5. WORKING PROCEDURES TO AVOID HIV INFECTION - ADVICE TO HEALTH STAFF INVOLVED IN LEPROSY CONTROL ACTIVITIES

5.  Working Procedures To Avoid Hiv Infection - Advice To Health Staff Involved In Leprosy Control Activities

 

1.  SEVERITY OF THE PROBLEM

Since the first cases were diagnosed in 1981, the HIV/AIDS epidemic has created millions of victims. Not a single country in the world is unaffected, and the estimates on the extent of the problem published by UNAIDS, the specialized United Nations Agency, are terrifying: by December 2003, about 40 million people, including 2.5 million children under 15 years, were living with HIV/AIDS. During the year 2003 alone, 5 million people were newly infected with HIV, and 3 million people died of AIDS. Sub-Saharan Africa is by far the most badly stricken area. In some countries, particularly in the southern part of the continent, more than 30% of the adult population is thought to be infected. The spread of the infection is also alarming in other parts of the world, particularly South- and South-East Asia and Latin America.

 Treatment does now exist, permitting a dramatic improvement in life expectancy and in the quality of life of HIV-infected people, but a complete cure of the infection does not. Treatment remains very expensive, and is only available for, or affordable by, a minority of patients. Even diagnostic tests are, in many areas, often not available. Meanwhile, the development of effective vaccines is still far from fruition.

 Leprosy, maybe because of its very long incubation period, does not seem to be influenced by the HIV epidemic, although some reports seem to indicate that anti-retroviral treatment could be a risk factor for developing a reversal reaction (which can, in some cases, be the first manifestation of leprosy). It is in any case always possible that a leprosy patient, as well as a health worker, is infected with HIV. For this reason, all precautions must be taken to avoid the spread of  HIV/AIDS in the community through leprosy control activities.

Although this document deals most specifically with HIV, many other diseases, such as hepatitis B or haemorrhagic fevers, can be transmitted through contact with infected blood. Prevention of the transmission of blood-borne diseases in health care settings should be a constant concern for health workers. The measures recommended below are basic hygiene measures that are effective in preventing these diseases, and, as such, they should always be implemented, even in settings where the level of HIV infection is thought to be low.

2.  PREVENTIVE MEASURES

The risk of health workers contracting HIV infection while dealing with leprosy patients or suspects is very small and no greater than that faced by health staff during other activities. Moreover, it is possible to reduce the risk still further through the adoption of various simple and inexpensive measures by all health staff.

As HIV infection can be spread by blood and blood products, there is one primary consideration which requires simple and appropriate action: none of the procedures used for leprosy control or care of patients should risk the spread of HIV from infected persons, including infected staff, patients or contacts, to those uninfected.

Fortunately, the Human Immunodeficiency Virus is quite delicate  and can easily be inactivated following 20 minutes’ contact with disinfectants such as fresh 0.5% sodium hypochlorite solution, 70% alcohol solution or 5% formaldehyde solution. Re-usable material should be carefully sterilized by boiling for 20 minutes or autoclaving using standard procedures.

 
Therefore, the Medico-Social Commission makes the following recommendations to Member-Associations and health staff dealing with leprosy:

  • Skin smears: although all actions capable of disseminating HIV should be limited as much as possible, the usefulness of taking smears is still acknowledged for a number of indications. As said in the report of the ILA Technical Forum, “Approximately 70 per cent of leprosy patients can be diagnosed by the single sign of skin patches with sensory loss. … However, 30 per cent of patients, including many multibacillary (MB) patients, do not present with this sign. Enlargement of one or more nerves is an important additional sign, to be supplemented by skin-smears, if these are available and of assured quality. … The skin-smear remains the most accurate means of classifying leprosy in the field. In practice, however, classification can be based on counting the number of skin lesions …”
  • Scalpels: disposable scalpels should always be used in cases where it is considered necessary to take smears or a biopsy, or for trimming ulcers. Field personnel who have to collect smears from several patients should thus carry with them the required number of scalpel blades.
  • Needles and syringes: only disposable material should be used for taking blood specimens, giving lepromin or drug injections.

If needles are used for sensory testing (for anaesthesia), one needle should be used for one patient only. Alternative methods of sensory testing using a ball-point pen, a nylon filament, cotton wool, a feather or a thermal tester are preferable. As long as these tools are used on intact skin, they can serve for many different patients without risk of transmitting disease.

  • Disposable gloves: disposable gloves should be worn for taking smears and biopsies, changing dirty dressings contaminated with blood or serum, and also when dressing ulcers and open sores. It is important that staff with dermatitis or cuts and abrasions on their hands should cover the cuts with waterproof dressings, and always wear gloves for the above procedures. Staff who have anaesthetic hands and/or open wounds need to be particularly careful.
  • Bandages: as much as possible, bandages should not be re-used, or at least never used for more than one patient. It is recognised that some clinics use woven or knitted bandages, which are intended to be reused. If they are to be reused, they should be autoclaved like any other non-disposable fabric, such as operation drapes and gowns.
  • Blood spillage: blood spilled in operations, etc., should be cleaned up by workers wearing gloves, and the stains washed down with bleach solution (hypochlorite). Areas of workers’ skin contaminated with blood should be swabbed immediately with 70% alcohol and then washed with soapy water.
  • Blood transfusion: only blood tested for HIV and found negative should be used in operations, resuscitation, etc. If tested blood is not available, plasma expanders only should be used, unless blood is required to save life.
  • Disposal of instruments: after use, needles and blades should be flamed and safely disposed of, so as to prevent accidental wounds and possible infection of those handling refuse.

The Medico-Social Commission emphasises the importance of health training in AIDS for all health staff in keeping with the policies and methods of the national Ministry of Health of the countries concerned. All health staff should be aware of the procedures laid down in their country for dealing with accidental needle-stick injuries.

3.  RESOURCE ALLOCATION

In order to enable staff to follow these recommendations, managers of leprosy control programmes and Member-Associations should make appropriate budgetary and administrative provisions in the context of the recommendations made to the general health care staff of the country in which they are working.

Other documents on protection against HIV infection

See the document produced by the WHO Global Programme on AIDS, Preventing HIV Transmission in Health Facilities  (GPA/TCO/HCS/95.16).

This document is a revision of an earlier text, originally written in 1987 and revised for a first time in 1992.

ILEP is a Federation of autonomous anti-leprosy Associations. The advice contained in this publication is not binding on ILEP Members.

The text of this Technical Bulletin can be freely quoted subject to acknowledgement of its source.