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Audiology and HIV: Developing Best Clinical Health Practices

Audiology and HIV: Developing Best Clinical Health Practices
Susan Cuttler, AuD, CCC-A, Vickie L. Adams, AuD, CCC-A
April 28, 2008
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This article is sponsored by HearUSA.

The human immunodeficiency virus (HIV) is the virus that causes AIDS (acquired immune-deficiency syndrome). Because the known means of HIV transmission, the exchange of bodily fluids, is not a typical part of the hearing health professional's daily experience, HIV has not been a major concern of audiologists. Although, in the mid 1990s, The American, Speech-Language, Hearing Association and The American Academy of Audiology printed educational brochures on the virus for audiologists and speech language pathologists because of their possible contact with infected patients. However, audiologists, under routine circumstances, do not come into contact with patients' blood, semen, vomit, or other known transmitters of the virus, at least not on a daily basis.

Still, most audiologists and other hearing health professionals at some point will work with patients infected with HIV and other blood-borne illnesses (Hepatitis B, for example). Additionally, as the science of audiology has expanded, audiological testing, treatments, and therapies have as well, increasing the audiologist's risk of HIV transmission through daily interaction with patients (Bankaitis & Kemp, 2005;Kemp & Bankaitis, 2000). Other medical practitioners, including surgeons, dentists, immunologists and other specialists, receive extensive training in managing potentially infectious waste material and in treating patients known to have HIV or other potentially infectious diseases. It is therefore important that information on working with this group of patients continues to be discussed within the audiology community.

As of December 2001, the Center for Disease Control (CDC) reported 57 proven cases of HIV transmitted to caregiver from patient (Sepkowitz & Eisenberg, 2005);therefore, the CDC has recommended what it refers to as "Universal Precautions" to prevent the spread of blood-borne infections in any healthcare setting (FDA, 1993).

HIV: The Latest Facts

Research into the development of safe clinical practices for hearing health professionals continues, and new anti-bacterial and anti-fungal cleansers are now available;however, this is just the starting point. A general background education in HIV/AIDS is also recommended.

The latest in HIV and AIDS research has determined the following (Evans, 2006):
 

  • The virus is most commonly spread through unprotected sex with an infected partner.


  • The virus enters the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex.


  • Research has clearly demonstrated that HIV is spread through contact with infected blood and other bodily fluids including mucous and vomit. Cerumen is not an infectious substance in and of itself, however when contaminated with blood, mucous, or pus it may become infectious. Because of this, every medical practitioner must take care to protect him/herself and patients. Cross contamination between practitioner and patient or from patient to patient is always a possibility.


  • Before HIV and its means of transmission were identified, many patients became infected with HIV and/or hepatitis through blood transfusions. Today, the screening and treatment of donated blood have significantly lessened the likelihood of HIV infection through blood transfer.


  • Other research findings indicate that even a small amount of blood can cause the spread of HIV and other disease-causing viruses. HIV is often spread among drug abusers who share contaminated needles or syringes, even when no blood is visible to the naked eye. Disinfecting contaminated needles in bleach and other solutions does not eliminate the possibility of cross contamination among those who share needles.


  • The spread of HIV between caregiver and patient is extremely rare. It is most often caused by accidental punctures with contaminated needles and other medical instruments;however, many of these instruments are used by audiologists today.


  • The human immunodeficiency virus has been found in saliva;however, there is no indication that the disease can be spread by contact with saliva from an infected individual. Further, no evidence exists that the virus can be spread through contact with urine, sweat, tears, or feces. HIV is not spread through casual contact such as sharing or touching cooking and eating utensils, towels, telephones, swimming pools, toilet seats, drinking fountains, doorknobs, or pets. Finally, contemporary research indicates that the virus is not spread by biting insects such as mosquitoes.


  • Women can pass HIV to their babies during childbirth. Approximately one-quarter to one-third of all untreated pregnant women infected with HIV will pass the infection to their babies. However, if the mother takes the drug AZT during pregnancy, she can dramatically reduce the likelihood that her baby will become infected with HIV.


  • HIV can also be spread to babies through their mother's breast milk if she is infected with the virus.

HIV and AIDS

Scientists have studied the relationship between HIV and AIDS for more than two decades, and although there is no doubt among the scientific community that AIDS is caused by HIV, HIV is not acquired immune deficiency syndrome. Many people infected with HIV show no symptoms of AIDS;nevertheless, patients infected with HIV who show no outward symptoms of AIDS still pose a potential health risk to audiologists and their patients.

Incidence Factors

There is no doubt that HIV continues to spread, in part because many of those who are infected have not shown any symptoms of illness. However, the incident rate of infection is warning enough that health care providers, including audiologists, must take precautions to prevent the further spread of the virus.

Consider these statistics (Until There's A Cure, 2007):



  • 22 million people have died of AIDS worldwide.


  • 42 million people live with HIV or AIDS, many of whom are unaware that they have been infected.


  • There are 14,000 new infections every day.


  • The AIDS epidemic is spreading most rapidly among minority populations. It is the number one cause of death among African-American males between the ages of 25 and 44.


  • The Center for Disease Control reports that African-Americans are seven times more likely to contract AIDS. Within Hispanic populations, the likelihood of occurrence is 300% higher than Caucasian populations.


  • 70% of all new cases in the U.S. occur in men.


  • Half of all new cases in the U.S. occur in people younger than 25 years old.

The Symptoms of HIV

As previously mentioned, many individuals infected with HIV show no symptoms initially. This leads to the unwitting further spread of the infection. Early signs of HIV infection include flu-like symptoms (usually within 30-60 days of infection), fever, headache, unexplained fatigue, and enlarged lymph nodes, which are a part of the body's immune system (CDC, 2007).

The following is a list of other symptoms, which usually appear long after the initial infection (CDC, 2007):



  • unexplained weight loss (AIDS was originally called the "wasting disease" when discovered in Africa)


  • frequent fevers and profuse sweating


  • regular yeast infections


  • skin rashes


  • coughing or shortness of breath


  • seizures


  • difficult or painful swallowing


  • mental symptoms including forgetfulness and unexplained confusion


  • diarrhea


  • loss of vision


  • nausea


  • coma

The Relationship Between AIDS and Cancer

There is a long, established relationship between the onset of AIDS and various cancers, particularly Kaposi's sarcoma, cervical cancer, and cancers of the immune system known as lymphomas (HearUSA, 2005). These cancers are thought to be initiated by viral infections including the HIV infection.

HIV kills or damages cells that make up the human body's immune system, which is the body's defense against disease. In doing so, HIV lessens the patient's ability to fight off diseases including suspected viral cancers. The appearance of these cancers usually indicates the presence of AIDS caused by the weakening of the body's immune system through the presence of HIV.

Health Care for HIV/AIDS Patients

Today, there are a number of tests to indicate the presence of HIV/AIDS. These tests detect the presence of HIV antibodies in blood samples, and test results are delivered in as few as three minutes. Early methods of detection can often stop the further spread of the virus and lead to better management of those individuals with the disease (CDC, 2006).

All care givers should be aware of basic clinical management methodologies for HIV/AIDS. There are four major classes of drugs found to be effective in the treatment of HIV/AIDS. These include: nucleoside and nucleotide analogs, protease inhibitors, non-nucleoside reverse transcriptase inhibitors and fusion inhibitors. These classes of drugs are most commonly prescribed as a "cocktail" of three or more medications. This multi-pronged approach to HIV/AIDS treatment is called highly active anti-retroviral therapy or HAART for short.

Through the use of HAART therapies, patients have lived longer, more productive lives. However, the side effects of these potent medications include liver problems, an increase in cholesterol, stroke, heart disease, osteoporosis, diabetes, skin rashes, and pancreatitis (Evans, 2006). In addition, patients often develop drug-resistant strains of HIV, leading to the discontinuation of HAART therapies.

Successful treatment of HIV/AIDS requires significant financial resources (medication often costs more than $1,000 per month) and an ability to understand and adhere to a complex regimen of treatment. Unfortunately, those who most need medical intervention often lack the resources to employ HAART therapies with long-term success.

Patient's Rights

Civil Rights are personal rights guaranteed and protected by the U.S. Constitution and by subsequent acts of Congress. They include the right to free speech, due process, equal protection of the laws, and to be free from discrimination.

All persons in the U.S. have the right to receive services in a nondiscriminatory manner from state and local social and health agencies, hospitals clinics, nursing homes or other agencies receiving funds from Health and Human Services. Therefore, one cannot be denied services or benefits simply because of your race, national origin, or disability.

The Control of Infection in the Practice of Audiology

Many infected individuals live long, productive lives with HIV and AIDS, thanks in part to extensive laboratory research and the development of HIV inhibitors. However, health care providers must take additional precautions when treating patients known to have either HIV or, subsequently, AIDS.

A problem arises when the patient is unaware that s/he is infected. Often, individuals with HIV do not receive adequate testing or early treatment, which then poses a health risk to all care givers. For this reason alone, the prudent practitioner will assume that every patient is a potential source of HIV. These care givers must take extra precautions to prevent infection in themselves, in staff members, and, of course, in their patients.

Vestibular testing, management of cerumen, real ear measurements, and other procedures may put the audiologist in direct or indirect contact with patients' bodily fluids. Thus, additional precautions must be taken by audiologists and other hearing health professionals to control transmission of HIV and other infections. Infection control has become a routine part of the work of hearing professionals.

Cerumen, the substance most likely to be encountered by an audiologist, of and by itself is not considered to be a transmission agent for HIV. However, cerumen may contain a patient's blood or mucous. The viscosity of cerumen makes the detection of fluids extremely difficult. For this reason, cerumen should be treated as infectious under all clinical conditions (Bankaitis & Kemp, 2005;Kemp and Bankaitis, 2000). It therefore becomes essential for the audiologist to undertake universal precautions to prevent the transmission of HIV from patient to practitioner and from patient to patient.

Best Practices for Audiologists

The Universal Precautions created by the CDC apply to all medical settings (CDC, 2002). These precautions are also OSHA (Occupational and Safety Administration) mandated. In other words, these precautions are law.



Assume all patients are potential carriers.
It may be counter-intuitive to consider a long-time patient a potential transmitter of HIV, but in many cases, individuals infected with HIV are unaware that they are infected and potential "carriers" of the virus. It is the professional's responsibility to protect him/herself and the other patients that make up the practice.

Due to the color and viscosity of cerumen audiologists must treat cerumen as a potentially infectious substance and cannot rely on visual inspection to determine whether it is contaminated with blood, pus or mucous.

Use approved barriers.
Barriers include latex gloves, eye goggles, masks (including full-face plastic shields), and disposable or cloth gowns. These barriers should be routinely cleaned after every examination or disposed of in a bio-hazmat approved container.

To err on the side of caution, audiologists should wear latex gloves whenever examining a patient. It is further recommended that hearing health professionals double glove when treating patients known to be infected with HIV, Hepatitis B, or other blood-borne illnesses. This includes treatment of fungal infections, ear drainage, and the making of impressions for hearing aid fittings.

To remove disposable gloves safely, follow these steps:

Peel gloves back from the wrist, turning them inside out in the process. Ensure that you do not touch the exterior portion of the glove after it has been used during patient examination or treatment.

Use inside-out first glove to remove second glove.

Discard disposable gloves in the trash unless contaminated with blood or other potentially contaminated fluids. In this case, dispose of gloves in an approved bio-hazmat container.

Wash hands thoroughly after removing gloves.

Hand washing / Hand Hygiene
Hands should be washed before and after any patient contact. Authorities agree that hand washing is the single most important step in eliminating the possibility of infection or cross contamination. Hands must be washed after every patient contact, after handling hearing aids or used examination instruments, before and after eating, and after handling or touching any potentially contaminated object or surface.

When washing their hands, health care professionals should use a medical-grade antibacterial soap. After washing for a minimum of 15 seconds, ensuring that all hand surfaces are scrubbed clean, rinse and dry hands using paper towels. In cases of skin roughness or soreness due to over-washing, use a waterless hand sanitizer.

To remind staff and patients, hand hygiene posters should be displayed in all restrooms and other cleaning facilities.

Fingernails should be no longer than ¼ inch in length beyond the finger tip. Artificial nails should not be used by health care providers having direct contact with patients. If nails do extend beyond the fingertips, use a nail brush to clean under each nail.

Disinfect all surfaces.
Disinfect any touch or splash surface including backsplashes around the sink area. Disinfection is an intermediate step between routine cleaning, which removes soil from objects may remove some pathogens in the process, and sterilization, which destroys all microbial life. Disinfection destroys specific pathogens, but will not eliminate all microorganisms.

Sterilize all examination instruments.
It is not enough to wash or disinfect examination instruments such as immittance probes and wax removal tools. This includes those used to remove cerumen from a patient's ear as well as those used to extract cerumen from hearing aids. These must be properly sterilized using a sterilization solution and procedure to ensure that they do not serve as instruments of HIV transmission. Other tools that may come into contact with infectious substances such as otoscope specula, Real Ear probe tubes, insert earphones, and headphone covers are "single-use" items and should be disposed of after each use.

Properly Dispose of All Infectious Waste
Dispose of all potentially contaminated waste properly in an approved bio-med hazmat container.

Keep all hazardous materials free of food, drinks, cosmetics, cigarette smoke, lip balm, and other potential transmitters of HIV.

All medical professionals must be familiar with proper management of potentially infectious or contaminated waste products. Materials that show blood or mucous, such as paper towels, disposable ear tips, or tissue, should only be handled with latex gloves. This infectious waste should be double bagged, labeled as infectious waste, and disposed of in a certified medical hazmat container.

Spills of bodily fluids, including blood or vomit, require special precautions to prevent the potential transmission of infectious diseases. These body fluid spills should be cleaned only by individuals wearing latex gloves. Fluids should be cleaned with disposable paper towels. Potentially infected areas should be rinsed clean and disinfected thoroughly with an approved cleanser.

The Development of an OSHA-Compliant Emergency Plan

OSHA (www.osha.gov) mandates that all medical practitioners develop a formal, written emergency policy to be implemented when transmission of bodily fluids is suspected or in other cases of possible cross contamination. The Administration suggests a plan comprised of the following:



Exposure Classifications
Exposure classifications include pathogen taxonomy, means of transmission, extent of exposure, and a complete listing of exposure dangers to patient, practitioner, and members of the practice's staff.

Annual Training
All staff members and medical professionals should undergo annual emergency training in case of exposure to contaminated materials or infected bodily fluids. This training will include an annual review of emergency protocols to be implemented as needed.

Protocols might include design of emergency escape routes, contact rescue and emergency services, quarantine infected areas, building evacuation, etc.

Post Exposure Protocols
All affected personnel should be tested as soon after exposure to contaminants as possible. Each exposed individual should undergo a complete medical evaluation and be immunized against Hepatitis B.

Recommended Guidelines Specific to Audiologists

Guidelines will vary from practice to practice;however, the following will serve as a general guide to audiologists and other hearing health professionals (HearUSA, 2005):



  1. Use latex gloves and a disinfecting wipe to remove used ear inserts, otoscope specula, and immittance tips.


  2. To ensure the proper cleaning and disinfection of surfaces, remove all gross contamination and wipe all surfaces with a disinfecting wipe. Wash surface a second time to completely disinfect. Allow to air dry. Surfaces include all examination instruments, earphones, ear cups, examination room countertops, and all patient contact surfaces.


  3. All hearing aids and ear molds should be carefully cleaned and disinfected with disinfecting wipes before an audiologist or staff member handles these items.


  4. Disinfect the hearing aid stethoscope prior to attaching another hearing aid.


  5. Immittance probe tips and wax removal tools should be cleaned using an ultrasonic cleaner and an appropriate disinfectant agent after each use.


  6. Probes and instruments should be rinsed with water after disinfecting.


  7. Disinfecting solution should be replaced after each use.


  8. Instruments, probes, and other non-disposable items must be sterilized if exposed to cerumen, blood, mucous, or other drainage. Sterilization is defined as the destruction of all microbial life. A solution for sterilization must be used and the proper procedure for sterilization must be followed in order to achieve this outcome.


  9. Remove all visible debris from cerumen management tools. Soak in a glutaraldehyde solution for 10 hours.


  10. Rinse instruments and air dry.


  11. Change glutaraldehyde every 28 days.


  12. Properly dispose of otoscope specula, real ear measurement tubes, EAR inserts, and headphone covers.

Conclusions

It is essential that audiologists recognize the significant danger HIV/AIDS presents to their health and the health of their patients. Without the extraordinary precautions described previously, HIV may be spread from patient to audiologist or from patient to patient.

It is simply good practice to assume that each patient is potentially infected with HIV even though they show no symptoms of infection. It can sometimes take years after HIV infection before the immune system is weakened to the point where AIDS symptoms appear.

It is important to reinforce the point that the transmission of HIV from patient to care giver is extremely rare, with fewer than 60 cases identified by the CDC over the past 20 years. It is not a virus that is spread easily when prescribed precautions are undertaken. In fact, HIV is a fragile virus that cannot survive outside the body for very long.

Thus, it falls on audiologists to take all necessary precautions in treating their patients. The hearing professional can not assume that the patient knows about his or her infectious state or that he or she would inform the audiologist of the presence of HIV even if known.

The Code of Ethics of the American Academy of Audiology states that "Individuals shall exercise all reasonable precautions to avoid injury to persons in the delivery of professional services or execution of research" (Part 1, Principle 2, Rule 2B).

Caution, prudence, assumption of infection, and proven clinical methodologies comprise the best course of action for the hearing health care professional. This enables audiologists to deliver required medical and quality of life services in a manner that is safe for the practitioner, staff, and patients.

References

Bankaitis, A.U., Kemp, R.J. (2005). Infection Control in the Audiology Clinic, 2nd Edition. Boulder: Auban, Inc.

Centers for Disease Control and Prevention (CDC). (2006, September). CDC releases revised HIV testing recommendations in healthcare settings. Retrieved September 9, 2007 from www.cdc.gov/hiv/.

Centers for Disease Control and Prevention (CDC). (2007, April 6). Organization of the HIV-1 Virion. Retrieved September 9, 2007 from www.cdc.gov/hiv/topics/basic/index.htm.

Centers for Disease Control and Prevention (CDC). (2002, February). Preventing occupational HIV transmission to healthcare personnel. Retrieved from www.cdc.gov/hiv/resources/factsheets/hcwprev.htm.

Evans, N. (2006). Nursing continuing education, Florida: HIV/AIDS. Retrieved September 9, 2007 from www.nursingceu.com.

Food and Drug Administration (FDA). (1993, April). Protecting patients and professionals from blood-borne diseases. Retrieved September 9, 2007 from www.thebody.com/

HearUSA. (2005). AIDS course 2004-2005. Online CEU course at HearUSA.

Kemp, R. J. & Bankaitis, A. E. (2000). Infection control in audiology. Retrieved September 9, 2007 from audiologyonline.com/articles/.

Sepkowitz, K. A. & Eisenberg, L. (2005). Occupational deaths among healthcare workers. Emerging Infectious Diseases, 11(7), 1003-1008.

Until There's A Cure. (2007). Vital statistics. Retrieved June 6, 2007 from until.org/statistics.shtml.

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Susan Cuttler, AuD, CCC-A

staff Audiologist and Regional Quality Manager

Susan Cuttler, Au.D., is a staff Audiologist and Regional Quality Manager for HearUSA.  She has over 10 years of audiology and hearing aid dispensing experience.


Vickie L. Adams, AuD, CCC-A