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Medical Issues Related to Caring for Human Immunodeficiency Virus-Infected Children In and Out of the Home

R. J. Simmonds, MD and Stephen Chanock, MD From Pediatr Infect Dis J, 1993;12:845-52 PERSPECTIVES ON HUMAN IMMUNODEFICIENCY VIRUS INFECTIONS. Edited by Philip A. Pizzo, M.D., and Catherine M. Wilfert, M.D.

Publication date: 10/01/1993

Table of Contents

INTRODUCTION

HIV TRANSMISSION
Presence of HIV in body fluids.
Risk of HIV transmission.

PREVENTION OF HIV TRANSMISSION
Home.
Day care.
School.
Athletics.
Management of exposures.

CONCLUSION

REFERENCES

POINT OF CONTACT FOR THIS DOCUMENT:

Tables
Summary of published studies of HIV seroprevalence among persons
Number of HIV-seronegative persons reporting various interactions
Universal precautions to prevent transmission of blood-borne

INTRODUCTION

Like all children human immunodeficiency virus (HIV)-infected children live, play, learn and are cared for in many settings. To protect HIV-infected children and their caretakers, family and playmates from acquiring transmissible infections, those responsible for the care of children should exercise safe infection control practices which include: (1) using recommended procedures to reduce the risk of disease transmission (2) educating children and their care providers regarding transmission of HIV and other infectious agents in a way that neither minimizes nor exaggerates risk; and (3) promoting understanding, confidentiality and compassion for children with HIV infection. To provide guidance for implementing such practices, this article reviews how HIV is transmitted, including the presence of HIV in various body fluids and the risk of transmission after various exposures, and provides specific guidelines for preventing the transmission of HIV in settings where children are cared for.

HIV TRANSMISSION

The serious nature of HIV infection, the presence of HIV in a variety of body fluids and the close contact that children often enjoy with their playmates and caretakers have combined to generate considerable concern about HIV transmission in homes, schools, day-care centers and playgrounds. Unfortunately the lack of understanding of how HIV is transmitted has sometimes led to fear and ostracism of children with HIV infection in situations that present no discernible risk to others. However, the understanding of HIV transmission that has accumulated over the past decade has prompted a rational approach to prevention and in most cases allayed unwarranted fears.

Presence of HIV in body fluids.

The replication cycle of HIV occurs exclusively within infected cells, although HIV may also be found extracellularly when new progeny viruses are released from the cell by budding. HIV preferentially infects and replicates in cells expressing the CD4 molecule, the ligand for viral attachment and subsequent cell entry (1). These cells include a subset of helper T lymphocytes, monocytes and macrophages. Although other cell types may be directly infected, lymphocytes and monocytes are the most important cells involved with HIV transmission for two reasons: (1) the wide distribution of these cells, including in blood and semen; and (2) the relatively high proportion of these cells that may be infected. HIV has been isolated from blood (2), semen (2), vaginal and cervical secretions (3), amniotic fluid (4), breast milk (5), alveolar fluid (6), saliva (7-9), tears (10), throat swabs (11) and cerebrospinal fluid (12). HIV nucleic acid sequences have been detected in urine by polymerase chain reaction (13). Free HIV, not associated with cells, has also been isolated from plasma and cerebrospinal fluid but its contribution to transmission is not well-documented (5,12,14). HIV has not been isolated from stool or vomitus; however, these fluids theoretically may contain HIV if they are contaminated with blood.

The presence of HIV in saliva and tears is particularly relevant to the possibility of HIV transmission to and from children. HIV was detected in saliva from 1 of 71 adults with HIV infection in one study (7), in 3 of 55 in a second (8) and in 8 of 20 in another (9). Nine of 19 throat swabs from HIV-infected children in one study contained HIV (11). Although such swabs are likely to be contaminated with lymphocytes from the tonsils or pharynx, the authors noted that the virus was also found in cell-free supernatants. HIV was isolated from tears from 1 of 7 infected persons (10). Despite these findings no case of transmission attributed to exposure to saliva or tears has been reported.

Risk of HIV transmission.

Several factors may contribute to the efficiency of HIV transmission, including the volume of blood or other inoculum, the titer of HIV in the inoculum (which may be related to the stage of infection), antiretroviral therapy received by the source person, the route of exposure (e.g. intravenous infusion vs. contact with a mucous membrane) and possibly the strain of HIV.

Considerable data have been collected to address the risk of HIV transmission after different routes of exposure. The risk of transmission of HIV to a recipient of a transfusion of HIV-infected blood is at least 95% (15), and the risk of transmission to the newborn of an infected mother is between 13 and 40% (16). HIV transmission through vaginal or anal intercourse or through sharing needles for drug injection has been responsible for the majority of acquired immunodeficiency syndrome cases in the United States (17), but the risk for transmission after single or multiple exposures by these routes is more difficult to quantify (18). HIV transmission has not been reported through inhalation of aerosols, bites from blood-sucking insects or ingestion of food prepared or served by an infected person.

Percutaneous or mucocutaneous blood contact. Prospective studies in occupational settings have estimated the risk of HIV transmission after a single percutaneous exposure to HIV-infected blood to be 0.3% (95% confidence interval, 0.1 to 0.7%) (19-21). In another study HIV transmission was not observed among 408 persons, including 50 children, who sustained needlestick injuries from discarded injection paraphernalia in an area of high prevalence of HIV infection in injection drug users (22).

In addition to those factors affecting transmission discussed previously, factors that may increase the risk of transmission after percutaneous exposure include injury with a hollow bore rather than a solid bore needle, increased depth of needle penetration and penetration through bare rather than gloved skin (23). HIV transmission after cutaneous or mucous membrane exposure to HIV-infected blood has been reported (24-25). However, because HIV transmission has not been reported among health care workers prospectively monitored after more than 2700 cutaneous and 1000 mucous membrane exposures (19-21), the risk of transmission after such exposures is probably much less than that after percutaneous exposure. In these studies the upper bounds of the 95% confidence intervals for the risk of HIV transmission after mucous membrane or skin contact with infected blood are 0.3 and 0.04%, respectively. All of the reported cases of transmission after mucocutaneous exposure have involved blood contact with mucous membranes or with skin that may not have been intact because of eczema or other skin conditions.

"Casual" contact. The risk of HIV transmission from the type of ordinary contact that is common among children in households, schools, day-care centers and other out-of-home child care settings is extremely small. A variety of studies addressing HIV infection among adult and child household members of infected persons have shown that none of more than 1000 household contacts who had no other risk for HIV infection were infected (Table 1). (18,26-41) None of the more than 200 000 cases of acquired immunodeficiency syndrome reported to the Centers for Disease Control and Prevention have been attributed to such contact.

Several of the household studies documented no HIV transmission despite the presence of household activities that might be expected to involve contact with blood or other body fluids (Table 2). Because HIV has been isolated from saliva (7-9), biting and kissing have been considered as exposures of particular concern. Although biting is common among young children (42), bites that result in blood contact are probably rare. Biting has been suggested, although not proved, as a possible mode of HIV transmission in two brief case reports (43-44). In the first report the sibling of a child infected with HIV by a transfusion was found to be infected, and the only exposure that was described was a bite that did not break the skin. In the second case a woman who possibly had other risk factors for HIV infection became infected around the time that she was bitten by her HIV-infected sister, who had blood in her mouth at the time of the bite. In contrast four studies of a total of 22 persons who were bitten by HIV-infected persons found that none of the bitten persons became infected (41,45-48). In one of these studies (47) 30 staff members were bitten, scratched or spat upon by an institutionalized person with HIV infection and aggressive behavior; none had seroconverted after 4 to 6 months of follow-up. In addition Rogers et al. (41) documented lack of HIV infection in 7 persons who bit HIV-infected children. Although data addressing the risk of HIV transmission from biting are limited, such transmission appears extremely uncommon.

One study suggested that blood contamination of saliva as a result of tooth brushing or passionate kissing might create a risk of HIV transmission (48). However, kissing has not been demonstrated to be a mode of HIV transmission.

These data indicate that HIV is rarely transmitted in circumstances related to children's care, education and normal play activities. Consequently the presence of HIV infection should not restrict children from participating in day care and school in most cases, as long as appropriate precautions are routinely taken and other health conditions do not interfere.

PREVENTION OF HIV TRANSMISSION

Knowledge of the risk of transmission of HIV and other blood-borne pathogens led to the development of precautions to prevent percutaneous, mucous membrane and skin exposures to blood-borne pathogens, including HIV (49-51). The principles of universal precautions include the use of safe practices and appropriate barrier precautions when contact is anticipated with blood or with body fluids that may transmit blood borne pathogens (Table 3). The most likely of these to be present in child care settings are blood and body fluids containing blood. Under universal precautions all patients are considered to be potentially infected with a blood-borne pathogen because the patient's infection status is often unknown.

Detailed recommendations regarding universal precautions have been published (49-51). The principles underlying universal precautions are applicable in health care and other settings, such as schools, day-care centers, playing fields and the home.

To prevent percutaneous exposures to blood-borne pathogens, including HIV, injuries with needles or other sharp items contaminated with blood must be avoided. Strategies to avoid such injuries include handling needles and other sharp instruments safely (e.g. not recapping, bending or breaking needles; disposing of sharp items in puncture-resistant containers), using self-sheathing needles or other mechanical devices shown to reduce the risk of injury to health care workers and limiting unnecessary use of needles. To prevent skin and mucous membrane exposures, appropriate barrier precautions should be used when contact with blood or other body fluids is anticipated. Gloves should be used for touching blood, body fluids for which universal precautions apply, mucous membranes and nonintact skin of all patients and for handling items soiled with blood or body fluids for which universal precautions apply (Table 3). Hands should be washed immediately after contact with blood and after removal of gloves. Masks, protective eyewear and gowns should be used when splashes to the face or body may be expected. Nondisposable instruments or devices that enter sterile tissue or through which blood flows should be sterilized after use; under no circumstances should needles, syringes or other such equipment be used for more than one person without being sterilized. Finally blood and blood-containing fluids spilled on environmental surfaces should be promptly removed and contaminated surfaces cleaned with bleach (diluted 1:10 to 1:100, depending on the amount of organic material present) or other Environmental Protection Agency-approved disinfectant; gloves should always be worn during cleaning and decontaminating procedures.

Although universal precautions do not apply to human breast milk or saliva, some precautions against exposure to these fluids may be necessary. Because breast feeding has been implicated in the transmission of HIV infection from mother to infant, the use of gloves should be considered in situations, such as milk banks, where exposure to human breast milk is extensive. Gloves should also be worn for contact with oral mucosa, for endotracheal suctioning and for other oropharyngeal procedures that involve exposure to blood-contaminated saliva. Gloves do not need to be worn when feeding a child with bottled formula or breast milk or cleaning oral secretions that do not contain visible blood. However, gloves should be worn when changing diapers that contain bloody stools and when handling other body fluids with visible blood. Gloves may also be necessary to prevent transmission of enteric and other pathogens, and of course hands should always be washed immediately after handling any body fluid, whether or not gloves are worn.

Home.

Children with HIV infection should be able to benefit from participation in all ordinary activities of home life. Safety and well-being can be enhanced by educating families of HIV-infected children about how HIV is transmitted. Such education should both emphasize ways to prevent transmission by minimizing contact with blood and other body fluids and promote ordinary family interactions by alleviating unfounded concerns about HIV transmission.

Four reports have suggested the possibility of HIV transmission during the provision of health care at home (52-55). With the increasing use of home parenteral therapy for HIV infection and other conditions, ensuring appropriate infection control practices in all homes in which such therapy is provided is essential (56,57). In particular persons providing medical and nursing care in the home should receive training in infection control practices; have adequate supplies of gloves, needles and puncture-resistant containers; and take precautions to exclude young children from situations where exposure to blood or sharp objects is possible (e.g. during medical procedures performed on others). The puncture-resistant containers should be kept out of the reach of children.

Day care.

No cases of HIV transmission in out-of home child care settings have been reported. Furthermore the low risk of HIV transmission after household exposure to persons, including children, with HIV infection argues against a significant risk of HIV transmission through the types of contact that occur routinely in child care settings. Therefore the Centers for Disease Control and Prevention, the American Academy of Pediatrics and the American Public Health Association have recommended that children with HIV infection be allowed to attend child care in most cases (58-60). Several considerations should be weighed when deciding about enrollment, including the child's propensity for aggressive biting, the child's likelihood of having uncontrollable bleeding episodes, the presence of oozing skin lesions that cannot be covered and the child's immune function. The child's physician should be directly involved with the decision about whether to enroll a child in day care.

The confidentiality of children attending child care must be protected to the greatest extent possible. A child's HIV status should be disclosed only with the informed consent of the parents or other legal guardians and then only to those who need such knowledge to care properly for the child. In general at least one staff member should be aware of the child's immunodeficiency so that potential exposures to blood-borne or other infections can be managed appropriately.

Because child care settings may contain children who are unknowingly infected with HIV or other blood-borne infections, staff members should adopt routine procedures for handling blood and other body fluids of all children. They also should be diligent in recognizing and managing exposures of all children to such common childhood infections as varicella and such serious infections as tuberculosis. The staff should notify the local health department and parents of all children of any exposures to tuberculosis, measles or other reportable communicable disease. Children who are immunosuppressed because of HIV infection or other conditions may be particularly susceptible to infection with some pathogens (e.g. Cryptosporidium) and to serious illness if infected with others (e.g. respiratory syncytial virus, varicella, Salmonella). Staff should be alert to exposures to these types of infections and notify all parents if such an exposure occurs. Finally to prevent transmission of vaccine-preventable infections, immunizations should be current for all children attending day care.

Toys should be kept clean and may be shared among all children. To prevent transmission of any pathogens, it has been recommended that toys that are mouthed routinely be cleaned and disinfected before being used by another child (60). Other toys should be cleaned and disinfected if they become contaminated by body fluids (e.g. blood, stool, vomitus).

To prevent the transmission of infections from child care workers to children, work restrictions may be necessary for workers who have certain infections (60). Day-care center staff with HIV infection who adhere to infection control precautions may care for children unless they have conditions that would place them at increased risk of transmitting infection, such as pulmonary tuberculosis or open skin lesions that cannot be covered (60).

In some communities day-care centers designed to meet the special medical, developmental and other needs of children with HIV infection may be available. These centers may afford a supportive environment for children with HIV infection but are not intended to be used to exclude these children from other daycare centers.

School.

The well-publicized instances of discrimination against children with HIV infection at school are particularly unfortunate because they cause unnecessary pain and anguish for children and their families while propagating the unfounded notion that HIV is likely to be transmitted in schools. No cases of HIV transmission in school have been reported, and current epidemiologic data do not justify excluding children with HIV infection from school or isolating them in school to protect others. Children with HIV infection should be able to participate in all school activities with the same considerations as other children, to the extent that their health permits. Guidelines for the education of children with HIV infection (58-61) and for the development of school policies (62) have been published.

Like other children with special health needs, children with HIV injection benefit from educational programs that provide necessary medical services, such as management of emergencies and administration of medications. Moreover, a sound educational program can help create a more accepting environment for children with HIV infection. Evaluating each child's medical and educational needs on a case-by-case basis, with ongoing communication among the family, health care providers and school health staff, can optimize benefits to the child (63). All educational institutions should have a policy regarding students and staff who have HIV infection.

Until children with HIV infection are no longer stigmatized and discriminated against, confidentiality will remain an important issue. The right to privacy must always be protected in accordance with state and local law. The persons aware of the child's HIV infection should be limited to those who need such knowledge to care for the child. In most cases such persons include the school medical advisor, school nurse and teacher. Because the administration of HIV-related medications in school may compromise confidentiality, the infected child should be encouraged to self-administer medications, with the approval of the school nurse or medical advisor when possible. Children can use nearly all services for children with special needs without revealing their HIV status.

Because blood exposures from fights, unintentional injuries, nosebleeds, shed teeth, menstruation and other causes may occur at school, all schools should be prepared to handle blood and blood-containing body fluids using the principles of universal precautions. Supplies of gloves, disposable towels and disinfectants should be readily available. All schools should institute policies for managing blood exposures, and all staff, including teachers, athletic coaches, cafeteria workers and maintenance workers, should be educated in infection control.

Athletics.

Many children and adolescents enjoy sports; one-third of girls and one-half of boys in United States high schools participated on varsity or junior varsity teams in 1990 (64). Participation in some contact sports may increase a child's risk of exposure to blood: forceful contact with hard surfaces, equipment, or other players may result in laceration or abrasion; and close player-to-player contact may lead to direct exposure to another person's blood. Nonetheless the risk of HIV transmission during sports is probably very low. Despite the large number of persons participating in contact sports, only one case of HIV transmission attributed to sports has been reported worldwide (65). In this case transmission was reported to have resulted from a collision that produced lacerations with copious bleeding and exchange of blood during a soccer match, but other modes of transmission for the young man who became infected were not satisfactorily excluded (65-66). An outbreak of hepatitis B virus transmission during contact sports has been reported among high school sumo wrestlers (67).

The American Academy of Pediatrics, the National Collegiate Athletic Association, the National Football League and the World Health Organization have published guidelines addressing HIV infection and sports (68-71). Athletes with HIV infection should be permitted to participate in competitive sports at all levels. However, because of the potential risk to the athlete's own health and the theoretical risk of HIV transmission to others during contact sports, athletes with HIV infection interested in participating in contact sports such as wrestling, boxing or football should be evaluated on a case-by-case basis. This evaluation should consider such factors as the likelihood of blood contact (e.g. intramural touch football vs. varsity tackle football), the athlete's propensity to bleed (e.g. thrombocytopenia) and the presence of skin lesions that cannot be covered during active sport. The American Academy of Pediatrics recommends that an HIV infected athlete considering a sport such as football or wrestling should be informed of the theoretical risk of transmission to others and be encouraged to consider another sport (68). The athlete's physician should be directly involved in the decision regarding participation.

The right to privacy should be protected; an athlete's HIV status need not be revealed to other players. On the playing field contact by trainers and first aid providers with blood should be minimized by following appropriate infection control measures, including promptly cleaning blood from skin with soap and water and from surfaces such as wrestling mats with bleach solution diluted 1:10 to 1:100; immediately controlling bleeding by covering abrasions, lacerations or other lesions; using gloves or other barriers when attending to wounds; and avoiding reuse of sponges, water or other first aid items to care for injuries involving blood. Finally the leadership role enjoyed by many coaches may provide them the opportunity to educate athletes and others about the risk of HIV transmission through unprotected sex and through the sharing of needles or syringes used to inject anabolic steroids or other drugs (72,73).

Management of exposures.

The United States Public Health Service has published detailed recommendations for managing occupational exposures to blood and body fluids that may contain HIV (74). Evaluation of an exposure should include determining the likelihood that the exposing fluid contains HIV, the volume of fluid and the route of exposure. If the source person is known to be infected with HIV or refuses testing, the exposed person should be evaluated for HIV infection as soon as possible and if seronegative should be retested periodically for a minimum of 6 months. During the follow-up period the exposed person should seek medical evaluation for any acute illness; refrain from blood, semen and organ donation; and take measures to prevent sexual transmission of HIV.

Blood or body fluid exposures also may occur in the home or in other nonoccupational settings (e.g. needlestick injury by family member providing home medical care). Although not specifically addressed in these recommendations, the management of nonoccupational exposures should be based on the same principles as that of occupational exposures, and access to information regarding postexposure management should be available to persons outside of medical centers (74).

CONCLUSION

Children with HIV infection deserve the same rights to health care, privacy, education and social interactions that other children enjoy. If appropriate guidelines are followed these rights can be respected without additional risk to the health or safety of the child or others. Educated and caring health care professionals can both provide appropriate health care to these children and help the community better to understand HIV infection and the needs of infected children.

Because recommendations may change, care providers should regularly consult medical literature and specifically follow updated recommendations of the American Academy of Pediatrics, the Centers for Disease Control and Prevention and other organizations.

Accepted for publication June 4, 1993.

From the Division of HIV/AIDS, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA (RJS), and the Infectious Disease Section, Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD (SC).

Key words: Human immunodeficiency virus infection, human immunodeficiency virus transmission, children, infection control, day care, education, athletics, home.

Address for reprints: Dr. R.J. Simmonds, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-45, Atlanta, GA 30333.

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Table 1

TABLE 1. Summary of published studies of HIV seroprevalence among persons having only household contact with HIV-
         infected persons in the United States and Europe
====================================================================================================================
 Reference           No.of Index     No.of Persons     No. HIV-         No. of        Year of       Location of
                      Persons        with Contact *    Positive      Persons-years     Study          Study
                                                                      of Contact
-------------------------------------------------------------------------------------------------------------------
Redfield et al.(26)     2 (0) +          3 (3)             0              N/A         1983-84         United States
Kaplan et al.(27)       4 (4)            4 (0)             0               12         1983-84         Newark
Jason et al.(28)       34 (N/A)         62 (N/A)           0              N/A         1983-84         United States
Berthier et al.(29)    24 (24)          70 (70)            0              146         1983-85         France
Fischl et al.(30)      45 (0)           29 (0)             0               58         1983-85         Miami
Melbye et al.(31)      14 (N/A)         26 (N/A)           0              N/A         1984            Denmark
Lawrence et al.(32)    29 (24)          39 (13)            0               65         1984            St. Louis
Brettler et al.(33)   N/A               51 (N/A)           0               95         1984-87         Massachusetts
Friedland et al.(34)   90 (0)          206 (155)           0              320         1984-87         New York City
Biberfeld et al.(35)   29 (20)          56 (20)            0              111         1985            Sweden
Romano et al.(36)      43 (N/A)         69 (14)            0              N/A         1985            Italy
Lusher et al.(37)     183 (N/A)        304 (>=22)          0              605         1985-89         United States
Muntean et al.(38)     18 (18)          45 (N/A)           0              N/A         1986 ++         Austria
Madhok et al.(39)      10 (N/A)         23 (N/A)           0              N/A         1986 ++         Scotland
Peterman et al.(18)    88 (0)           63 (19)            0              142         1988 ++         United States
Berntorp et al.(40)    19 (N/A)         21 (N/A)           0               42         1988            Sweden
Rogers et al.(41)      25 (25)          89 (10)            0              115         1990 ++         United States
  Total               657 (115)       1167 (326)           0 &           1711
-------------------------------------------------------------------------------------------------------------------
 * Excludes persons with other risks for HIV infection (e.g. sex partners of index persons, children born to mothers with
   HIV infection, injection drug users).
 + Numbers in parentheses, number of children. Children generally defined as <=18 years old, age cutoff different or not
   specified in some studies.
++ Year of publication of report.
 & Rate of infection in persons with only household contact = 0 of 1711 person years of contact (95% confidence interval,
   0 to 0.18 of 100 person years of contact).
 @ N/A, information not available
======================================================================================================================

Table 2

TABLE 2. Number of HIV-seronegative persons reporting various interactions
         with HIV-infected household contacts in three studies

==============================================================================
                           No. in Study with Household Interaction
                         -----------------------------------------------------
                         Rogers (41)   Friedland (34)   Lawrence (32)   Total
-----------------------------------------------------------------------------
Slept together               27             78                           105
Bathed together              25             21                            46
Kissed on lips               52             36                            88
Shared comb                  49            134                           183
Shared toilet                19            192                           211
Shared toothbrush            14             27                            41
Shared eating utensil        39             80                           119
Gave injections               4                              25           29
==============================================================================

Table 3

TABLE 3. Universal precautions to prevent transmission
         of blood-borne pathogens
===========================================================================
                   HAND WASHING IS NECESSARY AFTER PHYSICAL
                         CONTACT WITH ALL PATIENTS

Body fluids to which universal precautions apply

    - Blood
    - Any body fluid containing visible blood
    - Semen and vaginal secretions
    - Body tissues
    - Cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic
      fluid

Body fluids and procedures for which hand-washing is sufficient for
  preventing transmission of blood-borne pathogens (unless fluid contains
  blood) *

    - Urine
    - Stool
    - Vomitus
    - Tears
    - Nasal secretions
    - Oral secretions
    - Diaper changing

Special precautions for other body fluids (see text)

    -  Breast milk
    -  Saliva
-------------------------------------------------------------------------
 * Gloves may be required to prevent transmission of other pathogens.
===========================================================================


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