Correspondence

Occupational Exposure to Blood among Medical Students

N Engl J Med 1997; 336:966-968March 27, 1997

Article

To the Editor:

I have two comments to make about the interesting Sounding Board article by Tereskerz et al. in the October 10 issue.1

First, the prompt initiation of prophylaxis (within one to two hours) after percutaneous exposure to the human immunodeficiency virus (HIV)2 requires knowledge on the part of both students and employees of the importance of immediate treatment. It also requires their willingness to leave the site of their clinical duties to obtain counseling and access to prophylactic medications. We have tried to remove these barriers by activating a 24-hour pager that students and employees are asked to call promptly after receiving a contaminated injury. We chose the number 6824 (corresponding to the letters OUCH) for this pager. The pager is carried by an experienced staff member to ensure that consistent and accurate information is provided. Students and employees who sustain contaminated injuries can thus speak directly to someone with accurate knowledge of the risk associated with contaminated injuries and the management options within 5 to 10 minutes of the injury without having to leave the work site. We have found this system to be useful in helping us reach people who receive contaminated injuries. In addition, it gives the students and employees the feeling that the institution cares about them — a useful benefit in this time of frequent litigation. As with individual physicians, institutions with a good bedside manner face a lower risk of litigation than they might otherwise.

I also wish to comment on the authors' suggestion that workers' compensation laws be amended to include medical students. Such a task would be much more difficult than the article implies. Medical students are neither a strong political lobby nor a group that engenders a great deal of public sympathy. Neither the federal nor any state government is likely to include medical students in workers' compensation programs. Furthermore, the issue can become more complex very quickly. If medical students are covered, why not nursing students, dental students, allied health students, or students in other fields? The alternative of improving health and disability insurance for medical students is much more realistic than including them in workers' compensation programs.

I applaud the authors for this timely article and hope it stimulates more dialogue on this important topic.

Stephen F. Wintermeyer, M.D., M.P.H.
Indiana University Medical Center, Indianapolis, IN 46202

2 References

1. 1

   Tereskerz PM, Pearson RD, Jagger J. Occupational exposure to blood among medical students. N Engl J Med 1996;335:1150-1153
   Full Text | Web of Science | Medline

2. 2

   Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIVMMWR Morb Mortal Wkly Rep 1996;45:468-480
   Medline

To the Editor:

Tereskerz et al. raise a number of important issues in their timely article concerning the occupational exposure of medical students to blood-borne pathogens such as HIV, hepatitis B, and hepatitis C.1 However, their recommendation that students not perform invasive procedures on patients known to be infected with these agents is problematic. In many instances, neither the patient nor the physician is aware of the infection,2 and an emphasis on patient status to guide practice seems inadvisable. Would the authors favor screening patients for blood-borne pathogens before allowing them to have contact with medical students? Perhaps more attention should be focused on other factors that may increase the risk of transmission, such as the patient's mental status and subsequent ability to cooperate.

Similarly problematic is the authors' suggestion that students demonstrate proficiency by serving as “volunteers under supervision.” As compared with the general population, health care workers have been shown to have higher rates of infection with pathogens such as hepatitis B.3 Although few data are available on the prevalence of blood-borne pathogens among medical students during the early phases of their training, some students will have been infected as a result of previous exposure. Any volunteer system would have to include safeguards to protect the confidentiality of these infected students who may feel obligated to “volunteer.”

Preventing infection of health care workers, including medical students, is a goal that deserves attention. As the article by Tereskerz et al. makes clear, however, a myriad of ethical and logistic issues will need to be addressed in the process.

M. Anita Barry, M.D., M.P.H.
Boston Public Health Commission, Communicable Disease Control, Boston, MA 02118

3 References

1. 1

   Tereskerz PM, Pearson RD, Jagger J. Occupational exposure to blood among medical students. N Engl J Med 1996;335:1150-1153
   Full Text | Web of Science | Medline

2. 2

   Kelen GD, DiGiovanna T, Bisson L, Kalainov D, Sivertson KT, Quinn TC. Human immunodeficiency virus infection in emergency department patients: epidemiology, clinical presentations, and risk to health care workers: the Johns Hopkins experience. JAMA 1989;262:516-522
   CrossRef | Web of Science | Medline

3. 3

   Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep 1990;39:1-26
   Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Dr. Wintermeyer that amending workers' compensation laws will be difficult. This should not preclude attempts to amend legislation to protect students. The International Health Care Worker Safety Center at the University of Virginia is committed to the advocacy of such change and will work toward that end. Although students have limited influence as a political lobby, physicians — represented by the American Medical Association, the Association of American Medical Colleges, and other medical associations — can participate in efforts to bring about change.

Disability insurance and health insurance offer an immediate solution for students. However, long-term workers' compensation would provide support for students with the additional advantage of addressing the institution's liability risk.

Dr. Wintermeyer is correct in asking why other types of students should not be covered. Exploring the legal nuances that apply to each type of student was beyond the scope of our article but should indeed be considered in the pursuit of any legislative amendments.

We applaud the development of a “hot-line” pager to provide immediate access to assistance after an exposure. An important aspect of this program is that students receive the same post-exposure follow-up care as employees.

We agree with Dr. Barry that strict adherence to the principles of universal precautions is essential during training and that it is not always known whether a patient or volunteer harbors a blood-borne pathogen. Excluding persons known to be infected will further reduce the risk of exposure to infectious agents. This selective policy does not exclude students from the clinical environment but lowers their risk until they become proficient.

We concur that students serving as volunteers also pose a potential infection risk. However, an important advantage of using student volunteers is that training can be conducted under controlled conditions on cooperative subjects. Student “volunteers” should be able to disqualify themselves without having to disclose the reason, in the same manner as blood donors, if they are potentially infectious or may suffer adverse consequences, such as syncope.

Many ethical and logistic issues remain. We hope that this dialogue will stimulate efforts to create safer working environments and ensure adequate compensation for the few who become infected as a consequence of learning their profession.

Patricia M. Tereskerz, J.D., Ph.D.
Richard D. Pearson, M.D.
Janine Jagger, M.P.H., Ph.D.
University of Virginia Health Sciences Center, Charlottesville, VA 22908