along in developing these policies, or in taking some leadership in giving you models, or have we just sort of left them out of the discussion in this process so far? MS. PARKER: I don’t think setting the policy or the standards are really what the issue is. It’s getting them enforced, or the problems that nurses are experiencing at least, and failure for an employer to provide gloves, which is the most common thing that’s needed, not masks, gowns, et cetera. Those are sometimes a problem, but, primarily, gloves is an issue. So, I don’t think it’s a lack of the standards, or that the CD standards aren’t adequate, it’s the lack of -- MRS. GEBBIE: I was dealing not just with the communicable disease standards, but with the standard for the employee’s side of the policy as well. Most of you said those aren't widely in place, or did I misunderstand. MS. PARKER: No, but if I send you our institution’s policy, it looks just like a policy that applies to any other 463 disease that someone would have, because we’re not treating HIV, AIDS or ARC any differently, and I’d be glad to forward that. MRS. GEBBIE: Thank you. MR. DeVOS: We’re going to wrap this up here in a minute, unless Doctor Elder has something. I was intrigued with your observations on what the medical profession is going to look like, and confidentiality. The Admiral is out making a presentation this noon, and he missed some of your insight on how these things are bringing to light other shortages and problems within this whole industry. I know he would have enjoyed your comments, they were right to the point, and maybe you want to say something else about that. DR. ELDER: I wanted to deal, for just a second, with the role of OSHA and NIOSH. In my written testimony, and I’d like to emphasize again, regulations that work best are the ones that are developed by the worker, tested before they are written, and they play a role in enforcement. They own it, and this is what Ms. Lynch said, and that is what has worked, and those of us who have been successful in hospital infection control, that’s what we do. We are in the process of writing an AIDS employee policy, but we’ve been eight months on it, we’ll be another year and a half. Now, what the gentlemen from NIOSH and OSHA told us, is that they put a statement in the Federal Register. These workers don’t read the Federal Register. Their supervisor doesn’t read the Federal Register. I can’t read it because the print is too small. And so, the people who respond are not the individuals doing the work, and so they carry out their hearings, where people testify, but they are not the ones who do the work. MRS. GEBBIE: Are any of the other regulatory bodies or certification bodies any better suited to help that ownership piece? DR. ELDER: CDC has been much more, because they ’ve had a track record of working with. Now, they are not regulatory. Now, the other thing that OSHA has is an image problen. They will walk into my hospital, flash their badge, and demand to see the director within less than two minutes. And, that is not seen as supportive. It is seen as a bit aggressive. 464 And, you know, they are really not the more welcome people. MR. DeVOS: He gives you a commendation if you are there within two minutes? DR. ELDER: No, no. MR. DevoS: A plaque? DR. ELDER: It’s a plaque all the way. MR. DevOS: Well, we want to thank all of you for participating. We’ve had a very exciting three days here, as far as outstanding people who took time to come and share with us, and give us the benefit of their experiences as we deal with this. It’s my privilege now to turn it over to Admiral Watkins, and he will conclude these set of hearings. CHAIRMAN WATKINS: At the close of these hearings today, I would like to take a moment to thank the staff and administration of the Indiana University Executive Conference Center, particularly, Mr. John Short, for the hospitality they’ve extended to us during these proceedings over the last three days. We always appreciate the many witnesses who’ve appeared before us, particularly, this panel here, all of whom have come a long distance to share their expertise and recommendations for dealing with the challenges of the HIV epidemic. So, we thank each one of you. We'll be working diligently over the next couple of weeks to incorporate many of the suggestions we have heard in these last three days into our final report to the President, which is scheduled to be presented to him on 24 June. Our final set of hearings, during which we will be receiving public testimony as we have done here, will be held next week, May 16, 17 and 18, in Washington, D.C. I’d like to also thank some dedicated members of my own staff, under the Executive Director, Polly Gauit, who have done a fabulous job on all of these hearings during these past five months, intensive work in preparation for them and bringing the superb witnesses before us. Robert Mathias, Eileen Nacosia, Christine Grady, Jackie Knox, in this particular case for these set of hearings, who have done ali the tough planning. Vicky Thornton for getting us moved around the country safely and happily. 465 I’d also like to thank my colleague on the Commission, Mr. Rich DeVos, for his military-like approach to chairing these hearings. He can get away with it even more than I can. So, thank you for coming today, and particularly, I’m pleased again to have Doctor Pierce with us. We have some very competent members of our Medical Review Committee who have come before the Commission today, Doctor David Henderson, and now, Doctor Phillip Pierce, and they are a credit to the Commission. We lean on them to keep us out of medical/technical troubles, and I’m delighted to have heard their two very fine presentations today. So, with those comments, then the Commission for this set of hearings will stand adjourned until Monday morning in Washington, D.C. 466 APPENDIX S| MADISON AVENUE <3 ROOM 3008 “i NEW YORK, NY 10010 CO-CHAIRS John E Jacob Jonn — Zuccott: MEMBERS Amalia Betanzos Robert Curvin Sandra Feldman Carole A Graves Bernard Jacobs J Richard Munro Bernard Rabinowitz David E Rogers, MD Bayard Rustin (Deceased) Frederick AO Schwarz, Jr. T Joseph Semrod Glorta Steinem Thomas B Stoddard Fr Victor Yanitelli, S J EXECUTIVE DIRECTOR Carol Levine Administered by the Fund for The City of New York CITIZENS COMMISSION ONAIDS ee FOR NEW YORK CITY AND NORTHERN NEW JERSEY (212) 779-0311 April 29, 1988 Admiral James D. Watkins Chairman Presidential Commission on the HIV Epidemic 655 15th Street NW Washington DC 20005 Dear Admiral Watkins: We are enclosing testimony on AIDS and the Workplace for the consideration of the Presidential Commission on the HIV Epidemic's hearings in Indianapolis on May 10, Thank you for the opportunity to present this testimony and we look forward to your response. Best regards. Sincerely, Eee t— John E. Jacob Co-Chair Sincerely, JDdhen F. Prec John E. Zuccotti Co-Chair Testimony of John E. Jacob and John E. Zuccotti Co-Chairs, Citizens Commission on AIDS for New York City and Northern New Jersey Submitted to the Presidential Commission on the HIV Epidemic for Hearings on AIDS and the Workplace Indianapolis, IN May 10, 1988 On behalf of the Citizens Commission on AIDS for New York City and northern New Jersey, we want to thank the Presidential Commission on the HIV Epidemic for the invitation to testify at the hearings on AIDS and the workplace in Indianapolis. We are grateful for the opportunity to present our written testimony for the record. We will also be very pleased to answer any questions about our testimony on the workplace or about the other areas on our agenda. We want to share with you the reasons the Commission chose as its first project, "Responding to AIDS: Ten Principles for the Workplace." We have received a very positive response to this project. But first some background about the Citizens Commission may be helpful. The Citizens Commission on AIDS is a private, independent group of prominent citizens--corporate executives, union leaders, and directors of nonprofit agencies--from the New York City - Northern New Jersey region, the epicenter of the HIV epidemic. Biographical information about the 15 members of the Citizens Commission is attached. The Commission was formed in July 1987 by a consortium of 17 foundations to stimulate private sector leadership in responding to AIDS. A list of these foundations is also attached. A cogent declaration of our charge from the foundations was expressed by David Rockefeller, then chairman of the Rockefeller Brother Fund. At the press conference announcing the formation of the Commission, Mr. Rockefeller said: 2 We face an awesome challenge in the months and years ahead, and those of us concerned with the welfare of our community must act now with sensitivity, intelligence and dispatch. One effective way a democratic society has traditionally responded in grappling with tough issues involving individual behavior and public policy is through a citizens! commission which can make an independent inquiry and present reasoned recommendations. We look to this Commission to recommend an action agenda in the fight against AIDS for individuals, families, educators, business people and labor leaders, as well as communities and government. The Workplace Principles As you are well aware, AIDS is a complex and multi-layered problem. In determining the special educational and /advocacy role the Citizens Commission could play, we chose to focus first on the workplace. We did so because t workplace is a critically important setting in which to achieve the goals of fair treatment and education, goals which we believe the members of the Presidential Commission share. Most adult Americans are employed; work is not only a source of financial support but also a vital link to a community of coworkers. We were impressed by the observation of Surgeon General C. Everett Koop that: \ Worksites in particular can serve as effective settings in which to provide AIDS education. And the ‘deat bine to 3 educate your employees about AIDS is before your corporation has its first AIDS case. Dr. Koop called on American business to "set the example for being fair and objective and for not succumbing to groundless hysteria." In our preliminary work we found that numerous studies and surveys have shown that corporate America has been slow to respond to AIDS in developing appropriate policies and programs. However, some companies have demonstrated the kind of leadership that the Commission wanted to recognize and encourage. Surveys have also shown that many employees still fear contracting AIDS from a coworker in an ordinary workplace and would avoid contact with a person with AIDS. We also heard ample testimony that most people with AIDS or HIV infection want to continue working insofar as their health permits, that the economic and mental health impact of this disease can be alleviated by keeping employees productive as long as possible, and that the most common complaint about discrimination involved workplaces. For all these reasons, the Citizens Commission decided to develop a set of principles that could serve as a framework for all employers, unions, and other employee representatives and business organizations that share the responsibility of responding to AIDS. Each company or agency must examine its existing policies and settings to determine the appropriate response. In some cases existing policies concerning disabling illness may be adequate to cover AIDS; in others, a review of such policies may reveal gaps that affect people with all such illnesses and disabilities. In all cases, however, education about AIDS is a new and pressing need, both to maintain a stable work environment and to give employees information about personal risk reduction. The ten principles developed by the Citizens Commission are based on the experiences--both negative and positive--of many individuals and corporations. They offer what we believe is a rational, compassionate, and prudent framework. Turning to the principles themselves, they are: 1. People with AIDS or HIV (Human Immunodeficiency Virus) infection are entitled to the same rights and opportunities as people with other serious or life-threatening illnesses. They should, if they choose, continue to work to the fullest degree possible; be granted reasonable accommodation for their disability, and remain eligible to receive health care and other benefits. Further, employers and unions should Suport counseling and Employee Assistance Programs for employees with disabilities and should consider developing techniques of case management that will provide the full range of needed services, including outpatient services, in the most economical and humane manner. 2- Employment policies must, at a minimum, comply with federal, state, and local laws and regulations. In New York State, New Jersey, and New York City, as well as 5 in many other jurisdictions, the law considers AIDS and HIV infection a "disability" or a "handicap" and prohibits discrimination on that basis. Employment policies should be based on the scientific and epidemiological evidence that people with AIDS or HIV infection do not pose a risk of transmission of the virus to coworkers through ordinary workplace contact. "Despite the inexorable spread of HIV infection and disease worldwide, the three routes of transmission initially described [infusion or inoculation of blood, sexual contact, and perinatal events] still remain the only ones demonstrated to be important." (Gerald Friedland and Robert Klein, New England Journal of Medicine, October 29, 1987) The routes of transmission that have been investigated and not shown to be involved in transmission are close personal contact, either in households where all sorts of items are shared, or among health care workers without exposure to blood. 4. The highest levels of management and union leadership should unequivocally endorse nondiscriminatory employment policies and educational programs about AIDS. Because of the fear and stigma surrounding AIDS, it is imperative that those in positions of leadership--the CEO of the organization and the head of the union or other employee organization--respond to workers' needs and concerns. That level of response is critical because it establishes the 6 seriousness with which the company and union are addressing AIDS. It also makes it more likely that policies and programs are implemented consistently. 5. Employers and unions should communicate their support of these policies to workers in simple, clear, and unambiguous terms. Policies and programs developed at the highest levels must be communicated to all employees in languages and formats they can understand. Foreign-language material should be used where appropriate. Different management and supervisory levels will require diferent educational efforts. 6. Employers should provide employees with sensitive, accurate, and up-to-date education about risk reduction in their personal lives. Education programs will vary, depending on the organizational setting and workforce composition. Education ideally should offer opportunities for discussion with qualified counselors and for referrals to other agencies where appropriate. Information about voluntary, anonymous or confidential testing conducted by public health agencies and other health care providers should be included. 7. Employers have a duty to protect the confidentiality of employees! medical information. Information about AIDS or HIV infection, like information 7 about other diseases, must not be shared with third parties, including coworkers, except when there is a justifiable need to know, and after the employee consents. 8. To prevent work disruption and rejection by coworkers of an employee with AIDS or HIV infection, employers and unions should undertake education for all employees before such an incident occurs and as needed thereafter. The experiences, both positive and negative, of dealing with AIDS in the workplace so far have reinforced the concept that education for all employees before any case of AIDS is known is the most prudent approach. The companies that have experienced the most serious disruption of work and the most distressing consequences for the affected employee are those that have refused to accept the reality that sooner or later someone in their workforce will be diagnosed with AIDS. 9. Employers should not require HIV screening as part of general pre-employment or workplace physical examinations. Because there is no evidence of risk of AIDS transmission through ordinary workplace contact (Principle 3), knowledge of an employee's serostatus has no relation to workplace safety. The use of HIV testing to avoid increased health benefits costs is discriminatory. This principle is directed toward routine, across-the-board employee screening; there may be a few, highly specialized occupational settings (such as virology labs) where screening may be warranted. 10. In those special occupational settings where there may be a potential risk of exposure to HIV (for example, in health care, where workers may be exposed to blood or blood products), employers should provide specific, ongoing education and training, as well as the necessary equipment, to reinforce appropriate infection cotnrol procedures and ensure that they are implemented. The goal of this education should be to guard against all blood-borne infections, including HIV and HBV (Hepatitis B Virus). The Response to the Principles As the principles were being developed, the Citizens Commission discussed them with various corporate, union, and other leaders and incorporated many of their suggestions and ideas. The Commission then asked a representative group of corporations, unions, and nonprofit agencies to publicly endorse the principles. This was, we felt, an essential step in bringing to wide public attention the need to address the problems of AIDS through the workplace. The response from this initial group of potential endorsers was very gratifying. There were questions, of course, but overall the response was heartening and positive. Many leaders were already implementing the principles. We want to pay particular tribute to IBM, which was the first corporation to agree to endorse the principles. A few of the initial group we solicited refused, mainly on grounds that any identification with the problem of AIDS might affect their public image (a response we felt reinforced the need for the principles in the first place). At our first public announcement, in February 1988, we listed thirty endorsers, from a wide variety of organizations. They included, in addition to IBM, AT&T, Chemical Bank, Dow Jones Company, the Rockefeller Brothers Fund, the City of New York, and ITT. Major news organizations--The New York Times, the Wall Street Journal, UPI, AP, New York Newsday-~-and others carried the story. The response was quite beyond our expectations. We have received nearly 1400 inquiries from all across the country, and from as far away as Australia. The World Health Organization has expressed interest in having a representative from the Citizens Commission participate in its consultation on AIDS and the Workplace. The inquiries come from large companies and small ones, unions representing a wide variety of workers, law firms, individuals, nonprofit agencies, health care institutions. Several publications have reprinted the principles in newsletter, manuals, and other management tools. All these groups are looking for some sensible guidance in this troubled area, and we believe, from their follow-up: comments, that the principles give them that framework. A few sample letters and press comment are attached. 10 The Citizens Commission is committed to continuing to disseminate the principles and to working with employer and employee groups to create an environment in which the difficult issues can be worked out fairly and rationally. We now have over 40 endorsers (an updated list is attached), and we will continue to seek further endorsements on a nationwide basis. Recommendations for the Presidential Commission 1. Perhaps the most important contribytion the Presidential Commission can make in the area of workplace policies and education is a forthright statement that people with AIDS or HIV infection should be accepted as full, functioning, productive members of society and that their continued employment (to the degree possible) enhances their w ll-being, promotes their financial self-sufficiency, and contributes to the economy and social stability of the nation. Such a &tatenent espousing nondiscriminatory goals from the Presidential Commission would help reduce the unjustified fear and stigma that still pervade the American workplace. 2. The Presidential Commission could also reinforce the appropriateness of the workplace as a site for education to reduce fear and anxiety and to provide information about personal risk reduction. 3. The Presidential Commission could also support the policies of the federal General Accounting Office and the Office 11 of Management and Budget as examples of appropriate actions at the governmental level. 4. The Presidential Commission could also commend those companies that have already established workplace policies and educational programs and encourage others to do the same. 5. Finally, the Citizens Commission on AIDS invites the Presidential Commission on the HIV Epidemic to endorse our workplace principles as a positive step from the private sector in responding to the challenges of AIDS. We thank you again for the opportunity to present the work of the Citizens Commission on AIDS and we remain eager to discuss our mutual interests further. LIST OF ENDORSERS OF WORKPLACE PRINCIPLES Endorsers at the time of press conference: i. 2. 3. 4. 5. 6. 7. 8. 9. 10. ll. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. American Red Cross in Greater New York American Telephone and Telegraph Company A. Philip Randolph Institute Archie Comics Atlantic Industries Atlantic Magazine Chemical Bank City of New York Dow Jones & Company Fund for the City of New York Girl Scouts of the U.S.A. Howard J. Rubenstein Associates International Business Machines Corporation ITT Corporation Johnson & Johnson Lambda Legal Defense and Education Fund Ms. Magazine National Urban League Newark Teachers Union The Rockefeller Brothers Fund The Salvation Army Sassy Magazine The Shubert Organization Time, Inc. Times Mirror Co. United Federation of Teachers United Jersey Banks U.S. News & World Report Warner Lambert Co. Wildcat Services Endorsers after press conference: 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. Design Industries Foundation for AIDS (DIFFA) Gay Men's Health Crisis Morgan Guaranty Trust Company of New York The Prudential Insurance Company Xerox Corporation NYS AFL-CIO Local 1931, Bridge and Tunnel Maintainers Hoffman-La Roche Inc. National Leadership Coalition on AIDS Battery Park City Authority Franklin Research & Development Corporation Squibb Corporation Che New ork Cimes NEW YORK, THURSDAY, FEBRUARY 18, 1988 Employers Adopt AIDS Code Thirty leading companies and or- ganizations endorsed a 10-point “bill of rights’ on AIDS issues in the work- place. Page B11. Employers Endorse AIDS Guidelines By BRUCE LAMBERT Some of the nation’s feading compa- nies and organizations yesterday en- dorsed a new 10-point ‘‘bil! of rights” on AIDS issues in the workplace, for- mulated by a citizens’ commission. Key elements of the code include a promise not to discriminate against worters with AIDS and a pledge to act to dispel co-workers’ fears of casual contagion. Medical records must be kept confxtential, it says, and tests for ar’'“odies to the AIDS virus should be P ited in hiring procedures and pi, calexaminations. The move, which reflects a growing involvement by employers in AID: issues across the country, was scribed as the first Ume that e group of companies and organizations in the United States has subscribed to a unt- form, written policy on AIDS, “1's distinctive — unique — at this point, but I think what they've done will certainly be replicated in other re- ons,” said B J. Stiles, the president of National Leadership lition on AIDS. The coalition, based in Washing- ton, was formed by business leaders last year to pro corporate action on AIDS. The new code was developed by the Citizens Commission on AIDS for New York City and Northern New Jersey. The commission was formed iast year with grants from 17 foundations “We believe the AIDS workplace principles can provide leadership in this complex and emotionally charged arena, in much the same manner that the Sullivan Principles offered guid- ance regarding investment policies in South Africa,” said the co-chairman of the commission, John E Zuccotti, a former deputy mayor. Among those adopting the AIDS prin- ciples were the International Business Machines Corporation, the American Telephone and Telegraph Company, the ITT Corporation, Time Inc., John- de- {son & Johnson, Dow Jones & Company, U.S. News & World Report, Warner- Lambert and Chemica) Bank. Endoreed by 30 Employers Joining in the endorsement were New York City’s government, the city's United Federation of Teachers, the Rockefeller Brothers Fund and or- ganizations ranging from the Salvation Army to Archie Comics. All told, the 30 employers endorsing the guidelines resent about 1.5 million employees lot all the companies solicited agreed to endorse the principles, the panel acknowledged "'] would say the majority agreed,’ Mr. Zuccotti said. Another commission member, Thomas B. Stoddard, said, “There is atil] an appalling lack of information.” Mr Stoddard is executive director of the Lambda Lega! Defense and Educa- tion Fund, & gay-rights group. Eatitied to Same Rights The A1DS commission's basic policy gays emp ¢ with AIDS ur .nfectsd with the human -immunodeficiency virus believed to cause acquired im- mune deficiency syndrome “‘are enti- tled to the same rights and opportuni- ties as people with other serious or life- threatening ilinesses."’ The code stresses scientific evidence that AIDS does not pose “‘a risk of transmission to co-workers through or- dinary workplace contact.” Management and union leaders should “unequivocally endorse” AIDS education and nondiscrimination, the code says, and employers should in- form workers on how to reduce AIDS risks in their lives. The commission, which is independ- ent of government, is financed by o-" prune as the Robert Wood Johnson ourdation, the United Hospital Fund, the Prudential Foundation, the Charles H. Revson Foundation, the New York Life Foundation, Hoffman-LaRoche and the Fund for the City of New York Mr Zuccotti's co-chairman is John E. Jacob, president of the National Urban League Besides Mr. Stoddard, these are the other panel members: the New School for Social Research. Sandra Feldman, president of the United Fed- erguon of Teschers. $0 cents Devore ent John E. Zuccotti, co-chairman o! the Citizens Commission or Carcle A. Graves, president of the Newark Teachers Union of the or AIDS for New York City anc puian president Shubert Northern New Jersey. J Richard Munro, chairman of Time Inv. Bernard Rabinowits, president of Auantic In- , dusiries. National Urban League Dr, Devid E Rogers, professor at the New York | Newark Teachers Union Hospital-Cornell Medical Center Rockefeller Brothers Fund Frederick A. O Schwars Jr. tawyer and former | Galvation Army New York City corporation counsel, Sassy Magazine —— Semrod, president of United Jersey Sn eee ne. Giorts Sietnem, founder of Ma Times Mirroro. . The Rev Victor Yanitelli, vicar Si Ignores United Federation of Teachers Loyola Roman Catholic Parish mn tian. | United Jersey Banks These are the companies and organt- | U.5. News & World Report zations that agreed to the guidelines: oe a mbert Co. American Red Cross in Greater New York American Telephone and Telegraph Co. A. Philip Randolph Institute (New Jersey) Archie Comics Atlantic lngusiries Atlantic magazine Chemical Bank City of New York Dow Jones & Co. Fund for the City of New York Giri Scouts of the U.S.A. . Howard J Rubenstein Associates International Business Machines Cerp. ITT Corp. Johnson & Johnson’ Lbmbds Legal Defense and Education Ma, magazine : los Anacles Gimes 30 Major Firms, Unions Support / AIDS ‘Bill of Rights’ in the Workplace By VICTOR F. ZONANA, Times Staff Writer NEW YORK—Thirty major em- ployers and unions have endorsed a new 10-point AIDS “bill of rights” that bara discrimination against affitcted workers and commits its signers to combat employce fears ‘about contracting the disease at work. The code of principles also re- jects mandatory testing of job ap- plicants or employees for antibod - tes to the virus Laat is believed to cause acquired immunity deficien- cy syndrome and stresses the need for strict confiden Jality of employ- ee medical records, “We believe the AIDS Work- vee Principles can provide lead- ship in this complex and emo- Uonally charged arena in much the game manner that the Sullivan Principles offered guidance re- "garding investment policies in South Africa,” said John E. Zuecot- U, co-chair of the Citizens Commis- ston on AIDS, the privately funded group that came up with the guide- nes, The code was endorsed by such major corporations as IBM, Ameri- can Telephone & Telegraph, ITT, Chemical Bank, Johnson & John- aon, Warner-Lambert, Time, Dow Jones and Times Mirror, publisher of the Los Angeles Times, New York City also agreed to abide by the principles, as did the Salvation Army, the Rockefeller Bros. Fund, the National Urban League and a pair of teachers unions in the New York area. Altogether, the endorsers have about 1.5 million employees, ed every two months, and organiz- ere sald they hope they will have attracted more participants from outside the New York area by the Ume the next list la released. “We've already had expressions of interest from Iowa and Califor- nla,” said Caro! Levine, executive director of the commission, though she acknowledged that several companies that were approached had refused to participate. Show “Speelal Courage” “This is a significant and valua- ble contribution that will help to remove the stigma attached to AIDS,” predicted Thomas B. Stod- Gard, executive director of the Lambda Legal Defense & Educa- tion Fund, a gay-rights group, tions have shown a very special courage and have set an example for others,” he said. Ronald Bayer, an medical ethics specialist at the Hudson Institute, said the guidelines were likely to have an impact far beyond the workplace. “Basically, the work- place serves as the school for adults,"-he sald. “If people can be taught to deal with this epidemic in e reasonable and thoughtful manner, they'll have a different perspective when confronted with the question of AIDS in their neighborhoods or their children’s achools,” Bayer a The need to better educate peo- ple on the causes of AIDS was underscored by the results of a era earlier this month by the Georgia Institute of Technology's Center for Work Performance Problema. Despite repeated assurances from the U.S. surgeon general and other medical authorities that AIDS cannot be transmitted through casual contact, 40% of those polled said they would think twice .ebout eating in the same cafeteria as a person with AIDS, and 37% said they would not share toola or equipment with such a rot. Pe pavid Herold, who conducted the Georgia Tech survey, said he welcomed guidelines but added, skeptically: “Let's see how they follow through.” ' He noted that “education is a nice term, like motherhood and The list of signers will be updat- companies and organisa- nationwide telephone poll of work- ler ggiq Cuathueed frean Page 8 ranted.” ea is often easier id onal programs about AIDS.” Tents ot ine their endorsement Union members, for example, The signers rejected yoga the principles simply codified “may not believe anyone Win ee Oe re ne thet ext re sinely, codified categorized as management,” he Pusperted because “i age other le- threatening ilinesses. said, citing a case in which pan- ppp “s bey elec IBM, for example, sent a letter to icked workers at a ulliity firm in an employee onteedy Ite 389.000 employees last Nove - the Southeast refused to accept the bag no relation to work “the a ber that reed, in part: “ToMers corporate medical director's assur- vey testing to avoid increased affected by AIDS will be encour- ances that It was safe to work with sity benefite cost is dilecrimina- aged to work as long as they are a person who had AIDS. tory” ble, and ther privacy will be ppert ‘The commission acknowledged, respected.” The mailing included Laber Su Vital however, that “there may be a few, Promuigators of the principles that support from lebor unions [a vital. One of guidelines states: “The highest levels of management end unton leadership should unequivo- cally endorse non-discriminatory employment policies and educa- . tease see AIDS, Page 5 highly specialized occupationad settings where screening = war- Guidelines on AIDS a vital step forward The Sullivan Principles, voluntary guidelines on fair employment practic- es for U.S. companies doing business in South Africa, have focused American companies’ thinking on how to respond to the issue of apartheid. With the Sullivan Principles, a prac- tical, reasoned voice offering responsi- ble guidelines emerged from the im- assioned chorus surrounding that ue, Now, the creators of a 10-point bill of rights for AIDS victims in the work place hope that their guidelines will ave a similar impact on that issue. The Citizens Commission on AIDS for New York City and Northern New Jersey, formed last summer with mon- y from 17 foundations, is seeking to imulate private-sector leadership in scaling with some of the non-medical aspects of acquired immune deficiency syndrome. It drew a bead on the work place, where its three primary concerns — out-of-hospital care, social impact and prevention and education — come to- gether. The greatest AIDS-related needs in that setting are for AIDS sufferers and carriers of the AIDS vi- rus to be assured of receiving the bene- fits they are entitled to and to be al- lowed to continue working to the fullest extent possible. The rights set forth in Responding to AIDS: Ten Principles-for the Wor. Place,” are little more than the rights to which every American feels enti- tled. But to people not only suffering from AIDS but also being subjected to the discrimination, fear and stigmat- ization that too often go with it, the principles hold hope of stability and reedom from uninformed hysteria. The focus of the guidelines is on edu- cation in the work place, both before AIDS becomes an issue and thereafter to dispel] co-workers’ fears, and on pro- tection of the rights of AIDS sufferers. The document asserts, in line with medica! evidence, that the AIDS virus is not transmitted through ordinary work-place contact and that victims deserve “the same rights and opportu- nities as people with other serious or life-threatening ilinesses.” The guidelines promise employees “sensitive, accurate and u ate ed- ucation about risk reduction in their rsonal lives”; the guidelines also of- er assurances against company dis- closure of medical records, against mandatory AIDS tests for new or pro- spective workers and against discrimi- nation against AIDS carriers. The commission tried out its princi- | les on a representative group of ma- or employers in the New York/New Jersey area. The response was overwhelmingly positive. So far, 30 major employers with a total of 1.5 million workers have endorsed the plan, with International Business Ma- chines Corp being the first to sign on. But a few corporations have begged off, citing a variety of concerns. Those who did sign the principles are to be commended for their leader- ship role and their courage, which may motivate others to follow suit or at Jeast encourage them to reflect on their own policies. Christopher Peck, Managing Editor Spokane Chroniéle William H. Cowles, 3rd, Publisher Donald W Gormley, General Manager Robert D. Fairchild. Business Manager G. Douglas Floyd, Editorial Page Editor C. Danie! Grady, Advertising Director Shaun Higgins, Consumer Marketing Director EDITORIALS FEBRUARY 19, 1988 * San Francisco Chronicle a * ee _ ——pows Employers, Unions Back AIDS ‘Bill of Rights’ Les Angeles Times ‘ New York Thirty major employers and unions have endorsed a new 10-point AIDS “bill of rights” that bars dis- erimination against afflicted work- ers and commits its signers to com- bat employee fears about eontract- ing the disease at work. The code of principles also rejects i atory testing of job applicants or eu.,«oyees for antibodies to the virus that is believed to cause AIDS, and stresses the need for strict confidentiali- ty of employee medical records. “We believe the AIDS Workplace Principles can provide leadership in this complex and emotionally charged arena in much the same manner that the Sulll- van Principles offered guidance regard- ing investment policies in South Africa,” said John Zuccotti, co-chair of the Citi- gens Commission on AIDS, the privately funded group that came up with the guidelines. The code was endorsed by major . corporations such as IBM, AT&T, ITT, Chemical Bank, Johnson & Johnson, Warner-Lambert, Time, Dow Jones and Times Mirror. The City of New York also agreed to abide by the principles, as did the Salvation Army, the Rockefeller Brothers Fund, the National Urban League and a pair of teachers unions in the New York area. Altogether, the en- dorsers have about 1.5 million employ- ees. The list of signers will be updated every two months, and organizers said that they hoped that they would have attracted more participants from outside the New York area by the time the next List is released. “We've already had ex- pressions of interest from Iowa and Cali- fornia,” sald Carol Levine, executive di- rector of the co on, though she acknowledged that several companies See Page C20, Col. € From Page Ci that were approached Had refused to participate. . “This is a significant and. valuable contribution that will help to remove the stigma attached to AIDS,” predicted Thomas Stoddard, executive director of use Lambda Legal Defense and Educa- ton Fund, a gay-rights group. “These companies and organizations have - shown a@ very special courage and have get an example for others.” —. Ronald Bayer, an medical ethics spe- ciatist at the Hudson Institute, said that the guidelines were likely to have an impact far beyond the workplace. “Basi- cally, the workplace serves as the school for adults,” he said, “If people can be taught to deal with this epidemic in a reasonable and thoughtful manner, they'll have a different perspective when confronted with the question of AIDS in their neighborhoods or their children’s scbools.” The peed to better educate people on the causes of AIDS was underscored by the results of a nationwide telephone poll of workers earlier this month by the Georgia Institute of Technology's Center for Work Performance Problems. Despite repeated assurances from the Surgeon General and other medical authorities that AIDS cannot be trans mitted through casual contact, 40 per- cent of those polled said they would think twice about eating in the same cafeteria as 8 person with AIDS, and 37 percent said that they would not share tools or equipment with such a person. David Herold, who conducted the Georgia Tech survey, said that he wel- comed guidelines but added, skeptically, “let's see how they follow through.” He poted that “education is a nice term, like motherheod and apple pie. But it is often easier said than done.” Promulgators of the principles agreed that support from labor unions ‘was vital. Td WALL STREET JOURNAL © 1686 Dow Jone: 9 Company, inc. Al Right: Rewrved THURSDAY, FEBRUARY 18, 1988 Employers Back Rights Policy For AIDS Cases By Rocen RIcKLers Staff Reporter of Tue Wat STREET JOURNAL NEW YORK — Major employers en- dorsed a set of principles on acquired im- | mune deficiency synérome in the work- place, which would protect the rights of employees with the disease and bar em- ployer-testing for the AIDS virus. The Citizens Commission on ALDS said it believes the “AIDS Workplace Princi- les,’ which it established, can “provide eadership” in “the same manner that the Sullivan Principles offered guidance re- ig investment policies in South Af- rica.” Many companies have been groping for a policy in the controversial and sensi- tive AIDS area. The citizens group said endorsers so far include, among others, International Busi- pess Machines Corp.. American Telephone & Telegraph Co., ITT Corp., Chemical New York Corp.'s Chemical Bank unit, Johnson & Johnson, Warner-Lambert Co., Time Inc., Times Mirror Co., U.S. News & World Report Inc., the City of New York, the Rockefeller Brothers Fund, the Salvation Army, the Girl Scouts of the U.S.A. and Dow Jones & Co., which publishes this newspaper. The statement of principles stresses that employees with AIDS are “entitled to the same rights and opportunities as peo ple with other serious or life-threatening ilinesses.” Ruling out discriminatory em- page policies, it rejects employer test- for antibodies to the AIDS virus in ei- ther pre-employment screening or work- place physical examinations. “Knowledge of an employee's antibody status has no relevance to workplace safety," the comunission said, citing evi- dence that the virus isn't spread by casual contact. In special situations such as health care, where risk may exist, em- ployers should provide safety training and equipment, the statement says. The statement also calls for protecting the confidentiality of employee medical records and conducting ALDS-education programs for workers. IBM Chairman John F. Akers said: “IBM tries to abide by these principles be- cause it is clear that the elimination of AIDS wil) require sustained efforts by all of us in the public and private sectors.” A spokesman said the company's practices already were consistent with the cammis- sion's principles. Formed by & of 17 foundations last year, the nis an educational and advocacy group focusing on AIDS Is- sues, especially in New York City and northern New Jersey. (7 wae , Me “ an Srlernil orl “fas CPEB) eter? t#led C ous rer redecire Office of the Charman af the Board Armonk. New York 1050-4-178$ January 19, 1988 JAN « . 1388 Mr. John E. Jacob President and Chief Executive Officer National Urban League 500 East 62 Street New York, New York 10021 Dear John: Thank you for your letter requesting my comments on "AIDS and the Workplace." It is my understanding that we have assisted in the development of the commission's principles, and many of our suggestions are incorporated in this latest draft. IBM tries to abide by these principles because it is clear that the elimination of AIDS will require sustained efforts by all of us in the public and private sectors. I am pleased to endorse these principles and urge the commission to widely circulate them. , Sincerely, JFA:ph Attachments ANDREW S MILLER EVA BURROWS General National Commander FOUNDED 1865 WILLIAM BOOTH, FOUNDER NATIONAL HEADQUARTERS OFFICE OF 799 BLOOMFIELD AVENUE > THE NATIONAL COMMANDER VERONA, N.J 07044 201 2380608 February 10, 1988 PERSONAL Mr. John E. Jacob President and CEO National Urban League 500 East 62nd Street New York, N Y 10021-8309 Dear John: Thank you very much for sending us a copy of RESPONDING TO AIDS: TEN PRINCIPLES FOR THE WORKPLACE as per our discussion, It is a beautifully drawn statement and we, at The Sal- vation Army, are glad to join with you in any way we possibly can to support such a fine program. It has compassion and courage and, also, great strength, Thank you again for giving us the privilege of joining with you in this fine program. God bless you richly. Very /sincer ly you ic A. Andrew S. Mi COMMISSIONE A ht Local 193t 2 ./'/ Bridge & Tunnel Maintainers Affiliated with DISTRICT COUNCIL 37 American Federation of State, County & Municipal Employees, AFL-CIO 125 Barclay Street, New York, N.Y. 10007 (212) 815-1015 (212) 678-8555 HARRIS BAYLEN President MATTY GAETA Vice President DAVID SHEA First Vice President March 23, 1988 AUGUST A. TREZZA, Jr. Secretary DONALD BROFMAN Ms. Carol Levine Treasurer Executive Director Citizens Commission on Aids 51 Madison Avenue Room 3008 New York, New York 10010 Dear Ms. Levine: I am please to be able to inform you that the Executive Board of AFSCME Local 1931 which represents the maintenance employees of the Triborough Bridge and Tunnel Authority (TBTA) has adopted "Responding to AIDS: Ten Principles for the Workplace" that were developed by the Citizens Commission on AIDS, as the policy of our local union. We will be publishing the principles in our local union newsletter, which is mailed to all of our members and retirees and will seek to have the principles endorsed by the three other union that represent TBTA employees. We will then seek to reach agreement with our employer on what type of Educational and Training programs are needed to deal with all of the possible ways that our members might be exposed and to teach the members how to respond to the problem with Aids in an informed and responsible way. We want to thank you for your assistance in this matter. Very trully yours, cc: Edward Oliva, Pres. SOBA Don Afflick, Pres. HB/am 1655 cc: Anthony Ma Pres, BTOBA in the public service ee eee ae te oe ee Mover S Frucher a - ~ = — President and Chiet BATTERY PARK CITY AUTHORITY P vecutive Ollicer April 6, 1988 Mr. John Ee. Jacob Co-Chairman Citizens Commission on AIDS 51 Madison Avenue, Room 3008 New York, NY 10010 Dear Mr. Jacob: I recently received a letter from Jane Hughes regarding the "Ten Principles on AIDS in the Workplace". After reviewing them carefully, I am pleased to add the Battery Park City Authority to your growing list of employers who support these principles. The work of your Commission is important to all New Yorkers and serves as an example for businesses around the nation. I’m happy that the Authority can be added to your list of supporting employers and unions. Sincerely, 2 Pat er « Frutcher ec: John E. Zuccotti Jane Hughes One World Financial Center, New York, NY 10281-1097 (212) 416-5320 Executive Office American Red Cross 150 Amsterdam Avenue . ter k New York, New York 10023 in Greater New Yor (212) 870-8810 February 15, 1988 Dear Misters Jacob and Zuccotti: We have reviewed "Responding to AIDS: Ten Principles for the Workplace" developed by the Citizens Commission on AIDS for New York City and Northern New Jersey that you recently sent to us. I am pleased to report that we, The American Red Cross in Greater New York, fully endorse the ten principles. Let me also take this opportunity to thank you for all the work the Commission has done and continues to do in this area. It is greatly appreciated by all of us. Cordially, General Manage Chief Executiy John E. Jacob John E. Zuccotti Co-Chairs Citizens Commission on AIDS 51 Madison Avenue Room 3008 New York, New York 10010 MONTROSE C-L:L-N-L-C A private, non-profit organization April 18, 1988 Ms. Carol Levine Executive Director Citizens Commission on AIDS 51 Madison Avenue, Room 3008 New York, NY 10010 Dear Ms. Levine: Than you very much for your prompt response to my request for information pertaining to "Responding to AIDS: Ten Principles for the Workplace." Please extend to the members of the Commission my compliments for their most scientific and humane approach, as evidenced by the end result,to the very delicate issue of AIDS in the workplace. The Montrose Clinic, though primarily a medical facility, is also a highly regarded AIDS educational resource center in the City of Houston. Consequently, we sit on many AIDS panels, subcommittees, task forces, coalitions, and the like. I would like to present your "... Ten Principles for the Workplace" as a very credible example of what we, here in Houston, should and can do as part of the crucial educational needs for our employers. Thanks again for your assistance, and if I can reciprocate in any way, please let me know. Executive Director cc: Ralph Lasher, Manager-AIDS Programs |} TJA:rlh 1200 Richmond Avenue @ Houston, Texas 77006 # 713 * 528 © 5531 or 528 « 5535 A Medical and Educational Resource Center for the Treatment and Prevention of Sexually Transmitted Diseascs franklin Research & Development Corporation Boston 711 Atlantic Avenue San Francisco Boston, MA 02111 Seattle 617.423.6655 April 25, 1988 Carol Levine Executive Director Citizens Commission on AIDS 51 Madison Avenue, Rm. 3008 New York, NY 10010 Dear Ms. Levine: We wish to thank you for all your help on our yet to be released study on the corporate response to AIDS. We project that the study will be made available to the public as of May 1, 1988. Within the study, we have urged corporations and other organizations to seriously consider adopting the principles set forth by the Citizens Commission on AIDS. Though your list of Supporters to date is impressive, we felt promotion of your organizations' principles would be a practical way to encourage others to adopt a compassionate response to the AIDS epidemic. Franklin Research and Development wishes to lend its Support to your organization as well. We are responding to AIDS through adoption of the "Ten Principles For The Workplace", as described in your literature. We endorse the Citizen's Commission on AIDS “Statement of Purpose" as we officially join the fight against AIDS. Enclosed is a sample copy of the insertion which we intend to include with our report. The enclosure lists the ten principles and an informational bottom portion, which allows one to either obtain more information or to endorse the principles. Please feel free to give us your feedback on the insertion, preferably by April 28. It would be helpful to us if you could keep track of how many endorsements or requests for information you received as a result of our report. In addition, we will forward a copy - O£ the report to you upon its release, We welcome any comments you might have concerning its contents. If you need additional Materials to complete our endorsement of the "Ten Principles For The Workplace" please feel free to contact us. Again, thanks for your assistance. We wish you well in the work you are doing. Sincerely, Joan L. Bavaria Elliot Sclar Franklin Research and Development Franklin's Insight Enc. “2 Investing for a better world Foundations Supporting CITIZENS COMMISSION ON AIDS February 1988 Rockefeller Brothers Fund The Robert Wood Johnson Foundation United Hospital Fund The Aaron Diamond Foundation Josiah Macy, Jr. Foundation The Prudential Foundation New York Community Trust Charles H. Revson Foundation Fund for the City of New York The Florence & John Schumann Foundation Health Services Improvement Fund, Inc. Victoria Foundation The Fund for New Jersey Hoffman-La Roche Inc. DIFFA The Hyde and Watson Foundation New York Life Foundation Howard Rubenstein Associates, Inc. Pro Bono Public Relations CITIZENS COMMISSION ON AIDS CO-CHATRS: John E. Jacob is the President and Chief Executive Officer of the National Urban League with which he has been associated since 1979. He is the recipient of many awards, including the Public Service Award from the United Black Fund in Washington and the Outstanding Community Service Award from Howard University's School of Social Work. John E. Zuccotti is a partner in the law firm of Brown & Wood, New York City. Mr. Zuccotti has served as Chairperson of the Mayor's Advisory Committee on Police Management and Personal Policy and Governor Carey's World Trade Center Task Force. He also served as First Deputy Mayor of the City of New York from 1975 to 1977. MEMBERS Amalia V. Betanzos is President of Wildcat Service Corporation, a non-profit employment program. She served in a variety of positions in Mayor John Lindsay's Administration, including Commissioner of the Youth Services Agency. She is a Member of the New York City Board of Education. Robert Curvin is Director of the Urban Poverty Program of The Ford Foundation. He is the former Dean of the Graduate School of Management and Urban Professions at The New School for Social Research. Sandra Feldman is President of the United Federation of Teachers. She is also Vice-President of the American Federation of Teachers and a member of the board of directors of the New York State United Teachers. In addition, Ms. Feldman is a vice president of the New York State AFL-CIO, and the New York City Central Labor Council. Carole A. Graves is President of ‘the Newark Teachers Union, Local 481, AFT AFL-CIO. Ms. Graves was a Commissioner on the New Jersey Public Employment Relations Commission. She has served in various organizations, including the National Organization for Women and The National Council of Negro Women. Bernard Jacobs is President of The Schubert Organization Inc. He is also the Director of the Aileen Inc. Memorial League of New York Theaters and Producers. J. Richard Munro is Chairman and Chief Executive Officer of Time Inc. He is the Chairperson of the New York Urban Coalition and is a member of various boards including the President's Council on Physical Fitness and Sport (Washington, D.C.) and the Governor's Business Advisory Board of New York State. David E. Rogers, M.D. is the Walsh-McDermott University Professor of Medicine at New York Hospital-Cornell Medical Center. He chairs Governor Mario Cuomo's Advisory Council on AIDS. Dr. Rogers was formerly President of the Robert Wood Johnson Foundation. Bayard Rustin, an advocate for civil rights, the labor movement, and humanitarian causes, was the Chairperson of the A. Phillip Randolph Education Fund at the time of his death in September 1987. Fritz A.O. Schwarz, Jr. is a partner in the law firm of Cravath, Swaine and Moore. He was Corporation Counsel for the City of New York from 1982-1986. He is a member of the American Law Institute, the American Bar Association, and the Association of the Bar of the City of New York. Bernard Rabinowitz is President of Atlantic Industries, Nutley, New Jersey, and Director of the Somerset Holding Company. He has served as Chairperson of the New Jersey Blue Ribbon Task Force on Local Health Planning and the Commissioner's Cardiac Services Committee. He is a member of the St. Barnabas Burn Foundation. T, Joseph Semrod is the President and Chief Executive Officer of United Jersey Banks, Princeton, and Chairman of United Jersey Banks in Hackensack, New Jersey. He is a member of The Board of Trustees and the Executive Committee of the National Urban League. He is a member of the Oklahoma and New Jersey Bar Associations. Gloria Steinem is a writer and editor. She was a founder of Ms. Magazine in 1972. Ms. Steinem has helped to found and continues to serve as board-member or advisor to the Ms. Foundation for Women, the National Women's Political Caucus, Voters For Choice, the Women's Action Alliance, and the Coalition of Labor Union Women. Thomas B. Stoddard is the Executive Director of Lambda Legal Defense and Education Fund, Inc. Mr. Stoddard was the Legislative Director for the New York Civil Liberties Union and a lawyer in private practice. He serves as Adjunct Professor of Law at New York University Law School. Victor Yanitelli, S.J. is the Episcopal Vicar for East Manhattan. He served as the Pastor at St. Ignatius Loyola Church and was President and then chancellor of St. Peter's College in Jersey City, New Jersey. To respond to the growing concern about AIDS and AIDS-related problems in the workplace, the Centers for Disease Control of the U.S. Public Health Service must develop and issue guidelines to protect all workers who may face occupational exposure to AIDS. The AFL-CIO recognizes that unions have the dual concern of seek- ing to protect the health and safety of workers occupationally exposed to AIDS and the rights of workers who are AIDS victims and individuals who may be at high risk. The AFL-CIO will therefore work with its affiliated umions to educate workers about AIDS and to provide guidance based on the Public Health Service's recommendations to protect workers who may be occupationally exposed to AIDS. As part of our commitment to pro- tect the rights of all workers on the job, we must protect the nghts of union members who are AIDS victims against unwarranted intrusions and other workers whose rights are threatened because of the disease. We oppose screening workers for AIDS unless and until the Centers for Disease Control recommends such action either for all employees or for specific job classifications. To lessen the tragedy and suffering of those unfortunate individuals who are diagnosed as AIDS victims and their families, the AFL-CIO will work to obtain adequate funding and programs to assure proper medical care and social support. Adonted by the AFL-CIO Convention Anaheim, California November, 1985 AIDS Acquired Immune Deficiency Syndrome (AIDS) is fast becoming a major public health problem in the United States. Over 12,000 AIDS cases and 120,000 AIDS-Related Complex (ARC) cases have been iden- ufied. Estimates of those already infected who have not yet contracted the disease itself reach as high as 1.2 million people. The number of AIDS cases doubles every ten months. At this rate 30,000 Americans will contract the disease by the end of 1986. There 1s no known cure for AIDS. The death rate among AIDS vie- tims to date is 50 percent. But for those who were among the first to be diagnosed as having the disease, the death rate 1s now approaching 100 percent. AIDS is a major health concern of workers as well as a public health danger. Service workers are particularly threatened: healthcare workers, correctional officers, public safety personnel, and teachers are among those frequently in contact with AIDS-exposed persons. AIDS is transmitted through intimate sexual contact, exchange of contaminated needles and blood transfusions. High risk groups include intravenous drug users, recipients of blood products, and homosexual men. Studies to date have shown the risk of AIDS transmission to be less than many other infectious diseases. However, due to the unknown charactenstics of the disease, a long incubation period (1-5 years), and the absence to date of any cure, appropriate public health precautions are essential. Despite the claims of the Reagan Administration, federal govern- ment support for AIDS research, education and patient services ts negligible relative to the gravity of the disease. Public concern about a fatal disease like AIDS for which there is no known cure is understandable and justified. Inadequate public educa- tion has resulted in a great deal of misinformation about the transmis- sion of the AIDS virus, increasing the public's anxiety about the disease. This has led to proposals to conduct screenings of certain oc- cupational groups of workers and discriminatory actions against high msk groups even though there ts no scientific justification for such drastic measures. _ Action must be taken to protect the public’s health while atthe same, time protecting the rights of AIDS victims and high-risk groups. The AFL-CIO urges increased federal funding for research on the cause, transmission and development of a cure for AIDS. Funds are also needed to educate AIDS victims, individuals in high-risk groups, and workers who may be exposed to the AIDS virus about the disease and appropriate measures to prevent its transmission. Programs and materials must also be developed to better inform the public about how the disease is and is not transmuted. October 1983 Convention AFL-CIO POLICY STATEMENTS ON AIDS AIDS Acquired Immune Deficiency Syndrome (AIDS) is a major public health problem. The cause 1s unknown. The method of transmission and real rate of incidence are unknown. There is no form of treatment or cure. AIDS patients often require prolonged periods of hospitalization In intensive care units at costs nearing $100,000. The mortality rate for AIDS victims 1s 100 percent within five years. As of August 5, 1983, there were 2,094 confirmed cases of AIDS, with 305 deaths. The number of AIDS cases doubles every six months. At the present rate of increase, we can expect over 50,000 AIDS victims by 1986. In addition to the primary threat AIDS poses to those who contract the disease, the public health 1s threatened by the effect the fear of AIDS has on blood donattons. AIDS is also a major workplace health problem. Healthcare employ- ees, public safety personnel, and other workers are fearful of contact with AIDS victims. Four health workers have developed AIDS. Though none of the four 1s known to be in a high risk category or to have had contact with AIDS patients at work, researchers have been unable to identify the method of transmission. Media coverage and the statements of some public figures have ex- acerbated the situation by fueling public fear. Discrimination against the minority groups most severely threatened by AIDS—gay men and Haitians—has risen as a result. Government support to AIDS victims and funding for research and education on AIDS is negligible relative to the gravity of the disease, its high fatality rate and its threat to the public health. The government's limited and slow response is traceable to the history of discrimination against people in the high risk groups. Unless strong action is taken, thousands of people will die needlessly and inexcusably of AIDS. The Federal Government must increase funds for research to deter- mine the cause of AIDS and to develop methods of diagnosing, treating and preventing the disease. That research shouid be part of a compre- hensive surveillance and monitoring plan which would establish the true extent of AIDS and identify its growth pattern. The public needs more information about AIDS. Particular effort should be made to inform and educate three groups: AIDS victims; high risk groups; workers in close contact with patients or members of high risk groups. The Federal Government should provide medical and social support for AIDS victims and their families. Adopted by the AFL-CIO Convention in fami, Florida Qctober, 1987 Acquired Immune Deficiency Syndrome Acquired immune deficiency svndrome (AIDS) is a major publie health problem in the United States. Over 40,000 AIDS cases have been reported in the US Many more people have AIDS related complex (ARC) and tt ts estimated that between | and 15 milhon Americans have been infected Studies have shown the risk of AIDS transmission to be Jess than many other infectious diseases. Transmission occurs primar- ily through intimate sexual contact or the sharing of contami- nated needles with an HIV infected person As a bloodborne dis- ease, AIDS ts not transmitted by the type of casual person-to- person contact that generally takes place between workers and clients or consumers in the workplace However, sume workers— hospital workers, emergency response medical technicians, law enforce- ment personnel, and others who come into direct contact with blood or body fluids at their jobs have some risk of exposure Education ts vitally needed for all workers to achieve a balance between two extremes irrational fear, which creates additional stress for workers, and insufficient concern, which leads to neglect of necessary precautions which can eliminate workers’ risk of ex posure to the AIDS viruses as well as more common infections such as Hepatitis B Equally important is the need to provide nealth care workers with gloves and other protective equipment to protect themselves against all bloodborne infectious Cciseases. However, surveys show that neither employer provided education nor protective equipment is adequate at this time. Toward this end, a number of AFL-CIO affiliates petitioned the Occupational Health & Safety Administration (OSHA) -in September 1986 to issue a standard to pro- tect workers from bloodborne infectious diseases. OSHA announced in July 1t would develop educational materials and begin enforcement of the Centers for Disease Con- trol's (CDC) infectious disease control guidelines through its general duty clause. As a result, certain types of employers such as hospitals, nursing homes and doctors' offices are being notified that: they are subject to inspections and fines if they are found to not conform to.CDC Acquired Immune Deficiency Syndrome page 2 guidelines. OSHA also promised a separate permanent health standard to cover bloodborne disease risks to workers. The labor movement will work with OSHA in developing the program and carefully monitor its implementation. AIDS affects minority communities disproportionately Black Americans comprise 24 percent of known AIDS cases, even though they comprise only 12 percent of the population Hispanics count for 14 percent of known cases, yet only comprise 7 percent of the population. Additional funding to support AIDS research, education, and health and social services should become a national priority. The AFL-CIO urges increased federal funding for research on the cause, transmission, and development of a cure and vaccine for AIDS. Persons with AIDS and ARC should be given the financial, social, and legal support to continue living their lives with dignity and self-respect. Education of the general public is also extremely important. Scientifically based information should be given the widest circula- tion possible, including appzopriate instruction In schools and public service announcements in print and electronic media. Persons with AIDS should be allowed to work as long as they are able to, and as long as they desire to continue at their yobs. AIDS should be classified as a disability and handicap under the state and federal laws to provide AIDS patients with legal protec- tion from work-related AIDS discrumination. Testing for HIV should be offered to those who want it, but only on a voluntary basis. Testing should be conducted in a setting which guarantees confidentiality, and anonymity, if requested Counseling both before and after testing must also be included as part of any voluntary testing program. HIV testing must not be made a pre-condition to obtain employment, or a condition to re- tain one’s job. Mandatory HIV testing is a violation of civil liberties and does not promote the public's health The AFL-CIO will continue to push for the promulgation of occupational health standards by OSHA which mandate the implementation of Centers for Disease Control (CDC) guidelines for protection against AIDS and other infec- tious diseases and include infectious diseases under the OSHA Hazards Communication Standard. Until such final standards are issued, the AFL-CIO urges OSHA to enforce all CDC infection control guidelines under the general duty clause of the Occupational Safety and Health Act. The AFL-CIO and its affiliates will educate their members about AIDS, work for health protections for workers 1n occupational contact with AIDS and other bloodborne diseases, lobby for in- creased funding for AIDS research, education, and social and health services, and fight against AIDS discrimination experienced by workers, the public, or persons with AIDS/ ARC. NATIONAL LEADERSHIP COALITION en ON AIDS B.J. Stiles B.J. Stiles is President of the National Leadership Coalition on AIDS. The Leadership Coalition was formed in 1987 by key representatives of business and corporate groups responsive to AIDS, and others, including labor, health, religious, and voluntary groups. Prior to forming the National Leadership Coalition on AIDS, Stiles was a consultant working with corporations and major private sector organizations responding to AIDS. His clients have included IBM, the American Council of Life Insurance, Health Insurance Association of America, the American Foundation for AIDS Research, the National AIDS Network, and others. His articles and Op Ed pieces on AIDS have appeared in the New York Times, the Los Angeles Times, the Christian Century, and others. Stiles has held distinctive positions in philanthropy, publishing, and public affairs. He served as Vice President of the Council on Foundations, and founded the Fellows Program of the Robert F. Kennedy Foundation. He directed the largest grantmaking division of the National Endowment for the Humanities and founded the publishing and communications program of The Urban Institute. Born in 1933 in Maypearl, Texas, Stiles is a graduate and distinguished alumni of Texas Wesleyan College, and an alumni of SMU. He pursued graduate studies at Vanderbilt University. Stiles has been active in civic affairs in Nashville, Tennessee where he lived for twelve years while editor of Motive Magazine. Since moving to Washington, D.c. in 1969, Stiles has served on numerous civic and national boards. TESTIMONY OF B.J. STILES PRESIDENT NATIONAL LEADERSHIP COALITION ON AIDS BEFORE THE PRESIDENT’S COMMISSION ON THE HIV EPIDEMIC AIDS IN THE WORKPLACE INDIANAPOLIS, INDIANA MAY 10, 1988 Since well over two dozen previous witnesses before this Commission represent organizations and corporations which have been critical actors in helping form the National Leadership Coalition on AIDS, I know that you are quite cognizant of our existence and our purposes. However, for the record, let me state briefly the origins, purposes, and accomplishments of the Leadership Coalition. The Coalition was formed one year ago this month after several months of planning by representatives of businesses and corporations, national voluntary, health care, and educational organizations, labor, gay, and religious bodies. We now have well over 100 members and our work is supported by membership dues, corporate and private foundation grants, and a few contracts. The Coalition’s three program objectives are: * To increase public/private sector collaboration on AIDS. * To improve business and labor response to AIDS. * To encourage balanced and informed consideration of public policies affected by AIDS. Our Board of Directors is comprised of 23 outstanding leaders representative of the diversity of American life. Each holds major posts within their respective professions and corporate structures. Together, they embody a depth and range of knowledge and commitment around AIDS unequaled in any other single segment of the private sector. The chair of our Board is Edward N. Brandt, Jr., M.D., Ph.D., who is chancellor of the University of Maryland at Baltimore, and a former assistant Secretary of the Department of Health and Human Services. Testimony Stiles Page 2 The Leadership Coalition was launched with the conviction that no single segment of society can marshall the resources required to resolve the fears and carry the burdens of coping with the HIV epidemic. Thus, we endeavor to increase collaboration and promote cooperation amongst all kinds of organizations in order to collectively resolve this costly and painful challenge. The purposes of the Leadership Coalition are: 1. To increase public/private sector collaboration in responding to the AIDS crisis; 2. To promote approaches to AIDS that are consistent with the American traditions of justice, fairness, and compassion; 3. To recognize and highlight emerging needs stemming from the AIDS epidemic; 4. To stimulate the development of informational campaigns as needed to serve unmet needs; 5. To serve as a practical resource-sharing and collaborative body for national and international organizations focusing on AIDS. 6. To stimulate private sector involvement in, and support for, the fight against AIDS. A few highlights of our work are: * Collaboration with Allstate Insurance to plan and host two national conferences attended by over 400 corporate executives and business leaders, who prepared the groundbreaking report and recommendations on corporate responses to AIDS. To date, over 20,000 copies of that report have been circulated to community and business leaders across the country. Testimony Stiles Page 3 * Cooperation with Fortune Magazine in surveying over 700 CEOs about their views and commitments in response to AIDS, and successive presentations to Fortune 500 companies of examples of how corporations are responding to the epidemic. Assistance to local and regional business groups and industry associations in mounting AIDS educational programs. Cosponsorship with PBS of a national videoconference on AIDS & the workplace, scheduled for May 24, with downlinks in over 60 locations across the country. This four-hour seminar is directed to managers and key executives of smaller businesses, often located in parts of the country not yet focusing on the impact of AIDS in their communities. Publication and distribution of a comprehensive brochure directed to co-workers and employees. That brochure, planned and underwritten by one of our corporate members--Joseph E. Seagram & Sons--has been distributed to employees of more than 800 small businesses, corporations, and organizations all across the country. Convened a two-day briefing for over 40 editors of religiously-identified publications, cosponsored by four national associations--the Associated Church Press, the Catholic Press Association, the Evangelical Press Association, and the American Jewish Press Association--to encourage more coverage of AIDS stories and greater editorial attention to the reporting on AIDS. Endorsed the "Ten Principles for the Workplace" developed by the Citizens Commission on AIDS for the New York-New Jersey Region; we are actively promoting’ adoption and usage of the principles in businesses across the country. Serve as a day-to-day information resource and strategic clearinghouse for press and media, funders, community-based care and Testimony Stiles Page 4 service providers, and a growing number of public policy planners eager to obtain up-to-date and reliable information about how the private sector is responding to AIDS. Simply put, our work to date consists of Coordinating and facilitating between and among those already active on the AIDS front, and those needing guidance and direction in getting started; Convening strategic meetings of decision makers to consider most pressing priorities, longer term strategies, and to connect critical actors; Probing for missing perspectives and underrepresented aspects of the epidemic, with special concern for encouraging balanced and informed consideration of public policies affected by AIDS, and with immediate attention focused on obtaining greater responses to AIDS from those sectors of society and locales not yet fully attentive to the impending demands of the epidemic. I am pleased to report that the receptivity to the Coalition has been positive, and we are enjoying a steady growth in members and outreach. We resist the temptation to launch programs of our own, and try to increase the utilization and visibility for the multitude of excellent programs and services available through our members and others. our resources as an organization are modest; that is, a staff of three augmented by a loaned corporate executive and several interns from time-to-time; a core budget of $300,000. Clearly, we rely upon our Board, our members, and a growing network of colleagues to accomplish our objectives. In concluding this organizational review, I’d like to observe that the one factor which caused us to pause before launching the Leadership Coalition was the impending appointment of this Presidential Commission. That is, one of the factors influencing those who founded the Coalition was the vacuum in Testimony Stiles Page 5 national leadership since the onset of AIDS, and our sense that this vacuum was contributing mightily to the fears and stigmatizing attitudes about AIDS. Some of us wished to rectify that and believed that a private sector leadership body was the most promising vehicle. After almost a full year of planning and negotiating, we learned on the eve of our formal organizing that this Commission was about to be announced by the President. Wise counselors admonished us to pursue, and argued that both ventures--and far more--were needed to help prod, probe and produce better actions. We were among the first to offer encouragement and assistance to your efforts, and applaud you and especially your Chairman for rectifying the early missteps and focusing on the real and complex issues associated with this extraordinary challenge. kkkKE What have we in the National Leadership Coalition on AIDS learned about the private sector’s responses to AIDS? Several themes emerge from our first year: 1. The missing element in mounting an effective response to AIDS is leadership. The growing arsenal of resources for fighting AIDS is now substantial. Your work has helped identify what gaps exist in funding, strategies, and personnel, and most of us expect that your report will provide a comprehensive roadmap to guide us into the near future of this epidemic, at least domestically. Yet without clear and strong voices, nationally and locally, the general public remains uncertain and anxious about whom to believe and how to respond appropriately and effectively. That uncertainty is aggravated by sensational stories, whether about mosquitoes, heterosexual vulnerabilities to the transmission of the virus, or which celebrity does or does not have AIDS. The fears and ignorance on which such uncertainty is grounded can be fanned into angry and even violent confrontations. Testimony Stiles Page 6 But, In every circumstance we have observed, uncertainty is transformed into reasoned, balanced, and compassionate actions when trusted and respected community leaders act positively and calmly. Fortunately, there are now extensive examples of how such leadership makes profound differences in the ways businesses, communities, and localities cope with this mounting crisis. When leaders speak up, responses are positive. Fears of reprisal, controversy, or conflict often cause key decision makers to hesitate in taking a visible role in responding to AIDS, yet there is no evidence to date that those who do step forward receive anything other than gratitude and support. The executives at Allstate could have mounted an employee education program, hosted community discussions, and contributed to organizations providing care, services and education. Those are all things that need doing. Yet, they chose to convene their peers and corporate colleagues in forming a national corporate response, and provided a welcomed and much-needed forun. The list of comparable pioneering efforts is growing, and now represents a diverse mix of industries, locales, and typologies for responding. Yet, there is not only room but urgency for more CEOs, religious and civic leaders, and public officials to step forward and provide sound, vigorous leadership. Plan and prepare before there is a crisis. Although many sound and balanced responses to AIDS have materialized from crisis or case-driven situations, every experience to date indicates that far more effective and balance@d AIDS programs and policies happen when developed before there are specific instances requiring action. Further, it is also clear that the best planning stems from Testimony Stiles Page 7 task forces and committees which fully represent thé diversity of factors comprising the AIDS epidemic. That includes, but by no means is limited to, those community groups already experienced in responding to AIDS, representatives of most-affected population segments experiencing AIDS, and well informed specialists with up-to-date knowledge about legal, medical, health and human service programs, and psychosocial ramifications of the epidemic. Such planning must be encouraged and launched at virtually every level of national life, and in every practical setting imaginable. As severely as the epidemic is now felt in many locales and segments of our society, we are still on the threshold of this crisis. Collaboration is imperative. This Commission has confronted and helped to identify how diverse and complex this epidemic is. Although clearly a health matter in its fundamental nature, AIDS touches every primary aspect of our lives and triggers concerns within every social institution serving our diverse needs and interests. Although each special sector of the AIDS epidemic requires particular and uniquely appropriate actions, our community response to AIDS must be devised and administered through the broadest possible planning and collaboration. No single institution or segment of society can be expected to resolve or shoulder the burdens of this epidemic. We must work together as we sort out the appropriate, realistic, and most effective ways to cope with the longer term demands of this evidemic. What are the appropriate partnerships between public and private sector institutions for shouldering Testimony Stiles Page 8 the financial costs triggered by AIDS? In that the epidemic thus far is more visible and pronounced in urban and metropolitan settings, how the costs can be spread equitably? Because the virus is spread through intimate and sometimes illicit activities, how do we move quickly to stop the transmission by advocating changes in behaviors, and keep constant with ethical and judicial principles which undergird our democratic society? In posing the questions, I readily acknowledge that few among us have even begun to plot the mechanisms for achieving meaningful answers, much less have the answers themselves. But we must not defer facing the immediacy of the need to bring our most critical national assets and intellectual resources to bear on this need to collaborate and cooperate as we endeavor to resolve the most immediate and pressing problems, but in ways which make us a healthier and more unified society. kkk Against such a broad and perhaps too idealistic a background, I urge the Commission to consider the following recommendations as it pursues its mandate and prepares its report for the President and to the nation: 1. That a national private sector leadership meeting be held soon after the completion of the Commission’s report to consider significant ways to disseminate and implement those findings most suited for action through public/private sector collaboration. The National Leadership Coalition would be pleased to work with the Commission to help convene such a meeting. That regional mechanisms be sought to convene critical leaders from both the public and private sector to consider special needs associated with AIDS requiring greater regional focus. Among those who could be instrumental in convening such meetings are the Department of Testimony Stiles Page 9 Commerce, particularly through its Small Business section, regional Chambers of Commerce, service clubs, and others with distinctive commercial and economic ties to regional interests. That greater effort be made to have drug-focused education, prevention, and rehabilitation endeavors become more attentive to HIV concerns, and that private sector drug education programs give AIDS-related concerns higher visibility. Workplace drug education programs are logical vehicles for helping to educate employees and their families about HIV prevention. That existing mechanisms within governmental structures be required to be more explicitly attentive to promoting AIDS prevention education, to serving as advocates for the particular needs of persons affected by AIDS, and to help adapt the ten principles ‘for the workplace developed by the private sector as standards and guidelines for public employers as well. That special initiatives be taken to work with all levels of the criminal justice system to promote sound and balanced training programs to cope with the complexities facing us as society confronts the intertwining problems of drugs, HIV, crime, and prison populations and their families. Allstate Edward L. Morgan, Jr. Assistant Vice President - ALLSTATE INSURANCE COMPANY TESTIMONY BEFORE THE PRESIDENTIAL COMMISSION ON THE HIV EPIDEMIC INDIANAPOLIS, INDIANA MAY 10, 1988 Admiral Watkins, Commission members and ladies and gentlemen, Allstate is honored with the opportunity to provide testimony at this public hearing on AIDS in the Workplace. The Allstate Forum on Public Issues was established in 1987 to provide a platform where leaders of diverse parts of American society could be invited to address pressing and critical issues. Its intent is to respond to the need for business to take a leadership role and to recognize that government cannot resolve all of society's problems. The Forum intends to deploy task forces and coalitions from a variety of professional disciplines to forward the action toward solutions and resolutions of major problems as they exist in contemporary American life. Last summer, in response to a call for action from the Surgeon General, Allstate chose AIDS in the workplace as the first issue to be dealt with by the Allstate Forum on Public Issues. It was the first national discussion and workshop dealing specifically with AIDS in the workplace. As a first step, Allstate asked Fortune magazine to conduct a survey of the nation's largest companies to determine their opinions and policies on AIDS. The survey showed that only one in five major U.S. corporations had or were developing policies dealing with AIDS in the workplace. Because AIDS has such a major human and fiscal impact on American business, it became apparent to us that companies large and small must deal with the issue as soon as possible -- preferably before an AIDS case actually arises within their workforce. More than 250 executives representing 150 major corporations and organizations met in Chicago last October to listen to experts on the issue at the first Allstate Forum on Public Issues entitled "AIDS: Corporate America Responds." As a result of that first meeting, task forces were established in the areas of human resources; medical/corporate health services; government/ legislative affairs; legal; corporate communications and corporate philanthropy. Task force representatives of 78.corporations and organizations met during a three-month period to gather data and develop AIDS in the workplace guidelines for employers. Some of the questions these task forces dealt with were: How should a company go about developing such a policy? What should it include? ° What form should it take? What else should companies do in dealing with the AIDS issue? Their recommendations were compiled in what we believe is the first comprehensive national report dealing with the issue of AIDS in the workplace written by and for the business community. I'd now like to cover a few of the guidelines that were developed by the Forum's task forces. They are contained in this report, entitled "AIDS: Corporate America Responds. A Report of Corporate Involvement." Among its major recommendations, the report notes that AIDS policies must have the active support of senior management. They should also be the product of a task force which includes representatives from such areas as corporate communications, medical, employee relations aiid human resources, legal, safety, affirmative action and corporate philanthropy. Where applicable, the task force should include members from management and labor unions. Outside medical and Tegal experts should also be called upon for guidance. The task force should analyze workplace risks with respect to the nature of their individual businesses. Consulting with other employers and community groups can provide additional perspectives. The ultimate goa] should be to develop a policy that provides safety and fairness for the workplace and compassion for persons with AIDS. Overall, an AIDS policy should: ° Develop a communications program for employees designed to minimize fears and help prevent the spread of AIDS by explaining the facts of AIDS and AIDS transmission. Such a program should also help explain the company's AIDS policies. ° Treat employees with AIDS in the same manner as any other employees with life threatening illnesses. ° Allow affected employees to continue working as long as possible, provide reasonable accommodations and job modification where appropriate and maintain eligibility for all company benefits. ° Discourage testing for the HIV virus within the employee population. ° Guarantee confidentiality of all medical information related to AIDS. ° Provide for referral of affected employees to appropriate company and community resources and experts for consultation and treatment. ° Encourage creative corporate philanthropy with respect to AIDS, especially in the areas of research, education, care and treatment, and technical assistance. ° And finally, the AIDS policy should be consistent, and tailored to the needs of individual companies. 10 These recommendations and many others were developed as a result of the task force process and we believe they can be of great value to both large and small corporations and organizations. We have responded to requests for more than 25,000 copies of the report, and the requests continue at the rate of more than 100 a week. Allstate printed the report and we have been providing single copies of it to companies and organizations at no cost. There is a charge -- which covers the printing and handling of the report -- for - multiple copies. 10 10 11 But we believe the report should have even wider distribution. The federal government could assist us by printing the report and making copies available through its publications catalogs. The Labor Department might consider distributing it through its regional offices. Other government departments, such as the Department of Health and Human Services and the Department of Education, could also assist in the dissemination of this report. Allstate is pleased to have had the opportunity to play a part in helping to address the AIDS issue in the workplace and we appreciate the opportunity to testify before this commission. Thank you. 11 11 Statement ot the U.S. Chamber of Commerce ON: AIDS IN THE WORKPLACE TO: PRESIDENTIAL COMMISSION ON THE HUMAN - IMMUNODEFICIENCY VIRUS EPIDEMIC BY: JAMES A. KLEIN DATE: May 10, 1988 ™-2 Chamrers mission is to advance hu:nan progress through an economic moutical ana social system based on individual treedem, centive, uwntictve, opportunity and responsibility The U.S. Chamber of Commerce is the world's largest federation of business companies and associations and is the principal spokesman for the American business community. It represents nearly 180,000 businesses and organizations, such as local/state chambers of commerce and trade/professional associations. More than 92 percent of the Chamber's members are small business firms with fewer than 100 employees, 59 percent with fewer than 10 employees. Yet, virtually all of the nation's largest companies are also active members. We are particularly cognizant of the problems of smaller businesses, as well as issues facing the business community at large. Besides representing a cross section of the American business community in terms of number of employees, the Chamber represents a wide management spectrim by type of business and location. Each major classification of American business—-manufacturing, retailing, services, construction, wholesaling, and finance-——numbers more than 10,000 members. Yet no one group constitutes as muchas 31 percent of the total membership. Further, the Chamber has substantial membership in all 50 states. The Chamber's international reach is substantial as well. It believes that global interdependence provides an opportunity, mot a threat. In addition to the 56 American Chambers of Commerce Abroad, an increasing number of members are engaged in the export and import of both goods and services and have ongoing investment activities. The Chamber favors strengthened international competitiveness and opposes artificial U.S. and foreign barriers to international business. Positions on national issues are developed by a cross section of its members serving on committees, subcommittees and task forces. Currently, some 1,800 business people participate in this process. STATEMENT . on AIDS IN THE WORKPLACE before the PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC for the U.S. CHAMBER OF COMMERCE by James A. Klein May 10, 1988 Mr. Chairman and members of the Commission, my name is James A. Klein. I am Manager, Pension and Health Care Policy for the U.S. Chamber of Commerce. It is an honor to be here today to testify on this most important issue, which the Commission has been charged to investigate. Overview The Chamber commends the effort of the Commission to hold these hearings and to seek input from the private sector on ways in which businesses can contribute to a better understanding of the Acquired Immune Deficiency Syndrome (AIDS) epidemic and to helping stop the spread of AIDS. The business community has many reasons to be vitally interested in the AIDS issue. The personal, human dimensions of the suffering caused by AIDS can not begin to be calculated. Employers -- like all individuals -- have an obvious concern for preventing and ameliorating that suffering. But concern about halting an epidemic such as AIDS takes on particular importance for employers. One of the tragedies of AIDS is that it disproportionately strikes young people who should be at the peak of their productive years. These are the American workers whose efforts are needed to maintain a productive and growing nation. 2. Employers are also concerned with the significant financial costs associated with the disease. As the epidemic spreads, health and other insurance costs will be enormous. By 1991 it is estimated that people with AIDS will need health and other services costing $8 billion - $16-billion. The American Society of Actuaries predicts that AIDS-related deaths may cost life insurance carriers as much as $70 billion by the year 2000 -- of which $20 billion will be borne by group life insurance policies largely sponsored by employers. The additional costs to businesses and the economy in terms of lost productivity and resources dedicated to AIDS that could be spent on other productive pursuits are all expenditures, direct or indirect, that are a vital concern to employers and the nation. These are some of the financial reasons why business shares the commitment to find cures and effective treatments for AIDS -- and why the Chamber is committed to helping foster better education about AIDS so that its spread can be slowed. For many of us who deal with AIDS issues on a daily basis, it may be difficult to appreciate the fact that in many communities very little is known about AIDS. The infrastructure of those communities (the health system, the educational system, local government agencies, businesses and the media) simply have not yet had to "gear up" to deal with AIDS. This is not too surprising when we look at the demographics of the epidemic and realize that, thus far, perhaps a half dozen or so major metropolitan areas account for the vast majority of AIDS cases. In most communities, individuals and businesses have not yet been confronted with the reality of AIDS among friends, co-workers, and employees. The official predictions on the pace of the epidemic underscore how the experience of those communities will change in the very near future. By 1991 fully 80 percent of all cases of AIDS will be found outside those few metropolitan urban areas that now account for the majority of AIDS cases. Along with the scientific battles that are being waged against the AIDS virus, the nation must prepare itself to wage a battle against simple misunderstanding or lack of information that will hinder the ability of individuals and businesses to respond appropriately to the great number of AIDS cases that we are likely to confront in the near future. fic Busi ncern I have previously mentioned, in broad terms, both the sympathy for human suffering and general economic concerns that the business community and the nation, as a whole, share about AIDS. Beyond these, employers have a host of other specific issues about which they are concerned in determining how best to respond to the specter of AIDS in the workplace. These concerns involve mainly legal and employee benefit issues and questions about the best role for businesses in the educational effort regarding AIDS. The legal issues that are or ought to be of interest to businesses include the following: Is an AIDS-infected person considered to be "handicapped" under federal, state, or local Jaw? If so, what are the reasonable accommodations that employers must make for handicapped employees? What is the relationship of AIDS to preemployment testing or screening policies that companies may use? What rights to confidentiality are owed to persons with AIDS? What notification rights, if any, are owed to co-workers of persons afflicted with the AIOS virus? What legal remedies are available to management if employees refuse to work alongside a person with AIDS? What are the advantages or disadvantages of promulgating written policies or guidelines on AIDS? What are the obligations, if any, to follow guidelines published by government agencies? Some commonly asked employee benefit questions include: Should AIDS be treated the same or differently than other catastrophic illnesses? What are the limitations or exclusions in benefits plans that will provide the financial protection to employees and their families and help management contain costs? Does the company's health plan pay for prescription drugs, mental health benefits, experimental treatments, and nursing home and hospice care? Does the benefit plan have adequate case management and utilization review provisions? What are the relative merits of self-insuring or purchasing insurance from a carrier? Some questions that employers ask themselves regarding their proper role in educational programs are no Jess probing. These include: If AIDS cannot be transmitted in normal workplace settings, is it appropriate for the company to address the issue with its employees? How can a company raise the issue of ~~ AIDS in the workplace without arousing unfounded fears? If a firm wants to convey AIDS information to its employees, what is the most suitable format to do so? Who are the appropriate Speakers and what are the best materials to use for an AIDS educational program? These are just a few of the myriad concerns and questions that employers are considering. Many of these questions have neither clear nor simple answers. Yet, where specific guidance can be given to employers, it is important that both government and the private sector help provide these answers or guidance. Where direct answers are not possible, it is at least important to alert the businesses to the vital questions that they must ask themselves. Chamber Activity / The Chamber has determined that the most important contribution that it can make to the many efforts being applied to the AIDS issue js to provide its members (and, in turn, their employees and families) with information that they need to deal with the many challenges posed by AIDS. Accordingly, the Chamber has taken several steps toward this end. The Chamber's Board of Directors adopted unanimously a policy statement on AIDS (Appendix A), which urges its members to engage in educational efforts on AIDS and to consider the adoption of policies on catastrophic illnesses. The policy statement also stresses the importance of employers familiarizing themselves with and taking steps to address employee benefits, legal issues, and health and safety considerations related to AIDS in the workplace. The Chamber also has devoted considerable attention to the AIDS issue in its broadcast and print media. The Chamber's morning news program Nation's Business Today, which is carried on ESPN, the nation's largest cable television network, has run several segments, including a special four-part serjes, on AIDS. The Chamber's magazine, Nation's Business, the largest monthly business publication in the country, has run a number of stories on AIDS (Appendix B) as has the Chamber's newspaper, The Business Advocate. Reflecting the composition of its membership, the Chamber's communications efforts have focused extensively on the concerns and needs of small and medium-sized businesses. -5- The Chamber's educational activity has now entered an even more in-depth phase. The Chamber will be publishing shortly a book AIDS: An Employer's Guidebook, which I have written, that focuses particularly on giving small businesses, local and state chambers of commerce, and other trade and professional associations necessary information about AIDS. Additionally, the Chamber will be offering seminars on "AIDS in the Workplace” next month at the Institutes for Organization Management, a continuing education program for state and local chamber of commerce executives. A medical authority and I will jointly teach a seminar on workplace AIDS issues, which will provide the program's participants with useful information that they can take back to their respective communities to share with their business members and employees. It is important to note that a great deal of activity in responding to workplace AIDS issues has been initiated by and taken place at the local and state level. Several state and local chambers of commerce have sponsored seminars on AIDS in the workplace, both to educate business people on the issues with which they need to be familiar and to encourage businesses to share this information with their employees. The Business Council of New York State, Inc. and the Minnesota Chamber of Commerce and Industry are just two state chambers that have launched statewide programs to bring the necessary information to as many communities as possible. Legislation To date, most legislative activity related to AIDS has occurred at the state and local level. Dozens of laws related to testing, discrimination, medical confidentiality, and other AIDS-related matters have been passed by states and localities. Hundreds more legislative proposals have been sponsored and are pending. The Chamber does not directly lobby the legislative process at the state or local level. At the federal level, where the Chamber does direct its efforts, the legislative process has moved cautiously, as have the Chamber's own legislative policymaking decisions. Most legislation actively considered by the Congress has involved the level of federal financial support devoted to AIDS research and treatment. The Civil Rights Restoration Act which became law earlier this year, did contain language modifying the Vocational Rehabilitation Act of 1973 to redefine the -6- term “handicapped individual” which may have ramifications for businesses in general and for employees afflicted with AIDS. However, legal analysts and even Members of Congress who supported the provision disagree as to whether the new law codifies, modifies, or reverses findings related to handicapped discrimination in the U.S. Supreme Court's decision in School Board of N County v. Arline, _U.S.___, 107 S. Ct. 1123 (1987). © These discrimination issues and others are certain to be the topic of further © Congresstonal consideration. The Chamber, in order to respond best to this legislative debate when it comes under active consideration’ by the Congress, has directed its Health Care Council to investigate further AIDS-related legislative proposals. The Council will, as hecessary and appropriate, make recommendations to the Chamber's Board of Directors $0 that the Chamber may actively engage in the debate on those issues of interest to its members. \ Recommendations Finally, I would like to fulfill your request for recommendations on steps that the Commission may take to respond best to the AIDS epidemic. These are discussed below. First, the Chamber respectfully urges the Commission to use its stature to convince private and public sector leaders to devote resources to educate the public about AIDS. Myths and misunderstandings can only be overcome by a strong commitment to give the public the information it needs to understand the facts on AIDS. A number of important Steps have been taken already. For example, the national mailing of the AIDS brochure to every American home wil] go a long way toward imparting critically important information. Certainly, official encouragement can be given to employers to initiate educational efforts to supplement the encouragement given by the Chamber and many other private organizations. However, the Chamber strongly urges the Commission to resist any effort that would require employers to sponsor educational programs or to adopt specific corporate policies. The Chamber notes with great concern that in California legislation has been introduced that would mandate employers to provide AIDS education to employees and to -7- promulgate written AIDS guidelines containing specific provisions. The Chamber certainly hopes that such legislation does not pass at the federal, state, or local level. . It would be a mistake to make mandatory what should be strongly promoted on a voluntary basis. A mandate fails to recognize the varied degree of employers' abilities to impart educational information to their employees. This is especially true when dealing with an issue as comp] ex and evolving as the AIDS epidemic. But a more fundamental reason for not requiring employers to sponsor educational programs or draft uniform quidelines is that it could send precisely the wrong message about AIDS and the workplace. As we all know, AIDS is not transmitted through normal contact in the workplace. It should not, then, become an employer requirement to educate the public about activity that is of a most personal nature. Clearly, such employer-sponsored education should be encouraged wherever it is believed appropriate by the employer. That has certainly been the thrust of the Chamber's efforts. But the prerogative of the employer not to become the AIDS-education source for its employees should be preserved. A second important function that the Commission could fulfill is to encourage that in every way practicable AIDS in the workplace should be handled like any other catastrophic illness. The Chamber believes that the facts about AIDS and the’ common interests of persons with AIDS, employers, and co-workers warrant this response. It is because the Chamber believes that persons with AIDS should be treated in the same way as those afflicted with other illnesses that it endorses the notion that employees with AIDS should be allowed to continue working as long as they are physically able to do so. Similarly, modifications to employee benefit plans to serve better the needs of employers and employees should be considered for both AIDS and other illnesses. For example, decisions on limitations of coverage or on implementing case management techniques in health benefit plans should be considered for AIDS on thé’ same basis as for other diseases. There are other issues in which the need to handle AIDS no differently than other catastrophic illnesses also becomes apparent. One area concerns medical confidentiality. Every individual is entitled to confidentiality regarding his or her medical condition. There are, however, certain situations in which it may be reasonable for others to be notified of a person's health status. For example, health care workers providing services to a patient and persons involved in reviewing medical records or processing claims forms in order to implement properly case management or utilization review techniques may have a legitimate need to know a person's AIDS diagnosis. Similarly, medical personnel or even co-workers who in an emergency may be exposed to the blood or bodily fluids of a person with AIDS, may have a legitimate need to know that the person to whom they are providing care has AIDS. Access to this information should be made available on the same basis as it is made available for other diseases. Other well-intentioned legislation that is meant to give special consideration to persons with AIDS and other disabilities could have unintended results. For example, pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) employers are required to extend to former employees health coverage under an employer plan for up to 18 months. Proposed legislation would extend that period by an additional 11 months for persons with AIDS and some other disabilities. No one denies that persons with disabilities need and deserve health care protection. But forcing employers to maintain individuals with high health Care expenses on the employer plan for an extended period beyond the current COBRA requirement may so greatly increase health insurance costs that many employers will be forced to respond to the change by curtailing the level or type of benefits provided to all employees. The Chamber has already seen this happen with COBRA as it now operates. Requiring special additional provisions for disabled patients could exacerbate this response. The Commission could perform a valuable service to all who are concerned about AIDS and its related issues by pointing out that proposals aimed at ameliorating problems for persons with AIDS could have negative results for those individuals and others. CONCLUSION The battle to defeat AIDS and the myths that accompany it will require Vigilant efforts by both the public and private sectors. The Chamber stands ready to contribute its efforts to helping corporate America respond to this vital challenge. ' Appendix A US. Chamber of Commerce Washington, D.C. 20062 AIDS Acquired Immune Deficiency Syndrome (AIDS) is a major and growing health problem in the United States, one which the business community, like society as a whole, must address ina fair, an effective, and a comprehensive manner. Employers should take reasonable and appropriate steps to assure that discrimination against employees with AIDS does not occur. Employers should: (1) treat those who are affected by AIDS or any other life-threatening or debilitating disease in a humane and understanding manner; (2) maintain appropriate confidentiality regarding medical information to preserve the AlDS-infected or -afflicted employee's right to privacy; (3) educate employees (and, in turn, their families) regarding AIDS, its causes, its transmission, and any potential occupational risks of exposure -- paying particular attention to the perceptions of various employees; and, (4) adjust employee-benefit plan practices, as necessary or appropriate, to better respond to AIDS. Due consideration must be given to the rights and responsibilities of employees with AIDS, employers, co-workers, customers and the public-at-large. Employers should monitor and stay current with medical and scientific developments regarding AIDS, and should revise company policies, accordingly. Recognizing that current evidence indicates that AIDS is not transmitted through casual contact, as necessary or appropriate, employers should consider providing written guidelines and training for those employees (such as health care workers) who may be identifted to be at higher risk of AIDS infection due to occupational exposure. To the degree practicable, employers should treat employees with AIDS in the same manner as employers would deal with employees who have other conditions that may be disabling -- that is, that the employees may continue on the job to the extent their health condition permits. Finally, employers should implement appropriate programs and policies to address AIDS, to minimize its economic and social costs, to protect the rights and provide comfort for those with AIDS, and to assure continued business operations without undue disruption or interference. Adopted Unanimously by the Board of Directors, U.S. Chamber of Commerce February 10, 1988 9322G/28 Nation’s Business August 1987 Al WEEN THe USTED Seas DS In The Workplace By Ira D. Singer Appendix B ike a bad dream without a morn- ing to end it, Acquired Immune Deficiency Syndrome (AIDS) is moving relentlessly into Ameri- ca’s smaller towns—and its smaller companies. Most executives are ill-prepared for the news that an employee has been diagnosed as having the condition. Managers find themselves pressed to make policy decisions that would have served both the person with AIDS and the company better if made calmly, in advance. If a company has not planned ahead, a manager’s initial reaction to a per- ceived AIDS threat can seriously harm the firm’s own health. Michael Wolfe, a pizza maker for a fast-food chain in Norfolk, Va., com- plained that he felt ill last December. A rumor spread that he might be af- flicted with the AIDS virus, which can have the symptoms of a bad cold or flu at first, but which eventually weakens the body’s immune system, allowing other opportunistic infections to strike and eventually kill. Without notice, Wolfe was fired by a vice president, who also announced his action to the chain’s supervisory staff. As it turned out, Wolfe did not have AIDS. But the company now has a dis- crimination lawsuit filed against it. “Many small companies are in a total vacuum on how to handle AIDS,” says Dr. Alan Emery, a clinical psychologist and consultant on workplace issues with the San Francisco AIDS Founda- tion. “They are unaware of the potential legal and benefits issues and are simply uninformed about the medical picture— much like most Americans.” The first thing employers need to know 1s how the condition can—and cannot—be contracted. AIDS is not transmitted through ca- sual social contact. “You have to really go out of your way to contract the vi- rus,” says Dr. James Mason, director of the Centers for Disease Control, the government’s main agency for monitor- ing AIDS. The AIDS, virus is spread in three ways: sexual contact, exposure to in- Ira D. Singer 1s a free-lance writer based in McLean, Va. When the Washington-based Council on Foundations found that an employee had AIDS, one of its earliest actions was to assemble managers to map out a plan of action. Managers (counterclockunse from left) Jean Urkums, Thomas M. Smith and Barbara Bode meet with CEO James A. Joseph. fected blood or blood products and from an infected mother to her unborn child. Dr. Anthony Fauci, director of the Na- tional Institute of Allergy and Infec- tious Diseases, says this means that “AIDS is a disease of behavior. It’s strictly a matter of what you do away from work.” Despite such reassurances, the work- ing world is getting the jitters. Paul Kaplan, president of Northern Hills Office Services, a janitorial main- tenance service company in Woodbury, N.Y., says many of his workers have refused to dispose of waste from medi- cal facilities, even when they have strict infection-control procedures. “They just won’t do it,” he says. “They’re scared to death. The problem is rampant throughout my industry.” “Employers cannot treat this like any other health or business problem,” says Dr. Alan Zox, executive director of the Albany, N.Y.-based Institute for Dis- ease Prevention in the Workplace, which offers training programs on AIDS. “People fear what they do not know.” | So far, almost half of all U.S. cases of AIDS have shown up in three cities: New York, San Francisco and Los An- geles. In New York—the nation’s creative and financial capital—AIDS 1s now the leading cause of death among women aged 25-29 and among men 30-39. But this urban concentration won't last. “It is only a matter of time before business people have AIDS in their workplaces,’ says Dr. Mason. ‘It’s coming.” he Third International Confer ence on AIDS—held in Washing- ton last June—confirmed Dr. Mason’s terse prognosis and these CDC statistics: @ Between 1.5 million and 2 million Americans already carry the virus. Many are unaware they are infected, but between 20 percent and 40 percent of those testing positive for the virus will develop AIDS within five years. @ In 1991, an estimated 145,000 Amenicans will be sick with AIDS and 54,000 will die—almost as many as were killed in the Vietnam War. 2 Nation’s Business August 1987 a AIDS is potentially the most costly and disruptive health problem employers will ever face. How do you prepare for it? First diagnosed only six years ago, AIDS got its U.S. foothold among ur- users. By the end of June, a total of 37,867 people in this country had been diag- nosed with AIDS, says CDC. Another 185,000 to 370,000, the agen- cy says, have AIDS-Related Complex (ARC), an early manifestation of infec- tion that also can be debilitating and often turns into AIDS. ases of heterosexual transmis- sion, which now account for only 4 percent of the total, will climb to 7 percent of the total by 1991, says CDC. Most of these cases occur when a heterosexual’s past partner was an intravenous drug user. Because AIDS has struck the big cit- ies most heavily, businesses there have been the first to develop AIDS policies. But business people all over the coun- try now need to establish what they will do to avoid discnmination suits, to con- trol the human and financial costs and to educate themselves and their em- ployees. Just as the immunity-smashing AIDS virus is spreading, so are the cases of employment discrimination involving people with AIDS or ARC, those per- ceived as having AIDS and members of high-risk groups, such as homosexual men. What can be learned from legal situa- tions such as the Norfolk pizza chain’s? “Employers simply need to learn that knee-jerk reactions without any basis 7 5 sac eve er amr oh efi anon ae - ra an n a hee b aE 4 d saw ee ates HS ee ge a a EPS ee Oe —, SH -Any reasonable Alezandria, Va., association executive Ellen Segalla (left) and ban homosexuals and intravenous drug | James Davis of Arizona’s Keystone Resort (right) are advised by Alan Emery on setting up AIDS policies. pegTo: €D Laan of information will get you in trouble,” says Leon Warshaw, whose New York Business Group on Health has spon- sored conferences on AIDS and the em- ployer. “Business owners need to learn quickly that discrimination is immoral, medically unjustified and illegal under federal and state laws to protect the handicapped,” says Victor Schachter, a . ne-y ~Sg"h= ‘ 5 Pe esa Ses Aeon p ea ARE SW OE eager Reig fe ‘ dpproadis to4109 4a | San Francisco lawyer who advises com- panies on AIDS cases. The Supreme Court ruled recently that a person with an infectious disease and a record of impairment from that illness is considered “handicapped” un- der the Federal Vocational Rehabilita- tion Act of 1973 and is protected from discrimination in all programs receiving federal financial assistance. illegal to discrminate against peo- ple with AIDS. A number of cities have adopted ordinances protect- ing those showing AIDS symptoms or those testing positive for the virus from discrimination on the job. Says Schachter: “Business people need to be aware that their reaction to an employ- ee with AIDS can teeter on the fringe of the law.” In 1986, the New York Human Rights Commission handled 314 AIDS- related job-discrimination complaints. There were three in 1983. Gay Men’s Health Crisis in New York City has been swamped with more than 3,000 requests for legal assistance. Many AIDS discrimination com- plaints are directed at small businesses. “They don’t have the time or inclination to do the research and create simple personnel policies that will allow every- one to be treated fairly, no matter what the circumstances,” says Mauro Mon- toya, legal services director for one of the nation’s leading AIDS clinics, the Whitman Walker Clinic in Washington. As AIDS spreads, your company will F urther, many states have made it - Nation’s Business August 1987 AIDS In The Workplace be faced with growing direct costs in health and pension plans and hfe insur- ance. You also will have to contend with declines in productivity, increases in ab- senteeism and higher labor turnover. he grim fact 1s that, once diag- nosed as having AIDS, few pa- tients live longer than three years. Those years are typically spent going in and out of hospitals, as patients find themselves unable to shake off diseases such as pneumonia. Johnson & Higgins, a benefits con- sulting firm in New York City, came up with its own estimates of the employer costs when two different hypothetical employees were disabled and then died because of AIDS. For a person making 325,000, the em- ployer’s costs for medical, disability, life insurance and retirement benefits could range from 398,000 to $198,000, the firm says. For an employee with a salary of $75,000, these benefit costs could range from $215,000 to $315,000. Just treating an AIDS patient can cost from $35,000 to $140,000. “Costs differ according to a few fac- tors,” says David Garratt, a vice presi- dent at Johnson and Higgins. “If you can keep hospitalization down, make special arrangements to use less expen- sive resources like hospices and home care and rely on community services like volunteer support, as they have done in San Francisco, you'll definitely be on the lower end,” he says. Perfecting ways of treating AIDS can result in higher costs that might be passed on to employers. Drugs such as AZT help to treat the opportunistic in- fections that attack AIDS patients. AZT itself costs $10,000 per year. Al- though the drug mercifully extends an AIDS patient’s life. AZT also extends the need for expensive medical atten- tion For the present, insurance companies are treating AIDS as they would any other major disease and are honoring existing contracts “It’s important to place AIDS in perspective,” says Steve Sieverts, vice president of Blue Cross and Blue Shield of the Natuonai Capital Area. “In comparison to other serious illnesses, the expenditure on AIDS 1s sull a small fraction of what it is for cancer, heart disease or trauma. This can change in the next several years, and this is what frightens people.” he self-insured smaller company faces the largest financial msk from AIDS, particularly if the company’s plan has no stop-loss provision calling for an insurance com- pany to cover catastrophic illness, or if the stop-loss is set unrealistically high. ‘All that a small firm with self-insur- ance needs is one or two cases of a . catastrophic ailment, and that business is history,’’ says management lawyer Stuart Bompey of New York City. Many believe AIDS will be a critical factor in Capitol Hill’s ongoing debate about catastrophic-care health insur- ance. “The AIDS issue might prove to be one of the key items used in Congress to argue in favor of employers provid- ing some minimum level of health in- surance and providing for catastrophic insurance that would automatically cov- er AIDS,” says Dallas Salisbury, presi- dent of the Washington-based Employ- ee Benefit Research Institute. A small business is mure vulnerable than a big. company to the repetitive disabilities that often accompany AIDS. “In a larger company you can move people around and have the luxury of pinch-hitting,” says CPA Joe Tumlin- son, chairman of the board of AIDS Foundation Houston. “In a small busi- ness you don’t have enough fat.” Already, AIDS has staggered the creative professions, which employ a number of people with high-risk behav- ior. “This type of creative talent is impos- sible to replace in the work force,” says Russell Radley, national director of the Design and Intenor Furnishing Foun- dation for AIDS, an education and re- search organization. “They are dying in such large num- bers that it is not uncommon to see several members of small firms already gone.” The shock of this terminal disease, of course, reverberates through the work- place Mickey Steinberg, executive vice president of John Portman & Asso- ciates of Atlanta, says he went through a string of emotions himself when he heard that an employee in his 180-per- son architectural and engineering firm had a confirmed case of AIDS. “My first reaction was, ‘That poor guy—what can we do for him?’ ‘My second reaction was, ‘Wait a minute. Do I have anything to be con- cerned about? Will my staff be affect- ed?’ “The third phase was ‘Hey, I don't know much about the disease and its transmission, but I sure intend to find out.’ ” hen James Joseph, president of the Council on Founda- tions, was informed that the group’s director of public in- formation, Bill Poe, had been diagnosed as having AIDS, he knew he had work to do on two fronts, he says He as- sured Poe that the Washington-based organization would help in every possi- ble way, and he quickly educated him- self on AIDS in order to calm his con- fused and frightened staff. Employees need to be reassured that the workplace 1s safe. For both Joseph and Steinberg, that meant bringing in local experts and coupling this with dis- cussion films, brochures and individual counseling. Steinberg also set up a shelf of AIDS-information matenals in the company’s library. Groups of managers are often the first to be informed. ‘It 1s a way to be straight with people and also to map out a plan,” says Stemberg. It 1s also the vital first step to assuage fears and replace them with facts. Joseph says that after assembling his senior staff, he decided to learn more before talking with the rest of his em- ployees. ‘I realized that senior manage- ment has the responsibility to set the tone of the company,” Joseph says. "I let everyone know that they were in no danger whatsoever.” The emplovee with ARC or AIDS should be encouraged to remain on the job, AIDS counselors say. Whenever possible, flexible hours. part-time duty and other schedules to reasonably ac- commodate the employee should be made available Bill Poe left the Council just three | } t t Nation's Business August 1987 weeks after he notified the group of his ailment. But the relationship did not stop there. Poe’s co-workers still keep in touch, visiting him often and helping him cope with periodic bouts in the hos- pitai. “This is important,” says Caitlin Ryan, an AIDS educator who worked with the Council. “Staying connected with Bill 1s critical for everyone to work through their own feelings, and it also gives Bill some hope and a sense of identity.” As they work with professionals such as Ryan, companies become better edu- cated on how to handle AIDS A year ago, only 4 percent of the nation’s companies had any type of AIDS policy statement. A recent sur- vey by National Gay Rights Advocates A Resource List AIDS is an emotional and medical issue that will not go away, but the fear of the disease can be quelled through edu- cation. In some companies, an informal seminar 1s appropriate. In others, a newsletter or brown-bag lunch meet- ings may work better. Here are some suggested resources to help employers and employees come to gnps with the facts, fallacies and fears surrounding AIDS: General information Your local health department and chap- ter of the American Red Cross. The U.S. Public Health Service AIDS Hotline: (800) 342-AIDS, (800) 342-2437. The U.S. Surgeon General's Report On AIDS (it is free). Write to: AIDS, Box 14252, Washington, D.C., 20044. (202) 245-6867. Books On AIDS In The Workpiace AIDS and the Employer: Gutdelines on the Management of AIDS in the Workplace, The New York Business Group on Health, Inc., 622 3rd Avenue, 34th Floor, New York, N.Y.,10017; (212) 808-0550. found 23 percent of responding compa- nies have developed, or are developing, written policies on AIDS. Two thirds now say they have policies forbidding employment discrimination against em- ployees with AIDS or ARC. Meanwhile, a couple of national groups have sprung up to push for more research and to foster business understanding The National Leadership Coalition on AIDS has been created to increase pub- lic/private sector collaboration. The American Foundation for AIDS Re- search ts assembling a business and la- bor leadership coalition to involve the workplace. Regional and local programs are also evolving. One such effort 1s being or- chestrated by Ric Wanetik, semor vice AIDS: Employer Rights and Re- sponsibilities, Commerce Clearing House, Inc., 4025 W. Patterson Avenue, Chicago, IIl., 60646. AIDS: The Workplace Issues, Ameri- can Management Association, Member- ship Publications Division, 135 W. 50th Street, New York, N.Y., 10020. Programs On AIDS In The Workplace AIDS in the Workplace Package, San Francisco AIDS Foundation, 333 Valen- cia Street, 4th Floor, San Francisco, Calif., 94103; (415) 864-4376. The pro- gram includes an informational video- tape, educational guide for managers and strategy manual. Managing AIDS 1n the Workplace, Workplace Health Communications Corporation, 4 Madison Place, Albany, N.Y., 12202; (800) 334-4911; in New York, (800) 942-1002. The AIDS Execu- tive Bnefing and Training Package in- cludes a videotape and manual. AIDS tn the Workplace Program, Center for Health Promotion, George Mason University, 4400 University Drive, Fairfax, Va., 22080; (703) 323- 2827. president at Marshall Field’s, the Chica- go-based department store chain. is aim'is to raise $1 million in a single night in September for the AIDS effort and also to awaken the Midwest business community to the realitids of the disease. “Here in the Midwest, we have had some time to get better information and benefit from) the experiences of the coasts,” he says. ‘Now it’s time for the business world here to move quickly because AIDS will hit us hard very soon. Chambers of commerce, civic or- ganizations, religious and educational resources are! all making progress so that the public at large, along with the business comniunity, can come to terms with the disease, its consequences and its prevention. | 1B \ e+, Reprinted From Natton’s Business August 1987 NationsBusiness The Magazine that works as hard as the people who read it. ’ \ Additional copies of this article are available. ‘ \ Send all orders or inquiries to; NATION’S BUSINESS REPRINTS, 1615 H Street, N W. ‘ Washington, D.C. 20062 (202) 463-5877 Copyright © 1987 by United States Chamber of Commerce. All nghts reserved. This maternal may not be reproduced. NB Repnnt Collection Copynght © 8664N8 Nation's Business October 1987 MUA UU TURTL Lh Preparing For The Worsi By Michael Pollick Many small-business insurance plans do not account for AIDS and other catastrophic illnesses. Is yours ready? ability. Enter a new and fatal ailment that kills its otherwise healthy victims in about two years and has no known cure. “If a plan started out three or four years ago, there was no reason to ac- count for AIDS,” says Charles Betley, who monitors Acquired Immune Defi- ciency Syndrome for the Washington- based Employee Benefit Research In- stitute. “If one person in a small company caught AIDS, that could pret- ty much throw a monkey wrench into its planning.” How much of a monkey wrench? Consider one Chicago case covered on a small-employer health plan by Mu- tual Benefit Life Insurance Company of Newark, NJ. A man covered by the plan lived 11 months after being diagnosed as hav- ing a fully developed case of AIDS. After two months of continuous hos- pitalization, the man’s relatives re- quested in-home care. Mutual Benefit’s “case-management team” agreed with the request, supplied hospital equip- ment for home use, 24-hour-a-day atten- dants and daily visits by registered nurses. The man’s care and treatment cost $186,053. The bill would have been even higher had the patient stayed in the hospital until he died. For just the last two months of his life, the hospital bill, at $763 a day, would have been $45,780, the insurance company says. Instead of that, the home-health-care cost was $3,253. The cost of treating an AIDS patient | can be as low as $35,000 or even higher \than for the Chicago victim. The typical employer makes other promises to his workers as well. A dis- bled worker who makes $25,000 might eive nearly that much in sick leave plus long-term disability payments. After an employee’s death, the typi- cal company-paid life insurance policy might provide for a payment of two times earnings, or $50,000 in this case, to the beneficiary. If the same worker is an executive making $75,000 a year, the disability company’s benefit plan, like any A insurance, is based on predict- Michael Pollick is a Washington- based free-lance writer. The man is an AIDS patient; the women are workers in a hos- pice, @ facility for the terminally ill. Hospices and death benefits would be magnified to $75,000 and $150,000 respectively. But taking care of the dying AIDS victim is the largest variable in keeping your benefits plan intact. The safest plans are those in which your compa- ny’s health experience 13 “pooled” by the underwriter with that of many oth- er companies. Smaller companies that have chosen to self-insure for health care and those that have ther premiums determined by their own experience are at the greatest risk when AIDS stnkes. Let’s say you have 100 employees. You are told that if you self-insure, you can expect health-insurance claims of and home care are grounng in favor as humane alter- natives to costly hospr- tal care. $150,000 to $200,000 per year—or $1,500 to $2,000 per person—and that you’ll have cash-flow advantages. True enough, on average. The aver- age company with 500 employees or fewer spent $1,861 per employee on health care last year. But all it would take is one $150,000 claim to raise the self-insurer’s cost to a much higher range—$3,000 to $3,500 per worker. A simular situation would occur in a pure experience-rated poli- cy—premiums would jump to match the previous year’s costs. “AIDS may be a convenient way to explain to small employers why they shouldn’t want to be self-insured,” says Preparing For The Worst Nancy Jones, a vice president of Bos- ton-based benefit-consulting firm John- son & Higgins HealthGroup. She points out that many other medical needs these days can be just as expensive. Helping a premature baby to live can cost $250,000 and so can saving a se verely burned person. The benefit plans facing the greatest risk are those without any outside stop- loss coverage, says W. Brian Harrigan, executive vice president of Westport Management Services, a Westport, Conn., benefit and insurance product- development firm. In a larger self-insured company with expected health costs of $1 million to $1.25 million, management might want to “lay off anything over that to the insurance company,” says Harrigan. For a premium of $25,000 to $30,000 a year, the insurance company would be liable for all health claims over $1.25 million up to some limit, such as $3 million. How the policy deals with hospitaliza- tion and whether it allows for flexibility are also key points. That means having ar. insurance-company case-manage- ment team to review serious cases and consid*r alternative treatments with doctor and patient. The alternatives in an AIDS case are administering to the patient at home and, sometimes, in a hospice, a facility for the terminally ill. “TI am encouraging employers to con- tact insurance companies that do offer case management or do offer home care or hospice or both,” says Mauro Montoya, legal director for Washing- ton’s Whitman-Walker Clinic, a non- profit health organization that takes care of AIDS-infected individuals under a contract with the city. Adding a package of cost-contain- ment measures that includes case man- agement and alternatives to the hospi- tal ‘‘tends to lower your costs righ: off the bat,” says David Garratt, a vice For More Information AIDS, HIV Mortality and Life Insur- ance, by Michael J. Cowell and Walter H. Hoskins. Society of Actuaries, Au- gust, 1987. AIDS in the Workplace: Resource Ma- terial (Second Edition). The Bureau of National Affairs, Inc., BNA Customer Service Center, 9485 Key West Ave., Rockville, Md., 20850. president at the Washington office of Johnson & Higgins HealthGroup. Gar- ratt says immediate premium savings of 3 percent to 10 percent a year are often possible. Using hospices and home care, San Francisco-based Pacific Bell has achieved one of the lowest health-care costs per AIDS victim in the country— $35,000. Chevron Corporation, also headquar- tered in San Francisco, this year began paying 100 percent of hospice and home-nursing expenses for plan mem- bers who have been diagnosed as termi- nally ill. “By getting him out of a $500-a-day bed in a hospital and putting him in a home environment, I think you’re doing both the company and the employee a benefit,” says Dr. Robert Swencicki, medical director for Chevron. Both companies employ case-man- agement teams to go over potentially expensive medical treatment with the patient and the doctor, and work out alternatives, often going beyond the written limits in the health plan. For example, Pacific Bell’s health plan calls for no more than four hours a day of in-home nursing care. The case-management team might look at a particular AIDS-infected indi- vidual’s needs and say that if he could get more home nursing, he could avoid going back into the hospital, says Neal Austin. Austin is staff manager for health-care cost containment at Pacific Bell. ‘We'll go beyond what the plan will pay, because we’ll save money in the long run,” says Austin. The small-business owner, Austin says, should “look at case manage- ment. Every major insurance company offers it.” Lately, the small-business owner 1s finding that if he doesn’t ask for cost- containment measures, the insurance company will. Insurance companies typ- ee NationsBusiness Additional copies of this article are available. Send all orders or inquiries to: NATION'S BUSINESS REPRINTS 1615 H Street, NW Washington, D.C. 20062 (202) 463-5877 Copyright © 1987 by United States Chamber of Commerce. All rights reserved. This maternal may not be reproduced. VB Repnat Collection Copyright © Nation’s Business October 1987 ically are offering the business owner choice: cost containment or a higher premium. ecording to a new study by Worcester, Mass., actuary Mi- chael J. Cowell, AIDS-related deaths already covered by life insurance may well exceed 10 percent of the life insurance industry’s total claims by the mid 1990s. Cowell’s study, “AIDS, HIV Mortal- ity and Life Insurance,” was based on a conservative set of statistics from the Centers for Disease Control—that 1.5 million Americans may be infected with the virus, and that only 15 percent of them would get fully developed AIDS after five years. But recently, both the CDC and the U.S. Surgeon General are supporting the prevailing medical belief that closer to 100 percent of those infected with the virus will see their immune systems wrecked by the ailment and then die from infections they otherwise wouldn’t have caught. So, if anything, Cowell’s resulting figures for life insurance liability are probably low. The U.S. life insurance industry 7 ready has paid out several hundred m. lion dollars on AIDS-related claims. At the end of 1986, Cowell says, about $20 billion of individual and $15 billion of group life insurance in the United States had been written on the lives of AIDS-infected individuals. Cowell, an actuary at State Mutual Life Assurance Company of America, did not try to estimate the billions of dollars of AIDS-related claims that may result from the fortunate possibility that drugs and treatments now being developed may extend the lives of AIDS victims well beyond the current 2.1-year average. Says benefit consultant Nancy Jones: “Good news on AIDS treatment is go- ing to increase costs.” 8 ess Reprinted From Natton’s Business *%3° October 1987 8675NB TESTIMONY OF PETER W. BERTSCHMANN VICE PRESIDENT - HUMAN RESOURCES, NEW ENGLAND TELEPHONE BEFORE THE PRESIDENTIAL COMMISSION ON THE HIV EPIDEMIC MAY 10, 1988 New England Telephone had a rather public learning experience about AIDS in the workplace beginning in the spring of 1985. We did some things right and we made some mistakes. By sharing our story, we hope others can benefit from our experience. One of our installation and repair technicians, Paul Cronan, identified himself as having AIDS-Related Complex (ARC). One month later, this employee went out on illness disability. Our company was just beginning to explore the issue of creating an AIDS policy. Senior managers from Human Resources, Legal, Labor Relations, Medical and Public Relations had met to discuss a number of issues about AIDS, among them the medical facts, the legal implications, the union issues and the company's corporate culture. Within a month, the group had a policy recommendation that was accepted by the officers of the company. Our policy is: "AIDS is treated like any other illness contracted by an employee. BIOGRAPHTCAL DATA Name: Present Position: Education: Bell System Career: Other Affiliations: Peter W. Bertschmann Vice President-Human Resources New England Telephone Company University of Connecticut A.B. Political Science, 1956 Employed by New England Telephone as a Supervisory Assistant in the Sales Department in 1961, and held various Sales assignments in New Hampshire and Massachusetts for the next five years. Appointed District Plant Superintendent-Maine in 1966; held numerous Plant assignments in Maine, Vermont and Massachusetts. Appointed Assistant Vice President-Plant in 1974. In 1976, became New England Telephone's first Director of Corporate Planning. Elected Vice President on April 1, 1976. Had responsibility for the overall day-to-day operations throughout Massachusetts. Appointed Program Director, Bell Advanced Management Program, University of Illinois, Fall Session 1978. Appointed Vice President-Residence for New England Telephone in December 1978, Vice President-External Affairs in October 1981, and Vice President-Personnel in February 1982. (department name changed to Human Resources in January 1984.) Member, Executives Club, Boston Chamber of Commerce Member, Board of Governors, Massachusetts Safety Council Director, Better Business Bureau, Boston Director, Roxbury Community College Foundation Director, Massachusetts Amateur Sports Foundation Director, Blue Cross of Massachusetts, Inc. "Accordingly, if an employee is diagnosed as having AIDS, but is not disabled from working, the employee cah return to work. "Tf an employee has work limitations, the company will make reasonable accommodations." In September 1985, after an inquiry from Paul, the company notified him that he could return to work when his physician felt he was able. However, very shortly afterward, his diagnosis was changed from ARC to AIDS, and the employee did not request to return to work at that time. Paul chose to go public with his situation and with his unhappiness with our company, and in December of 1985, he sued New England Telephone for breach of privacy, employment discrimination and violation of his civil rights. He sought recovery for, among other things, emotional distress. After an out-of-court settlement in October of 1986, Paul Cronan returned to work. By terms of the settlement, he did not return to his original work location. Rather, he went back to a location where he had worked for a number of years in the past. Based on medical recommendations, he returned to work on a half-day basis. The employees's job as an installation technician required him, on occasion, to enter people's homes to do work. And although he returned to work half days, he wanted, and we wanted him, to assume his normal duties, as much as possible. The company gave Paul Cronan the full range of assignments it gave to other installation and repair technicians. Up to that point, the company had dealt with AIDS on the policy level, without fully understanding the workplace implementation issues. And we hadn't yet learned the value of company-sponsored education efforts. Because of the public nature of the case, we asked for and received permission from Paul to "condition" the workforce before his return to work. Local union leaders, management, and his co-workers were briefed on the situation, and provided with the facts on the disease. While this was a good first step, it was not enough. On Paul's second day back at work, 29 of his co-workers walked off the job. Although not unanticipated, we had a labor relations and a media relations crisis on our hands. We needed a strategy to make our policy become a reality, and we recognized we had to demonstrate understanding and compassion for all of the employees affected. Our objectives were to get our employees back to work, get out of the media limelight, and, to the extent possible, make sure that such an incident never happened again. we initiated a four-phase education program for about 1,000 employees in and around the area where Paul Cronan worked. The local management team was involved at every step of the process, as were our union representatives. The first day, we showed a videotape on AIDS in the workplace, produced by the San Francisco AIDS Foundation. The next day, two doctors (one selected by the union and one Paul Cronan's personal physician) visited the local workplace to answer estions employees had about AIDS and its transmission. Anxiety levels began to drop after this second Session As a next step, employees and their families were invited to an evening session at a local hotel. Again, doctors presented the facts about AIDS transmission and were available to answer questions. A number of spouses and even some teenage children attended. After that session, we felt comfortable that employees had had an ample opportunity to learn and understand the facts about AIDS and how it is and isn't transmitted. And 25 of the 29 employees had returned to work. 4 ( For any employees who were still afraid, we offered voluntary individual or group counseling sessions. We made a decision not to withhold pay from the employees who had walked off the job -- something that's not commonly our practice. By doing so we acknowledged our concern for all employees, and attempted to avoid punitive or confrontational actions. We learned several important things during these events. The first is never assume that employees are getting the message from other sources. Second, one opportunity to hear the facts isn't enough. Repetition is key. Third, employees'! fears and concerns must be taken seriously. Fourth, employees need to have a chance to have their questions answered. And finally, and perhaps most importantly, we learned that education takes care of 98 percent of the problems associated with AIDS in the workplace. Although we made it through our first episode of workplace AIDS, we realized we needed to put in place a long-term effort to educate employees. An educated employee, we learned, is our best defense against another incident. As a first step, we sent a brochure on AIDS and its transmission to our 27,000 employees at their homes, with a letter from our corporate medical director that explained the company policy on AIDS. The letter included a phone number employees could call for more information. Our medical department doctors have made themselves, and outside experts, available to talk to employee groups about the issue of AIDS in the workplace. Our major effort began about nine months ago when we asked area business leaders to join us in sharing their experiences about how the disease has affected their workplace. Last fall, that group became the New England Corporate Consortium for AIDS Education. In addition to New England Telephone, members include: Bank of Boston, Bank of New England, Cabot Corporation, daka Inc., Digital Equipment Corporation, Lotus Development Corporation, Polaroid and TEXTRON. The group agreed to fund production of a videotape about AIDS in the workplace and provide ancillary written materials, including a program planning guide and a manual for managers and supervisors. Golden Green Productions, which won an Emmy for its NOVA special "AIDS: Chapter One," is producing the tape, and George Moseley, on the staff of the Harvard University School of Public Health is writing the materials. Dr. Timothy Johnson, medical editor for ABC News, is our on-camera host. Throughout our efforts we have worked closely with representatives from Boston's AIDS Action Committee, the American Red Cross, the Massachusetts Department of Public Health and business associations. When nine major corporations band together on any issue, it makes a powerful statement. And we wanted to deliver a strong message to our employees, other businesses and to the community at large. That message clearly is that businesses need to take responsibility for educating their employees about AIDS. TESTIMONY OF PETER W. BERTSCHMANN VICE PRESIDENT - HUMAN RESOURCES, NEW ENGLAND TELEPHONE BEFORE THE PRESIDENTIAL COMMISSION ON THE HIV EPIDEMIC MAY 10, 1988 SUMMARY OF RECOMMENDATIONS o Set a clear policy on how an employee with AIDS will be treated. Communicate that policy to all employees. o Provide employees with educational materials on AIDS; educated employees are the best defense against AIDS incidents in the workplace. Never assume employees are getting the message from other sources. Repetition of facts is key to employee understanding. Educational material must acknowledge employees' fears and concerns. Employees must have a chance to have questions answered. Supervisors and managers must receive additional educational support to prepare them to handle an AIDS case in their workforce. SUMMARY OF RECOMMENDATIONS NEW ENGLAND TELEPHONE Page 2 o Work with other area businesses in producing educational material to: - Demonstrate to employees, the community and other businesses that business needs to take responsibility for educating employees. - Defray the cost of producing/obtaining educational materials. - Make educational materials available to other businesses for a nominal fee. o Maintain contact with area AIDS education experts such as local AIDS Action Committees, the American Red Cross and AIDS coordinators at various business associations. NEW ENGLAND CORPORATE CONSORTIUM FOR 0.0 Se aa EDUCATION PUBLIC RELATIONS CONTACT: FOR IMMEDIATE RELEASE April 11, 1988 Wendy Sinclair 9:00 a.m. New England Corporate Consortium for AIDS Education 185 Franklin Street Boston, MA 02110 TELEPHONE: (617) 743-4667 NEW ENGLAND BUSINESSES JOIN FIGHT AGAINST AIDS _- NINE MAJOR CORPORATIONS CREATE EDUCATIONAL PACKAGE TO BENEFIT WORKPLACE Nine major New England corporations announced today that they have formed a private partnership -- called the New England Corporate Consortium for AIDS Education -- to produce AIDS educational materials for the workplace. The Consortium members include New England Telephone, Bank of Boston Corporation, Polaroid Corporation, TEXTRON, Digital Equipment Corporation, Lotus Development Corporation, daka Inc., Cabot Corporation and Bank of New England Corporation. The package -- which includes a videotape and three manuals -- will be offered to businesses for a nominal fee. Production began in early March and is scheduled for completion in July. -more- Rank al Boston iakad Sow baathip foot etn dank ol Sew Fridland Ccrpearatian Loy ald patpeedie bd orgs tatters Pe dated edge iy ea Fabot Corporation Peats see deapetiye iC ete lea mAb Emmy Award-winning producers Thea Chalow and Betsy Anderson are producing the videotape, and Harvard University faculty member George B. Moseley III is writing the manuals. New England Telephone President and Chief Executive Officer Paul O'Brien said that the companies formed the Consortium when they began planning AIDS education programs for their own employees. "When nine major corporations band together, it can make for a very powerful presence,” O'Brien said. “That was our intent, “We wanted to deliver a strong message to our employees, other businesses and to the community at large, and the message is clear: businesses need to take responsibility for educating their employees about AIDS." Polaroid Corporation President and Chief Executive Officer I. MacAllister Booth also stressed the importance of education. “We all need to know the facts about AIDS," said Booth. “Workplace AIDS education can save lives through prevention, minimize fear and foster compassionate treatment for people with AIDS. "Most importantly," Booth added, "knowing the facts can help all sectors of our society work together to eradicate this terrible disease." . According to daka Inc. President and Chief Executive Officer Terry Vince, the Consortium also wanted to “defray the \ cost of materials for other businesses. -more=- "Some of the AIDS packages on the market are expensive and not all businesses can afford them. The small and not-for-profit organizations are especially vulnerable," Vince said, "The Consortium wanted to guarantee an affordable package, so we designed the videotape and manuals with royaity-free, nonexclusive rights in mind,” he added. "That kind of arrangement removes the obstacle of high cost.”: George B. Moseley III -- a faculty member in Harvard University's Department of Health Policy and Management at the School of Public Health -- is donating his services to the Consortium by writing the manuals. Moseley teaches executive health law seminars for colleges and universities across the country. His research and teaching focus on the legal and management aspects of healthcare in the workplace. Thea Chalow and Betsy Anderson of Golden Green Productions were contracted by the Consortium to write and produce the videotape. Co-producers of the Nova program AIDS: Chapter One, Chalow and Anderson won the National Emmy Award in 1985 for Outstanding Coverage of a Continuing News Story. They specialize in production and creative services with a focus on science, health and technology. Richard Tilkin, manager of creative services at New England Telephone, is the executive producer. -###H- PRESIDENTIAL COMMISSION ON THE HIV EPIDEMIC INDIANAPOLIS May 10, 1988 A.A. HERRMANN TESTIMONY JOHNSON & JOHNSON IS COMMITTED TO THE HEALTH AND SAFETY OF ITS EMPLOYEES AND THEIR FAMILY MEMBERS. [HAT COMMITMENT IS WRITTEN INTO OUR CREDO AND IS HIGHLY VISIBLE ALL AROUND US IN THE FACILITIES AND PROGRAMS OF LIVE FOR LIFE®. LIVE FOR LIFE 1S AN ACTIVE PARTNERSHIP OF HEALTH RELATED SERVICES -- ASSISTANCE, BENEFITS, MEDICAL, SAFETY AND WELLNESS. THIS IS A COORDINATED WAY OF PROVIDING OPPORTUNITIES FOR OUR EMPLOYEES TO BECOME THE HEALTHIEST IN THE WORLD AND TO MAXIMIZE THE HEALTH AND WELL BEING OF OUR EMPLOYEES AND THEIR FAMILIES ON A VOLUNTARY BASIS. THIS COMMITMENT CANNOT BE MET IN THE 1980’S UNLESS WE ARE WILLING TO JOIN THE EFFORT AGAINST AIDS. AIDS cuts across ALL SEGMENTS OF OUR SOCIETY. IT CAN BE DISRUPTIVE TO OUR FAMILIES, SCHOOLS, COMMUNITIES AND WORKPLACES. JOHNSON & JOHNSON OFFICES AND PLANTS ARE NOT ISOLATED FROM IT. IT HAS CAUSED EVERYONE TO RETHINK, AT A VERY FUNDAMENTAL LEVEL, OUR ATTITUDES WITH REGARD TO LIFE STYLE, BEHAVIOR AND THE APPROPRIATENESS OF THE WORKPLACE AS A SITE FOR EDUCATIONAL INTERVENTION, TO MEET THIS CHALLENGE, JOHNSON & JOHNSON HAS UNDERTAKEN A COMPREHENSIVE AIDS woRKPLACE CAMPAIGN WITH FIVE MAJOR COMPONENTS: 1. A Corporate AIDS Potrcy PosITION STATEMENT. 2. SpeciatL LIVE FOR LIFE AIDS Epucatrion Procram. 3. BeNneFIT PLAN CoVERAGE-EXPANSION. 4, BIOHAZARDS GUIDELINES. 5. =PuBLIc/CommMUNITY SUPPORT, WHERE APPROPRIATE: MAINTENANCE AND PROTECTION OF EMPLOYEE HEALTH IS A POLICY OF OUR CORPORATION. Our AIDS PoLicy PosiTION STATEMENT COMPLEMENTS THIS POLICY AND ADDRESSES RIGHTS TO EMPLOYMENT AND BENEFITS, CONFIDENTIALITY, TESTING, BIOHAZARDS GUIDELINES AND EDUCATION INITIATIVES. AIDS TESTING IS PERFORMED ONLY ON A VOLUNTARY BASIS. -2- Tue LIVE FOR LIFE EpucaTIon PROGRAM BEGAN WITH A SPECIAL TRAINING SESSION FOR ALL PERSONNEL MANAGERS, PHYSICIANS, NURSES, EMPLOYEE ASSISTANCE AND WELLNESS ADMINISTRATORS AT EACH OF OUR 72 OPERATING FACILITIES TO EDUCATE AND SENSITIZE THEM TO THE AIDS 1ssue. AWARENESS AND EDUCATION PROGRAMS ARE AVAILABLE FOR ALL EMPLOYEES. MANY OF THESE PROGRAMS ARE AVAILABLE FOR THEIR FAMILIES. OUR EMPLOYEE ASSISTANCE AND MEDICAL DEPARTMENTS PROVIDE CONFIDENTIAL COUNSELING. A VARIETY OF VIDEO TAPES AND BROCHURES HAVE BEEN DISTRIBUTED. THe H.B.0./SurGeon GENERAL Koop TAPE TITLED “AIDS: EVERYTHING YOU AND YOUR FAMILY NEEDS TO KNOW BUT WERE AFRAID TO ASK” AND THE C.D.C. BROCHURE TITLED “WHAT YOU SHOULD KNOW apouT AIDS” HAVE BEEN HIGHLIGHTED. LAST FALL THE NATIONAL AIDS AWARENESS TEST SPONSORED BY METROPOLITAN LIFE WAS PROMOTED THROUGH DESK DROPS TO EVERY EMPLOYEE IN THE TOP 25 VIEWING MARKET AREAS IN THE COUNTRY WHERE THE PROGRAM WAS OFFERED. “News FoR Lire,” THE LIVE FOR LIFE NewsLetter, DISTRIBUTED QUARTERLY TO EACH EMPLOYEE'S HOME, HAS INCLUDED ARTICLES ON AIDS. HEALTH CARE BENEFIT PLAN COVERAGE HAS BEEN EXPANDED TO INCLUDE VOLUNTARY AIDS TESTING AND LIQUID AUTOLOGOUS BLOOD FOR TRANSFUSIONS FOR EMPLOYEES AND FAMILY MEMBERS. -3- ORTHO DIAGNOSTIC SYSTEMS, ONE OF OUR COMPANIES, RECEIVED A SPECIAL RECOGNITION LETTER FROM SURGEON GENERAL Koop FOR SUPPORTING THE PRINTING AND DISTRIBUTION OF THE SURGEON GENERAL’S BROCHURE ON AIDS. WE PARTICIPATE AS A MEMBER OF THE NATIONAL LEADERSHIP COALITION ON AIDS, WHICH IS A WASHINGTON BASED GROUP THAT IS DEALING WITH POLICY AND PUBLIC ADMINISTRATION ISSUES. IN ADDITION, WE SUPPORT THE AIDS RESEARCH FOUNDATION AND WERE COSIGNATORIES OF THE AIDS TEN PRINCIPLES PROPOSED BY THE CITIZENS COMMISSION ON AIDS, Active AIDS RESEARCH IS UNDERWAY IN SEVERAL OF OUR COMPANIES PURSUING POSSIBLE APPROACHES TO TESTING, VACCINES AND PHARMACEUTICALS. JOHNSON & JOHNSON RECENTLY AWARDED A GRANT OF $500,000 over FIVE YEARS TO JOHNS HopKINS MEDICAL SCHOOL IN SUPPORT OF CONSTRUCTING SPECIAL RESEARCH LABORATORIES FOR THAT INSTITUTION'S AIDS RESEARCH ProGramM. AS YOU KNOW, THE ROBERT Woop JOHNSON FOUNDATION, ALTHOUGH ONLY INDIRECTLY ASSOCIATED WITH JOHNSON & JOHNSON, HAS SPENT $20 MILLION ON AIDS PROGRAMS MAKING IT THE LEADING SUPPORTER OF AIDS PROGRAMS AMONG ALL PHILANTHROPIES AND CORPORATE DONORS. IN SUMMARY, JOHNSON & JOHNSON’S COMMITMENT IN THE AREA OF AIDS IN THE WORKPLACE SPECIFICALLY AND ON A VERY BROAD SCALE GENERALLY HAS BEEN COMPREHENSIVE, SUSTAINED AND COMPLEMENTED ~l- BY APPROPRIATE POLICIES AND GUIDELINES. JoHNSON & JOHNSON’S LIVE FOR LIFE PROGRAM HAS PROVIDED A MARVELOUS VEHICLE 10 COMMUNICATE WITH EMPLOYEES AND THEIR FAMILY MEMBERS REGARDING AIDS. WE WOULD BE PLEASED TO ANSWER ANY QUESTIONS AND CONSIDER REQUESTS FOR MORE INFORMATION REGARDING THESE PROGRAMS. PRESIDENTIAL COMMISSION ON AIDS WORKSHOP HEARING - INDIANAPOLIS, INDIANA MAY 10, 1988 SUBJECT: Workplace Policy Development - Amway Corporation Il. Panelist - Dwight W. Sawyer Vice President - Human Resources DEVELOPMENT - AMWAY'S LIFE THREATENING ILLNESS POLICY With the advent of AIDS growing impact on the population in general, and specifically the work force, Amway elected to develop a policy around "Life Threatening Illnesses", rather than just on the subject of AIDS. It was felt that employees with any type of life threatening i]Iness should be treated in a similar manner as it pertains t9 corporate policies and procedures. To develop the policy, we reviewed available material on what other companies have done. From such material and general publications on the subject, we designed a policy which was felt to be fair to all employees and consistent with Amway's philosophy. Communications Que to the in-born fear of the unknown by the populace in general, it was felt that the major way of educating employees of all levels on the subject of a life threatening illness, specifically emphasizing AIDS, was through communications. A. Meetings 1. Employee Meetings Amway is in a unique position since we have a 700 seat auditorium and conduct monthly employee meetings covering all three shifts. In early 1987 we decided to do a continuing information program on the subject of AIDS starting in the Employee Meetings with presentations and updates by the President of the Corporation, Rich DeVos. We followed that by showing a video presentation entitled "AIDS Alert". We continue to give updates on the subject in these meetings. Management Meeting Early this year after developing our Life Threatening Illness Policy, a meeting was held with all management personnel in which the Life Threatening Illness Policy was reviewed (copy provided). In addition, we had a presentation Jy Or. Richard Tooker who is currently the Chief Medical Officer of Kalamazoo County and is recognized in Western Michigan as a very knowledgeable person on the subject of AIDS. | This meeting was followed by a complete Employee Méeting devoted to the subject of the Life Threatening ITiness’ Policy, Tne meeting also included a presentation by Dr. Tooker similar to that presented to the management. Library Reference Material a. To further supplement members of management's kndwledge on the subject, the booklet "What a Manager Should Know About AIDS in the Work Place" was distributed to them (copy provided). | We also established jn our corporate library videos, books, and pamphlets which are available to all employees for gaining more information on the subject (list provided). Ill. IV. PURPOSE OF LIFE THREATENING ILLNESS POLICY A. Recognition As stated earlier, one of our major purposes was not to single out AIDS, but to include it as one of many life threatening illnesses such as cancer, hepatitis B, multiple sclerosis, heart disease, etc. Needs and Wants of Employees We also know that in order to establish a policy that could be accepted by all employees, we would have to answer the majority of their needs and wants. Work Treatment The policy was felt to also need the establishment of fair and equitable work treatment for employees with jllness as well as other employees. Therefore, it would have to contain guidelines on employees meeting acceptable performance standards along with action for those who feel threatened. Precautions Furthermore, we felt the policy had to reserve the right to have employees examined if a safety or health problem might exist. DEALING WITH LIFE THREATENING ILLNESS A, POLICY - To accomplish the above noted points of the purpose, we designed the policy. 1. Information - One of the first areas of development was information. 2. Who To Contact - This point was established as being important so that employees could gain more information, and know directly who to contact for this information. What_Is Available - We next provided an opportunity for them to understand the educational material that was available for better understanding of the subject. This would include, of course, material in the Corporate Library. Referrals - This becomes a very important point since psychologically many employees need help in any one of the life threatening illness situations, which at times can be better provided through outside agencies. One of our major referrals is through an Employee Assistance Program wherein the employee can be referred without the corporation having any direct contact, thus maintaining confidentiality. Benefits - Provide the employees a contact point in our Benefits Department to discuss the health leave coverage they would receive, 3. REASONABLE ACCOMMODATIONS l. Employees - We feel employees have to know that they would have the opportunity for the corporation to make reasonable work accommodation for them within the confines of availability and business needs. Transfers - We included in the policy provisions for employees with the illness, the opportunity to transfer into other positions if they requested. Other Employees - We recognize that other employees may feel threatened and, therefore, have established an opportunity for them to seek transfers, however, in the normal manner of Signing on to open vacancies. co * 4. Refusal to Work - Those employees who might feel threatened, who would walk off the job and refuse to work, simply would not be paid and there are provisions for corrective action to be taken as well. SENSITIVITY - THERAPEUTIC IMPORTANCE - We also recognized that any employee may contract life threatening illness. We further recognize that sometimes their job becomes one of the most critically important thing in their lives during the period of their knowledge of having the illness. We, therefore, feel it is very important to provide them the opportunity to work as long as they are able to perform duties in a reasonable manner. CONFIDENTIALITY - NEED-KNOW COMMITTEE - Rather than have a procedure for every occurence of a life threatneing illness, Amway believed a small committee could review the status of each situation and provide assistance while maintaining confidentiality. Therefore, it established a "Need to Know Committee" consisting of a representative from the Medical, Legal, and Human Resources Departments who are the only ones in the company with the information concerning the illness of the employee, unless the employee has disseminated the information on his/her own. This committee is responsible for making decisions if others are in a need-know category to assure the safety of the employees, customers, and Amway products. The committee is also in a position to act in an advisory capacity for the il] employee, explaining what is available in the way of benefit coverage, agency referrals, reasonable work accommodations, etc., as required. VI. Vif. A. FATRNESS The company's major concern nas been developing a policy that is fair to the employee with the illness as well as fellow employees in such a way that it assures safety and protection of each individual as well as our products and customers. RECOMMENDATIONS A. C. A, Policy - Company snould not single out AIDS as a separate policy, but include it as one of the life threatening i]1nesses. Cominunications - Company should provide employees information through meetings (if possible), literature, bulletin board material, library data, etc., on a continuing basis to keep them informed and minimize misunderstanding about such an illness. Change - We feel that it is important as a caring company to establish a policy early to protect all of our employees through sound procedures and communications. However, a company must also recognize that changes may be necessary in a policy as information changes. CONCLUSION We appreciate the opportunity to present to the Presidential Commission Amway's approach to the subject on AIDS as one of the Life Threatening I]lInesses that can occur in the workplace i. Mwy, snoe WITHOUT GOING SHOPCING DISTRIBUTION PRINTED INUSA Bulletin No. STANDARD PRACTICE BULLETIN Sheet No. pero Date 01/15/88 SUBJECT: SUBJECT: LIFE-THREATENING ILLNESSES POLICY (New SPB) PURPOSE Amway recognizes that employees with life-threatening illnesses including, but not limited to, cancer, multiple sclerosis, hepatitis, heart disease and AIDS may wish to continue to engage in as many of their normal pursuits as their condition allows, including work. As long as these employees are able to meet acceptable performance standards, and medical evidence indicates their conditions are not a threat to themselves or others, management should be sensitive to their conditions and ensure they are treated consistently with other employees. At the same time, Amway seeks to provide a safe work environment for all employees and customers. Therefore, precautions should be taken to ensure that an employee's condition does not present a health and/or safety threat to other employees, customers or Amway products. HOW TO DEAL WITH EMPLOYEES WITH LIFE-THREATENINTG ILLNESS A. An employee's health condition is personal and confidential. Regardless of the problem, the health condition should never be discussed with an employee's co-workers whether on or off the job site. Strong precautions should be taken to protect information regarding an employee's health condition. B. Management should contact the Administrator of Safety, Health & Disability (X-6769)/Head Occupational Nurse (X-6174) if they believe employees need information about terminal illness, or a specific life-threatening illness, or if they need further guidance in managing a situation that involves an employee with a life-threatening illness. C. Management should contact the Administrator of Safety, Health & Disability/Head Occupational Nurse to determine if a statement should be obtained from the employee's attending physician that continued presence at work will pose no threat to the employee, co-workers, customers or products. Amway reserves the right to require an examination by a medical doctor appointed by the Company. D. When warranted, reasonable accommodations should be made for employees with life-threatening illnesses consistent with the business needs of the unit. A reasonable attempt should be made to transfer employees with life-threatening illnesses who request a transfer. 4/80 0A7898 0-470 SPB 437 Page 2 1/15/88 III. IV. ~-£, Management should be sensitive and responsive to co-worker's concerns, and emphasize employee education. Employees who feel threatened by a co-worker's life-threatening illness should not be given special consideration beyond normal transfer requests. Employees who leave a job site or refuse to work with an employee having a life-threatening illness will not be paid for their time away from work. Disciplinary steps may be taken. F. Management should be sensitive to the fact that continued employment for an employee with a life-threatening illness may sometimes be therapeutically important in the remission or recovery process, or may help prolong that employee's life. G. Management should encourage employees to seek assistance from established community support groups for medical treatment and counseling services (Employee Assistance Center - 458-8540). INFORMATION RESOURCES FOR LIFE-THREATENING ILLNESSES A. Management and employee education materials on Jlife- threatening illnesses can be obtained from the Administrator of Safety, Health & Disability or the Head Occupational Nurse. B. Referral to agencies and organizations that offer supportive services for life-threatening illnesses can be obtained from the Administrator of Safety, Health & Disability/Head Occupational Nurse/Human Resources Administrators. C. Benefit consultations to assist employees in effectively managing health leaves and other benefits can be obtained through Benefits Supervisor (X-5095). HOW CONFIDENTIAL MEDICAL INFORMATION WILL BE HANDLED A "Need-To-Know" Committee, consisting of medical, legal and employee relations representatives will be established to review the status of employees with life-threatening illnesses. Based on the illness and how it can be communicated, a decision will be made to inform others who need to know the information to assure the safety of employees, customers and Amway products. ~_ PRESIDENTIAL COMMISSION ON HIV EPIDEMIC TESTIMONY FOR WORKPLACE POLICIES, DEVELOPMENT, AND IMPLEMENTATION, MAY 10,1988 The Private Section Response Panel THE RED CROSS AIDS PREVENTION PROGRAM Sigrid G. Deeds, Dr.PH, AIDS Advisor Carole Kauffman, RN, MPH, Manager AIDS Education Program The fundamental principals of the Red Cross —- humanity, impartiality, neutrality, independence, voluntary service, unity and universality - are particularly meaningful to the American Red Cross! role in AIDS education and have contributed to the successful implementation of programs nation-wide. The American Red Cross began educating active and potential blood donors about the risk of AIDS in 1983 in order to prevent donations by infected persons. To meet the growing challenge of the AIDS epidemic in October 1985, the Red Cross made AIDS education a critical objective for its field units nationally and overseas. In taking this decisive action, the Red Cross made a long-term commitment to mobilize its network of thousands of chapters, blood regions, and military service units to conduct AIDS educational outreach programs. The goals of the Red Cross AIDS Public Education program are to slow the spread of the AIDS virus by providing reliable, factual information about the risk of contracting AIDS, to demystify the disease and reduce unwarranted fears surrounding AIDS. In partnership with other public and private agencies, the Red Cross has developed and distributed a variety of AIDS public 1 education materials reaching an estimated 50 million plus Americans. In addition, the Red Cross chapters and blood regions have conducted a vast range of community education and service programs on AIDS The major emphasis in the first years of the Red Cross AIDS education Program has been on nation--wide information and mass media. As public interest and awareness have risen, it is clear that targeting more defined audiences with more Specific messages is required in order to achieve the goals of AIDS education. We therefore, have set a priority for youth, minority groups, and workplace programs. Providing creditable information on the AIDS epidemic is a logical extension of the Red Cross! relationships with business, industry, and labor, as well as a logical expension of its provision of health and safety courses to workers in their places of employment. Members of the business and industry community have Supported the American Red Cross throughout its history by providing leadership at the board level, and the fund raising level, as well as in responding to emergencies and disasters. We also have a continuing interactive relationship with organized labor which has played a key role in Red Cross blood donor recruitment drives, fund raising and membership campaigns, and in the provision of services in the community. The health and safety programs of the Red Cross, particularly First Aid and CPR, have been delivered in workplace settings since their inception. In 1987, 4 million certificates were issued for training in these two courses alone, and it is estimated that 25% of them were delivered at worksites. Helping employers cope with the demands of the AIDS epidemic is a natural extension of these interrelationships. Among those who have met the CDC case definition for AIDS and have been reported, 21% are estimated to be in age group 20 to 29 years and 67% in age group 30 to 49 (CDC AIDS Weekly Surveillance Report, Feb. 1988). The majority of persons at these ages are gainfully employed, therefore, the workplace is an obvious location for education for the prevention of AIDS. The need for workplace education is highlighted by a recent national probability sample of 2000 American households in which the nature of workers’ beliefs and attitudes about AIDS was explored by telephone interview. A little over one third of the workers reported being fearful of using the same bathroom, eating in the cafeteria or sharing equipment with a person with AIDS. Thirty-five percent stated that they did not believe the reported evidence that AIDS can be transmitted by sexual contact or blood contamination. However, sympathy was evident in the positive response by 75 percent that they would favor making special work arrangements for the person with AIDS as health deteriorated, and 81 percent said they would be willing to help the individual perform aspects of the job that were difficult for the person with AIDS. Of the sample, 86 percent had no personal experience with anyone having the disease or dying from AIDS. The percentages with no experience were higher among blue collar workers and persons with some high school education. (D.M. Harold, College of Management, Georgia Tech, Atlanta GA, Feb. 88) Chapters have provided AIDS workshops, seminars, and conferences to corporations, small businesses, health care providers, insurance industry representatives, government employees and have established a statewide program to train emergency workers in the state of California. The American Red Cross AIDS Prevention Program in the Workplace was based on the above-mentioned experiences and the pioneer work and experience of the Los Angeles Red Cross chapter. After the training package was tested in the field, the program was made available to the field in January of this year. Called "Working Beyond Fear", the purpose of the program is to provide factual information to employees about the high-risk behaviors related to AIDS so that they can take appropriate action to avoid exposure to the virus. It is also intended to allay fear about working with persons who are HIV positive. The chapter AIDS contact person works with the employer's representative to customize the presentation to the specific business. Because there is great variability in workplace settings and organizational cultures, in education and interest and in levels of experience with AIDS, the format is designed to maximize flexibility while retaining a standardized core of accurate information to insure quality. The recommended format is a two-hour workshop conducted by a trained Red Cross facilitator which includes a thirty minute video "Beyond Fear" and several video case studies designed to ereate discussion around the issues of relationships and contacts with co-workers infected with HIV, confidentiality concerns, and management responses to worker concerns. Access to community resources for additional help and information is stressed. It is possible to provide shorter information sessions, however, this results in less dialogue with the participants and less overall impact. Red Cross chapters provide the training sessions to employees at various levels throughout the organization; they have also trained employees so that organizations can carry out their own training. The fees that are set by the chapters recover the costs that are incurred in providing the materials and the manpower. There is variability across the country but an average charge is $150 for a workshop for approximately thirty participants. Examples of the scope of chapter workplace AIDS activity are the programs that were conducted by the Atlanta chapter staff and 202 volunteers. In one year half of the 333 programs were delivered to businesses and industries including corporations, utilities, a motel chain and federal workers. The Westchester County chapter finds more demand by middle sized companies such as manufacturers and nursing homes noting that large scale corporations in their region utilize their own medical departments and training capacity to provide AIDS training internally. Los Angeles chapter has found the demand for workplace education escalating in the last three months. Their requests have increased to approximately 25 different industry requests per month, attributable to the changing and growing 5 caseloads of persons with AIDS and the consequent personal encounter experiences of employers and employees. Preliminary results obtained from 124 employees participating in a pilot test of the American Red Cross AIDS Workplace Education Program suggest that the program is successful in increasing employee knowledge about AIDS, reducing employee fears regarding HIV expossure through casual workplace contacts, improving respect for the confidentiality of medical records and for allowing a person to work as long as possible, as well as improving overall employee confidence in handling an AIDS related situation in the workplace. In addition, the pilot data suggest that the program may stimulate discussions about AIDS outside of work with friends, family members and spouses. BARRIERS Barriers that are noted in chapter experience: AIDS is not given a high priority by many companies. Providing company time for education is costly and the returns may, at the time, be indirect. Companies with hourly wage employees are particularly reluctant to release employees. Utilizing employee time such as 45 minute lunch break is not sufficient time to provide an effective intervention. One Red Cross AIDS manager notes the size of the company does not matter. They have served workplaces ranging from 10 to 27,000 employees and note that the attititude of the senior management is the critical factor. RECOMMENDATIONS Lessons that have been learned from our recent experience as well as from previous health promotion efforts in the workplace are first that education that leads to action and behavior change requires interaction, clarification, and discussion. A one-way delivery of information may trigger the very few persons who are already convinced. In addition: l. The time to provide AIDS education to the workforce is now, before a crises over an infected employee or close relation occurs. The program must be tailored to the specific organization since circumstances vary widely within workplaces as well as within the community contex. A two-hour session is minimum to achieve effective learning outcomes. Voluntary attendance can result in attendance only by those already most knowledgeable about AIDS or those at least risk. Mandating attendance for all employees results in attendance by those who may be at highest risk, particularly IV drug abusers, promiscuous persons, and bisexual men as well as attendance by individuals who may have unreasonable fear and bias. Providing education on company time conveys the message about the importance of the AIDS topic. ‘It hakes education more effective in that employees may socialize through lunch or break time and not give complete attention to the presentation. One solution is to combine some employee time with employer time so that the time cost is mutually shared. An employee or department designated as the locus for on- going information and up-dates on AIDS, who can serve as a referral to community resources, is an effective follow on providing reinforcement for the educational intervention. New information and understanding of AIDS requires continuous attention and individual circumstances will change and personnel will need additional information and services. We commend The Ten Principles for the Workplace endorsed by the National Leadership Coalition on AIDS, calling for education before an AIDS incident occurs, for sensitive, accurate, and up- to-date education, simple, clear and unambiguous language for policies, and specific ongoing education and training for high- risk occupational settings. These support effective educational principles. BENEFITS What are the potential benefits of AIDS education? The impacts of education is these areas of private and sensitive beliefs are complex and deep-rooted. The variables influencing change are many and deeply rooted in our society. Nevertheless we can anticipate some measurable effect of our education. One general and immediate benefit that is noted by one chapter in their’ follow-ups with companys in a high prevalence region is an improved sense of morale. The employees express the feeling that’ management really cares about their welfare. Conversation about AIDS leads to more openness on other EAP issues that influence productivity and absenteeism such as drug and alcohol abuse and family relations. The more that workers understand about the characteristics of the disease, its transmission and patterns, the more they understand the science that provides the biomedical background; the more realistic their perceptions about their own individual risks will be. They can accept that high risk behavior is not the monopoly of unknown others but is an every day option for many in the workforce. Attitudes and understanding about sexual behavior and drug use, along with perceptions of peer and community attitudes influence decisions on abstinence, monogamy, safe sex, and avoidance of substance abuse. These understandings and changes come about through internalizing information, reacting to it, discussing and refining their individual understandings. Along with behavioral intention interpersonal skills to resist peer pressure and group support and reinforcement may be required which require far more intensive educational experiences that can be provided in this introductory course. In addition to avoiding high risk behavior individually, this educational process can lead to an understanding of the non- contagious aspect of the disease and compasssionate concern for those who are HIV positive. This is the basis for avoiding worksite crises and panic. Thus, the immediate impact of education will be changes in knowledge levels and shifts in attitude that predispose persons to alter risk behavior or maintain current safe behavior. A major influence on achieving behavioral adaptation through education is environmental. The attitudes of nearby persons, the culture of the workplace, the community and national climate reward, support, and reinforce the individual. The caring and knowledgeable community according to our Surgeon General is required to deal expeditiously and humanely with the AIDS epidemic. In addition to a high level of knowledge about the characteristics of HIV and its transmission, such a community has an attitude of acceptance of the community problem as a problem of all; avoids stigmatization; engages in reasoned dialogue to achieve a balance in terms of civil liberties versus control and protection; cooperates in planning and allocating resources to meet the needs of those already infected and sick as well as the needs for continuing education. Employees are not only workers but are also family members and members of communities. They volunteer for their churches, on school boards, as members of service organizations and social groups. They give blood. Thus, the AIDS education provided and the atmosphere created in each place of employment extends far beyond the issues of the workplace in a ripple effect. Just as employees represent other relationships and shape community norms and response, so do the employers in their roles as community leaders, opinion-makers, influencers of legislation, resource allocators and philanthropists. The costs of initiating workplace education include both the costs of providing the service, which we have previously indicated with the cost of each employees time and the planning and follow-up time of the assigned personnel. This cost must be balanced against the incalculable costs of the loss of 10 productivity, work stoppages, adversarial relationships between management and employees and the larger community which will eccur if employees are left to their own unsystematic ways of gathering information and opinions about this unprecedented epidemic. The long-term costs of prevention and education should also be considered and compared to the costs of one case of AIDS. The study by Scitovsky and Rice estimated the Hospital Costs Alone For One PWA at $60,000 to $75,000 based on 1984 prices. The American Red Cross as a humanitarian agency with the mission of responding to emergencies has a committment to continue providing prevention programs and services to aid business and industry cope with the AIDS epidemic. 11 3 American Red Cross National Headquarters Washington, DC 20006 AIDS EDUCATION FOR THE WORKPLACE A NEW COURSE FROM THE AMERICAN RED CROSS WORKING BEYOND FEAR WORKING BEYOND FEAR is designed to actively engage your workforce in AIDS education by providing the facts concerning AIDS. Your employees will have an opportunity to apply this information to actual workplace situations and life styles as protrayed in three brief simulated video case studies. YOUR EMPLOYEES WILL RECEIVE: Current, reliable, non-sensationalized information about AIDS. Instruction on how the virus is and is not transmitted, and how to protect themselves from possible infection. Appreciation for the present and future impact of the disease in the United States, your local community, your company, and the individual. An opportunity to strategize in a non-threatening setting their response to an AIDS-related event at work. YOUR COMPANY WILL BENEFIT THROUGH THE DEVELOPMENT OF EMPLOYEES TRAINED TO RESPOND TO THE AIDS EPIDEMIC ON THE BASIS OF INFORMATION RATHER THAN UNWARRANTED FEAR. COURSE INFORMATION: * One to two hours of video presentations and guided discussion customized to your setting. Presentation by Red Cross trained facilitators. Designed for groups of up to 30 employees. For more information contact your local Red Cross chapter, or write. AIDS EDUCATION PROGRAM AMERICAN RED CROSS NATIONAL HEADQUARTERS WASHINGTON, D. C. 20006 HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page [1] of [6] OBSTACLES TO PROGRESS LACK OF DATA ON EDUCATIONAL EFFECTIVENESS. Data are required in order to improve educationa] programs for AIDS and expend scarce resources in the most effective way. RECOMMENDATIONS Support of the federal government and foundations to fund research in health education and behavioral science for AIDS. Cureently, data on effectiveness, "what messages" to "what groups" "in what order" for "what impact are virtually non-existent. In order to support cost-effective decision making by business and industry, data are required. Estimated Cost: $1.5 to 2 Million for one Based Upon: Longitudinal studies of health education interventions of suf- ficient intensity and sample size to be measurable five year study Carole Kauffman, R.N., M.P.H. AIDS Manager Sigrid G. Deeds, Dr.P.H., Advisor rz. ‘ LG Z Name Ss American Red Cross iqnature May 6, 1988 Date HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page [2] of [6] OBSTACLES TO PROGRESS DOLLAR COSTS OF PROVIDING AIDS EDUCATION IN SMALL BUSINESSES. Priorities of survival and cash flow in many smal] businesses poses a significant barrier to reaching employees. Many of these employees may also lack health and insurance benefits RECOMMENDATIONS Study and experimentation is recommended for creative financing of AIDS programs in the workplace such as subsidies, tax credits and foundation funding to overcome the barrier of costs of employee time for education, particularly for small business Estimated Cost: jo qata Based Upon: Carole Kauffman, R.N., M.P.H. AIDS Manager Sigrid G. Deeds, Dr.P.H., Advisor rE. , LG. ol S Name American Red Cross ignature May 6, 1988 Date HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page [3] of (6) OBSTACLES TO PROGRESS NEED FOR INNOVATIVE WAYS TO PROVIDE AIDS EDUCATION TO LEARNERS WHO ARE NOT AMENABLE TO STANDARD METHODS OF EDUCATION--particularly printed materials. Language and reading barriers along with attitudinal mindsets against print and group education make reaching groups with high risk behaviors difficult. RECOMMENDATIONS Research on effective learning technologies including computer assisted learning, games, visual and aural teaching is recommended. Experimentation with methods to reach low-literacy populations is critical. Demonstration and evaluation projects in AIDS education and prevention of sufficient length and funding to make impacts on risk behaviors, particularly substance abuse, are recommended to the federal government and foundations.’ Estimated Cost: jot available Based Upon: Carole Kauffman, R.N., M.P.H. AIDS Manager Sigrid G. Deeds, Dr.P.H., Advisor te Z LNG él, Name American Red Cross Signature May 6, 1988 date HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page {4] of g] OBSTACLES TO PROGRESS senshi LO PRO STANDARDIZED ITEMS ON KNOWLEDGE, ATTITUDE, AND BEHAVIOR ARE NOT AVAILABLE FROM PUBLIC OPINION POLLS. Significant variation between public opinion surveys makes monitoring of trends and changes over time in public changes in knowledge, attitudes and behavior unavailable. Opinion polls are invaluable sources of information in massive campaigns. RECOMMENDATIONS More precise items for assessing progress in national, community and business & industry education to measure changes in public opinion are needed. A Standardized core of knowledge, attitude and behaviorritems to be created by a consensus of public opinion pollsters is recommended for periodic inclusion in national polls. Estimated Costs: Based Upon: The American Red Cross AIDS Information Monitor: A Summary of National Public Opinion Surveys on AIDS: 1983 to 1986. S. Blake, E. Arkin , 1988 (in press) Carole Kauffman, R.N., M.P.H. AIDS Manager - Sigrid G. Deeds, Dr.P.H., Advisor Beet AFG. L, Name American Red Cross Signature May 6, 1988 Date HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page (5] of ) OBSTACLES TO PROGRESS EMPLOYEE AIDS EDUCATION AND POLICY MODELS FROM THE PUBLIC SECTOR WHICH CAN BE EMULATED BY THE PRIVATE SECTOR. The recent Office of Personnel Management policy/#8 AIDS a commendable example of public sector leadership. Absence of employer policies related to AIDS which include provisions for AIDS education are a barrier to progress RECOMMENDATIONS _ State and local government agencies as well as federal agencies concerned with the AIDS epidemic are themselves, employers of large numbers of personnel who need to provide basic AIDS education. We recommend that public servent model and reflect the best examples, serving as exemplars for the private industries and the non-profit sector. Estimated Cost: Based Upon: AIDS "Corporate American Responds" Fortune Magazine & Alistate Insurance national survey of U.S. companies Carole Kauffman, R.N., M.P.H. AIDS Manager Sigrid G. Deeds, Dr.P.H., Advisor treert AAG. sh Name American Red Cross Signature | May 6, 1988 Jate HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page [6] of [ 6] OBSTACLES TO PROGRESS Lack of operational data and criteria for effectiveness of AIDS workplace Programs. AIDS education for the workforce represents a significant investment for employers because of the time requirements.’ Health education expertese is less available in business and industry than expertese in other areas of AIDS problem-solving --yet education is our only prevention weapon for the epidemic - RECOMMENDATIONS A panel of health education experts representing public health, workplace health promotion, substance abuse prevention experience be assembled by the Presidential Commission to promulgate educational principles and criteria for quality AIDS education programs for the workplace. See attached Estimated Cost: Based Upon: Panel of 12 times 3 meetings American Red Cross testimony- approximately $10,000 Carole Kauffman, R.N., M.P.H. AIDS Manager Sigrid G. Deeds, Dr.P.H., Advisor a? ‘ ANd. Z, Name Signature American Red Cross May 6, 1988 Date RECOMMENDATIONS ON EFFECTIVE WORKPLACE EDUCATIONAL PROGRAMS AMERICAN RED CROSS ‘Sigrid G. Deeds, Dr.P.H. RECOMMENDATIONS Lessons that have been learned from our recent experience as well as from previous health promotion efforts in the workplace are first that education that leads to action and behavior change reqiires interaction, clarification, and discussion. A one-way delivery of information may trigger the very few persons who are already convinced. In addition: l. The time to provide AIDS education to the workforce is now, before a crises over an infected employee or close relation occurs. - 2. The program must be tailored to the specific organization since circumstances vary widely within workplaces as well as within the community contex,. 3. A two-hour session is minimum to achieve effective learning outcomes. 4. Voluntary attendance can result in attendance only by those already most knowledgeable about AIDS or those at least risk. Mandating attendance for all employees results in attendance by those who may be at highest risk, particularly IV drug abusers, promiscuous persons, and bisexual men as well as attendance by individuals who may have unreasonable fear and bias. | 5. Providing education on company time conveys the message about the importance of the AIDS topic. It makes education more effective in that employees may socialize through lunch or break time and not give complete attention to the presentation. One solution is to combine some employee time with employer time so that the time cost is mutually shared. 6. An employee or department designated as the locus for on- going information and up-dates on AIDS, who can serve as a referral to community resources, is an effective follow on providing reinforcement for the educational intervention. New information and understanding of AIDS requires continuous attention and individual circumstances will change and personnel will need additional information and services. We commend The Ten Principles for the Workplace endorsed by the National Leadership Coalition on AIDS, calling for education before an AIDS incident occurs, for sensitive, accurate, and up- to-date education, simple, clear and unambiguous language for policies, and specific ongoing education and training for high- risk occupational settings. These support effective educational principles. ORAL TESTIMONY OF HENRY C. RYDER BEFORE THE PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC Indianapolis, Indiana May 10, 1988 I shall try not to be repetitive of what I have included in my pre-submitted written testimony, except to call attention, as a way of summary, to the five guidelines for employers found at Tab 10 of my written testimony. They are: Employers should deal with employees who are AIDS victims the same as they would with employees with other serious or life-threatening illnesses. Employers should develop and adopt a written policy on dealing with AIDS in the workplace. They should then exhibit a strong commitment to the policy and train management and supervisors regirding the policy. Employers should provide employees with sensitive, accurate and up-to-date education about risk reduction in their personal lives. To prevent work disruption and rejection by co-workers of an employee with AIDS or HIV infection, employers should undertake education for all employees before such an incident occurs and as needed thereafter. In special occupational settings, such as health care where workers may be exposed to blood or blood products, employers should and, in some cases such as Indiana, must provide specific ongoing education and training, as well as the necessary equipment to reinforce appropriate infection control procedures and insure that they are implemented. Employers must protect the confidentiality of all medical records of employees who are AIDS victims. Except in unusual circumstances where the occupational setting requires the employee to handle blood or body fluids, employer should not screen current employees or job applicants for AIDS. This guideline is directed towards routine across-the-board employee screening. These five guidelines or variations thereof are what we are advising employers, both directly in the lawyer-client relationship, and in seminars which are proliferating throughout the country. Aids in the workplace is the hottest of the hot issues in employment law today. A bibliography this week on books, pamphlets, videos and educational materials is incomplete next week. Policies, the samples of which are found at Tab ll, are being urged upon employers. "Adopt them." "Commit to them," “Educate your work force." That is what we are preaching. What I am going to recommend now to this Commission is not what we are telling employers. The recommendation will be controversial, for it would mean a change in the law as it has been interpreted to date. Nevertheless, it needs to be made, it needs to be debated, and the underlying problem needs to be addressed by this Presidential Commission. My recommendation is this: That the Presidential Commission recommend the adoption of legislation to permit pre-employment testing for the AIDS virus and to exempt an employer from liability if the employer refuses to hire because of a positive AIDS test. Now let me explain this recommendation and justify it before I get hit with allegations of being unfair, discriminatory against the AIDS victim, and lacking in compassion. First, it is not a recommendation that would alter any legislation that protects an existing employee who either is or becomes an AIDS victim (and I use that term in the broadest sense, including a person who has tested positively for having the HIV). The recommendation applies only to applicants for empl ent. Secondly, if the employer is to be saddled with the cost of insuring existing employees who have or contract the disease (a cost for which estimates range from $75,000 to $150,000 per AIDS victim), not including lost production time from AIPS victims who contract and miss work because of opportunistic illnesses, is it fair to require that employer to hire persons as employees because they are infected with the AIDS virus? Doesn't the fulcrum of fairness tip the scales the other way when it comes to the employer's obligation to hire applicants for employment? The issue is one of cost. Should the employer bear the cost of paying increasing insurance premiums and lost days of production for non-employees who are AIDS victims and who seek employment? For many marginally profitable employers and small businesses, the answer to that question, if "Yes", will spell bankruptcy or closing. And who benefits from that result? I am suggesting, by this recommendation, that the Presidential Commission on the HIV Epidemic come up with some alternative recommendation for the unemployed AIDS victim rather than tell the employer, as the law has been interpreted to date: “It is your responsibility not to discriminate against the handicapped AIDS victim who applies for employment." All of us, not just the employers and not just the AIDS victims Should bear the cost of this epidemic until the cure or adequate defense to AIDS is discovered. I rest my case. Henry C. Ryder BARNES & THORNBURG 1313 Merchants Bank Building li South Meridian Street Indianapolis, IN 46204 (317) 638-1313 PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC AIDS I HE WORKPLACE Workplace Policies: Development and Implementation Indianapolis, Indiana May 10, 1988 Henry C. Ryder Robert K. Bellamy BARNES & THORNBURG 1313 Merchants Bank Building 11 South Meridian Street Indianapolis, IN 46204 317/638-1313 II. IIt. IV. TABLE OF NTENTS INTRODUCTION. ..ccscceeveccccvecseveecsceruveens THE PROBLEM... eee we renee revere envercesesens THE LAWS... ccc cccroe eves scrrecvecscsrvcevevees 1. HANDICAP DISCRIMINATION LAWS........c0c00-% A. FEDERAL LAW... cer cevcnccccccsessevene B. STATE LAWS... cece cer cevreceogeccccene C. CITY ORDINANCES..... vow eee etussceeee 2. THE NATIONAL LABOR RELATIONS ACT,...-+e0e- 3. EMPLOYEE RETIREMENT INCOME . SECURITY ACT (ERISA) ..-cccececvccccccuceees 4, OCCUPATIONAL SAFETY AND HEALTH © ACT (OSHA) .....cccccccccccrrcccseeveseeens 5. NEW INDIANA AIDS STATUTE......cccpcecseece 6. COMMON LAW TORT LIABILITY......cceceeceease 7. COLLECTIVE BARGAINING AGREEMENT........e4- GUIDELINES FOR EMPLOYEES... ccccccccesseccaveevece SAMPLE POLICIES... ccecccvevevecccccccccccesegeece EDUCATION PROGRAMS... cs cccerecccraccsnseecccccecs Ll. Management and Supervisory ProgramsS....... 2. Non-Management Employee ProgramS....eesecs 3 * Other educational resources. seeeewagaeeeeneees JI ON ww WwW Ge ‘10 ll 13 14 15 17 19 20 20 21 22 ar @ co ta) NO ~ | 10 ll 12 BARNES & THORNBURG 1313 Mercharies Bank Building 1] South Meridian Screet Indidnapolis, Indiana 46204 (317) 636-1313 To Call W rter TWX 610-341-3427 B&T LAW IND Telecoprer (317) 231-7433 May 10, 1988 Indianapolis, IN INTRODUCTION Presentation To The Presidential Commission On The Human Immunodeficiency Virus Epidemic AIDS IN THE WORKPLACE Panel on Workplace Policies: Development and Implementation. The issue of AIDS in the workplace is one of the “hot” issues in labor and employment law. We are happy to share with the Presidential Commission on AIDS what labor and employment lawyers from our firm have been advisine management people from both large and small businesses at seminars, workshops and symposiums. There are many laws, both federal and state, that impact upon the issue of how an employer deals with the issue of AIDS in its workforce. An employee is also faced with possible common law tort liability, and if unionized, an employer's bargaining obligations and collective bargaining agreement must be honored. Within these legal constraints, there are guidelines for employers that can be recommended, written policies that should be adopted, and educational programs that should be instituted. Henry C. Ryder Robert K. Bellamy Indiunar. + Fore Waane South Bend Elkhart Washington. DC I, THE PROBLEM AIDS is in the workplace and unless or until someone finds a cure, it is there to stay. Unless there is a medical breakthrough of some kind, most employers in this country will be confronted directly with AIDS problems for years to come. The number of reported AIDS cases and deaths resulting from AIDS has grown alarmingly. Comparing reported AIDS cases from just a year ago (April 1, 1987 to April l, 1988), they increased nationally by 72% (33,482 to 57,575). Deaths from AIDS increased almost proportionately, from 19,394 to 31,836 (64%). In Indiana, the number of AIDS cases reported by the State Health Commissioner almost doubled from April 1, 1987 to April 1, 1988 (157 to 312). Deaths from AIDS in Indiana increased by 73%, from 105 to 182, in a like perioa,+ For employment purposes, AIDS is generating questions far more rapidly than the courts, the administrative agencies, and the legislatures are producing answers. The Indiana Legislature produced a 1988 comprehensive AIDS bill which will become effective July 1, 1988. This bill will particularly impact upon employers where the job requirements involve employees handling body fluids in the regular course of employment. lThese statistics were obtained from the office of the Indiana Health Commissioner. -2- II, THE LAWS - This presentation will summarize the laws that relate to the protection of the AIDS victim? in the employment relationship, as well as those laws that deal with the protection of workers in a workplace where an AIDS victim is present. This summary will not purport to treat these questions exhaustively. It will only identify some areas of where laws can be expected to impact upon the employment relationship. This presentation will not attempt to examine those laws that deal with the protection of the general public from transmission of the disease by an AIDS carrier or statutes that bear on insurance restrictions. 1. HANDICAP DISCRIMINATION LAWS. A. FEDERAL LAW. The Federal Rehabilitation Act of 1973 does not apply to all employers. This Act, at Sections 503 and 504, imposes a duty upon the Federal Government, employers with federal contracts, and employers who are recipients of federal assistance not to discriminate against “handicapped” persons. The Act defines a handicapped individual as: 2rne term “AIDS victim", as used in these materials, will refer to persons who have been infacted with the AIDS virus, even those persons who display no physical symptoms of the disease, and who may or may not develop AIDS. -3- “Any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities, or (ii) has a record of such impairment, or (iii) is regarded as having such an impairment." The Federal Rehabilitation Act protects from discrimination only handicapped individuals who are “otherwise qualified" for the job. The Federal Act also requires an employer Subject to this Act to make "reasonable accommodation" to enable the handicapped employee to perform the essential functions of the handicapped employee's job. Neither AIDS nor any other disease is automatically removed from the coverage of the Federal Rehabilitation Act of 1973 simply because it is a contagious disease. The United States Supreme Court decided that question in 1987 in School Board of Nassau County v. Arline, 480 U.S. __ (1987), 94 L.Ed. 24 307. In that case, the School Board had dismissed a teacher because of the threat a tuberculosis affliction posed to the health of others. The Supreme Court said that was not a valid reason under the Rehabilitation Act and that a person would be considered handicapped even though she or he had a contagious disease. However, the Court pointed out that the Act protected only handicapped persons who are “otherwise qualified" and said that "a person who poses a significant risk of communicating an infectious disease to others in the workplace will not be otherwise qualified for his or her job if reasonable accommodation will not eliminate that risk." The Court then listed several factors for evaluating the risk of communicating a disease to others. The factors are: (a) The nature of the disease (how the disease is transmitted), (b) The duration of the risk (how long is the carrier infectious), (c) The severity of the risk (what is the potential harm to third parties), and (d) The probabilities the disease will be transmitted and will cause varying degrees of harm. The Court also explained that in making these findings: "Courts normally should defer to the reasonable medical judgments of public health officials." Id. at 321. Since the most current prevailing medical opinion is that AIDS cannot be transmitted by casual workplace contact, it would appear that an employee with AIDS is not likely to pose a “significant risk" and would thus be “otherwise qualified" to perform the job. As the AIDS victim's disease progresses, there may come a time when the employee might be considered sufficiently contagious after suffering from opportunistic infections to be deemed unqualified for the job. Likewise, an AIDS victim may arguably 2.e unable to perform the duties of the job if the employee is frequently absent or physically unable to perform some or all of the job tasks. B. STATE LAWS. Most states also prohibit employers from making employment and hiring decisions on the basis of a physical handicap if the person is otherwise qualified. There are wide variations in state statutes. For example, the Indiana Civil Rights Law (I.C. 22-9-1-1 et seq.) prohibits employment discrimination based upon handicap, but has a more restricted definition of handicap than the Federal Act. The Indiana Law does not expressly include within its protection one who has a record of having a physical disability or impairment nor does it include within the definition of handicapped one who is merely regarded as having an impairment or disability. Also, the Indiana Law contains no duty of reasonable accommodation. The Indiana law applies to employers with six or more employees. Although the narrower language of the Indiana Handicapped Act would appear to give an employer an argument that AIDS carriers and victims who manifest no physical symptoms of the disease are not handicapped under the Indiana definition, there has been no case decided to support such an argument. Administratively, AIDS victims are treated by Indiana authorities as “handicapped". While state and local case law in other jurisdictions is at an inconclusive and evolving level, the trend thus far has been to afford protection to AIDS victims regardless of statutory definitional constraints. Cc. CITY ORDINANCES. An employer engaged in business in a major city should also look to see if the city where its plant or work force is engaged has passed an ordinance or executive order prohibiting discrimination against persons suffering from AIDS or its related symptoms. Such ordinances have been passed in San Francisco, Los Angeles, Philadelphia, Washington, D.C., New York, and probably other cities. 2. THE NATIONAL LABOR RELATIONS ACT AIDS problems also raise several questions under the National Labor Relations Act (NLRA). The NLRA protects employees who are engaged in "concerted activity”. Employees Cannot be fired or disciplined for engaging in protected concerted activity. Where there is no Union involved and there is no collective bargaining agreement with ano strike clause, an employer could have some or all of its employees walk off the job rather than work with an employee who has tested positive for AIDS. So far, the National Labor Relations Board has not ruled on whetier such a walkout would be protected concerted activity. However, as a general requirement, concerted protest over a Safety hazard to be protected must be based on a “reasonable good faith" belief that the employees would be exposed to dangerous working conditions. Daniel Construction Co., 267 NLRB 1213 (1983). Since current medical Opinion is that AIDS cannot be transmitted through casual workplace contact, it is doubtful that such a concerted refusal to work with an AIDS victim would meet the reasonable good faith standard. Even where there is a collective bargaining agreement with a no strike clause, employees may lawfully refuse to work under “abnormally dangerous conditions." To qualify for this © exemption, employees must prove the abnormally dangerous conditions with ascertainable objective evidence. Again, on the basis of present medical knowledge, it would seem doubtful that burden of proof could be carried. 3. EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) Section 510 of ERISA prohibits an employer from discharging an employee “for purposes of interfering with the attainment of any right to which an employee may be entitled to under an employee benefit plan." In Kross v, Western Electric Co,, 701 F.2d 1238, 1243 (7th Cir. 1983), the court held that the plaintiff stated a claim cognizable under §510 by alleging that he was discharged for the purpose of depriving him of continued participation in the employer's company-provided life and medical insurance plans. In Folz v. Marriott Corp., 594 F. Supp. 1007 (W.D. Mo. 1984), the court found that the employer violated §510 by discharging an employee with multiple sclerosis to deny him the advantages of certain employee benefit plans. Thus, an attempt to discharge an employee because of the insurance costs associated with AIDS could run afoul of ERISA. ERISA could also serve as an impediment for an employer determination not to hire an individual who has tested positive for AIDS if the employment decision is based upon a determination not to increase the risk of future claims under the employer's medical insurance plan. An ERISA violation is independent of any employer violation of handicap discrimination laws. An employer that meets the commerce test and has a health or pension plan may be subject to ERISA. -10- 4. OCCUPATIONAL SAFETY AND HEALTH ACT (OSHA) AIDS questions could also arise under OSHA, which imposes two basic duties upon an employer: (a) the employer must comply with all OSHA standards and (2) the employer must furnish employees a place of employment "free from recognized hazards that are causing or are likely to cause death or serious physical harm." The Department of Labor and the Department of Health and Human Services on October 30, 1987, issued a Joint Advisory Notice (attached) relating to AIDS and the protection of health Care workers against occupational exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) (52 FR 41818). On November 27, 1987, OSHA issued an Advance Notice of Proposed Rules making for a standard to reduce occupational exposure to the Hepatitis B Virus (HBV) and the AIDS virus. 52 FR 45438 (Nov. 27, 1987) and as corrected in 52 FR 47097 (Dec. 11, 1987). See attachment. These OSHA Proposed Rules parallel those of the Department of Labor regarding the requirements for a safe workplace for health care workers dealing with potential AIDS contamination. The Joint Advisory Notice is currently being enforced under existing OSHA Regulations. -ll- There are no OSHA regulations concerning employees other than in the health care industry relating to AIDS in the workplace. Apparently because the potential of direct blood contact is not as great in other industries as jin the health care industry, regulations were not promulgated regarding the protection of other workers. This is based on the supposition that the disease can only be transmitted by: (1) intimate Sexual contact; (2) use of unsterilized needles; (3) blood transfusions or direct blood exposure of an infected person, and (4) pregnant women to fetus. Further, it is based on the supposition that it cannot be contacted through casual contacts. However, the issue of employees who work in a meat packing plant or other type of food industry has yet to be addressed. -12- Ty r il 7 it d f Geos _ Friday October 30, 1987 | Part Il Department of Labor Office of the Secretary Joint Advisory Notice; Department of Labor/Department of Health and Human Services; HBV/HIV; Notice 41818 DEPARTMENT OF LABOR Ottice of the Secretary Joint Advisory Notice; Department of Labor/Department of Health and Human Services; HBV/HIV The Department of Labor hereby gives notice of a joint cover letter and Jo:nt Advisory Notice. entitled “Protection Against Occupational Exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV),” which will be mailed on or about October 30, 1987 to health-care employers throughout the United States. The letter and Notice are attached heretn and is being mailed to epproximately 500,000 employers. Signed at Washington. DC. this 21st day of October 1987 Michael E. Baroody, Assistant Secretary for Policy. US Deporiment of Labor. U.S Department of Labor Secretary of Labor Washington. DC October 30, 1987 Dear Health-Care Employer We ure whiting ‘0 you about 8 senous health-care problem that faces all Ainencans but is particularly acute for health-care workers. That problem is potentral exposure to hepatitis B virus (HBV). human immune deficiency virus (HIV) which causes acquired immunodificiency syndrome (AJDS). and other blood-borne diseases The Centers for Disease Contro! (CDC) which 18 part of the U.S. Department of Health and Human Services (HHS) believes that as many a6 16,000 health-care workers per year may be infected by the HBV. Nearly ten percent of those who become infected become long-term carriers of the virus and may have to give up their profession. Several hundred health-care workers will become acutely ill or jaundiced from hepatitis B, and #8 many 6s 300 health-care workers may die annually as a result of hepatitis B infections or complicanons Infection with the HIV in the workplace represents a small bul real hazard to health- cere workers. Fewer than ten cases heve been reported to date, but It is not clear that these include all such infections. The CDC expects that with 1.5 millon persons now believed to be infected by HIV. the number of AIDS cases in the general population may grow to as many a8 270.000 by 1991 from the 40.000 which had been reported by August. 1987. The incresses in AIDS cases and in the number of individuals who are infected with the virus will mean an increased potential for exposure to health-care workers. Fortunately there are reasonable Precautions which can be taken by health- care workers tc prevent exposure to HBV. HIV. end other blood-borne infectious discases. Precautions for HBV and HIV have been published by the CDC on several occasions. most recently on June 19. 1987. and on August 21. 1987 The enclosed advisory notice, entitled “Protection Against Occupational Exposure to Hepatitis 8 Virus (HBV) and Human Immunodehiciency Virus (HIV),” reflects many of the precautions addressed in the CDC guidelines and includes other precauhona which should be considered. It 1s the legal responsibility of employers to provide appropriate safeguards for health- care workers who may be exposed to these Ganger sus viruses. For that reason, the Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor (COL) is beginning « program of enforcement to insure that health- care employers are meeting those needs. OSHA will respond to employee complaints and conduct other inspections to assure that appropriate messures are being followed. OSHA 18 currently enforcing its existing regulations and statutery provisions relating to the duty of an employer to provide “safe and healthful working conditions.” OSHA is also seeking input about what additional regulatory action may be needed In an Advance Notice of Proposed Rulemaiurg which will be published un the Federal Repisler States with approved plans to operate their own occupational safety and health program enforce standards comparable to the Federal standards und are encouraged to enforce State counterparts to the Genera! Duty Clause State plen standards, unlike Federal standards apply to State, county. end municipal workers as well as to pnvate employers. DOL joins HHS in urging the widest possible edherence to the appropnate precautions as exemplified by the CDC guidelines and the joint advisory notice. All health-care workers who may be exposed ta HBV or HIV should receive training and should uulize eppropriete precautions. If you have further questions. please contact your State public health department or OSHA office, or call the Public Health Services National AIDS Hotline. 1-800-342- AIDS. Every effort will be made to respond to your questons in a hmely and wformative manner. Your uniuns, and professional and trade associations are siso aveilabla to answer your questions. We are making every effort to kesp all interested parues informed. The dangers of HBV and HIV are very real. but you can prevent or minimize those dangers for health-care workers through the utlzetuon of the appropriste precautions recommended by the CDC. ° Thank you for your ume and consideration. Very truly yours. William E. Brock. Secretary of Labor. Ons R. Bowen, M.D.. Secrvtary of Health and Human Services. Enclosure. Federal Register / Vol. 52, No 210 / Friday. October 30. 1987 / Notices Department of Labor/Department of Health and Human Services—joint Advisory Notice: Protection Against Occupational Exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) October 19, 1987. f. Background Hepatit:s B (previously called serum hepatitis) is the major infectious occupational health hazard in the health-care industry, and a mode! for the transmission of blood-borne pathogens. In 1985 the Centers for Disease Control (CDC} estimated (1] that there were over 200,000 cases of hepatitis B virus (HBV) infection in the U.S. each year. leading to 10,000 hospitalizations. 250 deaths due to fulminant hepatitis. 4.000 deaths due to hepatitis-related cirrhosis, and 800 deaths due to hepatitis-related primary liver cancer. More recently [2] the CDC estimated the total number of HBV infections to be 300,000 per year with corresponding incresses in numbers of hepatitis-related hospitalizations and deaths. The incidence of reported clinical hepatitis B has been increasing in the United States. from 6.9/100,000 in 1978 to 9.2/100,000 in 1981 and 11.5/100,000 in 1685 [2]. The Hepatitis Branch, CDC, has estimated {unpublisbed] that 800-600 health-care workers whose job entails exposure to __ blood are hospitalized annually, with over 200 deaths (12-15 due to fulminant hepatitis, 170-200 from cirrhosis. and 40- $0 from liver cancer). Studies indicate that 10% to 40% of health-care or dental workers may show serologic evidence of past or present HBV infection (3]. Health-care costs for hepatius B and non-A. Non-B hepatitis in health-care workers were estimated to be $10-S12 muilion annually (4). A safe. immunogenic, and effective vaccine to prevent hepantis B has been availabie since 1662 and is recommended by the CDC for health-care workers exposed to blood and body fluids {1, 2. $-7]. According to unpublished CDC estimates, approximately 30-40% of health-care workers in high-nsk setungs have been vaccinated to date. According to the most recent data available from the CDC [8], acquired immunodeficiency syndrome (AIDS) was the 13th leading cause of years of potential life lost (62,882 years) in 1984. increasing to 11th place in 1985 (152.595 years). As of August 10, 1987. a cumulative total of 0.081 AIDS cass (of which 558 were pediatric) had ber reported to the CDC, with 23.168 [37 6) of these known to have died {9| Although occupational HIV infection Federal Register / Vol. 52. No. 210 / Friday. October 30. 1987 / Notices has been documented [10]. no AIDS éase or AIDS-related death is believed to be occupationally related. Spending within the Public Health Service related to AIDS has also accelerated rapidly, from $5.6 million in 1982 to $494 million in 1987, with $791 million requested for 1988. Estimates of average lifetime costs for the care of an AIDS patient have varied considerably, but recent evidence suggests the amount is probably in the range of $50,000 to $75,000. Infection with either HBV [1.2] or human immunodefiency virus (HIV, reviously called human T- ymphotrophie virus type I!/ tymphadenopathy-associated virus (HTL Usyiav ec) ut AIDS-sssociated retrovirus (ARV)) (11, 12] can lead toa number of life-threatening conditions. including cancer. Therefore. exposure to HBV and HIV should be reduced to the maximum extent feasible by engineering controls, work practices, and protective equipment. (Engineenng controls are those methods that prevent or limit the potential for exposure al or near as possible to the point of origin. for example by eliminating a hazard by substtution or by isolating the hazard from the work environment.) dl. Modes of Transmission In the U.S, the major mode of HBV transmission is sexual, both homosexual and heterosexual. Also important is parenteral (entry into the body by a route other than the gastrointestinal tract) transmission by shared needles among intravenous drug abusers and to a lesser extent in needlestick injuries or other exposures of health-care workers to blood. HBV is not transmitted by casual contact, fecal-oral or airborne routes, or by contaminated food or drinking water (1, 2. 13]. Workers are at nsk of HBV infection to the extent they ere exposed to blood and other body fluids; employment without that exposure. even in a hospital. carries no greater risk than that for the genera! population [1]. Thus, the high incidence of HBV infection in some clinica! settings is particularly unfortunate beause the modes of transmission are well known and readily interrupted by attention to work practices and protective equipment, and because transmission can be prevented by vaccination of those without serologic evidence of previous infection. Identified risk factors for HIV transmission are essentially identical to those for HBV. Homosexual/bisexual males and male intravenous drug abusers account for 85.4% of all AIDS cases. female intravenous drug abusers for 3.4%, and heterosexual contact for 3.8% (9). Blood transfusion and treatment of hemophilia-coagulation disorders account for 3.0% of cases. and 1.4% are pediatric cases. In only 3.0% of all AIDS cases has a risk factor not been identified [9}. Like HBV, there 13 no evidence thal HIV is transmitted by casual contract, fecal-oral or airborne routes, or by contaminated food or drinking watert [12-14]. and barriers to HBV are effective against HIV. Workers are at risk of HIV infection to the extent they are directly exposed to blood and body fluids. Even in groups tha presumably have high potenhal exposure to HIV-contaminated fluids and tissues. e.g.. health-care workers specializing in treatment of AIDS patients and the parents. spouse, children. or other persons living with AIDS patients, transmission is recognized as occurning only between sexual partners of as 8 consequence of mucous membrane or parenteral (including open wound) exposure to blood or other body fluids (10, 11, 13-16}. Despite the similarities in the modes of transmission, the risk of HBV infection in health-care settings far exceeds that for HIV infection (13, 14}. For example. it has been estimated (14. 17, 18] that the risk of acquiring HBV infection following puncture with a needle contaminated by an HBV carrier ranges from 6% to 30%—far in excess of * the nsk of HIV infection under similar circumstances, which the CDC and others estimated to be a less than 1% (10, 13, 16}. Health-care workers with documented percutaneous or mucous-membrane exposures to blood or body fluids of HIV-infected patients have been prospectively evaluated to determine the nsk of infection after such exposures. As of June 30, 1987, 88S health-care workers have been tested for antibody to HIV in an ongoing surveilience project conducted by CDC [19]. Of these, 708 (80%) had perculsneous exposures to blood. and 175 (20%) had a mucous membrane or en open wound contaminated by blood or body fluid. Of 396 health-care workers. each of whom had only a convalescent- phase serum sample obtained and tested 90 days or more post-exposure. one—for whom heterosexual transmission could hot be ruled out—was seropositive for HIV antibody. For 425 additional heslth- care workers, both acule- and convalescent-phase serum samples were obtained and tested: none of 74 health- care workers with nonpercutaneous exposures seroconverted. and three (0.9%) of 381 with percutaneous exposures seroconverted. None of these three health-care workers had other documented risk factors for infection. 41819 Two other prospective studies to assess the nsk of nosocomial acquisiticn of HIV infection for health-care workers are ongoing in the United States. As of April 30. 1987, 332 health-care workers with a total of 453 needlestick or mucous-membrane exposures to the blood or other body fluids of HIV- infected patients were tested for HIV antibody at the National Institutes of Health (20]. These exposed workers included 103 with needlestick injunes and 229 with mucous-membrane exposures; none had seroconverted. A similar study at the University of California of 129 health-care workers with documented needlestick injuries or mucous-membrane exposures to blood or other body fluids from patients with HIV infection has not identified any seroconversions (21). Results of a prospective study in the United Kingdom identified no evidence of transmission among 1250 health-care workers with parenteral or mucous- membrane exposure to blood or other body fluids. secretions, or excretions from patients with HIV Infection (22). Following needlestick injuries. one health-care worker contracted HBV but not HIV, and in another instance a health-care worker contracted cryptococcus but not HIV from patients infected with both (14}. This risk of infection by HIV and other blood-borne pathogens for which immunization is not available extends to all health-care workers exposed to blood. even those who have been immunized against HBV infection. Effective protection against blood-borne disease requires universa! observation of common barrier precautions by all workers with potential exposure to blood, body fluids. and tissues [10,13]. HIV has been isolated from blood. semen. saliva, tears, unne, vaginal secretions, cerebrospinal fluid. breast milk, and amniotic fluid (10.23}, bul only blood and blood products, semen. vaginal secretions, and possibly breas! milk (this needs to be confirmed) have been directly linked to transmission of HIV (10,13]. Contact with fluids such as saliva and tears has not been shown to result in infection (13-18). Although other fluids have not been shown to transmit infection. all body fluids and tissues should be regarded as potentially contaminated by HBY or HIV, and treated as if they were infectious. Both HBV and HIV appear to be incapable of penetrating intact skin. but infection may result from infectious fluids coming into contact with mucous membranes or open wounds (including inapparent lesions) on the skin [14.16] if @ procedure involves the potential for 41220 skin contact with blood or mucous tnembranes, then appropriate barriers to shin contact should be worn. e.g.. gloves. Investigations of HBV nsks associated with dental and other procedures that might produce particulates un air, e.g., centrifuging and dialysis, indicated that the particulates generated were relatively large droplets (spatter), and not true serosols of suspended particulates that would represent a risk of inhalation exposure (24-26). Thus. if there is the potential for splashes or spatter of blood or fluids. face shields or protective eyewear and surgical masks should be wom. Detailed protective measures for haalth-care workers have been addressed by the CDC (10.13.23,27- 33]. These can serve as general guides for the specific groups Co-...u, eu ior '* * tue ueveiopment of comparable procedures in other working environments. HIV infection ia known to have been transmitted by organ transplants (34} and biood transfusions (35) received from persons who were HIV seronegative at the time of donation. Falsely negative serology can be due to improperly performed tests or other laboratory error, or testing in that “window” of time during which a recently infected person is infective but has not yet converted from seronegative to seropositive. (Detectable levels of entibodies usually develop within 6 to 12 weeks of infection [36]. A recent report (37] suggesting that this “window” may extend to 14 months is rot consistent with other data, and therefore requires confirmation.) If all body fluids and tissues are treated as infectious, no additional level of worker protection will be gained by identifying seropositive patients or workers. Conversely, if worker protection and work practices were upgraded only following the return of positive HBV or HIV serology. then workers would be inadequately protected during the ime required for testing. By producing a false sense of safety with “silent HBV- or HIV-positive patients, a seronegative test may significantly reduce the level of routine vigilance and result in virus exposure. Furthermore, developing. implementing. and administering a program of routine testing would shift resources and energy sway from efforts to assure compliance with infection control procedures. Therefore. routine screening of workers or patients for HIV antibodies wilI'not substantially increase the level of protection for workers above that achieved by adherence to strict infection control procedares. Federal Register / Vol. 52. No. 210 / as On the other hand, workers who have had parenteral exposure to fluids or . issues may wish to know whether their own entibody status converts from negative to positive. Such a monitonng program can lead to prophylactic interventions in the case of HBV infection, and CDC has published guidelines on pre- and post-exposure prophylaxis of viral hepatitis (1.2). Future developments may also allow effective intervention in the case of HIV infection. For the present. post-exposure monitoring for HTV at least can release the affected worker from unnecessary emotional stress if infection did not occur, or allow the affected worker to protect sexual partners in the event infection is detected (10,36). ‘Ml. Summary The cumulative epidemiologic data indicate that transmission of HBV and HIV requires direct, intimate contact with or parenteral inoculation of blood and biood products. semen, or tissues {30,11,13,14,16,23]. The mere presence of, or casual contact with, an infected person cannot be construed as “exposure” to HBV or HIV. Although the theoretical possibility of rare or low-risk alternative modes of transmission cannot be totally excluded. the only documented occupational risks of HBV and HIV infection are associated with parenteral (including open wound) and mucous membrane exposure to blood and tissuea (2,20,13,14.16]. Workers occupationally exposed to blood, body fluids. or tissues can be protected from the recognized risks of HBV and HIV infection by imposing barriers un the form of engineenng controls. work practices, and protective equipment that ere readily available, commonly used. and minimally intrusive. IV. Recommendations General “Exposure” (or “potential exposure”) to HBV end HIV should be defined in terms of actual (or potential) skin, mucous membrane. or parenteral contact with blood. body fluids, and Gesues. “Tissues” and “fluids” or “body fluids” should be understood to designate not only those materials from humans, but also potentially infectious fluids and tissues associated with laboratory investigations of HBV or HIV, e.g.. organse and excreta from expenmental arumals, embryonated eggs. tissue or cell cultures and culture media, etc. As the first step in determining what sctions are required to protect worker health. every employer should evaluate all working conditions and the specific Friday. October 30. 1987 / Notices eres tasks that workers are expected to encounter as @ consequence of employment. That evaluation should lead to the classification of work-related tasks to one of three categories of potential exposure (Table 1). These categones represent those tasks that require protective equipment to be worn during the task (Category 1); tasks that do not require any protective equipment (Category 112); and an intermediate grouping of tasks (Category II) that also ¢o not require protective equipment. but tiat inherently include the predictable job-related requirement to perform Category I tasks unexpectedly or on short notice, so that these persons should have immediate access to some minimal set of protective devices. For example. law enforcement personnel or firefighters may be called upon to perform or assist in first aid or to be potentially exposed in some otber way. This exposure classification applies to tasks rather than to individuals, who in the course of their daily activities may move from one exposure category to another as they perform vanous tasks. For individual Category I and I tasks, engineering controla, work practices. and protective equipment should be selected after careful consideration, for each specific situation, of the overall risk associated with the task. Factors that should be included in that evaluation of risk include: 1. Type of body fuid with which there will or may be contact (e.g. blood is pt greater concern than urine), 2 Volume of blood or body fluid hkely to be encountered (e.g. hip replacement surgery can be very bloody while comeal transplantatian is alnost bloodless), ° 3. Probability of an expasure taking place (e.g., drawing blood will more hkely lead.to exposure to blood than will performing a phynaal examnation}, 4. Probable route of exposure [e g. needlestck injuries are of greater concern than contrect with soiled linens), and §. Virus concentration in the fluid or tissue. The numberof viruses per * milliliter of fluid in research isboratory cultures may be orders of magnitude higher than in blood. Similarly, viruses have been jess frequently found in fluide such as sweat, tears, urine. and saliva Engineering controls, work practices. and protective equipment appropnate to the task being performed are critical to minimize HBV and HIV exposure and to prevent infection. Adequate protection can be essured only if the epproprate controls and equipment are provided and all workers know the spplicebie Federal Register / Vol. 52, No. 210 / Fnday. October 30. 1987 / Notices -_= work practices and how to properly use * the required controls or protective ejuipment. Therefore. employers should establish a detailed work practices program that includes standard operating procedures (SOPs) for all tasks or work areas having the potential for exposure to fluids or tissues, and a worker education program to essure familianty with work practices and the ability to use properly the controls and equipment provided. It is essential for both the patient and the health-care worker to be fully aware of the reasons for the preventive measures used. The health-care worker may incorrectly interpret the work Practices o74 amttective enninment un s.gnifying that a task is unsafe. The patient may incorrectly interpret the work practices or protective garb as evidence that the health-care provider knows or believes the patient is infected with HBV or HIV. Therefore, worker education programs should strive to allow worker (and to the extent feasible. the clients or pabents) to recognize the routine use of appropnate work practices and protective equipment as prvdent steps that protect the health of a if the employer determines that Category | and UJ tasks do not exist in the workplace, then no specific personal hygiene or protective measures are required. However, U.ese employers should ensure that workers are aware of the risk factors associated with transmission of HBV and HIV so that they can recogruze situstions whi:b pose increased potental for exposure to HBV or HIV (Category I tasks) and know how to avoid or minimize personal risk. A comparable level of education is necessary for all citizens. Educational! materials such as the Surgeon General's Report can provide much of the needed information (12,38)}. If the employer determines that work- related Category | or U tasks exist, then the foll procedures should be implement Administrative The employer should establish formal procedures lo ensure that Category I and II teske are properly identified, SOPs are developed, and employees who must preform these tasks are adequately trained and protected. If responsibility for implementation of these responsibilities is delegated to a commuttee. it should include both management and worker representatives. Administrative activities to enhance worker protection include: 1. Evalueting the workplace to: a. Establish category of nsk classifications for all routine and reasonably anticipated job-related tasks. b. Identify all workers whose employment requires performance of Category I or Il tasks. c. Determine for identified Category I cr If tasks those body fluids to which workers most probably will be exposed and the potental extent and route of exposure. 2. Developing, or supervising the development of. Standard Operating Procedures (SOPs) for each Category I and I! task. These SOPs should include mandatory work practices and sestactve.equipment for each Category Land Il task. 3. Monitoring the effectivenes of work practices and protective equipment. This includes: a. Surveillance of the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used. b. Investigation of known or suspected parenteral exposures to body fluids or tissues to establish the conditions surrounding the exposure and to improve training, work practices, or protective equipment to prevent a recurrence. TABLE 1. EXPOSURE CATEGORIES CATEGORY I. Tasks That Involve Exposure To Blood. Body Fluids, Or issues. All procedures or other job-related tasks that involve an inherent potential fur mucous membrane or skin contact with blood. body fluids. or tissues. or potential for spills or spleshes of them, are Category I tasks. Use of appropriate protective measures should be required 7 every employee engaged in Category tasks. CATEGORY IL Tasks That Involve No Exposure To Blood, Body Fluids, Or Tissues, But Employment May Require Performing Unplanned Category I Tasks. The norme! work routine involves no exposure to blood. body Auids. or tussues, but exposure or potential exposure may be required as s condition of employment Appropriate protective measures should be readily available to every employee engaged in Category 1 tusks. CATECORY IIL Tasks That Involve No Exposure To Blood, Body Fluids. Or Tissues, And Category 1 Tasks Are Not A Condition Of Employment The normal work routine involves no exposure to blood. body fluids, or 41821 a tissues (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person whe perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way. Tasks that invoive handling of implements or untensils, use of public or shared bathrc om facilities or telephones. and personal contacts such as handshaking are Category IL! tasks. Training end Education The eoployer should establish an initial and periodic training program for al] employees who perform Category I and [I tasks. No worker should engage in any Category | or Il task before receiving training pertaining to the SOPs, work practices, and protective equipment required for that task. The training program should ensure that al! workers: 1. Understand the modes of transmussion of HBV and HIV. 2. Can recognize and differentiate Category I and I tasks. 3. Know the types of protective clothing and equipment generally appropriate for Category I and II tasks. and understand the basis for selection of elothing and ec sipment. 4. Are familiar with appropriate achons to take and persons to contact :f unplanned Category I tasks are encountered. 5. Are familiar with and understand all the requirements for work practices and protective equipment specified in SOPs covering the tasks they perform. 6. Know where protective clothing and equipment is kept. how to use it properly, and how to remove. handle. decontaminate. and dispose of contaminated clothing or equipment. 7. Know and understand the Limitations of protective clothing and equipment. For example, ordinary gloves offer no protection against needlestick injurtes. Employers and workers should be on guard against s sense of secunty not warranted by the protective equipment being used. 8. Know the corrective actions to take in the event of spills or personal exposure to fluids or tissues, the appropnate reporting procedures, ard the medical monitonng recommended in cases of suspected parenteral exposure Engineering Controls Whenever possible. engineering controls should be used es the pn™.rTy method to reduce worker exposure ‘7 * 41822 Federal Register / Vol 52. No 210 / Friday. October 30, 1987 / Notices harmful substances. The preferred approach in engineering controls is to use. to the fullest extent feasible, intnnsically safe substances, procedures. or devices. Substitution of a hazardous procedure or device with one that is less msky or harmful is an example of this epproach. e.g., a laser scalpel reduces the risk of cuts and scrapes by eliminating the necessity to handle the conventional scalpel blade. Isolation or containment of the hazard is an alternative engineering control technique. Disposable. puncture- resistant containers for used needles, blades. etc.. isolate cut and needlestick injury hazards from the worker. Clove boxes. ventilated cabinets, or other enclosures for tissue homogenivere sonicators. vortex mixers, etc. serve nol only to isolate the hazard, but also to contain spills or splashes and prevent spatter and mist from reaching the worker. After the potential for exposure has been minimized by engineering controls, further reductions can be achieved by work practices and, finally. personal protective equipment. Work Practices For all identified Category I and I! tasks, the employer should have wniten., detailed Standard Operating Procedures (SOPs). All employees who perform Category I or II tasks should have ready access to the SOPs pertaining to those tasks. 1. Work practices should be developed on the assumption that all body fluids and tissues are infectious. General procedures to protect healthcare workers egainst HBV or HIV transmussion have been published elsewhere (1. 2, 23, 28-33). Each employer with Category I and U tasks in the workplace should incorporate those general recommendations. as appropriate. ot equivalent procedures into work practices and SOPs. The importance of handwashing should be emphasized. . 2. Work practices should include provision for safe collection of fluids and tissues and for disposal in accordance with applicable local, state, and federal regulations. Provision must be made for safe removal. handling, and disposal or decontamination of protective clothing and equipment, soiled linens. etc. 3. Work practices and SOPs should provide guidance on procedures to follow in the event of spills or personal exposure to fluids or tissues. These procedures should include instructions for personal and srea decontamination a8 well as appropnate management or supervisory personnel to whom the + incrdent should be reported. 4. Work practices should provide specific and detailed procedures to be observed with sharp objects. e.g., needles, scalpel blades. Puncture- resistant receptacies must be readily accessible for depositing these materials after use. These receptacles must be clearly marked and specific work practices provided to protect personnel tesponsible for disposing of them or processing their contents for reuse. Personal Protective Equipment -~ Based upon the fluid or tissue to which there is potential exposure. the likelihood of exposure occurring. the potential valume of maternal the probabie route of exposure. and overall working conditions and job requirements, the employer should provide and maintain personal protective equipment appropriate to the specific requirements of each task. For workers performing Category | tasks. a required minimum array of protective clothing or equipment should e specified by pertinent SOPs. All Category | tasks do not involve the same type or degree of risk, and therefore all do not require the same kind or extent of protection. Specific combinations of clothing and equipment must be tailored to specific tasks. Minimum levels of protection or Category I tasks {n most cases would include use of appropriate gloves. If there is the potential for splashes. protective eyewear or face shields should be worn. Paramedics responding to an auto accident might protect against cuts on metal and glass y weering gloves or gauntlets that are both puncture-resistant and impervious to blood. If the conditions of exposure include the potential for clothing becoming soaked with blood, protective outer garments such as impervious coveralls should be worn. For workers performing Category 0 tasks, there should be ready access to appropriate protective equipment. ¢.g., gloves, protective eyewear. or surgical masks. specified In pertinent SOPs. Workers performing Category Il tasks need not be wearing protective equipment, but they should be prepared to put on appropriate protective garb on short notice. Medical In addition to any health-care or surveillance required by other rules, regulations, or labor-management agreement, the employer should make available at no coat to the worker: 1. Voluntary HBV immunization for all workers whose employment requires them to perform Category | tasks and who test negative for HBV antibodies. Detailed recommendations for protecting health-care workers from viral hepatitis have been published by the CDC [1}. These recommendations include procedures for both pre- and post-exposure prophyiaxis. and should be the basis for the routine approach by management to the prevention of occupational hepatitis B. 2. Monitoring, at the request of the worker. for HBV and HIV antibouies following known or suspected parenteral exposure to blood, body fluids. or tissues. This monitoring program must include appropriate provisions to protect the confidentiality of test results for all workers who may elect to participate. 3. Medical counseling for all workers found. as @ result of the monitoring described above, to be seropositive for HBV or HIV. Counseling guidelines have been published by the Public Health Service {1. 2, 38]. Recordkeeping Lf any employee is required to perform Category 1 or i tasks, the employer should maintain records documenting: 1. The administrative procedures used to classify job tasks. Records should describe the factors considered and outline the rationale for classification. 2. Copies of all SOPs for Category | and 0 tasks. and documentation of the administrative review and approval process through which each SOP passed. 3. Training records. indicating the dates of training sessions. the content of those training sessions along with the names of all persons conducting the training, and the names of all those receiving training. 4. The conditions observed in routine surveillance of the workplace for compliance with work practices and use of protective clothing or equipment. If noncompliance is noted, the conditions should be documented slong with corrective actions taken. 5. The conditions associated with each incident of mucous membrane or parenteral exposure to body fluids or tissue, an evaluation of those conditions. and a description of any corrective measures taken to prevent a recurrence or other similar exposure. References 1. Centers for Disease Control: Recommendations for protection agains! viral hepatitis. Morbidity and Mortality Weekly Report 34:313-24, 329-35, 7 June 1985 2 Centers for Disease Control: Update on Hepatitis B prevention. Morbidity = Federal Register / Vel. 52. No. 210 / Friday. October 30. 1987 / Notices and Mortality Weekly Report 35.353-60. 19 June 1987. . 3 Palmer D.L. Barash, M., King. R.. and Neil, F.: Hepatitis among hospital employees. Western J Med 138:519-523, 1983. 4. Grady. G. F. and Kene, M. A.: Hepatitis B infections account for multi- mutlion dollar loss. Hosp Infect Contr 6:60-62, 198%. S. Centers for Disease Control: Hepatitis B virus vaccine Safety— Report of an inter-agency group. Morbidity and Mortality Weekly Report 31:465-67, 3 September 1982. 6. Centers for Disease Control: The safety of hepatitis B virus vaccine. Morbidtty and Mortality Weekly Report 32:134-36, 18 March 1983. 7. Centers for Disease Control: Hepatitis B vaccine—Evidence confirming lack of AIDS transmission. Morbidity and Mortality Weekly Report 33.685-87, 14 December 1984. 8. Centers for Disease Control: Changes in premature mortality—United States, 1984-1985. Morbidity and Mortality Weekly Report 36.55-S7, 6 February 1987. 9. Centers for Disease Control: Update—Acquired immunodeficiency syndrome—United States. Morbidity and Mortality Weekly Report Supplement, 36:522-526, 14 August 1987. 10. Centers for Disease Control. Recommendations for prevention of HIV transmisvion in health-care settings. Morbidity and Mortality Weekly Report Supplement, 36(2S): 1S-16S, 21 August 1987. 11. Centers for Disease Contrel: Update—Acquired immunodeficiency ayndrome—United States. Morbidity and Mortality Weekly Report 35:757~86, 12 December 1988. 12. Koop. C. E.: Surgeon General's Report on Acquired Immune Deficiency Syndrome, US DHHS. October, 1986. 36 p. 13. Centers for Disease Control: Recommendations for preventing transmission of infection with human T- lymphotrophic virus type L/ lymphadenopathy-essociated virus In the workplace. Morbidity and Mortality Weekly Report 34:681-66, 601-05, 15 November 1985. 14. Viahov. D., Polk, B. F.: Transmission of human immunodeficiency virus within the health care setting. Occup Med State of the Art Reviews 2:429-450, 1987. 15. Gestal, J. J: Occupational! hazards in hospitais—Risk of infection. Br J Ind Med 44:435~442, 1887. 16 Centers for Disease Control: Update—Human immuncdeficiency virus infections in health-care workers exposed to blood of infected patients Morbidity and Mortality Weekly Report 36.255-89, 22 May 1987. 17. Grady, G. F.. Lee V. A.. Prince. A. m., et al.: Hepatitis B immune globulin for accidental exposures among medical personnel—Final report of a multicenter controlled trial. J. Infect Dis 138:625~838, 1976. 18. Seeff, L. B.. Wright, E. C., Zimmerman. H. J., et al.: Type B hepatitis after needlestick exposure— Prevention with hepatitis B immune globulin. Ann Intern Med 68:285-293, 1987. 19. McCray, E.: The cooperative needlestick surveillance group. Occupational nsk of the scquired immunodeficiency syndrome among Sait care workers. iy engi § Med 314:1127-1132, 1966. 20. Henderson.‘D. K., Saah, A. J., Zak. B. j.. et al.: Risk of nosocomial! infection with human T-cell lymphotrophic virus type IlI/lymphadenopathy-associated virus in e large cohort of intensively exposed health care workers. Ann Intern Med 104:644-647, 1996. 21. Gerberding J. L.. Bryant-LeBlanc, C. E. Nelson. K.. et al: Risk of transmitting the human immunodeficiency virus, cytomegalovirus. end hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions. ] infect Dis 156:1-8, 1987. 22. McEvoy, M., Porter, K., Mortimer, P., Simmons, N.. Shanson. D.: Prospective study of clinical. laboratory. and ancillary staff with accidental exposures to blood or other body fluids from pstients infected with HIV. Br Med ] 294: 1595-1597, 1987. 23. Centers for Disease Control: Human T-lymphotrophic virus, type ITI/ lymphadenopethy-associated virus— Agent summary statement. Morbidity and Mortality Weekly Report 35:540-42, 547-49, 29 August 1988. 24. Petersen, N.].. Bond, W. W., : Favero, M. S.: Air sampling for hepatitis B surface antigen in a dental operatory. J Am Dental Assoc 99: 465-467, 1979. 25. Scariett, M.: Infection control practices in dentisty, in Proceedings of the National Conference on infection Control in Dentistry. Chicago, May 13- 14, 1986, pp 41-51. 26. Bond, W. W.: Modes of transmission of infectious diseases. in Proceedings of the National Conference on Infection Control in Dentistry. Chicago, May 13-14, 1986. pp 29-35. 27. Centers for Disease Control: Recommendations for preventing transmission of infection with human T- lymphotrophic virus type 111/ lymphadenopathy-sssociated virus during invasive procedures. Morbidity 41223 and Mortality Weekly Report 35.221-23. 11 Apnil 1988. 28. Centers for Disease Control: Acquired immune deficiency syndrome (AIDS}—Precautions for echnical and laboratory staff. Morbidity and Mortality Weekly Report 31.577-0. 5 November 1982. 29. Centers for Disease Control: Acquired immunodeficiency syndrome {AIDS}—Precautions for health-care workers and allied professionals. Morbidity and Mortality Weekly Report 32:450-452, 2 September 1983. 30. Centers for Disease Control: Recommendations for preventing possible transmission of human T- lymphotrophie virus type 1I!/ lymphadenopathy-associated virus from tears. Morbidity and Mortality Weekly Report 34:533-34. 30 August 1985. 31. Centers for Disease Control: Recommended infection-contro! practices for dentistry. Morbidity and Mortality Weekly Report 35.237~42, 18 April 1986. 32. Centers for Disease Control: Recommendations for providing dialysis treatment to patients infected with human T-lymphotrophic virus, type 111/ lymphadenopathy-associated virus. Morbidity and Mortality Weekly Repert 35:376-76, 383, 13 June 1986. 33. Williams, W. W.: Guidelines for infection control in hospital personnel. Infect Control 4:328-349, 1983. 34. Centers for Disease Control: Human immunodeficiency virus infectons transmitted from an orgen donor screened for HIV antibody— North Carolina. Morbidity and Mortality Weekly Report 36:306-8, 29 May 1987. 35. Centers for Disease Control: Transfusion-associated human T- lymphotrophic virus type IlI/ lymphadenopathy-associated virus infection from a seronegative donor- Colorado. Morbidity and Mertality Weekly Report 35:389-01, 20 June 1926. 36. Centers for Disease Control: Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. Morbidity and Mortality Weekly Report, 36:509+515, 14 August 1987. 37. Ranki, S.-L., Krohn, M., Antonen. J., Allain, J.-P., Leuther, M., Franchini. C.. and Krohn, K:: Long latency precedes overt seroconversion in sexually transmitted human-immunodeficiency- virus infection. Lancet 2(8559}: 569-553. 1987, 38. Centers for Disease Control Fac:s About AIDS. US DHHS, Spnng 1987.9 PP. 41824 * References Not Cited Centers for Disease Control: Update on acquired immune deficiency syndrome (AIDS) United States. Morbidity and Mortality Weekly Report 31.507-14, 24 September 1982. Centers for Disease Control: Prevention of acquired immune deficiency syndrome (AIDS)}—Report of interagency recommendations. Morbidity and Mortality Weekly Report 32: 101-4, 4 March 1083. Centers for Disease Control: Acquired immunodeficiency syndrome (AIDS) update—United States. Morbidity and Mortality Weekly Report 32:309-11, 24 June 1983. Centers for Disease Control: An evaluation of the acquired immunodeficiency syndrome (AIDS) reported in health-care personnel— United States. Morbidity and Mortality Weekly Report 32:358-60, 15 July 1983. Centers for Disease Control: Update— Acquired immunodeficiency syndrome (ALDS)}—-United States. Morbidity and Mortality Weekly Report 32:389-91, 5 August 1983. Centers for Disease Control: Update— Acquired immunodeficiency syndrome (AIDS)}—United States, Morbidity and Mortality Weekly Report 32:465-67, 9 September 1983. nters for Disease Control: Update— Acquired immunodeficiency syndrome (AIDS}—United States. Morbidity and Mortality Weekly Report 32:688-91. 6 January 1954. . Centers for Disease Contro!: Prospective evaluation of health-care workers exposed via parenteral or mucous-membrane routes to blood and body fluids of patients with acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report 33: 181-82, 6 April 1984. Centers for Disease Control: Update— Acquired immunodeficiency syndrome (AIDS)}— United States. Morbidity and Mortality Weekly Report 33:337-39, 22 June 1964. Centers for Disease Control: Update— Acquired immunodeficiency syndrome {AIDS}— United Staten. Morbidity and Martality Weekly Report 33:661-64, 30 November 1984. Centers for Disease Control: Update— Prospective evalustion of health-care workers exposed via the parenteral or mucous-membrane route to blood and body fluids of patients with AIDS— United States. Morbidity end'Mortality Weekly Report 34:101-3, 22 February 1098S Centers for Disease Control: Update— Acquired immunodeficiency syndrome (AIDS}—United States. Morbidity and Mortality Weekly Report $4:245-46, 10 May 1985. Centers for Disease Control: Education and foster care of children infected with humee T horsbaranhic virus type Ill/lymphadénopathy- associated virus. Morbidity and Mortality Weekly Report 34:517-21, 30 August 1985. Centers for Disease Control: Update— Evaluation of human T-lumphotrophic virus type I1/lymphadenopathy- associated virus infection in health-care personnel—United States. Morbidity and Mortality Weekly Report 34:575-78, 27 September 1985. Centers for Disease Control: Update— Acquired immunodeficiency syndrome (AIDS}—United States. Morbidity and Mortality Weekly Report 35:17-21, 17 January 1988. Centers for Disease Control: Apparent transmission of human T-lymphotrophic virus type Lll/lymphadenopathy- associated virus from a child to a mother prividing health care. Morbidity and Mortality Weekly Report 35: 76-79, 7 February 1988. Centers for Disease Control: Safety of therapeutic immune globulin preparations with respect to transmission of human T-lymphotrophic virus type Lll/lympedenopathy- associated virus infection. Morbidity and Mortality Weekly Report 35:231-33, 11 April 1986. Centers for Disease Control: Acquired immunodeficiency syndrome (AIDS) in Western Palm Beach County. Florida, Morbidity and Mortality Weekly Report 3$5:609-12, 3 October 1986. . Federal Register / Vol. 52. No. 210 / Friday, October 30, 1987 / Notices Centers for Disease Control: Availability of informational materials on AIDS. Morbidity and Mortality Weekly Report 35:819-20. 9 January 1987, Centers for Disease Control: Survey of non-U.S. hemophilia treatment centers for HIV seroconversions following therapy with heat-treated factor concentrates. Morbidity and Mortality Weekly Report 36:121-24, 13 March 1987. Centers for Disease Contral: Tuberculosis end AlDS—Connecticut. Morbidity and Mortality Weekly Report 36:133-35, 13 March 1987. Centers for Disease Control: Human immunodeficiency virus infection in transfusion recipients and their family members. Morbidity and Mortality Weekly Report 36: 137-40 20 March 1987. Centers for Disease Control: Antibody to human immunodeficiency virus in female prostitutes. Morbidity and Mortality Weekly Report 36: 157-61, 27 March 1987. Centers for Disease Control: Self- reported changes in sexual behaviors among homosexual and bisexual men from the San Francisco City Clinic cohort. Morbidity and Mortality Weekly Report 36: 187-89, 3 April 1987. Centers for Disease Control: Classification system for human immunodeficiency virus (HIV) infection in children under 13 years of age. Morbidity and Mortality Weekly Report 36: 225-30, 235-36, 2¢ Apri! 1987. Centers for Disease Control: Tuberculosis provisional data—United States, 1086. Morbidity and Mortality Weekly Report 36:254-S5, 1 May 1967. Centers for Disease Control: Trends in humen immunodeficiency virus infection among civilian applicants for military service—United States, October 1985— December 1986. Morbidity and Mortality Weekly Report 36:273-76, 15 May 1987. For further information call: National OSHA Information Office, (202) 823-0148. (FR Doc. 87-24780 Filed 10-29-67: &:45 am) GRLLING CODE 6610-29-18 49520 ADVANCE NOTICE OF PROPOSED RULEMAKING ON STANDARD GOVERNING HEALTH CARE WORKER EXPOSURE TO AIDS AND HEPATI- TIS VIRUSES Standards Setting—Hepatitis B Virus and Human Immunodeficiency Virus Exposures-—Advance Notice of Froposed Rulemaking. OSHA requests comment by January 26, 1688, on reducing occupational exposure to hepatitis B virus (HBV) and human immunodeficiency virus (HIV or AIDS virus). Petitions for an emergency temporary stan- dard filed in September 1986 by several unions (1985-1986 Developments 49046) were denied by OSHA on the ground that the available data did not meet the statutory criteria for an _OSHA concluded that the appropriate course of action was to initiate regular rulemaking and collect additional information. With the Department of Health and Human Services, the agency announced the mailing of advisory notices (New Developments { 9488) to formally alert some 500,000 health care employers that they can be held legally accounta- ble for failure to implement Centers for Disease Control guidelines on protection against bloodborne diseases. OSHA is currently enforcing safeguards under existing regulations and the general duty clause. Text of the November 27, 1987, Federal Register notice (52 F.R. 45438), including a oo published in the December 11, 1987, Federal Register (52 F.R. 47097-47109), ollows. Back reference: { 1027. - SUMMARY: This notice announces the initia- pational Safety and Health Act of 1970 (the tion of the rulemaking process and requests Act}, 29 U.S.C. 655. This notice briefly sum- information relevant to reducing occupa: marizes the ongoing activities in this area tional exposure to hepatitis B virus (HEV) and describes the information availabie to and human immunodeficiency virus (HIV or OSHA concerning HBV and HIV infections, AIDS virus] under section 6(b) of the Occu- existing guidelines for worker protection, (The next page is 10,487-3.) Employment Safety end Health Guide 4 9520 867 12-22-87 and risk estimates. The notice invites inter- ested parties to submit data, comments and other pertinent information regarding OSHA's development of a pro standard for occupational exposure to HBV and HIV. DATES: Comments in response to this ad- vance notice should be submitted by Janu- . ary 26, 1988. ADDRESSES: Comments should be submitted in quadruplicate to the Docket Officer, Occu- tional Safety and Health Administration, ket No. H-370, Room N-3670, U.S. De- partment of Labor, 200 Constitution Ave, .. Washington, DC 20210. FOR FURTHER INFORMATION CONTACT: Mr. James F. Foster, Occupational Safety and Health Administration, U.S. Department of Labor, Office of Information, Room N-3647, 200 Constitution Ave., NW., Washington, DC 20210, Telephone (202) 523-8151. SUPPLEMENTARY INFORMATION: 1. Introduction Many health-care workers are at risk of infection with the viruses that cause hepati- tis B and acquired immune deficiency syn- drome (AIDS) due to their exposure to contaminated blood and other body fluids. Occupational exposure, which can occur as the result of needlestick or cut injuries, oc- curs when contaminated blood or body fluids come in contact with mucous mem- branes or broken skin. Examples of occupa- tions with potential for exposure include physicians, nurses, dentists, phiebotomists, laboratory personnel, blood bank personnel, paramedics, morticians, and housekeepers and laundry workers in health-care facilities. Although OSHA has no standard that was designed specifically to reduce occupational exposure to these viruses, there are a num- ber of existing regulations that apply to this hazard. An example is 29 CFR 1910.132 (per- sonal protective equipment) which requires employers to provide: Protective equipment, including per- sonal protective equipment for eyes, face, head and extremities, protective clothing, respiratory devices, and protective shields and barriers ° * ° wherever it is neces- sary by reason of hazards of proceases or environment * * * encountered in a man- ner capable of causing injury or impair- ment in the function of any part of the body through absorption, inhalation or physical contact. In addition, section 5(a) the General Duty Clause of the Act requires that each employer: Employment Safety and Health Guide New Developments * * * furnish to each of his employees em- ployment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees. In 1983, OSHA issued a set of voluntary guidelines designed to reduce the risk of oc- cupational exposure to hepatitis B (Docket H-370, Exhibit Number (Ex.) 425). The voluntary guidelines, which were sent to em- ployers in the health-care industry, includec a description of the disease, recommendea work practices, and recommendations for use of immune globulins and the hepatitis B vaccine. Guidelines for vaccination and pos- texposure proms teste heve been issued by the Centers for Disease Control (CDC) (Ex. 4-9). OSHA has not issued guidelines for re- ducing occupational exposure to HIV, but guidelines have been issued by the CDC (Ex. 6-153), the American Hospital Association (AHA) (Exs. 6-75; 6-76), and the American Gecupational Medical Association (AQMA) The Departments of Labor (DOL) and Health and Human Services (HHS) have formed a working group to develop an exten- sive and far reaching plan regarding blood- borne diseases in the workplace. Pursuant to this plan, and in order to provide immediate protection in the health-care workplace against HBV and HIV, the Department 1s taking the following steps: @ First, we are currently implementing a targeted inspection program under the OSH Act to examine actual work practices among health-care workers at risk from exposure to blood-borne diseases. @ Second, DOL and HHS have issued a Joint Advisory Notice (52-FR 41818, Octo- ber 30, 1987) to ensure that health-care and other affected employers are fully aware of the applicable guidelines regarding blood- borne disease. @ Third, DOL and HHS will jointly begin an extensive educational effort which targets health-care workers, involving as many interested employer and employee or- ganizations and governmental agencies as ible, and emphasizing education, train- ing and technical asaistance. OSHA will require adherence to existing regulations and will apply the General Duty clause in order to protect health-care work- ers from the risks of blood-borne diseases. In addition, a careful assessment of the extent to which actual work practices conform to the guidelines, as well as the reasons for any 7 9520 10,488 difference between practice and guidelines, is an essential starting point for the develop- ment of a proposed standard. OSHA intends to use information gathered in these targeted inspections as one part of a program to assess actual work practices. The Department of Health and Human Services, which will continue to play a pri- mary role in developing consensus recom- mendations and guidelines for protecting against HBV and HIV infections in the 7 9520 New Developments 867 12-2287 workplace, will be reviewing the various guidelines aiready issued in this area to de- termine if the need exists for updating. OSHA will also work with HHS to develop additional materials intended for worker ed- ucation that can be easily reproduced and distributed. There is agreement that educa- tion and training are important to assure optimum use of available protective measures. ©1987, Commerce Clearing House, inc. 865 128-87 OSHA will also be working with other Public Health Service agencies, local agen- cies, universities, hospitals, and state and local health-care departments in an effort to provide both health-care employers and workers with the latest information on blood-borne diseases. This will be useful in the country's overall response to address these infectious diseases. 2. Petitions for Emergency Temporary Standard On September 19, 1986, the American Federation of State, County and Municipal Employees (AFSCME) petitioned OSHA to take action to reduce the risk to employees from exposure to certain infectious agents (Ex. 2A). They requested that OSHA issue an emergency temporary standard (ETS) under section 6(C) of the Act. The petition- ers also requested that OSHA immediately initiate a section 6(b) rulemaking that would require employers to provide the HBV vac- cine at no cost to employees at risk for HBV infection and would require employers to foliow work practice guidelines such as those issued by the Centers for Disease Control. AFSCME also requested that OSHA amend the Hazard Communication Standard (48 FR 53280) to require a training program for employees exposed to infectious diseases, counseling for pregnant employees about dis- eases that have reproductive effects, and posting of isolation precautions in patient areas and in contaminated areas. On September 22, 1986, the Service Em- loyees International Union, the National Union of Hospital and Healthcare Employ- ees, and RWDSU Local 1199—Drug, Hospi- tal and Healthcare Union petitioned the Agency to promulgate a standard to protect health-care employees from the hazard posed by occupational exposure to hepatitis (Ex. 3). They requested that, as a mini- mum, the standard should contain all of the provisions in OSHA's 1983 guidelines with special emphasis on making workers aware of the benefits of vaccination. In addition, they wanted OSHA to immediately issue a directive stating that employers must pro- vide the HBV vaccine free of charge to all high risk health-care workers. After reviewing these petitions and the available data, OSHA determined that the appropriate course of action is to publiah an ANPR to initiate rulemaking under section 6(b) of the Act and to collect further infor- mation. Concurrently with the collection of | this information, the Agency will enforce existing regulations and section 5aX1) of the Act, and the Agency will undertake an edu- Employment Sefety and Health Guide New Developments 10,489 cational program in cooperation with the Department of Health and Human Services. OSHA has determined that the available data do not meet the criteria for an ETS as set forth in section 6&(c) of the Act. The peti- tions, therefore, have been denied. How best to protect against blood-borne diseases in the health-care workplace is a Question with broad public health implica. tions in an area, control of biological hazards, where OSHA has not been tradi- tionally involved. Before we proceed, we in- tend to have the benefit of full airing of the issues through the public comment process. The Agency's objective is to assure both pro- fessional and support staff a safe working environment. 3. Heaitn ciicves Hepatitis B Hepatitis B, a liver disease, is caused by the hepatitis B virus. Many people who are infected with HBV never have symptoms. The usual symptoms of acute infection are flu-like and include fatigue, mild fever, mus- cle and joint aches, nausea, vomiting, loss of appetite, abdominal pain, diarrhea, and jaundice. Many pregnant women who are acutely or chronically infected in the months before and after delivery transmit the virus to their children. Although most infected individuals recover, severe HBV in- fections may be fatal. Chronic carriers of the hepatitis B virus may develop a chronic hep- atitis which may progress to cirrhosis, liver cancer, or death. The usual modes cf transmission of HBV are contaminated blood or blood products, sexual contact, needle-sharing and from in- fected mother to infant. HBV is not trans- mitted by casual contact, touching or shaking hands, eating food prepared by an infected person, or from drinking fountains, telephones, toilets or other surfaces. The CDC estimates that 300,000 new hep- atitis B infections occur each year with about 18,000 occurring in health-care work- ers. Of these, approximately two-thirds (12,000) are estimated to be the result of occupational exposure. Approximately 3,000 of these 12,000 cases are clinically recogniza- ble infections, 600 are hospitalized, and more than 200 die from acute and chronic effects of the infection. Nearly 10 percent of all sinose infected become long-term carriers ° . A hepatitis B vaccine is available which is safe and effective in the prevention of HBV infection. This vaccine has been recom- mended by the CDC for persons at substan- 79520 2V,43U tial risk of HBV infection. including health- care workers and emergency personnel (Ex. 4-9). Acquired Immune Deficiency Syndrome AIDS is a disease in which the human immunodeficiency virus invades the body, destroys the immune system and allows other infectious agents to invade the body and cause disease. Persons who are infected with HIV may have no symptoms, may have AIDS-related complex (ARC), or may show symptoms diagnostic of AIDS. Individuals with ARC may have enlarged lymph nodes and a fungal infection of the mouth (thrush), which may be accompanied by fatigue, weight loss, and mild to moderate immuno- logical abnormalities. AIDS is frequently di- agnosed when the patient develops an opportunistic infection, fan infectious dis- ease which is only likely to occur when the immune system is depressed), such as Pneumocystis carinii pneumonia or malig- nancies such as Kaposi's sarcoma. The usual modes of transmission of HIV, as with HBV, are sexual contact, needle sharing, infected blood or blood products, and from infected mother to infant. HIV is not transmitted by casual contact, touching or shaking hands, eating food prepared by an infected person. or from drinking fountains, telephones, toilets or other surfaces. AIDS was first recognized in 1981. More than 40,000 cases of AIDS have been re- ported. An additional 1.5 million people are estimated to be carriers of the virus that causes AIDS but have no symptoms of the illness. Experts predict that by the end of 1991, the United States will reach a cumula- tive total of 270,000 AIDS cases. Infection with HIV, the virus that causes AIDS, ap- pears to represent a small but real occupa- tional hazard to health-care workers. Only a few such cases of infection have been re- ported to date (Ex. 6-153). To date, no antiviral drugs are available to cure AIDS. However, antiviral drugs and vaccines are being researched. Prevention of transmission is currently the only approach to controlling this disease. Cytomegalovirus The AFSCME petition also discussed oc- cupational exposure to cytomegalovirus (C and its potential threat to pregnant women. CMV, an ubiquitous virus that in- fects most ple in the United States at some time in their lives, usually does not cause recognizable illness. However, the vi- rus can cause serious illness in congenitally infected newborns and in immunocom- 7 9520 New Developments 865 12887 promised individuals where the virus may be an opportunistic pathogen. Congenitally infected newborns may have cytomegalic in- clusion disease, a serious infection that in- volves the liver, spleen, and the central nervous system. Many AIDS patients have CMV infections, and their body fluids may contain cytomegalovirus. 4. Occupational Exposure to HIV and BBY P po an Hepatitis B and acquired immune defi- ciency syndrome are caused by viruses, in- fectious agents that are capable of human to human transmission. This transmission from one individual to another may result in infection and disease. A link has been estab- lished between occupational exposure to blood and other body fluids ano wue crans- mission of both HIV and HBV. A common mode of occupational exposure has been a needlestick with a blood-contaminated nee- dle. Cut injuries, caused by blood-contam- nated sharp instruments, and splashes of contaminated blood onto non-intact skin or mucous membranes are other modes of occu- pational transmission. Employees at risk of blood, body fluid, or needlestick exposures are at greater risk of infection with HBV or HIV. These include, but are not limited to nurses, physicians, dentists, and other dental workers, emer- gency room personnel, laboratory and blood bank technologists and technicians, phlebot- omists, dialysis personnel, paramedics, emergency medical technicians, medical ex- aminers, morticians, and others whose work involves close contact with patients or po- tential contact with their blood, with their body fluids, or with corpses. Other workers such as hospita) housekeepers, hospital laun- dry workers, firefighters, and law enforce- ment officers may also be at risk when their duties result in exposure to contaminated 5. State Plans When a final federal standard is promul- gated, the 25 states and territories with their own OSHA-approved occupational safety and health plans must adopt a compa- rable standard or amend their existing State standard, if not as effective as, the Federal standard, within 6 months. These states or territories are: Alaska, Arizona, California, Connecticut, Hawaii, Indiana, Iowa, Ken- tucky, Maryland, Michigan, Minnesota, Ne- vada, New Mexico, New York, North Carolina, Oregon, Puerto Rico, South Caro- lina, Tennessee, Utah, Vermont, Virginia, the Virgin Islands, Washington, and Wyo- ©1987, Commerce Ciearing House, Inc. B63 12887 ming. (In Connecticut and New York, the plan covers only State and local government employees.) 6. Request for Comments Public comment is requested to assist OSHA in its evaluation of the risks and methods of reducing occupational exposure to HBV and HIV. OSHA also requests that interested parties submit any pertinent health data not discussed in this notice. Comment is requested on the following is- sues relating to health effects, technological and economic feasibility, and provisions which should be considered for inclusion in a comprehensive standard. Specifically, sci- entific and technical data and expert analy- sis and opinion are sought on the following issues: (1) Scope of coverage: There is evidence that workers such as health-care employees exposed to blood and other body fluids are at increased msk of infection with HBV and HIV. Are there employees in occupations other than health-care who are at risk for HIV and HBV infections and who should be included in any rulemaking? What types of facilities should be included under health- care facilities? Should coverage be limited to health-care facilities or expanded to cover other facilities such as mortuaries or infec- tious wastes operations? (2) Public Sector Employees: OSHA has no direct jurisdiction over state and local gov- ernments which may employ health-care workers, emergency medical technicians, fire fighters, and law enforcement officers. However, the 25 states with approved State Plans will be required to extend their cover- age to public employees who are at occupa- tional risk for HBV and HIV infection. What public sector employees are at in- creased risk for HBV and HIV infection? How many of these individuals are located in states with approved State Plans? Are there conditions unique to any of these occu- pations that are not seen in the private sec- tor? What items of personal protective clothing and equipment can be used to re- duce the risk of occupational exposure? When should they be used? What work prac- tices will reduce their exposure? What train- ing is needed? What are current practices? (3) Significance of Risk: How many em- ployees are at risk for occupational ex to HBV and HIV? What information should OSHA consider to assess potential health risks from exposure? Are there any data, such as medical records or unpublished stud- 1e8 NOt now in the record, that should be Employment Safety and Health Guide New Developments 10,491 included in OSHA's decision-making pro- cess? Is there evidence that exposure to pa- tients with cytomegalovirus presents an increased occupational risk for health-care workers, particularly pregnant health-care workers? If so, how should this risk be reduced? (4) Modes of transmission: What is the risk of becoming infected as the result of a single or multiple exposure to blood or body fluids from individuals who are seropositive for HBV or HIV? What tasks in addition to those discussed place employees at risk of infection with HBV and/or HIV? (5) Methods of Controlling Exposure: What current control technologies, work practices, or precautions are availavie us iu use? How and when are they applied in spe- cific work settings? How effective are they in preventing or reducing exposure? Are there situations when these work practices cannot or should not be employed? What is the extent of worker acceptance of these methods? What are their costs and what is the time necessary for their implementa- tion? Should health-care facilities require that blood and body fluid precautions be fol- lowed for all patients? In addition to the guidelines published by OSHA, CDC, AHA, and AOMA, what other guidelines are avail- able? To what extent are they followed? Are there specific medical instruments or other devices such as puncture resistant needle containers or self-sheathing needies availa- ble to reduce the potential for exposure? How can such devices reduce exposure? Where should these devices be located rela- tive to their point of use? How much do they cost? (6) Personal protective clothing and equip- ment: What barrier techniques are available to reduce the likelihood of infection? Under what conditions should gloves be used? When should eye protection and/or gowns be used? What additional clothing or equip- ment should be used? Should gowns or other clothing be fluid-proof or fluid-resistant? How often should gloves, gowns, eye protec- tion or other equipment be changed? grould such equipment be cleaned and reused? Do adequate supplies of this clothing and equip- ment exist? What is the cost associated with this personal protective clothing and equipment? (7) Vaccination programs: What are cur- rent practices for administering HBV vac- cine to health-care employees? Should the employer be required to provide the hepati- tis B vaccine to employees? If so, who should receive the vaccine? What possible risks are 7 9520 10,492 associated with the HBV vaccine? How many or what percentage of employees have already received the complete vaccine se- ries? Are there circumstances where the vac- cine is contraindicated? What are the elements of a successful vaccination pro- 9 What factors are associated with a high degree of employee compliance with such a program? t are the costs of a vaccine program? Are there any state or lo- cal government regulations that require vac- cination against HBV? (8) Management of needlestick/cut/ splash injuries: These injuries are common occurrences in the health-care settings and are associated with the transmission of HBV and HIV. What is the appropriate manage- ment of such an injury when it results in exposure to blood from a patient known to be infected with HBV or with HIV? With blood from a patient of unknown status? Are these employees given the opportunity for voluntary antibody testing free of cost? How can the confidentiality of the employee's test results or other pertinent medical infor- mation be assured? (9) Medica! surveillance: Is it necessary to establish medical surveillance programs for workers at risk of occupational exposure to HBV and HIV? Do employers currently pro- vide specific procedures as part of medical surveillance for HBV and HIV? What is the oasis for selecting these procedures? At what frequency are they performed? Is there evi- dence that risk is reduced due to implemen- tation of medical surveillance programs? Should pregnant employees or women of childbearing age be subject to additional medical surveillance? (10) Training and education: How are em- ployees currently informed of the occupa- tional hazards associated with HBV and HIV? How should employees be trained to ensure that they understand the nature of HIV and HBV infections and the ways to reduce the likelihood of occupational expo- sure to these viruses? How many employees currently received training? How often is or should this training be repeated’ training programs available? Should this training address occupational exposures only or should it address personal behavior that increase risks as well? (11) Generic standards: Are there diseases other than hepatitis B and AIDS whose modes of transmission and methods of con- tro! are sufficiently similar to warrant in- cluding them in a “generic standard” for bloodborne diseases? If such a generic stan- dard would be more appropriate than a lim- q 9520 New Developments 865 128-87 ited one encompassing only hepatitis B and AIDS, what diseases should be included? To what extent are health-care workers at risk of contracting these diseases in their workplaces? (12) Advances in hazard control: How could OSHA structure a standard on blood- borne diseases so that the standard would reflect, on a continuing basis, technological advances and other improvements in meth- ods of control which were developed after promulgation of the standard? Similarly, is there any way OSHA could use a source outside the agency, such as guidelines pub- lished by the Centers for Disease Control, which are updated frequently, as indicative of what regulatory protections employers must provide for their employees? (13) Effectiveness of Alternative Ap- roaches: How can OSHA best accomplish its goal of ensuring that workers at signifi- cant risk are protected from occupational ex- posure to HIV and HBV? What additional protection would be afforded by a perma- nent standard, in light of the immediate on- going activities of DOL and HHS and ex- isting regulations? (14) Environmental Effects: The National Environmental Policy Act (NEPA) of 1969 (42 U.S.C. 4321, et seq.) the Council of Envi- ronmental Quality (CEQ) regulations (40 CFR Part 1500; 43 FR 55978, November 29, 1978), and the Department of Labor (DOL) NEPA one Regulations (29 CFR Part 11; 45 FR 51187 et seq., August 1, 1980) require that Federal Agencies give appropri- ate consideration to environmental issues and impacts of proposed actions significantly affecting the quality of the human environ- ment. OSHA is currently collecting written information and data on possible environ- mental impacts that may occur outside of the workplace as a direct or indirect result of promulgation of a standard for occupational exposure to the viruses that cause hepatitis B and AIDS. Possible environmental im- pacts include hazardous infectious wastes that are generated as the result of medical, research or other related activities. Informa- tion submitted should include any negative or positive environmental effects that could result from the regulation. In particular, how would regulation of worker exposure to HBV and HIV alter ambient air quality, water quality, solid waste or land use? 7. Public Participation Interested parties are invited to submit comments on any or all of these and other pertinent issues related to the development ©1987, Commerce Clearing Houes, inc. 86S 128-87 of a standard for HBV and HIV by January 26, 1988, in quadruplicate to the Docket Of- fice. Docket No. H-370, Room N-3670, U.S. Department of Labor, 200 Constitution Ave., NW., Washington, DC. 20210. All written comments submitted in response to this notice will be available for inspection and copying in the Docket Office at the above address between the hours of 8:15 am and 4:45 pm, Monday through Friday. All timely written submissions will be consid- ered in determining the nature of any proposal. List of Subjects in 29 CFR Part 1910 Occupational Safety and Health Adminis- tration, occupational safety and health; health; protective equipment, infectious dis- eases. AIDS. Acquired Immune Deficiency Syndrome, Hepatitis B. New Developments 10,493 Authority and Signature This Advance Notice of Proposed Rulemaking was prepared under the direc- tion of John A. Pendergrass, Assistant Secre- tary of Labor for Occupational Safety and Health, 200 Constitution Ave., NW., Wash- ington, DC 20210. It is issued pursuant to section 6(b) of the Occupational Safety and Health Act (84 Stat. 1893; 29 U.S.C. 6565). Signed at Washington, thi of November, 1987, DE this 24th cay John A. Pendergrass, Assistant Secretary. [FR Doe. 87-27424 Filed 11-25-87; 8:45 am . 5. INDIANA D T TE This new statute, effective July 1, 1988, deals with all aspects of AIDS, including issues that are relevant to the work place. (Statute attached). Section 17 of the Act (pp. 19-21) covers the employer's obligation with regard to health care workers and emergency medical technicians and other emergency . personnel (police and fire) whose work would bring them into contact with body fluids. The Act provides that an employer shall provide training and the necessary equipment to each employee who has duties that require the employee to have direct contact with blood or body fluids. An outline of the Indiana AIDS Act is also attached. -13- OUTLINE OF AIDS ACT D Section 1. Definition of how State Board will allocate funds to a political subdivision in the Prevention of Acquired Immune Deficiency Syndrome (AIDS). Section 2. Reporting requirements under the Act, when reports are to be made and what they are to contain. Section 3. (a) Except as provided in Section 3(b), may not perform a test without consent of the individual or repre- sentatives of the individual and a physician shall document such consent. Under (b) there are exceptions when and where a test can be performed. Subparagraph (b) provides that the test for the antibody HIV may be performed if one of the following c. .itions exist: (1) If ordered by a physician who has obtained a health care consent or implied consent under emergency circumstances and the test is medically necessary to diagnost or treat the patient's condition. (2) Under a court order based on clear and convincing evidence of a serious and present health threat to others posed by an individual. Any hearing held under this subsection shall be held in camera at the request of the individual. (3) (b) If the test is done on blood collected anonymously as part of an epidemiologic survey. Court can order testing under 1.C. §35-38-1-10.5(a) or I.C. §35-38-2-2(a) (15). Section 4. States when information is to be held confi- dential and under what limited conditions can it be released. States that information may not be released or made public upon subpoena (1) (2) (3) or otherwise except under the following circumstances: Release may be made of medical or epidemiologic information for statistical purposes if done in a manner that does not identify any individual. Release may be made of medical or epidemiologic information with the written consent of all indi- viduals identified in the information released. Release may be made of medical or epidemiologic information to the extent necessary to enforce public health laws or to protect the health or life of the main party. Otherwise, information must be kept confidential and disclosure of such information Scould result in a Class A misdemeanor. Section 5. Provides that attending physician or health care provider in preparing the body of a deceased must place a notice in a conspicuous place stating “observe body fluid precautions" when there is reasonable cause to believe that Geath was caused by an infectious disease including HIV. infec- tion. Section 6. Provides that a State Board agent may enter property under certain circumstances with presentation of proper credentials and under emergency conditions. Section 7. Deals with issue of infectious waste materials and how to dispose of them. Section 8. Deals with what is “a carrier" of a com- municable disease. Definition of a communicable disease or dangerous communicable disease is one that is so classified by the State Board of Health. This would include tuberculosis and apparently AIDS. Section 9. The person who has a communicable or infectious disease shall not work in a food establishment in any capacity in which epidemiologic evidence indicates the person may spread the disease. Section 10. This deals with dangerous communicable @isease exposure notification for emergency medical care providers. Primarily deals with those instances where emergency medical providers, firemen, law enforcement, paramedics, etc. are exposed, in the course of their employment, to body fluids which could transmit disease and what actions they must take. Section 11. Definition of a blood bank, storage facility or hospital: and defines various tests. Section 12. No implied warranty in organ transplant or blood transfusion and requirements on blood testing. Section 13. The State Board of Health must establish procedures to reasonably insure safety of the donor of blood and the recipient of whole blood plasma or blood products. Section 14. It is required that blood banks perform a screening test for blood to be used in transfusions and keep certain records. Section 15. Again deals with confidentiality and states a person may not disclose or be compelled to disclose information collected under this Chapter or under rules adopted under this Chapter. This information may not be released or made public in response to a subpoena or otherwise except under the follow- ing circumstances: (1) Release may be made of the information for Statistical purposes if done in a manner that does not identify any individual. (2) Release may be made of the information with the written consent of all individuals identified in the information released. (3) Release may be made of the information to the extent necessary to enforce public health laws or to protect the health or life of a named person. A person who discloses information can be guilty of a Class A misdemeanor. Section 16. Blood centers shall report the name and address of a blood donor to the Board when a confirmatory test of the blood donor's blood confirms the presence of antibodies known as the HIV virus. Also specifies the notice that must be given the donor. Provides that if a person recklessly, know- ingly or intentionally donates, sells, or transfers blood that contains HIV antibodies commits a Class C felony and it becomes a Class A felony if it results in the transmission of the virus to another person. Section 17. Those who work in the work place where body fluids are handled in regular course of employment are to be given certain education and protection by their employers. It provides: that an employer shall provide training and the necessary equipment to each employee who has duties that require the employee to have direct contact with blood or bodily fluids in the scope of the employee's employment. The employer shall comply with the following: (1) The training must be provided before the individual is given an assignment where contact of blood or body fluids is likely. (2) The training must include training and the universal precautions and other infection control measures that the Board has adopted. (3) An attendance record must be maintained of an indi- vidual participation in the training that is provided. An employer must provide training and shall develop a written personnel policy. There are sanctions for failure to comply. Section 18. Provides for payment of state funds for care of certain victims. Section 19. Changes expiration date. Section 20. Sets up an AIDS Advisory Council. Requires that the governing body of a school corporation must establish a council known as an AIDS Advisory Council and provides who shallI be on it. Section 21. School corporation must include in its cur- riculum instructions concerning the AIDS disease and must consider recommendations of the AIDS Advisory Council. Section 22. Application for a marriage license must contain information and acknowledgement that the applicants affirm they have received the information described regarding AIDS. There is a form of acknowledgement. Section 23. Describes the type of information the Circuit Court Clerk must distribute to marriage license applicants regarding information on AIDS. Section 24. Amends the statute which states what the Court must consider in imposing a sentence for a crime. It adds that in the case of a sex crime, if the crime created a risk of transmission of HIV virus or the crime involves a controlled substance the Court must consider this in imposing a sentence. Section 25. Requires that certain information be obtained from the probation officer concerning any person with HIV virus. Section 26. Requires that the court order a person to undergo screening for HIV if that person has been convicted of @ sex crime or convicted of an offense related to use of controlled substance. Section 27. Requires notification of persons of a positive test of AIDS if they have been the victim of a crime regarding a sex crime. Section 28. Requires the person who committed the crime to pay the cost of the test. Section 29. Certain conditions of probation may include test for HIV. Section 30. Adds further definitions to the Act. Section 31. Repealed. Section 32. Adds additional definitions to the Act. Section 33. State Board to provide information to all physicians and dentists. Section 34. Training for those required to handle body fluids must be completed before September 1, 1988. Section 35. State Board must. provide information to citizens of State of Indiana. Section 36. Sections 1-32--effective July 1, 1988; Sections33-35--upon passage. Second Regular Session 105th General Assembly PRINTING CODE Amendments Whenever an cxisting statute (ora section of the Indiana Constitution) is being amended. the text of the existing provision will appear in this atyle type, additions will appear in this style type. and deletions will appear in thie etyte type Additions Whenever a new atatutory provision ia being enacted (or a new constitutional provision adopted), the text of the new provision will appear in this style type Also, the word NEW will appear in that style type in the introductory clause of each SECTION that adds a new provision tothe indiana Code or the Indiana Constitution SENATE ENROLLED ACT No. 9 AN ACT to amend the Indians Code concerning acquired immune deficiency syndrome (AIDS) ° Be it enacted by the General Assembly of the State of Indiana: SECTION 1. IC 16-1-3.4-6 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 6. The state board shall consider the following factors in determining the allocation to a political subdivision of funds that are appropriated from the general fund to the state board for the prevention of acquired immune deficiency syndrome (AIDS): (1) The population size. (2) The reported incidence of the human immunodeficiency virus (HIV). (3) The availability of resources. SECTION 2. IC 16-1-9.5-2, AS ADDED BY P.L.196-1987, SECTION 1,1S AMENDED TO READ AS FOLLOWS. Sec. 2. (a) Each: (1) physician licensed under IC 25-22.5; (2) administrator of a hospital licensed under IC 16-10-1, or the administrator's representative, or (3) director of a medical laboratory, or the director's representative; shall report to the local or state health officer designated by the state board the information required to be reported by the rules adopted under section 1 of this chapter. (b) Each: (1) physician licensed under IC 25-22.5, (2) hospital licensed under IC 16-10-1; and (3) medical laboratory; shall report to the state board each case of human immunodeficiency virus (HIV) infection, including each 6 carried out in a manner consistent with rules adopted by the state board under section 8 of this chapter. Treatment may include the following: (1) Incineration. (2) Steam sterilization. (3) Chemical disinfection. (4) Thermal inactivation. (5) Irradiation. Sec. 3. As used in this chapter, “infectious waste” means waste that epidemiologic evidence indicates is capable of transmitting a dangerous communicable disease (as defined by rule adopted under IC 16-1-9.5-1). Infectious waste includes the following: (1) Pathological wastes. (2) Biological cultures and associated biologicals. (3) Contaminated sharps. (4) Infectious agent stock and associated biologicals. (5) Blood and blood products in liquid or semiliquid form. (6) Laboratory animal carcasses, body parts, and bedding. (7) Wastes (as defined under section 8 of this chapter). Sec. 4. As used in this chapter, “pathological waste" includes tissues, organs, body parts, and blood or body fluids in liquid or semiliquid form that are removed during surgery, biopsy, or autopsy. Sec. 5. As used in this chapter, “secure area” means an area that is designed and maintained to prevent the entry of unauthorized persons. Sec. 6. This chapter applies to persons and facilities that handle infectious waste, including the following: (1) Hospital. (2) Ambulatory surgical facility. (3) Medical laboratory. (4) Diagnostic laboratory. (5) Blood center. (6) Pharmaceutical company. (7) Academic research laboratory. (8) Industrial research laboratory. (9) Health facility. (10) Office of a health care provider. (11) Diet or health care clinic. (12) Office of a veterinarian. (13) Veterinary hospital. (14) Emergency medical services provider. (15) Mortuary. 7 Sec. 7. (a) Before infectious waste is placed in an area that is not a secure area and before the waste is sent for final disposal, all infectious waste must be: (1) effectively treated on site; or (2) transported off site for effective treatment; according to rules adopted by the state board under section 8 of this chapter. (b) A facility shall treat liquid infectious waste or those excreta that are infectious waste as required by subsection (a) or flush the liquid infectious waste or those excreta that are infectious waste in compliance with rules established by the state board of health under IC 4-22.2. Sec. 8. (a) After consulting with ean advisory committee composed of representatives of persons or facilities that handle infectious wastes, the state board shall adopt rules necessary under IC 4-22-2 to carry out this chapter. (b) The state board shall adopt rules under this section after considering the guidelines of the following: (1) United States Environmental Protection Agency. (2) United States Centers for Disease Control. | (3) United States Occupational Safety and Health Administration. (4) State department of labor. (5) State department of environmental management. SECTION 8. IC 16-1-10.5 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS Chapter 10.5. Prevention and Control of Communicable Diseases. Sec. 1. As used in this chapter, “carrier” means a person who has tuberculosis in a communicable stage or another dangerous communicable disease. Sec, 2. As uséd in this chapter, “communicable disease” has the meaning prescribed by the state board under IC 16-1-9.5-1. Sec. 3. As used in this chapter, “dangerons communicable disease” means a communicable disease that is classified by the state board as dangerous under IC 16-1-9.6-1. Sec. 4. As used in this chapter, “designated health official” means: (1) the state health commissioner; (2) an assistant state health commissioner; or (3) a person designated by the state health commissioner or assistant state health commissioner to 8 implement this chapter or IC 16-1-9.5 in a specific situation. Sec. 5. As used in this chapter, “health directive” means a written statement, or, in an emergency, an oral statement followed by a written statement within seventy- two (72) hours, to a carrier issued by a designated health official under this chapter. Sec. 6. As used in this chapter, “noncompliant behavior” means behavior of a carrier that is not in- compliance with a health directive. Sec. 7. As used in this chapter, “provider” has the meaning set forth in IC 16-4-8-1. .Sec. 8. (a) The state board shall tabulate all case reports of tuberculosis and other dangerous communicable diseases reported under IC 16-1-9.5 or under rules adopted under IC 16-1-9.5. The state board shall determine the prevalence and distribution of disease in Indiana and devise methods for restricting and controlling disease. (b) The state board shall include the information on the prevalence and distribution of tuberculosis and other dangerous communicable diseases in its annual report. (c) The state board shall disseminate the information prepared under this section. Sec. 9. Acarrier is a serious and present danger to the health of others under the following conditions: (1) The carrier engages repeatedly in a behavior that has been demonstrated epidemiologically (as defined by rules adopted by the state board under IC 4-22-2) to transmit a dangerous communicable disease or that indicates a careless disregard for the transmission of the disease to others. (2) The carrier's past behavior or statements indicate an imminent danger that the carrier will engage in behavior that transmits a dangerous communicable disease to others. Sec. 10. The health officer may make an investigation of each carrier to determine whether the environmental conditions surrounding the carrier or the conduct of the carrier requires intervention by the health officer or designated health official to prevent the spread of disease to others. Sec. 11. (a) A person who has reasonable cause to believe that a person: (1) is a serious and present danger to the health of 9 others as described in section 9 of this chapter; (2) has engaged in noncompliant behavior; or (3) is suspected of being at risk of infection; may report that information to a health officer. (b) A person who makes a report under this section in good faith is not subject to liability in any ci-il, administrative, disciplinary, or crimina’ ation. (c) Aperson who knowingly or recklessly makes a false report under this section is civilly liable for actual damages suffered by a person reported upon and for punitive damages. (d) A patient’s privilege with respect to a physician created by IC 34-1-14-5, is waived regarding any information about a patient reported to a health officer or designated health official under this section or about a patient's noncompliant behavior in any investigation or action under this chapter or under IC 16-1-9.5. Sec. 12. If a designated health official reasonably believes that a carrier presents a serious and present health threat (as described in section 9 of this chapter) by failure or refusal to comply with a health directive, the designated health official may file a petition under IC 16-1-9.5-4. Sec. 13. (a) If a designated health official determines that a carrier has a dangerous communicable disease and has reasonable grounds to believe that the carrier is mentally ill and either dangerous or gravely disabled, the designated health official may request immediate detention under IC 16-14-9.1-6.5 or emergency detention under IC 16-14-9.1-7 for the purpose of having the carrier apprehended, detained, and examined. The designated health official may provide to the superintendent of the psychiatric hospital or center or the attending physician information about the carrier's communicable disease status. Communications under this subsection do not constitute a breach of confidentiality. (b) If the written report required under IC 16-14-9.1-7(b) states there is probable cause to believe the carrier is mentally ill and either dangerous or gravely disabled and requires continuing care and treatment, proceedings may continue under IC 16-14-9.1. (c) Ifthe written report required under IC 16-14-9.1-7(b) states there is not probable cause to believe the carrier is mentally ill and either dangerous or gravely disabled and requires continuing care and treatment, the carrier shal] 10 be referred to the designated health official who may take action under this chapter or under IC 16-1-9.5. Sec. 14. (a) The court shall determine what part of the cost of care or treatment ordered by the court, if any, the carrier can pay and whether there are other available sources of public or private funding responsible for payment of the carrier's care or treatment. The carrier shall provide the court documents and other information necessary to determine financial ability. If the carrier cannot pay the full cost of care and other sources of public or private funding responsible for payment of the carrier's care or treatment are not available, the county is responsible for the cost. If the carrier provides inaccurate or misleading information, or later becomes able to pay the full cost of care, the carrier becomes liable to the county for costs paid by the county. (b) Except as provided in subsections (c) and (d), the costs incurred by the county under this chapter are limited to the costs incurred under section 20 of this chapter. (c) However, subsection (b) does not relieve the county of the responsibility for the costs of a carrier who is ordered by the court under this chapter or IC 16-1-9.5 toa county facility. (d) Costs, other than costs described in subsections (b) and (c) that are incurred by the county for care ordered by the court under this section or IC 16-1-8.5 shall be reimbursed by the state under IC 16-11-8-1. Sec. 15. (a) The chief medical officer of a hospital or other institutional facility may direct that a carrier detained under this chapter or under IC 16-1-9.5-4 be placed apart from the others and restrained from leaving the facility. A carrier detained under this chapter or under IC 16-1-9.5-4 shall observe all the rules of the facility or is subject to further action before the committing court. (b) A carrier detained under this chapter or under IC 16-1-9.5-4 who leaves a tuberculosis hospital or other institutional facility without being authorized to leave or who fails to return from an authorized leave without having first been formally discharged is considered absent without leave. (c) The sheriff of the county in which a carrier referred to in subsection (b) is found shall apprehend the carrier, and return the carrier to the facility at which the carrier was being detained upon written request of the 11 superintendent of the facility. Expenses incurred under this section are treated as expenses described in section 14 of this chapter. Sec. 16. A carrier who poses a serious and present danger to the health of others and has been voluntarily admitted to a hospital or other facility for the treatment of tuberculosis or another dangerous communicable disease who leaves the facility without authorized leave, or against medical advice, or who fails to return from authorized leave shall be reported to a health officer by the facility within twenty-four (24) hours of discovery of the carrier's absence. If a health officer fails or refuses to institute or complete necessary lega] measures to prevent a health threat (as described in section 9 of this chapter) by the carrier, the case shall be referred to a designated health official for appropriate action under this chapter or under IC 16-1-9.5. Sec. 17. A designated health official may file a report with the court that states that a carrier who has been detained under this chapter may be discharged without danger to the health or life of others. The court may enter an order of release based on information presented by the designated health official or other sources. Sec. 18. Within thirty (30) days of the proposed release of any prisoner known to have tuberculosis in a communicable stage or other dangerous communicable disease from any state penal institution, the chief administrative officer of the penal institution from which the prisoner will be released shall report to the state board the name, address, age, sex, and date of release of the prisoner. The state board shall provide the information to the health officer having jurisdiction over the prisoner's destination address. Each health officer where the prisoner may be found has jurisdiction over the released prisoner. Sec. 19. The administrator of a hospital or other facility for the treatment of tuberculosis or another dangerous communicable disease may transfer or authorize the transfer of nonresident indigent carriers to the state or county of their legal residence if they are able to travel. If the carrier is unable to travel, the administrator may have the carrier hospitalized until the carrier is able to travel. Costs for the travel and hospitalization authorized by this section shall be paid by the carrier under section 14 of this chapter or by the state board if the carrier cannot pay the full cost. 12 Sec. 20. (a) To protect the public health in an emergency, the court may order a health officer or law enforcement officer to take a person into custody and transport the person to an appropriate emergency care or treatment facility for observation, examination, testing, diagnosis, care, treatment, and, if necessary, temporary detention. If the person is already institutionalized, the court may order the institutional facility to hold the person. Orders under this subsection may be issued in an ex parte proceeding upon an affidavit of the designated health official. Upon a determination by the court that probable cause exists to believe that the person presents a serious and present danger to health (as described in section 9 of this chapter) and that irreparable harm is likely to result to others if the person is not immediately prevented from engaging in the activities that pose a serious and present danger to health, the court shall issue an order imposing on the person the least restrictive limitations, including detention, that are necessary to eliminate the health threat. (b) The affidavit must set forth the specific facts upon which the order is sought and must be served on the person immediately upon apprehension or detention. An order under this section may be executed at any time. (c) A person may not be held under subsection (a) longer than seventy-two (72) hours, exclusive of Saturdays, Sundays, and legal holidays, without a court hearing to determine if the emergency hold should continue. (d) Notice of the hearing on the continuation of the emergency hold must be served upon the person held under thie section at least twenty-four (24) hours before the hearing. The notice must specify: (1) the time, date, and place of the hearing; (2) the grounds and underlying facts upon which the emergency hold is sought; (3) the person's right to appear at the hearing and to cross-examine witnesses; and (4) the person's right to court appointed counsel under IC 16-1-9.5-5. (e}) The court may order the emergency or continued holding of the person if it finds, by clear and convincing evidence, that the person would pose an imminent health threat to others if released. However, in no event may the emergency hold continue longer than five (5) days unless a petition to implement medically necessary procedures to 13 protect the public's health is filed under IC 16-1-9.5-4. Ifa petition is filed, the limitations imposed by the court may continue until a hearing on the petition is held under IC 16-1-9.5-4. That hearing must occur within five (5) days of the filing of the petition, excluding Saturdays, Sundays, and legal holidays. Sec. 21. (a) Identifying information voluntarily given to the health officer or an agent of the health officer through a voluntary contact notification program may not be used as evidence in a court proceeding to determine noncompliant behavior under this chapter or for purposes of IC 16-1-9.5. (b) The provisions of IC 16-1-9.5-7 regarding confidentiality apply to information obtained under this chapter. (c) A court may release to an individual, or to a representative designated in writing by that individual, information or records relating to the individual's medical condition if the individual is a party in a pending action involving restriction of the individual's actions under IC 16-1-9.5 or this chapter. A person who obtains information under this subsection is subject to IC 16-1-9.5-7. Sec. 22. The superintendent or the chief executive officer of the facility to which a carrier has been ordered under this chapter or IC 16-1-9.5 may decline to admit a patient if the superintendent or chief executive officer determines that there is not available adequate space, treatment staff, or treatment facilities appropriate to the needs of the patient. Sec. 23. This chapter is not intended to interfere with the right of an individual to select any mode of treatment, including reliance upon spiritual means through prayer alone for healing. However, all other provisions of this chapter apply. Sec. 24. The state board may adopt rules under IC 4-22-2 to implement this chapter. SECTION 9. IC 16-1-20-21 IS AMENDED TO READ AS FOLLOWS: Sec. 21. A person who has a communicable or infectious disease shall not work in a food establishment in any capacity in which epidemiological evidence indicates the person may spread the disease. SECTION 10. IC 16-1-45 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS: Chapter 45. Dangerous Communicable Disease 14 Exposure Notification for Emergency Care Providers. Sec. 1. As used in this chapter, “dangerous communicable disease” has the meaning set forth in IC 16-1-10.5-3. Sec. 2. As used in this chapter, “emergency medical care” has the meaning set forth in IC 16-1-39-2. Sec. 3. As used in this chapter, “emergency medical care provider” means a firefighter, law enforcement officer, paramedic, emergency medical technician, or other person who provides emergency medical care in the course of the person's employment. Sec. 4. As used in this chapter, “emergency medical service facility” has the meaning set forth in IC 16-1-39-2. Sec. 5. (a) An emergency medical care provider who is exposed to blood or body fluids while providing emergency medical care to a patient shall notify the emergency medical service facility receiving the patient, within twenty-four (24) hours after the patient is admitted to the facility, on a form that is prescribed by the state board and the emergency medical services commission. (b) The exposure to blood or body fluids under subsection (a) must be of a magnitude that has been demonstrated epidemiologically to transmit a dangerous communicable disease. (c) The emergency inedical care provider shall _ distribute a copy of the completed form required under subsection (a) to the following: (1) The receiving medical facility. (2) The facility that employs the emergency medical care provider. (3) The state board. Sec. 6. (a) Except as provided in subsection (b), a physician designated by an emergency medical service facility shall notify the medical director of a facility employing the emergency medical care provider described in section 5 of this chapter if: (1) within seventy-two (72) hours after a patient is admitted to the facility, the facility obtains information from the patient's records or a diagnosis at the facility that the patient has a dangerous communicable disease; and (2) the emergency medical care provider has complied with section 5 of this chapter. (b) An emergency care provider may designate a physician other than the medical director of the facility 15 that employs the emergency care provider to receive notification on the form described in section 5(a) of this chapter. (c) The notification required by this section shall be made within forty-eight (48) hours after the facility determines that a patient has a dangerous communicable disease that is potentially transmissible through the incident. Sec. 7. (a) Ifmedically indicated, a physician notified under section 6 of this chapter shall contact the emergency medical care provider described in section 5 of this chapter: (1) to explain, without disclosing information about the patient, the infectious disease to which the emergency medical care provider was exposed; and (2) to provide for any medically necessary treatment and counseling to the emergency medical care provider. (b) Any expenses of treatment and counseling are the responsibility of the emergency medical care provider or the provider's employer. Sec. 8. (a) Except as provided in sections 6 and 7 of this chapter, a person may not disclose or be compelled to disclose medical or epidemiological information referred to in this chapter. (b) A person responsible for recording, reporting, or maintaining information referred to in this chapter wo recklessly, knowingly, or intentionally discloses or fails to protect medical or epidemiological information classified as confidential under this section commits a Class A misdemeanor. (c) In addition to the penalty prescribed by subsection (b), a public employee who violates this section is subject to discharge or other disciplinary action under the personnel rules of the agency that employs the employee. Sec. 9. A person who makes a report under this chapter in good faith is not subject to liability in any civil, administrative, disciplinary, or criminal action. Sec. 10. The state board shall adopt rules under IC 4-22-2 to carry out this chapter. SECTION 11. IC 16-8-7-1 IS AMENDED TO READ AS FOLLOWS: Sec. 3. (a) As used in this chapter, unless etherwice provided; the terms “bank”, er “storage facility”, “hospital”, “physician”, er and “surgeon” shad have the same meaning es defined by set forth in IC 4644, 29-2-16-1. (b) As used in this chapter, “blood center” includes a 16 blood bank, a blood storage facility, a plasma center, or other facility where blood or blood products are donated or sold. (c) Asused inthis chapter, “confirmatory test” means a laboratory test or a series of tests approved by the state board and used in conjunction with a screening test to confirm or refute the results of the screening test for the human immunodeficiency virus (HIV) antigen or antibodies to the human immunodeficiency virus (HIV). (d) As used in this chapter, “screening test” means a laboratory screening test or a series of tests approved by | the state board to detect the presence of the human immunodeficiency virus (HIV) antigen or antibodies to the human immunodeficiency virus (HIV). SECTION 12. IC 16-8-7-2 IS AMENDED TO READ AS FOLLOWS: Sec. 2. (a) The procurement, processing, distribution, or use of whole blood, plasma, blood products, blood derivatives, or other human tissue, such as corneas, bones, or organs by a bank, storage facility, or hospital and the injection, transfusion, or transplantation of any of them into the human body by a hospital, physician, or surgeon, whether or not any remuneration is paid is declared to be for all purposes the rendition of a service and not the sale of a product. No such services shel} give rise to an implied warranty of merchantability or fitness for a particular purpose, nor give rise to strict liability in tort. (b) A hospital, physician, or other person is not required to perform another screening test on whole blood, plasma, blood products, or blood derivatives that are provided by a blood center if the blood is labeled indicating that it has been tested as required under section 4 of this chapter. (c) A blood donor may specify that the donor's blood must be used for the donor or another person specified by the donor. Blood that is donated under this section must be tested for the human immunodeficiency virus (HIV). SECTION 13. IC 16-8-7-3 IS AMENDED TO READ AS FOLLOWS: Sec. 3. The indiana state board of health shall estoblish reasenable standards for the preeurement; preeessing; and distribution of whele bleed; plasma; bleed preduecte, er bleed derivatives: adopt rules under JC 4-22-2 to carry out the purposes of this chapter. In formulating such standerde rules, the Indiana state board of health shall consider present medica! and scientific practices in the field and any other proper procedure that should be followed to 17 reasonably insure the safety of the donor and recipient of whole blood, plasma, blood products, and blood derivatives. Such etendards shall be promulgated in the menner provided by law for the promulgation of rules and regulations of administrative bodies and may be rescinded; amended er modified in the same menner. SECTION 14. IC 16-8-7-4 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 4. (a) A blood center shall perform a screening test on a donor's blood before blood, plasma, a blood product, or a blood derivative is distributed for use. (b) The blood center shall label blood, plasma, a blood product, or a blood derivative to indicate the results of the tests required by this chapter. The blood center shall also label each blood sample with the name and address of the blood center. (c) The blood center shall perform a confirmatory test on a blood donation from a donor when the screening test performed under subsection (a) yields positive results. (d) The blood center shall dispose of a blood donation after a confirmatory test has been performed. The disposal must be made under rules adopted by the state board under this chapter and IC 16-1-9.7. (e) A blood center shall report to the state board the .esults of each confirmatory test conducted under subsection (c). (f) A blood center shall attempt to notify a donor when the confirmatory test on the donor's blood indicates the presence of antibodies to the human immunodeficiency virus (HIV). (g) The state board shall distribute to blood centers guidelines concerning screening tests and confirmatory tests. (h) An employee who is responsible for conducting the screening test required under this section who knowingly or intentionally fails to conduct the screening test commits a Class A misdemeanor. (i) Each health care provider that administers blood transfusions shal! keep a record of the blood center that furnished the blood. These records shall be made availabie to the state board for inspection. SECTION 15. IC 16-8-7-5 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 5. (a) A person may not disclose or be compelled to disclose information collected under this chapter or under rules 18 adopted under this chapter. This information may not be released or made public upon subpoena or otherwise, except under the following circumstances: (1) Release may be made of the information for statistical purposes if done in a manner that does not identify any individual. \2) Release may be made of the information with the written consent of all individuals identified in the information released. (3) Release may be made of the information to the extent necessary to enforce public health laws or to protect the health or life of a named person. (b) Except as provided in subsection (a), a person responsible for recording, reporting, or maintaining information required to be reported under this chapter who recklessly, knowingly, or intentionally discloses or fails to protect information classified as confidential under this section commits a Class A misdemeanor. (c) In addition to subsection (b), a public employee who violates this section is subject to discharge or other disciplinary action under the personnel rules of the agency that employs the employee. SECTION 16. IC 16-8-7-6 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS. Sec. 6. (a) A blood cente: shall require a blood donor to provide to the blood center the following information: (1) Name. (2) Address. (3) Date of birth. (b) A blood center may request a blood donor to provide the blood donor's social security number. (c) A blood center shall report the the name and address of a blood donor to the board when a confirmatory test of the blood donor's blood confirms the presence of antibodies to the human immunodeficiency virus (HIV). (d) A blood center shall provide to a blood donor information to enable the blood donor to give informed consent to the procedures required by this article. The information required by this subsection must be in the following form: NOTICE (1) This blood center performs a screening test for the human immunodeficiency virus (HIV) on every donor's blood. (2) This blood center reports to the state board of 19 health the name and address of a blood donor when a confirmatory test of the blood donor’s blood confirms the presence of antibodies to the human immunodeficiency virus (HIV). (3) A person who recklessly, knowingly, or intentionally donates, sells, or transfers blood or a blood component that contains antibodies for the human immunodeficiency virus (HIV) commits transferring contaminated blood, a Class C felony. The offense is a Class A felony if it results in the transmission of the virus to another person. SECTION 17. IC 16-10-7 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS: Chapter 7. Training in Health Precautions for Communicable Diseases. Sec. 1. As used in this chapter, “employer” has the meaning set forth in IC 22-8-1.1-1. Sec. 2. As used in this chapter, “facility” means a building where an individual handles blood or other body fluids in the regular course of the individual's employment. Sec. 3. Asusedin this chapter, “universal precautions” means procedures specified by rule adopted by the state board of health under IC 4-22-2 that are used to prevent the transmission of dangerous communicable diseases, including acquired immune deficiency syndrome (AIDS), through blood or other body fluids. Sec. 4. An employer shall provide training and the necessary equipment to each employee who has duties that require the employee to have direct contact with blood or body fluids in the scope of the employee's employment. The employer shall comply with the following: (1) The training must be provided before the individual is given an assignment where contact with blood or body fluids is likely. (2) The training must include training in the universal precautions and other infection control measures that the board adopts by rule under IC 4-22-2. (3) An attendance record must be maintained of an individual's participation in the training that is provided. The record must be made available to the board for inspection under sectior. 6 of this chapter. Sec. 6. An employer who is required to provide training under section 4 of this chapter shall develop a written personnel policy that: 20 (1) requires the use of universal precautions when an individual has direct contact with blood or other body fluids; and (2) provides sanctions, including discipline and dismissal if warranted, for failure to use universal] precautions. Sec. 6. (a) The state board of health may designate an agent who, upon presentation of proper credentials, may enter a facility to inspect for possible violations of this chapter or rules adopted under this chapter. (b) The board may commence an action under IC 4-21.5-3-6 or IC 4-21.6-4 for issuance of an order of compliance and civil penalty not to exceed one thousand dollars ($1,000) per violation per day against any person who: (1) fails to comply with this chapter or rules adopted under this chapter; or (2) interferes with or obstructs the state board of health or its designated agent in the performance of its official duties under this chapter. (c) The state board may commence an action against a facility licensed by the state board under either subsection (b) or the licensure statute for the facility, but the state board may not bring an action arising out of one (1) incident under both statutes. (d) The state board may report to any other board or agency responsible for licensure, registration, or certification of health care providers, facilities, or other health care workers an individual or facility that is found to be operating in violation of this chapter or rules adopted under this chapter. Sec. 7. (a) A person who believes that this chapter or the rules adopted under this chapter have been violated may file a complaint with the state board of health. A complaint must be in writing unless the violation complained of constitutes an emergency. The board shall reduce an oral complaint to writing. The board shall maintain the confidentiality of the person who files the complaint. (b) The board shall promptly investigate all complaints received under this section. (c) The board shall not disclose the name or identifying characteristics of the person who files a complaint under this section unless: (1) the person consents in writing to the disclosure; or 21 (2) the investigation results in an administrative or judicial proceeding and disclosure is ordered by the administrative law judge or the court. (da) The board shall give a person who files a complaint under this section the opportunity to withdraw the complaint before disclosure. (e) An employee must make a reasonable attempt to ascertain the correctness of any information to be furnished and may be subject to disciplinary actions for knowingly furnishing false information, including suspension or dismissal, as determined by the employer. However, an employee disciplined under this subsection is entitled to process an appeal of the disciplinary action under any procedure otherwise available to the employee by employment contract, collective bargaining agreement, or, if the employee is an employee of the state, a rule as set forth in IC 4-15-2-34 and IC 4-15-2-36. (f) The employer of an employee who files a complaint in good faith with the board under this section may not, solely in retaliation for filing the complaint: (1) dismiss the employee; (2) withhold salary increases or employment related benefits from the employee; (3) trarsfer or reassign the employee; (4) deny a promotion that the employee would have received; or (5) demote the employee. Sec. 8. The state board of health shall adopt rules under IC 4-22-2 to implement this chapter. SECTION 18. IC 16-11-8-1 IS AMENDED TO READ AS FOLLOWS: Sec. 1. (a) Each county, city, and municipal corporation owning and operating a hospital or sanatorium under IC 16-11-1, IC 16-11-6, or IC 16-12-21 is entitled to receive from the state for each tuberculosis patient treated and cared for at the hospital or sanatorium an amount per day equal to the amount approved by the governing body of the hospital or sanitorium as the average daily semi-private room rate charged to each of its patients less any amounts received for such purposes from any third party payors. (b) With the approval of the state budget director upon the recommndation of the state budget committee, each county that has incurred costs for a carrier under IC 16-1-9.5 or IC 16-1-10.5, other than costs incurred under IC 16-1-10.5-20, is entitled to a pro rata share of the funds remaining at the end of the fiscal year in the account established under this section. 22 SECTION 19. IC 16-11-8-111S ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 11. This chapter expires July 1, 1989. SECTION 20. IC 20-8.1-11 1S ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS: Chapter 11. Acquired Immune Deficiency Syndrome (AIDS) Advisory Council. Sec. 1. As used in this chapter, “AIDS” means the communicable disease known as acquired immune deficiency syndrome. Sec. 2. As used in this chapter, “council” refers to the AIDS advisory council established by this chapter. Sec. 3. (a) The governing body of a school corporation shall establish a council. (b) Subsection (a) does not apply to a school corporation that has: (1) established an advisory committee composed of parents, students, teachers, administrators, and representatives of the state board of health; and (2) met and identified educational materials and resources reflecting community standards on AIDS before February 15, 1988. Sec. 4. The council consists of thirteen (13) members. The governing body shall appoint all the members of the council. Sec. 5. One (1) member of the council must be: (1) arepresentative of the local or state board of health; and (2) trained in the area of dangerous communicable diseases, including AIDS. Sec. 6. The remaining members must include the following persons: (1) Two (2) students. (2) Two (2) teachers. (3) Two (2) parents or guardians of children who attend public schools governed by the school corporation. (4) Two (2) representatives of school administrators. (5) Two (2) representatives of the health care professions, one (1) of whom must be a physician licensed under IC 25-22.5. (6) Two (2) citizens who reside in the community served by the school corporation. Sec. 7. Each council member has a term of two (2) years, beginning upon appointment. If a successor is not appointed at the end of the term, the term continues until a successor is appointed. 23 Sec. 8. The council shall, at its first meeting of each year, elect a chairman, vice chairman, and secretary. Sec. 9. The officers elected under section 8 of this chapter have terms that begin upon election and end upon the election of a successor. Sec. 10. The governing body of the school corporation shall furnish the council with the necessary staff to conduct its business. Sec. 11. Atthe first meeting ofthe year, a representative of the local or state board of health, or a person approved by the state board of health, shall instruct the members of the council on the source, transmission, and prevention of AIDS. -— Sec. 12. At the second meeting of the year, the council shall hold a public meeting and solicit testimony from members of the community concerning community attitudes and values on matters that affect the instruction on AIDS that is presented within the school corporation. Sec. 13. The council shall do the following: ()) Identify and study educational materials and resources on AIDS that are available for use in the schools within the schoo! corporation. (2) Determine which educational materials and resources are based on sound medical principles and reflect the attitude of the community. (3) Recommend to the school corporation educational materials and resources on AIDS that reflect the standards of the community. Sec. 14. The governing body of the school corporation shall consider the recommendations of the advisory council. SECTION 21. IC 20-10.1-4-10 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 10. (a) Each school corporation shall include in its curriculum instruction concerning the disease known as acquired immune deficiency syndrome (AIDS) and shall integrate this effort to the extent possible with instruction on other dangerous communicable diseases. (b) A school corporation shall consider the recommendations of the AIDS advisory council (as established in IC 20-8.1-11) concerning community standards on the conient of the instruction, the manner in which the information is presented, and the grades in which it is taught. 24 (c) Literature that is distributed to school children and young adults under this section must include information required by IC 20-8.1-7-21. (d) The department, in consultation with the state board of health, shall develop AIDS educational materials. The department shall make the materials developed under this section available to school corporations. SECTION 22. IC 31-7-38-3, AS AMENDED BY P.L.180-1986, SECTION 1, IS AMENDED TO READ AS FOLLOWS: Sec. 3. (a) An application for a marriage license shall be written and verified. The application shal! contain the following information concerning both of the applicants: (1) Fall name. (2) Birthplace. (3) Residence. (4) Age. (5) Names of dependent children. (6) Full name (including the maiden name of a mother), residence, and birthplace of the parents of dependent children. (7) Astatement of facts necessary to determine whether any legal impediment to the proposed marriage exists. (8) An acknowledgment that both applicants must sign, affirming that they have received the information described in section 3.5 of this cl.apter, including a list of test sites for the virus that causes AIDS (acquired immune deficiency syndrome). The acknowledgment required by this subdivision must be in the following form: ACKNOWLEDGMENT I acknowledge that I have received information regarding dangerous communicable diseases that are sexually transmitted, and a list of test sites for the virus that causes AIDS (acquired immune deficiency syndrome). Signature of Applicant Date Signature of Applicant Date (b) The application shall be recorded by the clerk, together with the license and certificate of marriage in a book provided for that purpose. This book is a public record. (c) The state board of health shall develop uniform forms for applications for marriage licenses. The state board of health shall furnish these forms to the circuit court clerks. The state board of health may periodically revise these forms. 25 (d) Notwithstanding subsection (a), a member ef the Old person who objects on religious grounds Amish Mennonite ehureh is not required to verify the application under subsection (a) by oath or affirmation or sign the acknowledgment described in subsection (a)(8). However, before the clerk of the circuit court may issue a marriage license toa member of the Old Amish Mennonite church, the bishop of that member must sign a atatement that the information in the application is true. (e) Ifa person objects on religious grounds to verifying the application under subsection (a) by oath or affirmation or to signing the acknowledgment described in subsection (a)(8), the clerk shall indicate that fact on the application for a marriage license. SECTION 23. IC 31-7-3-3.5 1S ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 3,5. (a) The circuit court clerk shall distribute to marriage license applicants written information or videotaped information approved by the AIDS advisory council of the state board of health concerning dangerous communicable diseases that are sexually transmitted. (b) The provider of the materials is responsible for all costs involved in the development, preparation, and distribution of the information required under this section. Except for the materials developed by the state, the state and county are net liable for the costs of materials used to implement this section and section 3 of this chapter. (c) Written information and videotaped information distributed by each circuit court clerk under subsection (a) must provide current information on human immunodeficiency virus (HIV) infection and other dangerous communicable diseases that are sexually transmitted. The information must include an explanation of the following: (1) The etiology of dangerous communicable diseases that are sexually transmitted. (2) The behaviors that create a high risk of transmission of such diseases. (3) Precautionary measures that reduce the risk of contracting such diseases. (4) The necessity for consulting medical specialists if infection is suspected. (ad) At the time of application for a marriage license, each circuit court clerk shall: ; (1) provide the marriage license applicants with 26 written information furnished under subsection (a) concerning dangerous communicable diseases that are sexually transmitted; or (2) show the marriage license applicants videotaped information furnished under subsection (a) concerning dangerous communicable diseases that are sexually transmitted. {e) In addition to the information provided marriage license applicants under subsection (d), each circuit court clerk shall inform each marriage license applicant that the applicant may be tested on a voluntary basis for human immunodeficiency virus (HIV) infection by the applicant's private physician or at another testing site. The clerk shall provide the marriage applicants with a list of testing sites in the community. (f) If materials required by this section are not prepared by other sources, the state board of health shall prepare the materials. (g) Anapplicant who objects to the written information or videotaped information on religious grounds shall not be required to receive such information. SECTION 24. IC 35-38-1-7, AS AMENDED BY P.L.320-1987, SECTION 1, IS AMENDED TO READ AS FOLLOWS: Sec. ’. (a) In determining what sentence to impose for a crime, the court shall consider: (1) the risk that the person will coramit another crime, (2) the nature and circumstances of the crime committed: (3) the person's (A) prior criminal record, (B) character; and (C) condition; (4) whether the victim of the crime was less than twelve (12) years of age or at least sixty-five (65) years of age; and (5) any oral or written statement made by a victim of the crime. (b) The court may consider the following factors as aggravating circumstances or as favoring imposing consecutive terms of imprisonment: (1) The person has recently violated the conditions of any probation, parole, or pardon granted him. (2) The person has a history of criminal or delinquent activity. (3) The person is in need of correctional or rehabilitative treatment that can best be provided by his commitment toa penal facility. 27 (4) Imposition of a reduced sentence or suspension of the sentence and imposition of probation would depreciate the seriousness of the crime. (5) The victim of the crime was less than twelve (12) years of age or at least sixty-five (65) years of age. (6) The victim of the crime was mentally or physically infirm. (7) The person committed a forcible felony while wearing a garment designed to resist the penetration of a bullet. (8) The person committed a sex crime listed in subsection (e) if: (A) the crime created an epidemiologically demonstrated risk of transmission of the human immunodeficiency virus (HIV); (B) the person had knowledge that the person was a carrier of HIV; and (C) the person had received risk counseling as described in subsection (g). (9) The person committed an offense related to controlled substances listed in subsection (f) if: (A) the offense involved: (i) the delivery by any person to another person; or (ii) the use by any person on another person; of acontaminated sharp (as defined in IC 16-1-9.7-1) or other paraphernalia that creates an epidemiologically demonstrated risk of transmission of HIV; (B) the person had knowledge that the person was a carrier of the human immunodeficiency virus (HIV); and (C) the person had received risk counseling as described in subsection (g). (c) The court may consider the following factors as mitigating circumstances or as favoring suspending the sentence and imposing probation: (1) The crime neither caused nor threatened serious harm to persons or property, or the person did not contemplate that it would do so. (2) The crime was the result of circumstances unlikely to recur. (3) The victim of the crime induced or facilitated the offense. (4) There are substantial grounds tending to excuse or justify the crime, though failing to establish a defense. (5) The person acted under strong provocation. 28 (6) The person has no history of delinquency or criminal activity, or he has led a law-abiding life for a substantial period before commission of the crime. (7) The person is likely torespond affirmatively to probation or short term imprisonment. (8) The character and attitudes of the person indicate that he is unlikely to commit another crime. (9) The person has made or will make restitution to the victim of his crime for the injury, damage, or Joss sustained. (10) Imprisonment of the person will result in undue hardship to himself or his dependents. (d) The criteria listed in subsections (b) and (c) do not limit the matters that the court may consider in determining the sentence. (e) For the purposes of this article, the following crimes are considered sex crimes: Rape (IC 35-42-4-1). Criminal] deviate conduct (IC 35-42-4-2), Child molesting (IC 35-42-4.3), Child seduction (IC 35-42-4-7). Prostitution (IC 35-45-4-2), Patronizing a prostitute (IC 35-45-4.3). Incest (IC 35-46-1-3). (f) For the purposes of this article, the following crimes are considered offenses related to controlled substances: (1) Dealing in cocaine or narcotic drug (IC 35-48-4-}), (2) Dealing in a schedule 1, II, or III controlled substance (IC 35-48-4-2), (3) Dealing in a schedule IV controlled substance (IC 35-48-4-3). (4) Dealing in a schedule V controlled substance (IC 35-48-4-4). (5) Possession of cocaine or narcotic drug (IC 35-48-4-6). (6) Possession of a controlled substance (IC 35-48-4-7), (7) Dealing in paraphernalia (IC 35-48-4-8.2), (8) Possession of paraphernalia (IC 35-48-4-8.3). (9) Offenses relating to registration (IC 35-48-4-14), (g) For the purposes of this section, a person received risk counseling if the person had been: (1) notified in person or in writing that tests have confirmed the presence of antibodies to the human immunodeficiency virus (HIV) in the person's blood; and (2) warned of the behavior that can transmit HIV. 29 SECTION 25. IC 35-38-1-9.6 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 9.5. A probation officer shal! obtain confidential information from the state board of health under IC 16-1-9.5-7 to determine whether a convicted person was a carrier of the human immunodeficiency virus (HIV) when the crime was committed if the person is: (1) convicted of a sex crime listed in section 7(e) of this chapter and the crime created an epidemiologically demonstrated risk of transmission of the human immunodeficiency virus (HIV); or (2) convicted of an offense relating to controlled substances listed in section 7(f) of this chapter and the offense involved the conditions described in IC 35-38-1-7(b)(9)(A). SECTION 26. IC 35-38-1-10.6 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 10.5. (a) The court shall order that a person undergo a screening test for the human immunodeficiency virus (HIV) if the person is: (1) convicted of a sex crime listed in section 7(e) of this chapter and the crime created an epidemiologically demonstrated risk of transmission of the human immunodeficiency virus (HIV); or (2) convicted of an offense related to controlled substances listed in section 7(f) of this chapter and the offense involved the conditions described in 1C 35-38-1-7(b)(9)(A). (b) If the screening test required by this section indicates the presence of antibodies to HIV, the court shall order the person to undergo a confirmatory test. (c) Ifthe confirmatory test confirms the presence of the HIV antibodies, the court shall report the results to the state board of health and require a probation officer to conduct a presentence investigation to: (1) obtain the medical record of the convicted person from the state board of health under IC 16-1-9.6-7(a)(4); and (2) determine whether the convicted person had received risk counseling that included information on the behavior that facilitates the transmission of HIV. (da) A person who, in good faith: (1) makes a report required to be made under this section; or (2) testifies in a judicial proceeding on matters arising from the report; 30 is immune from both civil and criminal liability due to the offering of that report or testimony. (e) The privileged communication between a husband and wife or between a health care provider and the health care provider's patient is not a ground for excluding inform.ition required under this section. () A mental health service provider (as defined in IC 34-4-12.4-1) who discloses information that must be disclosed to comply with this section, is immune from civil and criminal liability under Indiana statutes that protect patient privacy and confidentiality, SECTION 27. IC 35-38-1-10.6 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 10.6. (a) The state board of health shall notify victims of the crimes listed in section 7(e) and 7(f) of this chapter if tests conducted under section 10.5 of this chapter confirm the person who committed the crime had antibodies for the human immunodeficiency virus (HIV), (b) The state board of health shall provide counseling to persons notified under this section. SECTION 28. IC 35-38-2-1, AS AMENDED BY P.L.305-1987, SECTION 36, IS AMENDED TO READ AS FOLLOWS: Sec. 1. (a) Whenever it places a person on probation, the court shall specify in the record the conditions of the probation. In addition, if the person was convicted of a felony, the court shall order the person to pay to the probation department the user's fee prescribed under subsection (b). Ifthe person was convicted of a misdemeanor, the court may order the person to pay the user's fee prescribed under subsection (c). The court may: (1) modify the conditions (except a fee payment under subsection (b)); or (2) terminate the probation; at any time. Ifthe person commits an additional crime, the court may revoke the probation. (b) In addition to any other conditions of probation, the court shall order each person convicted of a felony to pay: (1) not less than twenty-five dollars ($25) nor more than one hundred dollars ($100) as an initial probation user's fee; and (2) amonthly probation user's fee of not less than five dollars ($5) nor more than fifteen dollars ($15) for each month that the person remains on probation; and (3) the costs of the laboratory test or series of tests to detect and confirm the presence of the human immunodeficiency virus (HIV) antigen or antibodies to 31 the human immunodeficiency virus (HIV) if such tests are required by the court under section 2 of this chapter; to the probation department. (c) Inaddition to any other conditions of probation, the court may order each pereon convicted of a misdemeanor to pay: (1) not more than a fifty dollar ($50) initial probation user's fee; und (2) not more thana ten dollar ($10) monthly probation user's fee for each month that the person remains on probation; and (3) the costs of the laboratory test or series of tests to detect and confirm the presence of the human immunodeficiency virus (HIV) antigen or antibodies to the human immunodeficiency virus (HIV) if such tests are required by the court under section 2 of this chapter; to the probation department. (d) All money collected by the probation department under this section shall be transferred to the county treasurer who shall deposit the money into the county supplemental adult probation services fund. The fiscal body of the county shall appropriate money from the county supplemental adult probation services fund to the county, superior, circuit, and municipal courts of the county for the courts’ use in providing probation services to adults. (e) All money collected by the probation department ofa city or town court under this section shall be transferred to the fiscal officer of the city or town. The fiscal officer shall deposit the money into the loca] supplemental adult probation services fund. The fiscal body of the city or town shall appropriate money from the local supplemental adult probation services fund to the city or town court of the city or town for the court's use In providing probation services to adults. Money may be appropriated under this subsection only to those city or town courts that have an adult probation services program. Ifacity or town court does not have such a program, the money collected by the probation department must be transferred and appropriated as provided under subsection (d). (f) The county or local supplemental adult probation services fund may be used only to supplement probation services and to increase salaries for probation officers. A supplemental probation services fund may not be used to replace other funding of probation services. Any money remaining in the fund at the end of the year does not revert to any other fund but continues in the county or local supplemental adult probation services fund. (g) A person placed on probation for more than one (1) crime may not be required to pay more than: 32 (1) one (1) initial probation user's fee; and (2) one (1) monthly probation user's fee per month; to the probation department. SECTION 29. IC 35-38-2-2, AS AMENDED BY SEA 276 OF THE 1988 REGULAR SESSION OF THE GENERAL ASSEMBLY, IS AMENDED TO READ AS FOLLOWS: Sec. 2. (a) As conditions of probation, the court may require the person to do any combination of the following: (1) Work faithfully at a suitable employment or faithfully pursue a course of study or vocational training that will equip the person for suitable employment. (2) Undergo available medical or psychiatric treatment and remain in a specified institution if required for that purpose. (3) Attend or reside in a facility established for the instruction, recreation, or residence of persons on probation. (4) Support the person’s dependents and meet other family responsibilities. (5) Make restitution or reparation to the victim of the crime for the damage or injury that was sustained. When restitution or reparation is a condition of probation, the court shall fix the amount, which may not exceed an amuunt the person can or will be able to pay, and shall fix the manner of performance. (6) Execute a repayment agreement with the appropriate governmental entity to repay the full amount of any public relief or assistance wrongfully received, and make repayments according to a repayment schedule set out in the agreement. (7) Pay a fine authorized by IC 35-50. (8) Refrain from possessing a firearm or other deadly weapon unless granted written permission by the court or the person's probation officer. (9) Report to a probation officer at reasonable times as directed by the court or the probation officer. (10) Permit the person's probation officer to visit hitn at reasonable times at the person’s home or elsewhere. (11) Remain within the jurisdiction of the court, unless granted permission to leave by the court or by the person’s probation officer. (12) Answer all reasonable inquiries by the court or the person's probation officer and promptly notify the court or probation officer of any change in address or employment. (13) Perform uncompensated work that benefits the community. (14) Satisfy any other conditions reasonably related to the person's rehabilitation. 33 (15) Undergo home detention under IC 35-38-2.5. (16) Undergo a laboratory test or series of tests approved by the state board of health to detect and confirm the presence of the human immunodeficiency virus (HIV) antigen or antibodies to the human immunodeficiency virus (HIV), if: (A) the person had been convicted of a sex crime listed in 1© 35-38-1-7(e) and the crime created an epidemiologically demonstrated risk of transmission of the human immunodeficiency virus (HIV); or (B) the person had been convicted of an offense related to a controlled substance listed in IC 35-38-1-7(f) and the offense involved the conditions described in IC 35-38-1-7(b)(9)(A). (b) When a person is placed on probation, the person shall be given a written statement of the conditions of probation. (c) Asa condition of probation, the court may also require that the person serve a term of imprisonment in an appropriate facility at whatever time or intervals (consecutive or intermittent) within the period of probation the court determines. (d) Intermittent service may be required only for a term of not more than sixty (60) days and must be served in the county or local penal facility. The intermittent term is computed on the basis of the actual days spent in confinement and shall be completed within one (1) year. The person does not earn credit time while serving an intermittent term of imprisonment under this subsection. When the court orders intermittent service, it shall state: (1) the term of imprisonment, (2) the days or parts of days during which the person is to be confined; and (3) the conditions. (e) Supervision of the person may be transferred from the court that placed the person on probation to a court of another jurisdiction, with the concurrence of both courts. Retransfers of supervision may occur in the same manner. This subsection does not apply to transfers made under IC 11-13-4 or IC 11-13-5. SECTION 30. IC 35-42-1-7 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS: Sec. 7. (a) As used in this section, “component” means plasma, platelets, or serum of a human being. (b) A person who recklessly, knowingly, or intentionally donates, sells, or transfers blood or a blood component that contains the human immunodeficiency 34 virus (HIV) commits transferring contaminated blood, a Class C felony. (c) However, the offense is a Class A felony if it results in the transmission of the human immunodeficiency virus (HIV) to any person other than the defendant. (d) This section does not apply to a person who, for reasons of privacy, donates, sells, or transfers blood or a blood component at a blood center (as defined in IC 16-8-7-1) after the person has notified the blood center that the blood or blood component must be disposed of and may not be used for any purpose. SECTION 31. IC 16-1-10 1S REPEALED. SECTION 32. (a) As used in this SECTION, “disease” means the disease caused by the human immunodeficiency virus (HIV) commonly known as (AIDS). (b) As used in this SECTION, “institution of higher education” has the meaning set forth in IC 22-4-2-31. (c) As used in this SECTION, “non-public school” has the meaning set forth in IC 20-10.1-1-3. (d) As used in this SECTION, “schoo! corporation” has the meaning set forth in IC 20-4-1-3. (e) Each school corporation, each governing body of a non-public school, and each institution of higher education shall provide information on the disease for all school employees during each school year. (f) The information must include current medical information on the following: (1) The etiology of the disease. (2) Behaviors that have been demonstrated epidemiologically to create a high risk of spreading the disease. (3) Precautions that reduce the risk of contracting the disease. (4) Incidence of the disease. (g) The school corporation, nonpublic school, or institution of higher education may contract with a person, group, or association to provide the information required by this SECTION. The contract must provide that the manner in which the information is provided is subject to the approval of the school corporation, the governing body of the non-public school, or the institution of higher education. (h) The information that is given to school employees who are less than eighteen (18) years of age must be 35 provided by the state board of education in accordance with IC 20-8.1-7-21. (i) This SECTION expires June 30, 1993. SECTION 33. (a) As used in this SECTION, “dentist” means an individual who holds a license to practice dentistry in Indiana issued under IC 25-14-1. (b) As used in this SECTION, “physician” means an {ndividual who holds a license to practice medicine in Indiana issued under IC 25-22.5-5. (c) The state board of health shall provide to all physicians and dentists semiannually current information on the etiology, prevention, transmission, and treatment of the disease acquired immune deficiency syndrome (AIDS) and those diseases related to the presence of the human immunodeficiency virus (HIV) in humans. The state board of health shall include information that will assist a physician or dentist to do the following: (1) Instruct employees on the universal precautions (as defined in IC 16-10-7-3). (2) Select appropriate means of disposing of infectious wastes. (3) Select effective methods of disinfection of contaminated wastes. (d) The state board of health shall collect appropriate information from physicians and dentists concerning issues related to the diagnosis and treatment of AIDS. (e) The state board of health shall report to the general assembly annually concerning the activities required under this SECTION. (f) This SECTION expires July 31, 1991. SECTION 34. (a) An employer who is required to provide training in universal precautions for employees under IC 16-10-7, as added by this act, shall provide the training before September 1, 1988, to each employee hired before May 15, 1988. (b) This SECTION expires November 1, 1988. SECTION 35. (a) The state board of health shall provide for the citizens of Indiana information on the disease caused by the human immunodeficiency virus (HIV) known as acquired immune deficiency syndrome (AIDS). (b) The information on AIDS must include a summary of the following: (1) The etiology of the disease. 36 (2) Behaviors that create a high risk of spreading AIDS. (8) Precautions that reduce the risk of contracting AIDS. (c) The state board of health shall evaluate methods of distributing the AIDS information and distribute the AIDS information through available methods, including free public service announcements. If the state board of health determines that available distribution methods are not adequate, it may incur the cost of mailing the AIDS information to every residential mailing address in Indiana. (d) This SECTION expires June 30, 1989. SECTION 36. Because an emergency exists, this act takes effect as follows: SECTIONS 1 through 32.....July 1, 1988 SECTIONS 33 through 35.... Upon passage 6. COMMON LAW TORT LIABILITY Common law actions for the torts of defamation and invasion of privacy could arise if an employer spreads confidential information regarcing an employee's AIDS-related condition. Common sense would dictate that an employer should assure that the medical records of an AIDS victim are kept confidential and disseminated only on a need-to-know basis, or as provided by statute, if, as in Indiana, such a statute exists. See Section 4 (p. 3) of Indiana AIDS Act. -14- 7. COLLECTIVE BARGAINING AGREEMENT If an employee who has AIDS is covered by a collective bargaining agreement, the employer will need to follow any contract procedures and requirements with respect to unpaid leaves of absence, health benefits or sick leave. Arbitration cases arising out of the final step ina grievance procedure may well be a forum in which AIDS-related cases in the workplace are litigated. Although arbitration cases have no binding effect outside of the employer involved, they, nevertheless, are often reported and give an indication of how an independent arbitrator views these issues. In one of the first published arbitration decisions to deal with AIDS in the workplace, State of Minnesota Department of Corrections, 85 LA 1185 (Gallagher, 1985), a prison guard who refused to conduct pat searches of prisoners because he thought he could contract the disease from infected inmates and was fired, was reinstated without backpay by the arbitrator because the arbitrator felt the employer was at least partially responsible for the guard's exaggerated fear of contracting the disease. The employer had issued an inaccurate memorandum to inmates regarding AIDS. -15- A unionized employer is also obligated to bargain with the union about “terms and conditions of employment.“ Since safety rules and practices are held to be terms and conditions of employment, an employer who institutes a detailed policy on AIDS may first be obligated to bargain with the union before instituting such a policy. -16- Tilt UIDELINES FOR EMPLOYER l. Employers should deal with employees who are AIDS victims the same as they would with employees who have other serious or life-threatening illnesses. 2. Employers should develop and adopt a written policy on dealing with AIDS in the workplace. They should then exhibit a strong commitment to the policy and train management and Supervisors regarding the policy. 3. Employers should provide employees with sensitive, accurate and up-to-date education about risk reduction in their personal lives. To prevent work disruption and rejection by co-workers of an AIDS victim, employers should also undertake an educational program for all employees before such an incident occurs and continue, as needed, thereafter. In special occupational settings, such as health care where workers may be exposed to blood or blood products, employers should, and in some cases such as Indiana, must provide specific ongoing education and training as well as the necessary equipment to reinforce appropriate infection control procedures. 4. Employers must protect the confidentiality of all medical records of employees who are AIDS victims. -17- 5. Except in unusual circumstances where the occupational setting requires the employee to handle blood or body fluids, employers should not compel either current employees or job applicants to be tested for the AIDS virus. State laws such as Indiana's new AIDS Act may prohibit compulsory AIDS testing. If the results are used to make an employment-related decision, the employer may be vulnerable to a charge of handicap discrimination or ERISA violation. -18- iV. Pp POLI Attached are three sample company policies. Sample Policy No. 1 includes AIDS with other life-threatening illnesses. It would be particularly adaptable to a small business that does not have a human resources department. If the Federal Handicap Law does not apply to the employer and no state law or city ordinance requires reasonable accommodations, the second sentence of the first paragraph of this policy can be omitted. Sample 2 is a longer and more detailed version of Sample Policy No. 1. Again, AIDS is treated as a life-threatening illness. There is more explanatory and educational material included in this policy statement. This Policy is shown as a sample policy by the Dartnell Corporation, 4660 North Ravenswood Avenue, Chicago, Illinois 60640, as a part of their publication entitled "AIDS in the Work place, Guide for Management". Sample Policy No. 3 is distinguished from the other two policies by its inclusion of ten specific guidelines for managers to follow. -19- (SAMPLE #1] COMPANY POLICY ON ASSISTING EMPLOYEES WITH LIFE-THREATENING ILLNESSES The policy of XYZ Company is to employ a person without regard to handicap if the person is able to efficiently and safely perform the duties of the person's job at the standards we have set, and this policy applies to employees or applicants for employment who have life-threatening ilinesses such as cancer, heart disease, or AIDS. XYZ Company will offer reasonable accommodations, if necessary, to employees or applicants who are afflicted with a life-threatening illness. We believe that anyone afflicted with a life-threatening illness deserves compassion, understanding and support. Should the need ever arise, we urge all employees to provide such compassion, understanding and support. (SAMPLE #2] COMPANY POLICY ON ASSISTING EMPLOYEES WITH LIFE-THREATENING ILLNESSES We at XYZ Company understand that most employees with disabilities, medical handicaps, or life-threatening illnesses such as cancer or AIDS benefit greatly from the normal routines of daily life. We understand that an employee's sense of self-esteem, worth, and good health are often enhanced by working at his or her regular job, despite a diagnosis. As long as you, our employee, are able to meet approved standards and job performance as set down in your job description, and as long as medical information indicates that your condition or handicap does not endanger you or other employees, all of our managers and supervisors will see to it that you are treated fairly and consistently with and by other employees. While we are concerned for you, we are also concerned for all our employees and customers. We must be concerned for the well-being of this company as well as your well-being. In light of these issues we will make available to all employees, supervisors, and managers through our Human Resources Department: e Education and counseling about handicaps and life-threatening illnesses. Appropriate medical and social services agency referrals. Answers to any questions or problems arising from insurance, union, or other benefits. We remind all employees, supervisors, and managers that: The health status of an employee is a private and confidential issue. Every reasonable step must be taken to protect the confidentiality of medical status and medical records. Our Human Resources Department is the first source for information or answers to questions employees may have. Our medical division is the source for information on contagion issues about any illness or medical condition. We will make every effort to accommodate our employees because of the nature of their illness. Transfers are available, when possible, should that be desired. We will not give special consideration to employees who feel threatened by another employee's condition other than through our normal procedures. Working provides a therapeutic benefit for many persons diagnosed with handicaps or life-threatening illnesses. Continued employment of valued, productive employees helps the company as well. In some cases we may request a physician's statement that a specific medical condition does not pose a threat to our work force. We also reserve the right to ask an employee to be examined by one of our approved physicians should we deem it necessary. We are an equal opportunity employer. We do not Giscriminate against any employee based on his or her handicap or perceived handicap under the law. [SAMPLE #3) COMPANY POLICY ON ASSISTING . EMPLOYEES WITH LIFE-THREATENING ILLNESSES XYZ Company recognizes that employees with life-threatening iilnesses including but not limited to cancer, heart disease, and AIDS may wish to continue to engage in as many of their normal pursuits as their condition allows, including work. As long as these employees are able to meet acceptable performance standards, and medical evidence indicates that their conditions are not a threat to themselves or others, managers should be sensitive to their conditions and ensure that they are treated consistently with other employees. At the same time, XYZ Company has an obligation to provide a safe work environment for all employees ard customers. Every precaution should be taken to ensure that an employee's condition does not present a health and/or safety threat to other employees or customers, Consistent with this concern for employees with life-threatening illnesses, XYZ Company offers the following range of resources available through Personnel Relations: Management and employee education and information on terminal illness and specific life-threatening illnesses. Referral to agencies and organizations which offer supportive services for life-threatening illnesses. Benefit consultation to assist employees in effectively manag:.ny health, leave, and other benefits. Guidelines - When dealing with situations involving employees with life-threatening illnesses, managers should: (1) (2) (3) (4) (5) (6) Remember that an employee's health condition is personal and confidential, and reasonable precautions Should be taken to protect information regarding an employee's health condition. Contact Personnel Relations if you believe that you or other employees need information about terminal illness, or a specific life-threatening illness, or if you need further guidance in managing a situation that involves an employee with a life-threatening illness. Contact Personnel Relations if you have any concern about the possible contagious nature of an employee's illness. Contact Personnel Relations to determine if a statement should be obtained from the employee's attending physician that continued presence at work will ‘pose no threat to the employee, co-workers or customers. XYZ Company reserves the right to require an examination by a medical doctor appointed by the Company. If warranted, make reasonable accommodation for employees with life-threatening ilinesses consistent with the business needs of the division/unit. Make a reasonable attempt to transfer employees with life-threatening illnesses who request a transfer and are experiencing undue emotional stress. (7) Be sensitive and responsive to co-workers' concerns, and emphasize employee education available through Personnel Relations. (8) No special consideration should be given beyond normal transfer requests for employees who feel threatened by a co-worker'’s life-threatening illness. (9) Be sensitive to the fact that continued employment for an employee with a life-threatening illness may sometimes be therapeutically important in the remission or recovery process, or may help to prolong that employee's life. (10) Employees should be encouraged to seek assistance from established community support groups for medical treatment and counseling services. Information on these can be requested through Personnel Relations or Corporate Health. V._ EDUCATION PROGRAMS . f Education programs will vary Yepending on the _ Sep Organizational setting and work force composition. There are two targeted groups: (1) management and Supervisors, and (2) all other employees. l. Management and supervisory p rams. Senior Management should be presented an overview of the employer's legal obligations and duties. Supervisors should receive training on how to deal with AIDS issues. This training should include not only a carefrl review of the company's written policy but also medical information about the disease. The education to supervisors should describe how to recognize performance problems and . handle performance reviews. Supervisors should be given Suggestions on how to respond to questions related to AIDS. This kind of review will also then identify in practical terms the legal issues that they should be aware of. A sample of questions and answers to AIDS issues in the workplace, copied with permission of Victor Schachter of Schachter, Kristoff, Ross, Sprague & Curiale, San Francisco, in their publication, "AIDS: A Manager's Guide" is attached. —-20- 2. Non-Management Employee Programs. A general education program for all other employees should be implemented. Small group meetings are suggested for providing accurate information on AIDS. Ideally, such education would offer opportunities for discussion with qualified counselors or medical experts. There are a number of videocassette tapes available on AIDS. Two such tapes are "AIDS: Can I Get It", available through Light VideoTelevision, Inc., 2100 Highland Circle, Needham Heights, Massachusetts 02194, and “AIDS: Everything You’ Wanted To Know But Were Afraid To Ask", available from Home Box Office, Inc., 1100 Avenue of the Americas, New York, New York 10036 (Subscriber Information Services). Education to employees should include information about voluntary, anonymous testing and where such testing can be obtained. Education to employees should also be directed to how co-workers should respond when they learn or hear of an employee who is or may be an AIDS victim. Proper education on AIDS before an incident arises can help prevent a hysterical reaction, which could lead to work disruption and rejection. -21- 3. Other educational resources: Videos: “AIDS in the Workplace,” Los Angeles, CA: AIDS Project Los Angeles “Overcoming Irrational Fear of AIDS," Urbana, IL: Carle Medical Communications "AIDS and the Health Care Worker," Deerfield, IL: Coronet/MTI Film and Video “Epidemic of Fear--Update Dec. 1987," San Francisco, CA: San Francisco AIDS Foundation “One of Our Own", Dartnell Publications, Chicago, I11. Books/Booklets: AIDS: A Manager's Guide, New York, NY: Executive Enterprises Publications Co., Inc. AIDS in the Workplace: Legal Questions and Practical Answers, Lexington, MA: Lexington Books/D.C. Health. AIDS in the Workplace, Chicago, IL: National Safety Council. AIDS in the Workplace: A Supervisory Guide, Chicago, IL: National Safety Council. AIDS and the Employer: Guidelines on the Management of AIDS in the Workplace, New York, NY: New York Business Group on Health. AIDS in the Workplace: A BNA PLUS Information Package, Washington, D.C.: The Bureau of National Affairs. AIDS in the Workplace, Alexandria, VA: International Personnel Management Association. AIDS in the Workplace: Policy Manual and Appendix, San Francisco, CA: San Francisco AIDS Foundation. AIDS: Corporate America Responds, B.J. Stiles, National Leadership Coalition on AIDS, 1150 Seventeenth St., N.W., Suite 202, Washington, D.C. 20036. -~22- 1. CHAPTER 6 KEY QUESTIONS AND ANSWERS TO AIDS ISSUES IN THE WORKPLACE May I ask a job applicant whether he/she has AIDS? In states where persons with AIDS are protected under handicap discrimination laws, an employer should not ask a job applicant whether he or she has AIDS, or refuse to hire such applicant because he or she has AIDS. Inquiries relating to AIDS would be improper except where seeking to make reasonable accommodation, or where clearly related to safe or satisfactory performance of the job in question. An employer may ask applicants if they can perform the specific duties of the position being sought. May I ask existing employees if they have AIDS? As a general rule, if AIDS is considered a protected handicap, then incumbent employees cannot be asked if they have AIDS any more than job applicants can be questioned. If, however, the employer's business involves activities in which AIDS transmission is considered a possibility, the employer may identify those positions involving increased risk of transmission and inquire of employees in those positions only. Positions of increased risk might include those in which employees must use sharp instruments such as needles, razors, knives, or dangerous machinery, or positions in which employees handle blood samples. The inquiries should be done privately, tactfully, and only for a job-related purpose. Employers should avoid singling out only high-risk AIDS groups (e.¢., males, persons of a particular national origin). May I require that a job applicant or existing employee submit to‘a test for the AIDS virus? : Absolutely not where prohibited by state law, such as California, Wisconsin, and Florida. An employer can require testing where not prohibited by state law, but it is of questionable use. If the results are used to make an employment-related decision, the company may be vulnerable to a charge of handicap discrimination. Moreover, the AIDS test does not reveal whether the individual has AIDS, but only whether there has been exposure to the AIDS virus. On the other hand, medical exams can be required as a condition of employment if the purpose is to determine suitability or fitness for work. Normally, when a medical examination is required, each member of the workforce is tested for medical fitness at the time of hire. If an employer believes an individual is not fit, or represents an undue threat to other employees based on the facts of the individual case or working conditions in that business or industry, then it may respond appropriately. Even though medical exams may be required as a condition of employment, if AIDS is a protected handicap, the AIDS antibody test probably cannot be made a part of tne exam for applicants or incumbent employees. May I refuse to hire an applicant who has AIDS, or retain an incumbent employee who has AIDS, because of the projection of the Company's possible increased costs in insurance benefits? Statutes, regulations and case law have uniformly held that applicants or employees who had the potential for incurring extensive health benefit costs due to their disability were protected from discrimination. This view represents a policy decision that employers must bear some of society's cost in providing work opportunities for the disabled. Thus, adverse action based on a prediction that an employee will become an unreasonable economic burden on the employer would not be permissile. 7. Do I have a legal duty to communicate my knowledge about an employee with AIDS to other employees? Given the current state of medical opinion that AIDS is not communicated by casual contact in the workplace, AIDS cannot be regarded as a health hazard normally transferable on the job. Therefore, an employer has no legal duty to communicate its knowledge about an AIDS affected employee to other employees. In fact, an employer may breach the employee's right to privacy and confidentiality of medical information by disclosing his/her condition. Moreover, such action may expose the employer to defamation claims. Should I consider education or training programs for my employees? Educating the workforce may well be the most important step to address AIDS issues in the workplace. A program of education ean help minimize hysteria over AIDS or defuse confrontation between employees with AIDS and other employees. It can also show management's good faith attempts to balance legitimate employee health concerns with the rights of persons who have AIDS. Educaticn should include a training program for company supervisors and managers which discusses the company philosophy and policy, medical information, employee benefit plans, embDloyment discrimination laws and how they epply to AIDS, and how to deal with job | actions by co-workers. Education for employees should include clarification of the company's AIDS policy, available benefit plans, employee assistance programs, and confidentiality policies. How should I handle employee refusals to work with an AIDS-identified employee and/or demand that an employee with AIDS be terminated? Employees generally have a duty to perform assigned work. An employer must evaluate each instance of employee refusal to work on a case-by-case basis to determine whether the refusal to work with someone ‘ who has AIDS is based upon legitimate concerns or upon misinformation and the general anxiety surrrounding AIDS. First, an employer should be sure the employee understands current medical knowledge and guidelines concerning AIDS. Next, an employer might consider accommodating any employee who is refusing to work with @ person with AIDS. Although there is no duty to accommodate an employee who refuses to work in this situation, it may be advisable to do so. Accommodation might include transfer, arranging for employees to volunteer to work with a person who has AIDS, allowing employees to wear protective garments or soliciting suggestions from employees for specific precautionary measures, If an employee continues to refuse to return to work, even after efforts at education and accommodation, the employer may have no choice but to replace the employee for refusing to work. The employer may explain that no other accommodation is possible, and provide the employee with some time off to consider the matter before final action is taken. The employer certainly has the right to replace an employee who refuses to work with an individual who has AIDS. It is unclear if an employee can be discharged or disciplined for stopping work to protest such a health concern, where two or more employees are involved ("concerted" activity), and they have a "good faith" belief that working conditions are unsafe. Given medical evidence that AIDS is not contagious through casual contact, the employees’ claim of "good faith" may be insufficient to prevent discipline. However, this question has not been decided by the National Labor Relations Board. Again, none of this uncertainty prevents an employer from replacing a striking employee — it only affects disciplinary action. 10. What should I do if I learn that co-workers are isolating or harassing an employee who has AIDS? Stop it. Managers should be cautioned to observe situations where employees may refuse to handle products from an employee with AIDS, share the same facilities, or use common equipment. Managers should educate the co-workers, admonish those who treat employees with AIDS unfairly and instruct them to cease such action. What are some examples of reasonable accommodation with respect to an employee who has AIDS? An employer need not incur more than minimal costs or minimally disruptive measures to accommodate an employee with AIDS. Non- burdensome modifications may include reducing the workload; instituting flex time: providing more frequent rest breaks; allowing the employee to work at home; allowing for time off for medical appointments; starting the work day later; giving sick leaves as necessary for treatment; and restructuring the job. May I transfer an employee who has AIDS to "protect" the rest of the workforce? An employer would clearly violate the law if it initiated an involuntary job transfer of an employee with AIDS because of fear of exposing the workforce. Isolating and removing an employee from his or her position should not be allowed when the employee can still perform the job if given reasonable accommodation. Of course, if the employee with AIDS voluntarily desires such a job transfer, then the employer can consider such an option. ll. 12, 18, What if an employee with AIDS requests a transfer to a job that reduces public or customer contact? An employer's obligation of reasonable accommodation extends to providing alternatives for the employee to perform the job for which he or she was hired. If the employee requests a transfer to a job that reduces public or customer contact, the company may voluntarily honor this request. However, in the absence of a practice to transfer individuals with similar long-term illnesses, an employer is generally under no legal obligation to do so. Since more than 70% of the known AIDS eases in the United States involve gay men, can! lawfully exclude or terminate gays from employment? Legally, it is permissible to discriminate against employees and job applicants on the basis of sexual preference except in the state of Wisconsin, some cities and some countics. As a group, homosexuals are not protected under Title VII or under most state fair employment laws. However, if AIDS is a protected handicap, it would be unlawful to take adverse employment action against gays to keep AIDS "out of the workplace." How contagious is AIDS? Unlike most transmissible diseases, e.g., colds, flu, measles, ete., AIDS is not transmitted through sneezing, coughing, eating or drinking from common utensils, or merely being around an infected person. Current medical opinion and experience has determined that casual contact with persons who have AIDS does not place others at risk. 14, 15. 16, 17, 18. Can employees acquire AIDS by drinking from the same glass or eating from the same dishes as a person with AIDS? Current medical opinion indicates that AIDS is not transmitted in households where people may drink or eat from common dishes or utensils. The virus associated with AIDS does not survive well outside of the body and would be killed by normal washing of dishes and other eating utensils. Can employees acquire AIDS from public restrooms, drinking fountains or telephones? AIDS is not transmitted through the air, food or water, or by touching any object handled, touched or breathed on by a person with AIDS. Therefore, AIDS cannot be acquired from public restrooms, drinking fountains or telephones. Can employees acquire AIDS from eating in an employer cafeteria where someone with AIDS is working as a cook or waiter/waitress? Medical experts agree that AIDS cannot be transmitted through the air or by handling foodstuffs, There are no known cases of AIDS that have been transmitted through food preparation or food handling. Can employees acquire AIDS by touching someone who has AIDS? There is no indication that AIDS is spread through any form of casual contact, including handshakes, bumping together in crowds, contact sports, or even casual kissing. Can persons with AIDS be isolated or quarantined by employers to prevent the spread of the disease? Not, if as expected, AIDS is a protected handicap. Medical opinion indicates that AIDS is spread only through direct blood-to-blood or semen- to-blood exchange, and not through the air, food or casual contact with 19. 20, persons with AIDS or articles they have handled or used. Therefore, there is no reason to isolate or quarantine a person with AIDS to prevent the spread of the disease. Do AIDS tests identify those who have the disease? The test determines only the presence of AIDS antibodies in the blood, due to exposure to the AIDS virus, HTLV-II]. The presence of AIDS antibodies in the blood means only that the person has been exposed to the virus at some time. It does not necessarily mean that the individual is carrying the virus, is capable of transmitting it to others or will develop symptoms of AIDS in the future. How does the definition of "handicap" apply to a person who has AIDS or ARC? The federal government and most states have adopted legislation forbidding discrimination against the handicapped. All these statutes share the underlying concept that persons whose physical abilities are impaired should not be deprived of work which they are capable of performing, and that each job applicant or employee should be judged on the basis of his or her present ability to meet the bona fide requirements of a job, The language defining covered disabled persons varies widely among the States. Federal law and many states define a handicapped person as one who has "a physical or mental impairment which substantially mits one or more of such person's major life activities." Several jurisdictions also expressly extend coverage to those who have a "record of such impairment" or are "regarded as having such an impairment." Other variations of the basic definition cover "anatomical, physiological, or neurological disability or infirmity ... caused by an illness;" or a "condition which constitutes a substantial disability." Persons with AIDS or ARC would appear to be covered because the ability to fight infection and preserve health is a "majer fe funation.” gimilany, the ayndrome of suppreased {mmune a 21. 22, 23. function is clearly a physiological disability or infirmity caused by an illness. Although these laws are relatively new, persons with AIDS are likely to be within the definition of "handicap" under federal and most state laws. Have any states actually de-lared AIDS to be a physical handicap? As of this writing, the Florida Commission on Human Rights is the only state agency which has adjudicated the issue and ruled AIDS to be a physical handicap. However, many states have informally indicated their belief that it is a physical handicap, and cases are currently pending before the state fair employment agencies in California, Wisconsin, Washington, and New York. Can an employer take adverse action against an employee who is living with a person who has AIDS? If AIDS is a protected handicap, no adverse employment action would be proper. Even if an employee shares an intimate relationship with someone who has AIDS, there is no method to predict whether he or she will contract AIDS. An employee who is qualified to perform his or her job must be treated in the same manner as all other employees. May I terminate or refuse to hire a person with AIDS based on the fears of co-workers or customers, or to protect the safety and health of co-workers or customers? An employer cannot terminate or refuse to hire a person with AIDS based on the fears of co-workers or customers, if AIDS is a protected handicap. State statutes and related administrative interpretations recognize the safety of the individual employee, co-workers, customers and the public at large as a legitimate concern. However, current medical knowledge about AIDS establishes that persons with AIDS do not present any danger to others by virtue of casual eontact in the workplace. 24. 25. What action may I take with respect to an employee who has AIDS if I have a legitimate concern for the individual's health? The "altruistic" defense, i.e., the employer is concerned that the employee's own health would be endangered by working, requires particularized analysis in each case, An employer cannot take adverse action against an employee who has AIDS unless it can be shown with reasonable certainty that the specifie physical conditions of the job are such as to aggravate the disease or interfere with its treatment. Furthermore, reasonable accommodation of the employee's needs would have to be fully explored, May an employer ever take adverse action against an employee who is considered handicapped because of AIDS? Virtually all jurisdictions provide that discrimination against the disabled is lawful if the essential requirements of the job cannot be performed after reasonable accommodation. Some state enforcement agencies and courts have interpreted these laws to mean’ that a hand capped individual is protected unless his or her disability “substantially affects" his or her ability to do the job. In addition, an employer may contend that the absence of a handicap is a bona fide occupational qualification (BFOQ). To establish this position, the employer must demonstrate that the physical condition of AIDS prevents proper performance of the job or represents considerable risk to others because of blood-to-blood contact, despite reasonable accommodation. This is normally a difficult standard to meet. However, there may be certain jobs in which the absence of AIDS would arguably qualify as a BFOQ, such as surgeons, lab technicians, or blood bank employees. 26, What should I do when an employee tells me he or she has AIDS? Management should refer the employee to a person within the company who is knowledgeable about AIDS and the company's policy. This person should advise the employee of the latest information from the CDC and others in the medical community; counsel the employee to ensure he/she has seen a doctor; advise the employee of hazards he/she might be exposed to in the workplace; and confirm the employee's illness and ability to work with his/her doctor. If the employee is uneasy about continuing to work, a short paid leave of absence may give the employee time to get advice and make a thoughtful decision. If management is forthright, humane, and fair, and keeps the employee well-informed, it is likely that the employee and the company will agree on arrangements which will be in the best interests of the company and all the employees. HEARING ON AIDS IN THE WORKPLACE May 1988 RECOMMENDATIONS Page [1] of (1) OBSTACLES TO PROGRESS 1. Employer's fears of: - unknown costs associated with employees who are AIDS victims. ~ reactions of other employees. - discrimination charges and/or lawsuits if employment related decisions affect AIDS victims. - failure to comply with all the laws involved as decisions are made that affect the AIDS victin. 2. Competing concerns of sympathy and fair treatment to the AIDS victim vs. need of the employer to operate at a profit in order to stay in oo RECOMMENDATIONS USLNESS -, 1. That the Presidential Commission recommend the adoption of legislation . to permit pre-employment testing for the AIDS virus and exempting an employer from liability if the employer refuses to hire because of a positive AIDS test. 2. Employers should adopt a written policy on AIDS that fits the employer's type of operation. 3. Employers should become knowledgable of the laws, federal, state and local, that impact upon their dealings with employees who are AIDS victims. 4. Employers should begin educational programs with their management and supervisory employees and with all other employees to do what is right within the law, what is compassionate to the AIDS victim, and what will alleviate fears. Estimated Cost: Unknown Based Upon: N/A Henry C. Ryder Ihe C ‘ Coy ken =) Name Stanstesy May 10, 1988 Date PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC WRITTEN TESTIMONY MAY 10, 1988 YVONNE ELLISON-SANDLER MANAGER EMPLOYEE ASSISTANCE PROGRAM LEVI STRAUSS & COMPANY Pe. 1 Goop AFTERNOON! IT IS MY PLEASURE TO BE WITH YOU TODAY TO TALK ABOUT THE SAN FRANCISCO Bay AREA CORPORATE RESPONSE TO AIDS, THIS KIND OF EXCHANGE OF IDEAS AND INFORMATION IS FUNDAMENTAL TO ANY SUCCESSFUL EDUCATIONAL ENDEAVOR, BUT IT IS PARTICULARLY IMPORTANT WITH REGARD TO AIDS BECAUSE OF ITS EPIDEMIC PROPORTIONS AND MANY MISCONCEPTIONS THAT SURROUND THIS DISEASE. Pe, 2 I'D LIKE TO SHARE WITH YOU A QUOTE FROM THE PLAGUE - BY ALBERT CAMUS: “EVERYBODY KNOWS THAT PESTILENCES HAVE A WAY OF RECURRING IN THE WORLD! YET SOMEHOW WE FIND IT HARD TO BELIEVE IN ONES THAT CRASH DOWN ON OUR HEADS FROM A BLUE Sky,” AIDS HAS CRASHED DOWN ON OUR HEADS FROM A BLUE SKY, EPIDEMICS OF LIFE-THREATENING DISEASES PROVOKE FEAR, CONCERN AND ENORMOUS ANXIETY IN PEOPLE, At Levi STRAUSS & COMPANY WE BELIEVE IT’S OUR RESPONSIBILITY TO NOT ONLY DEFUSE THE FEAR AND ANXIETY OUR EMPLOYEES HAVE ABOUT AIDS, BUT To DO WHAT WE CAN TO PREVENT THEM ALTOGETHER, Pe, 3 IGNORANCE OF THE CAUSES AND TRANSMISSION OF AIDS FUELS THESE FEARS AND CONTRIBUTES TO MYTHS ABOUT THE RISKS AND DANGERS OF CONTRACTING AIDS, At Levi STRAUSS & COMPANY WE HAVE MADE A COMMITMENT TO EDUCATE AND INFORM EMPLOYEES ABOUT AIDS BASED ON THE BEST AVAILABLE MEDICAL KNOWLEDGE TO UNDERSTAND THE DISEASE. We WANT EMPLOYEES TO KNOW THAT A PERSON CARRYING THE AIDS VIRUS IS NOT A THREAT TO CO-WORKERS, SINCE AIDS IS NOT SPREAD BY COMMON EVERYDAY CONTACT. QUR OBJECTIVE HAS BEEN TO: - CURB FEARS - PROVIDE PSYCHOLOGICAL SUPPORT - PROVIDE FINANCIAL SUPPORT Pe, 4 In SAN FRANCISCO IT HAS BEEN A TRUE SPIRIT OF COOPERATION BETWEEN THE MEDICAL, GOVERNMENT, AND BUSINESS COMMUNITIES WHICH HAVE DRIVEN THE DEVELOPMENT OF GUIDELINES TO MANAGING AIDS IN THE WORKPLACE , Pe, 5 THIS AFTERNOON, I WOULD LIKE TO DESCRIBE OUR AIDS AWARENESS PROGRAM AT Levi's. I WILL DISCUSS: 1) Our Company PHiLosopHy on AIDS 2) Support AND EDUCATION PROVIDED THROUGH OUR EMPLOYEE ASSISTANCE PROGRAM, AND 3) FINANCIAL SUPPORT THROUGH EMPLOYEE BENEFITS 4) AND FINALLY. WHAT WE HAVE DISCOVERED ARE THE CRITICAL ELEMENTS To successFUL AIDS EDUCATION. Pe. 6 AppRESSING AIDS IN THE WORKPLACE WAS NOT AN UNUSUAL RESPONSIBILITY FOR LS&Co. TO ASSUME. WE ALREADY HAD IN PLACE AN EMPLOYEE EDUCATION PROGRAM IN THE EMPLOYEE ASSISTANCE PROGRAM THAT PROMOTES WELLNESS AND PROVIDES INFORMATION ON VARIOUS HEALTH ISSUES, As AIDS BECAME AN INCREASINGLY SERIOUS NATIONAL HEALTH PROBLEM, WE FELT AN EVEN GREATER COMMITMENT TO TAKE ACTION -- TO DO WHAT WE COULD TO CURB FEARS IN THE WORKPLACE AND STOP THE SPREAD oF AIDS, PG, 7 Qur Company PHILOSOPHY WE DO NOT HAVE A POLICY speciFic To AIDS at Levi's, WE HAVE, HOWEVER, A COMPANY PHILOSOPHY, THIS PHILOSOPHY, STATES THAT ALL EMPLOYEES BE TREATED EQUALLY WITH DIGNITY AND RESPECT - INCLUDING EMPLOYEES WITH AIDS, EmPLovees wiTH AIDS ARE TREATED THE SAME AS OTHER EMPLOYEES WITH LIFE-THREATENING ILLNESSES. IT WAS THIS PHILOSOPHY THAT GUIDED OUR RESPONSE To AIDS, Pe. 8 WE EMBARKED ON AN EDUCATION PROGRAM BEFORE WE HAD OUR FIRST CASE OF DIAGNOSED AIDS at Levi’s, IT WAS NOT AN UNUSUAL RESPONSIBILITY FOR Levi Strauss & COMPANY TO TAKE ON, WE HAD IN PLACE AN EMPLOYEE EDUCATION PROGRAM IN THE EMPLOYEE ASSISTANCE PROGRAM THAT PROVIDED INFORMATION ON VARIOUS HEALTH ISSUES AND PROMOTED WELLNESS, Pg, 9 In 1983, WE RESPONDED TO A CALL FROM A MANAGER WHO WAS TERRIFIED THAT SHE COULD GET AIDS FROM A GAY EMPLOYEE SHE SUPERVISED, EAP RESPONSED QUICKLY TO HER CONCERNS BY OFFERING EDUCATION ABOUT HOW AIDS 1S TRANSMITTED, WE ASSURED HER THAT HER WORK ENVIRONMENT WOULD NOT BE PUTTING HER AT RISK, THE EMPLOYEE, AS IT TURNS OUT DID NOT HAVE AIIK, BUT THAT CALL SERVED TO ALERT US TO THE NEED OUR EMPLOYEES HAD FOR ACCURATE, UP-TO-DATE INFORMATION ON AIDS, Pg, 10 SHORTLY THEREAFTER, WHEN Bob HAAS, NOW THE PRESIDENT OF LEVI STRAUSS AND CoMPANY, STOOD IN THE LOBBY OF OUR HOME OFFICE WITH REPRESENTATIVES OF A LOCAL AIDS ORGANIZATION, HANDING OUT PAMPHLETS TO EMPLOYEES, THE MESSAGE WAS CLEAR - THAT SUPPORT FOR AIDS EDUCATION WAS COMING FROM THE TOP, IT WAS NOT LONG AFTER THAT A WORKPLACE PACKAGE WAS DEVELOPED IN COORDINATION WITH THE BAY LEADERSHIP TASK FoRCE AND THE SF AIDS FounDATION, 7 Pe, U1 ' THESE MATERIALS WERE PREVIEWED AT A DAY-LONG CONFERENCE HOSTED BY THE BAY LEADERSHIP TASK Force AND LEVI STRAUSS & Co. ON MarcH 21, 1986, 200 Bay AREA BUSINESSES HAD THE OPPORTUNITY TO VIEW THE VIDEOTAPE AND THE ASSOCIATED MATERIALS AND HEAR FROM SAN FRANCISCO EXPERTS ON AITS, At Levi Strauss & Co., WE UTILIZE THESE MATERIALS IN THE FOLLOWING WAYS: 1D) THe Employee ASSISTANCE PROGRAM OFFERS AIDS EDUCATION TO COMPANY DEPARTMENTS (By THIS TIME MOST HOME OFFICE EMPLOYEE HAVE ATTENDED A SESSICN), — IN ADDITION TO SHOWING THE VIDEO, “TaLK ApouT AIDS” AND PROVIDING PRINTED INFORMATION, A MEDICAL EXPERT IS PRESENT TO DISCUSS ANY QUESTIONS. WE ALSO TALK ABOUT THE COMPANY PHILOSOPHY, AND EMPLOYEE BENEFITS, Pe, 12 2) A PSYCHOLOGIST OR SOCIAL WORKER FROM THE EAP LEADS A DISCUSSION OF THE PSYCHOLOGICAL ASPECTS OF CATASTROPHIC ILLNESS, THE PRIMARY OBJECTIVES OF THESE TRAINING PROGRAMS ARE TO INFORM EMPLOYEES OF THE MEDICAL FACTS; TO MAKE SURE THEY UNDERSTAND THE COMPANY PHILOSOPHY ON AIDS, AND TO LET THEM KNOW OF RESOURCES AVAILABLE FOR FURTHER INFORMATION, 5) Pe, 15 SINCE WE KNOW THAT DISTRIBUTING WRITTEN MATERIAL ALONE DOES NOT GUARANTEE THAT IT WILL BE READ, WE MAINTAIN AN EXTENSIVE HEALTH EDUCATION LIBRARY WITH AUDIO AND VIDEO TAPES AS WELL AS BROCHURES AND BOOKS. EMPLOYEES ARE FREE TO CHECK THESE MATERIALS OUT TO TAKE HOME, WE HAVE A COMPANY HEALTH AND FITNESS NEWSLETTER THAT HAS A REGULAR AIDS COLUMN TO CONTINUALLY INFORM EMPLOYEES ON THE LATEST INFORMATION REGARDING AIDS, 4) >) 6) Pe, 14 WE CFFER CONFIDENTIAL INDIVIDUAL COUNSELING AND REFERRAL or ARC SERVICES TO EMPLOYEES WITH AIDS, AS WELL AS THEIR FAMILY MEMBERS AND CO-WORKERS. WIE PROVIDE MANAGEMENT CONSULTATION AND DEPARTMENT COUNSELING WHEN A PERSON HAS OR IS RUMORED TO HAVE AIDS, We HAVE A Company AIDS Task FoRCE WHICH PROVIDES DIRECTION AND GUIDANCE ON Company AIDS activities. EAP, LeGaL, PERSONNEL, ComMMUNITY AFFAIRS, BENEFITS, WoRKER’S Comp., CORPORATE COMMUNICATIONS AND OPERATIONS ARE REPRESENTED, TWO MEMBERS OF THIS TASK FORCE ARE PERSONS WITH AIDS or ARC, /) 8) Pe, 15 IN 1987 WE FOCUSED OUR ATTENTION ON DELIVERING AIDS EDUCATION TO OUR FIELD LOCATIONS. WE TRAINED ALL COMPANY Human RESOURCES MANAGERS TO LEAD AIDS EDUCATION PROGRAMS IN THEIR RESPECTIVE FACILITIES WITH THE ASSISTANCE OF A MEDICAL EXPERT. IN 3 MONTHS WE HAVE HELD MANDATORY AIDS EDUCATION FOR OUR EMPLOYEES IN “HE FIELD, - 14,000 EMPLOYEES EDUCATED - $60,000 Down TIME - EXTREMELY WELL-RECEIVED IN 1988 we ARE PLANNING TO FocUS ON AIDS EDUCATION TO THE SALES FORCE AT LEVI STRAUSS & COMPANY AND CONTINUE THE EFFORTS IN PLACE IN HOME OFFICE AND THE FIELD, Pe, 16 QUR PHILOSOPHY OF TREATING ALL EMPLOYEES EQUALLY AND WITH DIGNITY AND RESPECT IS ECHOCHED IN OUR BENEFITS “PHILOSOPHY.” EMPLOYEE BENEFITS ARE THE SAME FOR ANYONE WHO IS ILL AND NEEDS TO GO ON EITHER SHORT OR LONG-TERM DISABILITY, MEDICAL AND LIFE INSURANCE REMAINS IN FORCE AND WE UTILIZE A CASE-MANAGEMENT APPROACH TO CUSTOMIZE A BENEFITS PACKAGE THAT IS TAILORED TO THE NEEDS OF EACH AFFECTED INDIVIDUAL, WE OFFER BOTH HOME-HEALTH AND HOSPICE CARE AS ALTERNATIVES TO MORE EXPENSIVE HOSPITAL CARE, WE ENCOURAGE PERSONS WITH AIDS To WORK AS LONG AS THEY ARE MEDICALLY ABLE AND INTERESTED IN DOING SO, SINCE 1982, THE LEVI STRAUSS FOUNDATION AND THE CORPORATION HAVE MADE A COMMITMENT WITH FINANCIAL CONTRIBUTIONS TO VARIOUS AIDS ORGANIZATIONS, Po, V We KNOW FROM EMPLOYEE FEEDBACK THAT OUR PROGRAM HAS BEEN WELL~ RECEIVED, WE ARE ALSO AWARE THAT EDUCATION IS AN ON-GOING PROCESS, Now, 1’D LIKE TO SHARE WITH YOU THE ELEMENTS THAT ARE CRITICAL TO successFUL AIDS EDUCATION, * First OF ALL, IT’S IMPORTANT TO TARGET AS SPECIFICALLY AS POSSIBLE THE EMPLOYEE POPULATION YOU ARE ATTEMPTING TO REACH, WITHOUT SOME NEEDS ASSESSMENT THE MATERIALS YOU DEVELOP MAY BE WAY OFF BASE. CULTURAL, ETHNIC, AND EDUCATION DIFFERENCES ALL NEED TO BE CONSIDERED. THIS CAN REPRESENT QUITE A TASK FOR THOSE COMPANIES WITH FACILITIES SCATTERED IN EVERY STATE, YET IT IS IMPERATIVE THAT MATERIALS BE SENSITIVE TO THESE ISSUES. [HIS BECAME APPARENT TO US AS WE PREPARED TO ROLL QUT OUR PROGRAM INTO THE FIELD. (CONTINUED » . 1) Pe, 18 THE MATERIALS DEVELOPED FOR San FRANCISCO WERE NOT WELL-RECEIVED IN PLACES SUCH AS BLUERIDGE, GEORGIA; AND BROWNSVILLE, TEXAS - BECAUSE IT MADE FOR A “WHITE-COLLAR” AUDIENCE ~ NO ROLE MODELS ON THE TAPE FOR OUR PEOPLE TO IDENTIFY WITH - AND IT REPRESENTED A BIG CITY, WEST COAST APPROACH FOR THIS REASON WE DEVELOPED NEW MATERIALS INCLUDING A VIDEOTAPE, "TALK ApouT AIDS" FoR OUR FIELD LOCATIONS DISTANT FROM THE BAY AREA. WE INTERVIEWED Levi STRAUSS & COMPANY HOURLY SEWING MACHINE OPERATORS ON THE TAPE TALKING ABOUT THE CONCERNS AND QUESTIONS THEY HAD ABOUT AIDS, WE TAILORED THE VIDEO TO A BLUE COLLAR AND FAMILY FOCUS, AND TRANSLATED THE TAPE IN CHINESE, SPANISH, AS WELL AS ENGLISH, THE TAPE AND THE AIDS EDUCATION HAS BEEN A TRUE SUCCESS, Pe, 19 WE HAVE LEARNED THAT THE SPEAKER MUST BE ABSOLUTELY CONFIDENT AND COMFORTABLE WITH THE DELIVERY OF AIDS INFORMATION, FOR THIS REASON, WE ALWAYS HAVE A LOCAL MEDICAL EXPERT ON HAND TO ANSWER QUESTIONS, WE HAVE ALSO LEARNED THAT IT 1S IMPORTNAT TO GIVE THE AUDIENCE REGIONAL sTaTIsTics ON AIDS, THESE CAN BE OBTAINED FROM THE CENTER FOR DISEASE ConTROL. PEOPLE IN TEXAS WERE FAR MORE INTERESTED IN LEARNING ABOUT AIDS WHEN THEY REALIZED THAT THEIR STATE WAS #4 IN AIDS INCIDENCE. P6, 20 MANY COMPANIES ALREADY HAVE EMPLOYEE INFORMATION PROGRAMS THAT PROVIDE INFORMATION ON HEALTH ISSUES. AN EXISTING PROGRAM THAT WORKS OFFERS A GOOD BASE TO BUILD ON, UTILIZING VEHICLES ALREADY IN PLACE, SUCH AS A COMPANY NEWSLETTER, OR COMPANY MEDICAL STAFF PROVIDES A FAMILIAR CONTEXT FOR EMPLOYEES AND CAN INCREASE THEIR COMFORT LEVEL WHEN DEALING WITH A SENSITIVE ISSUE SUCH AS AIDS, EMPLOYERS AND CO-WORKERS SHOULD TREAT ALL MEDICAL INFORMATION OBTAINED FROM EMPLOYEES WITH STRICT CONFIDENTIALITY, THE CONFIDENTIALITY OF EMPLOYEE MEDICAL RECORDS SHOULD BE IN ACCORDANCE WITH EXISTING LEGAL, MEDICAL, ETHICAL AND MANAGEMENT PRACTICES, Pe, 21 - ° OBTAINING SENIOR MANAGEMENT SUPPORT IS VITAL TO ANY AIDS EDUCATIONAL EFFORT. NOT ONLY DOES THIS LEND CREDIBILITY TO THE PROGRAM BUT PROMOTES VISIBILITY TO EMPLOYEES AND TO OTHER COMPANIES AS WELL, THE “Buy-IN” OF COMPANY LEADERS ASSURES THE PROGRAM OF A HIGH PRIORITY AND ENCOURAGES SUPPORT FROM EMPLOYEES AND MANAGERS, - EMPLOYEES WITH ANY LIFE-THREATENING ILLNESSES, INCLUDING AIDS or ARC, SHOULD BE ALLOWED TO CONTINUE WORKING AS LONG AS THEY ARE MEDICALLY CLEARED TO WORK AND ARE ABLE TO PERFORM THE JOB, - EMPLOYEES WHO ARE AFFECTED WITH AIDS oR ANY LIFE-THREATENING ILLNESS SHOULD BE TREATED WITH COMPASSION AND UNDERSTANDING, WORK ACCOMMODATION SHOULD BE AVAILABLE WHEREVER POSSIBLE. Pe, 22 FINALLY, IT IS VERY IMPORTANT TO ADDRESS THE PSYCHOLOGICAL ASPECTS OF THE DISEASE AS WELL AS THE MEDICAL FACTS. WE TEND TO OVERLOOK THE GRIEF AND LOSS ISSUES THAT CONFRONT A DEPARTMENT WHEN A CO-WORKER IS SEVERELY ILL, MANY EMPLOYEES FEEL UNCOMFORTABLE NOT BECAUSE OF FEAR OF CONTAGION, BUT BECAUSE THEY DO NOT KNOW HOW TO RESPOND TO AN ASSOCIATE WITH TERMINAL DISEASE. SMALL GROUP DISCUSSIONS GUIDED BY A TRAINED MENTAL HEALTH PROFESSIONAL CAN HELP EMPLOYEES COPE WITH THE SITUATION, IN ORDER TO LAUNCH A SUCCESSFUL EDUCATION EFFORT ABOUT AIDS, EMPLOYEE FEARS MUST BE IDENTIFIED, ACKNOWLEDGED, AND TALKED ABOUT. ONCE THESE FEARS ARE IDENTIFIED, THEY MUST BE DIGNIFIED - UNDERSTOOD AND RESPECTED BY MANAGERS AND CO-WORKERS, CREATING A CLIMATE OF MUTUAL RESPECT, UNDERSTANDING AND CLEAR COMMUNICATION WILL INCREASE THE LIKELIHOOD OF success IN AIDS EDUCATION IN THE WORKPLACE, Pe, 23 WE HAVE LEARNED THAT EMPLOYEES MUST HAVE ENOUGH [INFORMATION TO PERCEIVE THEMSELVES AT RISK BEFORE THEY WILL BE RECEPTIVE TO LEARNING ABOUT PREVENTION. ONCE THEY ARE CONVINCED THAT THIS IS A PROBLEM THAT DOES INDEED AFFECT THEM, EMPLOYEES ARE EAGER TO LEARN MORE, THE MOST EFFECTIVE WAY TO AVOID UNNECESSARY DISRUPTION IN THE WORKPLACE IS TO PREPARE AND EDUCATE BOTH MANAGEMENT AND EMPLOYEES ABOUT AIDS BEFORE THE FIRST CASE, Pe, 24 DEALING WITH AIDS GETS AT THE VERY HEART OF THE CONNECTION BETWEEN THE HUMAN AND THE ECONOMIC SIDE OF woRK. AIDS 1S A cosT ISSUE, A PRODUCTIVITY ISSUE, A HUMAN RESOURCES ISSUE, A LEGAL ISSUE, - AND IT IS A HUMAN ISSUE, ONE FOR ALL OF US TO TAKE VERY SERIOUSLY, QUR HOPE IS THAT BY SHARING INFORMATION ON OuR AIDS PROGRAM THAT PERHAPS WE CAN MOTIVATE OTHER COMPANIES TO JOIN IN PREVENTING THE SPREAD OF AIDS, — END -- LEVI STRAUSS & CO. AIDS IN THE WORKPLACE Background Levi Strauss & Co. has an established tradition of responsible corporate citizenship and support for employee community service. The company relies upon individual employees and employee groups (Community Involvement Teams) to help the company identify emerging issues of urgent community need. In 1982 a group of San Francisco employees asked for the support of the company’s senior management committee. They spoke about a dread new disease called AIDS. They wanted to distribute educational materials in the lobby of the company’s headquarters and raise funds. They were concerned, however, that some co-workers would be reluctant to ask questions or take literature because they might be identified as gay or as a person with AIDS. One of the senior executives offered a way to solve tne problem. He suggested that some of his colleagues volunteer to help staff the information booth. Bob Haas, executive vice president and chief operating officer, signed up for the first day. The collaboration between concerned managers and employees, which began in the company’s boardroom, has since spawned a large number of innovative and important AIDS initiatives. These efforts have made a significant contribution not only to San Francisco’s model program to combat AIDS but also to the efforts of large and small communities throughout the United States and abroad where the company has its operations. The company’s AIDS related activities are summarized in the material that follows. ADD ONE I. Levi Strauss & Co. AIDS-related Personnel Policies * The company does not have a special, AIDS policy. Instead, it addresses the needs of employees with AIDS and their co-workers within the framework of its general approach to employee relations. * The company does not test job applicants for AIDS and there are no AIDS screening questions on employment applications. * Employees with AIDS/ARC are treated with compassion and understanding --as are employees with any other life threatening disease. * Employees with AIDS can continue to work as long as they are medically cleared to do so; they are also eligible for work accommodation. * Employees are assured of confidentiality when seeking counseling or medical referral. * Company medical coverage, disability leave policy and life insurance do not distinguish between AIDS and any other life threatening disease. * The company’s medical plan supports home health and hospice care for the terminally ill. * A case management strategy is implemented whenever an individual employee becomes critically ill. * Managers are held accountable for creating a work environment that is supportive of an employee with AIDS. * The company regards itself as having a responsibility to educate its employees so that neither unwarranted fear nor: prejudice affect the work environment of people with AIDS. * Individual, family or group counseling is available to employees and their families through the company’s Employee Assistance Program (EAP) or through outside agencies. * The EAP staff also conducts department and management counseling sessions upon request about issues such as how to handle rumors about AIDS, how to deal directly with people’s feelings when a colleague becomes ill with AIDS, what colleagues can do to be helpful to a person with AIDS and how to deal with the grief associated with the death of a colleague. ADD TWO Il. Levi Strauss & Co. Employee Education Program The company was among the first to develop and implement a comprehensive corporate education program. These materials (in English, Spanish and Chinese) have been broadly distributed to other businesses and community organizations by the company and through the San Francisco AIDS Foundation. The company’s program seeks to create a climate of mutual understanding and respect and open lines of clear and direct communication. Employees are encouraged to identify their concerns and fears, and the issues raised are addressed in a dignified and sensitive manner. * All domestic and international managers have received AIDS education training. Sessions include an overview of the company’s philosophy about the disease, a discussion of how the disease is and is not contracted, a review of employee health benefits an update on the latest AIDS information and a question and answer session. Whenever possible, a local medical expert participates in these sessions. * The company has developed its own training manuals for managers, two video tapes and brochures for employees. The tapes and print material are available to employees for use at home with family members. They were also donated to the San Francisco AIDS Foundation for broad public distribution. * The company has provided employees with ongoing information about AIDS by running a series of articles in its HEALTH & FITNESS tabloid and other employee publications. Newsletters and fact sheets are available at work sites. At the San Francisco headquarters, representatives from AIDS agencies participate in health fairs and medical experts are regularly featured in an employee noon time lecture series. * In 1985 an AIDS Employee Task Force was established to help develop and evaluate company educational efforts, ensure that there are ongoing new program initiatives, provide advice about grants to community agencies and offer general counsel to management. The group meets monthly and includes employees from the operating companies and staff functions such as personnel, legal, communications, community affairs and administrative services. Employees with AIDS/ARC are also represented. ADD THREE III. Levi Strauss & Co. AIDS-related Community Initiatives As the company gained a reputation for having developed a comprehensive set of AIDS initiatives, it became a resource for the business community, for nonprofit agencies, AIDS educators and the media in San Francisco, throughout the United States and abroad. * In 1985 Bob Haas urged his peers in San Francisco to join in organizing a one-day seminar on AIDS in the work place. When the conference was held in early 1986, Bob hosted a group of CEOs for breakfast and opened and closed the meeting. The event is viewed as the first significant gathering of business leaders to address AIDS. It attracted more than 200 participants from approximately 150 companies. * The company provided funds and technical assistance to help develop the "AIDS in the Workplace" educational materials that were distributed at the conference and that continue to be a standard reference document in this field. * In 1986 the company helped to organize and hosted a one day conference for Northern California Grantmakers (NCG). This event brought together funders and representatives of the organizations providing services to people with AIDS. More than 150 people attended this meeting which led to an NCG Task Force on AIDS and a dramatic increase in philanthropic support for AIDS in the region. * In 1986 Levi Strauss & Co. offered its early and public opposition to a repressive ballot initiative aimed at people with AIDS and those in at-risk groups. Bob Haas sent out letters to business leaders urging them to do likewise. The defeat of this measure in California, which was sponsored by supporters of Lyndon LaRouche, helped discredit similar efforts launched by this group in other jurisdictions. This measure has been resurrected and reintroduced in California this year and the company has again expressed its public opposition. * In 1987 the company provided two of its managers to chair an AIDS task force organized by the Bay Area United Way. The task force efforts have led to a collaboration involving the United Way, the California Business Roundtable, the Chamber of Commerce and major public and private sector employers. The company has provided technical assistance and financial support for materials aimed at CEOs who do not have an employee education progran. ADD FOUR IV. Employee, Company & Levi Strauss Foundation Support for AIDS-related Organizations In 1982, with full company support, employees in San Francisco began fundraising and volunteer activities to support people with AIDS. These efforts have since been matched in locations as diverse as San Antonio, TX. and Scotland. The company and the Levi Strauss Foundation have made or matched cash gifts and grants totaling more than $ 425,000. The company has also helped organize and legitimize AIDS agencies in areas where public attitudes have been unfriendly. Company executives and employees have been available to the media and in public forums to increase awareness and urge appropriate public and private sector initiatives. * Levi Strauss & Co.’s first contribution to the San Francisco AIDS Foundation was made in 1983. In subsequent years Bay Area recipients have included the Hospice of San Francisco, Inc., the Shanti Project and the Bay Area AIDS Crisis Fund of the United Way. * Corporate funds have also been used for an educational film produced for European television, AIDS organizations in Canada and Scotland. * The Levi Strauss Foundation makes contributions to nonprofit organization to match employee cash contributions, volunteer and board service. Employees have used this program to support AIDS-related agencies since 1983. * The company has recognized that AIDS raises difficult issues for some individuals and locales and that there have been virtually no services available to people with AIDS/ARC in some communities. For this reason, the company has played a leadership role in organizing public/private partnerships and providing start up funding in places such as Arkansas, Tennessee and the Rio Grande Valley in Texas. * In 1987 the Foundation recognized the need to direct more resources to agencies serving minority and IV drug abusing populations. In this instance as well, it has assisted community agencies that had not yet been successful in attracting more traditional funders. In 1988 the Foundation issued a "Request for Proposals" from agencies in the Bay Area serving these groups. ADD FIVE IV. Employee, Company and Levi Strauss Foundation Support for Aids-related Organization... * In 1988 a special employee "AIDS Action Team" was established at the company’s San Francisco headquarters. The team receives staff support for its efforts to increase employee volunteer and fundraising activities. * Until fairly recently, it has been difficult for the media to find corporate officials who would discuss AIDS. Many companies either thought it inappropriate to comnent, worried about the controversial nature of the subject matter or feared being stigmatized as having a work force that included people with AIDS. The company’s president and CEO, senior vice president for human resources, employee assistance program director, and communications and community affairs staff have tried to accommodate every reasonable request from journalists. We have also contacted employees with AIDS/ARC and, consistent with their own wishes, have made them available for interviews . * Since 1986 Bob Haas has been an Honorary Director of the San Francisco AIDS Foundation; he recently received a special award at the Foundation’s Leadership Recognition Dinner. Board chair William Glenn said in part, "As the first CEO of a major corporation to recognize the seriousness of the AIDS problem, you took vigorous and effective steps to care for your employees and educate your workforce." * The company received a Cable Car Award in 1988 from the Cable Car and Awards Show for "Outstanding Contribution by a Business " in the fight against AIDS. * Bob Haas has written the introduction for a book to be published in June, 1988, Managing AIDS in the Workplace, by Dr. Alan Emery and Mr._ Sam Puckett. * In May 1988, the company responded to an invitation and sent its director of Employee Assistance to testify before the President’s Commission on AIDS. * The company is a member of the National Coalition on AIDS. ADD SIX ‘Vv. Levi Strauss & Co.'s Commitment to Corporate Social Responsibility From its very inception, the company has been committed to its employees and to the communities where they live and work. This heritage goes all the way back to our founder, Levi Strauss, who besides overseeing his growing company, devoted his time and resources to numerous charitable and philanthropic activities. The company encourages its employees to take an active part in their communities. In 1970, Levi Strauss & Co. pioneered an employee volunteer effort called "Community Involvement Teams." In 1984, the White House honored this program and presented the company with the President’s Volunteer Action Award for Corporate Volunteerism. The Levi Strauss Foundation receives an annual gift from the company and makes grants and contributions in the United States. In 1987, combined corporate and Foundation cash contributions in the U.S. and abroad were more than $5 million. The company also has an established product donation program and allows community groups to use its facilities. The corporation’s long-standing commitment to good citizenship is also reflected in the daily operation of its business. It has a general code of ethics that governs all of its employees and a performance review system that holds managers accountable for compliance with this code. A commitment to equal employment opportunity and affirmative action is a core company value that predates government mandated programs. In addition to its recent efforts regarding AIDS, during the past two years the company has also launched a major initiative to assist those who are eligible for legalization under the provisions of the new United States immigration legislation. The company conducted workshops in its plants to explain the law, printed educational materials, guaranteed loans for eligible workers and their dependents, and supported public education and outreach efforts that have won the praise of the INS, the Congress and immigrant advocacy organizations. In 1984, Columbia University School of Business awarded the company the Lawrence A. Wein prize in Corporate Social Responsibility for “its pioneering accomplishment in corporate philanthropy ... and its profound commitment to its employees and to the communities in which they live." MCARTHUR JC NEUROLOGICAL AND NEUROPSYCHOLOGICAL ASPECIS OF HIV-1 INFECTION Prepared for the Presidential Commission on the HIV Epidemic: "AIDS and the Workplace" SUMMARY AND RECOMMENDATIONS Frequency of Neurological Impairment in HIV=-1 Infected Persons Progressive cognitive and behavioral deterioration (HIV dementia) develops in a proportion of patients with AIDS, however, the exact frequency (prevalence) is uncertain and ranges from 8% to as high as 66%. The development of dementia is by no means an inevitable outcome of HIV infection. A number of studies have been completed or are underway to examine the frequency (prevalence) of neurological or neuropsychological abnormalities in healthy HIV-1 infected individuals. These are persons with no constitutional symptoms, i.e. in the Centers for Disease Controi Groups II and III, who do not have AIDS or AIDS-related complex. It is estimated that there may be 1 to 1.5 million Americans who fit this category. The bulk of the studies to date have demonstrated that: healthy HIV-1 infected individuals do not have a substantially higher frequency of neurological/ neurepsychological abnormalities than uninfected controls. A recent World Health Organization consultation corivened to examine these issues produced the following conclusion: " .. there is no justification for HIV-l serologic screening as a strategy for detecting functional impairment in asymptomatic persons in the interests of public or private safety." In healthy HIV-1 infected persons, neurological or neuropsychological complaints are more likely to be caused by alternate factors such as alcohol/drug use, previous neurological disease such as head injury, anxiety, or depression. Recommendations 1. Definitional criteria for HIV dementia need to be established to aid in the clinical care of patients and in the conduct of treatment trials. >, Continuation of ongoing longitudinal studies of the neurological and neuropsychological manifestations of HIV infection with closer collaboration among researchers and pooling of data where appropriate. 3. Development of quick, yet sensitive and specific, screening tests for neurological involvement by HIV that can be applied to groups with varying risk behavior, education, and cultural characteristics. 4. The initiation of detailed studies of the pathogenetic mechanisms by which HIV-l produces neurological dysfunction. Such studies will delineate the markers and determinants of neurological disease and will aid in the planning of effective therapeutic strategies. 1 REVIEW OF PUBLISHED AND ONGOING STUDIES 1. Multicenter AIDS Cchort Neuropsychological Study (MACS) AS part of the Multicenter AIDS Cohort Study (MACS) neurological and neuropsychological, eening has been completed on more than 1800 homosexual and bisexual men.”’“ Excluding individuals with AIDS related complex (CDC Group IVa) or AIDS, data from 819 HIV-1 infected and 836 HIV-1 seronegative men have been analyzed. ‘The groups did not differ significantly in age or educational level. The analyzed group was healthy, without constitutional symptoms, i.e. in CDC Groups II or III (persistent lymphadenopathy). Ten percent of both the HIV-1 infected men and the HIV-1 seronegative controls screened positive based on their performance on the neuropsychological tests. The performance of the healthy HIV-1 infected individuals could not be differentiated from the controls based on either mean performance or the number of individual tests performed abnormally. The frequency of neurological symptoms was assessed using a self-administered neurological questionnaire. There were no differences between the healthy HIV-1 infected individuals and the controls. A smaller group of HIV-1 infected men has been reassessed at 6 monthly intervals for one year. An analysis of neuropsychological test performance during that interval did not reveal any trend toward deterioration or decline in neuropsychological performance. Various laboratory tests have been studied and correlations examined with neurological examination findings and/or neuropsychological performance. Cerebrospinal fluid abnormalities? including pleocytosis, elevated total protein, increased specific and non-specific IgG, and HIV-1 isolation were frequent, but occurred as frequently in asymptomatic HIV—-1 infected controls as in those with neurological/neuropsychological abnormalities. Magnetic resonance imaging showed a high frequency of mild non-specific abnormalities, including atrophy and white matter focal hyperintensities that were present in both infected and non-infected individuals and that did not correlate with neurological/neuropsychological abnormalities. Comment: These data suggest that there is no increased prevalence of neurological symptoms or neuropsychological test abnormalities in otherwise healthy HIV-1 infected men compared to appropriate age and education matched controls. The participants were self-selected and highly educated, and may therefore not be representative of the general population. Magnetic resonance imaging and cerebrospinal fluid analysis are frequently abnormal, but the laboratory findings do not correlate with clinical status. Longitudinal follow-up will determine the predictive and prognostic value of these tests. 2. US Air Force Studies Marshall et al have used neurological and neuropsychological instruments to screen all US Air Force personnel with positive HIV serology. Neuropsychological testing was administered to 135 asymptomatic HIV 2 seropositive individuals. One hundred and twenty four had the Minimental Status Examination (a brief "bedside'' mental status examination) and 36 had more detailed neuropsychological testing. Cerebrospinal fluid was also examined. The control group consisted of individuals who had had mild head injuries. No significant detectable neuropsychological dysfunction was observed in the asymptomatic HIV seropositive individuals and there was no correlation between neuropsychological performance and spinal fluid abnomalities.4 Comment: These data confirm those of the MACS, and have now been extended to several hundred USAF personnel. The evaluations were not performed blinded to serostatus and the controls may be unreliable. 3. cOC San Francisco Cohort Study In a study of 85 homosexual/bisexual men in CDC Groups II or Ill, Janssen and co-workers found no difference in neurological abnormalities or neuropsychological performance between HIV seropositive individuals (15%) and controls (18%). (Janssen, unpublished). 4. San Diego Group In this neuropsychological and magnetic resonance imaging study of 55 ambulatory homosexual men, all subjects were either patients at UCSD or participants in a longitudinal study of HIV infection.? ‘The study groups included 15 patients with AIDS, 16 with ARC, 13 HIV seropositive subjects, and 11 HIV seronegative individuals. It is not clear how the control group was selected. Comparison of the group mean scores for the individual neuropsychological measures showed marginal significant differences only on the Category test (a non-verbal test of abstraction taken from the Halsted battery) compared to controls and on the PASAT (a test requiring attention and mental processing). Individuals were also classified as “abnormal” by rating each subject's performance on each test. Individuals were classified as "abnormal" if at least one test was "definitely impaired" or at least two tests were "probably impaired." Using this method, the rate of neuropsychological abnormalities appeared to increase and was noted in 1 of 11 HIV seronegative individuals, 7 of 13 HIV seropositives (44%), 7 of 16 ARC, and 13 of 15 of AIDS patients. Magnetic resonance imaging scanning also showed abnormalities in 9 of 13 patients with AIDS and 5 of 10 patients with ARC, but was not performed in the HIV seropositive group or in the seronegative controls. Comment: These data were interpreted in the discussion to "suggest that persons with asymptomatic HIV infection may have incipient central nervous system impairment." It is important to note 4a) the small size of the study groups, b) the lack of information about the HIV seronegative control group, c) the fact that group means showed no significant differences between HIV seropositive patients and the seronegative controls, d) classification of individual performance as normal or abnormal relied on published neuropsychological norms, which may not be appropriate for this study group, 3 e) the effects of depression and anxiety were not considered in the analysis. 5. CDC Lymphadenopathy Syndrome Study Janssen et al studied 39 homosexual/bisexual men with lymphadenopathy syndrome and 38 HIV seronegative homosexual/bisexual controls. Study participants were physician-referred. Six LAS patients had histories suggesting mononeuropathy, 9 had symptoms suggesting distal symmetrical polyneuropathy, 9 had had herpes zoster radiculitis. Blinded clinical and neuropsychological assessment was abnormal in 9 of 18 LAS patients compared with 2 of 26 controls. Of those abnormal, the majority scored in the mildly impaired range and did not appear to have functional limitations. The cD4 (T helper lymphocyte) count was significantly lower in the LAS group, but there was no association between the CD4 count and neuropsychological performance. Janssen concluded from this that "mild neurological abnormalities in LAS are common and that HIV may directly or indirectly be the cause." Comment: The significance of these data is uncertain. None of the individuals showed signs of clinical dementia and longitudinal follow-up will be essential in determining whether these subtle neuropsychological findings are progressive or predictive of subsequent neurological outcome. Janssen has re~examined the data and has completed follow-up on the majority of these patients. Although unpublished, his impression is that the majority of the LAS patients with neuropsychological abnormalities found initially probably had more constitutional symptoms and therefore would not be truly classified in CDC Groups II and III (Janssen, personal communication 1988) .7 6. National Institute of Mental Health In this small scale study, 13 patients with AIDS, 9 HIV seropositive patients, 4 HIV seropositive patients with chronic active hepatitis (CAH), 5 HIV seronegative patients with CAH, and 6 healthy controls were compared on their performance on a battery of neuropsychological tests. No significant differences were cbserved between the HIV seropositive patients and healthy controls. 7. Memorial Sloan Kettering Group Neuropsychological performance was compared in 20 HIV seronegatives, 16 asymptomatic HIV seropositive individuals, 44 newly diagnosed AIDS patients, and 40 AIDS patients referred for neurological consultation. Significant reductions in performance were noted in the two AIDS groups, with impairment most prominent on tests assessing motor speed and fine control, concentration, problem solving, and visuo-spatial performance. The asymptomatic HIV seropositive individuals were not significantly different from controls on any of the tests used.® 8. Intravenous Drug Users Study Silberstein and coworkers demonstrated neuropsychological test abnormalities in approximately 40% of a group of intravenous drug users in New York City. Detailed clinical information and follow-up was not provided.? Summary _of Neurological/Neuropsychological Data pata from three studies involving over 1000 subjects, predominantly homosexual/bisexual men, have shown no significant increase in neurological or neuropsychological abnormalities in HIv-1 infected, otherwise healthy persons when compared to HIV-1 seronegative controls. Other data, based on small study groups, raise the possibility of some increase in subtle neuropsychological abnormalities in these persons. The weight of current evidence suggests that HIV infected individuals in CDC Groups IT and III do not have an increased prevalence of neurological or neuropsychological abnormalities. When neuropsychological abnormalities are detected in HIV-1 infected persons, other alternative etiologies can often be found, for example alcohol or drug use, depression, previous head injury, or learning disorders. It is unknown whether presumed HIV-related abnormalities are transient and reversible, persistent, or progressive. It is also uncertain whether these neuropsychological abnormalities progress into HIV dementia. None of these studies have yet completed longitudinal or repeated assessments, which would ascertain whether HIV-1 infected individuals show a decline in neurological and neuropsychological performance over time. Similarly, no information yet exists on whether certain variables are markers, i.e., predictive or prognostic for future development of neurological impairment. The factors that determine whether or not progressive neurological deterioration will occur are uncertain. The diagram below illustrates some of these unknowns. Almost everyone who becomes infected with HIV-1 can be expected eventually to develop inmunosuppression, however, some individuals (A) remain neurologically normal. Other individuals develop neurological symptoms and signs leading to dementia in parallel with the development of immunosuppression. In some (B), the deterioration is slow and only mild dementia develops; in others (c), the neurological deterioration is more rapid and severe dementia develops. In other patients (probably only a minority of those with dementia), the neurological deterioration occurs early and before the development of immmosuppression. The factors or variables "XYZ" which determine the different courses are not known at the present time. Delineation of these variables will be of profound importance in planning effective therapeutic strategies. HIV_ INFECTION AND DEMENTIA a OE, ote ‘ v Pee ha es Rpt” Madtatn, a3 tae s ate “hn, hy is tg. Neate Be, ot , ae wv . wag? Fes ms , a ree . ae uippres sion: va wi 4 poebee tas 5 100% A NORMAL 5 iN; = MILD 5 DEMENTIA = : oe O = uu D Zz | HIV INFECTION DEMENTIA IMPLICATIONS AND RECOMMENDATIONS : 1. Definition of HIV dementia. Despite its inclusion in the Centers for Disease Control (CDC) list of AIDS-defining conditions, no consensus yet exists on the definitional criteria for HIV dementia. Accurate diagnosis of HIV dementia is of importance for clinical care of patients and for conduct of treatment trials. Recommendations: Groups from organizations such as the American Academy of Neurology, American Neurological Association, American Psychiatric Association, American Psychological Association should be convened to establish definitional criteria. 2. Epidemiology and pathogenesis of neurological manifestations of HIV infection. The prevalence of HIV dementia varies widely, from 8% (San Francisco series) up to 66% (Memorial Sloan Kettering autopsy series), depending on geographic area, patient population, and definitional criteria used. Accurate epidemiological information will be essential in planning future health care needs and will only be obtained from some of the ongoing longitudinal studies already underway, such as the Multicenter AIDS Cohort Study and the USAF studies. Numerous prospective neurological/neuropsychological studies are underway both in the US and in Europe. These studies will be important in defining the incidence, prevalence, and natural history of the neurological manifestations of HIV infection. The use of azidothymidine (AZT) is so widespread now that it has to be recognized that the majority of individuals in these studies are likely to be taking AZT. It is hopeful that these studies will produce information 6 the patterns of clinical, neuropsychological, and laboratory abnormalities that are predictive for development of or progression of neurological disease. Recommendations: A. Collaboration between studies in terms of selection of test batteries, avoidance of unnecessary duplication, and pooling of data where possible using techniques such as meta-analysis. B. Appropriate controls must be included in longitudinal studies to allow for the effects of drug and alcohol use, anxiety, psychiatric disorders, and education. C. Precision must be used in the description of study groups, particularly for the stage of systemic disease or of immunological competence (measurement of T helper lymphocytes). D. Extension of these studies into other risk behavior groups, for example, intravenous drug users, children, hemophiliacs. E. Identification, where possible, of markers which are predictive, in the healthy HIV infected individual for the subsequent development of neurological involvement. F. Delineation of the pathogenetic mechanisms underlying HIV related neurological disorders. Current test instruments. At present, there is no standard neurological/neuropsychological battery for the assessment of HIV related abnormalities. Many of the research studies use complex series of tests which are difficult to administer and score, culture specific, and time-consuming. Additionally, many of the test batteries in use may not bear a relationship with clinical or functional status. Recommendations: The eventual goal of the numerous longitudinal studies should be to develop and refine a suitable neurological/ neuropsychological battery for assessment of HIV related abnormalities. Such a battery should be: A. Both sensitive and specific for HIV related dysfunction B. Easy to administer in the field without extensive training C. Adaptable for non-English speakers, persons with no/low education, and be culture non-specific D. Not affected by learning effects if used repeatedly E. Should correlate with clinical or functional capacity References l. 2. 4. 8. 9. McArthur JC, Ostrow D, Selnes 0, DiGiovanni C, Cohen B, Phair J et al: Neuropsychiatric manifestations of human immmodeficiency virus infection: results of an initial screening evaluation of homosexual/bisexual men (abstract). III International Conference on Acquired Immunodeficiency Syndrome (AIDS) June 1-5, 1987, Washington, be McArthur JC et al: Low prevalence of neurological and neuropsychological abnormalities in healthy HIV~-1 infected individuals: results from the Multicenter AIDS Cohort Study (in preparation) McArthur JC, Cohen BA, Farzedegan H, Cormblath, DR, Selnes OA, Ostrow D, Johnson RI, Phair J, Polk BF: Cerebrospinal fluid abnormalities in homosexual men with and without neuropsychiatric findings. Ann Neurol 23 (suppl) :S34-S37, 1988. Marshall DW, Goethe KE, Mitchell JE, Brey RL, Cahill WI: Neurologic and neuropsychological status of human immunodeficiency virus (HIV) serum antibody positive asymptomatic patients (abstract). Neurology 38(suppl): 247, 1988. Rubinow DR, Berrettini CH, Brouwers P, Lane HC: Neuropsychiatric consequences of AIDS. Ann Neuro 23(suppl) :S24-S26, 1988. Tross S, Price RW, Navia B, Thaler HT, Gold J, Hirsch DA, Sidtis JU: Neuropsychological characterization of the AIDS dementia complex: a preliminary report. (in press) Janssen RS, Saykin AJ, Kaplan JE, Spira TJ, Pinsky PF, Sprehn GC, Hoffman JC, Mayer WB, Schonberger LB: Neurological complications of human immmodeficiency virus infection in patients with lymphadenopathy syndrome. Ann Neurol 23:49-55, 1988. Grant I, Atkinson JH, Hesselink JR, Kennedy GJ, Richman DD, Spector SA, McCutchan JA: Evidence for early central nervous system involvement in the acquired immunodeficiency syndrome (AIDS) and other human immunodeficiency virus (HIV) infections. Ann Int Med 107:828-836, 1987. Silberstein CH, McKegney FP, O'Dowd MA, Selwyn PA, Schoenbaum E, Drucker E, Feiner C, Cox CP, Friedland G: A prospective longitudinal study of neuropsychological and psychosocial factors in asymptomatic individuals at risk for HTLV-III/IAV infection in a methadone program: preliminary findings. Intern J Neuroscience 32:669-676, 1987. 8 | WHO STATEMENT ON NEUROPSYCHOLOGICAL ASPECTS OF Hiv INFECTION Global Programme on AIDS Division of Mental Health World Health Organization in persons with the disease AIDS or in those ili watn tna ATDS-related complex important neurological and poychiatric elinical conditions have been recognized to occur. In some cases thease conditions have been Linked to effects of the ATMS virus (human immuncdeficiency virvse * EIV) in the brain and nervous system. As a result, concern has aiso ooen expressed about whether persons infected with HIV who are otherwise nealthy might experience difficultaes in neuropsycnological function, A four-day Gonsultation (14-17 Marcn iGf8) «as convened un Geneva by the WHO Global Frogramme on AIDS (GPA) antl the Division of Mental Eealtn (MNH) ta examine currently available scientific and medical data on the neuropsycholopical effects of HIV infection. with gartaicular attention to PIV infected but otherwise healthy individuals. in order to review the broad range of issues involved, 48 experts from i7 countrics attended this meeting, representing the disciplines of neurology, psycniutry, psychology, neuroblology, epidemiology, social work, occupational health, ethics, clinical research, and health policy. The Consultation reported that: "At present, there 1s no evidence for an increase of clinically significant neurological or nevropsychological abnormalities in CDC Group II or Group III HIV-1 Seropositive (i.a., otherwise asymptomatic) individuals as compared *o HIV-1 seronegative controls. Therefore, there is no justification fur HIV-1 serologic screening as a strategy for detecting euch fenctzonsl impairment in asymptomalic persons,” The most important outcome of rhese deliberations is that governments, emplovers and the public can te assured tinut based on tne weight of svailable scientific evidence, otherwise healthy HIV-infected individuals are no more lixely to be funcrionally impaired than urinrected persons. Thus, iV screening would not be a usefel scrategy ro identify Funcrional impairment in otherwise healthy persons. Yurthermere, there ais no evidence rnat PIV screening of healthy persors would te ucetui in predicting the onset of functionsai impaimment ir persons wid remain otherwise Lealthy,. The Consultation recommended rhat as additional scientific infermation becomes available, this information and its policy implications should be reviewed, The meeting also made a series of recommendations regurding the need for and types of future research and noted that the frequency of occurrence of neuropsychiatric conditions in clinically ill patients (i.e., those with AIDS related complex and AIDS) will require a review of the types of services which will be required for the care of patients. A complete report from the Consultation will be available within one month. IMPLICATIONS OF THE HIV-ASSOCIATED SECONDARY INFECTIONS FOR THE WORKPLACE Relevant Medical Information Testimony of Frank S. Rhame, MD Before the Presidential Commission on the HIV Epidemic May 10, 1988 SUMMARY THE PROBLEM. HIV-caused immunodebility causes an increased incidence of infection due to over 30 pathogens. Predisposition to these secondary infections raises the follow- ing questions: Oo To what extent does the increased prevalence of the HIV-associated infections cause HIV-infected persons to pose an excess hazard to healthy persons? immunosuppressed persons? pregnant women? newborns? Oo Should special efforts be undertaken to diminish exposure of HIV-infected persons to other potentially or actively infectious persons? ° Should HIV-infected persons be restricted from occupation required animal ex- posures? environmental exposures? overseas travel and requisite immuniza- tions? CONCLUSION. Workplace transmission of most of the HIV-associated secondary patho- gens is not a problem because they (1) do not spread from person-to-person or do so only during intimate contact, (2) colonize all humans from early in life, and/or (3) do not cause illness in healthy persons. The most important exception is Mycobacterium tuber- culosis, the cause of tuberculosis. Tuberculosis is a problem because (1) dormant focal infection commonly becomes active in HIV-infected persons, (2) infectious tuberculosis ean be present without characteristic symptoms, and (3) M. tuberculosis can be trans~ mitted by the airborne route to unsuspecting healthy persons. However, the severity of the problem is diminished because (1) most US HIV-infected persons do not harbor dor- mant tuberculosis foci, (2) the type of tuberculosis which usually develops in HIV- infected persons is less infectious, (3) M. tuberculosis transmission is less common in the workplace than the home, (4) astute physicians detect and treat tuberculosis before it becomes very infectious, (5) tuberculosis is uncommon in exposed contacts who receive proper post-exposure prophylaxis, and (6) active tuberculosis, should it develop in a con- tact, can almost always be successfully treated. Special precautions for HIV-infected persons in all other circumstances are either not necessary or, in certain unusual circumstances, can be accomplished with minimal disruption and without significant increases in infection hazard to HIV-infected persons or their associates. RECOMMENDATIONS 1) HIV-infected persons should receive attentive medical care by physicians who recognize their increased tuberculosis risk and are knowledgeable about diagnosing tuber- eulosis in this context. When active tuberculosis is recognized in any person, careful evaluation of contacts, in cooperation with local health authorities, is necessary. 2) It is probably desirable to exclude HIV-infected, varicella-zoster virus suscept- ible persons from situations of intense chickenpox exposure (eg, school outbreaks). 3) There are unusual, occupation-related infection hazards which pose risks to HIV- infected persons which are sufficiently greater than the risk to healthy persons that special counselling with optional! self-exclusion is appropriate. These situations include overseas travel to areas of poor sanitation or increased transmission of certain exotic pathogens, environmental exposure to soil in areas of coccidioidomycosis endemicity, ex- posure to Cryptosporidium (eg, large animal veterinary work), and exposure to Toxoplas- ma (exposure to animal flesh or cat feces). Known HIV-infected persons should not re- ceive oral polio vaccine or BCG vaccine. The magnitude of the increase in risk to asymptomatic HIV-infected persons in these situations is insufficient to constitute a basis for anti-HIV screening. Classification of the transmission mechanism of the pathogens causing excess infections in HIV-infected persons Transmission mechanism environment (including food)-to-person. Person-to-person trans- mission does not occur Animal-to-person. Person-to-person. Spread occurs readily, all humans repeatedly ex- posed. Most persons colonized early in life. Person-to-person. Fecal- oral transmission. Person-to-person. Trans- mission requires pro- longed, intimate expo- sure. Person-to-person. Air- borne. * parentheses indicate less important transmission mechanisms AIDS-defining Viyeobacterium avium complex Mycobacterium Kansasii other non-tuberculosis myco- bacteria Cryptococcus Salmonella Toxoplasma Coecidioides Histoplasma (Salmonella)* Cryptosporidium+ Pneumocystis cariniit+ Candida albicans encapsulated bacteria (Salmonella) (Cryptosporidium) Isospora cy tomegalovirust herpes simplex virus . ?Kaposi's sarcoma agent JC virus Mycobacterium tuberculosist+ + specific discussion follows Other pathogens Nocardia asteroids Listeria monocytogenes Legionella Aspergillus Acanthamoeba (Strongyloides) (Listeria monocyto- genes) Microsporidia papillomavirus vaccinia virus varicella-zoster virust+ measles virus MYCOBACTERIUM TUBERCULOSIS BACKGROUND Virtually all Mycobacterium tuberculosis infection arises after inhalation of small airborne droplet nuclei. Droplet nuclei are naked bacteria left over after the moisture from coughed droplets has evaporated. These droplet nuclei can travel long distances through the air. The bacteria become deposited in the deepest portion of the lungs, the alveoli. In hosts with no immunity to M. tuber- culosis, bacterial multiplication occurs without opposition. The organisms travel to the lymphatics draining the lungs and become disseminated throughout the body. After about six weeks, a normal host develops immunity and begins to destroy most of the bacteria. The relevant type of immunity is "cell mediated immunity." In addition to killing bacteria this type of immunity produces a posi- tive tuberculin skin test, a red lump appearing 2-3 days after M. tuberculosis proteins are injected into the skin. About 5% of the time this host response fails and the newly infected person develops active tuberculosis. In most cases, how- ever, all the bacteria are destroyed except for a small number of residual a In these foci living tuberculous organisms “remain. ; These organisms stimulate the immune system and maintain the positive skin test. Over the remaining years of the infected person's life, the foci can "break down" and advance to active tuber- culosis, The possibility of development of active tuberculosis is increased in proportion to the weakness of the immune system of the host. Old age, aleohol- ism, immunosuppressive drugs, cancer, and AIDS all substantially increase the probability of the failure of the host to keep the M. tuberculosis organisms walled up in the dormant foci. When active tuberculosis develops, it occurs 90-95% of the time in the lungs. Some organisms become shed into the sputum. The infected person, by coughing, can produce droplets containing M. tuberculosis organisms. Most of these droplets fall to the earth within a meter or two. But, if they are of the right size, the water portion of the droplet can evaporate yielding a droplet nucleus which can remain airborne. Production of droplets containing M. tubercu- losis is markedly aggravated if the host develops a cavity in the lung. These cavities contain large numbers of organisms because they communicate with the airways which permit high oxygen levels to assist organism growth. By connecting with the airways the organisms are much more aggressively shed into the sputum. In contrast, tuberculosis which develops in other parts of the body (eg, bone, kidney) is not infectious at all. One exception, a type of extrapulmonary disease which is infectious, is tuberculosis of the larynx. In general, even with pulmonary tuberculosis, there is great variation in the degree of infectiousness of patients. Infeetiousness declines rapidly when appropriate therapy is instituted. Persons with active, infectious tubereulosilts should not be considered “otherwise quali- fied" to work. Tuberculosis is common in AIDS patients. In the CDC data approximately 2% of AIDS patients develop TB a). ‘This is probably an underestimate since sub- sequent infections (those arising after the presenting, AIDS-defining infection) are probably underreported. It is probably the case that the majority of AIDS patients, if they harbored dormant tuberculosis foci prior to their HIV infection, will ultimately develop active tuberculosis. In about half of AIDS patients de- veloping tuberculosis, the tuberculosis is the presenting opportunistic infection (2). The remaining tuberculosis cases arise after the diagnosis of AIDS. In AIDS patients, in contrast to tuberculosis in other persons, between half and two-thirds of the time, the tuberculosis is extrapulmonary or disseminated. In a non-AIDS contact disseminated tuberculosis is quite uninfectious. Preliminary data from two studies of household contacts of AIDS patients with tuberculosis, comparing skin test reaction rates with household contacts of non-AIDS patients with tuber- culosis, suggest that the relative non-infectiousness of disseminated tuberculosis holds for AIDS patients as well. ARGUMENT FOR RESTRICTION Tuberculosis occurs about 200 times more commonly in AIDS patients than the general US population. At least 2% of AIDS patients develop tuberculosis (1) while the case rate in the US population is about 9 per 100,000 per year (3). Since half the tuberculosis in AIDS patients is the first symptomatic manifestation of HIV disease, a period of infectiousness can go unrecognized in persons who are unaware of their HIV illness and/or are not receiving attentive medical care. Even though the symptoms are generally present, they may be non-specific (mal- aise, weight loss, fever, sweats) or attributable to a number of other conditions (cough, sputum production). Tuberculosis can spread through the air to totally unsuspecting healthy persons. Tuberculosis is a potentially fatal illness and is particularly hazardous for the very young (less than 6 years of age). Although tuberculosis rates in the United States are higher in blacks, today it ean oceur in all populations of HIV-infected persons. HIV-infected persons who may develop tuberculosis cannot be reliably recognized as harboring dormant tuberculous foci by a history of tuberculosis exposure or a positive skin test (which HIV-induced immunodebility can render false negative). COUNTERARGUMENT Only a minority (less than 5%) of US HIV-infected persons harbor dormant tuberculous foci. Most tuberculosis cases arising in HIV infected persons are not infectious at all (extrapulmonary cases) or relatively uninfectious (disseminated cases), Lung cavities, which require a competent immune system to create, are uncommon in HIV-infected persons. In general, HIV-infected persons receive closer medical attention than the average tuberculosis patient which should reduce the period from activation to treatment. Tuberculosis transmission is relatively uncommon in the workplace. The rate of tuberculosis transmission from persons of equivalent infectiousness is a function of the time spent sharing the space, the volume of the space shared and the air change rate in the space. Household transmission which may average 20%, is probably 5-10 fold more effi- cient than workplace transmission. When tuberculosis exposure is recognized, well developed techniques exist to manage exposed contacts. If a transmission to a contact occurs it can be recognized by the "conversion" from a negative to a positive skin test. A year of therapy with isoniazid, a relatively safe drug, almost always prevents the development of active tuberculosis and can often eradicate any nacent dormant tuberculous foci. Even if active tuberculosis develops in a contact it can almost always be successfully treated. CONCLUSION It is important to be sure that HIV-infected persons have attentive medical care and that chronic or respiratory illness developing in persons of unknown HIV Status be correctly evaluated. In HIV-infected persons, these evaluations should include blood and sputum culture for M. tuberculosis. When attentive medical care is present, tuberculosis in HIV-infected persons can almost always be arrested before substantial infectiousness occurs. Appropriate management of contacts of persons with infectious tuberculosis is necessary. Local health de- partments can often assist in evaluating contacts. 1. ae 3. Selik RM, Stareher ET, Curran JW. Opportunistic diseases reported in AIDS patients: frequencies, associations, and trends. AIDS 1987; 1:175-182. Centers for Disease Control: Tuberculosis, Final Data - United States, 1986. Morbid Mort Weekly Rept 1988; 36:817-9. Chaisson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF, Hope- well PC. Tuberculosis in patients with the acquired immunodeficiency syn- drome; clinical features, response to therapy and survivaL Am Rev Respir Dis 1987; 136:570-574. - ¢ VARICELLA-ZOSTER VIRUS BACKGROUND The varicella zoster virus (VZV) is the virus which causes chickenpox (vari- cella) and shingles (zoster). When a person first becomes infected by the VZV, chickenpox ensues. The virus then becomes latent jn sensory nerve ganglia (pea Ab) & sized bodies composed of the main portion. of, nerve éells), At any time thereafter the VZV may reactivate as shingles. Shingles is a chickenpox-like eruption which oceurs in the distribution of the sensory nerve affected. In immunosuppressed patients the shingles eruption, which starts localized, can disseminate and produce severe illness. Mild second cases of chickenpox can rarely occur in highly immu- nosuppressed persons. A chronic VZV viremia (blood stream infection) rarely occurs in AIDS patients. Persons with chickenpox are highly infectious, producing cases in over 70% of susceptible household contacts. The virus is spread by the airborne route. Persons with chickenpox can infect others at long distances. Direct contact with the fluid from shingles lesions can also cause chickenpox in susceptible persons (those who have never previously had chickenpox). Note that exposure to VZV, whether from a person with chickenpox or shingles, will produce chickenpox in the contact not zoster. VZV infection is severe in HIV-infected people. Often the first manifesta- tion of HIV-infected children is a particularly severe case of chickenpox. These cases can proceed to fatal pneumonia. Shingles eruptions are more common and more severe in HIV-infected persons. Dissemination occasionally occurs. The drug acyclovir (brand name Zovirax) is an effective and safe therapy for all VZV illness. However, therapy must be instituted early to be maximally effective. ARGUMENT FOR RESTRICTION Since chickenpox in HIV-infected persons is severe and since VZV can be transmitted by the airborne route quite efficiently it is important to protect HIV- infected persons from chickenpox exposure. Since the chickenpox can be severe in all immunosuppressed persons and VZV iliness is common in HIV-infected persons it is important to keep HIV-infected persons away from highly immunosuppressed contacts. Such restrictions are particularly appropriate for hospitals and other contexts with large numbers of immunosuppressed patients. COUNTERARGUMENT Protection of HIV-infected persons from VZV exposure is unnecessary when a person has had chickenpox previously. Approximately 98% of US adults have had chickenpox and therefore are not VZV susceptible. Although VZV illness can be more severe in an asymptomatic HIV-infected person, most HIV-infected persons become symptomatic before severe immunodebility is present. As long as chickenpox is promptly treated with acyclovir, severe illness can be aborted. Chickenpox exposure in most workplace contexts is quite uncommon. CONCLUSION It is probably appropriate to exclude known HIV-infected VZV susceptible persons from situations of intense chickenpox exposure. An example might be a school teacher working in an elementary school during a chickenpox outbreak. The severity of chickenpox in asymptomatic, HIV-infected persons is not increased enough nor does it occur often enough to provide a basis for screening. Further exclusions are unwarranted because of (1) the low fraction of adults who are VZV -10- susceptible, (2) the infrequency of VZV exposure in most workplace contexts and (3) because of the improbability of severe VZV infection in those promptly treated with acyclovir. The most common manifestation of VZV illness in HIV-infected persons is Shingles. Shingles does not become infectious until visible lesions are present. Furthermore, VZV spread from persons with shingles is not airborne; it requires direct contact with the moisture from the lesions. Although a person can be infectious for VZV in the day or two before developing overt manifestations of chickenpox this situation is sufficiently uncommon to make exclusion of HIV- infected persons from contact with immunosuppressed patients unnecessary. -il- PNEUMOCYSTIS CARINI BACKGROUND P. carinii is a protozqng parasite which colonizes in the lungs of all or vir- tually all humans. Animal model data strongly suggest that airborne infection occurs readily. Serological data from humans suggest that colonization occurs by the first or second year of life. The parasite causes no difficulty in persons with a normal immune system. Severe pneumonia, which can be fatal, occurs in AIDS patients and others who have abnormal cell mediated immunity. It is widely believed that outbreaks of Pneumocystis pneumonia occured among debilitated orphans after World War IL Occasional outbreaks of pneumo- eystis have been reported since but they are uneonvineing (4). In the US, all or almost all pneumoeystis pneumonia arises from loss of control of colonizing organ- isms. ARGUMENT FOR RESTRICTION HIV-infected persons can be presumed to be more efficient disseminators of Pneumocystis cysts, even in the absence of overt Pneumocystis pneumonia. Im munosuppressed persons who are not already colonized (eg newborns, immuno- suppressed infants, and immunosuppressed persons recently having completed a course of anti-Pneumocystis therapy) should be protected from HIV-infected persons. COUNTERARGUMENT No convincing demonstration of Pneumocystis pneumonia attributable to exposure to a particular person has ever been produced. Even if the speculation that HIV-infected persons are more vigorous disseminators of Pneumocystis and be ~-12- proven, is likely that exposure to airborne Pneumocystis cysts occurs during all human interactions, CONCLUSION The supposition that HIV-infected persons are relatively efficient Pneumo- cystis disseminators and that such dissemination might pose an excess hazard to immunosuppressed patients is too speculative to constitute a basis for restrictions on HIV-infected persons. 4. Rhame FS, Streifel AJ, Kersey JH Jr., MeGrave PB. Extrinsic risk factors for pneumonia in the patient at high risk of infection. Am J Med 1984; 76:42- 52. -13- CYTOMEGALOVIRUS BACKGROUND y au Cytomegalovirus (CMV) ultimately infects over half of Americans and larger percentages of gay men and persons in the underdeveloped world. Most humans, after initial infection, become intermittent asymptomatic shedders during the balance of their lives. CMV can be isolated intermittently from saliva and genital secretions of such persons. CMV disease occurs exclusively in persons with weak- ened immune systems and fetuses. If a pregnant woman has a primary (ie, initial) CMV infection the consequences to the fetus can be severe. Even mothers who were infected prior to their pregnancy can transmit the virus to their fetuses, albeit less efficiently, if there is reactivation of maternal shedding during preg- nancy. CMV is, by far, the most common infectious cause of congenital malfor- mation. In many ways, CMV transmission is similar to HIV transmission: (1) asymp- tomatic, infectious persons are common (2), transmission requires intimate expo- sure and is inefficient on a per contact basis (3), but, since there are so many asymptomatic shedders, persons repeatedly exposing themselves by intimate contact have a high probability of ultimately becoming infected. In the commu- woe, - ani ~~ nity, CMV transmission§ ape sexual, from mother to infant either before birth or as a result of nursing, horizontally between toddlers (eg, in day care centers), and from toddlers to their parents. CMV has a high probability of reactivating during the course of HIV disease. Persons with AIDS who have also been infected by the CMV generally have moder- ate to severe CMV disease by the time of death. Shedding of CMV from such persons is probably of greater magnitude than from asymptomatic shedders. -14- ARGUMENT FOR RESTRICTION Because CMV infected, immunodebilitated HIV-infected persons are so often vigorous CMV shedders, contact between such persons and pregnant women and immunosuppressed patients should be prevented. Since it is unclear that prior CMV infection protects against superinfection with different CMV strains, those Peace § restrictions should extend to all pregnant women and im munosuppressed womep. COUNTERARGUMENTS No transmissions of CMV between adults have ever been documented in the absence of intimate contact. If contact with secretions from CMV shedding adults ay ‘ ‘who are likely, health care workers might be expected to be the group at highest risk. At least five large surveys of health care workers working with immunosup- pressed patients and newborns, the two ‘contexts in which CMV disseminators are most likely to be found, have not found CMV acquisition rates to be higher than those found in the general population. CMV excretion among HIV-infected persons is not abnormally high until sufficient immunodebility has occurred that they are ee otherwise asymptomatic. CONCLUSION No proscription of association with HIV-infected, CMV shedders is warranted beyond those precautions which should be observed for the HIV infection itself. -15- CRYPTOSPORIDIUM BACKGROUND Cryptosporidium is a protozoan intestinal parasite of animals and humans. In humans with normal immune systems, the parasite produces a self-limiting gastrointestinal illness. Diarrhea rarely lasts more than a week. Persons with HIV-induced immunodebility can have severe prolonged diarrhea. Such patients b Mh tenes gactpet ar are unable to clea the parasite, altegether and can produce quarts-of-watery diarrhea a day persistentiy. There is no effective therapy. Cryptosporidium transmission occurs by the fecal-oral route. Transmissions ‘ bee sam ee ne from humans and animals occur. Most of the animal ,Sourees, have been large animals, and outbreaks among veternarians and large animal handlers have oc- ete chee curred. ARGUMENT FOR dalam Because eryptosporidium ean produce a progressive, incurable, severely debilitating diarrheal illness in AIDS patients, HIV-infected persons should be proscribed from large animal handling and veterinary practice. COUNTERARGUMENT Cryptosporidium transmission to a human requires a gross breach in hygeinic practice (transfer of stool to the mouth). Cryptosproidiosis can be cleared by HIV-infected persons with no or mild immune system damage. CONCLUSION HIV-infeeted persons with mild immunodebility should be counseled about the importance of avoiding oral exposure to animal stool HIV-infected persons -16 - with moderate or severe immunodebility should consider voluntary alteration of occupational tasks to avoid working with large animals, particularly cattle, which have gastoenteritis. The magnitude of these hazards are insufficient to warrant routine screening of large animal handlers. va4-6 M709 TESTIMONY OF MARTIN D. SCHNEIDERMAN STEPTOE & JOHNSON Some Employment Law Issues Stemming from the AIDS Epidemic BEFORE THE PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC MAY 10, 1988 Indianapolis, Indiana My name is Martin Schneiderman. I am a partner with the law firm of Steptoe & Johnson in Washington, D.C. I have submitted for your convenience a curriculum vitae that outlines my academic and professional background, focusing on my activities speaking and writing on legal issues stemming from the AIDS epidemic. In my law practice, I specialize in two areas: first, providing personnel, labor and equal employment opportunity advice and representation on behalf of companies and, second, contract litigation involving principally government contracts. I am also an adjunct professor at the Georgetown University Law Center teaching equal employment opportunity litigation. I appear here not on behalf of any client or interest group. I am here in my personal capacity to offer my views and to assist the President’s Commission on HIV in dealing with the most difficult issues at hand. The AIDS epidemic is fraught with a range of problems that challenge many disciplines including medicine, law, ethics, economics, and public policy. Given the scope and importance of the issues, your task is formidable indeed. I am here today to offer my assistance in whatever way I can. In light of my specialization, I will focus on legal issues, particularly as they relate to the employment setting. With respect to the AIDS epidemic, the pre-eminent body of law applicable to employment involves protection of the handicapped. Unlike federal laws on sex, race, national origin and age discrimination, the federal law barring discrimination against the handicapped applies to selected sectors of the population. The Federal Rehabilitation Act of 1973 applies to federal employees, employees of government contractors and subcontractors, and employees of organizations receiving federal assistance. In addition to federal law on the subject, there is an array of state and local laws. Forty-nine of the fifty states have laws barring discrimination against the handicapped. I have submitted for your information a paper that discusses in some detail current developments under the federal handicap protection law, particularly the recent Supreme Court decision in Nassau County v. Arline. I should add that, beyond laws protecting the handicapped,there are other laws of real consequence applicable. to the employment setting. ERISA prevents employers from terminating employees to avoid payment of health and other fringe benefits. The NLRA protects certain employees in pursuing concerted activity. OSHA requires employers to take reasonable steps to provide a workplace free of known hazards. Because time is so limited, I would like to focus on three federal policy issues bearing upon employment -- one policy seems quite correct and effective; another plainly wrong; and a third needing much closer medical and legal attention. First, the federal government has rather effectively implemented the policy of allaying concerns that AIDS is not spread through the casual contact of a workplace setting. A pre- eminent concern of employers has been the hysterical reaction of co-workers and customers. There are still many problems and more work to do, but much progress has been made. | Second, as to the health care industry, the federal government has adopted a policy of discouraging testing and calling for universal precautions. When invasive procedures are planned, this head-in-the-sand approach seems unrealistic and unreasonable. For such procedures, precautions ought to be based on real rather than assumed information. Lastly, I want to outline an issue that clearly needs more medical and legal analysis. The commendable effort to calm unfounded fears about the spread of AIDS perhaps has led to overlooking a less hazardous, but nonetheless real, workplace concern. I refer to this concern as the “secondary infection” or "effects of HIV infection.” | As you are well aware, persons with AIDS are often vulnerable to opportunistic infections -- infections that do not pose a real risk to persons with normal immune systems. However, we have also witnessed a growing number of other infections which would appear threatening to the general population. For example, large numbers of persons with AIDS have been attacked by tuberculosis, meningitis, and various bacterial and parasitic causes of diarrhea. Should not the possible spreading of these infections be a matter of concern in the workplace setting? In a similar vein, a number of hospitals have rules barring pregnant health care workers from working with AIDS patients. CMV is one of the foremost concerns. Are these concerns also applicable to the workplace setting? These issues suggest that there may be a need to monitor the condition of persons with AIDS on an individual basis to assess particular workplace problems. We hear the commonplace policy that persons with AIDS should be permitted to work as long as they “feel fit.” I do not quarrel with this laudable objective; however, there may be need for a reservation to the effect that it is the AIDS victim’s overall condition, including the risk, if any, of contagious secondary infections, that must be evaluated in order to determine fitness to work. Another workplace problem stems from the fact that the virus seems to attack nerve and brain cells. According to the literature, a growing number of AIDS patients present dementia conditions. Obviously, certain occupations may be simply too health or safety sensitive to risk the onset of dementia. Even more alarming in this connection are the preliminary indications that dementia may be one of the early signals of AIDS in. infected persons who are otherwise asymptomatic. These are not questions to which I have answers today, nor do I believe anyone else does. What is important, as we continue to learn more about HIV, the. AIDS disease, and its secondary effects, is that we avoid the premature adoption of policies and rules that may prove to be ill-adapted to the evolving medical, legal, or social challenges posed by this epidemic. RECOMMENDATIONS In light of the substance of my testimony and the materials provided, I offer the following recommendations for consideration by the Presidential Commission on the Human Immunodeficiency Virus Epidemic: 1. Continue efforts to educate the public regarding transmission of AIDS so as to minimize responses arising from hysteria or panic. 2. Reconsider present policies discouraging testing in advance of invasive medical procedures. (Health care workers and patients ought to be able to act on the basis of real rather than presumed assumptions.) 3. Sponsor extended medical analysis of the secondary infection issue and determine the scope of any workplace problems. 4. Sponsor extended medical analysis of the dementia issue and determine the scope of any workplace problems. SEMINARS IN WHICH MARTIN SCHNEIDERMAN HAS BEEN A SPEAKER "AIDS, Medical Facts, Social Challenges, Ethical Dilemma,” sponsored by the Hubert Humphrey Institute of Public Affairs, Minneapolis, Minnesota, January 16, 1986. Legal Aspects of a Medical Crisis, Seminar by the Law Journal Seminars-Press, Washington, D.C., February 6, 1986. American Law Institute-American Bar Association Video Law Review, televised via satellite to 43 cities on February 27, 1986, Martin Schneiderman, Planning Chairman. “Everything You Always Wanted to Know About AIDS,” sponsored by the Washington Board of Trade, Washington, D.C., March, 1986. Annual Meeting of the President’s Committee on Employment of the Handicapped, Washington, D.C., April 30, 1986. Speaker on “AIDS and Employment.” “Employment Problems Arising from the AIDS epidemic,” speech delivered at the meeting of the Association of Legal Personnel Administrators, Capital Chapter, September, 1986. National Symposium sponsored by the Labor Relations Section of -the D.c. Bar, Washington, D.C., titled “AIDS: Labor and Employment Issues Raised by the Increasing Incidence of AIDS and HIV Infection.” Martin Schneiderman, Faculty Chairman. March 4, 1987. Equal Employers Subscribers Conference, Washington, D.C., June 29, 1987. Maurer Research Institute, Madison, Wisconsin, July 30, 1987. Statement before Subcommittee on Health and the Environment Committee on Energy. & Commerce, U.S. House of Representatives, Washington, D.Cc., September 29, 1987. “AIDS - The Crisis for American Business,” co-sponsored by AIDS Policy & Law Newsletter, Washington, D.C., November 2-3. 1987. Delaware AIDS Advisory Task Force, Wilmington, Delaware, April 16, 1988. In addition, Mr. Schneiderman has been interviewed and appeared, or has been quoted, in the national media, including the National Law Journal, New York Times, Miami Herald, Wall Street Journal, U.S. News & World Report, CBS Evening News and C-Span. CONTAGIOUS DISEASES DEEMED ‘HANDICAPS’ UNDER FEDERAL LAW BY MARTIN SCHNEIDERMAN AND SAMUEL PERKINS* Acquired immune deficiency syndrome (AIDS) has reached epidemic proportions, both in the United States and worldwide. The disease has grown at a staggering rate, and its mortality rate appears to be at or near 100 percent. The disease raises an array of socio-economic, political, and legal issues like no other in the recent past. Reports on AIDS reflects both myth and reality, hysteria and reason. While much progress has been made in understanding the cause, the course, and the transmission of the disease, much remains uncertain and unknown. As medical knowledge develops, the legal system -~- and the legal profession -- must grapple with a number of novel issues stemming from the disease. Particularly in the employment area, there is often a conflict between the rights of individuals afflicted with the disease and the rights of those who perceive some personal hazard. * Martin Schneiderman, a partner at Steptoe & Johnson in Washington, D.C., specializes in government contracts and in personnel consulting for employers. Samuel Perkins, also a partner in that firm, specializes in litigation and counseling in the areas of employment, energy, and contracts. Except for an updated section on the Civil Rights Restoration Act, this is substantially the same article as printed in the Legal Times, May 11, 1987. Where and how these conflicts are to be resolved remains to be dealt with by courts and legislatures. In School Board of Nassau County v. Arline, 4/ The Supreme Court took a first, tentative step in this controversial and largely uncharted area. At first glance, it appears to be sheer happenstance that the Arline case provides the fulcrum of the AIDS controversy. Arline did not involve an AIDS patient or someone who tested positive for the AIDS virus. Rather, the specific issue presented was whether a teacher susceptible to tuberculosis was entitled to the protection of Section 504 of the Rehabilitation Act of 1973.2/ Yet in light of the growing legal debate about the problems raised by AIDS in the workplace, many had surmised that Arline would serve as a vehicle for confronting some more pressing AIDS-related legal problems. The analogy from tuberculosis to AIDS as a communicable disease was readily af «1107 S.Ct. 1123 (1987). 2/ 29 U.S.C. § 794 (1982). Unlike Title VII of the Civil Rights Act of 1964, there is no generally applicable federal law regarding discrimination against the handicapped. However, the Rehabilitation Act of 1973, 29 U.S.C. §§ 701-706 (1982), covers large sectors of the population. Section 501 applies to federal employment, 29 U.S.C. § 791 (1982); § 503 applies to government contractors and subcontractors. 29 U.S.C. § 793 (1982); § 504 applies to programs receiving federal assistance, 29 U.S.C. § 794 (1982). apparent. Moreover, there was otherwise no compelling reason for the Court to grant certiorari. Since the decision was issued on March 3, 1987, most commentators have applauded it for clarifying that a debilitating contagious disease like tuberculosis -- and implicitly AIDS -- falls within the protective reach of the federal Rehabilitation Act. For what the decision accomplishes, the praise is appropriate. No longer can anyone realistically argue that the full-blown form of AIDS is not covered by the federal law because it is contagious. It must be emphasized, however, that Arline only scratches the surface of the medical~legal employment problems caused by the AIDS epidemic. In Arline, AIDS is mentioned only in a footnote, in which the Court specifically reserves judgment on what is unquestionably the most pressing public policy issue -- whether individuals who have been infected with the virus but are asymptomatic are as protected by the law as those actually suffering from the disease. The decision also suggests that AIDS problems in an employment setting need to be treated on a case-by-case basis, with the Court outlining a series of knotty medical-legal standards. When evaluated in light of growing data about secondary infections, 3/ this approach seems certain to bring to 3/ CDC Classificanon System for HTLV-3 LAV Infections, 35 Morbidity & Mortality Weekly Rep. 334 (May 23, 1986); (continued...) the fore many medical and legal questions that have not received adequate attention. Arline in Context Gene H. Arline worked as an elementary school teacher for 13 years in Nassau County, Fla. Arline had first contracted tuberculosis at age 14. She suffered a relapse in 1977, and two more in 1978. Upon learning that she was again suffering from the disease, the local school board terminated her employment in 1979, essentially because of the continued recurrence of her illness. Arline brought suit in federal court alleging that her dismissal violated Section 504 of the Rehabilitation Act of 1973. After a trial, the District Court found in favor of the school board. It held that, while Arline "suffers a handicap,” she was nonetheless not a “handicapped person” under the terms of the federal law. The District Court found that it was "difficult... to conceive that Congress intended [persons suffering from] contagious diseases to be included within the definition of a handicapped person.” The court added that even if Arline were covered, she would in any case not be regarded as a person 3/ (...continued) Tuberculosis -- United States 1985. Possible Impact of HTLV- 3 LAV Infection, 35 Morbidity & Mortality Weekly Rep. 74 (Feb. 7, 1986). “otherwise qualified” to teach elementary school, as would be required if the law were to apply. The 11th Circuit reversed, holding that persons with contagious diseases fall “neatly” within the statutory and regulatory framework of Section 504. The appeals court remanded the case for further findings as to whether the risk of infection precluded Arline from being regarded as “otherwise qualified” for her position and to consider the application of the “reasonable accommodation” requirement of the statute.4/ The District Court’s opinion seemed to be based more on instinct and intuition than on a close analysis of the federal law and implementing regulations. It is true that the legislative history of the Rehabilitation Act contains no reference to contagious diseases. Nevertheless, the 1974 amendments to the act greatly expanded the definition of a "handicapped individual” to include “any person who (i) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (ii) has a record of such impairment, or (iii) is regarded as having such an impairment.” 2/ The regulations issued by the Department of Health and Human Services included an even more comprehensive definition of 4/ Arline v. School Board of Nassau County, 772 F.2d 759 (11th Cir. 1985). 5/ 29 U.S.C. § 706(7)B. a handicap, including “[a]ny physiological disorder or condition.”§/ The regulations further define “major life activities” as such functions as “caring for'oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working. ”2/ Thus, if the statute did not clearly include tuberculosis (and AIDS) within its definition, certainly the regulations did so. There was, of course, some basis for the argument supporting the District Court opinion. The’ Rehabilitation Act and its legislative history contained no specific reference to contagious disease. While this reading of the law might seem overly technical and inconsistent with the purpose of 1974 amendments, which broadened the definition of “handicapped” to include those who are impaired or regardless of impaired, it was not entirely baseless. 6/ Specifically, the regulations state that a “physical or mental impairment” means: (A) Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special speech organs; cardiovascular, reproductive; digestive; genital; urinary; hemic and lymphatic; skin; and endocrine; or (B) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. 45 C.F.R. § 84.3(3) (1985). 7/ 45 C.F.R. § 84.3(4) (2) (ii) (1985). Decision No Surprise Nevertheless, the 1lith Circuit’s reversal of the District Court was no surprise. Even before that decision, counsel for employers generally were cautioning their clients that persons with full-blown AIDS -- and probably those with lesser, but significant, AIDS-related symptoms as well -- would probably be considered to be within the protective reach of the various handicap laws. The surprise in Arline, therefore, was not the outcome, but that the Supreme Court accepted certiorari. It is true that the case presented a matter of first impression -- namely, the question of whether contagious diseases were covered by the law -~ but there were no contrary decisions, and the legal basis for the 11th Circuit’s decision seemed well-founded. For that reason, there was at least a suspicion that the grant of certiorari had more to do with the Court’s concern over AIDS controversies to come than over the specific decision of the 11th Circuit. Another major player in the case was the Department of Justice, which intervened to present its views on the reach of the Rehabilitation Act with respect to contagious diseases. This followed the lines previously laid down by the department in June 1986 in its AIDS opinion letter, commonly called the "Cooper Memorandum.” 8/ The Cooper Memorandum conceded that AIDS was a handicap under the law, but then added a loophole of gargantuan proportions. It stated that discrimination because of AIDS was unlawful but that discrimination because of fear of contagion, irrational or not, was not discrimination based on handicap. This argument did not appear particularly persuasive. To say that AIDS is a covered handicap, but that a major concern stemming from that handicap was outside the protective reach of the law, seemed illogical. Employers’ counsel generally recognized the weaknesses of the Cooper Memorandum and advised their clients to await resolution by the courts. Like the Court of Appeals’ decision, the Supreme Court’s ruling contained no real surprises. First, the Court directly faced the issue of whether tuberculosis as a contagious disease was a handicap within the protective reach of the statute. Noting that Arline had suffered tuberculosis in an acute form that had affected her respiratory system and had required her hospitalization, the Court found this condition a serious enough impairment to have affected one or more of her "major life activities.” The Court further ruled that Arline’s 8/ Memorandum by Assistant Attorney General Charles J. Cooper, on Application of § 504 of Rehabilitation Act to Persons with AIDS, directed to Department of Health and Human Services. Daily Lab. Rep. (BNA) No. 122, at D-1 (June 25, 1986). history of infections established that she had a “record of impairment” within the meaning of the act and was therefore handicapped. The Court’s initial rejection of the Cooper Memorandum theory appeared to turn on concepts of distinguishability: We do not agree with petitioners that...the contagious effects of a disease can be distinguished from the disease’s physical effects on the claimants in a case such as this. Arline’s contagiousness and her physical impairment each resulted from the same underlying condition, tuberculosis. It would be unfair to allow an employer to seize upon the distinction between the effects of the disease on a patient and use that distinction to justify discriminatory treatment. 107 S. Ct. at 1128. On a second try, the Court more directly explained what it meant. According to the Court, “[t]he Act is carefully structured to replace such reflexive reactions to actual or perceived handicaps with actions based on reasoned and medically sound judgments.” 107 S. Ct. at 1129. Thus, the fact that some person may have contagious diseases that in fact pose a serious health threat to others under certain circumstances does not provide a logical basis for excluding from the coverage of the act all persons with actual or perceived contagious diseases. In short, the Court rejected the argument of the Department of Justice. Tuberculosis, and almost certainly full- blown AIDS, will be regarded as handicaps under the federal law. Implications for AIDS Cases - 10 - Two aspects of the decision are certain to stir further controversy. First, the Court intentionally set aside for future consideration one of the more pressing legal questions raised by the AIDS epidemic. Recognizing that its decision would be read for its implications in dealing with the AIDS epidemic, the Court made only a single express reference to AIDS, in footnote 7: The United States argues that it is possible for a person to be simply a carrier of a disease, that is, to be capable of spreading a disease without having a "physical impairment” or suffering from any other symptoms associated with the disease. The United States contends that this is true in the case of some carriers of the Acquired Immune Deficiency Syndrome (AIDS) virus. From this premise the United States concludes that discrimination solely on the basis of contagiousness is never discrimination on the basis of a handicap. The argument is misplaced in this case, because the handicap here, tuberculosis, gave rise both to a physical impairment and to contagiousness. This case does not present, and we therefore do not reach, the question whether a carrier of a contagious disease such as AIDS could be considered to have a physical impairment or whether such a person could he considered, solely on the basis of contagiousness, a handicapped person as defined by the Act. 107 S. Ct. at 1128 n. 7. The importance of this footnote can be explained by reference to what we know about the cause and transmission of AIDS. The cause of AIDS has been established as a retrovirus that is now commonly referred to as the human immunodeficiency virus (HIV). Three general categories are used by physicians to classify the nature and effect of HIV infection. First, an infected person is diagnosed as having full-blown AIDS when he or she manifests one of the “opportunistic infections” - ll = listed by the national Centers for Disease Control.2/ These opportunistic infections signal that the retrovirus has seriously degraded the immunological capability of the person. As is commonly known, a diagnosis of AIDS is nearly always fatal, with life expectancy varying from an average of two to five years after diagnosis. Approximately 30,000 cases of full-blown AIDS have been diagnosed in the United States. Many other persons who have been infected with the virus manifest have lesser symptoms. Collectively referred to as AIDS-related complex (ARC), these range from generalized swelling of lymph nodes and simple fever or lethargy to more serious neurological disorders. The exact number of ARC patients is unknown but is estimated to be at least 250,000. Not Ili but Affected Finally, and from the employment perspective most important, a vastly larger number of people have at one time been infected with the virus but are not now ill with AIDS or ARC; they are asymptomatic. The virus itself cannot be routinely isolated in the blood of these persons, but the fact that the 9/ Revision of the Case Definition of Acquired Immune Deficiency Syndrome for National Reporting -- United States, 34 Morbidity & Mortality Weekly Rep. 373 (June 28, 1985). - 12 - virus has been present can be inferred from the presence of antibodies stimulated by the virus.20/ Prevailing medical opinion is that these seropositive persons have been infected with the virus at one time, are presumed to have the virus dormant in their systems, and certainly are presumed capable of transmitting the virus to others. The modes of transmission, according to prevailing medical opinion, are distinctly limited, including sexual intimacy involving exchange of bodily fluids, transmission of blood via shared needles among intravenous drug abusers or via transfusion of contaminated blood or blood products. +1/ Overwhelming evidence indicates that the AIDS virus is not transmitted by the casual contacts occasioned by a normal workplace setting. Since one or two million Americans are estimated to he seropositive, it is easy to see the importance of the Court’s express refusal to reach the question of whether a carrier of a 10/ There are a series of tests that can provide a highly reliable method for detecting the antibody -- an enzyme~linked immunosorbant assay (ELISA) followed by a confirmatory Western Blot test. Persons who present positive results to these tests are referred to as “seropositive.” For an excellent layonented discussion of tests and other medical issues, see Staff & Brubaker, The AIDS Epidemic (1985). 11/ In addition to these modes of transmission, the virus is also transmissible from an infected mother to her child at the time of birth. - 13- contagious disease like AIDS could be considered a handicapped person under the Rehabilitation Act. This question has considerable socio-economic overtones, and there are plausible arguments on both sides. On one hand, it may be argued that a person who is seropositive is by definition asymptomatic, not ill, and is not suffering a. physical or mental impairment. On the other hand, such a person has been infected by a virus, and the effect of that infection is an alteration of his or her sexual practices, surely an important life function. Moreover, such persons may well be “regarded as impaired” by others. Given the level of hysteria about AIDS, given the reality that a tragically high percentage of these seropositive persons will run a course of illness to full-blown AIDS (estimates now range from 30 percent to 40 percent and may well prove higher) and given an employment milieu conducive to an increased emphasis on testing, there is no question that the issue requires the closest care and attention. Since the record before it involved tuberculosis, not AIDS it is understandable, if unfortunate, that the Supreme Court chose not to deal with this issue. But these problems are of enormous dimension and importance. A decision affording seropositive persons no protection at all coulda mean isolating millions of people from their jobs and communities. - 14 - On the other hand, the handicap laws today are too diverse to permit development of a uniform position on the issue.22/ And those laws as developed and interpreted to date, are not fully equipped to accommodate the interests of all the parties in dealing with what amounts to an international plague. When Congress comes arcund, as it surely will, to addressing the AIDS issue, it should decide on a comprehensive course of action. Making the Accommodation While the Court’s specific reservation regarding the treatment of seropositive persons is an open invitation to future debate and litigation, the last portion of its opinion will probably cause even more litigation in the long run. Having determined that Arline was handicapped, the Court next dealt with the question of whether she should be regarded as “otherwise qualified” for the job of elementary school teacher. The Court outlined a need to conduct an individualized inquiry in weighing the goal of protecting the 12/ As indicated above, the Federal Rehabilitation Act of 1973 does not have the reach of Title VII. It applies to designated sectors of the population. Moreover, more than 40 states have their own enactments prohibiting discrimination against the handicapped or disabled -- many modeled after the Rehabilitation Act. Some jurisdictions, particularly municipalities (including the District of Columbia, Minneapolis, New York, San Francisco, and Los Angeles), have anti-discrimination provisions covering sexual preference, which might also become a consideration. For an excellent survey and discussion of these laws see Leonard, AIDS in Employment Law Revisited, 14 Hofstra L. Rev. 11(1985). 15 = handicapped against the legitimate concerns of exposing others to significant health and safety risks. Basing its analysis on an amicus curiae brief filed by the American Medical Association, the Court listed the basic factors to be considered in this inquiry. The inquiry would include determinations, based on reasonable medical judgment, about (a) the nature of the risk (how the disease is transmitted); (b) the duration of the risk (how long the carrier remains infectious); (c) the severity of the risk (what the potential risk is to third parties) and (qd) the probabilities the disease will he transmitted and will cause varying degrees of harm. After these assessments are made, the next task is to determine whether the employer reasonably could accommodate the employee under established standards. The Court remanded the Arline case for findings on the duration and severity of Arline’s condition, whether her disease remained contagious, and whether the school board could have reasonably accommodated her. The last section of the Supreme Court’s opinion should kindle certain types of inquiry in AIDS cases that have been largely overlooked by both the medical and legal communities. In particular, it seems appropriate to focus on the secondary infections associated with AIDS and to make an evaluation, similar to that suggested by the Court, of the hazards raised by these infections. - 16 - As noted above, there is very persuasive evidence that the AIDS virus is not transmitted through the casual contacts normally associated with workplace settings. And because of this well-supported medical conclusion and the assumption that AIDS, at least at some level, would be treated as a handicap, many employers have simply assumed it sufficient to regard AIDS as an illness not transmissible in the workplace and, thus, of no direct concern to employers or employees, except to the extent that it impairs the ability of those afflicted to perform their job. This position has considerable validity and serves the appropriate role of reassuring employers and co-employees that they will not catch the AIDS virus in the normal workplace setting. The effort to quell public hysteria and provide education about the transmission of AIDS must be commended and further encouraged, Nevertheless, applying the specific lines of inquiry suggested by the Supreme Court to decide the “otherwise qualified” issue does focus attention on certain points that may be overlooked by the more common pronouncements about AIDS and the workplace. Some examples come particularly to mind. First, settings in which medical and dental care are being provided commonly involve so-called invasive techniques. There is no question that the employment problems raised in this setting with - 17 - respect to the possible transmission of AIDS are distinctly different from the problems in an office or factor environment. Although the Public Health Service has advised that adequate preventive techniques exist to prevent the transmission of the disease and therefore recommends against testing, monitoring, or other employment restrictions, the test outlined by the Supreme Court does not seem to permit such a facile conclusion. Given the opportunity for a breakdown in any of these preventive techniques and most particularly the devastating consequences of an accidental transmission, the case-by-case determination of the Supreme Court suggests might well call into question some seemingly straightforward pronouncements about those performing invasive techniques. Two other areas of employment in which similar, if less well-defined, concerns arise are the food-handling industries and positions for which inoculation against other diseases is required, as in the case of jobs requiring foreign travel. Finally, the Supreme Court’s individualized approach to issues of handicap discrimination will lease to increased focus on secondary effects of AIDS. Most of the infections to which AIDS patients are susceptible are referred to as “opportunistic” because they can mount a successful attack only against a - 18 - compromised immune system. As such, these infections by and large do not pose a hazard to the general population.13/ There are, however, increasing reports of secondary infections that do pose risk to the general population. For example, the incidence of tuberculosis, whose hazards and possible severity are well-known, is on the upswing. Second, AIDS patients often have contagious bacterial and parasitic conditions that give rise to from mild to severe diarrhea. Finally, many AIDS patients shed various types and quantities of cytomegalovirus (CMV). CMV, a very common virus that does not pose a risk to the general population but does attack the human fetus, is regarded as one of the leading causes of mental retardation. There is considerable medical controversy about how CMV is transmitted, and informed medical opinion may well develop a concern that AIDS patients need to be monitored and, in appropriate circumstances, separated from potentially pregnant women. Unfortunately, Arline is only the beginning of the Supreme Court’s involvement with AIDS. Since the record before the Court dealt with tuberculosis and not AIDS, it is not surprising, but still somewhat disturbing, that the Court did not deal with some of the more pressing issues. 13/ These infections would pose a hazard to others but with AIDS who suffer from a compromised immune system, like those receiving various cancer chemotherapies and radiological therapies. - 19 - The medical community has already shown an enormous commitment to answering many of the difficult questions and has already produced some tangible results. For the legal community to understand how the competing interests need to be adjusted, it is critical that it keep a watchful eye on the developing body of medical knowledge. We have witnessed developments that amount to a politicization of the AIDS epidemic. What is essentially an important public health issue is being used to promote certain special interests. On one hand, organizations that have long been ardent opponents of homosexuality have used the AIDS debate to further their moral pronouncements. On the other hand, gay and lesbian rights organizations have espoused positions that focus on protecting their constituency -- perhaps at the expense of sound public policy considerations. As the disease has spread and been recognized as a public-health menace for heterosexuals as well as homosexuals, perhaps considerations of the public welfare will prevail over polarization by special interest groups. Arline is only the beginning. There will be no happy ending. We hope for just an ending. The Civil Rights Act of 1987 At the time that legislation was pending in Congress to overrule the Supreme Court’s decision in the Grove City case, an - 20 - effort was made in Grove City College, et al. v. Bell, 465 U.S. 553 (1984) to overrule Arline by amending section 504 of the Rehabilitation Act to provide that individuals with contagious diseases would not be considered as “handicapped.” This approach was rejected; instead, Congress attempted to codify Arline by providing that, for employment purposes, “an individual who has a currently contagious disease or infection and who, by reason of such disease or infection, would constitute a direct threat to the health or safety of other individuals, or who by reason of the currently contagious disease or infection, is unable to perform the duties of the job,” is not to be regarded as “handicapped.” Civil Rights Restoration Act of 1987, Pub. L. No. 100-259 (1988). The oddly negative wording of the amendment appears to leave open the same questions in the AIDS area as did the Arline decision itself. As suggested above, the questions include whether the Rehabilitation Act covers the infected, but asymptomatic, individual; what tests apply to determine whether an employee is able to perform the duties of the job, and whether those tests include close scrutiny of the issue of secondary infections; and, finally, to what extent an employer may take into account a relatively remote but extremely threatening contingency connected with the illness (such as the possibility of dementia for an airline pilot) in considering potential danger to health and safety. woe Or U.S. SMALL BUSINESS ADMINISTRATION Sle —\F WASHINGTON, D.C. 20416 Bry jad SS OFFICE OF CHIEF COUNSEL FOR ADVOCACY ; STATEMENT OF HONORABLE FRANK S. SWAIN _. CHIEF COUNSEL FOR ADVOCACY BEFORE THE PRESIDENTIAL COMMISSION ON HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC “THE ECONOMIC IMPACT OF THE HIV EPIDEMIC ON SMALL BUSINESS" MAY 10, 1988 Little attention has focused on the implications of the HIV epidemic for small business, which employ over half of the nation's work force. Yet small firms' ability to respond to AIDS differs from that of larger companies. These differences relate to the scale of the business, the way that it is organized, and the ability of small firms to flexibly respond to external legal and financial factors. In general, unlike their large firm counterparts, small businesses experience low and variable profits and cannot afford to employ human resource personnel or offer extensive employee benefits. To assist the Small business community with AIDS-related issues, the Commission should adopt the following recommendations, among others: o Low-cost or free education materials providing general and legal AIDS-related information specific to small firms should be disseminated to small employers. Oo The National Leadership Coalition On AIDS, discrimination representatives, and others that have worked directly with CEOs of larger companies on this issue should target small business owners as well. QO The Commission should urge states to adopt National Association of Insurance Commissioners model underwriting guidelines affecting AIDS and ARC. The guidelines seek to prohibit sexual orientation as a factor for use in underwriting standards. o A study should be commissioned to examine the extent to which AIDS has (a) resulted in tighter underwriting restrictions in the individual and small group health insurance market; and (b) led to a drop in existing nongroup coverage, or significant increases in premiums for individuals and small firms. The study should include strategies for voluntarily expanding health care benefits in small firms. 0 Alternatives to employer-sponsored health insurance for individuals and small firm employees who are high-risk should be assessed, such as state risk pools and Medicaid expansion. 1 Mr. Chairman, and members of the Commission, I am pleased to be a part of this hearing on issues relating to the HIV epidemic and the workplace. Little has been done to examine the implications of AIDS for small business, but this public health problem poses unique and important challenges for small firms. The Office of Advocacy of the U.S. Small Business Administration is authorized by P.L. 94-305 to represent the views and interests of small business before the Congress and Federal agencies and other policy forums. My testimony raises several public policy concerns with respect to the epidemic's effect on small firms and their workers. In general, small firms' capacity to respond to AIDS differs from that of large businesses. I will describe these differences and recommend ways that the Commission's report can address the particular situation of the small business community. Specifically. I urge the Commission to include in its report the following recommendations, which fall into two categories: those relating to education about the disease and employer legal responsibilities and those relating to employee benefits: (1) Low-cost or free education materials providing general and legal AIDS-related information specific to small employers should be developed and disseminated by government agencies and private groups; (2) Existing organizations should develop outreach strategies to inform small employers of their legal responsibilities and help them to establish formal or informal policies before they ~ a are faced with an AIDS-related issue; (3) Employers of all sizes and experts in counseling and mediation/arbitration should develop creative strategies for providing employee counseling and mediation/arbitration services to small firms; (4) The Commission should urge states to adopt National Association of Insurance Commissioners (NAIC) model medical/lifestyle guidelines affecting AIDS and ARC: (5) A study should be commissioned to examine the extent to which AIDS has affected medical underwriting for small group health insurance. The study should include recommendations for voluntarily expanding health coverage among small business; and (6) Alternatives to employer-sponsored health insurance for high-risk individuals and small firm employees, such as state risk pools and Medicaid expansion, should be assessed. WHY AIDS IS A SMALL BUSINESS ISSUE Ninety-nine percent of our nation's 17 million businesses are small firms that employ fewer than 500 employees. These businesses employ approximately one of every two people in the work force, account for two-thirds of the more than 10 milliom jobs created in the United States since 1980, and contribute 48 percent of our nation's Gross National Product (GNP). By the year 2000, it is likely that small businesses will employ an even greater share of the work force, as small-firm-dominated industries continue to grow. Small firms are also the leading providers of initial work experience and on-the-job training for new workers. Studies have consistently shown that small businesses increase productivity and produce more technological innovation than larger firms.? Small business are a driving force behind our growing economy, yet relative to large businesses. small businesses are extremely vulnerable to the effects of the AIDS epidemic. While both large and small employers must anticipate the increasing occurrence of AIDS, small employers’ ability to respond to the disease may be difficult in several critical ways. These differences relate to the scale of the business, the way that it is organized to provide products and services, and the ability of small firms to flexibly respond to external legal and financial factors. Small businesses are an important part of our Nation's culture and economy. We need to understand how AIDS will affect them $o that effective and fair public policies concerning this threatening disease can be developed. lsee generally, The State of Small Business: A Report of the President 1987, U.S. Small Business Administration, Office of Advocacy, U.S. Government Printing Office. THE SMALL EMPLOYER Small firms are more labor intensive than large companies: they typically depend more on people than machines. Thus, when workers are suffering from health problems small businesses Will likely suffer greater productivity losses than larger businesses. With estimates of up to $55 billion for productivity losses by 1991 due to AIDS, * it is likely that more than half of these losses will be to small employers. Thin and variable profits makes absorbing such costs difficult for small firms. Moreover, because of their size, many small businesses may not be flexible or able to accommodate protracted absences or find substitute work for employees with AIDS. The relatively small scale of income and profits of small employers is, unfortunately, often reflected in the very smallest employers not offering health care insurance to employees. The growth of AIDS cases may exacerbate difficulties small employers already confront in establishing employee benefits. First, it is likely that health and life insurers will tighten underwriting restrictions for small firm employers and employees, who already are more costly to 2"The AIDS Epidemic and Business," Business Week, March 23, 1987, p. 123. insure. The result will be a decline in the availability of benefits. Second, small firms that are able to provide employee benefits do not enjoy the benefits of a large employer's risk pool. Because a small firm's risk pool has fewer employees among which to spread costs, one case of AIDS could raise costs for experienced-rated benefits to the point where the benefit is prohibitive for all employees. Additionally, large and small employers differ in their ability to absorb other less measurable AIDS-related expenses, such as costs for complying with legal requirements related to discrimination, testing, and confidentiality. Unlike their large firm counterparts, small employers usually do not retain in-house legal staff or human resource experts. Neither can small businesses typically employ in-house training or employee benefit personnel. Establishing and administering education or counseling programs or company policies, therefore, can be quite costly. Limited small firm resources means that avenues for education--both in terms of reaching small employers and educating their workers about AIDS--will differ from large companies. For some small firms, balancing education with the preservation of confidentiality may be a particular problem. The potential for all employees within a small firm to learn that a co-worker has AIDS is greater than within a large company. Although there are no statistics on the incidence of AIDS among small companies, many small firm-dominated industries employ persons who are perceived to be susceptible to the syndrome, Prejudices on the part of the American public against people perceived to be AIDS carriers likely spills over to the small employer, co-workers, and customers in these industries. Worried over the loss of customers that could result from even the perception that an employee has AIDS, and financially unable to provide health care and other benefits, the small employer may be tempted to turn away qualified job candidates perceived to be highly at risk to the disease. In both large and small firms, co-workers of persons with AIDS are fearful of the disease. This fear can translate into responses ranging from refusal to share a water fountain to strikes. In 1986, 29 New England telephone workers walked off the job when they discovered a co-worker tested positive for the disease. More typically. persons with AIDS, who are most be in need of support from co-workers, may be shunned and isolated. There is a significant potential that a small employer will increase his or her exposure to labor law complaints, because irrational fears on the part of employers and employees are bred by ignorance or misconceptions about the disease. It is essential to educate small employers before they are faced with an actual case of AIDS in order to mitigate disputes in the workplace. Additionally, in an environment where AIDS-related laws are newly enacted or frequently changing, many small employers may be unaware of their responsibilities. A plethora of Federal, state, and local laws vary with respect to requirements and exemption levels for small businesses. For example, Federal anti-discrimination laws exempt firms with fewer than fifteen employees, while discrimination laws in some states exempt firms with fewer than five employees, and municipal anti-gay discrimination ordinances may apply to all firms, regardless of size. In an evolving legal environment, however, many small employers have successfully negotiated problems once they are brought to their attention. Mediation and arbitration are less costly and time-consuming than litigation, and have yielded positive results with employers of all sizes.° 34strategies for Dealing with AIDS Disputes in the Workplace," Robert E. Stein, The Arbitration Journal, Vol. 42, No. 3, September 1987. Policy recommendations to increase small employers' awareness of the disease and their own leqal responsibilities Small employers face many of the same issues generated by AIDS as large employers. Much of the difference between the two lies in their capacity to deal with the disease: large corporations have used their more extensive resources to develop innovative and effective educational tools and provide employee support services. For example, Levi Strauss, BankAmerica, Pacific Telesis, Wells Fargo, Chevron, and AT&T contributed funds to make a videotape, "An Epidemic of Fear." But most small employers cannot afford to pay the $400 price tag for an "AIDS in the workplace" kit, which includes the tape. and is sold by the AIDS Foundation. On the other hand, the tape may be shown by a trade association or other consortia geared toward small employers. Initiatives developed by large corporations can be modified or creatively marketed to small companies and their associations so that existing resources are maximized. For example, the New England Corporate Consortiun, which is comprised of‘large employers, is designing a videotape and materials on AIDS that will be sold at minimal cost (i.e., postage and handling) to small employers. The Commission can assist small employers in the areas of education and legal matters related to AIDS by adopting the following recommendations: (1) Low-cost or free educational materials providing general and legal AIDS-related information specific to small firms should be disseminated to small employers. There is a wide variety of potential sources for developing and distributing materials, including government agencies; business and health coalitions; small business trade associations; Chambers of Commerce; gay rights organizations; and Human Rights Commissions. Larger corporations, many of which have already developed and distributed such materials, could play an important role in lending smaller businesses resources and expertise to develop their own materials. (2) The National Leadership, Coalition On AIDS, discrimination representatives, and others that have worked directly with CEOs of larger companies on this issue should target small business owners ‘as well. On-site assistance is needed to inform small employers of their legal responsibilities, to help employers interested in establishing formal policies, and to address small firm employees in informal settings. -10- (3) Methods should be found to utilize private and public resources to provide small businesses with employee counseling, mediation, and other support which they otherwise could not afford. For example, larger firms ina community could pledge the use of their AIDS counselors for on-site rotations at smaller firms. Alternatively, small businesses could pool together to pay for their legal and counseling needs. EMPLOYEE BENEFITS The AIDS epidemic raises major concerns about the future of small business employee benefits. Workers in very small firms are less than half as likely as large firm workers to be offered employer-sponsored health, life, sick, or disability benefits. These benefits are essential for victims of AIDS, who may otherwise be unable to find or afford coverage. Most small employers are also interested in providing employee benefits to workers. But relative to larger businesses, these companies are at a competitive disadvantage in attracting and retaining employees because of their lower rates of coverage. AIDS will make this problem worse. Employee benefits will be less available and out of the reach of many small businesses. -ll- The qap between large and small firm employee benefits A 1986 employer-based survey reveals that 55 percent of firms with fewer than 100 employees offer health benefits, compared to 98 percent of firms with more than 100 workers. (See Appendix 1.) Health care is ranked as the second most common fringe benefit provided by employers (vacation benefits are first). For sick leave, 36 percent of small firms and 79 percent of large companies offer this benefit. Approximately 29 percent of small employers with fewer than 100 workers offer life insurance benefits, compared to 83 percent of larger companies. Short-term disability benefits are offered by 10 percent of small firms and 40 percent of large; for long term disability the figures are 8 percent and 51 percent, respectively. The gap between small and large firm benefits widens as firm size decreases. It is important to focus on the impact of AIDS on small employer health insurance for several reasons. First, health insurance is the most prevalent of the four benefits mentioned 4"Health Care Coverage and Costs in Large and Small Business," ICF Incorporated, for the U.S. Small Business Administration, Office of Advocacy, April 15, 1987, p. II-2. ~12- above, and presumably the most important to persons with AIDS. Second, 84 percent of private health insurance is provided through employers, as opposed to life and disability insurance, which have lower rates of group coverage. Third, Congress and state legislatures are increasingly looking toward mandating that small employers provide access to health coverage for the working uninsured and their dependents. Nearly one-half of the nation's 8.2 million working uninsured are employed in firms of fewer than 25 employees.” AlDS-related expenses may make current efforts to expand coverage among these firms dramatically more costly and difficult. Unlike larger firms, these companies are medically underwritten, which means that the health status of each individual in the insured group is assessed. And as a study conducted by the Office of Technology Assessment (OTA) noted, “individual and small group (i.e., individually underwritten) coverage is perhaps the most vulnerable to financial loss in the wake of an unanticipated AIDS epidemic."® It is likely, then that it will be harder 5u.S. Small Business Administration, Office of Advocacy, tabulations of U.S. Census SIPP data, 1984. 6"AIDS and Health Insurance, An OTA Survey," Jill Eden, Laurie Mount, Lawrence Miike, Office of Technology Assessment, February 1988, p. 41. -13- for small firms to qualify for health insurance as insurers seek to protect themselves from financial losses due to AIDS. AIDS and medical underwriting practices for small firms Data show that health premiums for small companies run 10 to 40 percent higher than large firms.’ This is primarily attributable to underwriting and administration costs: it is much more costly for an insurer to cover 10 employees in 100 firms than 1000 employees in one large firm. Very small firms, usually with fewer than 20 employees, and individuals are medically underwritten, which is an expensive process. Medical underwriting assesses the health status of each individual to determine whether or not the firm will be accepted for coverage and in some cases whether certain employees or illnesses are excluded from coverage. This differs from group coverage where rating is based on the group as a whole. Very different criteria are used to underwrite individuals or small groups than are used for underwriting large groups. - 2g cm 7The ICF Study found a 10-percent cost differential. Other estimates range as high as 40 percent. See M. W. Brian Harrigan, quoted in Business Insurance (April 21, 1986). p. 14. The Health Insurance Association of America estimates the premium differential at 20-30 percent; see U.S. Congress, House, Committee on Small Business, Health Insurance Coverage and the Small Employer, Hearings, statement of Karen Williams of the Health Insurance Association of America, House, 100th Cong., lst sess., (May 6, 1987). -14- Justification for medical underwriting is based on the diversity and potential risks presented by a small group. Insurers seek to protect themselves by avoiding adverse selection, whereby less healthy employees in a small group sign up for coverage. The smaller the group, the less room for Spreading risks. Insurers, therefore, attempt to screen out or restrict benefits for higher risk persons in small groups. In a large group there is less of a need to do so, as the group's overall risk is average. There are also non-medical underwriting factors which commercial insurers use to assess individual risk including: age, occupation, financial status, place of residence, and sexual orientation. The OTA data show that 78 percent of responding companies rated occupation as a very important or important factor, 26 percent rated place of residence as very important or important, and 9 percent rated sexual orientation in these categories. (See Appendix 2.) Information for individual underwriting may require the applicant to submit an attending physician statement, physical exam, blood or urine screens, or involve a financial or personal investigation. Depending upon state law, applicants may be asked whether or not they have tested positive for AIDS, or displayed symptoms associated with the syndrome. -15- In addition to screening for high-risk individuals, insurers often exclude or restrict (i.e., need home office approval) coverage for certain industries, many of which are comprised of small businesses. AS one insurance manual notes, ineligible industries “create special hazards which cannot be included in the underwriting of group insurance...Also it is often not practical to give in-depth consideration to a particular prospect because our major function is to extend our service to as many employees as possible."® The breadth of excluded industries is wide and varies considerably depending on the insurance company and its location. For example, one insurance company manual: states that janitorial services, gas stations, and health care facilities are ineligible, and that grocery stores, restaurants, and liquor stores and dealers are eligible on restricted bases. (See Appendix 3.) Current law does not prohibit industry exclusions or restrictions and we do not suggest that ‘this be changed. The Unfair Trade Practices Act, which has been adopted in some form by all states, distinguishes between fair ‘and unfair discrimination. Unfair discrimination is that which is 8Ppromoting Health Insurance In The Workplace: State and Local Initiatives To Increase Private Coverage, American Hospital Association, April, 1988, Figure 8, pg. 28-29. -~16- actuarially unjustified, i.e., discriminates between individuals of the same class and equal expectation of life. Insurers are not compelled to do business with any industry/person. In addition, they can exclude or restrict coverage in industries or for persons deemed to be high risk. Insurers must be able to provide evidence that excluding a particular individual or industry from coverage conforms to sound underwriting practices. But unless a complaint is filed, there is no way of viewing such data. Small businesses, for example, may be unaware that insurers are not marketing in their particular industry, or of the reasons for such practices. The risk of AIDS presents particular problems for medically underwritten small groups. As the OTA study reveals, insurance companies are responding to the financial impact of AIDS with: "plans to reduce company exposure in the individual and small group health insurance markets (e.g., by introducing tighter underwriting guidelines) and to expand HIV or other testing...It is difficult to assess whether AIDS has reduced the availability of nongroup health coverage; insurers, for example, can effectively eliminate their role in the market by pricing nongroup policies so high that no one will buy them."? 9»AIDS and Health Insurance." p. 34-35. -17- At this point it is impossible to determine the extent to which small firms have been turned down for coverage or experienced exorbitant premium increases because of AIDS. There are, however, a few examples of publicly registered complaints. ?° The sheer costs of AIDS does increase the potential for discrimination as insurers seek to protect themselves from financial losses attributable to the disease. Small firms that are not high-risk, but located in certain industries or hire employees with characteristics perceived to be high-risk, may be unable to find coverage. Premium hikes due to actual or anticipated AIDS-related costs may also lead to lower coverage among small firms. 101n New York, a pending complaint with the State Insurance Department was filed on behalf of a haircutting salon that was turned down for what appears to be unfair sales practices and unfair discrimination in the sale of health insurance based upon the perceived sexual orientation of applicants (Faith Unisex Haircutters, Inc. v. The Guardian, filed with the New York State Insurance Department, November 1987). Plaintiffs in a lawsuit in California contend that a reinsurance company discriminated against Unmarried males that work in occupations that have been stereotyped as gay, such as florists, interior decorators, or jewelry, or fashion designers (National Gay Rights Advocates and David Hurlbert v. Great Republic Life Insurance Co., and Does I-XX, San Francisco Super. Ct., No. 857323). Health insurance rates for a small public relations firm in San Francisco soared to $600 per month per employee after an employee with ARC filed claims ("Small Firms Feel Pain of Insurance Increases," San Jose Mercury News, February 29, 1988, p. 7C). -18- Many very small health and life insurers are understandably concerned that their financial solvency may be jeopardized by a few claims for AIDS. Policies to address this concern must be balanced with the need to reverse the decline in employer-based health coverage and prevent discrimination. Policy recommendations related to AIDS and small business health insurance Legislation and public policies must be sensitively crafted in light of the preceding considerations. The effects of legislation designed to ensure individual and small group access to health insurance and avoid discrimination may in practice have the opposite effect. For example, District of Columbia laws forbidding HIV antibody testing or exclusion of AIDS from health insurance coverage caused most insurance companies to withdraw entirely from this market. Rather than extend coverage to persons with AIDS, the result is that little or no coverage is available to individuals or medically underwritten small businesses. A decrease in small group coverage may also occur from a recently enacted Federal law designed to extend employer-sponsored health coverage beyond an employee or -19- dependent's affiliation with the firm.?+ The law requires employers with at least 20 workers to continue to offer health benefits at group rates to former workers and dependents who would otherwise lose coverage. The former employee/dependent pays 102 percent of the premium's cost. Although the goal of extending employer-based coverage through this law is admirable, many employers report that only persons utilizing health benefits--such as persons with AIDS--continue to purchase coverage. The result of such adverse selection is higher rates for the entire firm. These costs, combined with new administrative costs for tracking and notifying former employees and their dependents, may lead to a drop in health care coverage among smaller companies (generally those with 20-100 employees). The Commission can assist small employers with AIDS-related employee benefit issues by adopting the following recommendations: (1) The Commission should urge states to adopt National Association of Insurance Commissioners (NAIC) model medical/lifestyle questions and underwriting guidelines affecting AIDS and ARC. The guidelines seek to prohibit llsgection 10001 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) added § 162(k) to the Internal Revenue Code. ~20- sexual orientation as a factor for use in underwriting standards. Neither "living arrangements," occupation, medical history, place of residence, or other specified factors may be used to establish an applicant's sexual Orientation. Fifteen states have adopted the recommendations or enacted laws which would accomplish the Same purpose. (2) A study should be commissioned to examine the extent to which AIDS has (a) resulted in tighter underwriting restrictions in the individual and small group health insurance market; and (b) led to a drop in existing nongroup coverage, or significant increases in premiums for individuals and small firms. Such a study should examine industries which are specifically excluded or restricted from health insurance coverage and the actuarial justification for these underwriting practices. The study should include strategies for voluntarily expanding health care benefits in small firms. (3) Alternatives to employer-sponsored health insurance for individuals and small firm employees who are high-risk should be assessed. State risk pools have been suggested by the insurance industry and gay rights advocates as one source of financing the costs of treating persons with -21- AIDS. 2 Medicaid expansion has also been suggested by health experts aS a viable way of covering a portion of the uninsured population in general, as well as persons with AIDS. CONCLUSION The anticipated increase in the number of AIDS cases points to the need for increased leadership within the small business community on AIDS-related issues. Trade associations are just beginning to poll their members on their experiences and perceptions. Ad hoc policies are being developed by individual small firm owners as they are confronted with an AIDS problem. Rather than waiting until the point of a crisis, however, small businesses need to be attuned to the facts of AIDS and apprised of how to respond. At the same time, policy experts and others working on this issue need to recognize small businesses' strengths and limitations. In a dynamic legal and policy environment, the small business perspective is an important one. 1 commend the Commission for recognizing this point of view and hope that my recommendations prove helpful. lZ"Health Insurance: Risk Pools for the Medically Uninsurable," U.S. General Accounting Office, GAO/HRD-88-66BR, April 1988, p. 26. APPENDIX 1 PERCENTAGE OF FIRMS WHICH OFFER DIFFERENT FRINGE BENEFITS, BY FIRM SIZE feoloveent Size of Firm Leese 100 tess Then Or Than Erinee Benefit Jasel 1-2 10-248 23-29 100-899 200¢ 100 fore 20a. Vecetion 59% 52% 75% a3 91% 95% 50% 92% 50% Heaith 56% a6% 78% 92% 98% 100% 55% 90% 55% Sick Leave 37% 32% &25 59% 77% 91s 36% 79% 36% Life ineurence $o0% 22 a5% 62% eos 94g 29% a3 29% Penalion/eoin 17¥ 9 22% aig 66% 79% 16% 69% 16% Bonus Plen 124 10% 13% 17% 17% 29% 11¥ 19% 19¥ Short Tere 10% TZ 124 26% 37% 552 10% aog 10% Disability . Long Tere 7 § 6% tag 23 aTZ 69% of 51g sp § Oieebility Sevings Pien 25 e 3% 12% 17% 29%. 25 19% 2X Cefeterie-Style 1Z 1% 2% - 12% 1% 3Z 1% Meaith Sener its . Vecetion, Sitch, of 3% thE 25% So% 75% 6% 54% 7% Health, Life and Pension or BOK No Anever 19% 20% 18% tag 1% 3% 19%, 7% 19% © (tees then 0,5 percent. NOTE: White each of the other fringe benefits categories fisted above msy be sexeuhet flow due te micaing deta, the hesith benefits had no missing date, Consequentty, benefits to other fringe benefits fisted shove mey be somewhet higher, SOURCE: ICF analysis of SBA, Office of Advocecy, Health Benefits Deta Base, 1986. the retie ef heselth - ~ - .- APPENDIX 2 + ~ « - Table 8.--Individuel Underwriting by Commercial Health Inaurere The Importance of Mon-Medical Factors flovex Ue od Underwriting Factor _, Ve t? Important Un{mportant (n-61)* : Number Percent Rumber —~ Percent Number Pereent Number Percent i. GBS. wc rccsecncesesaneeseeeenesers 23 38% 20 aBz 6 10% 3 “$3 2, type of occupation.............. 18 30 - 29 a8 11 18 3 5 3. avocetion ° (e.g., race car driving)......... 9 15 39 64 "9 15 4 7 &. financial statua................ 30 16 26 43 20 33 5 8 5. health endangering . personal habits (o.g., drug abuse}...... cece eee 93 3 5 0 -- i 2 6. heslth enhencing parsonel behavior (e.g., non-smoking)... 6 10 34 56 a 15 12 20 J. &blegel or methiceal behevior... 44 72 13 21 2 3 2 3 6. place of residence......... veces 9 5 13 21 21 34 24 39 0. sezuel orientation........ ae | 2 4 7 13 21 43 70 ®One company did not reapond to this question. bpefinitions: Very Important - Critical to underwriting process; can affect ecceptance/rejection. Important - Alweys considered but will never by itself affect acceptance/rejection. influence coverage Limits (e.g., exclusions or waiting period) and/or premium. Unimportant - Rarely effects ecceptance/rejection, coverage limits, or premium ~~ unless in conjunction with other more importent factors. Never Used - Never considered. CRow percenteges my not totel 100 due to rounding. SOURCE: Office of Technology Assessment, 10988. It may, however, APPENDIX 3 me o7™ & oot 4 Insurer A Industry Eligibility industries Ineligible for Health Insurance Coverage under Three Selected Insurer Plans Some activities create special hazards which cannot be included in the underwriting of group insurance, par- ticularly under Master Trust programs. Also, it is often not practical to give in-depth consideration to a particular prospect because our major function is to extend our service to as many employees as possibie. Therefore ,thefollowing industnes are ineligible. Ineligible Industries Any group with known uninsurable risks Auto Dealers - Used Aviation Personnel Bars or Taverns . Car Washes and Parking Lots Commercial Fishing Construction Workers (using heavy equipment, or at heights) Divers Drilling, Oil and Gas Wells (or repair or maintenance) Entertainment, Amusement or Athletic Groups Explosives Exterminators Gas Stations Hospitals and Nursing Homes Junk Dealers, Salvage Yards, and Refuse Collection Leather Tanning Longshoremen Logging Mining or Extraction (mineral or fuel) Moving Companies Personal Services (e g. domestic help) Public Employee Groups Security Guards Trucking Firms (long distance - overnight) Window Washing insurer B Industries with Special Consideration Auto Dealers - New ? Auto Repair Shops '2 Barber Shops and Beauty Parlors '?2 Church Related Groups ° Hotels, Motels, Lodges ' 2 > ¢ Landscaping '?¢ Light Construction 24 Loca! Transit (taxis, buses) '? Local Trucking # Real Estate Agencies ' 2 Restaurants ' 23 ' Mandatory 3 month waiting period. 2 No Disability Income. + Management only. “ Only ff clearly a year-round operation. 5 Only those engaged in full-time employment, such as a church affiliated school. Certain types of groups present hazards which cannot be accepted within the Trust underwriting guidelines. A partial listing of such groups would include the following: Aviation Amusement Parks Auto Dealers & Service Stations Bars & Restaurants Beauty Salons & Barber Shops Car Wash Operations Hospitals Manufacturing of Dangerous Products Convenience Stores Political Subdivisions Entertainment Logging or Mining Operations Taxi Operations Farming & Ranching Parking Lots Non-Profit Organizations Mobile Home Sales, R.V. Dealers Marine Enterprises Religious Groups Nursing & Rest Homes Motels Unions, Fratemais Liquor Stores Scrap Collectors/Dealers APPENDIX 3 (CONTINUED) insurer C Ineligible Industries Medical-Life Construction Companies (involved in building 4 or more stories) Country Clubs, Health/Sport Clubs, Athletes Entertainment Groups, Artists, Authors Explosives Companies - Manufacturing or Transport Exterminators Foundries Gambling Related Businesses Garages Garbage/Trash Collection Companies Gas Stations Goverment Agencies (with long-range financing) Grocery Stores Hospitals, Clinics, Nursing Homes and Health Care Facilities Hotels and Motels insurance Agencies Janitorial Services Junk Dealers and Scrap Dealers Liquor Stores and Dealers Logging and Lumbering Operations Massage Parlors X = Not Eligible for Benefit Plan. * » Eligible for Lite Only Benefits. * DX x DX uxM«MK MK MK KK D Medical-Life Medical Practitioners Mining, Quany and Drilling Operations Motion Picture Theatres Moving Companies Municipalities, Political Subdivisions Parking Lots Pawn Shops/Collection Agencies Petroleum Producers (drilling operations) Pilots and Flight Personnel Property Management/Development Companies Real Estate Sales Offices Restaurants, Drive-ins and Catering Services Salesmen working on a commission basis only Schools and School Districts Security Guards/Watchman Services, Detectives Social, Vocational Counseling Services Truckers - Long Hau! only Vending Machine Companies Firms which have more than 50% of its employees related by blood or mamiage Firms with no employer/employee relationship R = Eligible on Restricted Bases, need Home Office Approval. Tne aforementioned listing is representative, but not necessarily all inclusive. The insurance carrier and/or administrator reserves the right to reject any case which, in its opinion, does not conform to sound undemriting requirements. you have any questions about the acceptability of a particular risk, cail our office for confirmation. Source: insurer training manuals, 1986-1967. xX* DX DX KK KK KK OX xD MxM DMM AIDS AND LABOR MARKET DISCRIMINATION Testimony Prepared for the Presidential Commission on the HIV Epidemic Indianapolis, Indiana May 10, 1988 David E. Bloom Sherry A. Glied Department of Economics Department of Economics Columbia University Harvard University New York, New York 10027 Cambridge, MA 02138 (212) 280-8758 (617) 868-3900 This testimony summarizes the results of a study in progress at the National Bureau of Economic Research on the impact of AIDS on the American labor market. The primary objective of the study is to determine whether employers' personnel decisions have been affected by the AIDS epidemic. We examine labor market data contained in two waves of the Census Bureau's Current Population Survey in order to measure the impact of the AIDS epidemic on selected labor market outcomes. The Census Bureau data are particularly well suited to doing research on this problem since they permit one to conduct two distinctly different analyses of the labor market impact of AIDS: (1) a comparison of labor market outcomes between cities with high and low numbers of reported AIDS cases at a point in time and (2) an analysis of changes in labor market outcomes over time within cities that have expecienced rapid growth in the number of AIDS cases. We find some statistical evidence that employers have discriminated against workers perceived to be members of high risk groups. We then analyze these results by considering -- at a conceptual level -- a firm's decision about employing individuals who may develop AIDS. In performing this analysis, we pay close attention to the legal environment that currently prevails in this general area. The analyses we have performed thus far support the following conclusions: (1) Discrimination against individuals who are either members of high cisk groups or who are perceived to be members of such groups (i.e., what we shall refer to hereafter as "high-risk" individuals) may be reflected in celatively lower wages or relatively higher unemployment. Ouc analysis of labor market data drawn from the March 1980 and the Macch 1987 Current Population Surveys (which provide a rough comparison of the pre-AIDS era and the present-AIDS era), reveals a notable increase in the unemployment rate of "high-risk" individuals in San Francisco. Indeed, while the overall unemployment rate among males aged 18-65 in San Francisco was identical in those two surveys (6.1 percent), the rate for males who were aged 30 and over and not currently married (i.e., some indication of being homosexual or bisexual) increased by a factor of five from 2.3 percent to 11.3 percent. In contrast, the unemployment rate among all other males aged 18-65 in San Francisco (i.e., individuals who would reasonably be considered as less likely to be homosexual or bisexual) declined by one-third from 6.8 percent to 4.6 percent. Since unemployed individuals must, by definition, be actively searching for and available for employment, we do not think that these results reflect a growing proportion of "high-risk" individuals who are unable to work due to health reasons. This observation is further confirmed by the stable proportion of "high-risk" individuals not in the labor force in 1980 and 1987. | Our analyses of unemployment data for the U.S. as a whole and for New York City and Los Angeles have not yet yielded any conclusive results. | o Our analyses of wage data provide no evidence of wage, discrimination against "high-risk" individuals in the U.S. overall, or in San Francisco, Los Angeles, or New York City. . (2) Discrimination against those perceived to be at high cisk for AIDS may be based on the added visible costs faced by employers because of AIDS as well as on the invisible costs that arise from the fears and perceptions of employers, co-workers, and customers. These costs can be divided into six categories: ' (a) increased health insurance premiums in the future (if the individual eventually develops AIDS and requires substantial medical care that is paid for by the employer's group health plan); (b) increased life insurance premiums in the future (if the individual subsequently develops AIDS and dies as a result of it and if his estate collects a life insurance benefit from an employer-purchased policy); (c) lost investments made in the hiring and training of individuals who subsequently become unable to work because of AIDS; (d) increased wages needed to recruit and retain other employees who prefer not to work with individuals who are perceived to be “high-risk;" (e) lost revenues because of customers who prefer not to do business with firms that employ "high-risk" individuals; and (£) any psychic costs incurred by an employer if one of his/her employees becomes ill or dies because of AIDS. It should be noted that the degree to which these costs will be financially meaningful in a particular personnel decision can vary widely across employment settings. It should also be noted that several of these costs are contingent upon an individual employee actually developing AIDS, while others ace incurred simply by employing either a known or likely member of a high-risk group —- even if a particular employee never develops AIDS (and even if the employee is not actually a member of a high-risk group). Moreover, because employers generally do not know whether a particular job applicant or employee is a member of a high risk group, the AIDS epidemic also increases the cost of employing individuals that the firm suspects may belong to a high risk group (e.g., males over the age of 30 who are not married). Our rough estimate of the expected cost to an employer of employing an individual who is a member of a high-risk group (i.e., homosexual/ bisexual men) is in the range 3,200 - 14,000 dollars. It reflects the additional cost, over the expected duration of employment, that a typical employer is likely to perceive when he/she compares the cost of employing a member of that high-risk group to the cost of employing an otherwise comparable individual who is not a member of that high-risk group. This is a lower-bound estimate since it only captures components (a), (b), and the hiring costs in component (c), above. (3) Existing laws provide only incomplete protection against discrimination to members of high-risk groups. Furthermore, laws that limit employers' ability to discriminate against a narrowly defined group may lead them to discriminate on a broader characteristic that encompasses both "high-risk" individuals and others. Under the present legal environment, with few exceptions, employers cannot legally discriminate against workers who have been diagnosed as having ARC or AIDS. With a few important exceptions, employers can legally discriminate against workers who are actual or likely members of high-risk groups but who are not otherwise known to be HIV-positive. Even in jurisdictions in which discrimination against individuals in certain high-risk groups is prohibited, such discrimination is quite difficult to prove. (4) The relatively high cost to employers of employing "high-risk" workers, and the difficulty of proving discrimination in the courts, give employers both the incentive and the opportunity to circumvent laws designed to protect those with AIDS and those in high-risk groups. | Thus, an important consequence of the AIDS epidemic is likely to be diminished labor market prospects for individuals who actually belong to high-risk groups ~- or who are perceived to be likely members of high-risk groups -~ despite the fact that many -—- and perhaps most ——- of those individuals will never test positive for HIV or develop AIDS. (5) Our results suggest that the current legal environment, which generally proscribes labor market discrimination against workers who are ill, effectively encourages employers to discriminate against those individuals who have characteristics that indicate that they are relatively more likely to fall ill. Any changes in the legal or economic environment that reduce the perceived costs to employers of employing "high-risk" individuals (e.g., government-provided health insurance coverage for AIDS) will lessen the extent of labor market discrimination against such individuals. Allowing employers to require HIV tests as a condition of employment will narrow the population discriminated against and benefit many "high-risk" individuals. But allowing testing for this purpose is inconsistent with the intent of most existing employment discrimination laws. Of course, there are also many other considerations -- not focused upon in our analysis -- involved in developing sound public policy on HIV testing. (6) The increasing prevalence of AIDS can be expected to result in measurable labor market discrimination against “high-risk" individuals outside San Francisco in the future. (7) Since most Americans with private health insurance are covered through an employment relationship, employment discrimination against "high-risk" individuals will result in a larger fraction of these individuals not having private health insurance coverage. To the extent that the incidence of AIDS among such individuals is relatively high, employment discrimination will tend to shift the burden of personal medical care costs due to AIDS onto both the individuals who develop AIDS and the public health insurance system (including Medicaid, public hospitals, and other users of the health care system who may end up paying higher rates to cover the cost of AIDS). (8) Although our analysis of Census Bureau data yields some results that are consistent with our knowledge of the basic operation of the labor macket, the results do not constitute direct or overwhelming evidence of discrimination. Further analysis is therefore necessary using individual case data as well as survey data sets with larger numbers of observations in which other aspects of labor market outcomes are examined as well, and in which attempts are made to standardize for differences in the Characteristics of the labor force across cities and over time. Insofar as these results are upheld, they represent evidence of changes in the labor market actually taking place as a result of the AIDS epidemic. Such evidence is a crucial ingredient in the formulation of public policy in this vital area. CASES INVOLVING AIDS EMPLOYMENT DISCRIMINATION Human Rights Commissions San Francisco - 1982-1987 - 153 formal complaints alleging AIDS discrimination of which 60-80% involved employment discrimination. 3 - 4 times as many informal complaints (settled without a formal procedure) were received as formal complaints. New York City - 1985-1988 - 48 formal complaints alleging employment discrimination on the basis of actual or perceived AIDS were received. 9 times as many informal complaints were received by the Commission. Massachussetts - 1985-1987 - 12 formal complaints filed alleging AIDS employment discrimination. Sample Court Cases Chalk v. Orange County Superintendent of Schools - 840 F2d JO1l - California school teacher moved to administrative position because he had AIDS - ordered reinstated. Shuttleworth v. Broward County - 639 F. Supp 654 - Florida county employee fired because he had _ AIDS sued under Rehabilitation Act. Doe v. Westchester County - D.N. 1lb-p-d-87-117683 - New York state hospital denied employment to HIV positive pharmacist- Human Rights Commission found probable discrimination. Wolfe v. Tidewater Pizza - Cir. Ct. Norfolk Va. no.c87-662- petitioner dismissed from job until he could prove he was HIV negative - case dismissed because Virginia law doesn’t cover perceived disabilities. Laredo v. Southwest Community Health Center - USDC N.M. civ- 86-1313-56 licensed New Mexico RN terminated because of HIV status, patients had complained - court found violation of Rehabilitation Act s.504. Doe v. Sinacola - Civ. Ct. Oakland Michigan, No.86-320825n2 - employee of excavating company fired after disclosing that he had AIDS - court ruled probably a protected handicap under Michigan law. AIDS and Other Types of Employment Discrimination in the Courts A LEXIS search of employment discrimination cases in 1987 found: Federal Cases State Cases AIDS 2 1 Racial Disc. 297 49 Sex Discrinm. 397 88 LEGAL ENVIRONMENT SUMMARY Type of Worker Employee or Prospective Hire with AIDS or ARC Employee or Prospective Hire with HIV Employee or Prospective Hire in Homosexual / Bisexual risk group Employee or Prospective Hire in IV Drug Abuse risk group Employee or Prospective Hire who is a Hemophiliac Employee or Prospective Hire who has had a blood transfusion rT L May discrinm. May discrin. May discrin. May discrin. May discrin. May discrim. e of Jurisdiction iL Discrin. prohibited prohibited May discrinm. but testing limited in Florida, Montana and Texas May discrin. May discrin. Discrin. prohibited Unclear - probably Ii! Iv Discrin. Discrin. prohibited Discrin. Discrim. prohibited prohibited Unclear - Discrin. may discrim. prohibited if policy is by sexual unrelated to orientation concern statute or about ordinance AIDS risk Unclear - as Discrim. above but prohibited drug abuse by AIDS may be a discrinm. disability ordinances Discrin. Discrim. prohibited prohibited Discrin, Discrim. prohibited prohibited may discrim. Type I States - no anti-handicap discrimination statute for private employees. Alabama Arkansas Delaware Idaho Mississippi Tennessee - Title 8 Ch.50 part 1 explicitly excludes contagious and infectious diseases from disability definition. Kentucky - ch.207.130 explicitly excludes contagious and infectious diseases from disability definition. Type II States - Statutes prohibit discrimination on the basis of an actual handicap. Arizona - s.41-1461 Connecticut - Title 46a ch.814c Florida - Title XLIV ch.760.22. Also limits on AIDS testing. Georgia - Ch.89-170 Indiana - Ch.22 -9-1-3 Kansas - Ch.44 Art.10 Maine - Ch.5 s.4553 Montana - Title 49 ch.1. Also limits on testing. Nebraska - s.48-1102. Nevada - Ch.613 New Mexico - Ch. 28 Art.1l North Dakota - $.14-02.4 Ohio - Title 41 s.4112.01 South Carolina - s.43-33-560 South Dakota - Ch.20-13 Texas - Title 8 s.121.002 and limits on testing. Utah - Title 34 ch.33 Virginia - Title 51.01 Type III States - Statutes prohibit discrimination on the basis of an actual or perceived handicap. Alaska - s. 18 ch. 80 California - Part 2.8 Div.3 Title 2 and Governor's Code s. 12900 and limits on testing. Colorado - s.24-34-301 Hawaii - Title 21 ch.378 Illinois - Ch.68 sec. 1-101 Iowa - Ch.60la Louisiana - Title 46 s.2251-6 - drug addiction not a disability. Maryland - Code s..03 Mass. - Ch.151lb and ch.111 and limits on testing. Michigan - s.37-1101 Minnesota -s.363.01.14 Missouri - Title 8 Div.60 ch.3 New Hampshire - Ch.354a Title 31 New Jersey - Title 13 ch.13 New York - §.292 art.15 North Carolina - Ch. 168a Oklahoma - Title 25 ch.21 Oregon - s.659.400 Rhode Island - Title 28 ch.5 Vermont - Title 21 ch.5 s.6 Washington - ch. 185 L. 1985 West Virginia - ch.5 art.1l Wyoming - Title 27 ch.9 Federal Employent - Rehabilitation Act Type IV Jurisdictions - ordinances and laws prohibiting discrimination on the basis of sexual orientation and/or AIDS. San Francisco Los Angeles Austin, Texas District of Columbia - Title 1 ch.25 s. 1-2502 Pennsylvania - Title 16 ch. 44 (public employees only) Wisconsin - Title 13 ch.1ll s. 2 April 28, 1988 MEMORANDUM TO: Presidential Commission on | the HIV Epidemic FROM: Patricia A. Wiley RE: Workplace Costs of AIDS "AIDS and Employer - Sponsored Insurance" Based on our consulting work with both corporate and non-profit clients on the workplace costs of AIDS, we offer the following practical recommendations to employers who must face the economic impact of AIDS on their emp loyer- sponsored insurance plans: ° Review all employee benefit plans: life, disability, medical and casualty, te determine if their design, funding and administration are appropriate for a catastrophic event like AIDS for both the individual who is insured and the company who sponsors the plans. ° Recognize that AIDS will have a financial impact on the company, and then measure and record its specific long and short term cost to the firm. ° Utilize a catastrophic medical case management program. ¢ Develop, publish and talk about a company policy on life threatening iliness that includes all aspects of human resource management: benefit plans, sick leave, confidentiality, right to work, employee safety, etc. Foster Higgins MEMORANDUM Presidential Commission on HIV Epidemic April 28, 1988 Page 2 ¢ Consider alternative resources: hospices, home health care, employee assistance programs, local AIDS groups, etc. - Employers should take an active role in AIDS education for employees and their families because frequent, understandable and persuasive education from a credible information source - like the company - is a no risk control over future insurance costs. * Keep current on AIDS developments. Act on what information is available now but keep policies and procedures flexible and cpen to changes in the future, * Take an active role in the larger community by supporting research, education, health care coalitions, and local support groups. Have input into areas that will have an indirect business impact like changing business markets, worker productivity and care for the uninsured. While the focus of our discussion has not been the government roje in the AIDS crisis, there are areas where government actions affect the employer and, therefore, influence the workplace responsibility of, and cost to, employers. Some of these areas includ:: * Growth of alternatives to acute care facilities like: hospice, home health, and long term care facilities. Foster Higgins MEMORANDUM Presidential Commission on HIV Epidemic April 28, 1988 Page 3 ¢ Standards set for consistency of employee policies like: employee con- fidentiality, testing, and international medical safety. ¢ Experimental medical treatments and development of drugs. ° Care for the uninsured. Foster Higgins Workplace Costs of AIDS "AIDS and Employer-Sponsored Insurance" Presidential Commission on the Human Immunodeficiency Virus Epidemic Written Testimony May 10, 1988 Patricia Wiley Managing Consultant A. Foster Higgins & Co., Inc. New York, New York Foster Higgins INTRODUCTION I am pleased about the opportunity to talk with you today although our subject igs a sad and tragic one. AIDS confronts us with the fact that nature can resist our attempts to control] it and that we now face what is unacceptable to us--an epidemic we can't control and are only beginning to understand. It's always a bit disconcerting to me to have the job of shifting the focus for a corporation from the pain AIDS brings to its sufferers, to the economic realities of the disease. But that's the pragmatic subject of my discussion with any of our clients who are responsible not only for their employees--but for the financial well being of their benefit plans. In the last few years of double digit medical inflation, organizations have sought ways to try to control benefit compensation--the same way they control cash compensation. Then, along came AIDS--and with it fear about the unknown impact it would have on benefit plans. What will AIDS do to the financial controls, legal stability and employee relations value which have been very carefully built into our benefit plans? What I try to do is help companies apply effective cost management techniques designed to control the costs of AIDS in all employee benefit programs. These techniques include: 1 Foster Higgins ° Identifying the company's risk factors; . Measuring the expenses associated with those factors; 7 Identifying the tools that are available to manage those expenses; ° Recommending cost control programs that are consistent with the company's philosophy and the magnitude of its problems. The structure of my testimony will be to take you through the steps we use in consulting with an organization on the economic impact of AIDS on the workforce. My discussion will focus on the practical issues an employer faces, and will indirectly articulate the insurance industry's general response to AIDS. Medical, life, disability and casualty benefit plans will be addressed. Also included as part of my testimony is a copy of “A Survey of Company Practices & Policies: AIDS and Benefit Plans." This survey was conducted by Johnson & Higgins/Foster Higgins in September of 1987. The focus of the Survey is on benefit plans and workplace issues, particularly: ° Corporate experience with AIDS; ° Employer's cost expectations; Foster Higgins . Plan design considerations: ° The use of cost containment programs; ° AIDS testing; ° Company policies; . Employee education dnd communication. The conclusions drawn are from the survey responses of human resource executives at 101 companies geographically spread across the United States. The companies surveyed employ between 1,000 and 10,000 people; half are in manufacturing and half are in the service sector. For the purposes of this discussion, I will be using the term "insurance" in its broadest context. Insurance will mean any formalized mechanism used by employers to handle their predictable and unpredictable employee benefits risk or expenses--either through self-insurance (keeping the risk the company's) or risk transfer (buying a group insurance policy from an insurance company). Whether an employer self-insures benefits or purchases them by buying a group insurance policy, the cost of AIDS related benefits will eventually rest with the employer. That is because of the long term nature of group insurance financing. Eventually, except for the very smallest employer-sponsored group 3 Foster Higgins \ t | plans, the cost of benefits paid out by the insurance company. is borne by the sponsoring employer--not the insurance company. In the short run, what the insurance company provides is claim administration,- cash flow and some risk transfer. However, if there are losses (expenses and benefits paid out exceed the premium) on a group plan--AIDS related or not--the insurer expects to eventually recover those losses from the employer over ensuing policy periods. Consequently, in the ‘ong run, the issues that bear on the employer and the insurance industry are essentially the same. Everyone has a vested interest in defining and managing AIDS related expenses. 4 Foster Higgins Beginning the Discussion on AIDS The work within a business organization to determine the cost issues of AIDS begins slowly because many organizations are reluctant to see AIDS as an issue for them. The starting point is a series of questions that are framed by the business culture and are not specifically insurance related, but we've found that unless they get addressed, the discussion about the business costs of AIDS never gets off the ground. The first guestion is usually "Why is AIDS different from other terminal disease? Why talk about AIDS specifically?" That is a good question to start with because it offers a chance to talk about the ways AIDS is not different. If a company has not thought out and developed its benefit policy for employees facing any life threatening illness, such as cancer or heart disease, then AIDS becomes an excellent reason to do so. It also establishes that, in order to avoid discrimination problems, the benefit plan must treat all employees--regardless of the nature of their illness--the same. The next question is "Was our benefit program ever intended to deal with AIDS?" Here it is helpful to remember the history of group insurance plans and the company's own benefit philosophy. Historically, employers sponsored benefit Foster Higgins plans so that their employees could remain productive despite the fact that each had personal concerns and objectives. If there is a life, disability and medical plan in place, then day-in/day-out employees can remain productive-- not worry about the financial burden if, for example, they got a severe illness, like AIDS. Actually, a group medical plan is the classic example of the purpose for which insurance programs grew up--a group of people can sustain the burden of a catastrophic illness that would financially ruin any one individual. AIDS fics this classic model. A study of 1,600 individual clients of NY's Gay Men's Health Crisis showed that only 20% were able to remain financially stable during the course of the disease by using their own assets or because of insurance. Another 30% were poor to begin with. The remaining 50% were impoverished during their illness. The final question: "Why should I worry about the business cost? It actually costs less for AIDS than a heart transplant." Despite the fact that we can try to manage them, AIDS insurance expenses are new ones, superimposed on our existing benefit plan costs. Overall, AIDS is going to increase business costs because a population which should not and was not expected to become sick and die will become sick and die. Think of someone who died prematurely. Right now the leading causes of premature death are: accidents, heart problems, homicides, suicide, and so on 6 = ‘3 Foster Higgins to number eleven which is AIDS. By 1991, AIDS will move up on that list to number three or four--and for men it will be second only to accidents. In addressing these and subsequent questions, it is also helpful to educate organizations about AIDS terminology itself. Most people still do not know the difference between being uninfected, testing positive, ARC and AIDS. These distinctions become important in discussions about business costs and personnel policies because each phase of the disease carries different expenses and responsibilities. The bottom line question you try to get an organization to address is: "How many AIDS illnesses and deaths will there be at my company? How much will they cost in the next five years and beyond that?" When these questions come up, it's helpful to remember that, right or wrong, AIDS remains a touchy subject to talk about in a business environment. It deals with sex and death. Individual and corporate attitudes are complicated by fear and can be very personal. AIODS is a new and unexpected business expense factor. But for now and some time into the future it will be a day-to-day factor in business. Facing AIDS and the questions it raises are the starting points for developing a business strategy for the insurance costs of AIDS. 7 Foster Higgins Identifying the Company's Risk Factors Once a company recognizes that AIDS is a potential expense for the benefit plan, the next step is measurement of the risk--how much AIDS will cost this year, next year, ten years from now. We have all heard statistics about AIDS in the population in general, but a company needs to be more specific for its own management projections. How many people in our group of employees are HIV infected? Have AIDS? Will die? How much will their disease affect expenses? Unfortunately, there are no easy answers to these questions. Statistics on the entire subject of AIDS as an insurance risk are sparse. As AIDS applies to the risk in employer-sponsored benefit plans, the literature is almost nonexistent. AIDS was first identified clinically in 1981. Until 1984, most of the imsurance industry and the general public saw AIDS as a disease affecting homosexual men--not of concern to them. It was not until 1985 that most insurance companies even began to record AIDS related deaths. On the medical side, the only way to find out on what disease each claim dollar is spent is to have an "“ICD-9 code" given to each treatment sent in on a claim form. (ICD-9 is a code developed and accepted by both health care providers and insurance payors for identifying expenses associated with Foster Higgins specific diagnoses. It is the 9th version of the International Classification of Diseases.) There have been several problems in identifying AIDS medical claims. First of all, there are many illnesses associated with AIDS and claims which are submitted under these diagnostic codes can be--but are not necessarily--AIDS related. Secondly, before October 1986, specific ICD-9 codes for AIDS did not exist--and insurance carriers were still tooling up their claim payment systems to use the new AIDS codes well into 1987. Lastly, the stigma associated with AIDS still leads many physicians to mask AIDS behind other diagnoses. This makes the data base to draw on for AIDS related insurance expenses vimited. It's limited because the disease itself is relatively new, because it took awhile for the insurance industry to recognize AIDS as a concern and begin to record AIDS claim data, and finally, because AIDS expenses in that subset of the population a company is interested in “employed with group benefits"--have only begun to be researched. All of these limits cannot stop us from trying to assess the impact of AIDS on benefits plan costs. There are tools that are available to see if the expected number of AIDS cases for a corporation's insured population (employees and dependents) over the next several years can be determined. 9 Foster Higgins The discussion that follows is an attempt to match the general data available’ (from the Centers for Disease Control, the Society of Actuaries and insurance companies) with statistics about a company's particular group of insured individuals. The statistics used and sample company results are not applicable to any particular company. A model with differing factors must be developed individually for each company. What is presented here is an example of a methodology which can be applied to help determine the expected prevalence of AIDS. The underwriting tools used to determine risk for a benefit plan are the demographics of the group to be insured and the actuarial value of the risk associated with those demographics. For, AIDS, sex, age, geographic location, sexual preference and drug use are the major factors that will determine the HIV infection rate and, therefore, the incidence of AIDS in an employee and dependent population. These risk factors can be reviewed as they might apply to a company's population. CDC estimates that between 1 and 1.5 million Americans are HIV positive. This translates into an average of 8 per 1,000 in the population age 20 and above. Within the age brackets of the employed population (age group 20-59), the HIV infection rate may be as high as 18 per 1,000 for men but less than 1 per 1,000 for women. 10 Foster Higgins Preliminary evidence indicates that the prevalence of HIV infection among , the insured population--individual and group--is about half the rate of the general population. Infection among group insureds is probably higher than among individual insureds because group plans have a broader base of people-- and probably more people from the risk groups. This means that for every 1,000 male plan participants between ages 20 and 59, a company can expect at least 9 who would test HIV positive--for every 1,000 women, the rate is Jess than one. This gives us how many employees test positive for HIV--not how many have AIDS. Early estimates by CDC were that 10% to 20% of HIV infected persons would ultimately progress to AIDS. Recently, a study of San Francisco data showed that 36% of those who tested HIV positive developed AIDS within 7 years after infection. More recently, there has been discussion that the vast majority of HIV infected subjects will eventually progress to a more serious stage of the disease and succumb to its complications. This means that by estimating the incidence of HIV infection in your population, a company could also be predicting the long term number of AIDS cases. Besides age and sex, there are other factors which can indicate whether a company is on the high or low side of general statistics. 11 Foster Higgins Geographic. Location: Over 70% of all reported cases have been in five states: New York, California, Florida, Texas and New Jersey. New York City, and San Francisco alone have reported 35% of all cases. While AIDS is not restricted to these areas and incidence will shift, benefit plan participants in these locations will continue to carry a higher risk. Sexual Preference: 15% of the people with AIDS have been male homosexual or bisexual. Although no one keeps statistics on sexual preference, there are estimates for this high risk group. For example, one study has said that 3% of the adult population is male homosexuals. Another 3% were male bisexuals during some part of their lives. Approximately 30% of the individuals in these groups (with a range of 20% to 70%) will test HIV positive. Drug Use: ‘The National Academy of Sciences estimates that there are approximately 750,000 "hard core" IV drug users in the U.S. The HIV infection rate average and range is similar to male homosexuals. Traditionally, it is expected, however, that very few of these individuals are employed or insured. This aséumption may be changing as the incidence of AIDS shifts to sex partners and children of IV drug users. Heterosexual Population: The Society of Actuaries report calls the HIV infection rate in this group "small but yet unestimated." Statistics are insufficient to include this group. ’ Foster Higgins These prediction tools can be used to estimate the expected incidence of AIDS for a company. The following are two sample employers with the same number of employees--but varying geographic locations. €mphasizing different statistics in the model, each predicts a different number of AIDS cases. 13 Foster Higgins Example A: An employer whose population is spread nationally, general age and sex statistics are used. Sports Distributors, Inc. Demographics: 10,000 employees ages 20-59 in 35 states 7,000 Male 5,500 Married 3,000 Female 1,800 Married Male Participants Female Participants Total Employee 7,000 Employee 3,000 Spouse 1,800 Spouse § 500 Total 8,800 8,500 17,300 HIV infected rate @ 9/1,000 @ .5/1,000 HIV positive 79 4 83 AIDS rate--7 years 36% 36% AIDS Cases 28 . l 29 14 © Foster Higgins 15 Foster Higgins Measuring the Expenses Associated with a Company's Risk Factors and Tools to Manage Expenses A. Medical Plans Estimates for the medical expenses associated with AIDS vary widely depending on the source. While the range can be from a few to hundreds of thousands of dollars, employers should focus on the experience of the insured population. For example, as of January, 1987, the average group medical claims paid by The Metropolitan Life Insurance Company for AIDS ranged between $48,000 and $62,000. The Prudential reports a similar range. Another measure of medical costs is the fact that most insurance companies now are adding 1% to their trend (inflation) factor to reflect expected AIDS claims. To lessen the financial impact of the costs of AIDS on the medical plan employers can review design, alternative resources and plan financing. The first consideration should be the basic design of the medical program and how it responds to catastrophic illness. The level of the plan's deductibles, out-of-pocket expenses, maximum benefits, copayments, and employee contribution to the premium should all reflect the company's attitude toward coverage for an illness which could be financially devastating to an individual and to a company. 16 Foster Higgins Next it is important to know what ai medical plan really is. Traditionally, health care benefit plans are insurance contracts which Stipulate benefit payments to be made once certain services are provided. These insurance contracts are not always flexible enough to encourage and pay for the most medically appropriate treatment that might be needed for diseases like AIDS. Traditional plans are tilted toward hospital reimbursement. But for AIDS, those plans which use HMO's, managed care, home health will ultimately cost less and may be able to deliver better care. Thus, the plan's approach to alternate delivery systems, preadmission review, concurrent review, discharge planning and case management should be reviewed. These programs are essential to assuring that quality, cost effective treatment in the appropriate medical environment is provided under the plan. There are specific areas where health care plans should be reviewed: Plan Design ° Case Management - Case management programs are designed to help patients experiencing catastrophic illnesses. These illnesses are typically managed poorly (from a care and cost perspective) by the health care delivery system. The diagnoses which benefit from case management are typically those which have experienced high medical 17 Foster Higgins expenses, a growth in incidence, and increased survival rates. The impact of these expense factors is ‘exaggerated by the provider community's general lack of coordinated, well-managed, long term care, and knowledge about specialized care alternatives. AIDS falls jnto this category. A case manager's role is to reduce the expense associated with a diagnosis like AIDS by coordinating and overseeing the management of a treatment plan and its expenditures. A personal, case management approach assures the company that the most appropriate treatment, from both the patient and company perspective, is being provided. Case management is probably the best potential source of AIDS cost control for company medical plans because case management takes advantage of alternative delivery systems. Most AIDS patients require some acute care over the course of the disease but do not require constant hospitalization. Often’ the services that are required are outpatient, home health care, or assistance with daily chores. Benefit plans that reimburse these services at the direction of a case manager when they replace more expensive hospital confinement will best manage their AIDS costs. The communication of case management to plan participants is the key to its success. A case management program depends on the understanding and acceptance of the case management program by plan 18 Foster Higgins participants, their families, physicians and facilities. If case management is not understood, it will not be used successfully. One case manager has reported a success rate of less than 50% of identified AIDS patients entering case management programs--the patient's concern was confidentiality. For many individuals confidentiality is a legitimate concern and can only be overcome by companies who clearly communicate corporate policies and employee rights. Alternative Delivery Systems - Since AIDS affects each patient differently, the treatment plan for each patient is different and should include alternatives to acute care like outpatient services, home health care, assistance with daily chores, or extended care facility. Benefit plans should be examined to see if they provide benefits and incentives for reimbursement of these services when they replace more expensive hospital confinement and provide an effective way to deliver medical care to AIDS patients. Hospices are designed for the terminally ill. A hospice, whose program's primary goal is to alleviate pain and provide services for a brief period before a patient's death, may be beneficial for some people with AIDS and should be included in a benefit plan. 19 Foster Higgins Qruqd Reimbursement - While no cure fs yet available for AIDS, there are a number of experimental drug therapy programs under development. Recently, AZT was taken off the experimental list and is now available for certain AIDS patients at an expense of approximately $10,000 per year. AZT represents the tip of the iceberg because as drug therapy evolves, drug expenses will increase under health care plans. Whether they will ultimately increase plan costs by extending life and medical care, or decrease plan costs by reducing opportunistic disease, remains to be seen. Medical plans and prescription drug plans should be reviewed to determine if coverage and benefit levels are consistent with the plan's overall design and financing goals. Mental Health - Often overlooked in the treatment of AIDS is the effect of the disease, not only on the patient, but on the patient's family, friends and co-workers. The design and utilization of the plan's mental health benefits should be reviewed. Eligibility - Many employers are concerned about anti-selection by new employees. The fear is that high-risk or infected individuals will join the workforce only because insurance is available. Eligibility, waiting periods and pre-existing condition restrictions can be included in a health plan, but it is usually not recommended 20 Foster Higgins for more than a limited per’od (like three months.) These plan restrictions, however, cannot be discriminatory and must meet state insurance requirements. In addition to reviewing medical plan design issues there are some alternative resources available to the benefit plan. These resources are often overlooked as tools for managing costs. Alternative Resources e HMOs - An HMO is designed to provide managed care and, therefore, many AIDS patients may see an HMO as an excellent source of coordinated medical care. If HMO utilization by AIDS patients increases, in the long run AIDS will increase HMO community rates. * Local Resources - The cost of treating people with AIDS can be substantially reduced by using community support services that help keep patients out of the hospital as long as medically possible. Many of these treatment centers are developed from local communities. Resources provided by local volunteer groups such as San Francisco's Shanti project and New York's Gay Men's Health Crises are not traditionally associated with health care plans. Employers need to be open to and supportive of these resources since they represent cost effective ways for AIDS patients to remain out of the hospital. 21 Foster Higgins ¢ Employee Assistance Plans (EAPS) can provide assistance to AIDS patients, their families and coworkers by helping to secure emotional support and meet non-medical needs during illness and after death. An EAP can have an impact on the medical costs of AIDS secondary victims--family, friends and coworkers--py addressing their counseling needs. Plan Financing The funding of the pian should be examined in several areas: * Self-Insurance - There has been an increase in self-insurance for medical benefit plans. A recent J&H survey found that 46% of employers self-fund their benefit plans, and 37% of those do so without any aggregate or individual pooled insurance. Aggregate or individual pooled insurance can be purchased from an insurance company by an employer who has chosen to self-insure. It allows the employer to transfer losses over a stipulated amount for the entire group of employees (aggregate) or an individual person (individual) to the insurance company for a stated premium. It is used by employers to set a maximum on their liability. Depending on the size of the company and the expected incidence of AIDS, a transfer of risk through individual and aggregate pooling levels may be appropriate. Small companies with high risk populations may reconsider 22 Foster Higgins self-insurance, Health Care Pooling - AIDS is the classic situation for which health insurance was originally designed--a catastrophic financial burden is shared by a group of individuals through the insurance mechanism because it cannot be borne by a single individual. What an employer needs to examine is the extent to which the company's group of employees can absorb the expense of the expected number of AIDS claims in any one year. This may lead to the establishment, or reexamination, of a health pooling level, so that the appropriate level of risk can be transferred to an insurance carrier. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) - Extended medical coverage is available to anyone who leaves an employer medical plan through COBRA. Since health care is essential to anyone who has, Carries or suspects they carry the AIDS virus, adverse selection by COBRA participants is anticipated. This cannot be taken into account when COBRA rates are determined, since COBRA charges are restricted by law to 102% of the active employee rates. Since COBRA participants’ claims are usually included in the plan experi- ence, cost management and financing activities should apply to them as well. AIDS affects other insurance plans as well; life, disability and casualty 23 Foster Higgins plans may be impacted. Life Insurance In 1986 AIDS related life insurance claims amounted to about 1% of total life claims paid. By the mid-1990's, the life insurance industry expects that AIDS related deaths from business in force now will exceed 10% of total life claims. While AIOS life insurance costs present us with the same prediction and some new anti-selection challenges, there are things we know about AIDS related death claims. First, the amount of the claims. There has been a lot of publicity given to the fact that the average amount of insurance for individual policies for those who are HIV infected is substantially larger than the industry average. The same is not true for group plans. Metropolitan Life reports the average AIDS related group life claim is about $40,000. Equicor reports $36,000. These amounts are in the same range as the average group claims for non-AIDS related deaths of active employees. In a basic group life plan, many of which are paid for entirely by the company, there is simply no chance for the selection of disproportionate amounts of insurance by someone who knows or suspects they are HIV infected. Therefore, a company can expect the average amount of the plan's AIDS related death claims to be the same as the average amount of 24 Foster Higgins the plan's current active employee death claims. Although the average claim amount remains unchanged--aggregate costs are higher--more people die at a younger age. In addition to basic group life plans, many employers also make available Supplemental group life plans where the employee contributes to some or all of the premium for the plan and can, in most cases, actually choose the amount of insurance to be covered for. Therefore, for supplemental and contributory plans, the picture is Slightly different. Individuals have more opportunity to select against the plan and buy disproportionate amounts of insurance. A review of expected mortality gives an understanding of the selection problem for the company. The expected monthly group life rate for $15,000 of life insurance for a 35 year old non-smoking male is $1. The rate for the same 35 year old would be $5 if he'd suffered heart problems. And if it were even for sale, $51 if he tested HIV positive. The reason for the rate increase is Simple--an HIV infected male at age 35 can anticipate a life expectancy of only 11 years from the time of infection. Compare this to the healthy, uninfected male who can expect an additional 43 years of life. The insurance industry has found that anyone who tests HIV positive is uninsurable because of the extremely high likelihood of death. Where allowed, insurance companies will test applicants who apply for individual insurance over a certain amount. This means that the only or easiest 25 Foster Higgins access to amounts of insurance above the individual policy testing limits imposed by insurance companies for their individual policies may be the employer's group insurance plan. What can be done with employer life benefit plans to control costs? Many of the same design and financing issues discussed for medical insurance apply for life insurance as well: ° Eligibility - Employees who initially decline group insurance and later seek coverage under the plan can be subject to individual underwriting. Where it is allowed, some ‘insurers may include antibody testing in this process. Since testing may be a sensitive personnel issue, organizations should be aware of their insurance carrier's practice. : Guaranteed Issue - Many insurers guarantee a minimum amount of insurance which will be issued to employees under a plan regardless of an employee's health. Over the years employer pressure on insurance companies has increased these levels. If group plans become the only “easy" access to higher levels of tife insurance, employers may need to consider lower amounts of guaranteed issue. ° Risk Transfer - A company can reexamine the amount of individual risk it wants to retain for each person--and transfer the rest, either to an insurance company through pooling levels or to the employees them- 26 ws FosterHiggins C. selves through an employee-pay-all group universal life plan. Generally, although employers will see AIDS related death claims sooner and more clearly than medical claims, the impact of AIDS on life insurance rates will not be felt as quickly as medical rates. This iS because life insurance rates are determined based on claim experience over the last several years (not just one year like medical plans), and it will take longer for life insurance rates to increase. Over the long run, however, increased mortality and amounts of insurance from AIDS claims will be reflected in rates and, therefore, employer expenses. Disability Insurance Disability plans include sick pay, short and long term disability. Not too much focus has been put on the AIDS expenses of these plans because they make up a small percentage of AIDS expenses and the death rate for AIDS patients is high. 80% die within two years of diagnosis and few AIDS patients have survived more than a few years. This actually serves to limit the liability under the disability plans. While an employer can expect immediate plan benefits to be paid out, there is little need to set up large disabled life reserves under an LTD plan. A disabled life reserves is a dollar amount determined by the insurance company based on the expected lifetime disability payments to the 27 Foster Higgins D. employee. The current trend toward self-insurance of disability plans, however, may be re-examined. One design consideration for disability plans is one to help prolong productivity for the company and the disabled employee. The plan ad- ministration should be flexible enough to allow employees to work when they are able, without jeopardizing access to their disability benefits for periods when they cannot work. Casualty Insurance Casualty coverages are not usually considered when AIDS is discussed. There are, however, AIDS related insurance concerns which go beyond benefits. Many employers will face workers compensation, third-party liability and other risk management issues. Worker safety is clearly a problem for employers involved in health care delivery as well as public sector employers, manufacturers of health care products and pharmaceuticals, and AIDS researchers. Employers may face growing personal injury claims arising from discrimination, testing and breach of confidentiality. It can be expected that casualty insurers will attempt to Jimit or eliminate coverage from liability arising out of AIDS related research, 28 Foster Higgins and product lines. Recommendations for Related Activities So far, the discussion has covered the direct business exposure of AIDS in the workplace--employee benefit and insurance costs. This is not the whole picture, however. As what we know and can do about AIDS changes daily, so does the employer's challenge. And, direct costs may only be a smal] part of AIDS impact on a business organization. Therefore, we also recommend that companies: . Read about what's been successful in providing AIDS care and controlling costs--and use what you can in your own organization. ° Keep track of the AIDS experience in your own benefit plans. Not only can it be useful to you in predicting your future, but you can add to the research on employer plans. ° The only cure right now for AIDS is education. If it is frequent, understandable and persuasive, education can be a no risk control over future insurance costs. Employers have a vested interest in making sure employees and their families understand the disease and how it will--and will not--infect them. ° Develop an AIDS or life threatening illness policy, publish it and 29 Foster Higgins talk about it with management, supervisor and employees. ° With our emphasis on insurance expense, a direct business cost, don't lose sight of the fact that indirect business costs, like medical research, changing business markets, and lost worker productivity, as well as societal costs, like care for the uninsured, may in the long term, be the more expensive AIDS costs. ° Act on the facts that are on hand now and listen for new developments. If you wait for all of the "facts" to become known, written and tested, it will be too late to take meaningful action. ‘ On the other hand, over the long haul, there are no absolute solutions. For example, the discussion of health expense today assumed no major medical breakthroughs. Don't develop an AIDS plan today and then freeze it in time--keep it open and flexible. The course of the epidemic from now until 1991 is predictable because it has already been set by what's happened. The future costs to business depend on what we do now. AIDS is not an inexpensive problem, but expenses can be identified and measured, and a strategy can be built to lower costs. Fortunately, the corporate strategy for AIDS can also be a caring one of treatment, prevention and management until we achieve a cure. Our AIDS study which follows shows that 81% of companies think that the 30 Foster Higgins medical expenses for AIDS for their plan participants belongs to their own company. Along with this demonstration of corporate responsibility, we at Foster Higgins will continue to be committed to working with corporations to help them provide employee benefit plans at an affordable cost. 31 __ Foster Higgins Testimony by Mayor William H. Hudnut, III before the Presidential Commission on the Human Immunodeficiency Virus Epidemic Public Hearing on AIDS in the Workplace -- Tuesday, May 10, 1988 I would like to thank the Presidential Commission on the Human Immunodeficiency Virus Epidemic for allowing me this opportunity to share my thoughts as a public employer about the AIDS epidemic in America and Indianapolis in particular. To date there have been 120 cases of AIDS reported in Marion County, with 59 deaths. It is estimated that 50 to 100 times that number of reported cases exist but have not been identified. The State of Indiana ranks 13th in the nation in the number of reported AIDS cases. By the end of 1989, statistics predict there will be 270,000 AIDS cases in America, with 179,00 deaths. All of our lives will be touched in some way by the AIDS virus, whether it be as an employer, co-worker, relative, or friend. We must marshal a compassionate and professional approach to AIDS. The City of Indianapolis is the ninth largest employer in Marion County with 4,763 employees. As the Mayor of this City, it is my responsibility to protect the rights of all of our citizens and all of our City and County employees. The AIDS epidemic represents a challenge in respecting individual rights while at the same time safeguarding public health. The federal and state government have worked hard toward developing policies and programs on AIDS. The recently announced federal government guidelines for employees and recently passed Page 2 May 10, 1988 legislation by the ‘Indiana General Assembly, with the leadership of Senator Patricia Miller from Indianapolis, places an emphasis on creating an awareness and understanding of AIDS-related issues and employee conduct toward AIDS-infected co-workers. I applaud this decision and the efforts of Health and Human Services Secretary Otis R. Bowen and Surgeon General C. Everett Koop in their recently announced campaign to mail an AIDS informational brochure to every household in the nation. It is our responsibility as employers and elected representatives of the people in this country to educate the public about AIDS--how it is transmitted and how transmission can be prevented. We take this responsibility seriously in Indianapolis. This afternoon I signed an Executive Order stating the City's policy on AIDS and our employees. I would like to share this policy with you in the hopes that it might serve as a guide for other municipalities across the state and nation. The Executive Order states the following: 1. The City of Indianapolis shall not discriminate against any employee or applicant for employment with respect to hire, tenure, terms, conditions, or privileges of employment or any matter directly or indirectly related to employment because the employee or applicant is or is suspected of being infected with the AIDS virus. 2. The City shall allow employees who are infected with the AIDS virus the same leave allowances and considerations as are available to an employee with any other type of physical or mental disability. Page 3 May 10, 1988 3. The Department of Administration shall develop an education program about AIDS and make it available to all levels of City employees. 4. The Director of the Department of Administration shall appoint an AIDS coordinator who shall be responsible for establishing an education program on AIDS, who shall keep current on the latest AIDS information and therefore act as an "AIDS clearinghouse" for the City, who shall generally coordinate all of the City's efforts in dealing with the effect of AIDS on the City's work force, who shall be the City's liaison with other agencies dealing with the AIDS question and who shall perform any other duties as assigned by the Director of the Department of Administration. 5. The City shall further make available to employees and the general community ongoing educational opportunities about AIDS through its program capabilities on Channel 16. 6. The Department of Administration shall explore the availability of counseling through its EAP and wellness programs for City employees who are infected with the AIDS virus. 7. The City shall make available to all City employees free AIDS testing should any City employee desire to be tested. 8. The City shall maintain the confidentiality of any information received regarding whether an employee is infected with the AIDS virus unless the employee explicitly gives written approval to disseminate such information. Page 4 May 10, 1988 9. All City agencies whose employees come into contact with blood or bodily fluids on a regular basis shall provide training and develop safety procedures to be used by their employees in dealing with such bodily fluids. 10. The City shall comply with all State and Federal laws regarding AIDS. On behalf of the policy makers and health officials in Marion County, I urge the citizens in our community to learn about AIDS and take the necessary precautions to prevent contracting AIDS. Thank you. CITY OF INDIANAPOLIS COUNTY OF MARION -. STATE OF INDIANA EXECUTIVE ORDER NO. | , 1988 ESTABLISHING AN AIDS POLICY REGARDING CITY EMPLOYEES WHEREAS, the spread of acquired immune deficiency syndrome (ALDS) iS a mattec of great pudilc concecn; and WHEREAS, the City desires to protect the rights ‘of its employees and to controt the spread of AIDS to the greatest extent possinle; ph oN NOW THEREFORE, by virtue of tne rere vested in me as Mayor of the City of Indianapolis, it ls neceby ordered ‘as follows: l. The City of Indianapolis shall not discriminate against any employee or applicant for employment with respect to hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment because the employee or applicant is or is suspected of being infected with the AIDS virus. 2. The City shali allow employees who are infected with the AIDS virus the same leave allowances and considerations as ace available to an employee with any other type of physical or mental disability. 3. Tne Department of Administration shall develop an education program about AIDS and make it available to all levels of City employees. 4, The Director of the Department of Administration shall appoint an AIDS coordinator who shali be responsible for estaolishing an education orogram on AIDS, who shall keep current on the latest AIDS information and therefore act as an "AIDS clearinghouse" for the City, who snall generally coordinate all of the City's efforts in dealing with the effect of AIDS on the City's workforce, who shall be the City's Liaison with other agencies dealing with the AIDS question and who shall pecform any other duties as assigned by the Dicector of the Department of Administration. 5. The City shall further make available to employees and the general community ongoing educational opportunities about AIDS through its program capabilities on Channel 16. 6. The Department of Administration shail explore the availability of counseling through its AP and wellness programs for City employees who are infected with the AIDS virus. 7. The City shall make available to all City employees Free AIDS testing should any City employee desire to be tested. 8. The City shall maintain the confidentiality of any information received regarding whether an employee is infected witn the AIDS virus unless the employee explicitly gives weitten approval to disseminate such information. 9. All City agencies whose employees come into contact with blood oc bodily fluids on a regular oasis shall provide training and develop safety procedures to be used by thelr employees in dealing with such bodily fluids. = 10, The City shall comply with all State and Federal laws regarding AIDS. Dated this (#® day of PY seas , 1988. CITY OF INDIANAPOLIS . % Ld ay: Ane Silegm Hf William H. Hudnut, III, Mayor APPROVED AS TO FORM AND LEGALITY: -— “KE istie L. HY11, Cocpération ‘Counsel 8481D/cl PUBLIC SECTOR ISSUES TESTIMONY OF JORDAN BARAB Health and Safety Coordinator American Federation of State, County and Municipal Employees Before the PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC May 10, 1988 Indianapolis, IN My name is Jordan Barab and I am the Occupational Health and Safety Coordinator for the American Federation of State, County and Municipal Employees. AFSCME has over 1.1 million members across the country. Many of these -- including hospital workers, mental health, emergency medical care, corrections, custodial and waste-water treatment commonly have on-the-job contact with blood or body fluids. | The purpose of my remarks today is to address the concerns of public employees. As you will see, the concerns of public employees are very often no different from private sector-- except for two areas. First, there are more public employees in such occupations as health care, corrections and other jobs which may have significant direct contact with persons with AIDS. Second, to the extent OSHA is stepping in to protect the health of care givers, it should be remembered that except for in 24 states which have federally approved OSHA plans, public employees in this country are not covered by OSHA and therefore do not fall only the targeted inspection progran. AFSCME has been dealing with AIDS since early 1983 when we received an urgent request for members of a local representing mental health workers. They had just received their first resident who was known to have AIDS. Management was trying to keep it secret and no training or education had been done. We were asked to come in to do training for the workers at the institutions. Since that time, information on AIDS has been AFSCME's most 1 requested item. As we began to do workshops for health care workers, mental health, corrections and others, we found a shocking pattern of disregard for basic blood-borne infectious disease precautions. Workers had not been trained, equipment had not been provided and work procedures had not been adjusted. For this reason, AFSCME petitioned the Occupational Safety and Health Administration in September 1986 for three items: - An Emergency Temporary Standard covering blood-borne diseases such as AIDS and hepatitis B; « Inclusion of infectious diseases into the Hazard Communication Standard, and - A generic OSHA standard covering all infectious diseases. As you may be aware, OSHA rejected all three of our requests in favor of a targeted inspection program. covering blood-borne infectious diseases and health care workers. As health care workers are not the subject of the hearing today, I will not concentrate to any great extent on the problems of these employees. I will address the remainder of my remarks to those public employees who are not hospital workers. CORRECTIONS AND MENTAL HEALTH Corrections officers and mental health workers across this country have expressed an enormous amount of concern about AIDS. As the population of most prison systems contains large numbers of I.V. drug users, there were a large number of prisoners with AIDS and with the HIV infection. Furthermore, corrections rt personnel frequently experience violence where there is exposure to blood, as well aS unsanitary condition where urine or feces is thrown at then. Mental health personnel also face these conditions, in addition to a number of persons who cannot be responsible for their actions. Furthermore, as cases of AIDS-related dementia increase, more' and more persons with AIDS will find their way into mental ‘health institutions. Institutional employees are in dire need of training. Traditionally management's first response is to say as little as possible, tell everyone not to worry and go on about business. This approach only’ increases whatever panic was already forming among the employees. We are frequently called in on an emergency basis to educate workers about AIDS. The second problem is that management often does not make protective equipment available -- even when obviously needed. This includes rubber gloves for cleaning up blood spills, and resuscitation masks for artificial respiration. Unfortunately, as correctional personnel are not classified as health care workers, they do not fall under the OSHA directives. Similarly, CDC has no guidelines for corrections institutions. CUSTODIAL EMPLOYEES AFSCME represents a large number of school and other custodial employees. While it is not immediately obvious that these persons would be concerned about AIDS, in fact, whenever a child is injured or ill, it is the school custodian who must Clean up. While this does not have to be a high risk venture, it is important that these workers at least be provided with gloves and training on how to clean and disinfect. Custodial personnel (and ground keepers) in other buildings report finding used needles in the trash or on the grounds. Again they need training on how to deal with such occurrences. We feel that blood -- wherever it is found -- should be treated like a toxic substance and that workers need to be trained to deal with it safely. Like Corrections personnel, school or building custodians do not fall under the OSHA guidelines. SANITATION As Bill Borwegan from the Service Employees International Union will make clear tomorrow, the infectious waste management procedures at many hospitals has completely broken down. This leads to infectious wastes being tossed out with the regular trash. We receive frequent reports from our members who are Sanitation workers about finding red bags full of bloody materials, needles, and sometimes even body parts. THE RIGHT-TO-KNOW Giving workers the "right-to-know" about the chemicals they are exposed to in the workplace has been one of the major health and safety items of this decade. Dozens of state and local laws and a major OSHA standard give workers the right-to-know about the chemicals they are exposed to. AFSCME feels that employees also need to be trained about the infectious diseases they may be exposed to. While it is obvious from my previous remarks that this is true for AIDS (and hepatitis B) it is also true for other diseases which should peripherally be the concern of this committee. For example, many persons with AIDS are developing active cases of tuberculosis. TB is an air-borne disease and the precautions used around persons with TB are therefore very different from those to be used around persons with AIDS or any other blood-borne disease. Workers who work around persons with AIDS therefore also need to be trained about TB. UNIVERSAL PRECAUTIONS The bottom line is that it is impossible to determine solely by a person's job title whether or not he or she will be exposed to blood or other body fluids. It is thereforé essential for all employers to analyze an employee's potential for exposure according to the actual work he or she does. This approach is _ endorsed by the Joint Advisory Notice issued by the Departments of Labor and Health and Human Services. TESTING AFSCME opposed any mandatory testing of any employees in any eccupation. Aside from the obvious civil rights problems such testing could cause, there is no evidence that infected employees are a threat to anyone else. There has been considerable controversy within our union, however about testing prison inmates or mental health patients. 5 Some feel that given the level of violence and unsanitary conditions in such institutions, such testing is warranted. Others feel it is unnecessary and, at most, should only be done if there has been a direct exposure. CIVIL RIGHTS One area I have not covered in my oral remarks is workplace discrimination against persons with AIDS. AFSCME strongly believes that AIDS or infection with HIV should fall under the provisions of the Rehabilitation Act of 1973 and that reasonable accommodations should be made for all who need them. I have not gone into great detail in this area in my testimony, because the concerns of public employees are not unique in this area. CONCLUSION Public employees do much of the most important -- and most dangerous -- work that this country needs to make life safe and enjoyable. In the case of AIDS, we will increasingly provide the bulk of the care givers -- in hospitals, prisons, mental health institutions, and schools. For this service, we need to receive proper education, training and protection which will enable us to do our jobs with the energy and caring that the public -- and the persons with this terrible disease -- have come to expect. INTERNATIONAL ASSOCIATION OF FIRE FIGHTERS, AFL-CIO PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC WRITTEN TESTIMONY MAY 10, 1988 RICHARD M. DUFFY DIRECTOR DEPARTMENT OF OCCUPATIONAL HEALTH AND SAFETY Richard M. Duffy TITLE: Director . Department of Occupational Health and Safety International Association of Fire Fighters, AFL-CIO Mr. Duffy directs the development and implementation of the occupational health and safety department_for an international labor union--the International Association of Fire Fighters. He is responsible for providing technical assistance to the 175,000 member union, organizing and conducting safety and health seminars, developing safety and health manuals and educational materials, providing liaison with professional and_ trade associations, federal agencies and other organizations. Mr. Duffy is also the administrator of the IAFF John P. Redmond Foundation, which is responsible for studies and symposiums on the occupational health and hazards of the fire service. The IAFF Department of Health and Safety consists of 9 full time health professionals and support staff which provides services in, the areas of protective equipment and_ clothing, occupational medicine and industrial hygiene, infectious disease, hazardous materials, fire service regulations and standards, and other relative issues in the area of fire fighters’ health and safety. Mr. Duffy holds a Masters of Science degree in Environmental (Occupational) Health. _ He serves a number of professional societies and organizations, including the Chairman of the Technical Committee on Fire Service Protective Clothing and Equipment, Member of the Technical Committee on Fire Service Safety and Health, Member of the Staff Standing Committee for Occupational Safety and Health of the AFL-CIO, Member of the Public Health Advisory Board of the Johns Hopkins School of Hygiene and Public Health, Member of the ANS! Z88 Committee for Respiratory Protection, Member of the F-23 Committee for Protective Clothing of the ASTM, Member of the_Board of Directors of the International Society of Respiratory Protection, Member of the Society of Occupational ad Environmental Health, Member of the American Industrial Hygiene Association, Member of the American Public Health Association and Member of the National Fire Protection Association. Mr. Duffy_has addressed fire fighters internationally on worker and fire fighter health and safety issues and has published numerous fire service manuals, books and articles. MY NAME !S RICHARD DUFFY, DIRECTOR OF THE DEPARTMENT OF OCCUPATIONAL HEALTH AND SAFETY FOR THE INTERNATIONAL ASSOCIATION OF FIRE FIGHTERS. | APPRECIATE THE OPPORTUNITY TO ADDRESS THE PRESIDENT’S COMMISSION ON AIDS. PRIOR TO DOING THIS, WE BELIEVE IT IS IMPORTANT FOR YOU TO UNDERSTAND WHAT OUR ORGANIZATION IS AND WHO WE REPRESENT. THE JAFF IS AN INTERNATIONAL UNION AFFILIATED WITH THE AFL-CIO AND THE CANADIAN LABOR CONGRESS. AT THE PRESENT TIME, WE REPRESENT APPROXIMATELY 170,000 PAID PROFESSIONAL FIRE SERVICE EMPLOYEES IN THE UNITED STATES AND CANADA. THE MEMBERSHIP OF THE IAFF IS EMPLOYED BY VARIOUS PARTIES WHICH INCLUDE: THE FEDERAL GOVERNMENT, STATES, COUNTIES, MUNICIPALITIES, FIRE DISTRICTS, AIRPORTS, INDUSTRIAL MANUFACTURERS, AND SO ON. FIRE FIGHTERS AS A GROUP ARE AT ‘RISK OF CONTRACTING HIV AND OTHER COMMUNICABLE DISEASES TRANSMITTED THROUGH THEIR CONTACT WITH BLOOD AND BODY FLUIDS. IN FACT, THERE’ ARE VERY FEW FIRE FIGHTERS WHO DO NOT COME IN CONTACT WITH INJURED AND BLEEDING VICTIMS OF FIRES AND OTHER ACCIDENTS, OFTEN IN A DANGEROUS | AND UNCONTROLLED ENVIRONMENT WHERE CHANCES _2- FOR EXPOSURE TO THESE DISEASES ARE GREATER. UNFORTNATELY, MUCH OF THE ATTENTION WITHIN THE MEDICAL AND SCIENTIFIC COMMUNITY HAS FOCUSED ON PROTECTING HOSPITAL WORKERS FROM INFECTIOUS DISEASES, PARTICULARLY AIDS. INSUFFICIENT ATTENTION HAS BEEN PAID TO PROTECTING EMERGENCY RESPONSE PERSONNEL, WHO WORK IN UNSTERILE ENVIRONMENTS THAT ARE LESS EASILY CONTROLLED THAN THE HOSPITAL ENVIRONMENT. ACCORDING TO THE 1986 IAFF DEATH AND INJURY SURVEY, 1.8% OF ALL FIRE FIGHTER INJURIES RECEIVED DURING EMERGENCY OPERATIONS WAS THE CONTRACTION OF A CONTAGIOUS DISEASE. CONTRACTING A CONTAGIOUS DISEASE WAS MORE PREVALENT THAN CARDIAC ABNORMALITIES, COLD INJURIES, HEAT EXHAUSTION/HEAT STROKE AMONG INJURIES RECEIVED AT AN EMERGENCY INCIDENT. THE ABOVE DOCUMENTATION INDICATES THAT THIS COMMISSION AND THE REAGAN ADMINISTRATION CAN NO LONGER IGNORE THE NEED OF EMERGENCY RESPONSE PERSONNEL AS IT DEVELOPS ITS POLICIES AND STANDARDS ON OCCUPATIONAL EXPOSURE TO HIV AND OTHER COMMUNICABLE DISEASES. -3- AT THE IAFF, WE ARE EXTREMELY PROUD OF OUR RECENT PUBLICATION, GUIDELINES TO PREVENT TRANSMISSION OF COMMUNICABLE DISEASE DURING EMERGENCY CARE FOR FIRE FIGHTERS, PARAMEDICS AND EMERGENCY MEDICAL TECHNICIANS. THIS WAS THE FIRST SET OF GUIDELINES SPECIFICALLY ADOPTED FOR EMERGENCY RESPONSE WORKERS. IT HAS BEEN WELL RECEIVED IN THE FIELD WITH MORE THAN 30,000 COPIES ALREADY DISTRIBUTED AROUND THE COUNTRY. THE NATIONAL FIRE PROTECTION ASSOCIATION (NFPA), A VOLUNTARY CONSENSUS STANDARD-MAKING ORGANIZATION, HAS RECENTLY TAKEN ACTION TO PUBLISH A ‘DOCUMENT ALMOST IDENTICAL IN CONTENT. \, WE BELIEVE THESE GUIDELINES REPRESENT A RATIONAL AND .PRACTICAL APPROACH TO THE PREVENTION OF COMMUNICABLE DISEASE DURING EMERGENCY CARE AND VICTIM RESCUE. IN THE EMERGENCY CARE SETTING THE INFECTIOUS DISEASE STATUS OF PATIENTS IS FREQUENTLY UNKNOWN BY BOTH PROVIDERS AND PATIENTS THEMSELVES. FOR EXAMPLE, IN PHOENIX, ARIZONA, FIRE FIGHTERS AND MEDICS RESPONDING TO A CALL FOUND A MAN LYING IN A PARKING LOT NEAR A BAR. THE MAN HAD BEEN BEATEN AND !NJURED, WAS -4- | RESPONDERS DID NOT KNOW, AS THEY EASED HIM ONTO A BACKBOARD WAS THAT HE WAS ALSO A CARRIER OF HEPATITIS B. AS THE VICTIM WAS BEING TAPED TO THE BACKBOARD, HE REVIVED AND BECAME VIOLENT. WHILE THRASHING, HIS NOSE BEGAN TO BLEED. HE ALSO SPAT AT THE FIRE FIGHTERS AND MEDICS. DURING THE STRUGGLE SEVERAL FIRE FIGHTERS SUFFERED CUTS. SINCE IN AN EMERGENCY CARE SETTING THE INFECTIOUS DISEASE STATUS OF PATIENTS IS FREQUENTLY UNKNOWN BY BOTH PROVIDERS AND PATIENTS THEMSELVES, THE IAFF BELIEVES THAT THIS COMMISSION AND THE REAGAN ADMINISTRATION SHOULD ENSURE THROUGH ITS’7 POLICIES AND REGULATIONS THAT ALL PATIENTS BE CONSIDERED INFECTIOUS. PRIOR TO ANY CONTACT WITH PATIENTS, EMERGENCY RESPONSE PERSONNEL MUST BE REQUIRED TO COVER ALL AREAS OF ABRADED, LACERATED, CHAPPED, IRRITATED OR OTHERWISE DAMAGED SKIN WITH ADHESIVE DRESSINGS. EMERGENCY RESPONSE PERSONNEL WITH EXTENSIVE SKIN LESIONS OR SEVERE DERMATITIS MUST BE REQUIRED TO REFRAIN FROM DIRECT PATIENT CONTACT AND FROM HANDLING ‘PATIENT CARE EQUIPMENT UNTIL HEALED. _5- WE BELIEVE IT JIS IMPERATIVE THAT ALL NEEDLESTICK/CUT/SLASH INJURIES BE RECORDED BY EMERGENCY RESPONSE PERSONNEL AND - OTHER HEALTH CARE WORKERS IN THE OSHA LOG. PROPER DOCUMENTATION OF SUCH EXPOSURES NEEDS TO BE MAINTAINED. WORKERS WHO SUFFER NEEDLESTICK INJURIES, OTHER PENETRATING WOUNDS, OR ARE SOMEHOW EXPOSED TO BLOOD/OR BODY FLUIDS SHOULD BE OFFERED MEDICAL ATTENTION IMMEDIATELY. SUCH MEDICAL ATTENTION SHOULD INCLUDE POST-EXPOSURE COUNSELING, VOLUNTARY TESTING AND PROPHYLAXIS. MEDICAL SCREENING TO DETERMINE A WORKER'S STATUS SHOULD BE PROVIDED AT NO COST BY THE EMPLOYER TO\THE EMPLOYEE. THE WORKER SHOULD ALSO BE OFFERED A FOLLOWUP TEST AT AN APPROPRIATE INTERVAL TO SEE IF CONVERSION HAS OCCURRED. EXPOSED EMPLOYEES AND THEIR FAMILIES SHOULD BE OFFERED MEDICAL COUNSELING IN ORDER FOR THEM TO DEAL WITH‘THE SITUATION. MEDICAL RECORDS SHOULD REMAIN CONFIDENTIAL BETWEEN THE EMPLOYEE AND THE ‘MEDICAL PERSONNEL CONDUCTING THE TESTING, COUNSELING, ETC. NN IN THE AREA OF PROTECTIVE CLOTHING FOR EMERGENCY RESPONSE PERSONNEL, THE IAFF BELIEVES -6- THAT STRUCTURAL FIRE FIGHTING GLOVES MEETING THE MINIMUM OSHA REQUIREMENTS AS CONTAINED IN 29 CFR 1910.156 MUST BE WORN IN ANY SITUATION WHERE SHARP OR ROUGH SURFACES ARE LIKELY TO BE ENCOUNTERED (E.G. VICTIM EXTRICATION). THE IAFF ALSO BELIEVES THAT THE USE OF DISPOSABLE LATEX OR VINYL GLOVES MUST BE REQUIRED FOR ALL PERSONNEL PRIOR TO INITIATING ANY EMERGENCY PATIENT CARE. MECHANICAL RESPIRATORY ASSIST DEVICES (E.G. BAG-VALVE MASKS, OXYGEN DEMAND VALVE RESUSITATORS) MUST BE AVAILABLE ON ALL FIRE DEPARTMENT VEHICLES THAT RESPOND OR POTENTIALLY RESPOND TO MEDICAL EMERGENCIES OR VICTIM RESCUES. THE IAFF ALSO BELIEVES MASKS/GOGGLES/GOWNS SHOULD BE PRESENT ON ALL _ FIRE DEPARTMENT VEHICLES THAT RESPOND OR \POTENTIALLY RESPOND TO MEDICAL EMERGENCIES OR VICTIM RESCUES. THE EMPLOYER MUST ENSURE THAT THESE ITEMS OF PROTECTIVE CLOTHING ARE DONNED BY ALL PERSONNEL PRIOR TO ANY SITUATION WHERE ‘SPLASHES OF BLOOD MAY OCCUR. STRUCTURAL FIRE FIGHTING HELMET FACESHIELDS DO NOT PROTECT THE EYES, NOSE AND MOUTH FROM LIQUID SPLASHES COMING FROM BELOW AND SHOULD NOT BE ALLOWED ' -FOR SUCH PURPOSES. THE IAFF ALSO BELIEVES THAT PUNCTURE-RESISTANT, SHATTERPROOF, DISPOSAL ‘CONTAINERS BE REQUIRED ON EACH FIRE DEPARTMENT -7- VEHICLES FOR PLACEMENT OF ALL USED SHARP OBJECTS. IN THE AREA OF CLEANING AND DISINFECTING, A CONCERTED EFFORT MUST BE MADE TO ENSURE THAT BLEACH IS NEVER USED ON FIRE FIGHTER PROTECTIVE COATS/TROUSERS, FIRE FIGHTER GLOVES, AND FIRE FIGHTER STATION/WORK UNIFORMS. BLEACH MAY COMPROMISE STRUCTURAL INTEGRITY AND/OR FIRE RETARDENCY OF THE FABRICS. WHEN CONTAMINATED PROTECTIVE CLOTHING CANNOT BE CLEANED WITH A MILD DETERGENT, THEN THAT CLOTHING MUST BE DISPOSED OF IN A PROPER FASHION. THIS COMMISSION AND THE REAGAN ADMINISTRATION MUST ALSO RECOGNIZE IN THAT CONTAMINATED CLOTHING SHOULD NEVER BE LAUNDERED AT HOME. WE MUST ALSO RECOGNIZE AND ACKNOWLEDGE THAT THE TRAINING OF EMERGENCY RESPONSE PERSONNEL ACROSS THE NATION IS HAPHAZARD AND NOT UNIFORM. TWO FIRE FIGHTERS IN BARRE, VERMONT ARE CURRENTLY UNDER INVESTIGATION FOR POSSIBLE SERIOUS DISCIPLINARY ACTION BECAUSE THEY PUT ON GLOVES AND GOWNS PRIOR TO TREATING A PRISONER “WHO ATTEMPTED “SUICIDE AND’ HAD ADMITTED IN OPEN COURT TO HAVING AIDS. NO FORMAL TRAINING WAS EVER PROVIDED TO THESE WORKERS WHO NOW FACE DISCIPLINARY ACTION DUE TO THEIR DECISION TO UTILIZE GOWNS. A WRITTEN BULLETIN FROM THE VERMONT DEPARTMENT OF HEALTH ADVISED USING INDIVIDUAL DISCRETION WHEN TREATING POTENTIALLY INFECTIOUS PATIENTS. A NURSE TRANSMITTING FROM A RADIO TO THE FIRE FIGHTERS AT THE SCENE INFORMED THEM THAT GOWNS WERE NOT NECESSARY WHEN TREATING AIDS PATIENTS. IT IS EVIDENT THAT A UNIFORM TRAINING PROGRAM FOR EMERGENCY RESPONSE senso NEEDS TO BE DEVELOPED AND \ IMPLEMENTED. . THE IAFF BELIEVES THAT. PROPER NOTIFICATION OF EMERGENCY RESPONSE PERSONNEL BE AN IMPORTANT POLICY CONSIDERATION. INCIDENTS, SUCH AS THE ONE THAT OCCURRED IN PRINCE GEORGE'S COUNTY, MARYLAND, WHERE FIRE FIGHTERS WERE DENIED KNOWLEDGE OF A PATIENT'S HIV STATUS BY THE HOSPITAL AFTER RESPONDING TO A SITUATION WHERE A MASSIVE AMOUNT OF BLOOD WAS PRESENT, SHOULD BE PROHIBITED. FIRE FIGHTERS LEARNED THAT THE PATIENT WAS HIV POSITIVE THROUGH INDIRECT SOURCES. THE INDIVIDUALS THAT TRANSPORT INFECTIOUS PATIENTS SHOULD NOT BE _ DENIED -ANFORMATION AVAILABLE TO OTHERS WHO TREAT THAT SAME PATIENT IN THE HOSPITAL. MOST HOSPITALS HAVE SYSTEMS IN PLACE, FORMALLY OR _g- INFORMALLY, TO NOTIFY THEIR OWN PERSONNEL WHO HAVE HAD A SIGNIFICANT CONTACT WITH A PATIENT, WHO, IN THE NORMAL COURSE OF TREATMENT, IS DISCLOSED TO BE INFECTED WITH A_ SERIOUS INFECTIOUS DISEASE. SEVERAL STATES HAVE ALREADY ADOPTED LEGISLATION MANDATING HOSPITALS TO EXTEND THIS SAME PROTECTION TO THE FIELD EMERGENCY RESPONSE PERSONNEL WHO ARE AT EQUAL OR PERHAPS HIGHER RISK OF EXPOSURE. IRONICALLY, MARYLAND HAS ADOPTED A LAW THAT REQUIRES NOTIFICATION FOR CERTAIN CONTAGIOUS DISEASES, BUT EXEMPTED HIV. MANY OTHER STATES HAVE ADOPTED HOSPITAL NOTIFICATION PROVISIONS FOR EMERGENCY RESPONSE PERSONNEL. ALTHOUGH THE IAFF BELIEVES THAT CONFIDENTIALITY PROVISIONS SHOULD BE INCORPORATED, WE DO NOT BELIEVE THE ISSUE OF PRIVACY SHOULD DENY WORKERS THE RIGHT- TO-KNOW ABOUT A PATIENT’S HEALTH STATUS. A NATIONAL NOTIFICATION PROCEDURE SHOULD BE A PRIORITY OF THIS COMMISSION’S RECOMMENDATIONS. AS WE HAVE MENTIONED, MANY IN THE MEDICAL COMMUNITY HAVE MINIMIZED THE RISK OF EXPOSURE FOR EMERGENCY RESPONSE PERSONNEL TO DISEASES, “SUCH AS AIDS. “HOWEVER, THOSE RISKS EXIST WITH CONSEQUENCES NOT ALWAYS STRICTLY MEDICAL. -10- FOR EXAMPLE, IN LOS ANGELES, CALIFORNIA, A FIRE FIGHTER RESPONDED TO AN AUTO ACCIDENT WHICH REQUIRED EMERGENCY MEDICAL CARE. THE AUTO AND THE PATIENT WERE LOCATED AT THE BOTTOM OF THE CLIFF AND THE FIRE FIGHTERS WERE REQUIRED TO RAPPEL DOWN TO REACH THE SCENE. THE VICTIM WAS FOUND TO HAVE STOPPED BREATHING AND INSTEAD OF WAITING FOR THE MECHANICAL RECUSITATOR TO BE LOWERED DOWN, CPR - WHICH INCLUDED MOUTH-TO- MOUTH BREATHING - WAS COMMENCED. DESPITE THIS HEROIC EFFORT, THE VICTIOM SUBSEQUENTLY DIED. IT WAS LATER DETERMINED THAT THE VICTIM HAD AIDS. WHEN THE FIRE FIGHTER EXPLAINED THE SITUATION TO HIS WIFE, SHE IMMEDIATELY BEGAN HYSTERICAL. FAMILY AND FRIENDS, INCLUDING FELLOW FIRE FIGHTERS, AVOIDED CONTACT. EVEN THOUGH BLOOD TESTING HAD BEEN PERFORMED WITH NO SIGNS OF THE AIDS VIRUS, THIS MAN HAD VERY REAL FEARS AND CONCERNS. THE IMPACT OF AIDS IN THE FIRE SERVICE HAS ANOTHER DIMENSION AS WELL. THAT IS, FIRE FIGHTERS WHO CONTRACT THE DISEASE WHETHER DUE TO “OCCUPATIONAL ‘EXPOSURE = OR PERSONAL LIFESTYLE. WHILE WE ARE IN AGREEMENT THAT CASUAL CONTACT AT MOST WORKSITES POSES NO -11- THREAT OF TRANSMITTING THE AIDS VIRUS, WE BELIEVE THE WORKPLACE ENVIRONMENT CONFRONTED BY FIRE FIGHTERS DOES POSE A POTENTIAL THREAT OF TRANSMITTING THE AIDS VIRUS TO FELLOW WORKERS AND THE GENERAL PUBLIC. THE EMERGENCY ENVIRONMENT FACED BY FIRE FIGHTERS IS OFTEN UNCONTROLLABLE WITH MANY HAZARDS. ACCORDING TO THE JAFF DEATH AND INJURY SURVEY, APPROXIMATELY 20% OF ALL INJURIES AT THE EMERGENCY SCENE ARE LACERATIONS AND CONTUSIONS. FURTHERMORE, ALMOST 10% OF ALL FIRE FIGHTERS CAN BE EXPECTED TO SUFFER A LACERATION OR CONTUSION DURING THE YEAR. THIS HIGH PROBABILITY OF OBTAINING A CUT DURING EMERGENCY OPERATIONS MUST PRECLUDE THE EMPLOYMENT OF INDIVIDUALS WITH AIDS. THAT 1S NOT TO SAY THE FIRE SERVICE LACKS COMPASSION. ONE OF OUR LOCALS IN WARRENSVILLE HEIGHTS, OHIO RECENTLY NEGOTIATED FOR A CONTRACT PROVISION WHICH PROVIDES THAT ANY FIRE FIGHTER WITH AIDS SHALL BE ENSURED OF HIS ENTIRE SALARY UNTIL HIS DEATH OR NORMAL RETIREMENT AGE. IT !S A POLICY THAT RECOGNIZES THE RISK OF EMERGENCY OPERATIONS IN EXPOSING FELLOW FIRE FIGHTERS AND “THE PUBLIC°TO BLOOD CONTAINING THE HIV VIRUS. IT ALSO RECOGNIZES THE RESPONSIBILITY TO REACH OUT AND ASSIST THOSE VICTIMS OF AIDS. -12- BEFORE CLOSING MY REMARKS, THE IAFF HOPES THAT THIS COMMISSION WILL UTILIZE ITS INFLUENCE TO SUPPORT THE ENACTMENT OF H.R. 3418. IN SUMMARY, THIS MEASURE REQUIRES HOSPITALS TO TRANSMIT NOTIFICATIONS TO THE EMPLOYERS OF EMERGENCY RESPONSE PERSONNEL WHO TRANSPORT A VICTIM TO A HOSPITAL WHO IS FOUND TO BE INFECTED WITH AIDS, HEPATITIS B, HEPATITIS NON-A/NON-B, PULMONARY TUBERCULOSIS, AND MENINGOCOCCAL MENINGITIS; PROVIDES FUNDING FOR THE DEVELOPMENT OF A TRAINING CURRICULUM BY THE CENTERS FOR DISEASE CONTROL FOR EDUCATING EMERGENCY RESPONSE PERSONNEL WITH RESPECT TO THE PREVENTION OF EXPOSURE TO_ INFECTIOUS DISEASES; ESTABLISHES THREE GRANT PROGRAMS TOTALING $25 MILLION FOR STATES TO IMPLEMENT THE CDC TRAINING CURRICULUM, CONDUCT DEMONSTRATION PROJECTS TO PROVIDE VACCINES, AND TO MAKE VOLUNATARY AIDS TESTING AND COUNSELING AVAILABLE TO EMERGENCY RESPONSE EMPLOYEES NOTIFIED OF AN EXPOSURE TO AN AIDS PATIENT; AND ENSURES EMERGENCY RESPONSE PERSONNEL MAINTAIN CONFIDENTIALITY AND NON- DISCRIMINATION PROTECTIONS FOR AIDS PATIENTS. - 13 - ONCE AGAIN, WE APPRECIATE THE OPPORTUNITY TO ADDRESS THIS COMMISSION. IT IS OUR HOPE THAT THIS COMMISSION AND THE REAGAN ADMINISTRATION WILL ENSURE THAT EMERGENCY RESPONSE PERSONNEL ARE ADEQUATELY TRAINED, PROVIDED PROTECTIVE EQUIPMENT, VACCINATED, AND NOTIFIED TESTIMONY OF DEWEY R. STOKES PRESIDENT, NATIONAL FRATERNAL ORDER OF POLICE TO PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNO DEFICIENCY VIRUS EPIDEMIC (AIDS) FACT SHEET Recommendations of the Fraternal Order of Police Mandatory reporting and analysis of job-related AIDS exposures and contractions and related circumstances. Nationally coordinated, law enforcement-oriented educational assistance utilizing compiled data on incidents and preven- tion, as well as current medical information. Federal assistance or subsidies to public employers to ensure availability of effective protective equipment. Mandatory notification by the health community to law enforcement personnel who it is determined have been exposed to positive HIV carriers. National policy concerning employers’ response to employee exposure to and/or contraction of AIDS, including: A. mandatory heaith insurance benefits; and, B. mandatory disability benefits. TESTIMONY OF DEWEY R. STOKES PRESIDENT, NATIONAL FRATERNAL ORDER OF POLICE TO PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNO DEFICIENCY VIRUS EPIDEMIC (AIDS) May 10, 1988 Mr. Chairman and Members of the Commission: I am pleased and privileged to have this opportunity to appear before you to speak on behalf of the 190,000 members of the Fraternal Order of Police. The spectre of AIDS has obviously been a matter of great interest in both the public and private employment sectors. With the possible exception of the health care community, I can think of no profession that iS more critically concerned with this issue than members of the law enforcement community. It is my intention today to very briefly identify the principal concerns of the members of the Fraternal Order of Police. Implicit is an understanding of the context in which law enforcement officers deal with the AIDS syndrome. It is not my purpose and I hope there is no need for me to list for you the various ways that law enforcement personnel most often become exposed to the AIDS virus. It should be enough to say that our members are asked to confront, control and often confine members of the public generally, and members of the highest risk groups specifically, under circumstances that are extremely dangerous -- in all senses of the word. In addition to the obvious ways that we come into contact with those who carry the virus, it is our responsibility to work the scenes of crime and accidents, usually on an emergency basis. Whether administering first aid to a bloody roadside accident victim or collecting evidence at a bloody crime scene, there are, or at least we have reason to believe that there are, great dangers in our job from this deadly virus. Our members are, by and large, an extremely dedicated group of professionals who voluntarily assume the responsibility and risk of fighting crime. Until recently, however, we have known of the dangers. We know what will happen if we're care- less. Our collective experience helps us to confront these risks, as well as the consequences. If injured or killed, we have known what would happen to our jobs, our families, our medical bills. We are trained to accept these facts of life. AIDS, and the fear of AIDS, however, is something altogether different. We read the newspapers, listen to the news, hear the horror stories. More than most people, however, we believe that we have reason to be concerned. And it's hard to do our job when, in addition to the other concerns we have learned to deal with, we must deal with the uncertainty sur- rounding the AIDS issue. We want to perform our duties fully and without reservation. However, we cannot be asked to do so without affording us a sufficient degree of assurance and protection against the real and, in many cases, imagined threat of AIDS. In addition, not only do we fear the contraction of this terrible affliction, and the obvious health consequences that follow, we must contemplate the practical and human consequences of exposure to and contraction of AIDS. These are some of the most common questions: Can I really get AIDS? How? Is there anything I can do to prevent it? Is there equipment? Who will pay for it? What happens if I'm exposed? What happens if I get AIDS? Will I lose my job? Will I be taken care of? Will I die? ° Who will pay the bills? ‘ Who will pay the doctors? What do I tell my family? If the worst happens, will my fammily be taken care of? As I'm sure you are aware, much general information is being distributed to the public. Many police departments have AIDS policies -- almost all of which are similar and tell us to be careful, to wear gloves when able, to handle evidence care- fully. Yet, these policies rarely tell us what will happen IF. Law enforcement personnel do not ask for the impossible -- we simply ask for the "truth" about AIDS -- about getting it, preventing it, and dealing with it if we get AIDS. Three general areas of concern exist in our minds: contraction; prevention; and, assistance. l. Contraction. How do you really get AIDS? Can you get AIDS from a crime scene, a bite, a fight? If any, how many law enforcement officers have contracted AIDS in the line of duty? How reliable are the statistics we're reading about who has or hasn't contracted AIDS? 2. Prevention. What are the most effective means of prevention? If there is equipment to minimize the risk of exposure, will governmental employers have the funds available to buy the necessary equipment? Are present policies sufficient? should police and emergency medical personnel be entitled to hazard communication notices? What steps should (and can) be taken to identify carriers of the virus who have had high risk contact with police officers (assaultive arrestees or detainees)? Are female officers who are or may be pregnant at greater risk? Should educational and/or informational efforts be directed at police officers, their spouses and their families to allay growing concerns that the officer may become exposed to the virus, bring it home and infect his/her family? Are the policies being promulgated by police departments throughout the country correct? Are they the product of last year's medical studies? 3. Assistance. What are the legal and factual consequences if a police officer contracts AIDS? Will I be suspended? Will I lose my job? Will I be considered injured? Will I be considered disabled? How long will sick leave last -- then what? Will my health insurance cover everything? Is getting AIDS covered by workmen's compensation laws? What assistance will be available to me and my family after we learn that I have been exposed to the virus? Who will help us deal with the fear, the stress? Who will help us through the testing period? Will counseling be available? And if I contract AIDS, will there be family counseling available to help me keep my family together? In the time available, I have listed just a few of our most pressing concerns. There are others. I noted just this past week that a New York Appellate Court reversed a lower court's Order that a woman who bit a deputy sheriff be tested for AIDS. How do we deal with the fact that often the courts will do nothing to assist us in those situations where a real possibility of AIDS contraction exists? In reviewing these issues, one common denominator exists -- education and information. We are bombarded with news about AIDS; yet, we are confused. Everyone's talking, but little is being said. Through a comprehensive, focused educational program, which is supplemented routinely and focused specifically for law enforcement personnel, many of the issues I have raised are addressed. Through the collection, analysis and distribution of real data, I believe many of the fears pervading law enforce- ment can be quieted. An educational program based on current data will allay fears, improve the prevention of AIDS exposure -3- and contraction, and assist officers and their families to cope with the fear and the fact. Accordingly, we have a number of recommendations that I will briefly list here: (1) Data should be collected through mandatory report- ing requirements of all law enforcement-related AIDS incidents. This would include job-related exposures and contractions of the virus, as well as underlying data concerning the circumstances of each case. While this data need not identify specific officers, the data could identify the most frequently occurring incidents and thereby assist in focusing our attention on the highest risk activities. (2) A specifically focused law enforcement educational program utilizing the data collected on incidents and the most current medical data available concerning the contraction and prevention of the virus. (3) Some form of subsidy or assistance should be offered to public employers to ensure that effective protective equipment is available -- despite the perpetual financial prob- lems public employers operate under. (4) A national policy should be established to stan- dardize the response of public employers to public employees who have been exposed to or have contracted the virus. (5) Specifically, guidelines, recommendations and requirements should be issued with respect to issues relating to health and disability insurance, workmen's compensation, disabil- ity pensions and after-care. Should law enforcement personnel who contract AIDS in the line of duty have to pay for their own tests and treatment? Be subject to deductibles? On behalf of the 190,000 members of the Fraternal Order of Police, I want to thank the Commission for its interest and this opportunity to present our views on this troubling subject. UNIVERSITY OF CALIFORNIA, SAN FRANCISCO BERKELEY * DAVIS * IRVINE » LOS ANGELES * RIVERSIDE * SAN DIEGO * SAN FRANCISCO SANTA BARBARA * SANTA CRUZ SCHOOL OF MEDICINE Please address reply to the undersigned at. THE MEDICAL SERVICE Room 5 H 22 San Francisco General Hospital 1001 Potrero Avenue San Francisco Califorma 94410 415) 821-8317 "Current Status of the Extent of Risk of HIV Infection to the Health Care Provider" Presidential Commission on the Human Immunodeficiency Virus Epidemic Testimony of: Henry F. Chambers, M.D. Assistant Professor of Medicine University of California, San Francisco and San Francisco General Hospital May 11, 1988 Surveillance for Occupational Transmission of HIV Among Health Care Workers at San Francisco General Hospital Summary as of May 1988 Since 1984 at San Francisco General Hospital, 623 health care workers intensively exposed to patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related-complex (ARC) (more than 1600 AIDS/ARC patients) have been enrolled in an ongoing prospective surveillance study to determine the risk of contracting human immunodeficiency virus (HIV) infection from occupational exposure. Exposure history and established risk factors for HIV infection are evaluated yearly by a confidential questionnaire and serum is obtained for HIV serologic testing (ELISA with indirect fluorescent antibody and Western blot confirmation). Four hundred sixty-eight workers who have no_ reported nonoccupational HIV risk factors have been tested prospectively: 206 (44%) are physicians, including 57 surgeons; 140 (30%) are nurses; and 51 (11%) are laboratory technicians. Fifty-one (11%) work solely in AIDS units or research labs and 123 (26%) work in intensive care units, the emergency room, or the operating room. Two hundred and twelve subjects have reported 625 accidental exposures to HIV infected blood (224 needlesticks and 401 mucocutaneous splashes). Of 180 subjects tested at least six months after 215 needlesticks, one acquired HIV infection after a deep needlestick injury. The seroconversion rate is 0.5% (upper 95% confidence limit of 1.4%) per needlestick exposure to HIV infected blood. No infections following splash exposures have been documented and the rate of seroconversion probably is at least 10-fold less. In intensively exposed health care workers, occupational transmission of HIV infection was detected only following needlestick exposure to HIV infected blood. The risk of other exposures is low. Measures to protect health care workers from occupational HIV infection should emphasize prevention of needlesticks. -3 OCCUPATIONAL RISK TO HEALTH CARE WORKERS OF CONTRACTING INFECTION BY HUMAN IMMUNODEFICIENCY VIRUS Henry F. Chambers and J. Louise Gerberding Health care workers clearly are at risk of contracting Human Immunodeficiency Virus (HIV) on the job. Who is at risk and the magnitude of risk still are being defined, but available data do permit some estimates. Centers for Disease Control recently reviewed the cases of suspected occupational transmission of HIV to health care workers (1). Information about risk of HIV infection to health care workers comes mainly from three sources. Prospective studies documenting seroconversion among health care workers who have well-defined exposure to HIV provide the best information about risk. Because type and number of exposures are known, a rate of seroconversion can be calculated for a given type of exposure. Another important source of information is surveillance data from cases of acquired immunodeficiency syndrome (AIDS) reported to CDC. Information concerning employment and risk factors for AIDS (e.g., homosexual or bisexual male, intravenous drug abuse, ‘transfusion, etc.) have been collected in most cases. Some assessment of risk to healthcare workers can be made based on these data. The least useful source of information are anecdotal case reports. Some cases have not been fully or appropriately investigated and the details have not been published. Even though an estimate of risk cannot be made based on these reports, exposures and routes of HIV transmission can be identified. To date there have been five well-documented cases of HIV infection transmitted by needlestick in 1188 exposures (1-4)(Table 1). The risk of seroconversion after needlestick is approximately 0.4-0.5% (upper 95% confidence limit of 0.8%). In prospective studies, all cases of HIV infection occurring in health care workers reporting exposure to HIV infected blood or body fluid have been transmitted by needlestick inoculation of contaminated blood. To put the risk of HIV infection from needlestick in perspective, rate of seroconversion following a single needlestick exposure to blood infected with hepatitis B virus (HBV) is 10-15% (5,6), or approximately 10-30 times greater than the risk for HIV. Seroconversion to HBV without seroconversion to HIV in a bronchoscopist following needlestick exposure to blood infected with both has been documented (7). No case of transmission of HIV by the mucocutaneous route has been identified in 2505 exposures reported in these prospective studies. However, in the United States three cases of HIV infection with documented seroconversion have occurred following mucocutaneous contact with HIV infected blood (8). CDC recently reviewed (1) the 22 published reports (4, 8-22) from the United States and abroad of HIV infection in health care workers with no known risk factors. Fifteen have reported needlesticks and seven have reported mucutaneous exposures as the route of infection (Table 2}. Thirteen cases were nurses or persons performing nursing duties; six were laboratory workers, technicians or phlebotomists; one was a physician (not a surgeon); and one was a dentist. HIV transmission has been described in two laboratory workers handling HIV infected cultures (21). HIV cultures are approximately 10,000 times more concentrated than HIV infected blood (10° to 10/ infections virus particles versus 10% virus particles)(23 and Michael McGrath, personal communication). One worker was infected by parenteral inoculation of infected culture material. The route of transmission is not well-defined for the other worker, but probably occurred through non-intact skin, Two cases of seroconversion have been documented in persons providing frequent daily nursing care to AIDS patients (11, 13), one of whom was an infant who had acquired AIDS following blood transfusion. In neither case were appropriate infection control measures, such as blood and body substance precautions, being adhered to. As of March 14, 1988, there have been 55,315 cases of AIDS in the United States reported to the Centers for Disease Control (1). Of the 47,532 cases with occupational information, 2586 cases (5.4%) have occurred in health care workers. Health care workers with AIDS were more likely than others to have no identified risk factor for AIDS. Of the 135 cases of health care workers who have no identified risk factor, complete information is available in 41 cases. Approximately 40% had needlestick or mucocutaneous exposure to blood. Two reported no patient contact. Eight were physicians (4 surgeons) and 16 were nurses or nurse assistants. Four were laboratory workers. There are approximately 6,000,000 health care workers in the United States, If one assumes that 10% of these work in areas where HIV infection is prevalent, then in the United States 57 of 600,000 potentially exposed workers (0.01%) to date have either contracted AIDS or have probably been infected by HIV acquired in the workplace. The occupations at greatest risk are nurses (46% of cases), laboratory workers (16%) and physicians (14%) (Table 3). The cumulative risk of acquiring HIV from multiple needlesticks probably depends on many factors (e.g., amount of blood injected, depth of injection, host factors, stage of HIV infection). The estimated effect of seroprevalence and number of heedlesticks (assuming a 0.5% seroconversion rate per exposure to HIV infected blood) upon risk of seroconversion is shown in Table 4. As the number of Areedlesticks increases, the risk of seroconversion approaches the Seroprevalence rate. As the seroprevalence increases above 1%, the risk of seroconversion from 10 or more ‘needlesticks approaches or exceeds the risk for seroconversion from a known infected source (i.e., 1/200). Needlestick exposure js the main route of transmission of HIV to health care workers. Although transmission of HIV by mucocutaneous route occurs, data from prospective studies suggest the risk is at least 10-fold less than for needlestick expesure. Transmission of HIV by other routes than these two has not been documented, Available data show that nurses are at the greatest risk, followed by laboratory workers, and then physicians. That these are the groups at risk is consistent with HIV transmission via inoculation of infected blood and not by the other routes. Efforts at preventing occupational transmission of HIV should be directed at reducing the number of needlestick injuries. REFERENCES 1. 10. 11. 12. 13. Centers for Disease Control. Update: Acquired immunodeficiency syndrome and human immunodeficiency infection among health-care workers. MMWR 1988 ;37:229-239. Henderson DK, Saah AJ, Fahey BJ, Schmitt JM, Lane HC. Prospective assessment of the risk for occupational/nosocomial infection with human immunodeficiency virus in a large cohort of health care workers [Abstract no. 76]. In: Program and abstracts of the Twenty-Seventh Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1987:109. Gerberding JL, Bryant-LeBlanc CE, Nelson K, et al, Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions. J Infect Dis 1987;156:1-8. Gerberding JL, Henderson DK. Design of rational infection control policies for human immunodeficiency virus infection. J Infect Dis 1987;156:861-4, Grady GF, Lee VA, Prince AM, Gitnick GL, Fawaz KA, Vyas GN, Levitt MD, Senior JR, Galambos JT, Bynum TE, Singleton JW, Clowdus BF, Akdamar K, Aach RD, Winkelman EL, Schiff GM, Hersh T. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial. J Infect Dis 1978;138:625-38. Werner BJ, Grady GF. Accidental hepatitis-B-surface-antigen-positive inoculations. Use of e antigen to estimate infectivity. Ann Intern Med 1982 ;97:367-9. Gerberding JL, Hopewell PC, Kaminsky LS, Sande MA. Transmission of hepatitis B without transmission of AIDS by accidental needlestick [letter]. N Engl J Med 1985;312:56. Centers for Disease Control. Update: human immunodeficiency virus infections in healthcare workers exposed to blood of infected patients. MMWR 1987;36:285-9. Anonymous. Needlestick transmission of HTLV-III from a patient infected in Africa. Lancet 1984:2:1376-7,. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl 2S). Centers for Disease Control. Apparent transmission of human T-lymphotrophic virus IIT/lymphadenopathy-associated virus from a child to a mother providing health care. MMWR 1986;35:76-9. Gioannini P, Sinicco A, Cariti G, Lucchini A, Paggi G, Giachino 0. HIV infection acquired by a nurse. Eur J Epidemiol 1988;4:119-20. Grint P, McEvoy M. Two associated cases of the acquired immune deficiency syndrome (AIDS). PHLS Commun Dis Rep 1985;42:4. 14. 15. 16. 17. 18, 19. 20. 21. 22. 23. Klein RS, Phelan JA, Freeman K, et al. Low occupational risk of human immunodeficiency virus infection among dental professionals. N Engl J Med 1988; 318:86-90. McCray E, The Cooperative Needlestick Surveillance Group. Occupational risk of the acquired immunodeficiency syndrome among health care workers. N Engl J Med 1986;314:1127-32. Neisson-Vernant C, Arfi S$, Mathez D, Leibowitch J, Monplaisir N. Needlestick HIV seroconversion in a nurse [Letter]. Lancet 1986;2:814. Oksenhendler E, Harzic M, Le Roux JM, Rabian C, Clauvel JP. HIV infection with seroconversion after a superficial needlestick injury to the finger _ [Letter]. N Engl J Med 1986;315:582. Ponce de Leon RS, Sanchez-Mejorada G, Zaidi-Jacobson M. AIDS in a blood bank technician in Mexico City [Letter]. Infect Control Hosp Epidemiol 1988;9:101-2. Ramsey KM, Smith EN, Reinarz JA. Prospective evaluation of 44 health care workers exposed to human immunodeficiency virus-1, with one seroconversion [Abstract]. Clin Res 1988;36:1A. Stricof RL, Morse DL. HTLV-III/LAV seroconversion following a deep intramuscular needlestick injury [Letter]. N Engl J Med 1986;314:1115. Weiss SH, Goedert JJ, Gartner S$, et al. Risk of human immunodeficiency virus (HIV-1) infection among laboratory workers. Science 1988 ;239:68-71. Weiss SH, Saxinger WC, Rechtman D, et al. HTLV-III infection among health care workers: association with needle-stick injuries. JAMA 1985;254:2089- 93. Petit A, Tersmette M, Terpstra F, deGoede R, van Lier R, Miedema F. Decreased accessory cell function by human monocytic cells after infection with HIV. J Biol 1988;140:1485-9. HEARING HEALTH CARE WORKER SAFETY MAY 11, 1988 RECOMMENDATIONS Page { ] of [ ] OBSTACLES TO PROGRESS 1. Lack of data adequately defining the probably low-risk of multiple, non-needlestick, exposures to blood (e.g., as a surgeon might routinely encounter during performance of an operation). RECOMMENDATIONS 1. Studies to define the risk of HIV infection for Surgeons and others who regularly are in contact with larger volumes of blood. 2. Efforts to prevent transmission of HIV in the workplace should concentrate on inter- ruption of exposures known to transmit HIV (e.g., needlesticks). Temptation to pre- scribe potentially expensive or impractical measures to prevent HIV transmission by unlikely routes not shown to pose a risk (e.g., aerosol transmission, contact with urine, etc.) should be resisted, as this diverts attention and needed resources away from prevention of exposures known to transmit HIV. 3. Use of HIV serologic testing as an infection control procedure or to screen all patients for the purpose of preventing occupational transmission of HIV should be avoided. Prevention of accidental exposures, not identification of infected persons (with all its attendant problems of confidentiality and potential for discrimi- nation) should be emphasized. Estimated Cost: $200,000-$500,000 Based Upon: Salaries for personnel and per study site laboratory tests for surveillance of surgeons for two years at a 400-bed medical center with 1-10% seropreva- lence of HIV in patients (e.g., San Francisco General Hospital). i s. ~ Henry F. Chambers, M.D. ee \ Yo faa Name Signature May 11, 1988 Date TESTIMONY OF WILLIAM J. MARTONE, M.D. ACTING DIRECTOR, HOSPITAL INFECTIONS PROGRAM, CENTER FOR INFECTIOUS DISEASES CENTERS FOR DISEASE CONTROL U.S. PUBLIC HEALTH SERVICE ATLANTA, GEORGIA BEFORE THE PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC MAY 11, 1988 Mr. Chairman and Members of the Committee: Good morning. I am Dr. William Martone, Acting Director, Hospital Infections Program, Center for Infectious Diseases. I have been with the Hospital Infections Program for over 6 years and formerly held the position of Chief, Epidemiology Branch, Hospital Infections Program. I appreciate this opportunity to appear before you today to discuss the risk of occupational acquisition of human immunodeficiency virus (HIV) infection by health-care workers. Epidemiologic information on this subject comes from several sources: the CDC nationwide AIDS surveillance system, case reports published in the medical literature, and prospective risk-assessment studies which have been conducted by CDC and others. The CDC nationwide AIDS surveillance system has provided information on persons fulfilling the CDC AIDS case definition since 1978. AIDS cases are classified as health-care workers if they have reported employment in a health care or clinical laboratory setting. As of March 14, 1988, 2,586 AIDS cases were classified as health~care workers. Health-care workers comprised 5.4% of the 47,532 adults with AIDS reported to CDC for whom occupation was reported. For comparison, about 5.7% of the U.S. labor force is employed in health services. Like AIDS cases in non-health-care workers, health-care workers with AIDS had a median age of 35 years, were predominately male, and the majority were white. Ninety-five percent of the health-care workers with AIDS have one or "Isolation Techniques for Use in Hospitals" was first published in 1970 and revised in 1975. The techniques and procedures outlined in this manual became widely accepted by hospitals nationwide and served as a resource for developing of their own infection control policies. Subsequent updates and revisions of this material were published in 1981-1985 as the "CDC Guidelines for Prevention and Control of Nosocomial Infections." Guidelines and recommendations were developed in consultation with recognized authorities on nosocomial pathogens and their modes of transmission in the health-care setting. CDC's first recommendations dealing specifically with the prevention of transmission of HIV in the clinical setting were published in November 1982 as a Morbidity and Mortality Weekly Report article entitled "Acquired Immune Deficiency Syndrome (AIDS): Precautions for Clinical and Laboratory Staffs." As new information about HIV became available, CDC periodically updated and expanded its recommendations to prevent transmission in the health-care setting. In August 1987, CDC published a comprehensive set of recommendations to prevent the transmission of HIV and other bloodborne infections in the health- care settings. These recommendations , entitled "Recommendations for Prevention of HIV Transmission in Health-Care Settings" were developed in consultation with recognized authorities on HIV and HIV transmission and were reviewed by over 50 representatives of nursing, medical and dental organizations; other allied health professional organizations; State and local health departments; and labor. CDC will continue to periodically review these and other recommendations as new information becomes available. You will hear more of the process by which CDC develops recommendations and guidelines from my colleague, Dr. Robert Mullan, of the National Institute for Occupational Safety and Health. I will be happy to answer any questions that you or other members of the Commission may have. more well-recognized non-occupational risk factors. The 5% of health-care workers with AIDS who are not categorized into one of the previously recognized transmission categories are categorized as having "undetermined risk." This compares with 3% of non-health-care workers with AIDS having "undetermined risk." The reasons for this difference are not known, but may include the occupational risk of HIV infection. Of the 135 health-care workers in the undetermined risk group, 74 (55%) are still under investigation to determine if other risk factors are present, 20 (15%) have either died or refused to be interviewed, and 41 (30%), could not be reclassified into a high risk group after follow-up investigation. These 41 included 8 physicians; 16 nurses, nurse's aides, orderlies; 4 clinical laboratory technicians; and 11 others. Two health-care workers had no contact with patients or clinical specimens. Of the 41, 17 (41%) reported needlestick or mucous membrane exposures to the blood or body fluids of patients during the 10 years before their diagnosis of AIDS. However, none of the patients was known to be infected with HIV at the time of exposure, and none of the health-care workers were evaluated at the time of exposure to document seroconversion to HIV antibody. Thus, case surveillance data suggest, but do not prove, occupational exposures as the source of HIV infection for at least some of Seal _these AIDS cases. Published reports provide information on 22 health-care workers whose HIV infections have definitely or potentially been ascribed to occupational exposures. In 15 of these health-care workers, occupationally related HIV infection was documented by seroconversions. Thirteen health-care workers had exposures to blood and one health-care worker had exposure to bloody pleural fluid of HIV infected patients. One additional case followed exposure to concentrated virus in a laboratory setting. The remaining 7 health-care workers also had occupational exposures to HIV; they were seropositive when tested but the dates of their seroconversions are not known because no baseline blood specimens were tested. Fifteen of the 22 (68%) cases developed infection following accidental injection of infectious material through’ the ON skin. The remainder had exposures through breaks in their skin or through | mucous membranes. iN ‘\ The surveillance data and case reports discussed above are usefil in ‘, ‘. documenting that risk exists, in monitoring trends over time, in obtaining descriptive information about individual cases, and in identifying possible unusual modes of HIV transmission. However, they do not provide information x on the magnitude of risk of infection. t f ‘ f In August 1983, CDC initiated a prosphetive surveillance system to quantitate the risk of HIV infection to health-care workers following specific occupational exposures. Health-care workers with parenteral (i.e., a | needlestick or cut), mucous membrane, or non-intact skin exposures to the . blood or body fluids of HIV-infected patients are enrolled in the surveillance system at the time of exposure. They receive serologic tests for HIV as soon as possible after the exposure, and are followed for a minimum of \L2 months \ thereafter to look for seroconversion. To date, approximately 1400 health-care workers have been enrolled from over 300 hospitals nationwide. Of these, 1070 workers have had HIV antibody testing at least 3 months after exposure; 870 had needlestick or other parenteral exposures to blood and 114 had mucous membrane or non-intact skin exposure to blood of HIV infected patients. Ninety-six had parenteral, mucous membrane, or non-intact skin exposures to other body fluids of HIV-infected patients. Four health-care workers have tested positive for HIV antibody; all were from the group of 870 workers who had had needlestick exposures to blood. Of these & health-care workers, 3 had documented seroconversions clearly linked to the exposure; baseline specimens obtained soon after their exposures were negative but subsequent specimens were positive. All 3 developed acute febrile illnesses compatible with an acute retrovirus infection. The fourth HCW had only a single blood specimen tested for HIV antibody, 10 months after the exposure. It was positive. This HCW had no known intercurrent illness. The health-care worker's sex partner was also seropositive, These findings made it difficult to know if the infection resulted from occupational or non-occupational exposure. None of these 4 health-care workers has developed AIDS. ~ If we conservatively assume that all 4 infections were the result of occupational exposure, the risk of infection following a needlestick exposure to HIV-infected blood in this study is 4 of 870 or 0.5%. For non-needlestick exposures, such as mucous membrane or skin exposure to blood of HIV infected patients the risk is lower than 0.5%. There have been no reports of transmission among health-care workers being followed in prospective studies which resulted from contact with a body fluid other than blood. Of note is that in the CDC prospective study 37% of the exposures were judged to have been potentially preventable in that they occurred while the HCW was recapping a used needle, improperly disposing of a used needle, or performing some other activity which is not in accordance with the recommendations published by CDC. Although the risk of infection following exposure to HIV-infected blood is low, the risk is not zero. With the increasing number of HIV-infected patients requiring medical care, the potential for occupational exposures will increase. For this reason, our current research effort is focused on 1) determining the risk of infection in health-care workers who haye frequent contact with blood, such as emergency room personnel and surgeons, and 2) identifying ways in which on-the-job exposures to blood can be: prevented. This involves defining in greater detail which types of exposures Yo blood are likely to result in transmission of infection to health-care workers, identifying situations in which these exposures are likely to occur, \ identifying measures which will be effective in preventing the exposur without compromising patient care, and in transmitting this information back \ % to health-care workers in the the form of practical guidelines and recommendations for them to follow in their daily work. For over 18 years, CDC has been active in developing guidelines and recommendations to prevent patient-to-patient, health-care worker-to-patient, and patient-to-health-care worker transmission of nosocomial, or hospital related, pathogens. A comprehensive set of recommendations entitled may @6 '22 12:61 Human Immunodeficiency Virus in the Health-Care Workplace The magnitude of risk for occupational transmission of the Human Immunodeficiency Virus (HIV) has now been measured in a number of longitudinel studieae Prospective evaluation of more than 800 health-care workers sustaining an adverse exposure to a sharp object contaminated with blood or blood-contaminated body fluids have demonstrated that the risk for a health- care worker becoming infected as a ragult of such exposures is approximately 0.4 ~ 0.5% (4 to 5 infections per 1000 injuries), Risks for infection aa a result of other exposures (e.g. mucous membrane splashes, cutaneous exposure to blood) are 60 6mall thet they currently elude precise measurement. Whereas these latter exposures can (and have been clearly documented to) result in HIV infection, the — for such an event ia quite small. More than 600 haaith-care workers who have suatained mucous membrane exposures to blood or blood-contaminated body fluids from HIV-infected patients have been evaluatad in four longitudinal studies. None have developed antibody to HIV. Risk associated with providing care for HIV-infected patients in the absence of an adverse exposure is again too emall to be measured precisely. In three separate prospective studies none of the more than 1200 health-care workers providing care for, but not reporting an adverse exposure fron, HIV-infected patients have acquired infection. Additional evidence suggesting a low relative risk for tranemission of HIV sa a result of providing care for HIV- infected patients come from the elegant studies of household contacta of HIV- infected patients. Exposures in this setting are likely to be even more intimate (and precautions presumably more lax) than for individuals providing patient care. To my knowledge, eight such studies of more than 500 household contacts of 260 AIDS patients are in progress. With the exception of sexual oi MAY 06 ’°838 12:82 Fle partners of infected individuals and children born to infected mothers (known routes for HIV transmission), none of the remaining 540 household contacts have acquired HIV infection. These data provide further evidence that the riak for occupational HIV transmission asaoctated with routine patient care activities 16 quite small, These magnitudes of risk for occupational HIV infection compara favorably with other risks that health-care workers have been taking in the workplace for yeara. For axample, the risk for occupational infection with hepatitis B virus following a percutaneous injury with a needle or sharp object which has been used on a patient known to be infectious for hepatitis B is 27.0 - 43.0%, The risk for clinical hepatitis following euch an injury ranges between 6.0 and 24.0%, The Centers for Disease Control estimates that 12,000 cases of occupationally-acquired hepatitis B will occurred in U.S. health«care workers in 1985. Although no deaths have yet been reported due to occupationally-acquired HIV infection, the Occupational Safety and Health Administration conservatively estimates that between 167 and 202 American health-care workers died of occupationally-acquired hepatitis B infection last year. The reason for citing these data on occupational transmission of hepatitis B is not to euggest that the risk for occupational tranemission of HIV is negligible, only to try to place these relative risks in perspective. Such data strongly support the implementation and continued use of "Universal Pracautions" for all hospitalized patients. Universal Precauttiona were first recommended by the Centers for Disaase Control in Auguet of 1987. These recommendations and guidelines note simply that blood and blood- containing body fluids reprasent risk to health care workers. Universal Precautions for all patients and specimens are, in my opinion, both prudence and appropriate. In a atudy from the University of Washington, either MAY 06 ’E3 lide F, hepatitis B surface antigen or antibody to HIV was datacted in 5,7% of samples gent to the clinical laboratory from patients not known to harbor a blood- borne infection. Thus, the sample that a health-care worker thinka is not a risk for infection cay wall be one that represents risk. Also, it seems likley that additional blood-borne viral infections will ultimately be identified. For a variety of reasons, then, the use of Universal Precautions seams prudent. In 4 own opinion, a major obstacle to the use of these precautions, and therefore to the protection of health-care workers, is that both training and tradition are standing in our way. In general, health-care workers have baen reasonably cavalier about cutaneous exposure to blood or blood~containing body fluids in the past. In a study from a hospital in California that has a large HIV-infacted patient population, compliance with recommended infection control precautione was marginal, at beat, despite intensive educational efforts by the hospital infection control staff. Prior to the implementation of \ Universal Precautions, 442 health-care workers participating fin our \ longitudinal study for the riek of HIV transmission reported more than 10,000 cutaneous exposures to blood or other body fluids in a one year period. For many years, such exposures have been “business as usual" for the health-care professional. Health-care workers need to learn a new approach to handling blood and bloodvcontelatng body fluids in the health-care setting. Percutaneous injuries also occur far too commonly, Again, in our own hospital, despite intensive educational programa designed to minimize such exposures, an average of 300 percutaneous injuries are reported to our Occupational Medical Service each year. Training of health-care workera (physiciane, nurses, and other allied health-care profeasionals) should include an emphasia on the risk for MAY O65 789 12:03 F.4 transmission of blood-borne infections in the health-care setting. Such an emphasis hae not been present in training programs in tha past. Prevention should also be emphasized. Hepacitis B is now a preventable illness; a safe and effective vaccine is now marketed, Health-care workers who have exposure to blood or blood-containing body fluids should be strongly encouraged to be fomunized with this vaccine. Health care workarg should be educated about techniques to be used to prevent percutaneous injuries and about appropriate disposal of needles and other contaminated sharp objects. In my view, protection of health-care workers will be best accomplished through a program that includes all of the following: 1) intensive education of health-care workers regarding the pathogenesis, routes of transmiseion and riske for transmission of all blood-borne infectious diseases; 2) inteneive education regarding preventive etrategies for health care workers, including use of Univereal Precautions for all patients (not just those suspected of HIV or hepatitis B infection), the use of appropriate barriers in the healthcare eetting, the advisability of hepatitis B immunization, and techniques to be used to prevent needle puncture injuries and injuries from other sharp objects; 3) an active hepatitis B immunization program; 4) an active program that insures the provision and immediate availability of appropriate barriars for health care workers performing procedures associated with the likelihood of cutaneous expogure, apray or spatter; and 5) a systematic program for follow-up for health-care workers sustaining adverse exposure to blood or body fluids from all patients in the health-care setting, Teatimony of David K. Henderson, M.D. to the Presidential Commission on the Human Immunodeficiency Viruas Epidemtc Table 1. Prospective studies of occupational transmission of HIV to health care workers exposed to HIV-infected blood or body fluids. Study (ref.) No. of infections/ No. of exposures (%, 95% confidence limit) Needlestick exposures Mucocutaneous exposures coc (1) Gerberding Henderson (2) Totals 4/870 (0.5%, 1.1%) 1/215 (0.5%, 1.4%) 0/103 5/1188 (0.4%, 0.8%) 0/104 0/401 0/2000 0/2505 (<0.03%, <0.1%) Table 2. Route of transmission of HIV for 22 published cases of HIV infection occupationally acquired by health care workers. Needlestick Mucocutaneous United States ll ( 7)P 5 ({ 4) Other countries 4 ( 3) 2 (1) Total 1S (10) 7 ( 5) a Data abstracted from reference 1. Number in parenthesis denotes documented seroconversion. Table 3. Occupations of HIV-infected health care workers without nonoccupational risk factors for HIV infection. HIV Occupation seroconversion AIDS case Total [%] (n=22) (n=41) (n=63) Nurse® 13 16 29 [46] Lab worker 6 4 10 [16] MD, not surgeon l 4 5 [ 8] Surgeon 0) 4 4 [ 6} Housekeeping ©) 7 7 [11] Dentist 1 ] 2 [ 3] Other/not specified 1 3 4 [ 6] No patient contact 0 2 2 [ 3] “ Includes persons performing nursing duties. Includes phlebotomists and technicians. Table 4. Effect of seroprevalence of HIV on risk of seroconversion after multiple needlesticks. Risk of seroconversion at each seroprevalence (3%) Number of needlesticks 0.1 1 10 50 100 Oe 1 1/200,000 1/20,000 1/2000 1/400 1/200 ~. 10 1/20,450 1/2045 1/204 1/41 1/20 100 1/2540 1/254 1/25 1/5 1/2.5 1000 1/1006 1/101 1/10 1/2 ] Assumes that rate of seroconversion is constant at 0.5% per single needlestick exposure to HIV-infected blood. SUMMARY STATEMENT Thomas L. Kuhlis, M.D. Patients with the Acquired Immunodeficiency Syndrome (AIDS) not only have human immunodeficiency virus (HIV) in many of their body secretions, but also excrete in high concentrations many other agents including cytomegalovirus (CMV), hepatitis B virus (HBV), herpes simplex virus type 2 (HSV-2), Epstein-Barr virus (EBV), and Cryptosporidium. Since March of 1984, through the use of detailed questionnaires and annual serologic testing, we have prospectively studied female healthcare workers (HCWs) at UCLA Medical Center to evaluate the risks of acquiring a HIV infection as well as other AIDS-related nosocomial infections. I have submitted to the Commission our published manuscript concerning HCW risks outlining data of 246 HCWs prospectively studied for one year. Currently, we have analyzed data for 430 HCWs with 1447 HCW-years of variable exposure to AIDS patients and their biological specimens. We have found no differences in seroprevalence between HCWs highly exposed (HE) to AIDS patients and their specimens and HCWs with no or low exposure (LE) to these individuals with respect to HIV (0% vs 0%), CMV (47% vs 49%), HBV (9% vs 12%), HSV-2 (20% vs 23%) and EBV (94% vs 95%). More importantly, seroconversion rates of HCWs studied for 1-3 years with HE and LE to AIDS patients have not been different. To date, no HCWs at UCLA including HCWs with needilestick injuries and mucous membrane exposures to HIV seropositive biological specimens have been identified. Recently we have presented data to the 27th Interscience Conference on Antimicrobial Agents and Chemotherapy showing that our HCWs also do not have an increased risk of acquiring a nosocomial cryptosporidial infection when caring for AIDS patients. In conclusion, we have demonstrated that the occupational risk of acquiring a HIV infection when caring for an AIDS patient or working with their biological specimens is low. When current or past CDC recommended infection control guidelines are practiced, there is not an increased risk of acquiring an AIDS- related infection caused by agents such as CMV, HBV, HSV-2, EBV and Cryptosporidium. Occupational Risk of HIV, HBV and HSV-2 Infections in Health Care Personnel Caring for AIDS Patients Tuomas L. Kunis, MD, SusAN VIKER, RN, Nancy B. Parris, RN, MPH, ALICE GARAKIAN, BS, JoHN SULLIVAN-BoLyai, MD, MPH, AND James D. CHerry, MD, MSc Abstract; We have prospectively followed for 9-12 months. 246 female health care workers (HCWs): 102 with high exposure (HE), 43 with low exposure (LE), and 10! with no exposure (NE) to AIDS (acquired immunodeficiency syndrome) patients. No HCWs have climcal, serologic, or immunologic evidence of HIV (human im- munodeficiency virus) infection. No HCWs in the HE group seroconverted to cytomegalovirus (CMV). One HCW in the HE group seroconverted to Hepatitis B virus (HBV), another HCW in the HE group seroconverted to herpes simplex virus type 2 (HSV-2) although all three groups were similar with respect to HBV and HSV-2 seropositivity. If hospital infection control practices are employed when HC Ws care for AIDS patients or work with their biological specimens, the nsk of occupationally acquinng a HIV, CMV, HBV or HSV-2 infection appears to be low. (Am J Public Health 1987; 77°1306-1309.) Introduction Health care workers (HC Ws) are now being exposed to patients with various manifestations of Human Im- munodeficiency Virus (HIV) infection and come in contact with many biological specimens in which HIV has been isolated. Because of the epidemiologic similanties of HIV and Hepatitis B virus infections, it is reasonable to assume that certain HCWs may seroconvert to HIV and possibly develop AIDS (acquired immunodeficiency syndrome}. As the number of exposures of HCWs to AIDS patients in- creases, the msk to the workers may also increase. To date, little attention has been paid to the possible acquisition of other nosocomial infections tn personnel who work with AIDS patients. This is important since AIDS patients often have opportunistic infections and actively excrete in high concentrations many agents including cytomegalovirus (CMV), Hepautis B virus (HBV), and herpes simplex virus type 2 (HSV-2). We report 9-12 month prospective data conceming the occupational nsk of HIV, CMV, HBV, and HSV-2 infections in female health care personnel at the University of Calformiaa—Los Angeles (UCLA) Medical Center. Female health care providers were evaluated to minimize the number of subjects being in high-risk AIDS groups. Methods Design Following institutional review board (IRB) approval and informed consent. female physicians, nurses, nursing aids, and laboratory technicians who have primary contact with AIDS patients or their biological specimens on a continual and routine basis at UCLA Medical Center were entered into the study. Also, female HCWs with similar job descriptions who have few or no contacts with AIDS patients or AIDS specimens were enrolled. There were no otner criteria for admission or exclusion from the study. A detailed self-administered questionnaire elicited infor- mation concerning demographics, sexual history, job de- From the Departments of Pediatncs and Infection Control, Center for the Health Sciences. UCLA School of Mediciné. (Dr Sullivan-Bolvay has since transferred to the Department of Pediatnes at the University of Illinois College of Medicine, Chicago ) Address repnnt requests to Dr. James D Cherry, Department of Pedhatncs. University of California at Los Angeles, School of Medicine, Los Angeles. CA 80024 This paper, submitted to the Journal December 8, 1986, was revised and accepted for publication Apni 7. 1987, © 1987 Amencan Journal of Public Health 0090-0036/878! 50 1306 scription, medical history relevant to immune system func- tion, and if they had received HBV vaccine. HCWs were also asked to estimate the intensity and frequency of exposure to numerous biological specimens of AIDS patients. The total number of potentially infective specimens that were handled by each study participant was determined. A limited physical examination identifying the presence or absence of cervical and axillary lymphadenopathy was completed. Blood was obtained by venipuncture for labora- tory testing. The questionnaire and blood samples were immediately coded for strict confidentiality. The investigators in the laboratory and the data analysts did not have access to the code. The investigator who obtained the questionnaires, blood samples, and who formed the code did not have access to the laboratory results of individual participants. Subjects were notified by mail of their serologic and immunologic results, and counseling was offered to all individuals. Referral services were formed if further counseling was required. Nine to twelve months after enrollment, the HCWs completed an updated questionnaire and had follow-up blood testing. Dunng the study period, UCLA Medical Center followed current Centers for Disease Control (CDC) recom- mended hospital infection control procedures for AIDS patients.! Laboratory Methods HIV immune status was determined by an enzyme immunoassay (Abbott Laboratories, N. Chicago, Illinois). Seropositivity by this technique was defined as one of two reactive interpretations on separate runs following a reactive result on the onginal determination. Reactive or nonreactive samples that were near the cutoff value were confirmed by western blot analysis. CMV serologies were determined by an indirect hem- agglutination method (Cetus Corporation, Emeryville, Cali- fornia). The presence of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (HBcAb) and surface antigen (HBsAb) were determined by an enzyme immunoassay (Abbott Laboratories, N. Chicago). HCWs were considered HBV seropositive when HBsAb was dem- onstrated in their sera. HSV-2 antibodies were determined by a microneutrali- zation technique as previously described by Rawls, et al* and modified by Bernstein, ef al,? except Vero cells were used instead of FS-7 cells An HSV-2/HSV-1 index was calculated AJPH October 1987, Vol. 77, No. 10 TABLE 1—Job Deseriptions of 246 Health Care Workers with High, Low, or No Exposure to AIDS Patients’ Biolagical Specimens and Who Were Followed Prospectively 9-12 Months High Exposure Low Exposure No Exposure Job Descriptions N = 102 N= 43 N= 101 Nurses 59 25 92 Clinical Lab Technicians 11 5 _— Respiratory Therapists 10 7 _ Research Lab Technicians 10 2 2 Phlebotomists 9 _ _— Chnical MDs ~ 1 7 Research MD/PhDs 2 1 _ Pathologists 1 2 — as described by Rawls, et al: Antibody titer to HSV-2 (log 10) — Antibody titer to HSV-1 (log 10) x 100. Sera exhibiting an index of greater than 85 were considered positive for HSV-2 antibody.* T-cell subset analyses were conducted using whole blood preparations labeled with fluorescent monoclonal an- tibodies Leu 3 and Leu 2 (Becton Dickinson, Mountain View, California), and counted by a flow cytometric method, as described by Hoffman and Hansen.‘ Serum glutamic-oxaloacetic transaminase (SGOT) was measured by standard automated methodology. Results Two hundred and ninety-two HCWs were evaluated in the intake portion of the study between March and November 1984. All personnel were HIV seronegative. Prospective follow-up data were obtained on 246 (84 per cent) of HCWs between January and August 1985. HCWs without follow-up were either no longer employed at the Medical Center or did not wish to participate further in the study. None of these individuals seroconverted to HIV or had symptoms consist- ent with HIV-associated illness to our knowledge. One hundred and two of 246 prospectively followed HCWs reported =50 AIDS specimen contacts (range 53-1510, mean + §.E. = 354 + 34) in the previous three years and were designated as the high exposure group. One hundred and one workers reported no exposure to AIDS specimens or patients in the previous three years and were designated as the no exposure group. The remaining 43 HCWs reported 1-49 AIDS specimen contacts (range 5~49, mean + S.E.: 20 + 2) and were designated as the low exposure group. HCWs reported exposures to a variety of body fluids and secretions from AIDS patients, including blood and blood products, urine, respiratory secretions, upper gastrointestinal secretions, pleural fluid, cerebrospinal fluid, and semen. Ten HCWs with needlestick and 15 HCWs with mucous membrane e~posures were identified in the AIDS exposure groups. The job descriptions of the HCWs are described in Table 1. There were no differences of importance between the high, low, and no exposure groups with respect to age, racial distribution, marital status, or|sexual histones (Table 2). No employees reported being an intravenous drug abuser or of Haitian descent. Three HCWs reported having a sexual partner who was an IV drug abuser, and two HCWs reported having sexual contact with a known bisexual. Five HCWs had received a blood transfusion since 1978. AJPH October 1987, Vol. 77, No 10 OCCUPATIONAL RISK OF AIDS TO HEALTH PERSONNEL TABLE 2—Demographic Data of 246 Health Care Workers with High, Low, or No Exposure to AIDS Patients’ Biological Specimens and Who Were Followed Prospectively 9-12 Months High Exposure Low Exposure No Exposure (162 subj.) (43 suby ) (101 subj ) Age + SO 33:8 37 = 10 3227 Race % White 72 60 71 % Black to . 21 1 % Oniental 19 19 18 Marital Status % Single/never marmmed 43 49 50 % Married 41 30 34 % Divorced 15 19 15 % Widowed 1 2 1 Desenption ct sexual partner in last 3 years % Male only 88 72 a9 % Male & Female 3 5 1 % Femaie only 2 7 1 % None 6 12 5 % Refused to answer 1 5 4 Lymphadenopathy ; No one on entrance to the study or at follow-up had significant lymphadenopathy. Two personnel reported hav- ing enlarged lymph nodes for a prolonget-period of time in the past three years, however both had been diagnosed as having a malignancy. Serologic Analysis No HCWs developed HIV antibodies dunng the fol- low-up period (Table 3). Even though all subjects were seronegative by enzyme immunoassay, |1 serum samples near the cutoff value of the assay were confirmed negative by western blot analysis. No HCWs im the high exposure group seroconverted to CMV during the 9-12 month study penod (Table 3). A nurse with high exposure to AIDS specimens seroconverted to HBV: however, she reported no accidental needlestick or membrane exposures from an AIDS specimen. Six of 246 (2 per cent) of HCWs reported receiving hepatitis B vaccine. When these HCWs are excluded from the anal- ysis, no differences in HBV seropositivity between groups were observed. Also, no differences were noted between groups with respect to abnormal SGOTs at follow-up. A nurse seroconverted to HSV-2 during the study period. This HCW did not answer questions pertaining to her sexual history, nor is it known whether she developed symptoms pertaining to HSV-2 infection. There was no demonstrated differences in exposure groups with respect to HSV-2 seropositivity. Immunologic Analysis \ No differences -were observed in the number of HC Ws with absolute T-helper counts <450 cells/mm? at follow-up (Table 3). Four health care workers in the no exposure group had T subset ratios less than 0.85. Two individuals had low T subset ratios during intake and follow-up, while a nurse who seroconverted to CMV had a ratio <0.85 at the follow-up blood draw. No ratio was less than 0.50 dunng either the study intake or followup period. Discussion Our data strengthen previous evaluations by confirming the low risk of occupationally acquired HIV infection.*° To date, only four HCWs with occupationally acquired HIV infection where HIV seroconversion was documented have 1307 KUHLS, ET AL. | . TABLE 3—Laboratory Data of 246 Health Care Workers with High, Low, or No Exposure to AIDS Patients (Specimens examined at Enrollment and 9-12 Months Later) | High Exposure Low Exposure No Exposure Group Group Group HIV (# seropositive) of102 0°43 0/101 (# seroconwsusceptible) 002 0'43 0/101 CMV (# seropositive) 48/102 29 43 54/101 (# serocanvsusceptible) 0'54 1.15 2/49 HBV (# seropositive)* 8/101 § 40 7/99 (# saroconv/susceptible)"” . 194 035 0/92 HSV-2 (# seropositive) 17/102 9 43 20/101 (# seroconv/susceptibie)""* 1/36 015 0/34 Abnormal SGOT"*** (#) 1 1 2 Abnormal Absolute T-helper count, CD, <450/mm? (#) 2 2 2 Abnormal T subset ratio CD./CD, <0 85 (#) 0 0 4 "6 HCWs reported recering Hepatdis B virus vaccine and wera HBSAb seropositive (HE-1, LE-3, NE-2 HCWs respectively) These HCWs were excluded from the analysis. **No HCWs became HBsAg positive at follow-up The HCW who seroconverted to HBV was HBcAb and HBsAb seropositive at follow-up *""The number of susceptible HCWs is determined by HSV-1 and HSV-2 seronegative indniduals at study intake The number of HSV-1 seropositive HCWs who seroconvert to HSV-2 cannot be determined by the microneutralizaton technique used. "40 1U been described.'*" In each instance, seroconversion was documented following a needlestick injury. Proper infection control procedures for AIDS patients must take into account the fact that AIDS patrents often actively excrete in high concentration many agents other than HIV which can cause symptomatic or asymptomatic infec- tions in HCWs. Nearly all AIDS patients have CMV anti; bodies'* !° and most actively excrete CMV in body fluids.15 Despite this fact, we found no CMV seroconversion in HCWs who were highly exposed to AIDS patients. Approximately 6 per cent of homosexual men in the United States have serum hepatitis B surface antigen and higher prevalence rates have been observed in intravenous drug abusers.'©'® Since these individuals represent two mayor high-risk groups for AIDS, one may expect to find hepatitis B seroconversion in HCWs working with AIDS patients. We observed only one nurse with frequent contact with AIDS patients but no needlestick or mucous membrane exposures who asymptomatically seroconverted during the study period. No differences were observed between the high and no exposure groups with respect to HBV seropositivity and no HCWs with needlestick injuries seroconverted during the study period. HSV infections are common in AIDS patients and can become chronic in nature.'>-!9 Oral, anal, and gemtal HSV-2 infections are frequently observed in AIDS patients. Only one 22-year old nurse seroconverted to HSV-2 dunng the study period. This HCW refused to answer questions con- cerning her sexual history and it is unknown whether she had any manifestations of HSV-2 infection. All exposure groups though had a similar prevalence of HSV-2 seropositivity. Although the number of HCWs we have studied is small, with recommended hospital infection control procedures in effect, the nsks of HCWs acquinng HIV or other AIDS-related infections such as CMV, HBV, and HSV-2 appears low. Because transmission of HIV may be related to the cumulative effects of many exposures to patients with AIDS, our group of health care workers will need to be continually monitored over several years. Also, other agents which commonly cause infections in AIDS patients should be investigated. 1308 ACKNOWLEDGMENTS We thank the female HCWs at UCLA Medica] Center for their continued support, Esleen Garratty for her technical help, and Leshe Sprng for her administrative assistance This research was presented at the 2nd International Conference on Acquired Immunodeficiency Syndrome (AIDS), June 23, 1986, Pans, France Funded by the Universitywide Task Force on AIDS, University of Cahforma REFERENCES 1 Centers for Disease Control Summary Recommendations for preventing transmission of infection with HTLV-ILV/LAV in the workplace MMWR 1985; 34 618-695 Rawis WE, [wamoto K, Adam E, Melnick JL Measurement of antibodies to herpesvirus tvpes | and 21n human sera. J Immunol 1970, 104.599-606. 3. Bernstein DJ, Garratty E. Lovett MA, Bryson YJ Companson of western blot analysis to microneutralizatidn for the detection of type-specific herpes simplex virus antibodies J Med Virol 1985, 15 223-230. 4 Hoffman RA, Hansen WP Immunofluorescent analysis of blood cells by flow cytometry. Int J Immunopharmacol 1981, 3 249-254, 5. Weiss SH, Saxinger WC, Rechtman D, Gneco MH, et af HTLV-II infection among health care workers—-association with needle-stick inju- nes JAMA 1985; 254 2089-2093 6 Hirsch MS, Wormser GP, Schooley RT, Ho DD, et al- Risk of nosocomial infection with human T-cell lymphotropic virus II (HTLV-II) N Eng} J Med 1985, 312.1-4. 7. Henderson DK, Saah AJ, Zak BJ, Kaslow RA, et al Risk of nosocomial infection with human T-cell lymphotropic virus type L]Mymphadeno- pathy-associated virus in a large cohort of intensively exposed health care workers Ann Inter Med 1986, 104 644-647. 8. McCray E, and the Cooperaturve Needlestick Surveillance Group Occu- pauonal nsk of the acquired immunodeficiency syndrome among health care workers N Engl J Med 1986, 314 1127-1132. 9 Gerberding JL, Bryant CE, Moss A. Levy JA, Carlson J, Sande ME Risk of acquired immune deficiency syndrome (AIDS) virus transmission to health care workers (HCW) Results of a prospective cohort study Program of the 2nd International Conference on AIDS, Pans, France, 1986: 124. w ‘10. Anonymous Needlestick transmission of HTLV-II from a patient infect- ed in Africa. Lancet 1984, 1 1376-1377 Il, Stncof RL, Morse DL. HTLV-IIVLAV seroconversion following a deep intramuscular needlestick injury N Engl J Med £986, 314 1115 12. Oksenhendler E, Harzic M, LeRoux JM, Rabian C, Clauvel JP- HIV infection with seroconversion after a superficial needlestick injury to the finger. N Engl J Med 1986. 315.582. 13. Nessson-Vemant C, Afn S, Mathez D, eral: Needlestick HIV seroconver: sion in a nurse Lancet 1986, 2.814. 14 Detels R, Visscher BR, Fahey JL, Schwartz K, et al: The relationship of cytomegalovirus and Epstein-Barr virus antibodies to T-cell subsets in homosexually active men JAMA 1984, 25) 1719-1722. AJPH October 1987, Vol. 77, No. 10 OCCUPATIONAL RISK OF AIDS TO HEALTH PERSONNEL 1§. Quinnan GV, Masur H, Rook AH, Armstrong G. ef al Herpes virus 17 Dietzman DE, Harsch JP. Ray CG, Alexander ER, Holmes KK. infections in the acquired immune deficiency syndrome JAMA 1984; Hepatitis B surface antigen (HBsAg) and antibody to HBsAg—prevalence 252 72-77 tn homosexual and heterosexual men JAMA 1977, 238:2625-2626 16 Schreeder MT, Thompson SE, Hadier SC, Berquist KR. et al: Hepatitis 18 Seeff LB Hepatitis m the drug abuser Med Clin North Am 1975, 79 843-848. B in homosexual men Prevalence of infection and factors related to 19. Centers for Disease Control Update. Acquired immunodeficiency syn- transmission. J Infect Dis 1982, 146 7-15. drome—United States. MMWR 1986, 35.17-21. Financing Health Services in Developing Countries: A Message from the Pan American Health Organization’s Director (an editorial) The countnes of Latin Amenca and the Caribbean are being forced to respond to the current economic cnsis with a series of externa! and internal adjustments, the effect of which ts to transfer substantial financial disorder through restnction of public expenditures and domestic investment have reduced resources destined for social sectors such as health, while reducing employment opportunities and family income at the same time. As a result, the poor and those in need continue to increase in number, while current and future ability to deliver public health services 1s weakened more and more. It 1s clear that continuation of this situation will intensify deficiencies of coverage in the years to come, and compromise the goal of health for all irredeemably. This situation, in addition to impinging on the health conditions of the population, has a negative influence on the level of general well-being and, above all, on the dedication and productivity of workers. In other words, global economic productivity 1s endangered, and therefore the outlook for economic recovery. From this it follows inevitably that we must focus attention on an economic analysis of health. Three actions which complement each other stand out aS.necessary to study the situation. The first is to inject health into the development process in such a way that it acquires political visibility and clearly shows its essential relationship to other aspects of progress: The second 1s to seek new or modified sources of manpower and methods of financing services. These actions should be compatible with national prionties and policies, with the responsibility of government to communities and the responsibilities of families for their own health Finally, it 1s necessary to redefine the destination and the utilization of our resources so as to meet real needs of people; we must address anew the pmnciples of health for all and the strategy of primary care, the expression of which requires the decentralization of resources that allows local systems of health to be strengthened. —Dr. Carlyle Guerra de Macedo, Director, PAHO, Bol of Sanit Panam 1987;102(5).1. (Translated from Spanish language by Dr. Alfred Yankauer, Editor, Amenican Journal of Public Health) AJPH October 1987, Vol 77, No. 10 1309 NATIONAL ASSOCIATION OF PHILIPPINE NURSES 633 Post Street, Suite 333 San Francisco, Califomia 94109 Testimony of Tel. (445) 673-6023 NORMA R. WATSON, R.N. Before the PRESIDENTIAL AIDS COMMISSION MAY 11, 1988 My name is Norma R. Watson. I have been a registered nurse since 1974 and was employed at San Francisco General Hospital since 1977. While I was the charge nurse caring for AIDS patients, I was denied the opportunity to know the diagnosis of these patients; and, when the diagnosis was known, I was specifically forbidden to wear protective gloves, masks, and gowns, When I attempted to do so, I was threatened with termination of employment by supervisors and attending physicians. The physicians, nursing supervisory personnel, and hospital administrators were presumably motivated by a desire to demonstrate that AIDS virus communicability and the danger of caring for AIDS patients was so low that infection control procedures were not necessary. To employ such measures would have indicated to a fearful public that there existed a real danger in coming in contact with or caring for persons infected with the AIDS virus. In a hospital environment constantly open to media scrutiny, the public's observation that medical personnel were employing barrier techniques in the presence of their arguments claiming that no danger existed appeared dangerously hypocritical. It is difficult to comprehend how medical personnel could rationalize any position so inconsistent with and detrimental to time-honored hospital infection control procedures; but, when viewed in the context that a high percentage of key personnel are self-defined as homosexuals and gravitated to SF General to participate in a disease process that, too, was associated with homosexual populations, it then clairifies to the uninitiated why this influential group of medical staff were willing to place their own philosophies precariously above the accepted standard of care. San Francisco's liberal political and social climate during the 1960's and 1970's attracted homosexuals from all over the nation and the world. The AIDS epidemic resulted in the migration of numerous homosexually biased health care workers, administrators, and physicians to work in what was seen as a medical, social, and personal survival situation. Over time, the hospital's employee population became heavily peopled by homosexuals, many of whom were already infected themselves (Ann Intern Med, 1985; 103:210-214--showing as many as 70% San Francisco homosexuals seropositive and accompanying death certificates) and eager to demonstrate, by example, that they themselves posed no risk to patients. I was forced to participate in this philosophy by being ordered to facilitate an abject abandonment of infection control procedures wherein nurses were ordered to "develop an effective approach, such as a contract with patient which: 1) acknowledges the patient's sexual needs 2) stresses the need to protect patients and staff from unnecessary disturbances 3) arranges for private place and time for sex 4) is noted in Kardex file 5) is in cooperation with medical staff." These sexual practices, executed on a 24-hour per day basis, were particularly disturbing to me since they exposed assumed to be healthy visitors to AIDS, a known, sexually transmissible, fatal disease. I have witnessed incidents where gloves were not only removed from the wards, making them unavailable for use in code blue and bloody situations, but were ceremoniously burned by hospital personnel in an effort to preserve the psychological and emotional sensitivities of the infected. Unfortunately, but seemingly ignored, was the known reality that AIDS patients harbor, secrete, and are capable of transmitting te others numerous infectious agents including Tuberculosis, Cytomegalovirus (CMV) and a multitude of other infectious organisms capable of infecting persons with normal immune systems. It is my contention that while working at San Franciso Genera: HBospital I was unnecessarily and negligently exposed to these organisms through an egregious abandonment of infection control procedures. This exposure resulted in my acquiring Tuberculosis and Cytomegalovirus infections. The Cytomegalovirus infection then causing numerous congenital malformations in my only son including premature calcification of cranial sutures (which later resulted in an extensive neurosurgical procedure), prematurity, malformation and disease of the genitals and related structures, defects of the axial skeleton, bilateral hearing loss, infection of the retina with high risk of blindness, special high risk of retardation, developmental delays, impairment of his future quality of life and earning ability. All the while that this tragedy was unfolding I attempted to use my administrative remedies to prevent this scenario from occuring and being repeated in other health care facilities to other health care workers. The enclosed publication Medical Malpractice, Verdicts, Settlements, and Experts, contains a special report entitled: "The Anatomy of a Modern Medical Tragedy: The case of Watson Vv. SF General Hospital" by Dr. Wm T. O'Connor, M.D. which delineates the chronology of events leading up to the present time. Included but not amplified was the failure of a number of institutions that were charged with the responsibility to protect health care workers. The Service Employees International Union, Public Employees Local # 790, City and County of San Francisco refused to adequately investigate health and safety violations of our closed union shop's contract or prosecute a grievance and failed to adequately represent me in a binding arbitration proceeding. I filed complaints of health and safety violations with California Occupational Safety and Health Administration and The California Department of Labor. Despite overwhelming evidence to the contrary, the California Department of Labor issued a complete clearance of the hospital prior to Cal OSHA's termination of the ongoing investigation. This was done, I believe, in a cover-up emanating from the State Capitol in Sacramento because if health and safety violations were found at a federally funded hospital (San Francisco General Hospital) millions of dollars of Federal funds could have been witheld. The California Nursing Association was also notified by myself regarding these health and safety violations; however, they failed to act upon them because I feel their concerns focused more on the confidentiality of the AIDS patients than the safety of health care workers. The inadequate addressing of these problems led to a demorallization of the nursing staff at SF Gen Hosp resulting in numerous resignations, early retirements and medical leaves of absence that culminated in a 40% reduction of nursing staff. This caused the loss of nearly 100 beds of hospital capacity due to inadequate staffing. As late as January of 1988, resulting from an unannounced State Department of Health investigation, SF Gen Hosp was cited for 28 major discrepancies of health and safety violations including a breakdown of infection control policy directly attributable to staffing shortages, inadequate supervision, and a failure to implement federal and state requirements in their infection control program. The hospital is still out of compliance as of this date largely due to the above mentioned existant problems and the stark reality that you cannot pay nurses enough to work under those conditions. I reiate these occurances because without intervention the Same scenario will be repeated across the nation if the issues of health care worker protection and infection control go unaddressed. In the midst of a critical nursing shortage, as the AIDS problem grows in other cities, health care workers will be threatened by the same set of circumstances I have faced. As long as health care workers are denied their right to know the diagnoses of the patients by this current obcession with confidentiality and their right to wear protective gear continues to be impaired by a delusional misrepresentation that AIDS patients pose no threat to others in close contact with them, they can end up as I have become--an innocent victim of this epidemic. My recommendations to prevent this and other tragedies are as follows: 1. Federal Legislation should not be motivated by a concern for risk group members' confidentiality in deference to health care workers' and the population's safety. 2. Federal Legislation should be forthcoming that guarantees healthcare workers the right to test for the presence of the virus and to immediately know the diagnosis so that they can take the "extraordinary precautions" with AIDS patients advocated by the CDC guidelines. 3. The Department of Interior and the Department of Health and Human Services should immediately coordinate their efforts to find specific geographic locations, such as islands, (similar to a policy inacted by an enlightened Swedish Government with a health care system recognized as being superior to our own, innovated wherein those persons infected by the virus are being placed in a health care resort facility in Stockholm harbor) so that the virus and the associated infectious diseases will be prevented from spreading to the general population. I cannot allow the suffering of myself, my family, and my only child to have served no purpose. Therefore, if no Federal Legislation or action is taken on these issues forthwith, it will be my recommendation to all healthcare workers to reject taking care of any patients who appear to be AIDS risk group members in order to protect themselves, their children, as well as other patients. ~-Norma R. Watson, R.N. bowma Ga ca . a, : te eN a o neo re bo aad 5 ney, 5 . een Ee . Po fo . Se a bay A 7 a a S in: . m es f ie an 2 ae i oe a - oa 4 ~ an * Creare ere Rete =P nett Volume 4, No 4 The Nation's Only Malpractice Jury Verdict ot Reporter April, 1988 ® HIGHLIGHTS PECIAL REPORT: The Anatomy of a modern medical tragedy’ The Case of Watson \ v San Francisco General Hospital p A "Four Nurses cn Staff at Leading Boston Malpractice Law Firm, p. 3 © Ritalin (Drug for Hyperactivity) Subyect of Five Suits Against Pediatricians — Informed Consent Central Issue, p. 4 © Failure to Diagnose Bacterial Endocarditis in Airline Pilot Ends His Career — $750,000 Minnesota Settlement. p 16 © College Cocd’s Undiagnosed Breast Cancer Brings Death — New York Federal Judge Approves $627,000 Judgment, p 17 ® Failure to Diagnose Testicular Cancer — $850,000 Florida Award, p 21 © No Liability for Alleged Failure to Diagnose Massachusetts Infant's Epiglottitis,p 18, But Failure to Diagnose Jaundice in Isnots Infant Results in $35 Million Structured Settlement. p 35 e Failure of Workers’ Compensation Carrier Physician to Diagnose Ulcer Condition Results in Release to Work and Death From Perforated Ulcer — $110,000 Texas Settlement, p 20 © Defective Anesthesia Machine Ventilator Stopped During Gallbladder Surgery — Connecticut Nurse's Aide Suffers Severe Hypovwa — $4 Million Structured Settlement. p 24 Heres a letter we just received from one of the South's leading malpractice lawyers Dear Mr Laska Back last summer, you may recall doing a MEDMAL search on any pending “failure to diagnose cystic fibr is" cases I am pleased to report the conclusion of our case prior to suit The use of your service wa instrumental in a quick resolution of this case As always. thanks for your assistance Sincerely, Don C Keenan * Want to know more about Mr Keenans case, see page 49 ' © Patient With History of Seizures Falls From Emergency Room Stretcher — Twenty-Six Year-Old Florida Man Now Requires Twenty-Four Hour Care — $5 Million Verdict. p. 26 ¢ World Champion Arizona Horseman Dies of Acute Asthma Attack Three Hours After Release From Hospital Emergency Room — $4 Million Verdict, p 25 ¢ Failure to Treat Massive Infection and Prolonged Use of Subclavian Catheter tn Ulcerative Colitis Patient — Death of Twenty- Two Year-Old Texas Woman in Mother's Arms at Home — $385,000 Settlement, p 27 ° Physician Intentionally and Maliciously Sews Estranged Wife's Vagina Shut During Hysterectomy Performed by Co-Defendant — California Jury Hits Physician-Husband With $5 Million Punitive Damages, p 28 * Sealed File? So What! The MEDMAL Database Captured the Case When It Was Filed and We're Not Under Any Court Order — Apparent Settlement Where South Carolina Gynecologist Wrongfully Performed Complete Hysterectomy When Only Authorized to Perform Exploratory Lap, p 28 ¢ Georgia Mental Hospital Attendants Allegedly Break Patient's Neck During Attempt to Subdue Him — Injury Untreated for Forty-Eight Hours and Complications Bring Death — $875.000 Settlement, p 31 e Alabama Veterinarian Alleges That Nurse Inappropriately Gave Injection Prior to Appendectomy Causing Sciatic Injury — No Liability. p 32 ¢ Indiana Court of Appeals Dismisses Case Alleging Emotional Distress Where Hospital Gives Wrong Babies to Mothers, p 33 (Continued on Page 3) House Passes Bill Striking Feres Doctrine in Malpractice Actions — But Reagan Administration Opposes It. The U S House of Representatives has passed a bill to let service personnel sue service doctors, i.e . the United States, for medical malpractice This bill nullifies the Feres doctrine which holds that a serviceperson on active duty can't suc another serviceperson on active duty for negligence because it would tend to undermine military discipline The bill. sponsored by Rep Barney Frank (D Mass.). passed the House 312-61 and contains limitations. For example. it only applies to *‘medical care furnished the members of the armed forces in a fixed medical facility operated by the United States." Moreover, it does not allow recovery for **mental or emotional disability’’ unless the disability is the direct result of a physical injury Further. the bill would deduct trom any malpractice award the amount of benefits paid under existing law Finally. it contains a $300.000 cap on damages Both the military and the Administration oppose the bill and it ts not expected to become law this year Our 21,000th MEDMAL Case. The 21.000th usable MEDMAL case was entered in the database last month Filed with the Wisconsin Medical Mediation panel, the claim alleges that the plaintiff went to see the defendant because she had a ‘*bulg- ing "on the left side of her naval after she ate. According to the claim, the defendant diagnosed a ‘*spigelian hernia” and performed surgery for it but did not find a hernia and the bulging was nothing but her stomach wall protruding According tothe claim the plaintiff 1s willing to settle this controversy for the sum of $25.000 Sherry A. Anderson v. John D. Reisch, M.D... Claim Filed January 16, 1988 John T. Fields 1135 Legion Drive Suite 201 Elm Grove. Wisconsin 53122 for the plaintitf Ritalin (Drug for Hyperactivity) Subject of Five Suits Brought by Same Law Firm in Massachusetts — Lack of Informed Consent Central Issue. Lawrence E Lafferty, chief medical counsel of the law offices of Robert T Karns, Inc . Boston. has become the lightning rod of a new round of litigation against the drug Ritalin — Lafferty has filed five lawsuits. each nanine different pediatricians as defendants The central issue in the suits appears to be lack of informed consent although improper diagnosis 1s alleged too The drug's proper name 1s methylphenidate hydrochloride and it 1s given to youngsters to control hyperactive behavior Parents claim that the drug designed to ‘‘calm down and help their children in school.’ has serious side effects including stunting growth, and causing hallucinations and toxic psychosis Peter C Peterson 1s handi- ing the cases with Lafferty and he told Medical Malpractice Verdicts, Settlements & Experts that he would like to hear from readers having experience with this drug and its use The address 1s Law Offices of Robert T Karns. Inc 9 Newbury Strect. Boston, MA 02116 (617) 247-0800 The firm sent us copies of these complaints Joshua Movnihan vy. Michael B. Robbins, M.D... Essex (MA) Superior Court No 592, Matthew A. Blake v. Bernard Portnoy, M.D., Bristol (MA) Superior Coun No 398, Anthonys Direnzo, Jr. ¥. Joseph R. Asiaf, M.D.. Plymouth (MA) Superior No 447 Bradley E. Marshall y. Dasid 1. Maltz, M.D.. Plymouth (MA) Superior No 446. Christopher Scully ¥. Marion E. Elfiott, M.D.. and Leo R. Muido, M.D... Plymouth (MA) Superior No 488 BACK ISSUES ... BACK ISSUES ... BACK ISSUES ... BACK ISSUES ... BACK ISSUES Yes. back issues of Medical Malpractice Verdicts, Settlements & Experts are available — but in photocopy only We will supply the first nineteen issues (June 1988 — December, 1986) as a set (nearly 6(X) pages) for $304 S50 (That s $15 50 per issuc. plus $10 00 postage and handling ) Individual issues in 1987 are $20 cach Payment must accompany orders which arc filled the same day that payment ts received Send orders to Lewis Laska, 90! Church Street, Nashville, TN 37203 SPECIAL REPORT: HEALTH CARE WORKER RISK FROM EXPOSURE TO AIDS PATIENTS — ANATOMY OF A MODERN MEDICAL TRAGEDY: THE CASE OF WAISON V. SAN FRANCISCO GENERAL HOSPITAL — PLAINTIFF'S EXPERT PROVIDES MEDICO-LEGAL CHRONOLOGY SUPPORTING ALLEGATION FHAT HOSPITAL'S FAILURE TO ALLOW NURSE/MOTHER TO WEAR PROTECTIVE CLOTHING WAS CAUSE OF CON- TRACTING CY TOMEGALOVIRUS WHICH CAUSED SEVERE BIRTH DEFECTS TO THE CHILD SHE WAS CARRYING — BOY'S FATHER IS ALSO A PHYSICIAN. The question 1s the most powerful one in the continuing medical and political debate regarding the AIDS plague To what extent are health care workers themselves at risk in caring for AIDS patients? If there 1s a risk, what 1s tts scope and what measures should be taken to protect the million health care workers who do (or might) care for AIDS patients and contract the deadly virus or some other disease” The importance of the question 1s so great that Medical Malpractice Verdicts, Settlements & Experts departs from its usual pohcy of only reporting closed cases and focuses special attention on an extraordinary suit now pending in California. James Nathanial Watson, a minor v. San Francisco General Hospital, et al., San Francisco Superior Court No 884846 The suit was filed on November 30, 1987, a companion suit, No 886236 was filed in December, 1987 In sts simplest terms, 1 { the suit alleges that the infant's mother. Norma Watson. was a nurse at the defendant hospital where she had been employcd since 1977 She became pregnant with James Nathanial in May. 1986 Suit alleges that the mother contracted both tuber- culosis and cxtomegalovirus from caring for AIDS patients (beginning in 1981) and the latter virus caused her son to be born with severe birth defects Suit alleges the mother/plaintiff was forbidden to take measures to protect herself and her ° unborn child from these infectious organisms given off by AIDS patients, in particular, she was prevented from wearing gloves, gowns and/or masks while caring for them The Watson case has become a cause celebré in the medical community due in part to the fact that the boy's father is/was a practicing reconstructive plastic surgeon, Dr James A Watson Both Dr Watson and his chief expert witness, Dr. William T O'Connor, have been outspoken in their attacks on the medical establishment for failure to warn and/or take precautions to protect health care workers from AIDS-related diseases Medical Malpractice Verdicts, Settlements & Experts has spoken with both Drs Watson and O°Connor and asked them to provide details regarding both the pending suit and the health prob- lem itself, What follows, under the title ‘‘The Medical-Legal Consequences of Abandoning Infection Control Procedures and the Risks to Health Care Workers.” 1s a medico-legal brief prepared by Dr O'Connor It tells only one side of the case — we did not contact the defense counsel to present a rebuttal — yet we feel justified in publishing this narrative at this ine rather than walling years for trial because of the importance of the subject matter Before tuming to Dr O'Connor's brief. let us ash. Have there been any other suits brought alleging that health care workers have contracted AIDS tor other diseases) from caring for AIDS patients? Of the twenty-eight AIDS related cases in the MED- MAL datubase only two allege imjury from such exposure The first case. Lisa Grosso +. W. Bradford DeLong, M.D., San Francisco Superior No 854879 (filed March 14. 1986). alleged that on April 4, 1985 the defendant surgeon performed a cranntoms ona patient known to be suffering fram AIDS The plainuff was a nurse assisting in the procedure According to the sunt during the course of the procedure the defendant negligently threw a kocker clamp holding a wire suture covered with the panent’s AIDS-infected blood at the plaintiff. resulting in a puncture wound to her right thumb through her special orthopedic closes Suit contended that as a result of the doctar’s acts she has been exposed to AIDS and has suffered ostracism and strained personal relations with friends and acquaintances due to her exposure to AIDS She has also sought psychiatric help The jnerdent happened at Pacifi, Preshyterian Medical Center in San Francisco The present status of the case 1s unknown the plainuff's counsel 1s Julian B Sapirstein of Flynn & Stewart 353 Sacramento Street Suite 1100 San Francisco, CA 94111 (415) 424-2800 The second sunt filed with the Louisiana Patent s Compensation Panel on June $, 1987 contends that the plaintitf a dietician for the defendant Alton Ochshner Medical Foundation was removing a meal tray from the roony of an AIDS panient at the hospital when she was stuck in the hand by an unsheathed hypodermic needle which lay concealed under papers on the tray According to the suit the plainuff was initially diagnosed as suffering from tuberculosis and had a positive reaction to the HTLV HI strain Moreover, at the time the incident took place the plainuff was pregnant and while her child 1s normal the plaintiff has been advised by doctors that the youngster must be tested for the rest of her life and is now considered as a hich risk for developing AIDS because of the mother’s exposure The case 1s Patricia Favorite, et al. v. Alton Ochsner Medical Foundation, et al., (no docket number) The present status of the case 1s unknown, the plainuff's counsel is Joseph Fo LaHatte, Jr . 4231 Canal Street New Orleans. LA 7OLT9, ($04) 428-5811 Finally. in an earher issue of Medical Malpractice Verdicts, Settlements & Experts we mentioned the case of Hacib Aoun v. Johns Hopkins, et al.. Balumore City Circuit No (unknown) filed by well-known malpractice trial lawyer Marvin Ellin of Bsalumore Suit alleged a cardiologist was the victim of ‘‘leaked"* information to colleagues that he had contracted AIDS Suit contends that the plaintiff contracted the disease from a cut on the finger when a glass tube of blood withdrawn from a leukemia patient broke in’ his hand It was later discovered that the patient also had AIDS Suit alleges that the hospital allowed word of the plamnuff s illness to spread among his colleagues and tried to avoid financial responsibility for him by defaming his character and driving him out of the hospital The Watson case was filed pro se Casas becoming more frequent in California) but plainuffs have the assistance of well- known San Francisco malpractice tnal attorney Robert Bokelman Their chicf expert witness, Dr William T O°Conner 1s president of HI ¥ E Foundation (Human Immunodeficiency Virus Eradication Foundation) formed in June, 1987 Dr O Connor, a Vietnam veteran, graduated with honors from the University of Colorado, where he received an award for academia achievement and community service He recensed his MoD from the University of Cincinnaty in 1981 and com- pleted internship/residency at the University of California at Davis He 1s currently board certified in family practice and since 1985 has been assistant clinical professor at U C -Davis, in the department of family practice medicine Dr O'Connor has been actively involved in the AIDS issue from a medical, scientific and political perspective for at least four years He has testified before the US House of Representatives and serves as a consultant for Rep Penny Pullen, a member of the President s AJDS Commission Dr O'Connor ts perhaps best known for his sixty-one page booklet ““AIDS The Alarming Reality’ first published in March. 1986 and revised three times since then (The fourth edition was printed January 6, 1988 ) The beak. written for laymen, 1s nevertheless well documented by some 163 footnotes to the medical literature His recom- mendations are certainly more cautious (and blunt) than usually seen in the press: Dr. O'Connor suggests not patronizing food handling institutions or health care institutions where AIDS patients are employed — he rejects the ‘‘null hypothesis” that AIDS can't be contracted by ‘‘casual contact,” a term that is not clearly defined, he says Similarly, he says that if yeu are placed in a hospital room with an AIDS patient, insist upon being moved to a different room He also urges discouraging sour children from playing with AIDS-infected school mates Dr. O'Connor's booklet 1s available for $5.00 per copy with discounts for multiple orders Dr. O'Connor can be reached at the H.I.V.E Foundation, P.O. Box 808 Vacaville, CA 95696 (707) 448-1710 Dr James Watson and his wife Norma, parents of the boy who is the subject of their suit, can be reached at 172 Pearce Hercules, CA 94547 (415) 724-0406. The Case of Watson s. San Francisco General Hospital: The Medical-Legal Consequences of Abandoning Infection Control Procedures and the Risks to Health Care Workers. by William T. O'Connor, M D. INTRODUCTION On November 40° 1987, James Nathanial Watson, a minor, by his guardian ad litem, Norma Watson and James A Watson filed a $500 million lawsuit m San Francisco Superior Court alleging that the willful negligence of the defendants (San Fran- cisco General Hospital City and County of San Francisco, City of San Francisco Department of Health. and numerous in- dividual co-defendants) was responsible for the infections Nurse Norma Watson sustained during her employment, one of which resultud in the birth defects of James Nathamal Watson, her only son INFECTION CONTROL Since the knowledge that contagious and communicable diseases could be prevented by avoiding contact with the infectious organisms invalved. infection control procedures have been practiced, implemented and enforced at institutional levels to protect patients and thase whose occupations expose them to such microorganisms Every licensed hospital in the country. and for that matter the Western world. has established guidelines. policies and/or procedures to insure that communicable diseases are not transnutted to employees, staff, or the public These policies are usually mandated by state or federal statutes as well as Contractual agreement through the federal funding source, consistent with the requirement to maintain a safe work place Ina modern effort to codify the standard, the Centers for Disease Control also publishes guidelines which act to direct the avuvities of insutuuons to specific diseases San Francisco General Hospital is recognized as a national leader by being the most experienced facility for infection con- trol and treatment of AIDS patients This experience was reflected in the September 1984 Infection Contro! Manual drafted during the time penod in question Several statements demonstrate a knowledge of the risks involved in caring for AIDS patients and rationalize restrictions pertaining to the use of infection contro! procedures “Excessive precautions should be avoided as this may impair patient care *’ “Until the etiology 1s rdentified. it seems prudent to institute certain precautions to protect individuals working with these patients These should include precautions for Hepatitis B and CMV viruses and any other precautions that may be needed for the various infections the patient may have Precautions should be taken to protect employees. patients, and visitors *” “Precautions Gloves for contact with blood and other body secretions Rationale To protect employce from the transmissible apent of AIDS. Herpes, CMV and other infectious agents ** “Masks are not needed for AIDS After five years experience with AIDS there 1s no evidence that the transmissible agent for AIDS 1s spread by the respiratory route ** Opponunisuc and other Infections (Pneumocystis, Mycobacterum avium and tuberculosis, CMV, etc ) I Masks (on patient outside of isolation room, on others in room or when patient cannot wear mask) when patient has tung invelyement. 1s coughing, and others have sustained close contact Until patient 1s diagnosed, others need to be protected from disease spread by the respiratory route Immuno-compctent persons need protecuon from M_ Tuberculosis Immunocompronused persons need protection from M Avium and Pneumocystis Although some AIDS patients have CMV in their lungs. it 1s not known if CMV can be transmitted by the respiratory route." The plainuff's suit alleges that the defendants failed to adequately warm or protect the nursing staff by denying them knowledge of paticnts diagnoses as well as forbidding them from wearing masks, gloves and gowns when treating AIDS patients. The ileged consequence was that the plainuffs were infected by Cytomegalovirus and Tuberculosis, two organisms that are un- questionably communicable and pathogenic C\ TOMEGALOVIRUS Cytomegalovirus (CMV) 1s a ubiquitous Herpes type virus that causes congenital defects and damage to more than 3.000 American infants every year, making it the leading viral cause of developmental disability — including mental retardation — m the country ! The congenital ma}formations and developmental disabilities are most severe when the infection is passed transplacentally to the fetus. resulting ina symptomatic infection at birth the magnitude of which appears to be correlated with the degree of prenatal insult Death occurs in as much as 30% of severely affected infants born with symptomatic congenital infec- tions > The occurrence of mental and psychomotor retardation, hearing loss, microcephaly with or without cerebral calcifica- tion. intrauterine growth retardation. prematurity, inguinal hernias in males, chorioretinitis, anomalies of the first brachial arch, structural detects, and defects of the tooth enamel have all been documented Overall, it can be anticipated that between 90% and 98% of infants with symptomatic congenital infection who survive will develop mild to severe handicaps,” the iikehhood of survival with normal intellect and hearing being small.*: >: 6 Crtomecalovirus can be transontted both vertically (from parent to child) and horizontally (from one person to another by direct or mdirect secretion contact) but all the modes of transmission are not completely understood. CMV can be transmutted te the fetus ether by primary infechon or reactivation of a latent infection.’ & A mother who suffers a primary CMV infection during pregnancy has up to a 40% chance of passing the infection on to her fetus and an adverse outcome is more likely when the infection occurs within the first half of pregnancy ° Primary infection can be decumented bv the simultaneous detection of IgG and IgM antubodies '° Serocpsdermologic studies have indicated that female health care workers have an occupational msk of acquiring CMV infection |! In the hosprtal setting. routine procedures for handwashing and infection control are at least partially effective in preventing transmission '4 8 '* 1? Tt has been recommended that ‘when caring for known CMV-excreting patients infection control should be combined with bedside signs that mdicate secretion precaution and a special recommendation that pregnant caretakers be especially carctul in handling such patients 7!" Cytomegalovirus ws extraordinarily prevalent among AIDS msk group members, more than 90% of homosexual men are scropositive |? One study found it to be the third most common form of opportumstic infection with 56% of all the patients having sznificant CMV-linked disease. mcfuding dissenunated infections in & of 25 individuals Cytomegalovirus can be isolated from blood or other body sites in at least 97% of AIDS patents °° TUBERCULOSIS Since the plainuff was also infected by tuberculosis during the time period while being required to treat AIDS patients. it1S pertinent to discuss the epidemiological aspects of this disease. Tuberculosis is now in epidemic proportions in the United States, and this 15 recognized by the Center for Disease Control to be a direct result of the AIDS epidemic. In New York City. reported cases of TB increased by 36% from 1984 to 1986, where one study of 58 male TB patients found that 53% were scropositive for the AIDS virus *' It has Jong been known that AIDS patients were at high risk for tuberculosis since 5% of the first 4 892 adult and adolescent AIDS patients reported to the New York City AIDS registry from 1981 through 1985 were infected with this bacterid- Tuberculosis is found in up to 60% of AIDS patients. many of whom are infected with ionrazid resistant strains **°4 Tuberculosis bacteria are known to be transmitted by the airborne secretion droplet route As many as 35,000 infectious units are dispersed in a stngle cough and greater than one million in a sneeze SOCIAL AND POLITICAL ENVIRONMENT A unique set of medical, social and political circumstances occurred in San Francisco, California with the coming of the Acquired Immunodeficiency Syndrome (AIDS) pandemic Some public health officials, physicians, supervisory personnel. _ and hospital administrators, presumably moti ated by a desire to demonstrate that AIDS virus communicability and the danger of caring for the patients infected by the virus was so low that infection contro! procedures (the wearing of masks. gloves. gowns, and proper containment and management of contaminated surfaces and objects) were not necessary To employ such 4 measures would have indicated to a fearful public that there existed a danger in coming in contact with or caring for persons infected with the AIDS virus In a hospital environment constantly open to media scrutiny, the public's observation that medical personnel were employing barrier techniques in the presence of their arguments claiming that no danger existed in coming in close contact with such patients might have appeared dangerously hypocritical. The pla:nuff in Watson s. San Francisco General Hospital contends that as a nurse caring for AIDS patients, she was denied the opportunity to know the diagnosis of these patients; and, when the diagnosis was known, she was specifically forbidden and threatened by termination of employment by supervisors and attending physicians to wear protective gloves, mashs. and gowns She contends gloves were not only removed from the wards, making them unavailable for use in Code Blue and blondy situations, but were ceremoniously burned by hospital personnel in an effort to preserve the psychological and emotional sensitivities of the infected It 1s the plaintiff's contention that while working at San Francisco General Hospital she was unnecessarily and negligently exposed fo these organisms through an egregious abandonment of infection control procedures. This exposure resulted in her acquiring Tuberculosis and Cytomegalovirus infections, the Cytomegalovirus infection then causing numerous congenital malformaniere in her only son including premature calcification of cranial sutures (which later resulted in an extensive neurosurgicay procedure}, prematurity, malformation and disease of the genitals and related structures. defects of the axial shovion, bilaterd heating joss. infection of the retina with high risk of blindness, special high risk of retardation, developmental delays. impairinent of his future quality of life and earning ability CHRONOLOGY OF PERTINENT EVENTS 1974 — Norma Warenn, plaintiff. obtains California Nursing Licensure February, 1977 — Plaintiff begins employment at San Francisco General Hospital 1YRT — Plainoff begins clinical care of AIDS patients as charge nurse Naventher, 1982 — Center for Disease Control publishes AIDS precautions for clinical and laboratory staffs Included are SLU OMents Glues should be worn when handling blood specimens, blood-soiled items, body fluids, excretions, and secretions as well ae Surlices muterials. and objects exposed to them Gowns should be worn when clothing may be soiled with bods fluids. blood. secretions. or excretions Precautions appropriate for particular infections that concurrently occur in AIDS patients should be added to the above. if needed September, 1984 — Norma Watson. plainuff, seroconverts to positive Tuberculosis skin test. Undergoes treatment for infec- hon with Isomazid fur one year subsequent to diagnosis of TB July, 1985 — Norma Watson and three other San Francisco General Nurses filed complaints with Califorma Dept of Oc- cupational Safety and Health Administration and California Dept of Labor alleging an array of health and safety violations by San Francisco Gen Hosp Complaints were lodged with Service Employces International Union, City Public Employ ces. Local #790 alleging health and safety violations of existing contract between said Umon and the City and County of San Francisco Norma Watson testifies before the U.S House of Representatives Subcommittee on Health and Environment of the Enerevy and Commerce Commuttce charging that she and approwmately 600 R N ‘s were being used as experimental ‘‘puinca pigs’ without informed consent in an ongoing secret study funded by the State AIDS Task Force to deternune the minimum stan- dards of protection for health care workers exposed to AIDS patients The study was subsequently published by J L_ Gerberding in The Journal of Infectious Diseases, July 1987, enutled, ‘Risk of Transmitting the Human Immunodefictency Virus. Cytomegalovirus, and Hepautis B Virus to Health Care Workers Exposed to Patients with AIDS and AIDS-Related Conditions * She also tesutied and presented supporting documents from staff meetings revealing an abandonment of infection contro! prcedures whercin nurses were ordered to ‘‘develop an effective approach. such as a contract with patient which 1) acknowledges the patient's sexual needs, (2) suresses the need to protect patients and staff from unnecessary disturbances. (3) arranges for private place and time for sex, (4) 1s noted in Kardex file, (5) 1s in cooperation with medical staff ‘* These practices, executed on a 24-hour per day basis, were particularly disturbing since they exposed patients and assumed to be healthy vistors to AIDS, a known, sexually transmissible, fatal disease 8 Included in the staff meeting notes of July 25, 1985 was the statement: ‘‘No patient gowns or isolation gowns are to be worn by staff *’ August, 1985 — Hearings held concerning Norma Watson and three other nurses who filed a complaint with The Califorma State Labor Commission relating to the hospital's refusal to allow them to wear masks and gloves while treating AIDS pa- tients and subsequent disciplinary action for so doing Dr Donald Abrams, defendant and assistant director of the AIDS clinic at defendant hospital. argues in San Francisco Chronicle newspaper that to wear gloves and masks ‘‘at any time 1s wrong. misrepresentative, and ignorant *’ Hospital's stand reported by Cal-OSHA public relations person is that masks and gloves are not necessary for the routine handling of AIDS patients Dr Lawrence Rose, Cal-OSHA'’s medical unit chief, testifies at hearing that he would recommend that nurses be allowed to wear such gear. State Labor Commission subsequently rules that there was no discrimination in San Francisco General's transferring the nurses to day shift but that since nursing was a protected class. they had the right to wear protective gear (masks, gloves, and gowns) when deemed necessary by their professional judgment September. 1985-November 1985 — Despite the Labor Commission ruling, plaintiff Norma Watson contends she was in- timidated with threats of ternunation and still forbidden to wear protective masks, gloves and gowns while caring for AIDS nanients October, 1985 -- RN Magazine publishes article regarding complaints made by Norma Watson wherein she was disciplined for demanding that nurses be allowed to wear masks and gloves while treating AIDS patients. November, 1985 — Norma Watson admitted to hospital after developing gastrointestinal ulcers which initially were believed to be caused by stress but later on histological examination are found to have Cytomegalic inclusions indicating infection by Cytomegalovirus Hospitalization lasted two weeks She was placed on medical leave of absence while being treated with numerous therupeuic modaliues through May, 1986 when it was determined that she was also pregnant December, 1985 -- Norma Watson requested through the office of California Assemblywoman Doris Allen that an inter- pretation of the Nursing Practice Act of the State of California be rendered by Attorney General John Van De Kamp specifically pertaining to a nurses right “to wear protective garments, gloves, masks, when treating patients who are considered to have infectious. communicable or contagious diseases “' The Attorney General's office directed the Board of Registered Nursing (B RN ) to respond to this request. March 20, 1986 — Norma Watson testifies before the Board of Registered Nurses in Los Angeles. California demanding ‘the establishment of a standard concise. and clear policy by the B R N. to implement a nurse’s legal, moral, and ethical right of wearing protective gear at their professional discretion while dealing with AIDS patients who are infectious, com- municable and contagious “* March 21, 1986 — The result of Watson s demand was the issuance of a ‘‘Statement on Delivery of Health Care to Patients with Communicable Discases © in which ‘‘the board also supports the nght of the nurse to know the patient's diagnosis/suspected diagnosis ina timely fashion in order to make an appropriate nursing care plan and to take necessary precautions to minimize the risk of contracting or spreading disease * May, 1986 — Conception of plaintiff, James Nathanial Watson July, 1986 — Asa result of patient's exposure to infectious agents and age, a choriome villi sampling and Alpha Fetal Protein (AFP) serology was accomplished. both indicating abnormal gestational events associated with a high probability of birth defects Results of tests were not divulged to Norma Watson January, 1987 — Birth of plaintiff James Nathanial Watson, determined to be premature, head shape noted to be irregular, small for gestational age. Jow hematocrit. and jaundiced enough to require phototherapy Breastfeeding was precluded by an absence of maternal milk production February, 1987 — Norma Watson awarded $15,000 Workman's Compensation claim resulting from gastrointestinal ulcers determined to be occupational in origin March, 1987 — Abnormal head shape insugated radtological exploration and referral to pediatric neurosurgeon where cranial synostosis and calcification of cranial sutures diagnosed by CT Scan Bilateral inguinal hermas and enlarging hydroceles diagnosed April, 1987 — Claim filed against San Francisco General Hospital, City and County of San Francisco, State of California. and numerous physicians and nurses who allegedly were negligent by exposing the plaintiff to unnecessary infectious risks. May, 1987 — Center for Disease Control's Morbidity and Mortality Weekly report documents first AIDS virus transmission to health care workers According to one published account, *‘San Francisco General Hospatal officials quickly called emergency infection control meetings to review policy . . . but most hospitals surveyed did not perceive a need for extraordinary measures. ‘We already have a stringent protocol in place and an ongoing educational program for staff based on CDC recommenda- tions.’ said a New York Hospital spokesman And from Barnes Hospital in St Louts came a similar comment: ‘We feel that the CDC report merely indicates the nced to follow the guidelines already in place And we're following the guidelines.’ Dr Gerberding (a co-defendant) . said that’ . . ‘we're now considering taking a more active role in monitoring compliance with the guidelines,’’* according to Medical World News, June 22, 1987. May 1987 — Surgery to relieve intracranial pressure accomplished by Tessier neurosurgical procedure on James Nathanial Watson Laboratory analysis indicated elevated IgG and IgM Cytomegalovirus antibody titers in infant Plaintiffs, both mother, her husband and son, found to be actively shedding Cytomegalovirus in urine and Cytomegalovirus was isolated from mother and infani’s biood June, 1987 — Surgical repair of bilateral inguinal hermias and hydroceles accomplished July, 1987 — Developmental evaluation noted developmental milestones retarded US Department of Labor tssues rules to protect health care workers from the hazards associated with AIDS, including a rule that requires use of ‘*personal protective equipment™’ in the workplace and a statutory provision that says employers have a general duty to protect ‘‘against recognized hazards likely to cause death or serious harm "’ August, 1987 — Neurologic:ophthalmalogic evaluation at UCSF indicated retinal scarring and depigmentation High fre- quency auditors impairment documented by BrainStem Evoked Response testing . November 30. 1987 — Plaintiff files the present lawsuit in San Francisco Superior Court against San Francisco Gen Hosputal, City and County of San Francisco, State of California, and numerous physicians and nursing personnel who allegedly ‘‘knew that patients actively secreting CMV posed a special risk of birth injuries to fetuses of women of child-bearing age who might be infected with CMY Furthermore, defendants, and cach of them knew that patients suffering from AIDS had a significant incidence of CMV infection approaching 100% Despite this knowledge. defendants, and each of them. failed to adequately warn and protect the nursing staff at San Francisco General Hospital from AIDS and associated opportunistic infections. including but not limited to hepatitis, tuberculosis, and CMV "" December &, 1987 — San Francisco General Hospital was inspected unannounced by California Dept of Health and Human Services finding ‘The lack of adherence to infection control policies and procedures seen on patient wards during the survey demonstrates inadequate monitoring of nursing practice by supervisory personnel *' “Infectious Waste The hospital has not defined ‘infectious waste’ as required in this section Consequently widespread differences in handling of materials which may or may not be classified as ‘infectious’ was observed "" “The facility failed to meet the requirements of these regulations by failure to implement the policies and procedures of its infection control program The following incidents were observed during this survey visit a) There were no isolation gowns available for a psychiatric unit patient with hepatitis precautions and for a patient 4D with wound precauuons b) On the psychiatric ward two ARC patients did not have signs posted with precautionary measures to be implemented and the medical record (care plan) did not address precautionary measures c) On the AIDS unit two patients had no precautionary measures posted inside or outside of the room d) In the Emergency Room soiled patient care equipment was stored in the nursing supply room with sterile supplies 10 e) In three instances during sterile dressing changes, sterile technique was not followed on wards 4B and ICU. h) Syringes containing skin test materials were in the specimen refrigerator in the dirty utility room on 6C. j) In Dialysis the reverse osmosis water analysis colony counts were above the acceptable standards. ‘The infection control program is not sufficiently staffed to provide the resources to develop and implement an effective infection control program The facility which 15 licensed for 518 general acute care beds with special emphasis on the care of AIDS patients. has only one Infectious Disease Nurse Comparable institutions have 2 or 3 times these staffing resources _. . a a result there are no apparent studies to document the infections present at the time of admission, acquired, or evident after discharge except sn limited areas.*’ : ‘*Sanitary and housckeeping problems as described indicate a lack of Infection Control involvement in hospital housekeep- ing efforts to provide a sanitary environment to avoid sources transmission of infections and communicable disease. The hospital has not provided staff or supervision for the successful correction of problems in the housekeeping area or provided the necessary staff to 1mplement the Infectious Disease Program."' January, 1988 California Dept of Health and Human Services, after review of discrepancy correction response from San Francisco General Hosp , states’ ‘After our review of vour plan of correction, we continue to maintain that the condition of infection control was out of comphance . . We are requesting that you appropriately review your plan of correction by February 1, 1988."" 1. Wilson, ‘Ar the Edge of Life An Introducnon to Viruses, A Report from the National Institute of Allergy and Infectious Diseases'’, (1980). p 16 2 Stagno. § Cytomegalovirus Infecuon a Pedtatrician's Perspecnve, Current Problems in Pediatrics, 1986, Year Book Medical Publishers. p. 646 3 Staeno. § Cytomegalovirus Infecnon a Pediatrician’s Perspective, Current Problems in Pediatrics, 1986. Year Book Medical Publishers pp 648-9 4 McCrakhenG J. etal Congenital cvtomegalic inclusion disease. A longitudinal study of 20 patients Am J Dis Child, 1969,117 522 5 Medearis, TN. Observations concerning human cytomegalovirus infecnon and disease. Bull Johns Hopk Hosp, 1964, 114,181 6 Berenberg, W , Nankervis. G. Long-tenn follow-up of chtomegalic inclusion disease of infancy. Pediatrics, 1970, 37:403. 7 Stagno, S , et al Congenital cytomegalovirus ufection Occurrence in an immune population, N Engl J Med, 1977, 296 1254 8 Schopferk. Lauber E . Krech, U * Congenual cytomegalovirus infection in newborn infants of mothers infected before pregnancy Arch Dis Child, 1978: 53-536 9. Stagno. S , Pass, R F , et al Primary Cytomegalovirus Infection in Pregnancy, JAMA, 1986, 256:14,1904 10 Stagno. $ : Cyromegalovines Infecnon a Pediatnician’s Perspective, Current Problems in Pediatrics, 1986, Year Book Medical Publishers, p 658. 1} Yeager, A S * Longitudinal, serological srudy of cytomegalovirus infections in nurses and in personnel without panent contact J Clin Microbiol, 1975, 2:448 12 Haneberg, B . ct al Antibodtes to cytomegalovirus among personnel at a children’s hospual. Acta Paediatr Scand, 1980, 69 407 Ll 13 Friedman, H M . et al Acquisition of cytomegalovirus infection among female employees at a pediatric hospital. Pediatr Infect Dis, 1984, 3.233 14 Dworsky. M E., Welch K, Cassady G, et al: Occupational risk for primary cytomegalovirus infection. N Engl J Med, 1983, 309-950.3333 15 Ahlfors, K., et al: Risk of cytomegalovirus infection in nurses and congenital infection in their offspring. Acta Paediart Scand, 1981; 70 819 16 Adler. $ P : Nosocemal transmission of cytomegalovirus Pediatr Infect Dis, 1986: 5:239. 17 Wilfert CV , et al’ Restriction endonuclease analysis of cytomegalovirus (CMV) DNA as an epidemiological tool. Pediatrics, 1982; 70'717. 18 Stagno S Cvtomegalovirus infection: A pediatrician's perspective, Current Problems in Pediatrics, Year Book Medical Publishers. Chicage, IL: 1986, p 660. 19 Laurence. J CMV Infections in AIDS Patents, Infections in Medicine, 1986, September; 262. 20 Lerner. CW. Tapper, ML Opportunistic infection complicanng acquired immune deficiency syndrome: Clinical features of 25 cases Medicine, 63:155-164, 1986 21 Center for Disease Control Tuberculosis, Final Data — United States, 1986, Morbidity and Mortality Weekly Report, Jan. 1, 1988, 36, #50 & 51° p 817-9 22 Center for Disease Control Tuberculosis and Acquired Immunodeficiency Syndrome — New York City, Morbidity and Mortality Weekly Report, Dec 11, 1987, 36:48 786 23 Pitchemh. AE. et al Tuberculosis, anpical mycobactenosis. and the acquired immunodefictency syndrome among Hainan and non-Hainan patients in South Flonda Ann Intern Med, 1984; 101. 641-645, 24 Pitchenth, AE. et al The Prevalence of tuberculosis and drug resistance among Hainans, N Engl J Med, 1982: 307 162-165 ANESTHESIOLOGY Florida Man Awarded $50,000 for Loss of Four Front Teeth — Damage From Oral Pharyngeal Airway. Plaintuff, a fifty-seven year-old retiree, suffered the loss of four front teeth with ensuing dental expense. bridge work, and other dental complications when his teeth were damaged from an oral pharyngeal airway when he was emerging from general anesthesia from an unrelated operation According to Jury Trials and Tribulations, the jury returned a verdict for the plainuff in the amount of $50.000 Plaintiffs experts: Merlin Jeffries, M D , anesthesiologist, John Kling, RN Defendant's experts: Richard Davis, M D , anesthesiologist, Gainesville Kublicks +. Owens and Northridge Hospital, Broward County (FL) No 83-24039 Lee Gay and Barbara McCauley for plaintiff R Barry Morgan and Kevin O'Connor for defendant Pharynx Trauma During Anesthetization Results in Mediastinitis and Death of Housewife — Post-Operative X-Rays Misread — $1,000,000 Award in Florida Wrongful Death Suit. The decedent, a forty-eight year-old housewife. died twenty six days after being administered general anesthesia at Hialeah Hospital from mediasunitis that was demonstrated to have been caused by trauma to the pharynx during the process of intubation preceding the administration of anesthesia An x-ray taken four hours after surgery which showed air in the subcutaneous tissues of the neck and which would have made the diagnosis obvious and greatly increased the decedent's chances of survival was misread by the radiologist The admitting and discharging physicians relying on the x-ray report ignored the telephone calls from the patient's family regarding the decedent's complaints of pain for two days post-opcration Four days post-opcration the decedent's husband contacted another doctor who immediately rehospstalized the decedent and initiated the indicated treatment' but to no avail In addition to her husband, the decedent was survived by a daughter, eighteen, and a son, twenty-one years of age. According to Jury Trials and Tribulations, the final verdict was for the plainuff in the amount of $1,086,516 Defendant ob-gyns, Raquel Cruz, M D and Nidia Marun, M D_ were found not guilty Dopico v. Cruz, M.D., Cruz, M.D., P.A., Midia Martin, M.D., Hugo Escalante, M.D., Hialeah Anesthesia Group-Torres & Escalante, P.A., Danea Mendez, M.D., and Simon, Pipes and ee} 12 STATE OF CALIFORNIA—HEALTH AND WELFARE aucNCY : GEORGE DEUKMEJIAN, Govemo: es DEPARTMENT OF HEALTH SERVICES ! SING AND CERTIFICATION _ MARKET STREET SAN FRANCISCO, CA 94103 January 21, 1988 Phillip Sowa Executive Director San Francisco General Hospital 1601 Potrero Avenue San Francisco, CA 94110 Dear Mr. Sowa: We have reviewed your plan of correction for the deficiencies observed during the December validation survey of San Francisco General Hospital. While we are favorably impressed with your indication that corrective action has been implemented for many of the cited deficiencies, we do have specific concerns with a number of your responses, which I discussed with you informaily on January 20, 1988. Item #1. Pertaining to staffing shortages. Your response does not provide a specific plan with a completion date which will correct chronic staffing shortages. While the closing of units to deal with nursing staff shortages is an option, it will have an effect on the number of licensed beds and approved services as reflected on the hospital license. See item #20 and 21. Item #2(c). Pertaining to adhering to infection control policies and procedures. You have indicated that this problem is reflective of policies and procedures being in transitior rather than a problem of supervision. We need to know when the new policies and procedures will be in place and when staff will be appropriately instructed and supervised. Item #3(b). This deficiency was deleted from the survey report. Item #4(b). Pertaining to nurse staffing shortage. We need to know when the hiring of nurses into vacant positions will be accomplished. Item #4(d). Pertaining to IV infusions. We would expect a more timely correction date. Phillip Sowa Executive Director -2- January 21, 1988 Item #4(e). Pertaining to NG tube feeding. We need a timely completion date and how the Facility will ensure physicians orders will be implemented. Item #5. Pertaining to staff shortages in laundry. The problem with laundry staff shortage has not been addressed. Items #7(e) (2) (3) (4). Pertaining to emergency room housekeeping. Our findings of these housekeeping deficiencies were observed by the evaluator and discussed with hospital staff who concurred with the findings at the time. This area will be re-evaluated - in a subsequent visit. Item #7(f). Pertaining to dirty windows. A correction date is needed. - ™ Item #10. Pertaining to housekeeping staff insufficiency. Throughout the survey administrative hospital staff acknowledged the problem of insufficient housekeeping staff and that the problem was budgetary. The current response that there is adequate housekeeping staff is unacceptable. We expect that all identified housekeeping problems will be corrected by March 1, 1988. We request that you develop a plan to assure adequate staffing will be available on an ongoing basis to resolve the housekeeping systems problem. tem #11. Pertaining to a definition of infectious waste. The issue of concern is the lack of uniformity within wards and departments of the hospital in the handling of material which might be construed as "infectious waste". This problem appears to be directly related to the lack of a clear definition of "infectious waste", We would expect that uniform policies and procedures be developed from this definition! The June 1988 compliance date is excessive. We would expect that this would be resolved no later than March 1, 1988. | Item #12. Pertaining to handling\of infectious waste. If this issue is to be resolved by new infections control policies and procedures, we need to know that these will be in place at an early date, but no later than March 1, 1988. \ Item #13(f). Pertaining to IV line. A more timel} completion date is required. \ Item #16. Pertaining to handling of clean linen. The.. handling/storage of linen with which we were concerned, was not for the immediate use of the patient or patients in the room. Phillip Sowa Executive Director =3- January 21, 1988 Item #17. Pertaining to soiled linen. The completion date is not timely. The problem should be resolved no later than March 1, 1988. Item #19. Pertaining to staffing and supervision. You have not addressed the staffing and supervisory problems which are related to the sanitary and housekeeping deficiencies at the hospital. Item #20. Pertaining to space conversion. It is necessary for you to submit information which will convincingly demonstrate that spaces can be re-converted to patient use within 24-hours. This includes the immediate availability of nursing and other staff. If this can not be done we would expect that you would request that the non-operational beds be put in suspense or removed from the license. Item #21. Pertaining to the reactivation of the Burn Center. The program flexibility was granted for a 3-month period. By March 15, 1988, we expect this supplemental service will be fully reactivated. After our review of your plan of correction, we continue to maintain that the condition of infection control was out of compliance. From our perspective the resolution of most of these issues relates to: 1) the development and implementation of infection control policies and procedures, which you have indicated are in transition, 2) providing appropriate training and supervision, and 3) obtaining additional staff as identified. We are requesting that you appropriately revise your plan of correction by February 1, 1988. Sincerely, K. 17- lnpe Lois M. Sharpe District Administrator Licensing & Certification LMS:dc cc: Ron Curry David Werdegar The Largest Daily Circulation in Northern California FRIDAY, DECEMBER 25, 1987 415-777-1111 kek Inspectors Find Dirt At S.F. General - ~ —--—— Secsreetestas - * eee oes aeevr cae an se eras Ree Se) te OR Pe ae Od Eee ee Sede ~ « ' 4 By Torri Minton A newly released state re- port has sharply criticized San Francisco General Hospita), claiming the facility suffers from staffing, Infection control and housckceping problems. The 26-page document contains much harsher criticisms of the city's primary public hospital than were leaked earher this week prior to the report's release. "___The report {s particularly trou- * bling because San Francisco Gener- ais widely seen asa national leader OPEN in infection control an care. The report could bring the loss of $45 million in Medi-Cal and Medi- _ care funding, and the hospital's li- cense could be jeopardized 1f state and federal authorities are not satis. fied The hospital has 10 days to ° percent. respond Anery hospitals officials said yesterday they are already plan- ning a rebuttal “We plan to challenge this ré- port at the highest level.” said Phil- lip Sowa, the hospitals executive administrator “If this means that we have to go to court, we will go to * court" _ Old frondards lospital officials maintain that thea investigators were using old rules and old standards in judging infechon control They said they disputed almost every one of the 22 deficiencies hsted in the document during five hours of wrangling with state inspectors on Tuesday ' “They mav have developed pol- icies and procedures on the fore- front, but J walt tell you that all the staff has not heen trained in those policies and procedures,” said Lois Sharpe, district, administrator for ‘the state Licensing and Certtfica- tion Departinent of Health Services, which conducted the probe “We were just holding them to basic.common sense infection con- trol guidelines 10 protect patients and employces,” Sharpe said She added that the hospital was judged according to federal, state and its own regulations Surprise Inspection A leam of seven Investigators who launched a surphise visit eart!- er this month reported finding soil- ed equipment stored next to sterile supplies, undated dressings and sy- ringes and 10 Instances where con- taminaled materials, including gloves, dressings, an intravenous catheter and needle, blood and a Specialized staffing,” sal S¢ container of liquid from a wound, were not discarded in compliance with infection control guidelines. Two lab workers were seen no wearing gloves while handling pa- tlent specimens. Lids were left open on infectious waste containers. Among the housekeeping prob- lems, the investigators found infec- tious linen bags piled on the floor and dirty laundry piled four feet high near the emergency room, forcing the door to be propped The hospital also was cited for taking 89 beds out of operation due to a lack of nursing staff. Other areas, such as housekeeping, laun- dry, maintenance, dietary, social services and medical records were found to be understaffed by 20 to 25 “These shortages compromised the hospital's ability to deliver pa- tient care and services,” the report said. Nurse Shortage At least 66 vacant budgeted nursing positions exist at the 500- plus bed hospital, according to Unit- ed Public Employees Union Local 790 Hospital administrators say there are about 200 total vacant staff positions. - “There are significant areas of the hospital where services are Cur- tailed because of an inability to get i Hank hoeniein, regional admifistrator for the state health department Hospital officials conceded that some of the citations were justified, including dust balls in corners, ciga- ret butts on floors of emergency- ward waiting rooms, lids off gar- bage cans, cracks in the floors and dirty windows But they blamed budget cutbacks and the nursing shortage for the facility's inability to clean and staff some wards Administrators, have already hegun meeting with housekeeping staff to correct the maintenance problems, Sowa said “There is no evidence that a single AIDS in{cction has ever been transmitted through a crack in the wall or dust on the floor,” sald Dr. ° Eugene Gottfried, director of clini- cal labs at the hospital » San Francisco General has re cently approved and published new ~ infection cpntrol guidelines, which are now in the process of being {m- plemented, Sowa sald He failed the state standards “antiquated” and sayd some of them date back to 1977. CY 7 min “* | 7 7 ThA / S/ 7 “ye -_ , / ch TAT ~~ jr, 4 ——— >. = _. { | Chicago hospital sets AIDS work-safety rules UNITED PRESS INTERNATIONAL CHICAGO — Doctors, nurses and other health care workers at Cook County Hospital will have to wear rubber gloves, masks, goggles and gowns whenever they come in- to contact with patients’ body fluids under a program to prevent spread of the AIDS virus at the facility. The measures, approved by the public hospital's medical staff, ex- ceed the infection control practices endorsed by the federal Centers for Disease Control, which call for pro- tective measures only if a patient is known to be infected with the AIDS virus, Dr. Agnes Latimer, Cook County medical Staff director, said Thursday. “As far as ] know there are only about three other bospitals in the country using this program,” Lati- mer said. “It’s not 2 widespread practice yet but I expect it will be.” “In San Francisco, officials at San sidermng similar guidelines 5 to pro-_ tect health care workers. A change in hospital polcy has Been quietly discussed for a year, and the hospi- tal is now taking a closer look at the existing system. In a large public hospital in a city where AIDS infection 1s prevalent — and where emergency treatment for vicums of freeway accidents, shootings, and stabbings 1s common — it 1s possible that personne! could Francisco Genera! Hospital are con- | One eo, care for someone with AIDS and not know it until they’ve been acci- dentally exposed, say SF. General 0 Cook y Hospital’s Latumer said the new program was imple- mented there because of growing concern that health workers might be unwitungly exposed to AIDS-in- fected blood. The Centers for Dis- ease Control recently reported that three health care workers may . have become infected after coming into skin contact with the blood of AIDS victims. Cook County will employ the Body Substance Isolation System developed at the University of Cali- forma at San Diego, which calls for routine use of rubber gloves when- ever they come into contact with the blood or other body fluids of any patient. Masks, goggles and gowns will be required if there is any chance they mav be splashed with the blood or body fluids of any patient, regard- less of whether the person has been diagnosed as having been exposed to the AIDS virus. “This policy will protect the health-care worker and the pa- tient,” Latumer said. “It will calm a high level of anxiety among the workers and will prevent a patent from contracting an infectious dis- ease from a health-care worker who accidentally came into contact witb an earber patient’s body sub- stances.” I SECOND AMENDED CLAIM AGAINST THE CITY AND COUNTY OF SAN FRANCISCO, THE CITY OF SAN FRANCISCO DEPARTMENT OF HEALTH, SAN FRANCISCO GENERAL HOSPITAL, PAUL VOLBERDING, M.D., MERVYN SILVERMAN, M.D., KEITH HADLEY, M.D., GRACE LUSBY, R.N., LEONARD JONES, R.N., GIANCARLAO FIDELLI, PHYLLIS HERTIL, R.N., CLIFF MORRISON, R.N., ELAINE COLEMAN, R.N., DONALD ABRAMS, M.D., JULIE GERBERDING, M.D., JUDITH SPINELLI, R.N., BONNIE TEMPKIN, R.N., DOROTHY WASHINGTON, R.N., LUISA BLUE, R.N. and SUSAN BUCKLEY, R.N. CLAIMANTS' NAMES: JAMES WATSON, individually, NORMA WATSON, individually, and NORMA WATSON on behalf of minor JAMES NATHANIEL WATSON CLAIMANTS' ADDRESS: 172 Pearce, Hercules, CA 94547 LAIMANTS' TELEPHONE: (415) 724-8662 AMOUNT OF CLAIM: $100,000,000.00 i: ADDRESS TO WHICH NOTICES ARE TO BE SENT: nehe iS JAMES AND NORMA WATSON 25" = 172 Pearce, Hercules, CA 9 $7: 7s Ne DATE OF OCCURRENCE OR TRANSACTION: January 5, 1987-3 = zZ EOw DID ACCIDENT OR TRANSACTION OCCUR: At all time? és tangnt ner2to JAMES WATSON and NORMA WATSON were and are husband anc willie. JAMES NATHANIEL WATSON is the infant chilé c= JAMES AND NORMA WATSON, born of their marriage on January 5, 1987. NORMA WATSON has enjoyed a successful nursing career fer approx:- mately twenty years. From 1981 to the birth of her child sne was employed as an R.N. by San Francisco General Hospizal. NORMA WATSON was forced to render "hands on" nursing care to haghly infectious AIDS patients who were coughing, Gripping secretions, sweating profusely, continuously excreting in the:r beds, etc. NORMA WATSON, in compliance with the mandate of her license under the State Nursing Practice Act, requested adequate protection wnen working with said patients snelad: ng masx and gloves to protect her family and hersesif from iniactices a:isease. She was not informec of the nature of the soecir.c Giseases that her patients had. “sre: ve eee ee NORMA WATSON was denied her request to use medical pro 2qelspment sucn aS Mas and gloves and was tnreateneG with 30D Terminaticn 12 sine dia net treat tne aforemention2. i1seases ROBERT & SCARE-MAN oe 3b SSD N Biel NS Ble lee Naw NN Te MOORE wae E INE STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY ™ GEORGE DEUKMEJIAN, Governor NEPARTMENT OF HEALTH SERVICES 744 P STREET SACRAMENTO, CA 95814 (916) 445-1248 February 10, 1988 Ms. Norma Watson, RN. 127 Pearce Hercules, CA 94547 Dear Ms. Watson: Governor Deukmejian has asked me to reply to your letter regarding AIDS and health care workers. The Department of Health Services” Licensing and Cerrificacion program is responsible for the licensure of general acute care hospitals and the investigation of complaints. I am forwarding vour complaint to Mr. Hank Schoenlein, Regional Administrator of Licensing and Certification”’s Centra] Region, Mr. Schoenlein is located at 1625 Shattuck Avenue, Berkeley, CA 94709. Mr. Schoenlein’s telephone number is (415) 540-2417. A member of Mr. SchoenJein’s staff wi]l investigate your complaint, and Mr. Schoenlein will share the investigative findings with me. I will then inform you of the results of the investigation. You may anticipate my response by February 26, 1988. lf you have any questions regarding this matter, Ms. Teresa Hawkes, Deputy Director of the Licensing and Certification program, may be cortacted by telephoning (916) 445-3054. Thank you for bringing this matter to my atterctiorn. Sincerely, | ‘ Ad: ar nl Ue ) Kenneth W. Kizer, M.D., M.P.H. Director 20 | 21 22. 23 24 25 26 27 28 | JAMES A. WATSON and NORMA WATSON 172 Pearce Hercules, California 94547 Telephone: 415/724-0406 In Pro Per ENDORSED San Francieco County Superior Court” NOV 301987 DONALD W. DICKINSON, Clerk BY: R, HIGGINS Deputy Clerk SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE CITY & COUNTY OF SAN FRANCISCO JAMES NATHANIEL WATSON, a minor, by NORMA WATSON, his Guardian ad Litem; NORMA WATSON; JAMES A. WATSON, Plaintiffs, SAN FRANCISCO GENERAL HOSPITAL, CITY AND COUNTY OF SAN FRANCISCO, CITY OF SAN FRANCISCO DEPARTMENT OF HEALTH, PAUL VOLBERDING, M.D., MERVYN SILVERMAN, M.D., KEITH HADLEY, M.D., GRACE LUSBY, R.N., CLIFF MORRISON, R.N., DONALD ABRAMS, M.D., JULIE GERBERDING, M.D., JUDITH SPINELLI, R.N., BONNIE TEMPKIN, R.N., STATE OF CALIFORNIA, STATE OF CALIFORNIA DEPARTMENT OF HEALTH SERVICES ' ADMINISTRATION, BLACK CORPORATION, | WHITE COMPANY, a co-partnership, and FIRST DOE through TWENTIETH DOE, inclusive, Defendants. “$848 46 COMPLAINT FOR DAMAGES FIRST CAUSE OF ACTION —- NEGLIGENCE PLAINTIFF JAMES NATHANIEL WATSON, A MINOR, THROUGH HIS GUARDIAN AD LITEM, ALLEGES AND COMPLAINS OF DEFENDANTS, AND EACH OF THEM: 1. For the purposes of this action, NORMA WATSON was appointed by the above-entitled court, and now is, Guardian ad Litem of plaintiff JAMES NATHANIEL WATSON, a minor. 2. Defendant CITY OF SAN FRANCISCO is, and at all times mentioned herein was, a chartered city, duly organized and existing under the laws of the State of California, and situated in the County of San Francisco. 3. Defendant COUNTY OF SAN FRANCISCO is, and at all times mentioned herein was, a county duly organized and existing under the laws of the State of California. 4. Defendant CITY OF SAN FRANCISCO DEPARTMENT OF HEALTH is, and at all times mentioned herein was, an administrative Gepartment of the City of San Francisco. 5. Defendant SAN FRANCISCO GENERAL HOSPITAL is, and at all times mentioned herein was, a municipal public hospital of the City of San Francisco, administered through the City of San Francisco Department of Health. 6. Defendant STATE OF CALIFORNIA is, and at all times mentioned herein was, a sovereign state of the United States of America. 7. Defendant STATE OF CALIFORNIA DEPARTMENT OF HEALTH SERVICES ADMINISTRATION is, and at all' times mentioned herein was, an administrative department of the State of California. 8. Plaintiff is informed and believes and thereon alleges that all times herein mentioned, defendants PAUL VOLBERDING, M.D., MERVYN SILVERMAN, M.D., KEITH HADLEY, M.D., GRACE LUSBY, R.N., CLIFF MORRISON, R.N., DONALD ABRAMS, M.D., JULIE GERBERDING, M.D., JUDITH SPINELLI, R.N., and BONNIE TEMPKIN, R.N., and each of them, were residents and/or practicing their -2- professions as nurses and physicians in the County of San Francisco, State of California. 9. The true names and capacities, whether individual, corporate, associate or otherwise, of defendants BLACK CORPORATION, WHITE COMPANY, a co-partnership, and FIRST DOE thrugh TWENTIETH DOE, inclusive, are unknown to plaintiff, who therefore sues said defendants by said fictitious names. Plaintiff is informed and believes and thereon alleges that each of said defendants is negligently or otherwise responsible in some manner for the events and happenings herein referred to, and negligently or otherwise caused injuries and damages proximately thereby to the plaintiff as herein alleged. 10. At all times herein mentioned, all of the defendants were the agents, servants and employees of their co-defendants, and each of them, and at all of said times, said defendants were acting in the full course and scope of said agency, service and employment, ll. Defendant SAN FRANCISCO GENERAL HOSPITAL is and at all pertinent times herein was located within the defendant CITY AND COUNTY OF SAN FRANCISCO, 12. Plaintiff JAMES NATHANIEL WATSON was born on January 5, 1987, in the City and County of San Francisco, and is, at the time of filing this complaint, a minor of the approximate age of 11 months. 13, The natural parents of plaintiff JAMES NATHANIEL WATSON are NORMA WATSON, mother and JAMES A. WATSON, father. 14. Plaintiff NORMA WATSON has enjoyed a successful nursing career for approximately 20 years. From 1981 until November, -3- 1985, she was employed as a registered nurse by defendant SAN FRANCISCO GENERAL HOSPITAL, and provided treatment to many patients known by defendants to be excreting tuberculosis, hepatitis virus and cytomeglovirus (CMV), including patients suffering from acquired immune deficiency syndrome (AIDS) and other opportunistic infections. At all times at which she rendered such treatment, NORMA WATSON was a woman of child- bearing age. 15. At all times herein mentioned, defendants knew that patients actively excreting CMV posed a special risk of birth injuries to fetuses of women of child-bearing age who might become infected with CMV. Furthermore, defendants, and each of them, knew that patients suffering from AIDS had a significant incidence of active CMV infection, approaching 100%. Despite this knowledge, defendants, and each of them, failed to adequately warn or protect the nursing staff at San Francisco General Hospital from AIDS and associated opportunistic infections, including, but not limited to hepatitis, tuberculosis, and CMV. 16. As a proximate result of the facts above set forth, NG Gadl fuberwele 19 (74 | plaintiff NORMA WATSON became infected with CMV, As a further proximate result of defendants’ negligence, her son, plaintiff JAMES NATHANIEL WATSON has suffered numerous debilitating and disabling birth defects caused by the CMV, including but not limited to malformation and disease of the genitals and related structures; malformation and defects of the axial skeleton, including the skull; bilateral hearing loss; infection of the retina, with high risk of blindness; special high risk of -4- — > retardation, developmental delays, impairment of his future quality of life and earning ability. JAMES NATHANIEL WATSON was first diagnosed with birth defects arising from CMV infection on or about the first week of April, 1987, which was the first knowledge that plaintiffs herein had of injury or damages. Plaintiff is informed and believes, and on such information and belief alleges that said injuries are of a permanent nature and will result in his permanent and total disability, to plaintiff's general damage in excess of the jurisdictional limits of the Municipal Court. 17. For a further proximate result of said carelessness and negligence of defendants, and each of them, and of the resulting injuries, plaintiff JAMES NATHANIEL WATSON has been obliged to incur expenses for medical care, hospitalization and treatment and will be obliged to secure medical care and treatment for the rest of his life, the reasonable amount of which plaintiff cannot State at this time, and prays leave to insert the same herein when fully ascertained. 18. Plaintiff has lost prejudgment interest pursuant to Civil Code § 3291, the exact amount of which plaintiff prays leave to insert herein when finally ascertained. 19, The aforementioned acts of the individually named defendants, and each of them, were willful, wanton, malicious and oppressive, and in conscious disregard of the safety of plaintiff, and justifies the awarding of exemplary and punitive damages against each of them in the amount of $10,000,000.00. 20. On or about May 22, 1987, plaintiffs presented to defendants CITY AND COUNTY OF SAN FRANCISCO, CITY OF SAN -5- FRANCISCO DEPARTMENT OF HEALTH, SAN FRANCISCO GENERAL HOSPITAL, PAUL VOLBERDING, M.D., MERVYN SILVERMAN, M.D., KEITH HADLEY, M.D., GRACE LUSBY, R.N., CLIFF MORRISON, R.N., DONALD ABRAMS, M.D., JULIE GERBERDING, M.D., JUDITH SPINELLI, R.N., and BONNIE TEMPKIN, R.N. by (serving a second amended claim on the Control- ler for the City and County of San Francisco for injuries, disability, losses and damages suffered and incurred by them by reason of the above-described occurrence, all in compliance with the requirements of § 905 of the Government Code. All indivi- dually named defendants were served by mail on May 22, 1987, and have not responded to the claims, which are deemed rejected as a Matter of law since more than 45 days have elapsed since service of same. Previously, on or about April 10,1987, plainiffs filed with defendant CITY AND COUNTY OF SAN FRANCISCO, a claim by personal service on the Controller of the City and County of San Francisco. Plaintiffs amended said aforementioned claim and served same on April 13, 1987 on the said Controller 21. On or about June 2, 1987, (CITY AND COUNTY OF SAN FRANCISCO) rejected the claim in its entirety. 22. On or about May 27, 1987, plaintiffs presented to the STATE OF CALIFORNIA and the STATE OF CALIFORNIA DEPARTMENT OF HEALTH SERVICES ADMINISTRATION by service of a first amended claim to the State Board of Control for the injuries, disability, losses and damages suffered and incurred by them by reason of the above-described occurrence, all in compliance with the require- ments of § 905 of the Government Code. Prior to this time an initial claim was similarly served on or about April 17, 1987. / 23. On or about July 8, 1987, the STATE-OF CALIFORNIA ~6- 20 2) 22 | 23 24 25 26 27 28 rejected the claim in its entirety. WHEREFORE, plaintiff prays judgment against defendants, and each of them, as hereinafter set forth. SECOND CAOSE OF ACTION - FRAUDULENT CONCEALMENT AS AND FOR A FURTHER, SECOND, SEPARATE AND DISTINCT CAUSE OF ACTION FOR FRAUDULENT CONCEALMENT, PLAINTIFF NORMA WATSON COMPLAINS OF DEFENDANTS, AND EACH OF THEM, AND ALLEGES AS FOLLOWS: 24. Plaintiff hereby incorporates by reference all of the paragraphs of the First Cause of Action of this complaint and makes Said paragraphs a part of this, the Second Cause of Action, as though fully set forth herein. 25. On information and belief at some time prior to the end of her second trimester of pregnancy, which time is presently unknown to plaintiff, defendants, and each of them, became aware through one or more laboratory blood tests that plaintiff NORMA WATSON had converted from a CMV negative to a CMV positive Status. 26. Defendants, and each of them, willfully and fraudulently concealed and failed to inform plaintiff NORMA WATSON of this change in her CMV antibody status. 27. AS a proximate result of said fraudulent concealment, plaintiff NORMA WATSON proceeded to conceive and bear a child, plaintiff JAMES NATHANIEL WATSON, without knowledge of the possibility of severe and disabling birth defects to plaintiff JAMES NATHANIEL WATSON, 28. This fraudulent concealment by defendants, and each of them, of the existence of plaintiff NORMA WATSON's CMV infection, -7- incurred in the course and scope of her employment, aggravated said injury (Labor Code § 3602(b)(2)) by causing her to conceive and give birth to plaintiff JAMES NATHANIEL WATSON, without having the opportunity to decide not to conceive and bear a child who had a high risk of incurring such severe and debilitating birth defects. 29. As a direct and proximate result of defendants’ fraudulent concealment, plaintiff has suffered and will continue to suffer severe emotional distress because of the future burden of caring for and meeting the needs of her child for the rest of her life and her worry about how her child will be cared for in the future, all to plaintiff's general damage in a sum to be determined at the time of trial. . a“ ae 30. By reason of the aforementioned acts of the defendants, and each of them, plaintiff NORMA WATSON has been required to, and will in the future be required to, expend money for medical a and hospital expenses in an amfount which has not yet been ascertained. “ 31. By reasons .of the aforementioned acts of defendants, and each of them, plaintitt NORMA WATSON has been prevented, and in the future will be prevented, from attending to plaintiff's usual occupation due to the necessity of caring for her severely disabled child, and therefore will incur damages for lost wages in an drount which has: not yet been ascertained. 32. / The aforementioned acts of the individually named defenddnts, and each of them, were willful, wanton, malicious and oppressive, and justify the awarding of exemplary and punitive damages in the amount of $10,000,000.00. -8- 10 ll 12 13 14 15 16 17 ie 19 20 21 22 23 24 25 26 27 28 ee ee WHEREFORE, plaintiff prays judgment against the defendants, and each of them, as hereinafter set forth. THIRD CAUSE OF ACTION (LOSS OF CONSORTIUM) AS AND FOR A THIRD SEPARATE AND DISTINCT CAUSE OF ACTION FOR LOSS OF CONSORTIUM, PLAINTIFF JAMES A. WATSON COMPLAINS OF DEFENDANTS AND EACH OF THEM, AND ALLEGES AS FOLLOWS: 33. Plaintiff JAMES A. WATSON hereby incorporates by reference all of the paragraphs of the First and Second Causes of Action of this complaint and makes said paragraphs a part of this, the Third Cause of Action, as though fully set forth herein. 34. Plaintiff JAMES A. WATSON is now and at all times mentioned herein has been the lawfully.wedded husband of plaintiff NORMA WATSON. 35. As a direct and proximate result of the aggravation of his wife's injury by way of fraudulent concealment by defendants, and each of them, plaintiff JAMES A. WATSON has been deprived of the services of his spouse and deprived of the comfort and solace usually and ordinarily provided by his spouse in good health and unimpaired vigor and strength, all to plaintiff's general damage in a sum to be determined at the time of trial. 36. The aforementioned acts of the individually named Gefendants, and each of them, were willful, wanton, malicious and oppressive, and justify the awarding of exemplary and punitive damages in the amount of $10,000,000.00. WHEREFORE, plaintiff prays judgment against the defendants, and each of them, as hereinafter set forth. -9- 10 1] 12 13 14 15 7 18: 19 20 21) 22 23 24 25 26 27 28 16 | FOURTH CAUSE OF ACTION INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS AS AND FOR A FURTHER, FOURTH AND DISTINCT CAUSE OF ACTION FOR INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS, PLAINTIFFS NORMA WATSON AND JAMES A. WATSON COMPLAIN OF DEFENDANTS, AND EACH OF THEM, AND ALLEGE AS FOLLOWS: 37. Plaintiffs hereby incorporate by reference all of the paragraphs of the First, Second and Third Causes of Action of this complaint, and make said paragraphs a part of this, the Fourth Cause of Action as though fully set forth herein. 38. As a direct and proximate result of the aggravation by defendants, and each of them, of NORMA WATSON's work-related injury by way of their willful, intentional and fraudulent concealment, plaintiffs JAMES A. WATSON and NORMA WATSON suffered, and will continue to suffer severe mental anguish upon the discovery of the initial birth defects of their son, JAMES NATHANIEL WATSON, and will continue to suffer said anguish upon the discovery and development of subsequent birth defects. Plaintiffs will suffer further mental anguish due to the burden of caring for and meeting the needs of their child for the rest of his life, and their worry about how their child will be cared for in the future. Plaintiffs will suffer and continue to suffer additional severe mental anguish due to the burden of worrying about the deterioration of each other's psychological and physical health as a result of the burden of caring for their son. Plaintiffs have suffered all of the above to their general damage in a sum to be determined at the time of trial. 39. By reason of the aforementioned acts of the defendants, -10- 21, 22 23 24 25 26 27 28 and each of them, plaintiffs JAMES A. WATSON and NORMA WATSON have been required to, and in the future will be required to, expend money for medical and hospital expenses in an amount which has not yet been ascertained. 40. By reasons of the aforementioned acts of defendants, and each of them, plaintiffs JAMES A. WATSON and NORMA WATSON have been prevented, and in the future will be prevented from attending to their usual occupations, and therefore will incur damages in an amount which has not yet been ascertained. 41. The aforementioned acts of the individually named defendants, and each of them, were willful, wanton, malicious and oppressive, and justify the awarding of $10,000,000.00. WHEREFORE, plaintiffs pray judgment against the defendants, and each of them, as hereinafter set forth. FIFTH CAUSE OF ACTION NEGLIGENCE/NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS AS AND FOR A FURTHER, FIFTH, SEPARATE AND DISTINCT CAUSE OF ACTION FOR NEGLIGENCE AND NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS, PLAINTIFF JAMES A, WATSON COMPLAINS OF DEFENDANTS, AND EACH OF THEM, AND ALLEGES AS FOLLOWS: 42, Plaintiff hereby incorporates by reference all of the Paragraphs of the First, Second, Third and Fourth Causes of Action of this complaint, and makes said paragraphs a part of this, the Fifth Cause of Action, as though fully set forth herein. 43, Due to defendants' negligent and reckless conduct, and each of them, plaintiff JAMES A. WATSON has suffered severe mental anguish and distress as described above in the Fourth -ll- ra Oo nS oS A — 23 24 25 26 27 28 Cause of Action. He has further become infected witn CMV. He | has further suffered the impairment of his marital right to procreate and have healthy children. As a result of defendants' negligent and reckless conduct, plaintiff JAMES A. WATSON has suffered general damages in a sum to be determined at the time of trial. 44. By reason of the aforementioned acts of the defendants, and each of them, plaintiff JAMES A. WATSON has been required to, and in the future be required to expend money for medical and hospital expenses in an amount which has not yet been ascertained. 45. By reasons of the aforementioned acts of the defendants, and each of them, plaintiff JAMES A. WATSON has been prevented, and in the future will be prevented from attending to plaintiff's usual occupation, and therefore will incur damages for lost wages in an amount which has not yet been ascertained. 46. The aforementioned acts of the individually named defendants, and each of them, were willful, wanton, malicious and oppressive, and justify the awarding of exemplary and punitive damages in the amount of $10,000,000.00. WHEREFORE, plaintiffs JAMES NATHANIEL WATSON, NORMA WATSON and JAMES A. WATSON pray judgment against the defendants, and each of them: (1) For plaintiffs' general damages according to proof; (2) For plaintiffs' medical and related damages according to proof; (3) For punitive or exemplary damages in the sum of $10,000,000.00 as against the individually named defendants; -j]2- NR WD ™ oO (4) For plaintiffs’ loss of income, wages and earning potential according to proof; (5) For prejudgment interest according to proof, pursuant to Civil Code § 3291; (6) For plaintiffs' cost of suit herein; and (7) For such other and further relief as to the court may seem just and proper. DATED: November FO , 1987. Mase Leda peer NORMA WATSON, Individually and as Guardian ad Litem of JAMES NATHANIEL WATSON In Pro Per 4 ne (y Cede AMES A. WATSON n Pro Per -1]3- Ww Pn » oOo ao nn Oo WA 10 ll 12 13 14 15 16 17 18 19 2] 22 23 24 25 26 27 28 ENDORSED JAMES A. WATSON and NORMA WATSON /EIL 172 Pearce Prancsco Goorty Hercules, California 94547 » Telephone: 415/724-0406 DEC 99 1987 In Pro Per BERALD W. DICKINSON, Cissh: ay MRARIA JEEYPINI AHO Deputy Clerk SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE CITY & COUNTY OF SAN FRANCISCO JAMES NATHANIEL WATSON, a minor, by No. QQo NORMA WATSON, his Guardian ad Litem; NORMA WATSON; JAMES A. WATSON, COMPLAINT FOR DAMAGES (Wrongful Life/ Wrongful Birth) [Civil Code §§ 1714(a), 3333) Plaintiffs, THE REGENTS OF THE UNIVERSITY OF CALIFORNIA, GENETIX CORPORATION, MITCHELL S. GOLBUS, M.D., MOREY FILLER, M.D., BLACK CORPORATION, WHITE COMPANY, a co-partnership, and FIRST DOE through TWENTIETH DOE, inclusive, Defendants. femme a ene Nee ee ee te ee ee Ce et ee ee ee ee ee ee Se FIRST CAUSE OF ACTION (Wrongful Life) PLAINTIFF, JAMES NATHANIEL WATSON, A MINOR, THROUGH HIS GUARDIAN AD LITEM ALLEGES: i. Plaintiff NORMA WATSON is the mother and plaintiff JAMES A. WATSON is the father of plaintiff JAMES NATHANIEL WATSON, a Minor born on January 5, 1987. -j- 10 1) 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2. For the purposes of this action, NORMA WATSON was appointed by the above-entitled court, and now is, Guardian ad Litem of plaintiff JAMES NATHANIEL WATSON, a minor. 3. At all times herein mentioned, the REGENTS OF THE UNIVERSITY OF CALIFORNIA, was and is a legal entity organized and existing under the Constitution and laws of the State of California, and was and is engaged in operating and managing medical services facilities rendering professional medical services, including genetic screening to patients who are members of the general public in the City and County of San Francisco, State of California. 4. At all times herein mentioned, defendant GENETIX CORPORATION was and is a corporation organized and existing under the Constitution and laws of the State of California, and was and 1s engaged in operating and managing medical services facilities, including genetic screening to patients who are members of the general public in the City and County of San Francisco, State of California. 5. At all times herein mentioned, defendant MITCHELL S. GOLBUS, M.D., MOREY FILLER, M.D., and FIRST DOE through FIFTH DOE, inclusive, were physicians and surgeons duly licensed to practice medicine in the State of California, and did practice in the City and County of San Francisco, State of California, and held themselves out to the public generally and to plaintiffs herein as being qualified and skilled in the practice of medicine, and as possessing and exercising that degree of skill and learning ordinarily possessed and exercised by other skillful physicians practicing medicine in the City and County of San -2- xn Op WG Oo @® 10 1} 12 13 14 15 16 17 18 19 20 2] 22 23 24 25 26 27 28 Francisco, State of California, and in similar communities throughout the United States. 6. The true names and capacities, whether individual, corporate, associate or otherwise of defendant BLACK CORPORATION, WHITE COMPANY, a co-partnership and FIRST DOE through TWENTIETH DOE, inclusive, are unknown to plaintiffs who therefore sue said Gefendants by said fictitious names. Plaintiffs are informed and believe, and thereon allege, that each of said defendants is negligently or otherwise responsible in some manner for the events and happenings herein referred to, and negligently or otherwise caused injuries and damages proximately thereby to the plaintiffs herein alleged. 7. At all times herein mentioned each defendant was an agent, servant and employee of the other defendants herein named; and at all of said times, each of said defendants was acting in the course and scope of said agency, service and employment. 8. Defendants MITCHELL S. GOLBUS, M.D., MOREY FILLER, M.D. and FIRST DOE through FIFTH DOE, inclusive are, and at all times herein mentioned, were employed by defendant REGENTS OF THE UNIVERSITY OF CALIFORNIA, GENETIX CORPORATION and SIXTH DOE through TENTH DOE, inclusive to evaluate and treat patients at the medical facilities of defendant UNIVERSITY OF CALIFORNIA at San Francisco. Defendants MITCHELL S. GOLBUS, M.D., MOREY FILLER, M.D. and FIRST DOE through FIFTH DOE, inclusive were, at all times pertinent hereto, acting within the course and scope of such employment with the permission and consent of their co- Gefendants. 9. Defendants had a duty imposed by contract and the law of -3- i0 1] )2 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 this state to inform parents of potential genetic defects evidenced by test results in their screening progran. 10. Prior to January 5, 1987, at a time when therapeutic abortion was medically feasible, NORMA WATSON underwent medical screening for potential birth defects in her fetus conducted by Gefendants herein. Those test results were diagnostic of birth defects in the child she was carrying. ll. Although the defendants had the abnormal test results evidencing diagnosis of birth defect in NORMA WATSON's fetus at a time when therapeutic abortion was medically feasible, they failed to notify NORMA WATSON or JAMES A. WATSON of their medical significance, or initiate intervention counselling as was their Mandatory duty. 12. In reliance on the diagnosis made by the defendants, and because of their failure to perform their duty to notify or initiate intervention counselling, plaintiffs NORMA WATSON and JAMES A. WATSON permitted the pregnancy to go to tern. 13. On or about January 5, 1987, minor plaintif£ JAMES NATHANIEL WATSON was born with birth defects including, but not limited to, malformation and disease of the genitals, malformation and defects of the axial skeleton, including the skull. Minor plaintiff JAMES NATHANIEL WATSON now suffers a special high risk of retardation, blindness, developmental Gelays, impairment of future quality of life and earning ability. 14. That if plaintiffs NORMA WATSON and JAMES A. WATSON had been correctly informed that the screening test results were diagnostic that their child would suffer birth defects such as //f w A 10 1) 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 described in the paragraph above, they would have elected the option of therapeutic abortion. 15. As a proximate result of the aforementioned defects and diseases suffered by minor plaintif£, secondary to the negligence of the defendants hereinabove alleged, plaintiff JAMES NATHANIEL WATSON is informed and believes and thereon alleges that he will be obliged to incur extraordinary expenses for medical treatment, specialized teaching, training, and equipment for an indefinite period in the future and to pay other expenses in the treatment of his condition in an amount according to proof at the time of trial, and that he will suffer a future loss of income in an amount according to proof at trial. 16. Plaintiffs herein anticipate the filing of an Offer to Compromise pursuant to CCP § 998, and if judgment is obtained exceeding the amount stated in said offer, plaintiffs will be entitled to interest on the amount of any judgment obtained in favor of plaintiffs, said interest to be computed from the date of filing of said offer to compromise. 17. As a further proximate result of the conduct of the Gefendants, and each of them, plaintiffs have incurred damages attributable to an ascertainable economic value, as hereinabove alleged; plaintiffs are thus entitled to prejudgment interest on said damages attributable to an ascertainable economic value pursuant to Civil Code § 3288. WHEREFORE, plaintiffs pray judgment against defendants, and each of them, as hereinafter set forth /// // 10 1} 12 13 14 15 16 17 18 19 20 2] 22 23 24 25 26 27 28 SECOND CAUSE OF ACTION (Wrongful Birth) PLAINTIFFS NORMA WATSON AND JAMES A. WATSON ALLEGE: 18. Plaintiffs NORMA WATSON and JAMES A. WATSON incorporate herein by reference the First Cause of Action. 19. As a proximate result of the negligence of the defendants, plaintiffs NORMA WATSON and JAMES A. WATSON were compelled to and did incur expenses for medical treatment, testing, equpment, etc. for minor plaintiff JAMES NATHANIEL WATSON in an amount that is not yet certain, and plaintiffs pray for damages in an amount in accordance with proof at the time of trial. 20. As a further proximate result of the negligence of Gefendants, plaintiffs NORMA WATSON and JAMES A. WATSON are informed and believe and thereon allege that they will be obliged to incur expenses for medical care, treatment, training, custodial care and equipment for minor plaintiff JAMES NATHANIEL WATSON for the rest of said child's life in an amount according to proof at trial. 21. Plaintiffs NORMA WATSON and JAMES A. WATSON have suffered the negligent infliction of emotional distress as a result of their child being born with birth defects, and have suffered general damages in an amount in excess of the jurisdictional limits of the Municipal Court. WHEREFORE, plaintiffs pray for judgment against defendants, and each of them, as follows: Sf f/f > WW A SN Oo WN 10 1] 12 13 14 15 16 17 18, 19 20 21 22 23 24 25 26 27 28 ON THE FIRST CAUSE OF ACTION: (1) For future medical and related expenses according to proof; (2) For prejudgment interest according to proof; (3) For interest as appropriate under CCP § 998; (4) For general damages according to proof; ON THE SECOND CAUSE OF ACTION: (5) For medical and related expenses incurred as a result of plaintiff JAMES NATHANIEL WATSON's condition according to proof; (6) For prejudgment interest; (7) For interest pursuant to CCP § 998 (8) For general damages according to proof; ON ALL CAUSES OF ACTION: (9) For costs of suit herein incurred; and (10) For such other and further relief as the court may deem proper. DATED: (en 2 | , 1987. \, pe G (2a. "rs A. WATSON vate | 4 are e Mar. de NORMA WATSON, Individually And as Guardian ad Litem for JAMES NATHANIEL WATSON STATS OF CA sttORNIA—STATE AND CONSUMER = VICES AGENCY GEORGE DLURMENAN Corernoy DEPARTMENT OF BOARD OF REGISTERED NURSING 1030 I3Tr STREET SUITE 200 SACRAMENTO CA 94244 2100 TELEPHONE (916) 322 3350 3/ai /ae as tatement on Delivery of Healtn Care to Patients With Communicadle Uisease The B30ard of Registered hursings supports the rignt of all consumers to receive Gisnified and competent healtn care as set forth im the California Administrative Code, Section 1443.5. Tne Board also supports the right of tne nurse to know the patient's diagnosis/ Suspected diagnosis in a timely fashion in order to make an appropriate nursins care plan anc to take necessary precautions to minimize the risk of contracting Or spreading disease. 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"AIDS called. - ‘time hoinl for. hos) +. hosp itals* . wy ot a D Hee feed a * & oo" “5 United Press Internationa}: Be fet NEW YORK'— The : spreading dis” ease AIDS is a “time bomb” for the nation’s hospitals, threatening to bur- den them with expensive treatment and waves of costly lawsuits, a re port by the American Hospital ASSO- ciation said yesterday. The report also said there are re ports of health care workers refusing to treat AIDs patients because of fears they may contract the fatal dis- ease. “No hospital is immune,” said the report in the magazine Hospitals, published by the AHA magazine for health care executives. It warned that AIDS has spread to all 50 states and could put some hos- pitals out of business because of “ig- norance of the disease, poor financial planoing, uneducated staff and lack of legal consc:ousness." ~~ = ° It described acquired immune de ficency syndrome as “a ‘ime dorab at hospitais’ door.” To better help the multi- billion dollar health incustry with the crisis, the AHA will broadcast a tive satel- lite teleconference ‘o the nation’s 0,000 hospitals Jan 22 — “The AIDS ~ Dilemma: Confronting rear with Facts.” __t: @ “wrongful terminatio * workers fired because they refused-_ ,% care for AIDS patients. ef _ tients.‘ — The "AHA report ‘alerts officials - low to avoid costly lawsuits such as t” from * E. Michael Kelly, a lawyer quotes! in ‘the report, believes hospitals . ..should gird for two wav of law-- ‘suits. The first may be oven ernploy: “y meat issues — the dismissal of work-_ ers who develop the rights of "hospitals to screen blood of workers and ferreting out those with AIDS or AIDS antibodies” .*7 ~~: The second wave, predicted to. come in two years and to be much costlier than the first, may come from patients, alleging hospital negligence over the failure to inform: them of positive AIDS test results,” failure to protect them from con f tracting AIDS in the hospital, failure *° to protect confidentiality of AIDS pa- 3 tients, and inadvertent use of AIDS--; contaminated blow. - =. “7 -. b a Another danger listed in the report. is the financial drain from treating* AIDS patients — double the daily ay-"~ erage cost for treating other Bae | -— me iw The ARA report, written by editor, : Suzanne Powills and the magazine's .- legal specialist, David Burda, also © said: “The real AIDS epideae may be one of fear- ~ . = ‘ “Despite repeated statements that AIDS is tracsmitted only through ex- - posure to the blood or sexual secre. | tions of :nfected people, rumors and myths abound in the general popula- tion. But the hospital is not immune - from fear. Anecdotes are surfacing“ about bealth care workers refusing. to treat AIDS patieots” ~“s FEBRUARY 1988 PROFESSIONAL UPDATE q This AIDS suit may open the way for a class action A former nurse at San Francisco General Hospital has amended the $100 mil- lion AIDS-related law suit she filed last spring against the city, the hospital, and certain hospital adminis- trators The plaintiff, Norma Watson, kX says she's revising her suit based on new findings. indicating that during her pregnancy she contracted cvtomegalo- virus and tuberculosis from AIDS patients, and that these infections caused her child's severe skeletal and neurological defects Watson claims hospital administrator: had forbid- den her to wear protective clothing while caring for AIDS patients. the major- It, of whom. she alleges. are infected with other highly infectious diseases. includ- ing CMV and TE Watson also claim that. earl in her pregnancy hos- pital officials knew — through blood test~—that she had become seroposi- tive for these infections and willful concealed that in- formation frum her Watson says she’s re- ceived calls from hundred~ of other nurses with AIDS- related complaints against their employers and 1s now considenng refiling the suit as a class action Is your unit always out of gloves? You're not alone Since the CDC advised caremvers to use AIDS precautions with all pa- tients, the demand for pro- tective clothing—especially glove~—has increased so dramaticalls that suppher- can't keep up with demand Two of the country's leading manufacturer-~ of Ja- tex glaves are building new factone~. but these facghtie~ won't be operating for at least a vear In the mean- time, the backlog of orders stands at about s1. months Man) hospitals are sub- stituting infenor vinv! gloves or gloves made of stenle, surgical-strength la- tex However, those sup- phes may soon dwindle a> well. the manufacturers warn What's more, they say. demand for gloves could double vet again in the next few vears as more peo- ple outside the health-care field begin to take precau- tions against AIDS Postal workers in Kansas City, for 12 RN FEBRUARY 1988 example, have started wearing gloves to protect themselves from blood and urine leaking from packages mailed to a local testing laboratory. Hospitals receive an official w on AIDS safegu The natjon’s 500,000 health-care employers have received the first official notice of their legal responsi- bility to protect workers against AIDS and other blood-borne diseases. A letter from HHS and the Oc- cupational Safety and Health Adminstration warns employers of their stnet accountability for fail- ing to implement CDC in- fection-control guideline The notice says employ - ers must provide gloves. masks, eve protectors. re- suscitation bags, and venti- lator devices They must also ensure that employee: wash their hands after re- moving gloves and after con- tact wth blood or other body fluids. use disposable needles and symnges, and clean up blood spills with a mixture of water and bleach. AIDS PRECAUTIONS CHANGING PRACTICE, RNs AGREE; OSHA ALREADY MOVING TO ENFORCE CDC GUIDELINES Rt reserved OF THE he spread of AIDS is already having a profound impact on the way nurses practice in many institutions But the transition to total infection control is taking place too slowly to satisfy some authorities, who say that too many hospitals and health care providers are taking unnecessary risks. How best to protect providers and patients has emerged as an especially painful issue in Califor- nia San Francisco General Hospi- tal is entangled in public debate about its employees’ compliance with the CDC's recently revised guidelines that call for gloves and, TY necessary, gowns, masks, and goggles when handling blood or ty fui in the care ol @ patients.” (See page 373.)_ There's good news too: the Cali- fornia Nurses Association is set- ting the pace in education with a “train-the-trainer” | movement that will reach up to 30,000 health care workers. Under a two-year contract with the state Health Ser- vices Dept., CNA has been train- ing health professionals who in turn are staging two-day sessions all over the state. Signs are that more hospitals are taking heed and moving toward the “body substances isolation” approach that takes the CDC guidelines to their logical conclu- sion: eliminating isolation of pa- tients except those with airborne infections Developed by nurses at UC/San Diego and Seattle’s Har- borview, the plan is to treat all patients as if they are infectious. “We don't want workers relying on test results and thinking, This person has AIDS, so be careful— but the person in the next bed is safe, so ] can relax,” explains Mar- guerite Jackson, epidemiology di- rector for UC/San Diego. “It’s the undiagnosed patient who gets you every time,” she points out. Many experts think the new stress on infection control is long overdue; Hepatitis B is killing over 200 health care workers every year. By contrast, the chance of con- tracting AIDS on the job is very small; only about a dozen health professionals are known to have been infected since 1979. OSHA stepping up response. At presstime, the Occupational Safe- ty & Health Administration was starting work on a new rule that will threaten hospitals with fines of up to $10,000 if they don’t take the necessary steps for curbing AIDS, Hepatitis B and other bloodborne diseases. The new OSHA standard could take up toa year to develop, but the agency has already beefed up sur- veillance and has responded to 18 complaints from health care work- ers in recent months. A blood don- or center was fined for failing to provide gloves: the other investiga- tions have not been completed. An OSHA official told AJN that most complaints deal with lack of protective equipment. In two cases, he said, hospital workers Body Substance lheletanisused | tn gl petienl cere. @@2 Signs posted in every room remind nurses to protect themselves and their patients by observing the body-substance Isolation system in use at Seattle’s Harborview. reported they were given “the kind of light plastic gloves used in food service, which would not afford the protection of a latex glove.” OSHA plans to make about 200 inspections this year. Meantime, though voluntary compliance seems to be gaining, AHA officials admit it's spotty, at best. In a recent SEIU survey of 47 depart- ments in 19 hospitals, workers re- ported that gloves, gowns and masks were easily accessible in only 47 percent of the departments and that only 44 percent of the hos- pitals were training all employees exposed to infection. ANA nurses report that some facilities routinely run short of gloves and protective garments, according to ANA lobbyist Donna Richardson, who has been working for tough enforcement. “Historically, nurses have al- ways cared for infectious patients and they continue to do it today,” she says. “But they should not be expected to do it without educa- tion and protective garments.” Many found recapping needies. For their part, some nurses need to work harder to overcome old hab- its, concludes the author of a sur- vey of Los Angeles ER nurses. Queried by telephone, all said they wore gloves to clean wounds, but over 50 percent did not wear them to start IVs, as CDC recommends. Half were recapping needles (a practice a CDC study has found to be responsible for over 40 percent of “preventable” exposures to AIDS.) Only 60 percent knew if their hospital had AIDS guide- lines, and two-thirds of that group could not say what the guidelines were Those answers were “troubling” to surveyor Harvey Bartnof. a phy- sician who heads AIDS education at UC/SF's medical school. His premise was that ER employees P~OFESSIONAL JOURN ‘4 AMERICAN NURSES’ Av” “CIATION © (060 American Journal of Nursing 872 MARCH 1966 FN URS JING NI 1 a 7 ee an mn : ] One way to avoid neediesticks is to plunge the used needle into a foam block before discarding it, as shown by Cindy Johnstonof _ Copley Memorial in Aurora, IL. needn’t wear gloves “routinely, for giving an injection, taking a pulse or auscultating lungs, unless there’s bleeding or open le- sions... But the CDC guidelines do mean that gloves should be used when starting IVs, drawing blood, suctioning, changing a urinary drainage bag or putting in Foleys or NG tubes.” He told AJN that the survey confirmed “what I see with my own eyes.” Health providers tend to fall into two camps, he said— “the Dr. and Ms. Machos, who feel they don’t need gloves, and the Space Suit Set, who'd like to wear two or three pairs.” Bartnof was optimistic, though: “I see more nurses wearing gloves.” “Hospitals are grappling.” Sur- veying hospitals and nurses around the country last month, AJN found most of them in vary- ing stages of consciousness-rais- ing. “There’s a lot of grappling,” commented an AHA official. “The heavy questions are how best to educate staff, which ones to edu- Contnued on page 388 STATE SAYS INFECTION CONTROL WAS FAULTY AT S.F. GENERAL SAN FRANCISCO CA ronically, a host of troubies at San Francisco General was pre- cipitated in part by the hospital’s own pre-eminence in AIDS care. The controversy has also been fueled by growing public fears and a movement by hospital unions to ensure employees’ safety. The 444-bed public hospital set | up the nation’s first dedicated AIDS unit and hes served as a model of compassionate care for up to 40 patients a day—a third of the city’s hospitalized AIDS victims. Like other public hospitals, however, SFG suffers from chronic shortages of funds and staffing. In December, its nurses and physi- cians lined up before the city’s board of supervisors and begged for help with a nursing shortage that’s left 66 RN positions open and forced the hospital to close two | units. The response was an investi- gation by the state Health Services Dept., which issued a report rap- ping the hospital for understaffing and for shortcomings in house- keeping and in its procedures for discarding contaminated materi- als. Two lab workers were seen handling patient specimens with- out gloves, said the report. That same month, SFG was hit with a suit by Norma Watson, an RN who says her year-old baby was_ born defective because she was ex- posed to the cytomegalovirus in cases. Watson left the staff two years ago alter protesting that “she was required to care for patients without protective gear her supervisors considered exces- sive. She's suing the hospital, the city, and the state for $100 mil- hon. SFG staffers say the evidence is that employees take too few pre- cautions—not too many. Staff physician Julie Gerberding has been tracking a group of 270 RNs, MDs, and lab techs since 1984. Ina report published in July, she said the results were “disturbing”: 56 percent were using “inadequate” precautions in AIDS cases. Only 14 percent were using precautions that surpassed the CDC guide- lines. More encouraging was the fact that none had become infected though over a third had sustained accidental exposure to blood or body fluids from patients with AIDS or ARC. Since the study was published, however, one SFG nurse has suffered a needlestick accident and has seroconverted. The lesson, says Gerberding: “The virus is not very transmissi- ble; we've seen just one infection.” Gontnued on page 390 GLOVE SHORTAGE SEEN EASING BY LATE 1988 Corrnns about the glove shortage are mounting as health care workers grow more conscious of AIDS precautions Demand has risen “drastically” for latex gloves, which have a “bet- ter feel” than vinyl, according to Les Jacobson of Baxter Health Care Supply. Often, he says, “a hospital has enough on the shelf for two days, period.” Like other suppliers, Baxter is building a new plant that will boost production from 1 billion to 1.5 bil- lion units a year. With the added capacity, he predicts the shortage will ease “over 1988 and 1989.” UCSD’s Marguerite Jackson, RN suggests that hospitals ease demand by supplying “industrial gloves—like dishwashing gloves” to housekeepers and others not giving direct care. MARCH 1988 373 F oN U R § I| N G AIDS PRECAUTIONS SEEN CHANGING PRACTICE Contnued from page 372 cate first, what kinds of equipment are needed. Some are doing this in an organized way; some are not.” At Los Angeles’ well-organized San Pedro Peninsula Hospital, “nurses are going through gloves like water,” reported ER nursing director Nancy Young. Young said the practice is to use a new pair of gloves fur every patient contact. San Pedro has posted signs in every room and is stocking crash carts throughout the hospital with prepacked kits containing a gown, gloves and goggles. ERNs at L.A.’s Kaiser-Panora- ma Cit}Hospital began using uni- versal precautions two years before the hospital officially adopted the CDC guidelines -last November. “When we get notice that a multi- system trauma victim is coming in, nurses are gloved, gowned and masked in advance,” said ER nurs- ing director Ruth Shaw. On the other hand, some admin- istrators hedged when asked if nurses were actually using gloves and other gear “They’re supposed to be doing it” was ‘one response that was typical of several. “It’s amazing how few precau- tions are being taken” at one New York City hospital, according to a nurse who works on a med-surg floor where 20 out of 40 patients are diagnosed with AIDS or ARC. “At best, we have five nurses; at worst, two nurses and two aides. Gloves are used when nurses can remember to put them on. When someone is falling out of a chair, your priorities change.” N.Y.’s push for education. New York union leaders confirmed that gloves are sometimes lacking in municipal hospitals and that workers are sometimes assigned to AIDS units without special train- ing The city’s Health & Hospitals Corp has been working with unions to develop a new training package—a three-hour session to be updated annually. “The goal is to reach all 40,000 H&H employees in the next year,” said Paul Moore, director of the AIDS Initiative. AHA staffers reported they were fielding a lot of questions about the cost of universal precautions. Backers of the body-substance sys- tem argued that the cost of sup- plying more gloves would be mini- mal, compared with the expense of the mandatory testing that some hospitals are weighing. “One law- suit is more expensive than extra gloves,” pointed out Lorraine Har- kevy, past president of the Asso- ciation of Infection Control Prac- titioners. Because data are lacking, how- ever, Houston's 1,218-bed Meth- odist Hospital is about to launch one of the nation’s broadest AIDS testing programs; every patient will be asked to take the test on admission. The CDC guidelines are “too cumbersome” and “‘a lot of worry and expense,” declared Dr. C. Eugene Carlton Jr., president- elect of the medical staff. More typically, hospitals are lumbering toward compliance. = 4 1 / The California Nurses Association is seeking legislation to allow disclosure of HIV test results to direct caregivers. Atleft, CNA officer Mary Foley talks toa reporter after testifying. “Don’t quote me!” pleaded the in- fection control nurse at a major D.C. hospital. “As baby nurses, we were all taught to recap, and some still do it. We're working to in- crease awareness and ordering more gloves.” Infectious patients are still isolated, she said, predict- ing that the hospital would convert to the body-substance system “within three years.” Memphis’ St. Joseph’s, too, is still placing infectious patients on isolation “because we lack the staff to do a really intensive education program,” according to an official. Disease-specific isolation is also the rule at Shreveport’s VA, where astaffer estimated that “nurses are wearing more gloves, but haven't quite adapted to using gloves to start IVs” Whether gloves need always be used to start IVs was questioned by some experts surveyed. The con- sensus though was heavily in favor: “When you start or disengage, a drop usually comes out,” said Brenda Stoller, a nurse who re- cently founded the Association of Nurses in AIDS Care. (ANAC’s address: Box CN 5254, Princeton, NJ 08543-5254 ) “A major shift in behavior." How to balance precautions with pa- tient safety and comfort was the issue that nurses brought up over and over. Said San Francisco Gen- eral infection expert Grace Lusby: “If you wear gloves all the time, forgetting to take them off, you're a hazard to patients. We're saying, Always change your gloves and wash your hands before going to the next patient.” Just as emphatic was Marguer- ite Jackson, one of the authors of the body-substance system: “The main purpose of precautions is not to protect employees from HIV infection—a very rare event. The real aim is to reduce cross-trans- mission between patients. “Practically,” she said, “we're Continued on poge 390 388 MARCH 1988 S.F. GENERAL FAULTED Contnued from page 373 Gerberding and other staffers complain it made no sense for the state to measure compliance at the hospital because it’s been working for months to phase in the body- substances system. The state re- port, for instance, criticized the staff for failing to post isolation signs for AIDS patients—a prac- tice that’s already been jettisoned. A massive inservice effort has been launched with open forums to be followed up with classes for ail 7,000 employees. “We were cited for not having put out a memo and made the transition overnight,” noted infection control coordina- tor Grace Lusby. But results are visible already, she reported: “Doctors and nurses are telling each other, Get away from there and put your gloves on!” “Our practice is changing rap- idly,” agreed director of nursing Judy Spinella. Staffing remains a problem: “With the highest salary scale in town, we have lots of appli- cants but no money to hire them.” Union rep Donna Gerber, an RN, prescribed a cure for the bud- get squeeze’ “Close more beds.” Said Gerber. ‘“‘We’re focusing on the relationship between under- staffing and accidental needle- sticks ... When one of our nurses seroconverted, everyone became educated much faster.” O AIDS CHANGES PRACTICE Continued from page 388 simplv talking about increased use of gloves and hand-washing But it calls for a major shift in behavior and thinking to practice in a set- ting where everyone is regarded as potentially infectious. “What this doesn’t mean is dressing like a robot for every patient interaction. It does mean forgetting our rigid rule-based sys- tems and using our professional judgment to assess in every case what we need to do to protect our- selves and our patients.” O MARCH 1988 Acquired Immunodeficiency Syndrome and Related Conditions The monthly update for health professionals VOLUME 3/NUMBER 2 (pages 25-40, 1S-4S) FEBRUARY 1988 Concern mounts over CMV exposure during AIDS patient care A former San Francisco General Hospi- tal nurse, NORMA WATSON, has filed a multimillion dollar lawsuit against the hospital, claiming she acquired cyto- megalovirus while caring for AIDS pa- tients and subsequently gave birth toa child with birth defects. She contends that she acquired CMV because she wasn't Hlowed to wear full protective isola- tion gear while caring for AIDS pe- tients, who commonly have CMV infections or excrete the virus. Although the suit has only been filed -- and Watson hasn't gotten a lawyer to represent her yet -- the case brings up new questions regarding the risk of health care workers acquiring CMV and other infections while caring for AIDS patients. In particular, CMV is of great concern to female health care workers of childbearing age, because of the possibility that they could pass CMV along to their unborn fetuses, causing major birth defects. Is there truly a risk? And if so, what isolation precautions are necessary to avoid exposure? Task force recommendations began controversy PATRICK JOSEPH, MD, associate profes- sor of medicine and infectious diseases at the University of California in San Francisco (UCSF), says the CMV contro- versy has raged for years, as studies within the last decade showed that in- fants, transplant patients, sand other immunosuppressed patients excreted CMV. As a result, many hospitals did have policies removing pregnant nurses from the care of those patients, but most began reevaluating those policies again in the 1980s. By then, newer studies had begun to show that bealth care workers weren't necessarily at higher risk of developing CMV when caring for immuno- suppressed patients. But several years ago, the issue resurfaced with AIDS patients, Joseph Says, when the UCSF Task Force on AIDS recopmended that pregnant workers not care for AIDS patients to avoid CMV expo sure. Although the task force later changed its recommendations to say that pregnant workers were not exempt from caring for AIDS patients, Joseph said the after- shocks of those initial guidelines still linger. He surveyed all the epidemiolo- gists at teaching hospitals in the San Francisco Bay area last year about how they handle pregnant health care workers caring for AIDS patients. He found that policies varied widely. *The garut [of responses] was every- thing from ‘We do nothing’ to ‘Absolute- ly, we don't allow pregnant women on the same floor as an AIDS patient.™ Highlights of this issue: @ Cryptosporidiosis risk to workers ........... 28 @ Lab worker's seroconversion studied ........ 31 @ Needle exchange program criticized ........ 35 @ Military’s policy on infected members ....... 36 CMV reactivates in AIDS patients CMV is a member of the herpes virus family. The virus is "ubiquitous? -- meaning it is present everywhere. When first infected with the virus, people may experience mild symptoms such as slight fever, myalgia, and coughing. Once infected, healthy people become carriers of the virus and show no fur- | ther symptoms of infection. But in AIDS patients, the dormant CMV "reactivates," causing opportunistic infections such as retinitis or gastroenteritis. Studies have shown that at least half of the U.S population has been exposed to CMV and are carriers of the virus. Other research indicates that when women acquire their first CMV infection during pregnancy, there is a 30% to 480% risk of transmission to their fetus, and that babies are more likely to have CMV- related birth defects when the mother becomes infected during the first half of gestation.© Studies also have shown that CMV is present in blood, semen, tears, saliva, breast milk, vaginal secretions, and cerebrospinal fluid. But how is CMV transmitted? Presumably, transmission could occur if workers touched their eyes, noses, or mouths with hands contaminated by secretions containing CMV. is CMV transmitted by sneezing? "CMV is spread by close contact with secretions," says THOMAS KODELS, MD, ' assistant professor of pediatrics at the Oklahoma Children's Hospital in Oklahoma City. He co-authored & study showing that of 246 health care workers working with AIDS patients, none seroconverted to CMV." (See p. 28 for a similar study Kuhls co-authored on cryptosporidial infections in AIDS patients.) However, even if workers get CMV- contaminated secretions on their hands, "if you wash your hands very well, the rjsk of transmission is extremely low," according to Kuhls. ROBERT BOKELMAR, a San Francisco attorney reviewing the Watson case, disagrees. He told AIDS Alert he believes CMV "is passed like a cold. It's puch more easily transmitted by breathing or sneezing. ... * Watson believes she acquired CMV on the job because her superiors wouldn't Sllow her to routinely wear "full pro- tective barriers" ~. mask, gown, and gloves -- when caring for AIDS patients, Bokelman said. Watson's suft claims she wasn't allowed to wear protective gear with all AIDS patients under San Fran- cisco General's newly inatituted system of universal infection control precau- tions. Under that system, AIDS patients aren't. placed on blood and body fluid precautions; workers wear certain pro- tective gear only when exposure to blood or body fluids is anticipated. (See related story, p. 29.) Norma Watson is unavailable for com- ment. However, her husband, JAMES A. WATSON, told AIDS Alert that his wife was "forbidden to wear a mask, gown, and gloves while dealing with infectious and communicable [(AIDS} patients. ... You [should] err on the side of precaution. it's a standard rule of thumb in medical procedures.” Watson said be is a sur- geon, but he’s unable to practice be- cause he has hepatitis B He said his wife has hepatitis 5 as well as pul mo- nary tuberculosis. AIDS ALERT (ISSN 0887-0292 — USPS-000478) is published monthly by Amencan Health Consultants Inc, 67 Peachtree Park Drive NE Attanta GA 303091397 Phone (404) 351-4523 Second class postage paid at Atlanta, GA POSTMASTER Send address changes to AIDS Alert, 67 Peachtree Park Drive, NE. Atlanta GA 30309-1397 Editor Theresa Waldron Subscription rates USA and Canada, one year (12 issues), $109 three years, $2768 Elsewhere, add $10 per year, total prepaid in US funds Back issues, when available $10.00 each AIDS Alen ts independent and ts not affiliated with any government agency or other organizations Opinions expressed are not necessarily those of this publication Mention of products or services does not constitute endorsement Clinical, legal, ano other comments are offered for general guidance only, professronal counse! should be sought for specific situations Copyright : 1988 by American Health Consultants Inc. Publisher Lasiie C. Norins, MD. PhD Vice-President and General Manager Robert Williford Executive Editor David Schwartz Assistan! Executive Editors Andrea Berry and Bon Meadows Copy Editor Rosemarie Smith. Promotion Manager Lyn Cohen Advertising Manager David Wilson. Circulation Manager Robin Saiet. Production Coordinator: Terri Sherrod All nghts reserved Reproduction. distribution or translation without express wntten permission is strictly prohibited. Newsletters published by the company include Addiction Program Management Mespita! Admitting Monthly AIDS Alen Mospital Employee Health Bach Pain Monitor Hospital Mome Health Clinica! Laser Monthly Mospha! infection Control Contraceptive Technoiogy Update Moeplta! Peer Review Corrvenience Care Update Moepha! Risk Management Discharge Planning Advisor Medical Ethics Advisor Orug Utilization Review Prospective Payment Survival Employee Meaith & Funess Same-Day Surgery 26 FEBRUARY 1988/AIDS ALERT Many infection control authorities claim full isolation gear is unnecessary - to protect workers from CMV. The precaution that's necessary to prevent CMV is handwashing," said JULIE GERBERDING, MD, director of the AIDS Health Care Worker Project at San Fran- cisco General. "And certainly, no health care worker at San Francisco General has ever been disciplined for washing his or her hands before or after having contact with any patient.® The CDC also does not advocate spe- cial precautions for CMV. Its 1983 "Guideline for Isolation Precautions in Hospitals," says nce routine special precautions (private room, masks, gowns, or gloves) are necessary when treating patients with known or suspected CMV. However, the CDC does say that because patients' wine and respiratory secre- tions may contain CMV, workers should Wear gloves to touch patient secretions and thoroughly wash their bands after. ward. Workers more likely to get CMV at home WILLIAM R. JARVIS, MD, acting chief of the epidemiology branch in the CIC Hospital Infections Program, says health eare workers are far more likely to acquire CMV from their own children than from hospital patients. CMV is endemic in the community, and children commonly acquire asymptomatic CMV infection from other children. Children attending day care centers copmonly acquire the virus from other , children because of close contact with other childrens' saliva and other secre- tions; they then pass it on to their family members. fFIn fact, with medical and nursing personnel who have infants and children at bome who go to day-care centers, [those personnel's] likelihood of being exposed to and acquiring CMV is greater from the children going to a day-care genter than it is from getting exposed at work," Jarvis explained. Joseph said there is concern that AIDS patients with CMV pneumonia could transmit CMV to workers via the airborne route. "We don't know that, and that's the difficulty with this disease," he told AIDS Alert. "It [could be] spread by aerosol.* JOBN CONTE, MD, associate ‘professor of medicine at UCSF and an infectious diseases physician, disagrees. *I suppose you could say if the [AIDS) patient has pneumonia, he might have CMV pneumonia and the risk [to the bealth care worker of acquiring CMY) might be greater," he said. "But we've not demonstrated such an increased risk, and in the studies that try to show [CMV] is a greater risk to health care workers, no one has been able to detect even one case" where occupational trans- mission occurred. "The fact is, CMV is fairly ubiquitous in AIDS patients, and if you try to show that this is some sort of a risk to health care workers, you're not able to." , Conte said he also believes CMV is "predominantly" a sexually transmitted disease. Consequently, it is difficult to determine whetber health care vorkers infected with CMV acquired it ocoupa- tionally or from their sexual partners. Anotber difficulty is matching genetic strains of CMV between workers and pa- tients; one study was unable to match the CMV strain of a pregnant nurse with the strain of CMV from the baby she was exposed to. Occupational transmission hasn't occurred Conte said occupational transpission of CMV "so far just hasn't been a prob- lem" in hospitals -- even in facilities caring for large numbers of AIDS pa- tients. "We've been dealing with AIDS since 1981, and I don't know of a single case" of occupational CMV. Gerberding studied 270 health care workers caring for AIDS patients.3 In that study, workers reported 342 acci- dental parenteral exposures to patients’ blood or body fluids, including needle- sticks or splashes onto their mucous membranes. Although five workers who did not have CMV antibodies before the study did develop antibodies on study follow. up, four of those workers did not report exposures. However, the one worker who did seroconvert for CMV -- a nurae in the AIDS clinic -- sustained a needle- stick injury from an AIDS patient, al- though it is not clear if ber injury was the means of transpission. "The rate of aoquiring [CMV] anti- AIDS Al FRT/EFRO Amy «00g je bodies in those health care workers highly exposed to AIDS patients was no different than it was for healtb care workers" with little or no exposure, according to Gerberding. "So, our study tells us that taking care of AIDS pa- tients did not pose a risk [of CMV] to health care workers beyond that which is experienced" by the general U.S. popula- tion. In 1987, the CDC updated its isola- tion precautions guidelines with the universal precautions strategy, whereby health care workers practice blood and body fluid precautions with all patients regardless of their diagnosis.’ Prac- ticing universal precautions does pro- tect workers from CMV, according to Jarvis. (See AIDS Alert, September 1987, PP. 142-143.) Does working with AIDS patients increase risk of cryptosporidiosis? A prospective study of 246 health care workers indicates they are not at increased risk of acquiring nosocomial cryptosporidiai infection from AIDS pa- tients. THOHAS LU. KUBLS, MD, assistant pro- fessor of pediatrics at the University of Oklahoma, Oklahoma City, and former infectious diseases research fellow at the University of California, Los Angeles, was one of the study's investi- gators. Because AIDS patients often excrete cryptosporidial oocysts, Kuhls and colleagues wanted to determine whetber workers caring for AIDS patients are more at risk of acquiring crypto- sporidial infections than workers without contact with AIDS patients. The study, which took place from 1984 to'198 at UCLA, included 246 health care workers. All were female, and most were ourses, but the study also included some physicians, allied health person- nel, and clinical laboratory workers. Researchers use 20-page questionnaires Using self-administered 20-page ques- tionnaires to determine workers’ expo- sure levels to AIDS patients, Kuhls separated the workers into three groups: ® workers with no exposure to AIDS watients (such as office workers); e workers with "low exposure” (such as workers who didn’t directly care for AIDS patients); @® workers with "high exposure” (such as nurses on AIDS wards). Investigators did ons- and two-year follow-ups of workers, testing them for cryptosporidial antibodies using an in- direct immunofluorescent antibody (IFA) metbod. They found that one worker with low exposure seroconverted to cryptospo- ridium during the study, and two workers with no exposure had four-fold increases in antibody titer, although they didn't actually serooonvert. Kuhls also found that those three workers never handled the feces of an AIDS patient, either in the lab or on the wards. None of the workers with high exposure to AIDS pa- tients seroconverted. Were exposures occupational? Acoording to Kuhls, "it's probably extremely likely" that the three workers who seroconverted or had increased eryp- tosporidial antibody titers "didn't ac- quire it occupationally” because they didn't bave contact with potentially infected patients. He explained that 50% of "healthy people" have antibody to eryptosporidium. Cryptosporidial infec- tions are "very conpmon® in children, often causing "mild illness,® such as a short bout of diarrhea, Kuhls said. However, "Cryptosporidium causes sig- nificant morbidity in immunocon promi sed patients such as AIDS patients," he noted. He stressed the necessity of wearing gloves to handle any patients’ feces, and to practice good handwashing after each of those contacts. Those infection control measures "sre adequate in con- trolling the msocomial transmission of eryptosporidium in health care workers,” Kuhls seid. — Based on his study, be concluded that ‘vorking with AIDS patients or their biologic specimens does not appear to increase the risk of occupationally acquiring a cryptosporidial infection." B 28 FEBRUARY 1988/AIDS ALERT Although he is aware that “each hos- nital does something different" with ealth care workers and AIDS patients, "I don't see any justification" for renoving pregnant personnel from AIDS patient care "if CMV is the risk you're concerned about and you're going to let pregnant personnel work with renal dial- ysis patients, leukemia patients, and nursery patients, all of whom have a high rate of excretion of the virus." if pregnant purses are removed from AIDS patient care, massive staffing shortages for AIDS patients will be a problem, Conte said. "Most nurses of childbearing age who might be pregnant or who might be trying to get pregnant at any given time" com- pose a large percentage of health care worker staffs, Conte explained. Removing pregnant personnel from caring for pa- tients known to have AIDS doesn't take into consideration that these workers wil still be caring for patients who are unknowingly human immuncdeficiency virus-positive, or who might not have AIDS but are excreting CMV, he said. Kuhls concludes: "The important thing to remember is that a number of studies have shown that by using good infection control, mainly by doing very good hand- washing, that you can stop the spread of CMV." References 1. Balfour CL, Balfour HH. Cytomega- lovirus is not an occupational risk for, nurses in renal transplant and neonatal units. JAMA 1986; 256:1909-1914. 2. Stagno S, Pass RF, Cloud G, et al. Primary cytomegalovirus infection in pregnancy. JAMA 1986; 256: 1904-1908. 3. Gerberding JL, Bryant-LeBlanc CE, Nelson K, et al. Risk of transmitting the human immunodeficiency virus, cyto- begalovirus, and bepatitis B virus to health care workers exposed to patients >with AIDS and AIDS-related conditions. J Infect Dis 1987; 156:1-8. 4. KuhlsTL, Viker S, Parris NB, et al. Occupational risk of RIV, HBV, and HSV-2 infections in health care person- nel caring for AIDS patients. Am J Pub- lic Health 1987; 77: 1306-1309. 5. Pass RF, Hutto C, Ricks R, et al. Increased rate of cytomegalovirus infec- tion amqng parents of children attending day care centers. New Engl J Med 1986; 3714: 1418-1478. 6. Yow, MD. Use of restriction en- zymes to investigate the source of a peipary cytomegalovirus infection ina pediatric nurse. Pediatrics 1982; 70: 713-7 16. 7. CDC. Recommendations for preven- tion of HIV transmission in health-care settings. MMWR 1987; 36:1S-18S. @ Knowing AIDS patient’s diagnosis protects against CMV, attorney says A Chicago bealth care attorney fa- miliar with the complaint filed by Norsa Watson, the San Francisoo nurse who claims she acquired cytomegalovirus oc- cupatiomally while caring for AIDS pa- tients, and subsequently gave birth to a child with birth defects, says he tbe - lieves the case would be an isolated one should it come to trial. (He asked not to be identified because he may be in- volved in the case eventually.) *I'm not sure there is any common law CMV case that has ended up in court," he told AIDS Alert. But, at the heart of the issue is the contention that workers have a right to know whether a patient has AIDS so they . can be “extra cautious" with those pa- tients, thereby protecting themselves from exposure to pathogens such as CMV as well as human immunodeficiency virus, the attorney said. Even though identifying patients as having AIDS goes against the universal precautions strategy recently advocated by the Centers for Disease Control and other infection control experts, "it will not hurt for precautions to be raised to a fairly high level,” he said, such as having workers wear gowns, masks, and gloves for all procedures performed on AIDS patients. "If you're going to be inerror, err on the side of precautions and informa- tion,” according to the attorney. ®I'm in favor of health care workers... being able to take [the extra] precau- tions that make them more con‘ortable and effective.*® AIDS ALERT/FEBRUARY 1988 — "In 1988, AIDS is a major problem," he added. "In 1978, none of us even knew it was out there. In 1998, we might have a whole new set of weirdness going on." MARGUERITE JACKSON, RN, MS, director of the epidemiology unit at the Univer. sity of California at San Diego Medical Center, and several colleagues have developed a universal precautions stra- tegy called "body substance isolation" (BSI), which uses the same basic con- cepts as universal precautions system of infection control.’ Jackson told AIDS Alert that BSI "is based on the premise that the unknown case is far more common than the known case for any disease -- including AIDS and HIV infection.* The system also is protective to the patient in general, because patients ere less likely to acquire nosocomial infections if workers practice BSI, she added. Workers should be careful with all patients By identifying known cases and taking precautions with only those patients, "the health care worker is making the assumption that the only people they meed to be careful with are the ones they know about. To protect both the patient and the worker, the worker should practice the same level of care for all patients," she said. Under BSI, workers wear gloves if they anticipate touching any patients' blood or body fluids, nonintact skin, or mucous membranes. They wear masks if they're performing procedures such as suctioning where the patient's saliva orm Sputum could splash in their faces; if the patient has an airborne respiratory infection such as tuberculosis, workers also wear masks. Caregivers wear plastic aprons if they anticipate a procedure Bay soil their clothing with blood or body fluids. Workers also are instructed to wash their hands after each patient contact. "We do not support dressing up like a obot to take care of AIDS patients," ackson said. Although BSI requires extensive per- sonnel training to implement because workers have to be "reeducated® with a totally new concept of patient care, Jackson said the system is actually more protective to workers than the old sys- tem of singling out known cases. BSI more specifically addresses protection against CMV and other opportunistic pathogens associated with all patients. "If you had an AIDS patient with full-blown pulmonary TB, he presents the same risk to workers as any other pa- tient with TB would present, and he needs to be on some kind of respiratory isolation," she said. "AIDS patients with infections aren't any different from any other patients with infec- tions." Reference 1. Lynch P, Jackson MM, Cummings MJ, et al. Rethinking the role of isolation practices in the prevention of noso- comial infections. Ann Intern Med 1987; 107: 243-246. B Sources of \ Information @ "AIDS Carriers in My Practice?" a videotape for physicians. $189 for in- stitutions; $89 for nonprofit organi- zations: $59 for individuals. Rental preview fee is $45, applicable toward purchase. Medical Video Productions, Department A, 859 Vistavia Circle, Deca- tur, GA 30033. Telephone: (404)634-9955. This 28-minute videotape, funded by the Centers for Disease Control and AID Atlanta, is designed ‘to help physicians identify HIV-infected individuals in their practices, take medical histories for HIV infection, and counsel patients and staff. e Living with AIDS and HIV. $40, cloth; $14.50, paperback. Sheridan House Inc., 145 Palisade St., Dobbs Ferry, NY 10522. The author of this book, David Mil. ler, a clinical psychologist at the Middlesex Hospital Medical School in London, includes the epidemiology, sani- festations, diagnosis, and psychological implications of dealing with AIDS pa- tients. FEBRUARY 1988/AIDS ALERT @ AIDS and the Law: A Guide for the Public. $22.50, cloth; $7.95 paperback. Yale University Press, 92A Yale Station, New Baven, CT 06520. This book, written by members of the Yale AIDS Law Project, addresses public health strategies, ethical issues, screening, and other legal diasues re- lated to AIDS. @ AIDS: Epidemiological and Clinical Studies. $28.50. The New England Journal of Medicine, Publications, 1440 Main St., Waltham, MA 02254-0803. This book contains 53 reprints of articles and special reports tracing the epidemiology, clinical characteristics, treatment, and public health implica- tions of AIDS from 1981 to 1987. @ AIDS Public Policy Dimensions. $32.50. Publications Program, United Rospital Fund, 55 Fifth Ave., New York, WY 10003. These proceedings of the 198 annual conference of the United Hospital Fund aod the Institute for Health Policy Studies inoclude the clinical, political, social, and financial aspects of AIDS health care. B® NIH study finds research lab worker with no clear exposure seroconverts National Institutes of Health scien-, tists are once again reporting on the research laboratory worker who was found to have antibodies to human immunodefi- ciency virus ina study of workers han- dling concentrated HIV. They say they are stil) puzzled about how the worker's transmission occurred, because the Worker apparently followed proper tech- nique and had no parenteral exposure to the virus. (See AIDS Alert, October 1987, pp. 158-159, for pore information “on the worker's seroconversion.) In the January 1 issue of Science (1988; 239:68-71), NIH researchers re- port the results of a prospective two- year study of 225 research lab workers under NIH contract. (Forty additional workers were in the study, but they veren't working directly with lab speci- Bens or HIV.) The one worker who was HIV antibody-positive had been working with the virus for 290 days prior to entering the study. Thirty-five lab workers reported some skin exposure to RIV; 13 said they didn't always wear gloves, and 10 said they had had some sort of "parenteral inoculation.* Although the one lab worker who seroconverted didn't report any exposures to HIV, he or she “was involved ina number of possible expo- sure circum stances [decontam inating equipment, cleaning up spills, or touch- ing potentially contaminated surfaces with gloved hands] as part of duties related to culture, production, or con- centration of large volumes of virus- positive tissue culture material,” the Science report claims. "The post plausi- ble source of exposure was contact of the individual's gloved hand with [HIV] culture supernatant with inapparent and undetected exposure to skin." Worker wore gloves, gown at all times The worker (who is not identified in any way) also told NIH investigators that he or she had worked with concen- trated virus under biosafety level 3 containment and had worn latex gloves and standard cloth laboratory gowns at all times. The worker didn't wear a mask but "did report occurrences of HIV con- tamination in the work area" The NIH is certain the lab worker acquired HIV occupationally because the HIV strain he or she was working with was "fingerprinted" to the same strain the worker was infected with. The worker also reported no personal risk factors for infection. STANLEY H. WEISS, MD, assistant pro- fessor in the department of preventive medicine and community health at the New Jersey Medical School, Newark, was prin- cipal author of the study. Weiss told AIDS Alert the study emphasizes existing recomendations for hospital or labora- tory workers, such as removing gloves after contact with potentially contan i- mated material, performing careful hand- washing, and putting on new gloves be- fore oontinuing with a procedure. But Weiss also recommends that lab workers handling HIV avoid possible hand contact with mucous membranes in the AIDS ALERT/FEBRUARY 1988 == 31 researchers "suggest it may be necessary mouth, eyes, and nose by wearing gog- gies, face shields, or a face mask when working with contaminated material. Does that mean the researcbers sus- pect the worker became infected because he or she wasn't wearing a mask or face shield and the virus may have infected the worker vis the airborne route? "No, we're not saying that," Weiss said. "We recommend wearing a mask, but we don't do that because of [potential risk of] aerosol exposure. The purpose of wearing goggles, a face shield, or a face mask is to avoid hand contact with the mouth, eyes, ears, and nose. And that's the reason we recommend wearing a mask, particularly if you're working with concentrated virus. ... We're simply recommending in general some modest changes in techniques that work- ers routinely utilize when working with the virus." Biotechnology group files suit against NIH JEREMY RIFKIN, president of the Foun- Cation on Economic Trends in Washington, D.C., @ public interest group that fo- cuses on biotechnology issues, filed a federal lawsuit last December against the NIH, "charging the agency with fund- ing hazardous AIDS and cancer research in violation of the National Env ironmen- tal Policy Act." Rifkin told AIDS Alert there isa "potential problem with labs across the country working with oncogenes and human retroviruses, including the AIDS virus. Several categories of experiments are J potentially deadly in terms of increas- ~ ing host range," he said, citing as an example work being done to replicate WIV in mice cells. According to Rifkin, , / "There are no protocols on what kind of laboratory that can be done in," such as biosafety level 1. or 2. Are lab workers at risk? "We think lab workers are at risk," He added. In the Science article, the worker was correctly following biosafety level 3 precautions; Rifkin said he Obtained earlier unpublished drafts of the Science article, and that in the earlier draft, Weiss and his co- Airecte revi to assess exposure potential for to reevaluate the suitability of this containment requirement for hand] ing highly concentrated infectious mate- rial -- not just AIDS." The infected worker "followed every requirement to the letter of the law.* Weiss wouldn't comment on Rifkin's contentions because of the impending - lawsuit. But he and his collaborators do make several recommendations in the Science article that go slightly beyond current standards for research labs. Perbaps most notable is the recompmenda- tion that research labs set up routine RIV antibody screening programs for workers bandling concentrated HIV. ®] think for the worker's protection and biosafety that all labs need to deal with the [routine screening] issue, and we recommend that routine, periodic serologic testing for HIV-1 be estab- lished as part of lab safety prograns,*" Weiss said. Researchers make updated recommendations Other strategies he and his collabo- rators recommend -- either as part of existing standards or beyond those stan- dards -- for any laboratory workers handling concentrated HIV are as fol- lows: e Lab personnel should periodically validate the "operational integrity" of equipment used to transport HIV- containing fluids. e When spills or leakage occur, lab should "initiate a formal ae workers... to identify corrective // actions to prevent recurrence." e Workers should be properly trained in how to process HIV materials and in decontaminating continuous flow zonal centrifuges. e If workers have dermatitis or akin lesions on\their hands or wrists, they "should not perform procedures involving the transfer of concentrated BHIV-1 mate- rials, even if their skin is protected by gloves." e If aworker even suspects he's been exposed to HIV, he should report the incident and be monitored by occupa- tional medicine personnel regularly for evidence of filness or seroconversion. e Avoid using needles and otber sharp 32 FEBRUARY 1988/AIDS ALERT 90. eo ee a — I NT eS CERTIFICATE OF DEATH 380f 06458 STATE OF CALIFORNIA etate raul eupare LOCA BCCIITPSTION BIGTONCT 400 CEaTtiricaTe eunerce ta maw OF OECLOENT— FAST | 18 mpoLE "6: Last ZA, GATE OF OlaTn iwente est, caee: = ' 28 wee James ' Clay |_ Morrison October 31, 1983 10630 9 $t1 4 @aCé/Enescry ne 6 SOatt oF Giatn : 7 AGE 1 passe t tsee 1) waeae te weyes Ma le White os Apri l l ’ 1937 66 a | ie "| @omere. DECEOENT | © Drermovegt OF OEICECT urets oe |B Bewe one Grerarnsee OF Ferns a 1G, Siete Meee ang GQieteruecs oF Matece Petar’ | California Henry C. Morrison = FL Genie Pendleton - FL 1) covenen ef Gael Counter 12. Secu, Mcwerrt Supece 92 Mapetes Btares 4 mant or SURVIVING SPOUSE (10 wierd Baree U.S.A. 544-364-1058 Divorced NA 19 Parwser OCegurseren vate 17, Eurcevce we aur camevse se states 18. Rese oF teocsrer of Bestmess Physician Surgeon | 13 Self-Essisyed Medicine 1PA Ubud Het FIC —— EAGT 2HCREES LSTOCET 200 BERETS Bf Lecenes) ima 10C. Cite eo: Tews roo ysua._ 45 _Gak Drive } Orinda RESIDENCE | i900 ceuere Tie sore 20 Rane 480 0DRESS CF INFOER ANT —seyeeesas Centra Costa California Mrs. Genie P. Morrison- Mother | ata. react oF etarn Hn covatr 2157 Golden Rain Rd. #6 puace =| Raloh K, Davies Medica) Center |San Francisco [Walnut Creek, CA 94595 DEATH rae STQCET AQDORCSS isTeEkt Ane Bemess OF LecatiOe: [210 cit¥ on town Castro & Duboce Streets 1San Prancisco ; Ps 22 DLaTe waS CAUSED BY 1 ENTER ONLY GONE COUSE PER LINE 708 A. 8. 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Follansbee, M.D.:1580 Valencia Street: S.F.,CA 29 soccer accregat swrcres ete 36 PLACE OF InsueT 31 rasuey ot waor yp O018 OF insyev——wente gst tEse 328. nous INJURY INFORMA - - TICN J] LOCATION cerncer sme aubece Of LOceTion abe CIT! oe 19WE) 14 DESCHI EE HOW INIUHT OCCUREES ievceTe warce sebuL TES Im misery CORONERS OnLy 35A 1 Ceevies tear Shore Geueece af TOR Neve Gate ane Proce States Pree ' 358 coeuNte-—“teearuer one BtceET es tithe V9SC cere signs Tot Coetts Shatin 46 Geowisce Or Law | Move MELO ae (InGu st iavtetidatians : J ! i . awk 36 asse08.7 08 37 O4fE——sonre ont sese | 38 Mang ome AgNstts OF CheRTED os Cetme tere 31D crhecece F AEeee OE UETE ome NiGeaty et Cremation | Nov. 2, 1983 | Oakmont Memorial Park: Lafayette, NOT EMBALMED AL 4 mo wk OF Pumhee, OCC OS OF oEAEOm atten of tute! 608 WCENSE NO $1 goteg F4cisinse=——qis PTY 42 pete secretes es seca, eas “om. Park & Mortuary | F-875 Ai galt Ze Ll erasmagtch NOV Q 2 198 6. (oy | Cc. —_—- ——— —= —_ =_— == —— - . . - THIS IS TO CERTIFY THAT, IF B=ARING THe Seal OF THE SAN FRANCISCO DEPARTMINT OF PUBLIC HEALTH, THIS IS A TRUS COPY OF THE DCCUMENT FILED IN TRIS OFFICE. No. 85 - (29 “ _ ; ‘Pout WAL bi, DATED: Cctober 11, 1985| DAVID WERDEGAR MY DIRSCTOR OF PUBLIC HEALTH AND LOCAL REGISTRAR SAN FRANCISCO, CALIFCRNIA CERTIFICATE OF DEATH 01403 STATE OF CALIFORNIA 3801 Sat aera com sO ROBERT JOSEPH LEONE March 1, 1984 1045 3. 52 4 mact §. ETHNICITY @ Bate oF BIRTH 7. AGE aw saan ’ vise cong se cosas Male White American July 7, 1951 32 "| jo CECEDENT ‘ sone or Oecaecer csravece | © Mame ane Greteriact * fs. uaa . 10 Gate Bepe ame Sietertacs oF BaTHEs reRaTa- |New York Carl J. Grisanti__New York Carolyn Leone New York New citizen oF Waar Counter 12 Sects. Secuasty musese {3 Gaurtas Svates 14, BaSh OF FUAVIVING BPOUSE UF wire cate U.S.A. 129-42-9550 Never Married NA" 13 Sasser Ccceration 10 mymoce oF Tees 17) feecerse ur sme Temores t9 Stare) 18 time of Cnousrer os Besiness Nurse _ oe UC Hospital Hospital 1A sheen Mee ekmCC—mebTBEET 2SCMESE WSTREET 225 25mb2 82 Loeer s~ ieee 19f eve ae Tews usua. {206 Diamond Street | @fd | San Francisco RESIDENCE | t9t) counts ; ae stare 20 same AD SODESS OF INFORMANT —eaLsten ae San Francisco | California Carolyn Grisanti (other) TIA PLacd OF DEATH - a county 15 Prospect Street PLACE | Presbyterian Hospital |. San Francisco | Fredonia, NY 14063 DEATH ZIC PTHECT aDORESS carate™ sa0 “uUFSEs OF LOCATION: 1 210 cit? Ge town | San Francisco ; 22 DEATH WAS GAUSED BY (ENTER OWLY ONE CAUSE PER LINE FOR A. B AND C) 2s was agate ecoeetsn ° IMMEDIATE CAUSE covenan? Co eee jt Kesoietcte rg Failore Zon. | orn “~~ Mo mite Gave BISE TO oul fo pe ons Comstegquce oF imveowas Ose Mierat Punrenuae! 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Mass, MD 2000 Van Ness San Francisco, Ca. 29 seecrre accraget tercing ete 30 «PLACE OF tmauat 31 caseey at ween | 322A pete ef inseer-—weer pay wesc 1328 noue INJURY \ INFORMA- 4 TION 33 AGCATION S7ECET ome Ho Ots OF LOCATION ONO CITT C8 19mE: 34 OESCRIOEN WOW INJURY OCCURRED (EVENTS WHICH CESULTED 10 InIEeT) ORONER S USE SSA ot Caomrisy Taat Ofare OCvEsES aT THe MOVs Gate ame Peace Staten Feen | 358 COsONE #——“sceatune ame BEGREE OF TITLE 1 38C, este signe ONLY Tee Cauoes Sretto as Miouiece oy Lae | wave weLe ae (foevest lavestigaricn) ~~ | 36 siteoniTion 37 GaTimsoare os 2O mame cee sponend be Cemetary of Coema tear . t 39 cuescoce 6 LiceDEE Sensan ann ausirens Cremation | Mar. 5, 1984 Daphne Fernwood Cemetery-Mill ey Not Embalmed 60 comet GF Fumthal GIREETOR (O08 FLOCOR ACTING 26 BuCe: Ot Leche ogpietgpe—“tiesstuse G2 wate accerree oF cece, saci ttese DUGGANS FUNERAL SERVICE — 44 ose WARS 1984 | Anhiigke ik state. [A B 0. E F. EGISTRAR . VS-It 116. 78. 2 eo THIS IS TO CERTIFY THAT, IF H=ARING THE SEAL OF THE SAN FRANCISCO DEPARTMIIT OF PUBLIC H&eaALTH, THIS IS A TRUE COPY OF THE DCCUMENT FILED IN THIS OFFICE. no. 85 - /]773 bud A 8a, AL is uy DATED: October 9, 1985| DAVID WERDZG eee DIRECTOR OF PUBLIC HEALTH AND LOCAL REGISTRAR SAN FRANCISCO, CALIFORNIA AGS F Progress Wed., August 28,1985 12345 es Just his opihion? Acquired immune deficiency syndrome may turn out to be truly the plague of the 20th century. Surely, the enormity of the impact AIDS will have on this nation, in multiple areas, has only been guessed at. And, as we have not yet survived the pathology of .he syn- drome, so we have not yet survived the politics of AIDS. Unfortunately, as we learned through the tragedy of blood transfusion-induced AIDS, the politics can be deadly, too. The results of a state Occupational Safety and Health in- vestigation into a complaint by San Francisco General Hospital nurses involving AIDS patient care are not in yet, but already the testimony of Cal-OSHA's medica! unit chief. Dr. Lawrence Rose. is being doubted, since he dissents from the prevailing hospital politics. Testifving in a hearing regarding four SFGH nurses who complained they were reprimanded for wearing protective masks and gloves while caring for AIDS patients, Rose said. ‘Although, so far, there 1s no scientific evidence’’ that masks and gloves are necessary in the routine handling of AIDS patients, he would recommend nurses be allowed to wear such gear. Rose's testimony must have hit a nerve in the body politic, for this week he was not answering his own calls, but a Cal- OSHA public relations person returned a call to Rose and termed Rose's testimony ‘'merely his own opinion and not the finding of the investigation.’ In fact, said the PR per- son. Rose's recommendation may or may not be part of the ultimate finding. We are not experts in disease control and would not argue with the hospital’s stand that masks and gloves are not necessary for the routine handling of AIDS patients were we not aware of a similar argument put forward a couple years ago by the blood banks, who in all honesty thought there was no danger of contracting AIDS from blood transfusions. Sad- ly. they were wrong. and 17 people in the Bay Area have died aiter having contracted AIDS through blood transfu- sions The nurses’ complaint argued for their right to protect themselves in the face of a disease whose etiology 1s not en- tirely known. That seems reasonable. . The hospital argues that masked nurses Increase the social isolation and aljenation already acutely felt by AIDS pa- tients. Perhaps. although it is difficult to believe that a person who has AIDS and 1s hospitalized with one of its deadly side- effects is not also acutely aware of the possibility of infecting others with his life-threatening malady. We think, too, that nursing care will be more personal and warm, if the nurses don't fear fortheirlives. . Dr. Donald Abrams, assistant director of the AIDS clinic at SFGH, said allowing nurses to wear gloves and masks ‘‘at any time js wrong, misrepresentative and ignorant."’ But he also admitted that ‘‘nothing in medical science is ever certain.” So. if the nurse's precautions turn out to be unnecessary. the harm done will be much less than if their fears turn out to be grounded In fact. The severity of the AIDS crisis is such that we can't afford 'o play politics with it. s/ 70/ gy: ~ Official says AIDS nurses should be allowed masks ———- By Nancy Keebler “y Bee Staff Writer Leg SAN FRANCISCO — Nurses at San Francis- it of ally gub- the eto h und om- wic D- ent art- ent , {0 or ior *to nd oa ed ohh. ‘nl of f- CO Wenerr! Hosnital cAnId¢ he free in chan whether they will wear masks and gloves when caring for AIDS patients, a Cal-OSHA medical officer said Monday. Dr Lawrence Rose, testifying before a state Labor Commission hearing officer, said health care workers who want to protect themselves “should not be disciplined. He added that he soon will issue a report recommending his agency order the hospital to allow workers to decide for themselves whether they should wear masks and gloves. Four nurses have charged discrimination, Saying they were reprimanded and a change in their shifts ordered because they wear masks and gloves around AIDS patients. Their attorney, Vasilios Choulos, described the nurses as being in a high-risk group for AIDS, and asked deputy labor commussioner Timothy Sakamaki, the hearing officer, to find that working conditions are hazardous and that the repmmands and shift change constitute job discriminauon. However, Deputy San Franciso City Attor- ney, Jerry Spain, representing the hospital, Said the nurses have not been repmmanded and the sbift change has been pul on bold until the hearing 1s over. “They have been treated exactly as all Nurses at San Francisco General have been treated,” he said. Sakamaki will give his findings on the char- ges to Labor Commissioner C. Robert Simpson, who bas until the first week of September to issue a decision. Nurse Julie Bernales testified that the hospi- tal urged nurses to wear masks when caring for AIDS pauients before and during the site's January inspection for renewal of hospital ac- creditauon, but later changed its policies. She testified that she has seen AIDS patients eaung jn the hospital cafeteria and drinking from water fountains. Sakamaki said the key issue is whether she complained about the alleged health hazards SPOT paces’ Gecess iG Guu]: Por vi ie uu pital ana woetner she was discriminated against because of it — not whether masks; should be worn. Bernales and another nurse, Norma Watson, testified that other health-care personnel, such as doctors and X-Ray technicjans, are not pro- hibited from wearing gloves and masks when they provide care to AIDS patients. They said the hospital limits the use of masks and gloves - around AIDS patients so as not to harm them. psychologically. . Healthcare workers at most hospitais wear’ masks and gloves when they care for AIDS pa-~ tients, said Rose, who praised San Francisco General for its AIDS program. He sald he didn't think it would change the bospital’s AIDS program much if a few workers chose to wear masks and gloves. “They ought to be allowed to wear masks and gloves if they professionally decide that,” he said. Hospital officials, who are expected to testi- fy Tuesday, refused to respond to Rose's com- ments. But Grace Lusby, the bospital’s Infection control coordinator, told The Bee Friday that the hospital follows procedures recommended by the Center for Disease Control, such as us- ing gloves when in direct contact with biood and body fluids, and wearing gowns if contami- nation of uniforms is expected. She called the complaints “totally false” and said, “We feel this is sumply a way to bring dis- grace upon us and we fee! very strongly that the precautions that we’re using are appropri- ate and are being handled eppropriate!y.” Cuft Morrison, assistant director of sursing, Sax purses at the hospital have been “upset that four nurses would speak for all of them.” Adison Moed, head nurse of the AIDS ward, told The Bee the policies are no different than on other units of the hospital. ~ > a a _ i iASE beer ‘ £eaean Ccridw — —sw oe eo —_———aa- ee ee San Francie Corenicle G/r» /8s State Official Defends S.F. AIDS Nurses Siy Mark Z. Berabek wurecs should be allowed var protective garments ad AIDS patients even if caution is unnecessary way be offensive, a state ‘hb Inspeeter said yester- “copie are reacting to the un- tanc PROGRESS NOTES known, and J think AIDS patients should understand that,” said Dr. Lawrence Rose, bead of the medical unit of the California Department of industria) Relations. “There are very big question marks.” Rose was testifying in the case of four nurses from San Francisco General Hospital who say they were puniihed for weersing gloves and masks while treating AIDS patients. The stata tabor commissioner must decide whether the nurses were vic- tims of job discrimination. malgtains that the transfer of the four murces to dlifereat shifts was tients suffering from the acquired immune deficiency syndrome “would be leas able to cope psycho- logically with the disease if they sce people masked up.” She insisted, however, “I have the right to deter- mine for myself whether to wear protective gear in whai J think is hazardous exposure.” He said the use of protective gear “doesn’t have to be detrimen- tal to the patient,” previded thet patients are informed of the concern some prefessten- als have about AIDS. Deputy City Attorney Jerry Spain, the lawyer for the hospital, assericd throughout the long hear- ing yesterday that the care and treatment of AIDG patients was ir- relevant. He argued that the scope should be limited to whether, as the nurses say, they were improperly disciplined for raising questions en conditions they deemed un- e. “Nothing in their complaint has to do with AIDS,” Spain argued. “They have been trented the same os all nusses under sts ndards set by the COC (US. Contess for Disease Spain contended that Bernales and a second nurse ‘who took the stand yesterday, Norma Wateon, were removed from tse night shift and put om days for retraining be- eause of problems wih thelr work performance. Under cross-exaniination, Ber- males and Watson bith conceded that they took thelr complaints their union representative, w chose not to pursue the matter. Clift Morrison, assistant dir tor of nuraing, said the four « fed the complaint are the o ones smong the 600 nurses at £ Francisco He will make a recornmendation the state labor commissioner w by law, must issue a decision by | flvst week in September. There are ne menetary or pu tive damages involved. If the ial commissioner upholds the nun claim, he will lesue a decision teil: San Pranctsco General & must | prevent nurses from p tective garments around AIDS tients if they so choose. Signing the complaint atic wikh Bernales and Watson w: nurses Concordia Suellen and | sara C. Bannag. _- = SAN FRANCISCO GENERAL HOSPITAL MEDICAL CENTER SIGN FULL NAME AND CLASSIFICATION A Patent problems a8 observed Ihrough systematic essessmen — — —_—o | joa ~b— -- jog. ee ee wat a ee a eae te ee DECEMBER 1985 PROFESSIONAL UPDATE Health personnel may have gotten AIDS from patients A nurse and a lab tech who've denied being in any of the groups at high risk for contracting AIDS have developed serum HTLV- ITI antibodies, the CDC has reported. They were among 26 of 1.750 health- care workers who tested positive for the AIDS virus. The nurse said she sus- tained two needlestick inju- ries, four months apart. while treating AIDS pa- tients. The lab tech also suffered two exposures— acut on the hand and a needlestick—while pro- cessing blood. Although the two will be monitored over the next sev- eral years, the CDC claims no more than 20% of those who contract the AIDS vi- rus develop the disease. Since the CDC study was released, six San Frap- Since health-care workers __ complications of AIDS. “Une, a surgeon, was not wn to have been in any of the high-ris ups. The CDC stall main that the risk of catching AIDS from patients is low. s/ 70/ os ~ Official says AIDS nurses should be allowed masks ——- By Nancy Keebler ey Bee Staff Writer Lege SAN FRANCISCO — Nurses at San Francis tat CO General Nnenital enauld he free tn ehanes ally whetter they will wear masks and gloves when caring for AIDS patients, a Cal-OSHA medical sub officer sald Monday. the Dr. Lawrence Rose, testifying before a state tt Labor Commission hearing officer, said health | eare workers who want to protect themseives G84 gnouid not be disciplined. He added that he GM: soon will issue a report recommending bis ixi¢ agency order the hospital to allow workers to . decide for themselves whether they should ‘€D- wear masks and gloves. ent Four nurses have charged discrimination. art saying they were reprimanded and a change in eat their shifts ordered because they wear masks vad gloves around AIDS patients. Their attorney, Vasilios Choulos, described the nurses as being in a bigh-risk group for ,to AIDS, and asked deputy labor commissioner or Timothy Sakamaki, the hearing officer, to find ror (Bat working conditions are hazardous and that “to the reprimands and sbift change constitute job iad discrimination. However, Deputy San Franciso City Attor- xe3 Hey, Jerry Spain, representing the bospital, al. said the nurses have sot been reprimanded o@ and the shift change bas been put on hold unti! eq (We bearing ts over. . “They Bave been treated exactly as all ‘a, BSurses at Sen Francisco General have been mnt treated,” Be said. of Sakamaki will give bis findings on the char- to- ges to Labor Commissioner C. Robert Simpson. f- WhO has until the first week of September to . {ssue @ decision. tte Nurse Julle Bernales testified that the bhospi- y, tal urged nurses to wear masks when ‘e@ for AIDS patients before and during the gate’s p- January Inspection for renewal of bospital ac- in Creditation, but later changed its policies. se —- She testified that she bas seen AIDS patients eating Jn the hospital cafeteria and drinking from water fountains. Sakamaki said the key issue is whether she complained about the alleged healt® hazards SPSS pOSSNS Scccss % Glues Pal ie us ite eu pita: ana whetner she was discriminated against because of it - oot whether masks should be worn. { Bernaies and another nurse, Norma Watson, testified that other health-care personnel, such Bibited Those ear, cennicians, are sot pro- bited from wearing gloves masks when they provide care to AIDS patients. They said the Bospita! limits the use of masks and gloves around AIDS patients so as not to barm them psychologicalty. Health-care workers at most hospitals wear masks and gloves when they care for AIDS pe- Gents, said Rose, who praiséd San Francisco General for its AIDS program. He said he dido't think it would change the hospital's AIDS program much if a few workers chose to wear masks and gloves. -“They ought to be allowed to wear masks and gloves If they professionally decide that," be said. Hospital officials, who are expected to testi- fy Tuesday, refused to respond to Rose's com- ments. But Grace Lusby, the hospital’s infection control coordinator, told The Bee Friday that the hospital follows procedures recommended by the Center for Disease Control, such as us» tng gioves when in direct contact with bicod and body fluids, and wearing gowns If contam}! nation of uniforms is expected. She called the complaints “totally false” and said, “We feel this is simply a way to bring dis- grace upon us and we feel vary strongly that the precautions that we're using are approprt- ate and are being handled appropriate!y.° C21? Morrison, assistant director of oursing, sair nurses at the hospital have been “upset that four nurses would speak for all of them.” Alison Moed, head nurse of the AIDS ward. told The Bee the policies are no different than on other units of the hospital. a aD ni inn in, ii, a_i ICTOR@ER 1088 RN v _—— - . d PROFESSIONAL UPDATE 08 RN MEMO FROM MARIANNE DEKKER MATTERA Dear Dr. & Mrs. Watson, Enclosed are a couple copies of RN, as you asked. The news item on your case is on page 10. As I noted, we're considering a longer story, but no decision has been reached yet. Thanks for your help. Cordially, Deas art Natt bia mes BG mecca Economica Company + Oradell, New Jersey 07649 * 201 262-3030 AIDS eet is enough? That’s the question raised at San Francisco General Hospital by four nurees who say they'vo been disci- plined—tranaferred tp am - other shift and forced to take: “retraining courses”—be- cause they insist on wearing masks and gloves when caring for AIDS patients. The hospital says masks are unnecessary in caring for ALDS patients and gleves ary newfed nly phen haw dling blood or body fhuids. Although the California . Jabor comrissiongr puled r9- ‘censly that the shift change - "is not discriminatory, he also said that wearing mask and gloves is s reasonable pro- tective measure, given - San 2 Francis (0 The Larges? Daily | Cheviation in Northern California wank ——— Ny Rick DelVeceklo A Sau Francieveo General Hospital nurse who claimed she developed ulrers beenuse of the strens of working aroand AIDS patients without the protection of mask and floves won a ecttle- ment yesterday from the city. in a settlement rcached before state Worker's Compensation Judge NURSE Fram Paget disability was relat eaposure w = ea 8 1@ Cunlrovers Over ber decision to violate the no- mask policy, Necause of her ulcers, Watson was unable to work for five months in 1963 and 1900. Watson, who fs on pregnancy leave, still has arditional ctalins pending egatnet the city for pernta- nent disability and paychiatele inja- ry. Her attorney, Uarry Willams, sald Tic lly ster patent Ta Make Cent: Cary Osan’ Ayn ate ney onen tre Tath THE MINIT TONE ny ahier Healt Catt ware 7 CAPR Hey CTV caves a - - Robert fl. Lawn beGibh lend, the tt FRIDAY, FEBRUARY 20, 1937 - ee _S.F. Nurse Wins AIDS Stress Claim agreed to pay Norina Wataon's eud glovee ca her to develo ‘ ned. ‘ n rainiestinal problems. teal bills and part of the wages she wal policy discourages nurses jont for a five-month period during rp Tt ae gqrar when which she was disahted with ulcers. TES PGA HT wilt ac: The amount of the settlement ) is unknown, because of the limitation in establishing the diagnosis. Risk without documented parenteral exposure - 8 studies of 2,957 health care workers. In at least five of these studies no seropositve health care worker were indentified. Strategies for Preventions Since there is no vaccine or effective prophylaxis available. Education of the health care providers is essential. In November, 1982, the CDC published precautions (similar to hepatitis B model). Additional information was published by COC in 1983, 1985, 1986 and 1987. The last one summarized all previously published. Evidence in Favor of Universal Precautions: (1) No serologic test is 100% reliable and the possiblity of patients being in the "window period" exists (2) Labeling human errors (3) No clinical test available for HTLV - Non A Non B hepatitis and HIV5 (4) Suggestions that health care providers has been far too careless in the past before implementation of Universal precautions (5) Applied to Trauma Surgeon There is not adequate time to obtain a serological tests before providing care. Patients risk factors are difficult to asses in this particular circumstance. Baker et al demonstrated a prevalence of 16% anti HIV antibody among random trauma patients admitted to Johns Hopkins Hospital Emergency room. Controversial Points ; There are a large number of physicians who feel they have a need or right to know the serological STATUS of their patients, and should be routinely tested as syphilis serology. "Testing is most easily justified when it is done in the patient's best interest". Conclusions | The potentially devastating consquences of HIV to the Trauma Surgeon and their families; the imperfection of the tests currently performed; the legalities and ethical controversies make the trauma surgeon as an early providers of care in an unknown risk population very vulnerable and concerned. BIBLIOGRAPHY Fahey B., Meehan P., Henderson D.: The Risk of HIV-1 Transmission in Health Care Workers; Infection in Surgery April 1988 Baker J.L., KelenG., Sivertson K., Quinn T.: Unsuspected Human Immunodeficiency Virus in the Critical I11 Emergency Patient. JAMA May 1987 Vol 257 No. 19 Meyer A. ; AIDS the Disease in the Relavence to Surgeons. ACS Bulleting Vol 71 No 11 November 1986 Bartlet J. : Testing for HIV Infection Recommendations for Surgeons Vol 73 No 3 American College of Surgeons March 1988 MMWR Supplement Recommendations for preventions of HIV Transmision in Health Care Setting CDC August 21 1987 Vol 36 No. 25 pe tbs a ate aS oe Concerns of the Health Care Professional DENTISTRY Report to the President's Commission on the Human Immunodeficiency Virus Epidemic Wednesday, May 11, 1988 Joan A. Phelan, D.D.S. Associate Professor Department of Oral Medicine and Pathology New York University College of Dentistry New York, New York Dental care considerations for patients with HIV and AIDS infection fall into four categories: fear of occupational transmission of HIV, resulting infection control concerns, the diagnosis, management and pathogenesis of oral lesions which occur as a result of HIV infection, and potential dental treatment complications which may occur in patients with HIV infection and AIDS. I. Low Occupational Risk of Transmission of HIV to Dental Health Care Workers . Studies in the United States have suggested that dentists are among the health care providers dt greatest risk of acquisition of hepatitis B infection. !*@ The similarity of the routes of transmission between hepatitis B and HIV and the recognized occupational risk of hepatitis B infection among dental professionals led to the concern among dental health care workers that there might also be an occupational risk of the transmission of HIV. I was a co-investigator in one study designed to assess the risk of such infection to dental health care workers.” Our study and others have consistently demonstrated that dentists and other dental health care workers are at low risk of occupational infection with HIV. Together, studies of dental health care workers in the 344,556 oy, study United States have included over 3000 individuals. identified one HIV seropositive dentist for whom no other risk for infection could be identified.> Other dental studies have not identified any seropositive dentists or other dental health care workers for whom there was no other identified risk. One dentist -2- diagnosed with AIDS is included in the Centers for Disease Control(CDC) series of 41 health care workers with undetermined risk. ! Although the measured risk of HIV infection for dentists and other dental health care workers is low, the results of studies of other health care workers suggest that there is a risk. Dental health care workers are at risk not only for accidental parenteral innoculation, but also for splashes with saliva containing blood.? They are also likely to be exposed repeatedly to persons infected with HIV, often for months or years before those persons become ill or know that they have HIV infection. Moreover, as the prevalence of HIV infection increases in the United States, dental health care workers will treat more infected patients. RECOMMENDATION: Studies of the occupational risk of HIV infection among dental health care workers must be continued, new studies initiated, and these studies must be financially supported in order to further define the occupational risk of transmission of HIV to dental health care workers and to present dental health care workers with the most accurate information possible in order for them to make rational decisions about their behavior. II. HIV Infection and Infection Control in Dentistry In the past, efforts to prevent transmission of infectious diseases during dental treatment were centered on the identification of infectious patients and the use of special precautionary procedures. Emphasis has been placed on taking an accurate medical history before initiating dental treatment in order to identify medical conditions which would require special dental management for ~3- 8,9 medically compromised patients. The attempt at identification of infectious patients has been part of this process. Up to the beginning of the AIDS epidemic, recommendations for dental treatment of patients known to be carriers of the hepatitis B virus included special infection control procedures which were different from those used for routine patients. In the beginning of the AIDS epidemic these same guidelines were applied to the treatment of patients with 10,11 AIDS. Not until more recently have universal infection control 12,13 In their procedures been widely recommended for dental care. concern for identifcation of HIV infected individuals and referral of these patients to hospital dental clinics for dental treatment, dentists have been doing exactly what they were taught to do to prevent occupational exposure to Hepatitis B. The experience of dentistry with Hepatitis B illustrates that this method of infection control did not work for Hepatitis B and should not be expected to be an effective means fo reducing the already low risk of occupational transmission of HIV. At the present time the most effective means of preventing transmission of HIV to dental health care workers is by the implementation of universal infection control procedures, i.e. the same procedures for all patients whether identified as infectious or not. RECOMMENDATIONS: 1. Studies to confirm the effectiveness of infection control procedures shou!d continue and new studies should be initiated. 2. New dental equipment should be redesigned in order to allow for optimum infection control. 3. Educational programs should be designed to teach the implementation of infection control procedures. These must be incorporated both into dental school curricula and into continuing education programs. 4. Studies to assess the success of education programs for implementation of infection control should be done. 5. Educational programs which provide accurate information to dental health care workers concerning HIV infection must continue and new programs must be initiated. 6. Implementation of infection control procedures will add to the cost of providing dental treatment. Fees for dental treatment and third party reimbursement will have to be adjusted to cover this additional cost. III. Oral lesions associated with HIV infection and AIDS Several studies and case reports have described the spectrum of oral lesions which occur in patients with AIDS and HIV 14,15,16 These include oral candidiasis, herpes simplex infection. ulceration, herpes zoster, hairy leukoplakia, gingival and periodontal disease, severe aphthous-type ulceration, Kaposi's Sarcoma and several other unusual oral neoplasms and opportunistic infections. Information about the treatment of these lesions is included in several reports. Three oral lesions may fulfill the CDC surveillance definition for the diagnosis of AIDS: chronic Herpes simplex infection, oral Kaposi's sarcoma and certain types of lymphoma. ?! | RECOMMENDATION: Although studies of the pathogenesis of these oral lesions and the relationship of these lesions to the natural history of HIV infection have been initiated and funded, additional studies are necessary. Studies to determine the most appropriate treatment of oral lesions will enhance the quality of life for patients with HIV infection. IV. Dental treatment planning concerns. for patients with HIV infection and AIDS There is no question that persons who are infected with HIV are entitled to dental treatment. Determining the appropriate location for the delivery of this treatment, in a private dental office or a special setting, has been the subject of controversy. The literature contains to date only one report of comlications occurring in one AIDS patient following endodontic(root canal) treatment. This lack of reports suggests that most dental treatment can be done without complications and, therefore, could be done within routine dental practice. However, there are no reports of studies of dental treatment of patients with HIV infection and AIDS. Therefore, we do not know whether this lack of complications is real. Personal communication with dentists and hygienists who treat many HIV seropositive patients has confirmed this lack of complications. However, dentists who routinely treat HIV positive patients have developed a variety of different treatment techniques which may or may not be successful in preventing complications. RECOMMENDATION: l. Studies should be initiated which are designed to assess the response of HIV positive individuals to dental treatment procedures. In summary, the impact of AIDS on the practice of dentistry has been extensive. The HIV virus has finally forced dentistry to think rationally about infection control. Questions about several oral diseases are being answered in the context of HIV studies. In the final analysis, our profession as well as our society will be measured by the extent and quality of our care and concern for human beings. 10. 11. l2. 13. 14. REFERENCES Mosley JW, Edwards VM, Casey G, Redeker AG, White E. Hepatitis B Virus infection in dentists. N Engl J Med 1975, 293:729-734. Smith JL, Maynard JE, Berquist KR, Doto IL, Webster HM, Sheller MJ. Comparative risk of hepatitis B among physicians and dentists. J Infect Dis 1976; 133:705-706. Klein RS, Phelan JA, Freeman K et al. Low occupational risk of Human Immunodeficiency Virus infection among dental professionals. N Engl J Med 1988; 318:86-90. Gerberding JL, Bryant~LeBlanc CE, Greenspan D, et al. Risk to Dentists from exposure to patients infected with AIDS virus. In Abstracts of the 26th Interscience Conference on Antimicrobial Agents and Chemotherapy. Sept 28-Oct 1,1986; Washington DC. American Society for Microbiology, 1986:283. Abstract No. 1015. Flynn NM, Pollet SM, Van Horne JR Elvebakk R, Harper SD, Carlson JR. Absence of HIV antibody among dental professionals exposed to infected patients. West J Med 1987; 146:439-442. ADA News. December 21, 1987. American Dental Association, Chicago, Illinois. CDC. Update: Acquired Immunodeficiency Syndrome and Human Immunodeficiency Virus Infection among Health-Care Workers. MMWR 1988;37:229-239. Little JW and Falace DA. Dental Management of the Medically Compromised Patient. St. Louis:The C V Mosby Company, 1984. Sonis ST, Fazio RC, and Fang L. Principles and Practice of Oral Medicine. Philadelphia:W B Saunders Co, 1984. Davis, DR and Knapp, JF. The significance of AIDS to dentists and dental practice. J Pros Dent 1984; 52:736-738. Emphasis: Infection control in the dental office: a realistic approach. JADA 1986; 112:458-468. CDC. Recommended infection control practices for dentistry. MMWR 1986:35:237-42. CDC. Recommendations for Prevention of HIV Transmission in Health-Care Settings. 1987;36:3S-18S. Andriolo M, Wolf JW and Rosenberg JS. AIDS and AIDS-related complex: oral manifestations and treatment. JADA 1986; 113:586-590. 15. 16. 17. 18. Silverman S, Migliorati CA, Lozada-Nur F, Greenspan D, Conant MA. Oral findings in people with or at high risk for AIDS: a study of 375 homosexual males. A Am Dent Assoc 1986; 112:1867-192. Phelan JA, Saltzman RB, Friedland GH and Klein RS. Oral findings in patients with acquired immunodeficiency syndrome. ORAL SURG ORAL MED ORAL PATHOL 1987;64:50-56. CDC. Revision of the CDC Surveillance Case Definition for Acquired Immunodeficiency Syndrome. MMWR 1987;36:3S5~15S. Hurlen B, Gerner NW. Acquired immune deficiency syndrome (AIDS)-complications in dental treatment. Report of a case. Int J Oral Surg 1984;2:148-50. LOW OCCUPATIONAL RISK OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION AMONG DENTAL PROFESSIONALS RopertS Kiem MD. Joax A Poeray. DDS., KatHerive FREEMAN. Dk.P H , CHarves SCHABLE. MS. GERALD H Friepiann, 11D Norwan Triecer. D M.D., MD., anv Neat H Streicsicer, M.D Abstract We studied 1309 dental professionals (1132 dentists 131 hygienists, and 46 assistants) without behav- ioral risk factors for the acquired immunodeficiency syn- drome (AIDS) to determine their occupational risk for infection with human immunodeficiency virus (HIV) Sub- jects completed questionnaires on behavior, type, dura- tion, and location of their dental practice, infection-contro! practices, and estimated numbers of potential occupation- ai exposures to HIV. Serum sampies were tested for anti- bodies to HIV and to hepatitis B surface antigen (unvacci- nated subjects). Fifty-one percent of the subjects practiced in locations where many cases of AIDS have been reported Seventy- two percent treated patients who had AIDS or were at \V'EN before idenufication of the human immuno- deficiency virus (HIV) as the etiologic agent tn the acquired immunodeficiency syndrome (AIDS). the likely routes of transmission were recognized and included homosexual!-” or heteroseaual* seaual activ - ity, exposure to blood or blood products.*’ sharing of contaminated injection equipment by intravenous drug abusers ® and perinatal transmission from an in- fected mother to fetus or newborn *!! Since the idenu- ficauon of HIV as the causative agent of AIDS,'*"4 seroepidemiologic studies have supported the idea that these routes are important in transmission '*!* The similarity between the epidemiologic features of AIDS and those of hepatuus B was recognized earl. From the Division of Infectious Diseases Department of Medicine, and the Departments of Dentistry and Biostaustics, Montefiore Medical Center, the De- partments of Medicine Dentistry, Oral and Maxillofacial Surgery , and Epidemi- ologs and Social Medicine, Albert Einstein College of Medicine, Bronx N + and the AIDS Program, Centers for Disease Contro!. Alanta Address repnnt requests to Dr Klein at the Montefiore Medical Cemer. 111 E 220th St , Bronx, NY 1046? Presented in part at the Third International Conference on AIDS June 4, 1987, Washington. DC increased risk for it Ninety-four percent reported acciden- tal puncturing of the skin with instruments used In treating patients Adherence to recommended infection-control practices was infrequent. Twenty-one percent of unvacci- nated subjects had antibodies to hepatitis B surface anti- gen. Only one dentist without a history of behavioral risk factors for AIDS had.serum antibodies to HIV We conclude that despite infrequent compliance with recommended infection-control precautions, frequent oc- cupationa! exposure to persons at increased risk for HIV infection, and frequent accidental! puncturing of the skin with sharp instruments, dental professionals are at low occupational risk for HIV infection. (N Engl J Med 1988, 318:86-90.) in the AIDS epidemic '®!® Hepatuius B also occurs with increased frequency among sexuall, acuve ho- moseaual men,?°-22 intra, enous drug abusers 2 -? re- ciprents of blood products,?*?’ heterosexual sexual contacts of infected persons.** and infants born to 1n- fected mothers 7" Studies in the United States have suggested that dentists are among the health care providers at great- est risk of acquisition of hepatitis B infection 33! The similarity in routes of transmission between hepauts B and HIV and the recognized occupational risk of hepantis B infection among dental professionals led us to study the occupational msk for HIV infection among such professionals. METHODS From October 1985 through May 1987, dental professionals were recruited for the studs by means of a mailing to dentists in the boroughs of Manhattan and the Brona in New York City. and solicitation at staff and society meeungs throughout the New York City metropolitan area and at health-screening activities at the an- nual meeting of the American Dental Association in Miami Beach in October 1986, Subjects declining parucipation were asked to Reprinted from the New England Journal of Medicine 318:86-90 (January 14), 1988 complete canonsmoush } a refusel form ind: LOW Risk OF HIN AMONG DENTAL PROFESSIONALS — KLEEN ET Al i" Table 1 Sex of Dental Professional and Location, Type, and Duration of Practice cating Uis reason fur nonpartaipwion Pat- nepants cave waitten miter med consent ali | completed a questinmare an demuourar | ke oinpe duration and locauan of practs: bebates plaine then athieh risk VEPs Pree s tach (GUN Papert type and esumated nuinhors of pagents (ae Sev” estimated numb: of acerdental parenters! Male inoculations and status of vaccinate Femais acaime hepa Bo The questionnare het Lowution of prasti¢ New York Cits been protested and medincabens had been . made to improve the validits af responses Venipure ius was perlormed speaumens wore Guded te casure confidently ane se- rum was testid for antebadies to HIN by enzvme immunoassays (Abbett Laborate- res North Chicaeo Reacuve results wore Oral sury- ‘ confirmed with the Western blot assay 7 In ontics b sw had not rece d the hepauus Penodonth + Bee ce eh doe soaines ben it Endodontics B vaccine. serum anubodies against hepatt- us B surface anugen were measured by ra- dioommunoassay | Abbou! Only a single in- practice (range) vesticatur was able tc lin} serologic results hew York City metropolitan area Miam. San Francisco Houston or Los Angeles 64 (61 0 Oud, OF 14) Other or unknown Pnncipal type of practic. Restorative dentistrs Other or none indicated Destat Diste Destisis Hycat sit Assy ats be (N= bL42: (N= EG iN = 4! aw ae ne fle JOO) (Be 0 1 (2) Uh Fe 131 t12) 131 (200) 448 (Op, 307 (23, 326 (291 68 (52; 2a tot: 422 (32) 134 (12) 37 (201 17 (Vi. Ibo tds 604 155, 26 (20), bath 636 (44) 595 (83) 53 (8) 28 (71 33 (21 19.42) ay7q77, Mean number of years in F9 (1-47) 12 (+331 1u)-27) 1&8 (1-87, with subject identific's The New York Cit metropolitan area was defined to include Nassau Suflolh and Westchester Counties and arcas of New York State New Jersey and Connecucut within 25 mules of New York City The principal Wwpe of pracuce was defined as the area of pracuce in which at least 50 percent of professional time was spent Subjects who reported parenteral drug abuse and men who re- ported having sexual relations with other men in the vears since 17) were analy zed separate RESULTS Two hundred siaty -six persons who declined to par- ticipate in the study anonymously completed refusal forms indicating one or more reasons for nonparticipa- tion. Reasons given for nonparticipation included a lach of ume (78 subjects). a need to think about the study more {68}. concern about the maintenance of confidenuality (61). not wanting a venipuncture (51). being in a group at high risk for AIDS and preferring not to be tested (15). a belief that the research project was not important (9), and other, including being re- ured, “knowing” that denusts were at high msk “knowing” that dentists were at no risk, a behef that the serologic tests are tnaccurate, and fear of revoca- tion of their dental license if they were found to be positive for HIV (62) A total of 1360 subjects participated in the study Blood specimens were not obtained from 13 sub- jects. who were excluded from further analysis. Also excluded were 25 subjects with no or uncertain pa- tient contact. Thirteen subjects who reported high- risk behavior (10 homosexual or bisexual men, 2 het- erosexual intravenous drug users, and | drug user who was homosexual or bisexual) were analyzed sepa- rately. The remaining 1309 subjects included 1132 dentists. 131 dental hygienists, and 46 dental as- sistants. The sex and the location, type, and duration of den- tal practice of the subjects are shown in Table 1. The mayority of the dentists were men; almost all the den- *The sex of one dentist Was NOl fecurded tal hygienists and assistants were women Approxi- mately half the subjects worked in New York City, the New York City metropohtan area, or other cities in which large numbers of cases of AIDS have been re- ported The majority of denusts practiced restorati denustry. Fitty-three (5 percent) were oral surgeons, and an additional 461 (41 percent) spent from !0 to 49 percent of their time performing oral surgery. The mean number of years in practice for all subjects was 18. The number of subjects who reported treating pa- tients known to have AIDS or to be at an increased risk of AIDS and the esumated numbers of such pa- tients treated are shown in Tables 2 and 3. Fifteen percent of subjects treated pauents with AIDS; 72 percent treated patients known to be at increased risk for AIDS. Some subjects treated hundreds of such patients. Because subjects were asked to estimate the numbers of their patients known to belong to each of the high-risk groups. 1t 1s likely that the esumated numbers were lower than the actual number of high- risk persons treated Use of recommended infection-control precau- tions®? by subjects in the study was inconsistent, 31 percent of dentists, 73 percent of hygienists. and 8 percent of dental assistants always used gloves when Table 2 Dental Professionals Who Treated High-Risk Patients Dentists HyGIEntsTs ASSISTANTS Tota! (N= 1132) (N= 131) (N = 46) (N = 1309) Pament Group no (%&} Pauents with AIDS 176 (16) 15 (11) 8(17) 199: (15) Persons at nsk for AIDS 822 (73) 98175) 29 (63) 949 (72) Homosexual or bisexual men 738 (65) 94(72) 28(61) 860 (66) Intravenous drug abusers 395 (3S) 32(24) 1737) 9 444 (34) Persons with hemophilia 260 (25) 24 (18) 6(13) 310 (24) 8b THE NEW ENGLAND JOURNAL OF MEDICINE Tabie 3 Estimated Numbers of High-Risk Patients Treated within Five Years. Drevtist* HycitNists ASSISTANTS All mediun nn trang.) of panenis treated Patients with AIDS 21-75) 1 l-6) 0-4) 2 (1-75) Homosexual or bisexual men 10 (1-700) 14 (1-300) $ (2-250) 10 (1-700) 10 800) 241-150) 31-30) 10 41-800) 21-100) 241-25; 301-10) = 2 (1-100) Intravenous drug abusers Persons with hemophili. treating pauents, whereas 7 percent. none, and 10 per- cent. respectively, never used gloves The remainder (G2 percent of denusts, 27 percent of hygienists, and 82 percent of assistants) used gloves intermittently, either during specific procedures or when specific pa- tients were perceived as being likely to have or be at an increased risk for a communicable infection. Likewise, the use of eve protection, masks, and disposable gowns was intermittent, the proportions ofall subjects who never used these precautions were 8, 9, and 61 percent. respectively. Ninety-eight percent of subjects who used precautions reported that they had in- creased their use of precautions since 1983, and 87 percent had done so completely or partly because of concerns about AIDS Accidental parenteral inoculations with sharp in- struments were common, as shown in Table 4. Some subjects estimated that hundreds of such events had occurred, with their number ranging up to 7500 over the preceding five years in one dentist. The results of serologic tests for hepatitis B in the subjects are shown in Table 5. A majority of subjects in all groups had not received the hepatitis B vaccine, and 2) percent of these unvaccinated subjects had antibodies to hepatitis B surface antigen Since other markers for hepatitis B infection were not measured, the observed seropositivity rates for hepatitis B are the minimum rates of hepatitis B infection among these subjects. Several subjects had potential nonoccupational ex- posures to HIV infection Forty-nine male subjects (4.9 percent) reported having had sexual relations with prostitutes in the years since 1978: the mean number of contacts was 5 (range, 1 to 50). Thirty-nine subjects (3.0 percent) had received one or more blood transfusions since 1978. Eight subjects (0.6 percent) reported having had sexual relations with one or more persons at increased risk of AIDS. Table 4 Accidental Parenteral Inoculations with Sharp Instruments. Jan 14, 1986, 1 1 | Only 1 of 1309 subjects not at increased rsh of AIDS because of high-nsk behavior had anubody to HIV confirmed by Western blotting (Table 6) This subject was subsequently interviewed confidenually. and a second serum specimen was obtained and con- firmed to be seropositive for HIV. He was a dentist who had been practicing restorative denustry in Man- hattan for 14 years. His only sexual contact for more than 10 years had been his wife. He said he had not had sexual relations with men, had not used illicit drugs, and had not received a transfusion of blood products He had never treated a patient known to have AIDS but had treated persons known to be at increased risk for AIDS His use of gloves, mashs, anc other precautions was intermittent, and before Febiu- ary 1985, when he increased his use of gloves because of concerns about AIDS, his use of precautions had been even less frequent He reported that he frequent- ly practiced without gloves, even though he often had obvious breaks in his skin He estimated that he had received two accidental parenteral inoculations within the previous year and 10 within five years He had not received hepatitis B vaccine and he had a negative test for antibody to hepatitis B surface anugen. The den- tist’s wife agreed to a separate confidential interview. She said she had not had sexual contact with anyone other than her husband for more than 10 years and that she had never used illicit drugs or received trans- fusions of blood or blood products She refused to be tested for HIV antibody Discussion HIV and hepatitis B infections occur with increased frequency in sexually active homosexual men,'"3:?°?* intravenous drug abusers,® 22? recipients of blood products.>"7:74-*7 infants born to infected moth- ers,”'!?9 and heterosexual sexual contacts of infected persons.*”8 HIV and hepatitis B are both found in blood, !2:!3.25.26 semen,3#35 and saliva.35-3% Therefore, the routes by which HIV may be transmitted appear to be similar to those known to transmit hepatius B. The similar epidemiologic features of HIV and hep- atitis B and the recognized increased occupanional msk of hepatitis B infection among health care workers™ have generated considerable concern among these professionals. Recent reports of HIV infections in nine health care workers that were apparently acquired occupationally as a result of accidental parenteral needle-stick injunes.*!"* of extensive contact with blood and body fluids in the ab- sence of recommended barrier pre- cautions.*>:*® and of accidenta! DENTISTS HyYGIenists ASSISTANTS (N = 1132) (N= 131) (N = 46) No (%) reporting accidental 765/816 (94) 93/98 (95) 40/46 (87) inoculations * Median estumated number (range) Within five years 10 (1-7500) 10 (1-125) 10 (2-1440) Within one year 3 (1-600) 2 (1-52) § (1-288) Within one month 1 (1-20) 3 (=15) 3 (1-25) TOTAL spills of blood on mucous mem- iia branes or abnormal skin,*’ have 898/960 (94) heightened this concern. However, it is important to recognize that al- 40 (1-7500) though anecdotal reports may dem- Piet onstrate that an occupational risk exists, they cannot define a rate of *The denomunators indicate the number of subjects in each group responding to the quesuon risk; such a definition would re- Nol 31% Nu 2? Tabie 5 Hepatitis B Status of Denta’ Professionals * Desmist® AyGisrs 6 Assittangs Totat Me= dit> = 13h (N= 4e; (N= 1304 nee 18 Hepatitis B vaccine statu Vacimales! 496 144, 39 (YL 419) 539 (41) Not vaceruated 636156: = 92 (70) 42 (91) = 770 (89) Unvaccinated subvects tested = 634. (99) = 92 (10) 41195) 767 (100) for hepauus B anubods Ant-HBsAg posits 1S] (241 9 (101 4010) 9 164 (24) Ant-HBsAe negaths. 483 (76 83 +O» 37 (90: 6Q5 (791 *Hb~A, denotes hepanus B surface anuiges quire studies of large numbers of health care workers exposed to persons with HIV infection or body fluids of such persons. Several studies of health care workers have shown the risk of nosocomial HI\ infection to be low In five studies of occupational risk for HIV infec- tion among health care workers that included 1673 subjects, most of whom were hospital workers caring for patients with AIDS. 770 of the subjects had had parenteral needle-stich injuries or contamination of mucous membranes or open wounds by body fluids from patients with AIDS Only 3 of the 1673 (018 percent) became infected with HIV 48-3- Dental professionals represent an important group to study for occupauonal nsk of HIV infection. Den- lists are among the health care professionals at highest nsk of hepatius B infection. with the risk for oral sur- geons being parncularly high 9*3!4°% Dental hygien- ists and dental assistants are also at increased msk.°° Dental! professionals are likely to be exposed repeated- ly to persons infected with HIV. often for months or vears before those persons become ill or know that the, have an HIV infection. In addition, dental professionals are at risk not onlv for accidental paren- teral inoculations but also for splashes and aerosoliza- uon of blood and saliva. Therefore. 1t is important to study this group of health care workers not only to define their risk of HIV infection but also because the, may be considered a “senunel’ population that is hkely to indicate the maximal anncipated rate of occu- pauonal risk for health care workers in general Although a substantial number of persons chose not 10 parucipate in this study, the subjects who were en- rolled were similar to those in previous studies of den- tal professionals in that only a minority had been vac- cinated against hepauus B.*’ there was a high rate of previous hepatius B infection among those not vacci- Table 6 Antibodies to HIV among Dental Professionals Gren i No Screener No. Posttrve (%} No high-nsh behavior 1309 1 (0 08) Denusis 1132 1 (009) Dental hygienists 13) 0 Denta! assistants 46 0 High-nsk behas ror” 13 4(3)) *Male homosexual or bisexual aciivity intravenous drug abuse or both LOW RISK OF HI\ AMONG DENTAL PROFESSIONALS — KLEIN ET AL Bu nated,22-31.53-56 their use of recommended infection- control precautions was intermittent.°°°" they had had frequent accidental parenteral inoculations with contaminated instruments.*° ** and they had recents increased their use of precautions in response to con- cerns about AIDS *° This study demonstrates that despite infrequent compliance with recommended infection-control pre- cautions, frequent occupational exposure to persons at increased risk for HIV infection, and frequent accidental parenteral inoculations with sharp instru- ments, dental professionals currently are at low occu- pational nsk for HIV infection Only | subject among 1309 without behavioral rish factors for AIDS had antibodies to HIV. The absence of other risks, as de- termined by the history obtained from this dentist and his wife, suggests that occupational exposure was the likely mode of acquisition of his HIV infection. If this assumption is accurate. then the observed risk among all subjects was | mm 1309 (95 percent confidence inter- val, 0 to 0 004), the risk among all subjects practicing in locations with a large number of cases of AIDS was ] in 673 (95 percent confidence interval, 0 to 0.008). and that among denusts practicing in these locations was | in 523 (95 percent confidence interval, 0 to 0.011) In an additional 529 dental workers studied in three separate investigations, no HIV infecuons were observed.??*! Patients who may present a risk of transmission of HIV to dental professionals cannot be detected reli- ably.>° Infected persons may not feel or appear ill. They may not consider themselves at high risk of in- fection or may choose not to inform the dental profes- sional about high-risk behavior Available serologic tests take me, often require confirmatory testung. and may yield false negative results In most locatons, regulations require voluntary informed consent for HIV testing. and withholding care from patients who refuse to be tested could be considered coercive. Therefore. routine practices to prevent occupational infection should be formulated with the idea that all panents have the potential to transmit infection This will be parucularly important as the prevalence of HIV infection among dental patients mcreases over time, and potential occupational exposures become more frequent. Strict adherence to recommended in- fection-control guidelines for dental professionals” should help to mimimize the risk of occupationally acquired HIV infection. We are indebted to Felice Burstein, Dr Bran Saltzman, Dr Lewis Schrager, Dr John McKutrich, Patricia Kahl and Phil Gia- lanella at Montefiore Medical Center for technical assistance. to Dr Enid Nerdle, Dr Kenneth Burrell, Judith Osborn and Virginia Edwards of the American Dental Association for cooperauon and support, to Dr Margaret Fischi for technical support to Leticia Vazquez for help in preparing the manuscnpt, to Dr Chet Siew, who performed the assays for antibodies to hepatitis B surface antigen on specimens collected at the annual meeting of the American Dental Association, to all the hospital dental departments and local professional societies that gave us access to their member- ship, and to the individual dental professionals who participated in the studs oti tal 10. M1 13 14 20 21 23 24 26 27 28 29 30 31 THE NEW ENGLAND JOURNAL OF MEDICINE REFERENCES Marmot M Fnedman-Kren AE Laubenstein L, et al Risk factors for Kapos s sarcoma in homoseaual mer Lancet 1982 1 1083-7 Jaffe H\\) Chor K Thomas PA. et al National case-control study of Kapo- si'5 sarcomd and Preumucy sts carini pneumonia in homosexual men Part 1 Epidemiologic results Ann Intern Med 1983 99 145-5) Auerbach DM Darrow WW, Jaffe HW., Curran JW Cluster of cases of the acquired immune deficiency syndrome patients linked by sexual contuct Am ] Med 198-4, 76 487-92 Hams C. Small CB. Klein RS, et al Immunodeficiency in female sexual partners of men with the acquired immunodeficiency syndrome N Engl J Med 1983, 308 1181-4 Update acquired immunodeficiency syridrome (AIDS) among patients with hemophilia — United States MMWR 1983 32 613-5 Evatt BL Ramsey RB. Lawrence DN, Zyla LD Curran JW. The acquired immunodeficrencs syndrome sn patients with hemophilia Ann Intem Med 1983 100 499.504 : Curran JW, Lawrence DN Jaffe Het al Acquired immunodeficiency syndrome (AIDS) associated with transfusions N Engl J Med 1984, 310 69- 78 Fnediand GH, Harn. C. Butkus-Small C et al Intravenous drug abus- ers and the acquired immunodeficiency: syndrome (AIDS) demographic, drug use, and needle-sharing patterns. Arch Inter Med 1985, $45 1413-7 Rubinstein A, Sicklich M, Gupta A etal Acquired immunodeficiency with reversed T,/T, ratios in infants born to promiscuous and drug-addicted mothers JAMA 1983, 249 2350-6 Oteske J, Minnefor A, Cooper R Jr. et al Immune deficiency syndrome in children JAMA 1983, 249 2345-9 Thomas PA, Jaffe HW, Spmra TJ, Reiss R. Guerrero IC. Auerbach D Unexplained immunodeficiency in children: a surveillance report, JAMA 1984, 252 639-44 ‘ Barré-Sinousst F, Chermann JC, Rey F. et al Isolation of T-lymphotropic retrovirus from a patient at msk for acquired immune deficiency syndrome {AIDS) Science 1983. 220 868-71 Gallo RC, Salahuddin SZ Popovic M, et al Frequent detection and 1sola- tion of cytopathic retroviruses (HTLV-IIL) from.patients, with AIDS and at risk for AIDS Science 1984, 224 500-3 Broder §, Gallo RC’ A pathogenic revovirus (HTLV-II) linked to AIDS N Engl J Med 1984, 311 1292-7 Antibodies to a retrovirus etiologically associated with acquired immunode- ficiency syndrome (AIDS) in populations with increased incidences of the syndrome MMWR 1984, 33 377-9 Acquired immune deficsency syndrome (AIDS) precautions for clinical and laboratory staffs MMWR 1982, 31 577-80 Landesman SH, Viewa) Acquired immune deficiency syndrome (AIDS) 4 review Arch Intern Med 1983, 143 2307-9 Ravenholt RT Role of hepatitis B virus in acquired immunodeficiency syndrome Lancet 1983, 2 885-6 ; McDonald MM, Hamilton JD, Durack DT. Hepanus B surface anugen could harbour the infective agent of AIDS. Lancet 1983, 2 882-4 Szmuness W. Much MI. Ponce AM, et al On the role of sexual behavior in the spread of hepatitis B infectton Ann Intern Med 1975. 83 489-95 Schreeder MT Thompson SE Halder SC. et a! Hepatitis B in homosexual men prevalence of infection and factors related to transmission J Infect Dis 1982 1467-15 Recommendation of the Immunization Practces Advisory Commuttee (ACIP) activated hepatitis B virus vaccine MMWR 1982 31 317-22 327-8 Louna DB Hensle T. Rose } The major medical complications of heroin addiction Ann intem Med 1967, 67.1-22 Gocke DJ. Greenberg HB, Kavey MB Hepatitis anugen detecuon of infec- tious blood donors Lancet 1969, 2 248-9 Pnnce AM An antigen detected in the blood dunng the incubauon penod of serum hepatitis Proc Natl Acad Sc: USA 1968, 60 814-21 Shimizu Y. Kitamoto O The incidence of viral hepatitis after blood wransfu- sions Gastroenterology 1963, 44 740-4 Kunin CM Serum hepatitis from whole blood incidence and relation to source of blood Am J Med Sci 1959, 237 293-303 Redeker AG, Mosley JW, Gocke DJ, McKee AP, Pollack W Hepatitis B immune globulin as a prophylactic measure for spouses exposed to acute type B hepatius N Engt J Med 1975. 293 1055-9 Recommendations for protection against viral hepaus MMWR 1985, 34 313-24, 329-35 Mosley JW, Edwards VM. Casey G. Redeker AG, White E Hepatins B virus infection in dentists N Engl J Med 1975, 293 729-34 Smith JL, Maynard JE. Berquist KR, Doto IL, Webster HM, Sheller MJ Comparative risk of hepatitis B among physicians and denusts 3 Infect Dis 1976. 133 705-6 Tsang VCW, Peralta JM Simmons AR Enzyme-linked immunoelectro- 33 35 3? 38 39 4] 42 43 4§ 47 48 49 ’ 50 51 52 53 35 37 58 59 61 Jan 14. 1988 transfer blot techniques (EITB) for studying the specificines of antigens and antibodies separated by gel electrophoresis In Langone J). van Vunakis H, eds Methods menzymology Vol 92 Immunochemical techniques Part £ Monoclonal antibodies and general mmunoassas methed. New York Aca demic Press 1983 377-91 Recommended infecuon-contro! practices for dentistry MMWR 1966 35 237-42 Zagury D, Bernaul J, Liebowntch T, et at HTLV-II in cells cultured frosr semen of two panents with AIDS Science 1984, 226 449-5) Heathcote J, Cameron CH, Dane DS Hepatus-B anugen in saliva and semen Lancet 1974, 1 71-3 Groopman JE, Salahuddin SZ Sarngadharan MG. et al HTLV-H1 in saliva of people with AIDS-related complex and healthy homosexual men at nsk for AIDS Science 1984, 226 447-9 Ho DD, Byington RE. Schooley RT. Fivnn T Rota TR, Hirsch MS Infre quency of isolation of HTLV-II virus from saliva in AIDS N Engl J Med 1985, 313 1606 Brodersen M Stegmann § Klein K-H, Trilzsch D. Rensch P Salivary HBAg detected by radioimmunoassay Lancet 1974 1 675-6 Villareyos VM, Visond KA. Guuérrez A, Rodnguez A Role of saliva unne and feces in the transmussion of Type B hepatius N Engl J Med 1975, 291 1375-8 Snydman DR, Bryan JA, Dixon RE Prevention of nosocomial viral hepau- ts, type B (hepatitis B) Ann Intern Med 1975, 83 838-45 Needlestick transmission of HTLV-II] from a patient infected in Afnca Lancet 1984, 2 1376-7 Stncof RL, Morse DL HTLV-HV/LAV seroconversion following a deep intramuscular needtesuch injury N Engl J Med 1986 314 1115 Oksenhendler E, Harzic M, Le Roua J-M, Rabian C Clauvel JP HIV infection with seroconversion after a superficial needlestick injury to the finger N Engl J Med 1986, 315 582 Neisson-Vernant C, Arfi S, Mathez D, Leibowitch J, Monplaisir N- Nee- diestick HIV seroconversion in a nurse Lancet 198A 2 R14 Gnmt P, McEvoy M Two associated cases of the acquired immune defi- ctency syndrome (AIDS) Public Health Lab Serv Commun Dis Rep 1985 424 Apparent transmission of human T-lymphotrophic virus type III ‘Ivmphade- nopathy-associated virus from a child to a mother providing health carc MMWR 1986, 35 76-9 Update human immunodeficiency virus infections in health-care workers exposed to blood of infected patients MMWR 1987, 36 285-9 Hirsch MS, Wormser GP, Schooley RT. et al Rask of nosocomial infection with human T-cell lymphotropic virus [1] (HTLY-IH) N Eng] J Med 1985, 312 1-4 Weiss SH, Saxinger WC, Rechtman D, et al HTLV-III infecnon among health care workers associauon with needle-suck injunes JAMA 1985, 254.2089-93 Henderson DK. Saah AJ, Zak BJ, et al Risk of nosocomial infection with human T-cell lymphotropic virus type [V/iymphadenopathy-associated virus ina large cohort of intensively exposed health care workers Ann Intern Med 1986 104 644-7 McCray E. Cooperative Needlestick Surveillance Group Occupational msh. of the acquired immunodeficiency syndrome among health care workers N Engl ] Med 1986, 314 1127-32 Gerberding JL. Bryant-LeBlanc CE, Nelson K, et a) Risk of transmitting the human immunodeficiency virus, cytomegalovirus. and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related condinons J Infect Dis 1987, 156 1-8 Feldman RE. Schiff ER Hepatitis in dental professionals JAMA 1975, 232 1228-30 Mosley JW, White E Viral hepatius as an occupational hazard of dentists J Am Dent Assoc 1975, 90 992-7 Weil RB, Lyman DO, Jackson RJ, Bernstein BA hepatitis serosurves of New York denusts NY State Dent J 1977, 43 587-90 Schiff ER, Chan Y-K, de Medina M, et al Veterans Admunistration coop- erative study on hepatitis and denustry J Am Dent Assoc 1986, 113 390-6 Echavez MI, Shaw FE Jr, Scarlett MI, Kane MA Hepatius B vaccine usage among dental pracutioners in the United States an epidemiologic survey J Public Health Dent 1987, 47 182-5 Gerbert B AIDS and infection control in dental pracuce dentists’ attitudes, knowledge, and behavior J Am Dent Assoc 1987, 114 311-4 Flynn NM, Pollet SM, Van Home JR, Elvebakk R, Harper SD, Carlson JR Absence of HIV anubody among dental professionals exposed to infected pahents West J Med 1987, 146 439-42 Lubick HA, Schaeffer LD Occupational risk of dental personne! survey ] Am Dent Assoc 1986, 113 10-2 Gerberding JL, Bryant-LeBlanc CE. Greenspan D, et al Risk to dentists from exposure to patients infected with AIDS virus In Abstracts of the 26th Interscience Conference on Anumucrobial Agents and Chemotherapy . Sept 28-Oct 1, 1986 Washington, DC Amencan Society for Microbiology, 1986.283 abstract ©Copyright. 1988, by the Massachusetts Medical Society Printed in the U.S A SERVICE EMPLOYERS INTERNATIONAL UNION, AFL-CIO, CLC ‘akeiv"stae : 1313 L STREET N.W. » WASHINGTON, DC 20005 + (202) 898-3200 JOHN J. SWEENEY RICHARD W_CORDTZ INTERNATIONAL PRESIDENT , INTERNATIONAL SECRETARY-TREASURER COMMENTS BEFORE THE PRESIDENTIAL COMMISSION ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC Presented by the Service Employees International Union, AFL-CIO, CLC May 11, 1988 NOTE: Requested one page summary and biographical sketch attached Good morning, My name is Bill Borwegen, an industrial hygienist and director of Occupational Health and Safety for the Service Employees International Union, AFL-CIO, CLC. SEIU represents 850,000 public and private sector workers. Many of our members have potential occupational contact with blood and bodily fluids. A third of our membership for instance are healthcare workers - predominately employed in blue collar positions. We also represent non-healthcare workers such as janitors, police officers, correctional officers, and park workers with potential occupational exposures from discarded IV drug user needles, attacks from violent individuals, and other sources. On behalf of these workers, I appreciate the opportunity to appear before the AIDS Commission today. This Commission has a broad mandate to recommend the proper course of action on a host of public health issues surrounding the AIDS epidemic. It is important that this Commission add its considerable weight to protect healthcare workers and others from occupational exposures to this deadly disease. Our union first became involved in AIDS-related programs 1984 when fear of AIDS transmission first arose in our membership. To assure that healthcare workers would he able to continue to provide care to their patients, it was critical that irrational fear be confronted with factual information and that adequate safety precautions be implemented. Our first step was to develop and produce educational materials for workers: a brochure AIDS and the Healthcare Worker, 350,000 of which have now been distributed, and our comprehensive The AIDS Book - Information for Workers, acclaimed by the Centers for Disease Control as the "best educational material available for workers", which has been distributed in the tens of thousands to state and local health departments and hundreds of healthcare institutions. Copies of both publications are included in the materials I am submitting today. In addition, we have conducted scores of seminars across the country training thousands of healthcare workers. Our education efforts have only served to reinforce the findings of our original research and to convince us that other critical actions must be taken now to protect workers from occupational exposures to blood and body fluids. As you know the mode of transmission of HIV is similar to that of Hepatitis B - an occupational illness referred to as “healthcare workers disease." It is caused primarily by needlesticks, cuts and other exposures to non-intact skin and mucous membranes. Hepatitis B strikes 12-15,000 healthcare workers every year, killing 200-300 of them and is responsible for 11% of all lost workdays in this industry. Clearly, this is the deadly evidence to prove that comprehensive infectious disease control programs are simply currently not in place. To address this‘lack of infection control procedures we petitioned the federal Occupational Safety and Health Administration (OSHA) in September, 1986 to issue a permanent standard to protect healthcare and other workers from the threat posed by Hepatitis B and thus indirectly protect workers from all bloodborne infectious diseases such as AIDS. This petition also requested that the Hepatitis B vaccine be made available to all high risk workers free of charge. ‘The: need for a permanent bloodborne disease standard has been endorsed by the American Public Health Association, American Occupational Health Nurses Associations and other labor organizations. Last summer, OSHA agreed to begin the standard-setting process and issued an advanced notice of proposed rulemaking to announce the Agency's intentions and solicit comments from interested parties. To assist OSHA in this process, SEIU conducted a survey of infectious disease control practices within 100 departments in healthcare and other institutions located in 13 states and 55 major Metropolitan areas. I have provided the Commission with a copy of our survey as submitted to OSHA and our recommendations for what we believe should be included in a permanent standard. One of the more significant findings in our survey that we would like to bring to the Commission's attention is the comparison between which occupations were most likely to receive training and protective equipment and which occupations were most likely to have contact with blood, bodily fluids, or cuts with needles and other sharps. We found that 75% of the registered nurses in the facilities surveyed had received infectious disease control training, but only 55% of the nurses aides and 35% of laundry workers. Regarding provision of the Hepatitis B vaccine, while two-thirds of departments surveyed made them available to registered nurses, the vaccine was provided only to 40% of nurses aides, 40% of maintenance workers, and 27% of housekeeping personnel. Yet in at least in one study of needlestick incidents published in the Journal of the American Medical Association, the highest incidence rate of injuries -- 127 per thousand workers -- was found among housekeeping personnel, followed by a rate of 104.7 per thousand for laboratory personnel, and 92.6 per thousand for RNs. This Commission could provide invaluable assistance to my Union, other organizations, and many individual health workers who are fighting for adequate worksite protections against infectious disease by, first, acknowledging the contribution of health workers who have responded to the AIDS epidemic responsibly and compassionately despite inadequate ‘protections and at least, in the early days of this problem, a distinct lack of accurate or reliable information. Second, I urge you include in your report a strong statement on the need for both adequate infection controls and consideration of the stress on care givers involved with AIDS patients. Specifically, I urge you endorse the OSHA efforts in regard to infection control to date and call for the expeditious completion of a permanent infection control standard as soon as possible, but under no circumstances to exceed one year. Such an endorsement would be a major boost towards the worksite protections health workers have long been denied. It is said that AIDS can be prevented almost exclusively through voluntary actions - and for the so-called high risk groups, such as IV drug users, homosexuals and heterosexuals - this is true. However, for our nation's healthcare workers and millions of other workers at potential risk, they have no choice being involuntarily exposed to bloodborne diseases as they struggle to earn a living and a paycheck. This is one area where government regulation can have a significant impact in stemming the morbidity and mortality caused by this national epidemic, as supported by substantial documentation and consensus on the need to act. We thank you for inviting us to speak, and believe our recommendations provide the Commission with a unique opportunity to act to provide healthcare and other workers with the protections they need and deserve. BILL BORWEGEN, MPH Director, Occupational Health and Safety Department Service Employees International Union, AFL-C1r0, CLC Washington, D.C. Bill Borwegen is an industrial hygienist and the Occupational Safety and Health Director for the Service Employees International Union (SEIU). SEIU represents 850,000 members and is the nation’s largest union of both healthcare workers and of building service workers. Half of the membership is employed in the public sector. Mr. Borwegen came to SEIU to create the union's first occupational Health and Safety Department staffed with a nationwide network of regional health and safety coordinators, as well as a Washington, D.C.-based staff. SEIU is recognized as a leading voice in such workplace hazards as asbestos in schools and other buildings, infectious disease control, indoor air pollution, office automation, and occupational stress. Prior to working for SEIU, Mr. Borwegen worked with the AFL-CIO’s Food and Allied Service Trades Department. He received a Bachelor’s Degree from Rutgers University in microbiology and environmental science and a Master's Degree in Public Health in environmental and industrial health from the University of Michigan. He is also a licensed sanitarian. HEARING HEALTH CARE WORKER SAFETY MAY 11, 1988 RECOMMENDATIONS Page [,] of [ ]] OBSTACLES TO PROGRESS Healthcare and many other workers have potential exposure to blood and bodily fluids. These workers represent a separate high risk group that are involuntarily exposed to both the Hepatitis B and HIV viruses. The fact that 12-15,000 healthcare workers contract hepatitis B and 200-300 die every year is strong evidence that comprehensive infectious disease programs have not been implemented and that further actions are needed. RECOMMENDATIONS __ : SEIU calls upon the Commission to recommend that the U.S. Government move as expeditiously as possible, but in no case later than within the year, to issue a permanent OSHA standard to protect all workers that encgunter potential occupational exposure to blood or bodily fluids. The standard must specify at a minimum training and adequate protective equipment, free provision of the hepatitis B vaccine, confidential voluntary HIV counseling and testing, and needlestick management programs. Estimated Cost: Based Upon: Bill Borwegen, MPH Name May 11, 1988 Date a wore: 4 MAY 3 et ARE NO ee - a . TTY v4 at ee te PRESIDENTIAL COMMISSION ON HIV Presented by Julie Chamberlain, RN, MHS Infection Control Coordinator Butterworth Hospital Grand Rapids, Michigan April 29, 1988 Presidential Commission on HIV Mr. Chairman: It is a pleasure to have this opportunity to describe experiences of health care workers who have cared for patients with AIDS at 3utterworth Hospital, a 529 bed community teaching hospital in Grand Rapids, Michigan. Butterworth, which last year had an average occupancy of 81%, or 28,77! discharges, is a tertiary referral center for an eleven county West Michigan area in cardiology, cardiovascular surgery, high risk obstetrics, microsurgery, neonatology, oncology, and trauma. My job as Infection Control Coordinator-is to prevent disease transmission and control infections by active surveillance, epidemiologic research of infectious disease problems followed by procedural or behavioral changes, and the education of health care workers in infectious diseases. We have been giving our hospital personnel educational sessions on AIDS since 1983; we treated our first two men with AIDS in 1984. Although presently the preponderance of AIDS patients are in the Detroit area, we currently are treating at least 20 different AIDS patients yearly. We usually have from | to 3 in house at one time receiving care in every department from critical care to radiology; only the nurseries, neonatal intensive care and newborn, have not as yet had an infant diagnosed with AIDS or a hemophiliac with HIV infected blood. Although my associate and | had presented many AIDS programs to hospital staff, this disease acquired new impact and produced heightened awareness and increasing fear when CDC announced in May, |987 that 3 health care workers who had experienced a work related blood exposure in the past now had blood which tested positive for the HIV Virus. Other contributing factors to this awareness probably were the media blitz that neither a cure nor a vaccine to prevent this dread disease was going to be found soon, and heterosexuals were contacting AIDS. It was no longer a disease of homosexuals, bisexuals and IV drug addicts. Even though 89% of the cases continued to be reported in those 3 groups (homosexuals, bisexuals and IV drug users) with known documented risk behaviors, our hospital staff was disturbed by the conflicting media reports of transmission perhaps by mosquitoes, kissing, or spread from toilet seats and doorknobs. We needed to continually combat these unfounded rumors perpetuated in the media, for example Masters and Johnson received more publicity for their new book than the excellent factual brochure from Surgeon General Koops. To combat this fear and to promote a sound knowledge base and a safer work environment, we taught and emphasized the concept of Universal Precautions to al! departments in the hospital, i.e. to those with direct patient contact like nurses and physicians as well as to those in supportive jobs like housekeepers, physical therapists, dietary workers, plumbers, etc. We were supported in this effort by the Infection Control Committee and administration and Infectious Disease Physicians. Universal Precautions means that one must consider all blood or body fluids as being potentially infective. This was a marked change from previous approaches to infectious disease as health care workers formerly used barrier measures based on clinical presentation until the diagnosis of a contagious disease had been made. Health care workers thus formerly exposed themselves unwittingly to Hepatitis B or other blood borne pathogens. ‘Ne have always promoted the practice of handwashing as basic to preventing disease transmission. However, Universal Precautions provides additional barriers along with handwashing to block inadvertent contamination by infective material. This equipment is gloves, glasses, masks, gowns, puncture resistant needleboxes for used sharps and needles, and resuscitation masks. They must be easily accessible for use. Altnough most staff were eager to use gloves when handling wet fluids, we observed conflicting reactions to these recommendations, even though they came from CDC, the Michigan Medical Society and the Michigan Department of Public Heatlh. Especially in high tech areas like ER and critical care, some staff'scoffed at the use of barriers for all blood exposure because traditionally health care meant risk of exposure to contagious diseases, accepted as part of their job. Young house staff and some physicians refused to wear gloves or goggles for procedures where splattering of blood was likely, perhaps a denial that AIDS was a problem in Grand Rapids. Others wanted to wear too much equipment for instance putting on a mask, gown and gloves just to enter an AIDS patient's room. Some nurses stated "new data is still coming out on this disease" or "the data is ambiguous, you can't prove that I'm 100% safe. Therefore, I'm not going to take a chance". This was often inappropriate for the circumstances, fear producing and isolating for the patient. The support services like housekeeping were especially fearful to clean the rooms of patients who had AIDS or who were rumored to be contagious. They found it difficult to believe that such a deadly disease could be killed by ordinary hospital detergents , a rumor unfortunately also believed by some nurses but now corrected. After extensive education a housekeeper last week reported she "feels a lot better now that needles are in hard plastic boxes and that gloves are worn for cleaning bathrooms and wet spills". Plumbers now wear heavy safety gloves, a practice they should have followed all along. Workers in laundry and instrument processing wear gloves for handling any soiled linens or instruments. There is no longer a feeling that bloody linen should be destroyed. A few years ao, nowever, | did receive a frantic call for help from a mortician who came to pick up the body of a 13 year old who died of leukemia. Because of misunderstanding, he thought the cause of death was AIDS. He was hysterical and didn't want to transport the body, stating "now I'm going to have to burn my new $300 suit". He also attempted to prevent the parents from kissing or holding the child at the funeral home, even though the parents had been constantly holding that child in the hospital. The fear in my midwestern conservative community towards AIDS could be a reflection of a lack of exposure to the terrible suffering exhibited by the numerous AIDS patients on the East and West Coast; usually I've seen the staff deliver concerned and compassionate unbiased care, without fear. A few staff who have shown little understanding or tolerance of the multiple problems confronting patients with AIDS or ARC often have a fundamentalist approach to life, believing that AIDS is God's vengence upon homosexuals. We've also heard some nurses state "that my husband (or father) doesn't want me to work with these patients". After they've learned about the disease and its specific transmission through blood and practiced using apprpriate barrier precautions, these staff members now practice according to Butterworth's mission "to support and improve the health of al! patients". I, too, had an uncomfortable reaction when | interviewed our first AIDS patient in | 984 who was to receive chemotherapy for Kaposis Sarcoma. He was not visibly very sick, nor was he bleeding or coughing. Although | was an educator and consultant for the hospital on AIDS and intellectually believed that the HIV Virus was contagious only through blood, | experienced terribly fearful thoughts when | shook this young man's clean dry hand - a totally unreasonable gut fear. | could see that | was at no risk but that -3- conflicting thought still passed through my head. Yet, | was talking to him in order to help him. | feel one has to actually work with an AIDS patient before one can truly understand this conflicting fear related to the instinctual need to survive. When health care workers can confront this need, in oneself, then one is able to give compasionate care. The casual attitude toward the use of barrier precautions lasts until they or their peers have an accident. If a needlestick accident occurs and blood infected with the HIV Virus mixes with the staff member's blood or splashes in their eye or mucous membranes, this accident evokes an instinctual terror. Overwhelming unrealistic fear erupts in the worker's mind, even though they know that the risk of contracting AIDS is very low. They strive for balance as this small poke forces them to dea! with their own mortality. Others exhibit this fear by demonstrating extreme anxiety, cry inappropriately, being edgy, even showing hostility toward the source patient. Sometimes the worker denies he is at risk. Finally at the end of the six month blood screening period the stress is cured by a good report - no infection. These staff members often need appropriate counseling in order to work during this anxious waiting period. One young doctor who tried to be very cool and casual after a needlestick was so excited when told of the good results that the relief in his voice flooded over ihe phone. Last fall with the many traumas coming into our ER from AeroMed who were bleeding excessively besides the hemophiliacs who had transfusions, there had been enough accidental exposures to infected blood to persuade the ER Docs and nurses to wear barriers and be more cautious. It's difficult to comprehend that a small needlestick will perhaps change your life. However, now even the surgeons are more carefully handling needles and blades than a year ago. OR nurses also carefully handle bloody instruments and equipment;, most now wear protective glasses to operate or deliver a baby and avoid soaking their clothing with fluids from the patient. Now although we don't routinely screen patients for HIV unless there are identified high risk factors, along with Universal Precautions we clearly but discreetly identify those patients with HIV infected blood. This identification is confidential but necessary information for those patients with + HIV who must have surgery or any invasive procedure, according to Dr. Koops. This protocol seems to be appropriate communication to forewarn other health care workers and yet protects the confidentiality of the patient. The confidentiality of diagnosis is an important issue for the patient both socially and economically as many of these patients haven't as yet told their parenst, siblings, wives that they are homosexual, bisexual or !V drug users. Unfortunately, some employers will also fire these men when it's known they have AIDS, even if they are able to meet customary job performance standards without hazard to themselves or to others. If health care workers use the Universal Precautions approach, the tricky balance between protecting both the staff and patient is accomplished as there is no obvious labeling like prominent signs on the patient's door. | One 55 year old man became very ill and was hospitalized at Butterworth while he was in the area visiting his hospitalized sick mother. He was currently divorced and working in Los Angeles, however, his family of 4 brothers and sisters and 5 children lived around Grand Rapids. He woula not talk about his life out West until after he'd been hospitalized for 3 weeks in intensive care. He then told the physician that his roommate had died of AIDS. He'd been on a ventilator and had many intervenous lines placed. The nurses and doctors were angry that he had knowingly placed them at risk, as he knew he too had AIDS. The staff did empathize with his problem; most of his family did not know he was homosexual except for a sister and one son. The staff handled the situation well and maintained confidentiality, even when they felt so exposed and misled by the patient. It was difficult but the diagnosis was kept quiet even when visitors and family asked questions regarding his death. Another 39 year old patient with a 2 year old child was a challenge as he at first refused to tell his wife he had AIDS. The staff had to be very careful to uphold his wish of silence until his physician persuaded him to tell his wife of her risk of exposure to HIV; the child could have been exposed in utero. This patient remained in our hospital for 3 months, because at that time neither a long term care facility nor Hospice were prepared to take AIDS patients. Then there was the 54 year old hemophiliac with a new wife and baby who came to our hospital so that his neighbors in a smal! nearby town wouldn't discover his true illness or discriminate against his family. Often we've found the hemophiliac patient is reluctant to tell the nurses and doctors that he has infected blood, fearing that he might receive less attention and care. One hemophiliac with infected blood told his nurse "he wasn't one of those, he didn't get AIDS that way" - meaning he clearly was not homosexual and wanted everyone to know that. However, at that time he was unable to find a dentist who would fill the cavities in his teeth, because of his infected blood. In summary, | think that health care workers now realize that certain procedures put them at risk of exposure to a deadly disease, There is protective equipment which will provide barriers to contamination from infected blood. However, their own professional skill and techniques are very important, if they are to protect themselves from splashing or needle sticks. Vaccination for Hepatitis B should be mandatory for all those who work in high risk areas. | feel our current blood screening process for high risk individuals is appropriate. | do not wish to see mandatory screening for all patients who enter the hospital, as our current blood screening tests for HIV are not that accurate. | hope CDC will continue to publish clear, concise data and that the government wil! fund AIDS research and aggressively market programs to every segment of our population to prevent AIDS transmission. -6~ PUBLICATIONS AND PAPERS PRESENTED Honors Sigma Theta Tau (International Honor Society of Nursing) Publications Chamberlain, J. and Buist, D. "Sign Language" a videotape presenting theory and demonstration of 1983 revised Center for Disease Control Isolation Precautions, |984, video sold by Care Video Productions, Cleveland, Ohio Papers, Conference Presentations: 1987 Michigan Society for Infection Control Spring Conference - "Scrubby Bear Project in Hospitals and Schools". 1984 Michigan Society for Infection Control Fati Conference "Isolation According to the New CDC Guidelines". Presentations 1987 "Professional Nursing Care of the AIDS Patient" - Grand Rapids District, MNA 1987 "Urosepsis and Sexually Transmitted Diseases," Urology Nurse Certification Course, MNA accredited, Butterworth Hospital--1986, 1987, !988 1987 "AIDS and Med Center Staff," Butterworth Hospital Med Centers 1987 = ="AIDS and Hetrosexuals," Grand Rapids Area Singles Group 1987 "AIDS in Pediatric Patients," Pediatric Nursing Staff, Butterworth Hospital 1987 “Avoid Nosocomial Infections, Improve your Practice" Grand Valley State College and Hope Calvin Nursing Students--annually since 1985 1987 "Nosocomial Infections," Grand Valley State College Graduate Class in Health Sciences 1987 "Implications of Nosocomial Infections to Medical Students," Grand Rapids Area Medical Education Center Medical Students--biannually since 1984 1986 "AIDS, Implications for PAR Nurses," West Michigan Society of PAR Nurses, Spring Meeting 1986 ="AIDS and You,'' West Michigan Insurance and Risk Managers Regional Meeting . 1986 "AIDS, Implications for Hospice," Grand Rapids Ho - _ ’ “Nurses must participate in the development of such policies. We know that = nurses identify and define infection control through their roles as staff nurses, 7 ' -- administrators; infection -control practitioners and risk managers. Dr. Julie Gerberding of San Francisco Memorial Hospital recently stated that thé common es —_- -” _. enominator for HIV occupational exposures is blood, needle sticks and nurses. —_ Therefore, we have a vested’ fmterest in employer policies on AIDS. — — 7 — 2” = - a FR me Ff ' me, = ~ 7. wu - * a +. ae = - - _ . lr tome 7 =~” * - - ~ ao athe om _- 7* + Cd — “ care workers. However, we co recognize that testing may be appropriate in certain situations. . - Random or routine testing of employees should not be permitted. If an employee displays symptoms of a medical condition,’ he/she should be assessed by a . a , cae = As you are aware, both-ANA and AACN oppe “e mandatory HIV testing of health - 10 - Employee Health and referred for further evaluation. All employee health information must be kept confidential. This is especially important regarding HIV tests because of possible adverse insurance actions and reports of employment and housing discrimination against persons infected with HIV. - We do support employer testing if it is done in accordance with the medical surveillance routine recommended by the CDC to document the job exposure. to HIV — after an occupational accident. Serologic testing after on the job exposure to HIV may be crucial in establishing a worker's compensation claim. Personnel _—_- -_ —_ policies should be developed prospectively for job exposure to HIV and address employer payment for initial serologic testing and-follow-up tests, -1ecord- keeping and access to records, confidentiality, and medicai and health counseling during medical surveillance. Health care- workers must be encouraged to report occupational accidents and seek appropriate medical surveillance. They must also - be assured that such actions will not be*subject to retaliatory actions-or that ~ the information willnot be used in legally impermissible wayss. ~ - a od . = _We have urged our membership to notify their. employers when they incur . 2, — occupational exposures to blood and body fluids. Those “who are managers. mus — rad - = = . / ware bd — educate. staff about the necessity for reporting exposures, and must ensure the appropriate follewe:: -There‘‘fiust not -be any disincentivesy.“or~health-caze i =f: -> . aime a ae : wo i Sa — - tee * tw — — + ee workers to responsibly repott occupational expasures. We are concerned~because ~ - _ we have heard anecdotal reports that nurses Wtio hawe experienced needle sticks have had difficulties with insurance companies regarding d¢overage. _ Likewise, we believe that policies must address the source patient of an occupational. exposure. That patient must be afforded the same protections of ” - ill - confidentiality, privacy and counseling as the employee. Testing must be accomplished with informed consent, and the employer should have prospective policies for the possible patient's refusal to test. Ideally, the assurance of anonymity through coding and sequestering of the results from the patient's chart will ensure the patient's compliance. However, some hospitals are reviewing court ordered testing of source patients who refuse. We do not support the reporting of such testing on the source patient's chart because of reports that some insurers are cancelling policies upon notification of such tests, ~ notwithstanding the results. Appropriate follow-up testing and counseling of exposed employees is necessary to enable employees to make appropriate decisions regarding family and — - marital decisions. Follow-up testing of employees must be done with anonymity, counseling with informed consent, and assurances of confidentiality. Ideally, if an the “source patient and his/her HIV. status is known, employees will not be in limbo regarding personal life decisions. ~* When the source patient or the HIV status of a patient is-unknown, the employee may have to forego marital or family planning decisions until his/her potential for serocenversion is ruled out, _— = -! =, ~~ ——_ - _ = = _— When health care workers are infected with HIV or have AIDS, their fitness - — ——_— 7 6 pie = ' tordaty should be evaluated in conjiinetiv.. 7,.th- his/her Family- health provider = m , 2 nd Employee Health. _ Although the final “aecisior may belong with Employee _ Health, we support the utilization of a review committee to which an employee may appeal an adverse decision. Confidentiality must be maintained throughout the process. Although medical follow-up of employees is necessary, such review should be -12- conducted by the employee's provider. The employee's health care provider can validate the employee's fitness for duty. Diagnosis information should be kept in the employee's medical records and not in employee personnel files. The provider need only document fitness for duty for personnel records. Any changes in work assignments should be done in the same manner as for other medical conditions. Ideally, the goal of such policies is to return the employee to his/her assignment utilizing the skills and talent of the employee. However, employers should be sensitive to the fact that persons infected with HIV may have compromised immune systems. Therefore, they are at increased risk of acquiring other infections and opportunistic diseases.- Such employees should be counseled about potential risks and appropriate infection control measures to ~~ minimize their exposure... The ‘employer -should observe established policies governing qualification requirements, internal placement and _ staffing requirements. - = -. = “. ~ _" to —~ —_ ~ -_ Employees infected with HIV should have access_to the same sick, disability = en _— . of vacation leave in the same”manner .aS employees with other medical conditions. a ._ =, rr Employers must -recognize- the need to pursue “medical care “or to* recuperate- from —™p on “ us = > 5 the treatment or effects of the illness. _ Although an employee's medical condition should be kept confidential by the : employer, there may be instances when fellow employees are aware of ‘the employee's condition. . Employers must have a written policy regarding employee | - ;eluctance or refusal to work with HIV infected employees. Appropriate education = and counseling must be available to dispel fears and ‘misinformation. _ Appropriate corrective or disciplinary action must be administered when education fails. ae ae .. ‘ - 13 - Such disciplinary action should be handled in the same manner as non AIDS related personnel problems. = The employer must ensure that employees infected with HIV are afforded the protections of Section 504 of the Rehabilitation Act of 1973. The Supreme Court has stated that persons with contagious diseases are included within the definition of handicapped. Therefore, they must not suffer discrimination because of their medical condition. ANA recognizes that employers cannot protect their workers from all harm. We believe, however, that an employer violates his duty to provide a safe and healthful place of employment if he does not take reasonable precautionary steps + ey _ to protect employees from reasonably foreseeable hazards, likely to cause~ death or serious injury. ANA also believes that the employer's obligation involves =z — more~tham cautioning an employee and ordering a prescribed action. . = co) a Employers -should otiefit employees regarding personnel policies regarding AIDS. The programs should reach all levels and be multidisciplinary. Enip loyees _ - - _ should be given an opportunity to ask questions and receive informed responses from designated atthorities..= or - = ‘*. = Employees must be monitered to ensure cou *liancge. with personnel and health " and safety programs. We have to acknowledge that workers are sométimes indifferent; careless, or forgetful about matters affecting their personal safety. Health care workers have historically put the patient's health ahead of their own. That is not an indictment, but an indication that occupational safety and health involves a partnership between employer and employee. However, the — e - - 14 - employer controls the workplace environment and, therefore, has a greater burden. Accordingly, the employer must enforce the health and safety program, and must be consistent and equitable to establish good faith in the program among employees. Recently, we received a call from a nurse in Georgia stating that her employer was giving educational programs on universal precautions. However, the employer was asking the employees to sign forms absolving the employer from —_ liability if the employees were exposed to HIV. We oppose such a policy as it seems prohibitive and inconsistent with accepted occupational health concepts and —_ laws. We have made inquiries regarding such policies to OSHA. — We hope that our recommendations wiIl aid the Commission in addressing +. occupational issues and AIDS. ‘ANA and AACN are sensitive to the difficulty and complexity of the issues addressed here today.- Our commitment to the provision - of nursing care to all patients is steadfast. However, the health and safety of - ~ health care workers” @ust be ensured.” We beliéve that scientific, logical, Fae —_ to compassionate, prospective policies can balance the health and safety interests - se ~ of health care workers and their patients. - - Te - -—~ ~ ee -—- - - ~ — ~= ae “- - - wm -~ . — “mt - - 7 Thank you for the opportunity to present our concerns and recommendations. AACH AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES PREVENTION OF TRANSMISSION OF BLOOD BORNE PATHOGENS ~ AACN supports the Centers for Disease Control (CDC) Recommendations for Prevention of HIV Transmission in Health Care Settings (1) which ~ emphasize the need: to treat blood and other body fluids from all patients as potentially infectious. This approach is referred to as universal precautions. Exposure to blood borne pathogens, such as Hepatitis 8 virus (HBV, previously called serum hepatitis) and human immunodeficiency virus (HIV, previously called HTLV-III/LAV) constitutes an occupational hazard to critical care nurses. These viruses have been found to be transmitted by intimate sexual contact, contaminated needles, and infected blood or blood products. Transmission from mother to infant may occur during gestation or at birth. Transmission may also result from infectious blood or body fluids coming into contact with mucous membranes or non-intact skin. The risk of HBV infection in health care settings far exceeds that for HIV infection, despite the similar modes of transmission. It has beén estimated that the risk of acquiring HBV infection following puncture with a HBV contaminated needle ranges from 6% to 30% (2,3,4). Under _ | similar circumstances; the CDC estimates the risk of HIV infection to be less than 1% (1,5,6). - o - Critical care nurses are among healtit care workers who are at a recognized occupational health risk for exposure to HBV, HIV and other blood and body ftuid- pathogens (7). WHEREAS, adherence to CDC’ guidelines on univessal precautions will | minimize fhe risk of.. transmission of HBV, HIV and other blood borne’ - pathogens, WHEREAS, serologic testing cannot reliably identify all patients with blood borne pathogens, and-implemen* <.®, precautions only.-on known < serologically positive patients-may cuz tu“ false sense of security and the taking of unreasonable risks (RY = ; - od .. WHEREAS, there is a vaccine available to prevent HBV transmission, WHEREAS, critical care nurses are among health care workers who provide — care to all patients, including critically i11 patients infected with HBV, HIV and other blood borne pathogens that may pose a potential biological risk. ° THEREFORE, BE IT RESOLVED THAT the American Association of Critical-Care Nurses strongly advocates implementation of the recommendations of the Centers for Disease Control on universal-- precautions in all health care settings, One Civic Plaza, Newport Beach, California 92660 - 714-644-9310 - FAX 714-640-4903 - TLX 296937 AACN UR 2420 PERSHING ROAD, KANSAS CITY, MO 64108, (816) 474-5720 1101 14TH STREET, N.W., WASHINGTON, DC 20005, (208%) 789-1800 ee rece ee een ae AMERICAN NURSES' ASSOCIATION STATEMENT ON SEROLOGICAL TESTING OF HEALTH CARE WORKERS FOR HUMAN IMMUNODEFICIENCY VIRUS ANTIBODY ~ — Acquired Immune Deficiency Syndrome (AIDS) has been declared the number one health priority by the U.S. Public Health Service. As the public becomes more concerned about the disease, the pressure for routine screening for the Human Immunodeficiency Virus (HIV) antibody is likely to mount. Pressure is apt to focus on health care workers because of their unique role in caring for persons with AIDS, even though the Centers for Disease Control (CDC) does not recommend routine serologic screening for health care workers, regardless of routine . participation in invasivé procedures. ~ - : ma The American Nurses' Association (ANA) opposes the routine serologic screeni of Pp ug health care workers for the HIV antibody. The HIV virus is transmitted through - intimate sexual or blood to blood contact. Therefore, the risk of HIV transmission for health care sworkers to patients is remote. Because HIV- is transmitted only through intimate sexual or blood to blood contact, routine serological screening of health care workers for the HIV antibody will not improve patient care or provide additional pretection against HIV transmission in the health care settings. The mere presence of HIV antibody in the absence of immunosuppression_or symptomelogy of Aids Related Complex (ARC) or AIDS does not affect or predict job performance problems. “In the absence of performance ‘problems or risk-to patients, other employees or the affected employee, the employer has no nead-.for such information. Additionally, since the mere presence of HIV antibody does not predict the eventual development of ARC or AIDS, it cannot be. used accuratély to predict insurance claims or increased costs for- emptoyee benefit plans. = ~ - - oe — ——_ ~ baal + ANA dnes support employer testing “it Lt ‘ts- eaowss in=3ccordante. with the medical ~™ surveilfance routine recommended by the. CDC. th. document on the jeb exposure to _aHIY ‘after an occupational accident. Serologic t Sting after on the job exposure to-HIV may be crucial in establishing a workers compensation claim. Personnel +: policies should be developed for on the job exposure to HIV and address employer payment for initial serologic testing and follow-up tests, record- -keeping and. access to reeords, confidentiality,. and medical and health counseling during medical surveillance. Health care workers must be encouraged to report occupational accidents and seek appropriate medical surveillance. They must also . be assured that such actions will not be subject to retaliatory actions or that the. information will not be used in legally impermissible ways. Cabinet on Economic and General Welfare November 12, 1986 ~ - American Nurses’ Association - Washington Office AMERICAN NURSES' ASSOCIATION AWN POSITIONS REGARDING SEE EEELEET! . a ACQUIRED IMMUNE DEFICIENCY SYNDROME oO ANA supports the availability of voluntary, anonymous HIV testing with informed consent and appropriate counseling by qualified health care professionals, and that these seeking services at drug rehabilitation, sexually-transmitted disease, and family planning clinics have access to anonymous testing and counseling about. health practices.: - Oo ANA opposes universal mandatory testing “for antibodies to the HIV -- virus, including compulsory testing of hospital patients and health care workers. 0 ANA supports increased federal funding for education, research and treatment in the fight against AIDS, — - 7 ° ANA is committed to protecting the civil and human rights of persons. affected with AIDS as well as those of caregivers. ANA is ‘opposed to ~ the discrimination against persons with AIDS or a positive HIV. ~ o ANA is “opposed to discrimination=in employment for handicapped- individuals and supports the inclusion of infectious diseases s including . AIDS under the Refiabilitation Act of 1973. —~. om! ~ - Ee - - - ° The ANA 1987 House of Delegates reiterated its “position that the . professional nurses provide care_to ail ~ ‘people -in need -of nursing " services regardless of the-illness-or the_ severity of that-disease. ~ ~~ o ANA gupports OSHA's .enforcement of the CDC recommendations on employee. ~ _ exposure to AIDS. ae = = - _ 9 ANA supports legislative efforts “ta assure equitable _cost- effective access to treatm@nt for all #IDS patients. _ vo. wn. ee ~~ ns . et ° ANA supports voluntary esting with’ pre "and “post counseling of those seeking family planning, prehatal care or drug treatment. oe - ae a — rt -“9O ANA supports legislation that- would increase access to affordable, quality care for well and sitk children on a 24 hour basis. — o +. ANA endorses H.R. 3071 and S. 1575, which provides $400 million for "is “voluntary AIDS testing and counseling programs. ° ANA endorses H.R. 4825 and S. 1220 which provide funding for AIDS ~ research arid education programs. _ —— v- -_ = 02/04/88 — American Nurses’ Association— Washington Office 1101 14th Street, N.W. Suite 200 Washington, 0.C. 20005 (202) 789-1800 ANA — An Equal Opportunity Employer Page Three H sf REFERENCES Centers for Disease Control: Recommendations for Prevention of HIV Transmission in Health-Care Settings. Morbidity and Mortality Weekly Report Supplement, 36 (2S):1 S-16 S, 21 August 1987. " Viahov, 0., Polk, B.F.: Transmtssion of human immunodeficiency virus within the healthcare setting. Occup. Med. State of the Art Reviews 2:429-450, 1987. ~ Grady, G.F., Lee, V.A., Prince, A.M., et al.: Hepatitis B. immune. globulin for accidental exposures among medical personnel - Final report of a multicenter controlled trial. J. Infect Dis 138:625-638, 1978. " Seef, L.B., Wright, E.C., Zimmerman, H.J., et al.: Type B _hepatitis after needléstick exposure - Prevention with hepatitis B immune globulin. Ann Intern Med. 88:285-293,- 1978. - Centers for Disease Control: Recommendations for preventing _ transmission of infection with human T-lymphotrophic virus ~ -.type III/lymphadenopathy - associated virus in the workplace. Morbidity andMortality Weekly Report 34:681-86, 691-95, 15 November 1985. ° Centers for Disease Control: Update - Human immunodeficiency virus - infections in flealth-care workers exposed to blood of ~~ = infected patients. Morbidity and Mortality Weekly Report 36:285-89, 22 May 1987. Department of Lager/Department of Health and Human Services. - Joint Advisory Notice:.P~-*ection Against Occupational Exposure to Hepatitis B + --+ (HBid and Human_-- _ - Immunodeficiency Virus (HIV), October 19, 1987. -_ _ — ‘ BVSTMT IMPLEMENTATION OF THE BODY SUBSTANCE ISOLATION SYSTEM (BSIS OR UNIVERSAL PRECAUTIONS TO ENSURE A SAFE HOSPITAL ENVIRONMENT REFERENCE - AHA Report AIDS/HIV Infection Policy: Ensuring a Safe Hospital Environment November, 1987 ENSURING A SAFE HOSPITAL ENVIRONMENT Effective Approaches: 1. Use of Protective Barriers for all Patients (Universal Precautions) 2. Testing for H.I.V. ENSURING A SAFE HOSPITAL ENVIRONMENT Background and Principles Any effective response to the problem of AIDS must be based upon an understanding of the disease. Although the virus which causes AIDS was identified only in 1983, and despite the fact that scientists do not yet have all the answers about the disease, a substantial body of scientific evidence has accumulated that is critical to the development of policies, both, by hospitals and by government. This research indicates that the human immunodeficiency virus (HIV) is relatively difficult to transmit, requiring direct exposure to the blood or other body substances f an infected individual. Consequently, transmission of the virus can be prevented by avoiding contact with infected blood or other body substances. The behavior changes needed to reduce the risk of infection depend largely on voluntary action rather than isolation of those with HIV infections. The goals of both public and hospital policies intended to reduce the risk of exposure should be consistent with the historical mission of health care providers. They should enable hospitals and other providers to deliver high quality and com- passionate care that is respectful of the interests of patients. Moreover, actions to prevent transmission of HIV infection should not interfere, unless absolutely necessary, with the interests of HIV-infected patients, particularly their interest in maintaining the confidentiality of sensitive medical information and in receiving the same care and consideration provided other patients. At the same time, the concerns and fears of health care providers and their staffs require careful attention and a commitment to the development and implementation of policies that can be effective in preventing transmission of HIV in the health care setting. Ensuring a Safe Hospital Environment For providers of health care, one of the most difficult issues raised by AIDS concerns the actions that are needed to ensure a safe hospital environment. Hospital staff members, including members of the medical staff, want to be assured that their risk of becoming infected while caring for patients is minimized. Patients want assurances that treatment in hospitals does not put them at risk. Two approaches to minimizing the risk of HIV transmission have received considerable public debate and discussion: the use of protective barriers for all patients (universal precautions) and testing for the HIV. (2) Safe Hospital Environment Universal Precautions Because it is often not possible to know when an individual may be infected with the HIV, consistent use of a barrier to reduce the chances of direct contact with potentially infected blood and body substances is the best way to avoid accidental exposure to HIV infection. Accordingly, universal precautions have been recommended by the Centers for Disease Control and the Occupational Safety and Health Administration for all health care workers whose functions could bring them into contact with blood and body substances. The effectiveness of universal precautions depends on vigilant compliance on the part of each individual staff member; in effect, universal precautions relies on the individual to take responsi- bility for his or her own potential exposure. For this reason, effective training and enforcement of these protective measures is essential. | The AHA has already adopted the policy that, to minimize the risk of transmission, either from patients to staff or staff to patients, all hospital, regardless of their HIV caseload, should adopt the use of universal precautions for avoiding exposure to blood and body substances.,' Universal precautions require the use of a barrier, such as gloves, gowns, masks, or protective eyewear, when exposure to blood or body substances is anticipated. As the term implies, these measures should be observed by all health care workers, including physicians, for all patients , including patients seen in emergency rooms and other outpatient settings. Hospitals should emphasize the need for observation of universal precautions in initial staff orientations and ongoing inservice education. HIV Testing The general issue posed: by HIV testing concerns the appropriate circumstances under which such a test should be performed in the hospital setting. The chief debate has centered on whether routine testing of patients or employees is necessary to reduce the risk of HIV infection. In order to assess the value of routine testing, it is important to evaluate why testing would be performed and what actions would result from "knowing" an individual's HIV status. If no different action would be taken or if the actions taken would not lessen the risk of transmission, then testing serves no purpose. Furthermore, if the actions taken would pose an unwarranted risk to the patient, then such use of testing would be highly questionable. Basing the use of protective measures on test results rather than implementing a universal program is ineffective in protecting patients and staff because it is often not possible to perform a test before treatment is required and there is a small but important risk of false negatives. Ultimately, consistent use of protective measures affords the best protection. HEALTH CARE WORKERS INFECTED WITH HIV |. STATEMENT: A. CONCLUSIONS: 1 There ts aminor risk of HIV transmission from HIV infected health care workers and doctors to patients during injections, ventilator therapy and invasive procedures. If HIV infected workers double gloved this would probably eliminate this risk 2. There 18 a moderate risk of HIV transmission from HIV infected surgeons during trauma, dental, and vascular surgery. Technologically improved gloves are required to eliminate this risk. 3. Broadly based mandatory HIV testing programs are both ineffective and inappropriate. B. RECOMMENDATIONS: 1. HIV tnfected health care workers and doctors should use double gloves when giving injections, doing invasive procedures, of working in patient’s mouth. 2. Develop technically improved surgical gloves that protect against needie puncture and other sharp injuries yet adequately transmit the sense of touch. Gloves that protect surgeons from cuts during trauma surgery will also prevent contamination of wounds by the surgeon's blood. 3. Develop impairment programs to accomplish the following: a) Impairment programs for health care workers and doctors. Professional societies should develop impairment programs, state societies and licensing boards should enforce them, and local societies and institutions Cprobably hospitais) imptement them. b) Develop a tocalty administered program to protect patients from the moderate risk of HIV transmission during trauma, dental, and vascular surgery by infected surgeons. 4. Mandatory HIV testing should not be part of a nationwide program to protect pattrents from HIV infected health care workers and doctors. 5. The public needs to accept the fact that health care workers and doctors have HIV infection. Public discussion needs to deal with this reality. C. ASSUMPTIONS: | have several assumptions that underly this presentation: 1 The belief that his/her health care workers Cincluding doctors and dentists) are HIV negative ts one component of public trust in the health care system. 2. The public's perception of health care workers’ HIV status and reality are incongruous. Harvey A. Elder, M.D., Chief, Infectious Diseases Jerry L. Pettis Memorial Hospital, Loma Linda, CA 92357 3 it ss trrational to perturb and coerce health care workers just because the public wants HIV negative health care workers. 4. A mayor task facing the health care sector its to bring rapprochement to this tncongruity. Rapproachement can occur when the hea!th care sector faces the public fantasy with candor and helps them comprehend that Atods is an easily prevented disease. Rapproachement can occur when the heaith care sector does not seek to buy public favor with the currency of workers’ civil rights. 5. The future of American medicine depends upon the way that rt meets the human immunodeficiency virus epidemic. if the epidemic 18 fought with medical excellence, alt appropriate public health measures, and compassion then American medicine will surmount higher lJevels of scrence, humanness, and integrity. 1. In this statement | address only those aspects of HIV spread that are unique probiems in health care settings. Issues of health care associated HIV spread focus on accidental blood exposure. Blood is the vehicle spreading a patient’s HIV infection to physicians or other health care workers. Blood is the vehicle spreading a physician's HIV infection to patients. 2. There are no elusive episodes of HIV spread in hospitals clamoring for special identification. There are no mysterious vehicies or routes of transmission Cwith the exceptions noted beiow). 3. Sexual spread of HIV, drug abuse, blood and blood products, and spread from mother to fetus can occur in the health care setting but they are not unique to this environment. 1 do not discuss these mechanisms of spread. 4. Food and laundry are not vehicles so HIV infected employees in laundry and food service are not risks to the patients. Housekeeping and maintenance personnel infected with HIV are not risks to patients Cif they do not share needles and syringes while dotng drugs or have sex together). § The s:ssue unique to the health care sector is accidental blood exposure, infected patient’s blood spreading to health care workers and infected physician's blood spreading to patients. The tatter is the focus of this presentation. 1't. SPECIFIC PROBLEMS A. HEALTH CARE WORKERS WITHOUT HANDS ON PATIENT CONTACT. Blood from workers without patient contact does not contaminate patients Even if infected these workers present no additional risk of HIV infection to patients. Health Care Workers Infected with HtV May 12, 1988 Page 2 of 13 HIV infected health care workers without hands on patient contact do not add to any patient’s risk of acquiring HIV infection. 8 HEALTH CARE WORKERS WITH HANDS ON PATIENT CONTACT Blood from health care workers can infect patients with HIV if the worker's blood exits the worker and exposes & susceptible site of the patient. A susceptible site can be any skin break or injury and maybe mucosa. Worker blood is a trivial exposure risk to susceptible patients under three circumstances: 1. the worker ts actively bleeding at some site Cinjury, etc.), This should not happen. Other then helping at an emergency, health care workers take care of their own bleeding before they provide patient care. Appropriate and enforced employee health policies will prevent this risk to patients. HIV infected health care workers with hands on patient contact who have a properly managed bieeding site do not add to any patient's risk of acquiring an HIV infection. 2. in the process of giving an injection the needie sticks the worker and contaminates the needle with worker blood before patient injection This occurs if the injection motion (for intradermal, subcutaneous, intramuscular, oF intravascular) sticks the nurse or doctor with the same motion that injects the patient. That 1s, st t8 not possible to stop and get a sterile needle before continuing the injection. This needle stick injury 18 the reverse of the usual problem. Potentially it takes HIV from the worker to the patient. if we assume: Such injurses occur tess than one per 1000 injections, Fewer than one per 1000 health care workers and physicians are HIV infected, HIV infection from a needle stick of an HIV infected health care worker occurs fewer than one per 100 sticks, What 1s the magnitude of this risk? lL estimate that an unimpaired HIV infected worker would have @ one per 100,000 injection chance of infecting a patient by needle stick. if the worker averages 20 injections per shift and works 250 shifts per year, the worker wilt make 5000 injections per year. On an average, it will take 20 worker years for a patient to acquire HIV infection from an unimpaired HIV infected worker. t estimate that in the United States the risk of patient acquired HIV infection from worker needie stick :8 about one per 100,000,000 needie sticks. If we assume 1,000,000,000 needle sticks per year, this totals about 10 health care related HIV infections from needle stick contamination per year. Health Care Workers infected with HIV May 12, 1988 Page 3 of 13 HIV infected health care workers who give patient injections subject their patients to a minimal excess risk of HIV infection. 1! estimate that in the United States the annual number is less than 10. A similar scenario can occur when physicians Cintensive care, emergency room, anesthes:ologists, and others who do invasive procedures), dentists, phiebotomist, IV therapist, blood gas technician, respiratory therapist, and ICU personne! do needle sticks and tnvasive procedures. Ouring any of these he/she could become injured and bleed. The worker's blood could contact the patient's procedure site (wound or some other susceptible site). Potentially HIV from the worker could enter and infect the patient. 1f we assume: Such tnjuries occur fewer than one per 200 injections, Fewer than one per 1000 health care workers and physicians are HIV infected, | HIV infection associated with an injury to an HIV infected health care worker occurs less' often than one per 20 procedures, What is the magnitude of this risk? | estimate that an unimpaired HIV infected worker would have @ one per 4,000 procedure chance of infecting a patient. if the worker averages 2 procedures per shift and works 250 shifts per year, the worker will make 500 procedures per year. On an average, it will take 8 worker years for a patient to acquire HIV infection from an unimpaired HIV infected worker. © | estimate that in the United States the risk of patient acquired HIV infection from worker needie stick i38 about one per 4,000,000 procedures. If we assume 10,000,000 procedures per year, this totals about 2 health care related HIV infections from procedures per year. HIV infected health care workers who perform procedures subject their patients to a minimal excess risk of HIV infection. | estimate that in the United States the annual number is less than 2. ‘ 3. with hand in the patient's mouth, the worker's hand is injured and bleeds into the patient’s mouth. A health care worker’s hand can become injured while doing some procedure in the patient’s mouth. This could happen when a respiratory therapist, anesthesiologist, or dentist has his/her hand cut by a sharp tooth edge or instrument. The worker's blood spills into the patient’s mouth and potentially HIV from the worker could enter and infect the patient. Health Care Workers Infected with HIV May 12, 1986 Page 4 of 13 if we assume: Such injuries occur fewer than one per 200 ventilator patients Coperating room plus intensive care units), Fewer than one per 1000 health care workers and physicians are HIV infected, Infection from a needie stick of an HIV infected health care worker occurs Jess often than one per 100 sticks, What is the magnitude of this risk? it estimate that an untmpaired HIV infected worker would have aoone per 20,000 chance of infecting a ventilated patients. if the worker averages 6 ventilated patients per shift and works 250 shifts per year, the worker will ventilate 3,000 patients per year. On an average, rt will take 6.6 worker years for a patient to acquire HIV infection from an unimpaired HIV infected worker. 1) estimate that in the United States the risk of patient acquired HIV infection from infected ventilator worker is about one per 20,000,000 ventilations. 'f we assume 10,000,000 ventitattons per year, this totals about 2 ventilator associated health care retated HIV infections per year. HIV infected health care workers who assist patients with ventilation and/or give mouth care subject their patients to a minimal excess risk of HIV infection. | estimate that in the United States the annual number is fess than 2. C. HEALTH CARE WORKERS WHO COULD PRESENT HIGH RISK TO A PATIENT The most serious risk of HIV transfer to the patient occurs when some sharp object injures the hand of an HIV infected doctor and he/she bleeds into the patient's wound. For all practical purposes this occurs during surgery, more commonly during trauma, denta!, and vascular surgery and less often during general and Qynecologic surgery and obstetrics. it 18 possible that injury caused bleeding of an HIV infected doctor will expose and infect the patient. lf we assume: Such injuries may occur as frequently as one per five surgeries, Fewer than one per 1000 doctors are HIV infected, infection from an HIV infected doctor bDieeding into a patient wound occurs maybe as frequent as one per 20 episodes of bleed, What 18 the magnitude of this risk? i estimate that an unimpaired HIV infected doctor would have aoone per hundred trauma surgeries chance of infecting trauma a patient. If the doctor averages one trauma surgery procedures per week and works 50 weeks per year, the doctor will do 50 trauma surgeries per year. On an average, it will take 2 trauma surgeon years for a patient to acquire HIV tnfection from an unimpaired HIV infected doctor. Health Care Workers Infected with HIV May 12, 1988 Page 5 of 13 | estimate that in the United States the risk of patient acquired HIV infection from worker needie stick is about one per 100,000 trauma surgeries Cor equivalent). If we assume 10,000,000 surgertes per year, this totals about 100 health care retated HIV infections from surgery per year. Trauma surgery Cand perhaps other surgeries) subject patients to an excess risk of HIV infection if the surgeon has an HIV infection. ! estimate that in the United States the annual number of surgery acquired nosocomial HIV infections is less than 100. D. POTENTIAL EXPOSURE TO Hiy Health care worker exposed to the blood of an untested patient possibly infected with HIV represents a speciat problem. By not knowing the other person’s infection status, he/she does not know if he/she could become infected. This worker does not know if he/she should take precautions until the time his/her HIV test would be positive. Finally, this worker does not know whether or not to continue testing for the next 14 months. Mandatory HIV testing of the patient in this circumstance would limit the autonomy of the patient while protecting the autonomy of the worker. The principles of nonmaleficence, beneficence, and justice require that HIV data for the worker be available. State regulations need to make it possible for the health care sector to protect health care workers. 1. Gloves give a measure of protection. If the worker is punctured, latex gloves may tamponade the puncture site and Iimit both the bleeding and the patient's biood exposure. Double gioves will increase tamponade and likely obliterate the puncture tract so that blood remains in the gloves and does not enter the patient. Technology could help with this. Surgeons need gloves that will block viruses and prevent puncture by needles and other sharps. if this can be done cheaply, the problems of HIV transfer by accidentat blood exposure would nearly disappear. Present glove technology is helpful. double gloving is better. New technology is needed to protect against punctures and cuts. 2. The risk of transferring HIV infection to patients by the mittions of health care workers and physicians 18 minimal. It as roughty the risk of taking a bath and tower than commonly accepted risks, such as driving to work. | do not mean to be heartiess in the face of a single exces case of HIV infection. What would testing accomplish ? Reference laboratory testing of all health care workers to protect the 14 patients ts a consideration. However, we Health Care Workers infected with HIV May 12, 1988 Page 6 of 13 must weigh the vaiue of control measure and datermine the cost benefit ratio." Testing would miss severa! hundred positives (false negatives), and mistabel severat hundred as positive (fatse positives). The dollar cost for testing would accede $40,000.000 plus overhead. The cost of maintaining the database is also high. When regulatory measures must check millions of people to identify 14, the costs Cincluding general impairment of patient care and increased cost) probably outweigh any benefits. Mandatory HIV testing of all health care workers and doctors neither effective nor ethical. is 3. The surgeons most at risk by infected patients are reciprocally, tf infected, the surgeons at greatest risk to patients. Appropriate gloves that would prevent cut and puncture injure of the surgeon would prevent the problem of hospital associated HIV transmiss:ron. The size of this population suggests that simple control methods lead by the professional! societies. ‘This recent statement of the Council on Ethical and Judicial Affairs of the American Medical Association gives direction and is germane: "A physician who knows that he or she has an infectious disease shoutd not engage in any activity that creates a risk of transmission of the disease to others." Programs to assist physicians comply with this statement should be directed and administered focally. In this more limited population that 18 a higher cisk to patients, HIV testing could be useful. The testing system needs to be under local control so they can execute it in an effective and humane manner. Targeted testing of those who if positive have a higher risk of infecting a patients 18 a more effective public health measure, it attempts to comply with the principles of nonmaleficence, beneficence, and justice. Transfer of HIV from infected surgeons to patients will not occur if the surgeons do not injure their hands during trauma surgery. This section identified the magnitude and the problems of HIV transfer from heaith care workers and physicians to patients. if the blood of an HIV infected health care worker does not spread to patients then the worker’s HIV does not spread to the patient and the patient does not get HIV infection from that worker. Many demand that all health care workers and doctors be free of HIV infection. This s:dea, somewhat understandable and Satisfying, +8 wholly impractical. | do not believe that the expectations of the health consumer can be met. Attempts to meet these demands by mandatory testing of unimpaired workers, reassigning those who are HIV positive and, if necessary, bimiting privileges or taying off unimpaired workers will interrupt health care and be socially disruptive without benefiting patrents. Health Care Workers Infected with HIV May 12, 1988 Page 7 of 13 The Presidential Commission on the Human Immunodeficiency Virus Epidemic can play an important role by documenting the impossibility of the public fantasy and that safe health care does not require the fulfillment of this want. With the exception noted, the presence of HIV infected health care workers and doctors does not carry significant risk to patients and other consumers of health care. 1. Though the risk is low, there is a risk of accidental patient exposure to HIV if the surgeon is HIV infected. Double gloving will probably decrease the risk and better surgical gloves can eliminate this risk. Professional societies and local practice groups implement control in cooperation with state boards. 2. The public assumption that their health care provider is HIV free creates a problem. It would be cruel to try to provide the public with HIV free health care workers. Further, this is impossible. The Presidential Commission on Human immunodeficiency Virus Epidemic can lead in public discussion of this problem. bit. ISSuEs A. MANDATORY TESTING OF HEALTH CARE WORKER: Some believe that HIV infected health care workers need to be identified and separated from patients. They advocate mandatory HIV testing of health care workers and reassignment including layoffs where necessary to achieve this goal. Pians to protect patients by mandatory testing are inadequatie and impractical. 1. HiV viremia begins weeks to months before seroconversion. Thus, HIV can expose patients whijle the test is still negative. Assume that the sensitivity and specificity of newer tests which identify HIV: antigens are known and adequate. Health care workers who were test negative can develop HIV viremia after the test and then spread HIV. Mandatory testing scenarios require Systematic testing at frequent intervals. 2. HIV testing is both anonymous and confidential. Workers will not cooperate with mandatory tasting plans that cause employees to toose employment or physicians to loose their practice. Enforcement of mandatory but anonymous and confidential testing will not be simple. It will be difficuit to develop an anonymous, confidential, mandatory testing system \that has sufficient documentation to verify the report in a legal setting. * 3. At the very least, a mandatory testing oem requires testing that 18s not yet availabie. it treats all heatth care workers and doctors as if they\ are equal risk to patients As | have shown, this 1 not true. 4. A better "test" would be identification of health care workers and doctors with high risk behaviors (practice anal receptive intercourse ofr share needies and do: drugs)! Absurd, but a better test nonetheless. Health Care Workers Infected with HIV May 12, 1988 Page 8 of 13 \ \ 1 \ 5. Testing removes the right of confidentiality for the tested population. It 18 against the principle of autonomy. The worker ss at the mercy of a person who uses the ltaboratory test for the sole purpose of protecting patients. This is against the principle of nonmaleficence because it discriminates against the worker and does unnecessary harm. Since there are other methods of achieving the principle of beneficence for patients, mandatory testing of health care workers seems to be a particularly onerous solution. 6. The several million health care workers Cincluding doctors and dentists), the probable number of HIV infected workers (many thousand), and the management of a database administered with uncertain accuracy and confidentiality, are all formidable demands upon a control system based on mandatory testing of ail health care workers. Mandatory testing of all health care workers will not protect all patients from HIV infected health care workers. it is costly both in dottiars and human agony. B. CONFIDENTIALITY in the health care sector, confidentiality needs major improvement. Charts, laboratory results, and consultations are available for examination by anybody who is "part of the system" or knows how to act as such. Charts and other medical information Cincluding faboratory reports) that await "charting" are usually open to scrutiny by those who are "part of the system." Charts are kept in rather open areas Con wards, or in clinic rooms) and can be reviewed by anyone who has physical access. In many settings, laboratory tests are available to anyone who knows how to work the computer Cincluding colleagues, friends, superiors, etc.) Confidentiality must be secure and privacy maintained even among friends. Health care workers should not browse charts of friends for casual or specific information. tt ss not professional, it 1s a source for gossip, and it tends to give the culprit a sense of superiority because he/she has privileged information. Breaching confidentiality 18 morally wrong. Breaches of confidentiality are actions against the principles of autonomy, nonmalteficence, and justice. Confidentiality needs did not emerge with the AIOS epidemic and are not timited to HIV testing. identical confidentiality needs exist for other tests, t.e. pregnancy test for a Catholic Nun, blood alcohol for a Mormon Bishop, urine drug screen for an Adventist Bible teacher. The patient and the patient's perception of his/her culture establish confidentiality needs. Health Care Workers Infected with HIV May 12, 1988 Page 9 of 13 Society's understanding 18s irrelevant The health care sector must provide confidentiality. Health care systems use data to make diagnostic and therapeutic decision Decision makers must have critical data if the health care system is to function. Data must flow unimpeded to the decision makers if the health care system is to be efficient. Conflict between the needs for efficient medical care and confidentiality 18 only apparent, tt 18 not real. Technology to solve this has existed for some time. | believe that the issue is personal. Personne! are reluctant to radically Change health care systems just to tmprove confidentiality. Confidentiality in health care needs radical improvement. Confidentiality is needed in all areas of medical care, not only in those related to HIV infection. C. HEALTH CARE WORKER IMPAIRMENT Does HIV tnfection in health care workers and Physicians pose a significant risk to patients? Yes. The significant risk is not the transmission of HIV, that 18s only a limited risk. The larger risk ts that HIV infection leads to mental deterioration with loss of memory and manual dexterity, impairment of judgment, and deterioration of personality. These serious problems are not unique to HIV infection and have been present for some time. Government with or without regulatory agencies can try to control HIV infected health care workers and doctors. Mandated systems often become adversarial. In an adversarial system anonymous, confidential, mandatory, HIV testing may not be dependable. Health care workers and doctors who feel discriminated against may try to protect themselves regardiess of the risk to patients. In adversarial systems colleagues often cooperate with "persecuted" workers while denial and other destructive coping mechanisms emerge. HIV infected health care workers and doctors often become highly susceptible to thé ordinary microbes present tn health care settings. As HIV infection progresses and becomes AIDS, the patient becomes weak, and are unable to work. These impairment issues should be handled by employee health in collaboration with impairment committees. The problems of impaired physicians and health care workers are not new. At least a decade ago most state licensing and credentialing boards developed programs that protect patients and help impaired workers (physicians, nurses, etc.) Professional societies at national, state, and local levels cooperated with regulatory boards and individual health care institutions to establish programs. These protect patients from impaired workers, confront the worker with the impairment, and offer him/her an opportunity to again become a functional and usefu! professional. Onty 1f the worker is e:ther unwilling or unable Health Care Workers Infected with HIV May 12, 1988 Page 10 of 13 to retrain and become functional does the worker loose his/her professional ticense. The programs are effective, humane and confidential. Impairment programs require several levels of cooperation Professional societies draw up the elements of the programs. State licensing boards and state chapters enforce. Local societies and institutions Cusuallty hospitals) implement the programs. Most impairment committees become a professional community supporting the impaired worker and family. Support tn a friendly atmosphere maximizes the worker’s chance for improvement. Many of these programs have worked wel! for a decade or more. The HIV epidemic adds a new dimension to the challenge of impaired physician and health care worker. Physicians and other health care workers do not become unemployable just because they have an HIV infection. | believe that tocal professional Societies and tnstitutions Chospitals) should use available mechanisms for treating impatred heatth care workers and doctors when they become impaired, mentally, dexterously, medically, microbrologically or immunologically (whether due to chemicals, HIV, senility, or other causes). They remain employable and should continue their employment and their benefits. When _ impaired and no longer employable, the health care system should continue the worker's health, disability, and life insurance. The significant risk of HIV infected health care workers to patients is not HIV transmission but impairment. Mechanisms of caring for impaired workers and doctors already exist and are working well. They should be extended to include workers with AIOS. IV. PERSPECTIVES 9 The care of patients with HIV tnfection 18 a public health problem and not a civil rights tssue. This 18 true whether patients are asymptomatic health care workers and doctors or patients with AIOS. The task of public health is to protect the poputace from epidemics by biocking transmission and to provide continuity of care during epidemics and other crisis with the feast possible disruption of civil rights. In the past, public health often followed the whims of dominant prejudices and discriminated against minorities. As an agent of discrimination public health added to the misery of epidemics. More recently (often since the advances in epidemiology) public health found ways to remove the reservoirs of pathogens, block their transmission and protect susceptible patients while being sensitive to therr civil rights. Health Care Workers Infected with HIV May 12, 1988 Page 11 of 13 We need epidemiologic studies to identify the magnitude of HIV spread from workers to patient. Current data from the health care setting do not identify significant HIV spread from workers to patients. Surgical gloves resistant to needles and other sharps would improve control. | happily acknowledge that health care is a civil right. But when health care becomes a means of enforcing civil rights then worker assignment, testing, test confidentiality, ete. are done to and done in manners that increase civil rights. When heatth care is subservient to civil rights, health care suffers. B. PUBLIC PERCEPTIONS THAT HEALTH CARE WORKERS ARE FREE OF Hiv ANFECTIONS VS REALITY: The belief that doctors are free of HIV 18 deeply held and when patients Cor patient families)? learned that a doctor was HIV infected, they fied. There are (probably) several thousand HIV infected health care workers and doctors. Most did not become infected by an accidental blood exposure from a patient while Providing health care. There is a severe shortage of health care workers in several parts of the country. HIV infected workers are carrying an important share of the work load. These workers are not a significant risk to pattrents. Do patients have a right to know their doctor's HIV status? Is the physician to hang his/her regutar HIV report on the waiting room wall for the comfort of patients? Other data are more critical. Does the doctor practice high risk behaviors, and if yes, when was the last occasion? What was the doctor's blood alcoho! level after his tast break Cecoffee or lunch)? What is the doctor’s urine drug screen? What are the results of the doctor’s hepatitis B panel? Serological test for syphilis? Even if the Tist seems absurd, these tests are more useful to patients than the HIV test. What should a health care worker or doctor do if- the patient or patient’s family wants to know? This matter requires sensitivity. Since | don’t believe that the patient has a right to know, the worker does not need to give a laboratory result. However, if this ts a matter of concern to the pattent Cor family), 1} trust that the worker would have the humanness to help them cope with a perceived threat to their fantasy. He/she might suggest they taik with his/her supervisor, and/or ask to be transferred to a different worker/doctor. Health Care Workers Infected with HIV May 12, 1988 Page 12 of 13 v. ETHICS® A. JUSTICE 1. "fairness," "desert," Qne has acted justly towards a person when that person has been given what he 18 due or owed, and therefore has been given what he deserves or can legitimately claim." p 169 2. "Equals ought to be treated equally and unequals unequally." p 171 B. BENEFI CENCE 1. "Beneficence ... Crefers) to acts tnvolving prevention of harm, removal of harmful conditions, and positive benefiting.” p 135 1. "Nonmaleficence is frequently explicated by terms ‘harm’ and ‘injury.'...Physical harms, including pain and suffering, disability, and death, without denying the importance of mental harms and other injuries. . (Not) intending, causing, permitting, and imposing the risk of death, although... other harms Care inctuded).” p 98 ; 2. "Nonmateficence ...€18) restricted to the: noninfliction of harm." p 135 D. AUTONOMY: 1. "Autonomy is a form of personal liberty of actions where the individual determines his/her own course of action in accordance with a plan chosen by himself/herself." p 56 Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, New York: Oxford University Press, 1979. Health Care Workers Infected with HIV May 12, 1988 Page 13 of 13 SUMMARY POLICY DEVELOPMENT FOR HEALTH CARE PROFESSIONALS WHO BECOME INFECTED. Dr. Phillip Pierce Health care workers (HCW) infected with HIV have posed a difficult dilemma for hospitals. Concerns over transmission to patients and public fear regarding contact with an infected HCW needed to be balanced with employee rights. Scientific information in this area remains limited yet policies are needed now. HCW have been shown to have a higher rate of HIV infection than the general population resulting from exposure in hospital as well as outside the hospital. Georgetown University Medical Center developed our first vrsitcten HIV policy fox NCW in 1986 and vevised this in 1987. Whig was wrirten iy a svbcomittec of the Infection Control Coumiiitee with reprorentatives frown the Satoctious Discase corvice, administration, Jegel sexvices, employee health und, wale Cw Vehetiors. fee CDC miblicacblon, “Revonmonaatieis Sor Peevontion of HIV transmission in HMoalth-Carce betcings" vas ueceo as allajor refereuce. ‘Lhe policy provides a detailed list of procedures that JiIIV positive employees can and cannot perfora, in general, routine examinations and blood drawing may be performed but conducting invasive procedurces, @.g., surgery Is not in direct. patient cere and are reassigned to non-patient care areas. The latter is designed to protect both patients and the infected worker. Wo routine testing of HCW is performed; it is the responsibility of the HCW to confidentially report a positive HIV Status to their supervisor. These policies are cautious to our kownledge no patient has become has become infected with HIV from a HCW. Our goal is to offer rigorous procedures to protect patients while resonably accommodating the infected worker. HEARING HEALTH CARE WORKER SAFETY MAY 11, 1988 RECOMMENDATIONS Page [ ] of [ ] OBSTACLES TO PROGRESS RECOMMENDATIONS 1. Hospitals must individually formulate specific policies for the management of HIV infected health care workers. 2. Hospital policies should be updated yearly as new information becomes available. 3. The Federal Government and national hospital organizations should continue to provide broad guidelines as a framework for hospital policies. 4, Seientific fact rather than emotional responses must form the basis for policy formulation. Estimated Cost: Based Upon: Phillip Pierce, M.D. Name . Signature May 7, 1988 Date GEORGETOWN UNIVERSITY HospPITAL lun F Stapleton M L: Meakal Dire: te + March 2, 1988 TO: Medical Staff Georgetown University Hospital Dear Colleague: The Executive Staff has approved the following policies designed to prevent transmission of the human immunodeficiency virus (HIV) in the hospital: l. Universal barrier protection - gloves, gowns and, in some instances, masks and protective eye wear (goggles) - is required whenever a task or procedure entails direct contact with the blood and/or body fluid of any patient. 2. Employees with AIDS will not be permitted to care for patients. 3. Employees who have HIV antibodies but are otherwise well may care for patients but may not perform invasive procedures, defined as follows" "Surgical entry into tissues, cavities, or organs or repair of major traumatic injuries 1) in an operating or delivery room, emergency department, or outpatient setting, including both physicians’ and dentists' offices; 2) cardiac catheterization and angiographic procedures; 3) a vaginal or caesarean delivery or other invasive obstetric procedure during which bleeding may occur; or 4) the manipulation, cutting, or removal of any oral or perioral tissues, including tooth structure, during which bleeding occurs or the potential for bleeding exists." This definition (developed by the CDC) includes invasive radiology, hemodialysis,’ plasmapheresis (hemapheresis), thoracentesis and paracentesis. Georgetown University Medical Center 0 3800 Reservoir Road NW Washington DC 20007-2197 Medical Staff March 2, 1988 Page two 4. Asymptomatic individuals with HIV antibodies may work in a "circulating" capacity in the above mentioned areas, as long as they are not performing an invasive procedure. They may perform physical examinations, including rectal and pelvic exams, blood drawing and lumbar punctures. 5. Employees with AIDS and employees who are HIV antibody positive without symptoms must conform to the above, whether tested at Georgetown or elsewhere. 6. Employees with AIDS and employees who are HIV antibody positive without symptoms who report their status in order to conform to 2, 3 and 4 above, will be given alternate assignments providing their health status permits, as determined by the employee health physician in consultation with the employee's own physician. 7. Members of the medical staff must conform to all of the above, whether employed or not. 8. The Executive Staff recommends that physicians performing invasive procedures (as defined above) request patients for whom such procedures are planned to voluntarily undergo testing for HIV antibodies. The informed consent of each patient should be recorded; the enclosed form has been prepared by hospital counsel to facilitate this documentation. 9, Patients who refuse HIV testing or who test positive will be treated with increased awareness of potential infectivity. 18. Patients with AIDS and HIV positive patients who are asymptomatic will not be refused care by Georgetown employees or medical staff members solely because of their illness. ll. The laboratory must receive blood for HIV testing no later than 1 P.M. the day prior to the invasive procedure. Unless admitted early enough to permit testing within the time frame stated above, the consent and blood drawing for this test must be accomplished before admission. Whether tested at Georgetown or elsewhere, the result should be entered into the patient's inpatient record when admitted for the procedure. Medical Staff March 2, 1988 Page three 12. Patients who require emergency invasive procedures that cannot be delayed for HIV testing, should be considered HIV and/or Hepatitis B positive. Should untoward exposure to blood or body fluids occur, followup testing should be done. 13. Patients who consent to HIV testing, should be assured of counseling in the event of a confirmed positive test. The attending physSician should provide such counseling either directly or through consultation with the division of infectious diseases. 14. The hospital will provide HIV and hepatitis B testing at no cost to those members of the medical staff who wish to be tested. Test results will be reported confidentially to the physician. A confirmed positive test will be reported confidentially to the Medical Director. HIV positive members of the medical staff who have no symptoms and members of the medical staff who suffer AIDS must conform to the restrictions stated above whether tested at Georgetown or elsewhere. Sincerely yours, yes, Speen. f . John F. Stapleton, M.D. J FS :mmm Enclosure We ; GEORGETOWN UNIVERSITY HOSPITAL CONSENT FOR HIV TESTING I have been informed that my blood will be tested for exposure to Human Immunodeficiency Virus (HIV), the virus believed to be the cause of Acquired Immune Deficiency Syndrome (AIDS). I will be informed of the results of this test and counseling will be made available if requested. The results of the blood test will become part of my permanent medical record and will be available for review by health care personnel involved in my care and the reimbursement thereof. The hospital will use its best efforts to protect the confidentiality of my medical record and will not release my medical record outside the hospital without my authorization, unless required by law. I consent to the performance of HIV testing. Signed: Patient or person authorized to consent for patient. f If other than patient state relationship: Date: Witness: Date: Georgetown University Medical Center 0 3800 Reservoir Road NW Washington DC 20007-2197 GUIDE TO HOSPITAL POLICY AND PROCEDURE GUIDELINES ON ACQUIRED IMMUNE DEFICIENCY SYNDROME Issue Date: April 15, 1986 Number 627.10 Effective Date: July 1, 1986 Page 1 of 6 Revised: March 3, 1987 Revised: October 8, 1987 Revised: January 13, 1988 I. INTRODUCTION - DEFINITION The acquired immune deficiency syndrome (AIDS) has emerged as one of the most devastating diseases of the immune system. The basic cause of ‘this syndrome is the human immunodeficiency virus, (HIV), formerly called human T-cell lymphotropic virus, type III, (HTLV-III.) The AIDS virus preferentially infects and destroys certain white blood cells called "T lymphocytes" that are essential for the functioning of the body's immune system. When the immune system is severely Gepressed or destroyed by HIV, infectious agents such as bacteria and other types of viruses that usually do not cause disease in persons with normal immune functions may have the opportunity to cause disease ("opportunistic infections") because of the body's weakened defenses. HIV. infection is defined/classified in several (3) stages: a) Those individuals with confirmed HIV serologic antibody status positive by the Western Blot method but who are not ill (no signs or symptoms of clinical infection). b) Individuals classified as having AIDS Related Complex or ARC are those in whom the HIV = + antibody status is confirmed positive by the .Western Blot method and who may have general- ized lymphadenopathy but are relatively healthy. Individuals diagnosed with ARC may or may not develop the "full blown" clinical picture of Acquired Immune Deficiency Syndrome (AIDS). c) Those individuals in whom the HIV serologic antibody status is confirmed positive by the Western Blot method and in whom their physician has diagnosed evidence of severe Il. AIDS Guidelines Policy Number 627.10 Page 2 of 6 opportunistic infection, which may or may not be life threatening, are classified as having "full blown" AIDS. The purpose of these guidelines is to provide overall guidance in areas of concern to those employed in a hospital setting. PATIENT CARE A. Mode of Transmission Evidence to date indicates that the mode of transmission of HIV is similar to that of the Hepatitis B virus: that is, the mechanism for transmission is through either sexual intercourse or direct contact with blood or body secretions. There is no evidence of airborne transmission. HIV is not transmitted by casual contact, i.e., general social interaction; shaking hands, talking, social kissing, sharing a meal, etc. There is no scientific evidence that HIV infection is transmitted during the preparation or serving of food or beverages. Precautions for the Health Care Worker: 1. Sharp instrument precautions--use approved puncture-resistant containers for sharp instrument disposal. Do not recap needles or bend them before , disposal. Use only needle-locking syringes to avoid accidental discharge of contaminated patient fluid. 2. Gloves are worn when handling any body fluid i.e., blood, urine, sputun, etc. 3. Gowns are worn when clothing may become contaminated with any body fluids. 4. Thorough HANDWASHING before and after caring for the HIV infected patient, and immediately after any blood or secretions spill onto the hands. 5. All contaminated (visibly soiled with potentially infectious material) dispos- able items will be red-bagged before discarding. . 6. Linen soiled with blood/body secretions will be handled as "isolation linen." 7. Label all laboratory specimens from HIV infected patients with "BLOOD AND III. EMPLOYEES A. B. Cc. 10. AIDS Guidelines Policy Number 627.10 Page 3 of 6 SECRETION PRECAUTIONS." Place specimens in the plastic ziplock bags found in the top drawer of the isolation cart (or ordered separately from CSS) before sending to the lab. A yellow sticker is to be placed on the Specimen to denote "isolation." Clean up any blood spills IMMEDIATELY with a 1:10 dilution of 5.25% sodium hypochlorite (bleach). Instruments and equipment soiled with blood should be dealt with in accordance with isolation procedures normally used for Hepatitis B. Lensed instruments should receive high-level disinfection after use on an HIV infected patient. Assign a private room for patients not able to attend to good hygiene. Ideally, all patients with active AIDS should be placed in a private room. Hospital Employees with AIDS, AIDS~Related Complex or HIV Antibody Positivity: l. CDC guidelines August 21, 1987 suggest that employees who are infected with HIV continue to be employed. In addition to the CDC recommendations, a case-by-case determination of infectivity of each infected employee shall be made by the Employee Health Service Medical Director - in consultation with the Hospital's Infectious Disease Division and the employee's private physician. Confidentiality regarding AIDS, ARC and HIV “antibody positivity will be strictly observed as stated in Hospital Policy 621.08, Confidentiality of Employee Health Records. Procedures 1. Employeés who are diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC) and/or known to be HIV antibody positive shall not be assigned to certain areas. (See Attachment A for defined areas.) AIDS Guidelines Policy Number 627.10 Page 4of 6 Employees who are known to have confirmed HIV antibodies or ARC and who are asymptomatic should receive counseling, by the Employee Health Service staff that the hospital environment may be hazardous to their health and that the employee will be responsible for acknowledging the potential risk. Employees who are known to have confirmed HIV antibodies or ARC and who are asymptomatic shall have periodic physical examinations by their private medical physician at the discretion of the Employee Health Service and/or the Medical Director of the hospital and the Department Chairman. Written health clearance will be provided to the Employee Health Service and/or the Department Chairman. In accordance with CDC guidelines, serologic testing of employees for HIV antibody will not be routinely conducted, except in the case of documented needle or sharp instrument puncture or mucous membrane exposure to the blood or body fluids of patients with documented AIDS, ARC or HIV antibody positivity. (See Policy 627.02, Needle Stick Exposure.) Hospital Policy 627.02 Needle Stick Exposure, section D, is amended to include AIDS, ARC and HIV antibody - surveillance. As recommended in CDC guidelines, an employee who sustains a documented needle or sharp instrument puncture, or mucous membhane exposure from a patient's blood or body fluids will be followed by EHS. Pregnant Employees Caring for HIV Infected/AIDS Patients: The Committee on the Control of Hospital Infections has issued the following statement regarding pregnant employees, written April 15, 1985: . "All Georgetown University Hospital employees/ staff shall follow at least the recommended precautions already established at GUH when there is interac- AIDS Guidelines Policy Number 627.10 Page 5 of 6 tion with suspected AIDS and/or proven AIDS patients. This is in compliance with current Centers for Disease Control (CDC) recommendations." IV. GUIDELINES RELATING TO EMPLOYMENT PRACTICES A. Hiring: As a general rule, it shall be the policy of GUH not to hire applicants with AIDS. Applicants with asymptomatic AIDS-Related Complex (ARC) may be hired for non-high-risk areas with the concurrence of a private physician and clearance from the Employee - Health Service. Applicants will not be routinely screened for HIV infection. Applicants known to be HIV antibody positive may be hired, but shall not be placed in areas Gesignated as high-risk for transmission from employee to patient. (See Attachment A.) B. Other Conditions: Any employee who has a medical condition which he/she believes would preclude him/her from working with patients diagnosed as having AIDS must first discuss the matter with his/her Supervisor and department head. If appro- — priate accomodation cannot be arranged the matter should be referred to the EHS Medical Director for resolution. ec, Axcmteree OL Q Lob — ) gehn F. Stapleton, M.D. Charles M. O'Brien, Jr. Medical Director Hospital Administrator AIDS Guidelines Policy Number 627.10 Page 6 of 6 ATTACHMENT A DEFINITION OF AREAS WHERE EMPLOYEES WITH HIV INFECTION MAY NOT WORK Employees diagnosed with AIDS will not be allowed to work in any clinical area at GUH. Clinical area is defined as one in which direct patient care is rendered. Employees diagnosed with AIDS RELATED COMPLEX (ARC) or those who are known to have confirmed HIV antibody positive blood without signs or symptoms of disease may work in any clinical area of the hospital but will not be allowed to perform invasive procedures anywhere in the hospital. InvaSive procedures are defined by the CDC as follows: "Surgical entry into tissues, cavities, or organs Or repair of major traumatic injuries 1) in an operating or delivery room, emergency departmemt, or outpatient setting, including both physicians' and dentists'offices; 2) cardiac catheterization and angiographic procedures; 3) a vaginal or cesarean delivery or other invasive obstetric procedure during which bleeding may occur; or 4) the manipulation, cutting, or removal of any. Oral or perioral tissues, including tooth Structure, during which bleeding occurs or the potential for bleeding exists." The above definition includes invasive radiology, hemodialysis, plasmapheresis (hemapheresis), thora- centesis and paracentesis. Asymptomatic personnel with HIV antibodies or ARC may work in a "circulating" capacity in the above mentioned areas, as long as they are not performing invasive procedure. They may perform physical examinations, including rectal and pelvic exams, blood drawing and lumbar punctures. O° PARTMENT OF HEALTH CARF UFINA.. ef STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER STATE LICENSING "'D DEFICIENCIES ONLY | (22 Deficiencies) ANO HUMAN SERVICES vid APPROVED _ ADMINESTRATION OMB No. 0938-0391 (X3) DATE SURVEY COMPLETED a (41) PROVIDER NUMBER 05-0228 (%2) MULTIPLE CONSTRUCTION A. BUILDING 8. WING STREET ADDRESS, CITY, STATE, Z1P,CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE-, SAN FRANCISCO, CA 94110 4 1D PREFID TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) "The following reflects the findings of the Dep: compliance VALIDATION visit, with a facus on infection control and nursing. -Representing the Department of Health Services: -Leon Starkman, M.D., Marlene D. Weiner, R.N. 1. 70701(a)(4) Administration “The Governing Body shall:..(4) provide appropriate physical resources and personnel required to meet the needs of the patients and shall participate in planning to meet the health needs of the community." Based on information provided by the hospital related to budgeted FTE positions and vacancies, it is determined that most departments are understaffed. The _nursing ices continues to be understaffed although the hospital has made efforts to obtain staff. Most support and ancillary services are understaffed by 20-25%. These departments include housekeeping, laundry, building and grounds, dietary, social services, finance and medical records. DOCUMENT NO. 22-00892 These VISIT NO. 000000875 Ursula Byrd, HFE 1, Shirley J. Gilbert, R.N., Karen Johns Nur, ~ 12/08/87 12/22/87 PROVIDER'S PLAN OF CORRECTION. (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY) - ID PREFIX TAG irtment be Health Services during a 7: — - ‘ q >. Borgman, R.N., Anriette. R.N., Donald Lee, HFE I, 12/23/1987 13:24 PROVIDER REPRESENTATIVE'S SIGNATURE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the inst for further Instructions.) Th provide sufficient protection to the patients. (Sea reverse plan of correction is provided. If deficiencies are ci FORM HCPAse067 (10-64) ted, an approved plan of HCFA TITLE correction is requisite to continued program participation. REGIONAL OFFICE (X35) = COMPLETION (X6) DATE If continuatlon sheet Page DATE jtution may be excused from correcting providing it is determined that other safeguards e findings above are disclosable 90 days following the date of survey whether or not a Toft 2 DEPARTMcNT OF HFAl =D. NJNAN SERVICES _ai APPROVED HEALTH LAKE FINAN: _AOMINISTRATION a © OMB No. 0938-0391 (M1) PROVIDER NUMBER | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/87 @. WING 12/22/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY,STATE,ZIP,CODE SAN FRANCISCO GENERAL HOSPITAL {001 POTRERO AVE., SAN FRANCISCO, CA 94140 SUMMARY STATEMENT OF DEFICIENCIES Id PROVICER'S PLAN OF CORRECTION 5) PREFID (EACH DEFICIENCY SHOULD SE PRECEDED PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS- BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) shortages compromised the hospital’s ability to deliver patient care and services as evidenced in this report. COMPLETION DATE Two hospital inpatient units (burn and med/surg-4C) are closed as a result of nurse staffing shortages. This has resulted in the diversion of patients to other hospitals in the community. 2. 70721(a) Employees "The hospital shall provide..., a continuing in-service training program and competent supervision designed to improve patient care and employee efficiency." The hospital does not provide adequate in- service training and/or supervision as evidenced by the following: a) Documentation was not sufficient to determine what departmental in-service (specific to tasks) the housekeeping and laundry staff has received since 1984. b) There was insufficient documentation that staff meetings constituted in-service training, since there was no information DOCUMENT NO. 22-00892 VISIT NO. 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE 12/23/1987 12:12 TITLE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing 1t is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Inatructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction 1s provided. if deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA*2587 (10-84) HCFA REGIONAL OFFICE tf continuation shast Page 2 of 27 DEPARTMENT @ ALTH AND HUMAN SERVICES HEALTH CARE. —_NCING ADMINISTRATION FORM APPROVED OMB No. 0938-03 (XT) PROVIDER NUMBER =| (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED . STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 Be A NS a 1eyoe/B * NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE,ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 ; (X4) tp SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION Sad PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE about time, content and instructor. This \ practice was observed in most sections of the clinical laboratories, Central Processing and Distribution (CPD), housekeeping and laundry departments. _| _¢) The lack of adherence to infection control . | policies and procedures seen on patient wards during the survey (see item #13), demonstrates ~ Jnadequate monitoring of nursing practice by supervisory personnel. 70213(f) Nursing Service General Requirements "There shall be a method of determining staffing requirements based on assessment of patient needs..." Although the hospital has a method of evaluating patient needs on each ward and determining how many nurses are necessary: a) The hospital does not have an acuity DOCUMENT NO. 22-00892 VISIT NO. 000000875 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE | (6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safegu provide sufficient protection to the patients. (See reverse for further Instruct{ons.) The findings above are disclosable 90 days following the date of survey whether or no plan of correction 1s provided. If deficiencies are cited, en approved plan of correction is requisite to continued program participation. FORM HCFA*2587 (10-84) " HCFA REGIONAL OFFICE If continuation sheet Page 3 of 4 DEPARTMENT OF # “H AND HUMAN SERVICES Toe Ae HEALTH CARE FIR NG ADMINISTRATION OMS No. 0938-0391 (X1) PROVIDER NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 03-0228 A. BUILDING 12/08/87 B. WING 12/22/87 NAME OF PROVIDER OR SUPPLIER ; STREET ADDRESS,CITY,STATE,ZIP,CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (M4) Ip SUMMARY STATEMENT OF DEFICIENCIES 1 PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION : CEACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION REFERENCED TO THE APPROPAIATE DEFICIENCY) DATE system which addresses the psychiatric nursing unit. 4, 70215(c)(1)(2)(3) Nursing Service Staff. "Sufficient registered nursing personnel shall be provided to:... 1) Assist the director of nurses for evening and night services and when necessary for day services. 2) Give direct nursing care based on patient need. 3) Supervise and coordinate care given by licensed vocational nurses and nurses assistants." Sufficient_nursing personnel are not provided as described below: b) Nursing service staffing was reviewed for the two weeks preceding the survey. Although critical care units were adequately staffed, 10 other units had a shortage of nursing personnel on six or more of the 14 days reviewed. On each of the 14 days these 10 units collectively had at least nine and up DOCUMENT NO. 22-00892 VISIT RO. 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE ; (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-e587 (10-84) # HCFA REGIONAL OFFICE e If continuation aneet Page 4 of dé pee A 12/22/1987? 16325 DEPARTMENT OF HEA' TH AND HUMAN SERVICES at HEALTH CARE Fin 4G_ADMINISTRATION _ MB No. 0938-0391 (X1) PROVivck NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/87 B. WING 12/22/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY ,STATE,ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 PREFID CEACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- TAG COMPLETION BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) x5 SUMMARY STATEMENT OF DEFICIENCIES i) PROVIDER'S PLAN OF CORRECTION . ! ) DATE to 21 positions not filled. One of the 10 wards had a shortage of 33 people over the two weeks, while the best staffed of the 10 had a total shortage of 10 people over the two weeks. * c) While the shortage of nursing staff is obvious, there are certain days when the shortages are serious in the general acute units. For example, on one evening shift the Obstetrics and Gynecology/Post-Partum Unit had scheduled eight nurses by acuity, but only five nurses worked. This occurred on two consecutive evening shifts. d) On ward 3B and 6C, 4 of 5 patients with IVs whose records were reviewed were not receiving the correct amount of fluid. Two of these 4 had received less than half what they should have received during a shift. e) A patient on 4A received half the ordered amount of the tube feeding or less on at least three shifts. No explanation was available in the record, and the amount of oral intake, if any, was not addressed. | | | DOCUMENT NO. 22-00892 VISIT NO. 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 12/22/1987 16:25 I. >Any deficiency Statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA*2587 (40°84) ; HCFA REGIONAL OFFICE If continuation sheet Page 5 of 26 % - all =< P55 i DEPARTMENT OF H" YH AND HUMAN SERVICES : FORM APPROVED HEALTH CARE FIK NG ADMINISTRATION _ OMB No. 0938-0391 (X71) PROVIDER NUMBER (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 * a EOTNG 13700787 NAME OF PROVICER OR SUPPLIER STREET ADDRESS, CITY, STATE,Z1P,COOE SAN FRANCISCO GENERAL HOSPITAL {004 POTRERO AVE., SAN FRANCISCO, CA 94110 , (X4) 1p SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION * (x5) PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX CEACH CORRECTIVE ACTION SHOULD BE CROSS- , COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE a s 5. 70825(a)(3)(C)(D)(c)(1) Laundry and Linen it .- Lf the hospital operates its own laundry, such laundry shall be..(C) maintained in a sanitary manner and kept in good repair. (D) Not part of a storage area." {c)(1) "Clean linen shall be sorted, handled and transported in such a manner as to prevent cross contamination.” ‘, On 12/08/87, the following deficiencies were observed in the laundry area: a) Dirt, debris, lint and washing powder were observed accumulated on the floor of the laundry area. b) The walls of the clean linen area were smoked damaged. c) A chair, pail, used chemical drums, and fire damaged ceiling tiles were observed stored in the clean linen area. DOCUMENT NO. 2200892 VISIT NO, 600000875 12/22/1987 16325 PROVIDER REPRESENTATIVE'S SIGNATURE " TITLE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguard: provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction 1s provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-2587 (10-84) HCFA REGIONAL OFFICE If continuatlon eheat Page 6 of 2f DEPARTMENT OF teaurn AWD HUMAN SERVICES HEALTH CARE F ‘CING ADMINISTRATION FORM APPROVED —— _ OMB _No. 0938-039. mm . (X41) PRUviDER NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0226 a BUILDING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL OG) 45 1001 POTRERO AVE., SAN FRANCISCO, 94110 PREFID TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) d) Staff were observed dropping and/or dragging clean laundry on the floor and processing it as clean linen. e) Moldy sheets were obsérved stored in a sink in the clean linen area. f) There was a heavy build-up of sediment on the washing machines. g) The bottom of the outside of the washing machines and the pipes on some of the machines were rusted and there were holes in the bottom of the washing machine. h) The laundry room floor was in need of painting. i) Dirt was swept in a corner in the stair-well between the clean and dirty laundry area and left there. j) Clean linen was observed uncovered adjacent to an area where construction work was in progress. k) The walls of the dirty linen area were in need of painting. DOCUMENT NO. 22-00892 VIStT NO. 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE 1d PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS: REFERENCED TO THE APPROPRIATE DEFICIENCY) 12/22/1987 16125 TITLE (x5) COMPLETION DATE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguarc provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not plan of correction 1s provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-2587 (10-84) HCFA REGIONAL OFFICE t If continuation sheet Page 7 of « DEPARTMENT OF HEALTH AND HUMAN SERVICES RM APPROVED HEALTH CARE “el ‘G_ADMINISTRATION 38 No. 0938-0391 (41) PROVIL. . NUMBER (X2) MULTIPLE CONSTRUCTION | (X%3) GATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12y08/a7 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS ,CITY,STATE,Z1P,COOE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (4) 5 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE cRoss- TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) ae (5) COMPLETION DATE 1) Two bags of infectious linen was observed stored opened, in a corner of the dirty laundry area. One of the bags was labeled infectious waste. m) The air flight belt system for processing dirty soiled linen was broken. n) The employee’s hand washing sink located in the clean linen room near the washing machines was dirty. o) Linen was observed stored on the floor of the corridor outside of the laundry area. p) Soiled and infectious linen bags were allowed to accumulate on the floor of | the soiled linen rooms near the units. se q) Dirty linen was stacked wee ef ° approximately four feet high in the soiled _ linen room in the emergency room area — forcing the door to be propped open. ; " ee eo 1. | 4d. { DOCUMENT NO. 22-00892 : - VISIT NO, 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE " ~ 12/22/1987 16:25 { .| TITLE DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disctosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-e587 (10-04) HCFA REGIONAL OFFICE If continuation sheet Pegs B of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE = ‘SING ADMINISTRATION OMB No. 0938-0391 €X1) PRu..-ER NUMBER (%2) MULTIPLE CONSTRUCTION (X3) DATE SURVc, COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0226 A. iat 12/08/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 KEY 95 PREFIO TAG CEACK DEFICIENCY SHOULD BE PRECEDED PREFIX CEACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) , ” GS) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION . | DATE r) Linen was observed stored directly on the floor of the linen and trash chute room. s) Infectious garbage was not placed in the container marked infectious waste. The above observation are a direct consequence of the lack of sufficient laundry housekeeping, buildings and grounds staff to maintain the laundry in good repair, and a clean, sanitary state. According to hospital data, 12 of 49 laundry/linen FTE positions are vacant. (Cross reference to 7070I(a) (4) governing body). 7. 70827(b)(1)(2) Housekeeping "There shall be written routines and procedures developed and maintained to include but not be limited to the following: (1) Daily cleaning of occupied patient areas, nurses’ station, work areas, halls, entrances, storage areas, restrooms, laundry, pharmacy, offices, etc. (2) Daily cleaning of specialized areas..." DOCUMENT NO. 22-00892 PROVIDER REPRESENTATIVE'S SIGNATURE VISIT NO. 000000875 12/22/1987 16:25 TITLE | (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction ts requisite to continued program participation. FORM HCFA-e5br (10-04) HCFA REGIONAL OFFICE If continuation sheet Page 9 of 26 DEPARTMENT OF HEALTR AND KUMAN SERVICES FORM APPROVES HEALTH CARE FINANCING ADMINISTRATICN VB Wo. 6936-G39% (XT) PROV NUMBER (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVE) .OMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BULLDING 12/08/87 12/22/87 NAME OF PROVIDER OR SUPPLIER - STREET ADDRESS, CITY, STATE, ZIP, COOE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES a) PROVIDER'S PLAN OF CORRECTION 15) PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- *- COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE a) On wards 5A and 3B the janitor’s closet was dirty and in need of repair. The walls were in need of painting. b} Tiles were missing and/or broken in the bathrooms of 5A10, 5A12, 5A36, 5A20, ~6C€10, 5A32, 5C14 and 5C22. c) On December 8, 1987 around 2:00 P.M. the floors of the patients rooms and bath rooms were in need of cleaning on 5A, 5C, 4D, and 6C as follows: 1. There was an accumulation of dirt and/or a mold Tike substahce in the corners and around baseboards. 2. There were dried splashes on the floors. 3. Debris on floors. 4. The traverse curtain rods were in disrepair in the rooms 5A36, 5A34, 5A28, 5A32, 5A20, 5C€24, and 5C30. DOCUMENT NO. 22-00892 VISIT RO. 000000875 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X85) DATE >Any deficiency Statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-é567 (10°84) HCFA REGIONAL OFFICE If continuation eheet Page 10 of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED ro: OMB No. 7 HEALTH CARE NCING ADMINISTRATION CTY Pave (DER WONDER 1X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 03-0228 A. BUILDING 12/08/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 4001 POTRERO AVE., SAN FRANCISCO, CA 94110 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION .e on) PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION PTA BY FULL REGULATORY OR LSC. TOENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE d) The facility did not follow its daily cleaning schedule on 5A, 5C, 40, and 6C as follows: 1. Waste receptacles were not wiped inside and out. 2. Window sills, furniture, night stands, over bed light, over bed trays, call buttons, wal? areas above and between sinks, underside of sink and plumbing, the walls surrounding the toilet, door handles and kick plates were not damp wiped. 3. Soil and litter were sweft into the corridor from patient’s rooms and picked up at that point. e) The floor of the acute emergency room was cracked in some areas, splashed, and in need of stripping and cleaning. 1. One container was overflowing with infectious waste. 2. The shower was covered with dirt and grime. 3. The floor of the waiting room was soiled with dirt, cigarette butts, and debris. DOCUMENT NO. 22-00892 VISIT NO. 060000875 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ' : »Any deficiency statement ending with an asterisk (*) denotes a deficiency which the fnstitution may be excused from correcting providing it fs determined that other safeguard provide sufficient protection to the patients. (See reverse for further {netructions.) The findings above ere disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-ebar (10-82 HCFA REGIONAL OFFICE If cont{nuatTon sheet Page 1 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION : ; ——MB No. 0938-0394 [ (41) PROV NUMBER (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVE. OMPLETED STATEMENT Ot OEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE,21P, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 4) Ip SUMMARY STATEMENT OF DEFICIENCIES 1D ! 3) PROVIDER'S PLAN OF CORRECTION PREFID CEACH DEFICIENCY SHOULD BE PRECEDED PREFIX CEACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION REFERENCED TO THE APPROPRIATE DEFICIENCY) TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | = TAG CATE 4. The bathrooms in the emergency room area were in need of cleaning. f) The windows of the facility were in need of cleaning. ih 8. 70837(a) General Safety and Maintenance "The hospital shall be clean, sanitary and in good repair at all times. Maintenance shall include provision and surveillance of services and procedures for the safety and well being of patients, personnel and visitors." yn The following deficiencies were observed: a) In the Central Processing and Distribution Department (CPD), floors were soiled and there was an accumulation of loose labels from packages adhering to the floor. c) Long cracks traverse the floor throughout the CPD. One was wide enough to begin to present a safety hazard as well as presenting a difficulty in cleaning. Another crack in the decontamination area measured approximately 1.5cm in width. | | DOCUMENT NO. 22+00892 VISIT NO. 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE 12/22/1987 16:25 TITLE (X6) DATE I >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM 3CFA°2987 (10°84) HCFA REGIONAL OFFICE If continuation sheet Page ‘i2 of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORH APPROVED HEALTH CARE FINANCING ADMINISTRATION _ 0. XT) PR ER NUMBER | (X2) MULTIPLE CONSTRUCTION (XS) DATE SUR. © COMPLETED : . 8/87 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/ 8. WING 12/22/87 NANE OF PROVIDER OR SUPPLIER STREET ADDRESS CITY, STATE, ZIP ,CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 O75 ; , 1cx5) SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- : COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING LNFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE d) Ceiling vents were partially clogged with dust. e) The operating room corridors were being used for storage of operating microscopes, blood warming equipment, carts, supplies and other equipment. f} The ICU corridor was being used to store a large wooden cabinet for supplies and for smal] oxygen cylinders. 9. 70833 “Autoclaves and Sterilizers... shall be maintained in operating condition at all times:" The reliability of the steam sterilizers is questionable as evidenced by eleven contract maintenance visits in October 1987 and at least 3 visits in November 1987. The back room of the sterilizers is in disrepair. Leaks are in evidence and patient gowns are used to soak up the accumulation of water. Rust is in evidence. Despite a directive from the infection control committee in June 1987, engineers have not been trained to maintain the sterilizers. The problem of positive spore tests began in February 1987. DOCUMENT NO. 22+00892 VISIT NO. 000000875 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE | Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-2587 (10-84) HCFA REGIONAL OFFICE If contThuatlon sheet Page 13 of 26 DEPARTMENT OF HEALTH AND BUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB No. 0938-0391 CAT) PRU =| .RRUMBER | (X2) MULTIPLE CONSTRUCTION (x3) DATE SUR\.. COMPLETED STATEMENT Gr DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/87 B. WING 4 2/22/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., GAN FRANCISCO, CA 94110 X49 ty SUMMARY STATEMENT OF DEFICIENCIES 1D PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (X35) COMPLETION DATE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY) Both steam sterilizers were shut down in June 1987 and materials had to be sent elsewhere. Two positive spore tests (which indicate improperly sterilized equipment) occurred with the wash sterilizer late in November, 1987. 10, 70827(d), 70701(a)(4) Housekeeping and Related Staff Insufficiency The conditions described above demonstrate the lack of sufficient housekeeping, buildings, and grounds staff. Hospital data show 21 of 155 housekeeping FTE positions are vacant. Similarily, the building and grounds department is understaffed. f ll. Infectious Waste 25117.5(a)(7) Health and Safety Code The hospital has not defined “infectious waste" as required in this section. Consequently widespread differences in handling of materials which may or may not be classified as "infectious" was observed. 12. 70847 Infectious Waste "Infectious waste as defined in Health and Safety Code Section 25117.5, shall be handled ‘and disposed of in accordance with the DOCUMENT NO, 22°00892 VISIT NO, 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE 12/22/1987 16325 TITLE (X6) DATE ~Any deficiency statement ending with an asterisk (*} denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse:for further {natructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction 1s provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-o587 (10-64) HCFA REGIONAL OFFICE tf eentinuation eheet Page 14 of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES . FORM APPROVED HEALTH CARE FY" ‘NCING ADMINISTRATION OMB_No. 0938-0391 (X71) PRL .sER NUMBER =| (2) MULTIPLE CONSTRUCTION | (3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 saber adel 1308/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (X4) ID (x5) SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION . PREFID CEACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD 8E CROSS- : COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Hazardous Waste Control Law, Chapter 6.5 Division 20, Health and Safety Code (beginning with Section 5000) and the regulation adopted thereafter (beginning with Section 66100) of this title.” Infectious waste, infectious soiled linen and regular soiled Jinen in bags were observed be collected and stored on the floors of ward utility rooms.. This is not an appropriate method of segregating or separate handling of infectious materials as required. Bags are not considered a suitable container for storage and should not be stored on the floor. Also, hospital policy Section 3.8-2 requires infectious waste bags to be placed | in an “infectious waste can" or carton. 13. 70739(a) Infection Contr ram "A written hospital infection control ~ program shall be adopted..." 5, The facility failed to meet—the_requirements of these regulations by failure to implement the policies and procedures of its infection- control program. The following incidents ° | were observed during this survey visit: | DOCUMENT NO. 22-00892 PROVIDER REPRESENTATIVE'S SIGNATURE VISIT NO. 000000875 12/22/1987 16:25 TITLE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instruct{ons.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation, FORM HCFA-2587 (10-84) HCFA REGIONAL OFFICE 1? continuation sheet Page TS of 26 DEPARTMENT GF WEALTH AND BUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB No. 0938-0391 (X1) PR. :R NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURV. COMPLETED STATEMENT ur DEFICIENCIES AND PLAN OF CORRECTION 05-0228 . BUILOTNG 12/08/87 12/22/87 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP, CODE - SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 SUMMARY STATEMENT OF DEFICIENCIES 1d PROVIDER'S PLAN OF CORRECTION (x5) PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- .° COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE a) There were no isolation gowns available for a psychiatric unit patient with hepatitis precautions and for a patient on ward 4D with wound precautions. b) On the psychiatric ward two ‘ARC patients did not have signs posted with precautionary measures to be implemented and the medical record (care plan) did not address precautionary measures. c) On the AIDS unit two patients had no precautionary measures posted inside or outside of the room. “ef d) In the Emergency Room soiled patient care equipment was stored in the nursing supply room with sterile supplies. e) In three instances during sterile dressing changes, sterile technique was not followed on wards 4B and ICU. f) On 4A an intravenous line stopcock used for intermittent antibiotic administration was, uncovered between uses. DOCUMENT NO. 22-00892 VISIT NO. 000000875 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE | (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instruct{ons.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. !f deficiencies are cited, an approved plan of correction ts requisite to continued program participation. FORM HCFA-2567 (10°84) HCFA REGIONAL OFFICE If continuation sheet Page 16 of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION WE No. 0938-0391 . [ (X1) PRO NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVe—Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reveree for further instructions.) The findings above are disclosable 90 days following the date of survey whether or not e plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued pregram participation. HCFA REGIONAL OFFICE FORM HCFA-e587 (10-84) If continuation sheet Page 18 ef dé DEPARTMENT OF HEA'TH AND HUMAN SERVICES HEALTH CARE F1HAl a_ADMINISTRATION FORM APPROVED 2 OMB No, 0938-0391 e (X1) PROVIDER NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED STATEMCNT OF DEFICIENCIES AND PLAN OF CORRECTION | 05-0228 A. BUILDING 1340 Br NAME QF PROVIDER OR SUPPLIER | STREET ADDRESS ,CITY, STATE, ZIP, CODE a " SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94140 (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5) PREFIO (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- .* COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE c) In the laboratory, when infectious waste containers are left unattended, lids should be closed over discarded patient specimens and especially microbiology waste. On 12/9/87 and 12/10/87, lids were left open when laboratory workers left their stations. This occurred with a waste container holding petri dishes with microbial growth. d) The chemistry section disposes of some glassware such as pipettes into a cardboard container not described in the disposal section of the "Biosafety Policies and Procedures." This method of disposal should be added and there upon officially approved by the appropriate persons and committee and subject to review by appropriate agencies. e) On a regular basis but at a low frequency, patient specimens were being delivered to the laboratory from the floors arrive without a protective bag or equivalent protection as required by hospital policy. It is estimated 5 of 100 specimens are delivered to microbiology without this protection per day. Other sources state a higher percentage. The observation of two of 12 serum tubes ; ° unbagged is within this estimated range. The DOCUMENT NO. 22°00892 ViStt NO. 000000875 1ef22si9a? 16225 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE »Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it fis determined that other safeguards provide sufficient protection to the patients. (See reverse.;for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HCFA-2587 (10-84) HCFA REGIONAL OFFICE If continuation sheet Page 19 of 24 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION : : OMB No. 0938-03¢ (x1) TOER HUMBER] (x2) MULTIPLE CONSTRUCTION (KS) DATE 8u...€Y COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-028 A. gui 12/08/87 NAME OF PROVIDER OR SUPPLIER ———T-STREET ADDRESS, CITY, STATE, Z1P, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., AN FRANCISCO, CA 94110 CX4) ty | SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5) PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE two tubes were in the VDRL tub with patient lab slips attached. Hospital policy requires such specimens to be bagged or otherwise enclosed. 16. | 70825(c)(1)(5) Clean Linen ‘” . "Clean linen shall be sorted, handled and transported in such a manner as to prevent cross contamination. Clean linen in patient care unit shall be stored in clean, ventilated closets, rooms. or alcoves, used for that purpose only.” The facility failed to meet the’ requirements of these regulations as evidenced by the | following observed incidents: a) On wards 3B, 30, 4A, 4B, 4E and 5A linen carts were observed, stacked with clean linen and not consistently covered throughout the survey. b) Clean linen was observed uncovered and unprotected on chairs and room furnishings in patient rooms thoughout the facility. DOCUMENT NO. 22-00892 VISIT NO. cooo00a75 ' 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguar provide sufficient protection to the patients. (See reverse for further Instruct{ons.) The findings above are disclosable 90 days following the date of survey whether or not plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM HOPA+Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguard provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction {s requisite to continued program participation. FORM HCFA-c507 (10-84) , HCFA REGIONAL OFFICE ee If continuation sneet Page of of 2 b DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION ; 4B No, 0938-0394 (X11) PROV NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVE, MPLETED STATEMENT ol VEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/87 STREET ADDRESS, CITY, STATE, ZIP, CODE NAME OF PROVIDER OR SUPPLIER 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 SAN FRANCISCO GENERAL HOSPITAL 4) ip | SUMMARY STATEMENT OF DEFICIENCIES 1D PREFIO (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG A 245} 70739(b) Infection Control Program - 18. "The system for reporting infection shall include and identify infections which are: PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE CROSS- “ COMPLETION REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 1. Evident at the time of admission to the hospital. ita 2. Possible acquired and evident during hospitalization. 3. Possible acquired during hospitalization and evident following discharge from the hospital." 70701(a)(4) Sufficient Infection Control Staff a4 "Governing body shall...provide... appropriate...personnel". The following deficiencies were observed with respect to these regulations: a) The infection control program is not sufficiently staffed to provide the resources to develop and implement an effective infection control program. The facility which is licensed for 518 general acute care beds (average daily census of 400 patients) with special emphasis on the care of AIDS patients, has only one Infectious Disease DOCUMENT NO. 22-00892 VISIT NO. 000000875 12/22/1987 16:25 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution ma provide sufficient protection to the plan of correction is provided. FORM HCFA-e587 (10-84) y be excused from correcting providing it is determined that other safeguards patients. (See reverse for.further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a If deficiencies are cited, an approved plan of correction is requisite to continued program participation. HCFA REGIONAL OFFICE If continuatlTon sheat Page e2 of 26 DEPARTMENT OF REALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FIN*NCING ADMINISTRATION @ OMB_No. 0938-0391 (X1) PRO. .JER NUMBER (X2) HULTIPLE CONSTRUCTION | (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 05-0228 A. BUILDING 12/08/87 B. WING 12/22/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY,STATE,Z1P,CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION ’ 0X5) PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) COMPLETION TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Nurse. Comparable institutions have 2 to 3 times these staffing resources. b) As a result there are no apparent studies to document the infections present at the time of admission acquired, or evident after discharge except in limited areas. c) The Dental Service had no quantification of its infection rate allegedly due to lack . of staff. mer at “'4 1 70701(a)(4), 70721(a) Staffing, Supervision 19, "Sanitary and housekeeping problems as described indicate a lack of Infection Control involvement in hospital housekeeping efforts to provide a sanitary environment to avoid sources transmission of infections and communicable disease. The hospital has not VISIT NO. 000000875 12/22/1987 16325 DOCUMENT NO. 22-00892 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE >Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it {s determined that other safeguards provide sufficient protection to the patients. (See reverse for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of correction {s requisite to continued program participation. FORM HCFA-cbe? (10°B4) HCFA REGIONAL OFFICE If continuation sheet Page 23 of 26 -- soe we tA ANU MUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION . OMB No. 0938-0391 (X1) P ER NUMBER (X2) MULTIPLE CONSTRUCTION | (X3} DATE SU. COMPLETEO STATEMENT! DEFICIENCIES AND PLAN OF CORRECTION | ‘05-02e A. BUILDING 12/08/87 NAME UF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (X53) PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX . CEACH CORRECTIVE ACTION SHOULD BE CROSS- TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG COMPLETION REFERENCEO TO THE APPROPRIATE DEFICIENCY) DATE provided staff or supervision for the successful correction of problems in the . housekeeping area or provided the necessary staff to implement the Infectious Disease Program. ft tay . no he othe ait Pyne? * ' * ++ vreb?? Y, . soy Fe te ob me hs The following are additional licensing deficiencies identified during the survey: 20, 70805, 70054 Space Conversion Hospital space has been converted without approval of the department. The average daily census is around 400. Eighty nine (89) beds are not currently used, the space being designated for housing for medical staff and clinic use because of lack DOCUMENT NO. 22-00892 VISIT NO. 000000875 12/22/1987 16125 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X5) DATE i? te nl 4 . >Any deficiency statement ending with an asterisk (*} denotes a deficlency which the institution ma y be excused from correcting providing it is determined that other saf d provide sufficient protection to the patfents. (See reverses for further Instruct{ons.) The findings above are disciosable 90 days following the date of survey whether or not & plan of correction is provided. If deficiencies are cited,.an approved plan of correctfon Is requisfte to continued program participation. FORM HCFA-é567 (10-04) HCFA REGIONAL OFFICE If continuation sheet Page 24 of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE F’*'ANCING ADMINISTRATION STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) F. 03-0228 -DER NUMBER 8. WING | (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED __ OMB No. 0938-0391 (X3) DATE SUkvcY COMPLETED 12/08/87 12/22/87 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP, COOE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (4) op PREFID TAG 21. 22. SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) of staffing. The displacement of the clinic equipment, furniture, staff, patients, and medical staff to alternate living arrangements would indicate great difficulty in reconverting to patient accommodation within 24 hours. vie 70363(a) Program Flexibility "All hospitals shall maintain continuous compliance with Special Permit Requirements." SFGH is licensed for 6 burn beds as a Special Permit service. The unit has been closed for at least 15 months for lack of*specialty nurses. Patients are being treated in the ICU with an alternate bathing technique. Prior approval was not obtained nor was supporting evidence submitted by the licensee to justify this alternative concept and procedure. 70473(a) Dental Service "Written policy and procedure ...maintained". The committee is not following its bylaws obligation of monthly meetings. Only 4 of 12 meetings in the past year were held. | DOCUMENT NO. 22-00892 VISIT NO. 000000875 PROVIDER REPRESENTATIVE'S SIGNATURE >Any deficiency statement ending with an asterisk (*) denotes e deficiency which the fnstitution may be excused from correctin provide sufficient protection to the patients. (See reveree for further Instructfons.) The findings above are disctosable 90 plan of correction is provided. If deficiencies are cited, an approved plan of correction is requisite to continued program FORM HCFA: e587 (10-84) HCFA REGIONAL OFFICE ' a? 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY) 12/22/1987 16:25 TITLE (x5) COMPLETION DATE | ¢X6) DATE g@ providing it is determined that other safeguards days following the date of survey whether or not a participation. If continuation sheet Page «5 of 22 FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION __—sOMB_No. 0938-0391 (kT) PRO. -t_- NUMBER (x2) MULTIPLE CONSTRUCTION | (X3) DATE SUR\ © MPLETED STATEMENT ( JEFICIENCIES AND PLAN OF CORRECTION 05-024. A. BUILDING 12/08/87 B. WING 12/22/87 NAME OF "ROVIDER OR SUPPLIER | STREET ADDRESS, CITY, STATE, ZIP, CODE SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVE., SAN FRANCISCO, CA 94110 (K) 5 ~ (5) SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFID (EACH DEFICIENCY SHOULD BE PRECEDED PREFIX CEACH CORRECTIVE ACTION SHOULD BE CROSS- . COMPLETION TAG BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) ~~ DATE 23. 70487(a)(5) ICNN Equipment The rooms designated for Level II babies did not all have a hygrometer and wall thermometer as required. 24, 70533(d)(1)(5) Outpatient Servite Space and Equipment a) The rooms used for procedures did not have a time lapse clock, a call mechanism or foot operated sinks for scrubbing as required. b) The operating room doors directly connect to a corridor used for through ‘traffic. This poses a privacy and infection control problem. DOCUMENT NO. 22-00892 PROVIDER REPRESENTATIVE'S SIGNATURE TITLE (X64) DATE VISIT NO. 000000875 {2722/1987 16325 ' ! we a >Any deficiency statement ending with an aster{sk (*) denotes a deficiency which the institution may be excused from correcting providing it 1s determined that other safeguards provide sufficient protection to the patfents. (See reverse,for further Instructions.) The findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. If deficiencies are cited, An approved pian of correction {s requisite to continued program participation. FORM HCFAs2>67 €10+84) HCFA REGIONAL OFFICE tf continuation sheet Page 26 of 26