Risk of HIV infection through touch?

[Spectre]

Dennis:

Thanks- and kudos- for a long and caring post. I have decided I need to update my Red Cross training to be better prepared to help anyone in need. I can always make a choice on the spot if there are special circumstances.

The Galls' kit is a primo idea. I will order one soonest.

The interaction in threads like this is why I love the The Firing Line. My thanks to our hosts, you really do have the best online forum.

Dennis-
Thanks for the clarification. You will be happy to know that, yes indeed, I have taken a chill pill.

Perhaps we are mincing words, but there is little room for disagreement in the evaluation of risk. There is however much room for discussion on an individuals tolerance to the risk. It is my objective to bring enlightenment and perspective to the risk involved and dissolve some of the disinformation, fear, and paranoia.

You stated that you would only go mouth to mouth with 6 people with very rare exceptions. To believe that is fine. To say that in a class you are teaching shows an extreme bias, which is not based on the facts presented. The reason I wrote the post was to counter that thought.

First let me say that I am purposefully vague about my profession on line. However if any of the regulars here at TFL would like specifics, I would be happy to email you and give the "ad nauseum". I generally like my ideas to be judged on content and not percieved expertise due to my background.

My point in bringing up kissing on a first date is that as well as you think you know someone- you don't. That girl your kissing is a representation of the general public- like it or not. Therefore mouth to mouth with the general public, with some exceptions(see individual described below, hooker, person with track marks or needle sticking out of arm, pulled out of a crack house, etc...), has minimal/negligible risk and even in above settings is smaller than most would think.

I believe I have a very real & experienced perception of the risk of infectious disease. I am neither "brave" or foolhardy(in this case anyway- more often foolhardy than brave). I would be very reticent about a liplock on a dishelved, stinky, yellow(from disease), blood splattered, suppurating ulcer laden individual. In fact, that person is probably not going to recieve a liplock from me, flimsy barrier or not. However given someone who does not have obvious extreme disease(or above circumstances) will recieve my help, flimsy barrier or no, because the risk is low. By the way I would not place much confidence in the barriers, as you know things get pretty sloppy and wet when it gets going- CPR that is. Better than nothing though.

I cannot refute your statistics about the # of EMS dying from disease contracted on the job(nor would I want to- true or not, it serves to remind us to be carefull) because I have no source, you have given none. But regardless, health professionals daily perform invasive procedures and are exposed to splurting fluids which skew the risk from a single mouth to mouth exposure by a good samaritan.

Point taken about the pnuemonia, i.e. be carefull! But poor example. The most common route of transmission of pnuemonia in a healthy individual is your own mouth/nose. Pnuemonia is not typically transmitted people to people. It is caused by viruses and bacteria which colonize your mouth and nose intermittently. Then if there is a breakdown of defenses, it infects you. That is why people in hospitals are not quarantined with pnuemonia(a very few bugs excepted). The vast majority are not "contagious" person to person(for reference- Robbins pathologic basis of disease, Cecils or Harrison's internal medicine texts are a good start). On top of this it is usually the very old and those with other major illness that die of pnuemonia.

Please do not misunderstand, there are bugs you can theoretically catch which have been pointed out previously(HIV, hep B,hep C), from CPR - but risk is very small. TB may be transmissable by CPR(I do not know) but I feel the risk would be small. I base this on the fact TB is not appreciably present in saliva, just sputum from deep within the lungs- in some people. If the TB is dormant(usually the case) the organism is "walled off" and more difficult to transmit. Usually you need to be in close & intimate quarters for a prolonged period of time to get TB. Given all of this I would never perform mouth to mouth on a person I knew for a fact had any of the above diseases. But when you multiply the odds of a person having these diseases with their tranmisabillity- well, you get the idea.

enjoy,

Olazul

BTW all-
I have always had the utmost respect for those who are in the business of helping and protecting. Be it military, LEO's, or EMS(any others?). There is something about choosing a profession to help others in need that is special. We may not always agree on the little details, but this does nothing to take away from the difficult jobs you have chosen. Even though this should go without saying, sometimes it is nice to say it anyway .

Olazul

[Dennis]

All,
Olazul is giving us more reliable, detailed, and SUBSTANTIATED information than I have heard in my eleven years in the field.

Olazul,
Thanks for sharing this information. It could save many rescuer and/or patient lives.

To the discussion:

1. Saying that a lady I would date and liplock is as great a medical risk as liplocking any stranger with no external signs of illness requires a leap of faith I can not make. Let us agree to disagree agreeably on that point.

2. Again, the thorough explanation I give in my class offsets the impression of bias you perceive here. I fully explain the range of opinions and express my viewpoint as just one among those of more experienced medical professionals. Suggesting that I should tout strictly and only the "party line" without sharing clearly identified opinions of experienced personnel will have to be our second point of agreeable disagreement. You have concentrated my attention on the possiblity of bias. I will strive to prevent it.

3. Separating Evaluation v. Tolerance of risk is worthy of much examination! As Holmes might say, "I perceive you have considerable expertise in this area." Perhaps I'm mincing words, but to say there is little room for disagreement in the evaluation of risk requires me to blindly trust the condescending opinion of those whose government job too frequently involves duplicity and "calming the masses".

(Please don't call me paranoid. I watched the government lie for twenty years in military intelligence. Later they lied about Agent Orange, "mystery" illnesses from the Gulf War, the stealing of most of my promised benefits, etc... We can e-mail the rest if you doubt the justifications of my distrust.)

4. MY problem? I just don't trust the CDC! Can you please evaluate for us, or at least comment on, these common stories?

4a. Years ago, CDC said our blood supply was safe and free from HIV/AIDS. The great tennis star Arthur Ashe (sp?) had heart surgery, received HIV-contaminated blood, contracted AIDS, put his loved ones at risk, and died through NO fault of his own. CDC lied about the efficacy of the early AIDS tests.
-- I've been told that more effective tests have virtually eliminated this risk.
-- Many healthcare professionals still recommend the patient donate his own blood, well before surgery, to eliminate this risk entirely. How common is this suggestion? Why?

4b. CDC's heavy-handed blundering into the political maelstrom of gun control really blew their credibility with me. They lied! Sweet & simple. They did not follow scientific methods here, they followed the "party line".

4c. CDC is funded with tax dollars. I truly fear their "fundings" may affect their "findings". (You don't get ahead proving the boss or funding authority is mistaken or telling lies.)

4d. Dr. Fasci of CDC (God, I hope that isn't YOU!) has put out tapes that seemed just a bit devious to me. I do not doubt his expertise, I am uneasey about his motives and worry about a possible hidden agenda.

4e. Too many times, when we discuss communicable diseases, the conversation swerves to the low risk of HIV/AIDS and never addresses the risks of the broad spectrum of communicable diseases!
-- I have been told in EMS over and over that TB is "an aerosol disease" that is "highly contagious". Now you ref heavy sources explaining EMS training was wrong.
-- Hepatitis: One PM said, "Don't worry about AIDS. Worry about hepatitis. That's what will end up killing you." That's verbatim.

5. Again, about the 200 EMTs who die from diseases they caught on duty. Jeez, I sure was hoping someone could prove that included both on and off duty: Motor Vehicle Accidents, falls, heart attacks, etc. etc. I still find "200" hard to believe...

Greatly appreciate the time and effort you're putting in here, Olazul. I also appreciate TFL understanding that appropriate evaluation of these risks is pertinent to many TFL readers.

Spectre,
Bet you never guessed what a can of worms this could be.
Great idea getting the training. First Aid works off duty too. Could save a loved one's life. Could also be good protection in court.

Stay safe, all.
----------
Unite!

[Spectre]

Dennis,

It is my understanding that the HIV virus is not what is detected in AIDS testing. What is detected are the body's antibodies attempting to fight the virus. This would be why it would be possible to have the virus-for some amount of time, at least- without it being detected in the tests.

[Dennis]

The ten o'clock news just came on. One of the top stories is about "an outbreak of bacterial meningitis" at our local high school. The news lady said at least four times that this meningitis can kill a patient and it is very contagious!
Turns out it is ONE case. Olazul is right about sensationalism, disinformation, etc.
The shool sent home a notice with each student telling the parents to have their children screened by a doctor for meningitis.
Sure it's better to be safe, but the news lady leaned forward, her eyes got big, her voice was super-expressive. A bit overdone, methinks.
---------
Unite!

Dennis,
I am happy to say that I am in no way connected to the CDC. I am in fact a simple "foot soldier" hoping to clarify an area where I have something to give.

Let me also say that I never want to be in the position of defending a government agency.

Now lets talk about HIV testing and the blood supply. Most stats are based on a population of 271 million in the U.S..

TESTING- Before being diagnosed with HIV you must have a positive EIA test(which tests for your antibodies to the disease) and a positive western blot. The accuracy of these tests combined is greater than 99%. There is a window where current tests cannot detect the virus. This is because sufficient antibodies do not yet exist. This window is generally 3mos. but can be up to 6. In certain very rare cases this window can last 2yrs or more.
If you are HIV+ and develop certain clinical conditions you are diagnosed with AIDS.

BLOOD SUPPLY- The blood supply is currently tested for HIV1, HIV2, HTLV-1, HepB, HepC, and Syphilllis. There is a window with HIV where the person is infected, and also infectious, where someone could give blood and not have it detected by the screening tests(see above). They do attempt to weed these cases out by denying people who even have risk factors for HIV. At the end of 1992 there were 4,959 cases of transmission by recieving blood/tissue products. All but 21 of those occured before screening started in 1985. To give you an idea of safety, there are around 17 million units of blood products used every year. Studies have shown blood product trasmission rates of HIV between 1/38,000 and 1/300,000. There was a study in 1990 by the CDC and American Red Cross that showed a rate of 1/225,000.

As to other infectious diseases and CPR. Some facts may have been posted already. Those diseases listed are the ones you should be most worried about.

HIV- Roughly .4% of the population in the U.S. is HIV+(.13% is documented HIV+). There have been no reported cases of transmission via CPR. There has only been one case of transmission via french kissing- I think this is believed to be a blood exposure in reality. There is a 1/250(4%) chance of contracting it through a needlestick. There have only been 54 documented and 133 possible cases of transmission of HIV to a U.S. healthcare worker since the inception of testing the disease(84-85?).

TB- I do not know if this has ever been spread by CPR. 10-15 million people are infected in the U.S.(vast majority is pulmonary). On average, only 10% will ever have the active/contagious form of the disease in their lifetime. If the disese is not active, it is not contagious. I have not seen numbers about the # of active cases currently in U.S, but this would be much less than 1-1.5 million( .4-.6% of population) because it would be spread over their lifetime. To spread pulmonary TB one must cough deeply and aerosalize the germ. I do not know if CPR mimics this cough, I doubt it does- really efficiently anyway(it is very difficult sometimes to get a good sputum from patients, even when they try hard). "Really contagious" is relative. If someone had active TB and I was in an ambulance I would treat it as such. But, in the realm of infectius disease, it generally takes a prolonged encounter- like living with someone. The odds of catching the disease from someone with ACTIVE TB, in this circumstance, is 23%. Of course just like the girl at the prom, you might get "lucky" the first time. Plus if you sum up the time you spend with these people as an EMT over 20 years it adds up to a prolonged exposure. The vast majority of TB is treatable with medication. There is a small percentage of drug resistant strains which is on the rise(did not look up the #, but again only 10% of these will ever have active disease)

Hep B- Occurance of less than 2% in population with ~1 million chronic carriers(.4% of pop). You can get this by a person with an acute infection or chronic infection. 6-10% go on to chronic infection, .5-2% go on to liver failure. Transmission has not been documented by kissing although it is present in saliva(you generally get this by sharing needles or sex). There are some cases of infection by bites. I do not know if any cases have been transmitted by CPR. You can get vaccinated against this disease. If you are an LEO, medical personel, still dating, or other dealing with the public in an intimate manner- vaccination is HIGHLY recommended. Make sure you get tested for seroconversion("immunity") after the series. You may have to have another round of shots.

HepC- I screwed up here before, I misread the stats. This is more common than I previously thought, with a prevalence of 1.8%(majority are carriers) in our society. If you get a needlestick there is a 5-10% chance of getting it. Routes of transmission are not well understood at this time other than it is definitely spread by blood contact. It is very bad though as most cases(70%) go on to liver failure and ~85%(or more) will develop carrier status. Treatment is available and is effective 15-30% of the time. No vaccine is available. Good news is that in recent years the incidence of new cases is down 75% due to screening the blood supply.

There are a myriad of other diseases including meningitis which can ruin your day. I would caution against dwelling on diseases too much. There is a saying that 2nd year medical students are all hypochondriacs, as they have learned alot of what can go wrong but have no clinical framework to put it in perspective. One can go mad thinking about germs.

To summarize the encouraging news:

HIV- no known cases of transmission by CPR.
Only 1 case of transmission by kissing.

TB- usually takes a prolonged encounter and really good coughing. BTW don't inhale the patients breath while giving mouth to mouth, turn face away etc.... Majority of cases treatable.

HepB- get vaccinated. No known transmission by kissing. Only .5-2% of infected go on to have liver failure.

HepC- This is bad. lets do the math though. Assume transmission rate of 5%(very high as this is low end for a needlestick). What are the odds that you will perform CPR in general public on a HepC+ person AND that you will contract this disease? .018 X .05 X 100%= .09% = 1/1,000 (we can probably add at least another zero or two here for mouth to mouth which would make it 1/10,000-1/100,000).

Again we are talking about one exposure of mouth to mouth with a person who is not blatently disgusting health/bloody wise. I would caution against placing your mouth on blood- this will increase your risk significantly. While I cannot give you one number, I think you can see that to get a bad disease from this type of exposure would be rare(my opinion, do with the information as you will). There are risks, minimize them when you can.

BTW- I have several messages out to the CDC and elsewhere as to whether there have been reported cases of hepatitis or TB (now HepC also)through giving CPR. Don't hold your breath. If I get it, so will you. Dennis, I will also attempt to get the # of healthcare workers who contract potentially terminal bugs/year.
Also- my #'s and information were derived from a large number of references, some up to 3-5 yrs old. They are very good approximations. I am not publishing, so I have not included the numerous citations. If anyone has a question about a particular fact or # I will tell you where I got it.

I really appologize for the length of the post. You won't have to suffer another long one from me for awhile - promise.

Olazul

This post was revised due to faulty information on Hep C(a little crow, on occaision, is good for the soul) and addition of a couple of clarifying stats elsewhere. No other changes in numbers were made.

[This message has been edited by olazul (edited 01-16-99).]

[Dennis]

Olazul,
Thank you so very much for the time, effort, research, and patience you've exercised here.

I'm going to get around your charge of "bias" by continuing to present (in my classes) the entire spectrum of "willingness to help" options. I will not identify my personal decisions but I will state that I have information "independent" of what I (in TFL) call the "party line" which negates many of the arguments we have heard in the past. (If I may, I'll e-mail later this week for some other info.)

I am astounded at the extreme differences between the material you have presented here on TFL and the information I have heard presented as facts here in the San Antonio/Austin area. (That's not a challenge for God's sake! All I've been given was word of mouth and contradictory. Rest assured I accept your research.)

Whether or not you have proven me "biased" or "wrong" is not the point. You have illuminated a flaw in my attempts to get as many people as possible ready, willing, and able to provide First Aid (including CPR). For that I thank you and assure you I will make changes which I believe you would find suitable.

Hmm, I guess we ought to give the TFL back to everybody else now, huh?

Spectre,
I don't know where you will ever see the subject of "Bloodborne Pathogens" expanded to "Communicable Diseases" as thoroughly as Olazul's last post. I don't know who Olazul is, but I will guarantee you "This ain't no First Aid Instructor!" Best of luck.

Dennis,

Thank you for the repartee'. I learned alot by trying to prove my point (this certainly was not on the top of my head). Good and fervent discussion is one of the spices of life!

The CDC and "powers to be" publish certain guidlines and statistics that are passed on to EMS, LEO's, RN's etc... and these folks are then expected to train the public. Their goal is to sell medical personal, and the public, on the dangers of diseases. Certain statistics are emphasized that will "sensationalize" their cause- IMHO. Paranoia, to a certain extent, is probably healthy in order to keep health professionals alert and minimize the exposure & personal risk. To lose a single EMT or LEO in the line of duty is always tragic. Therefore we all have been trained to view every contact as extremely dangerous(rightfully so?). This keeps the professinals using universal precautions and joe public using rubbers- this saves alot of lives.

In defense of this training is that medicine is complicated and at times the experts don't agree, so the message is generally simplified. Also the CDC does publish pretty complete statistics, just that at times you have to look for them and have the background to put it in perspective. Also keep in mind that people acquire, and die from, disease every day. I hope my post will not relax your guard. There is danger. Make an informed decision.

This training can be counterproductive in the case of CPR and the general public. You have been taught a certain way to keep you "safe". Again the professionals risk and exposure over a career is significant, much different from a single contact by joe public. Therefore all of those hours spent training you to be carefull(plus your considerable experience), greatly outweigh one sentence in the instructors manual about there being a "small risk by CPR"- and usually they only talk about HIV. Any rational person would view this with a certain amount of skepticism.

I am sure you do an admirable job of teaching, and you are to be commended for your effort and time. You are performing as any rational being(sounds like much better actually) in your position would. IMHO- the "powers that be" have brought this on themselves. It is no wonder that only ~50%(I think) of the time does a bystander perform CPR to help.

I would enjoy an email, and your right we should return TFL to others . This entire post is obviously only my personal opinion.

Best regards,

Olazul

All,
Sorry if I am beating a dead horse but I just ran across a recent review of all reported cases of transmission of infectious disease through CPR. The entire article can be found at www.acponline.org/journals/annals/15nov98/infeccpr.htm

The bottom line only 15 cases of transmission of disease by CPR in the last 30yrs. Only a couple of cases were fatal.

Only exception is if you are pregnant you should not perform mouth to mouth because you could contract a normally benign virus(CMV) which is really bad for the fetus.

Olazul

[This message has been edited by olazul (edited 01-25-99).]

[Dennis]

Olazul,

Many thanks. It is printing as I speak (?type?). I will read & heed.


[This message has been edited by Dennis (edited 01-26-99).]