Download Minnesota Department of Health Guidelines For School Placement

Minnesota Department of Health Guidelines
For School Placement of Children and Adolescents
Infected with Human Immunodeficiency Virus (HIV)
Revised: July 2002
Statement of the Issue
School-aged children who are infected with human immunodeficiency virus (HIV) reside in
Minnesota. Therefore, a statewide policy on school placement of HIV-infected children and
adolescents is needed. To avoid unwarranted fear and confusion by students, parents, teachers
and school administrators, the following guidelines have been developed. These
recommendations are based on current scientific data regarding the transmission of HIV and
apply to all infected school-age children and adolescents in kindergarten through grade twelve.
Separate guidelines have been developed for the placement of HIV-infected children in
preschool and childcare settings.
Background
In the United States, 90% of pediatric HIV infection has been acquired by maternal-to-infant
transmission. Currently, almost all cases of HIV infection in children younger than 13 years
have been acquired perinatally. It is also possible for children to acquire HIV infection
postnatally through the ingestion of breast milk.1 The 1994 Centers for Disease Control and
Prevention (CDC) recommendation that HIV-infected pregnant women receive antiretroviral
medication to prevent perinatal transmission and the 1995 recommendation that all pregnant
women be screened for HIV infection has made perinatal transmission of the virus in the United
States a rare occurrence.2,3 However, not all mothers are screened for HIV infection, drug
prophylaxis to prevent perinatal transmission occasionally fails, and a few children with HIV
infection immigrate to Minnesota.
HIV has been recovered from blood and other body fluids, including cerebrospinal fluid, human
milk, semen, vaginal and cervical secretions, amniotic fluid, saliva, tears, and synovial, pleural,
peritoneal, and pericardial fluids. Other body fluids and secretions that are visibly contaminated
with blood may contain HIV and pose a risk of transmission. All body fluids containing HIV
pose a theoretical risk, but some (e.g., tears, urine, and stool) have not been implicated in
transmission of the virus. A sufficient quantity of virus and a portal of entry that permits
infection of host cells are required for transmission.
The three recognized settings in which HIV transmission occurs are as follows:



from a mother with HIV infection to her infant during pregnancy, delivery, or
breastfeeding;
direct inoculation of infected blood or blood-containing tissues, including transfusion,
transplantation of organs or tissues, and use of contaminated needles or penetrating
injuries with needles or sharp objects contaminated with blood; and
between sex partners by contact with infected semen, vaginal or cervical secretions, or
blood with mucosal surfaces.1
Transmission of HIV has not been shown to occur in schools or childcare settings4,5 and several
studies have failed to find casual transmission of HIV in other settings.6,7,8 Transmission of HIV
from infected children or infected adults to uninfected persons during routine daily activities,
such as household care, is rare and is likely to be related to unrecognized and unprotected
exposure to blood or infectious body fluids.9,10,11
MDH Position

Students infected with HIV can be allowed to attend school, before and after-school
programs, and to participate in sports in an unrestricted manner, with rare exceptions,
because the risk of transmission of HIV in these settings appears to be negligible. No
cases of HIV transmission occurring in a school setting have been reported.

The presence of HIV-infected students in school does not constitute a significant threat to
other students or staff. In addition, for most HIV-infected students, the benefits of
unrestricted school attendance outweigh the risks they may have of acquiring potentially
serious infections in that setting.
Confidentiality
Knowledge of a student’s HIV status is not required for school entry. If a school is notified of a
student with HIV infection, the number of persons aware of the infection should be limited to
those who need such knowledge to care for the child.
Evaluating Potential Risk
Some HIV-infected students may pose more of a potential risk to others. Students who have
medical conditions, such as oozing skin lesions that cannot be covered or bleeding disorders that
may result in spontaneous bleeding (such as severe thrombocytopenia) or children with
behavioral issues such as frequent biting behavior may pose an increased risk of exposing others
to blood or high-risk body fluids. Such children may require a more restricted environment.
Although biting is a possible mode of transmission, the risk of such transmission is believed to
be extremely low.
For infected students with such medical or behavioral conditions, individual judgments need to
be made regarding placement of those students in an unrestricted school setting. The
Commissioner of Health may convene an Advisory Committee to evaluate any such student on
an ad-hoc basis. The committee will consist of several members and will include the State
Epidemiologist (and other MDH representatives as needed), representatives from the Minnesota
Department of Children, Families, and Learning, a pediatrician with expertise in infectious
diseases (including care of HIV-infected patients), and the child’s primary care physician.
If the committee determines that a specific student may pose an increased risk or exposure to
others, additional discussions will be held. These discussions may include the superintendent of
the school district, the primary teacher of the student, and the designated school nurse for the
school in which the student is to be enrolled. The State Epidemiologist will chair the committee
and will be responsible for convening the committee as necessary. The committee’s
recommendations to the Commissioner on each student’s placement will be based on the
likelihood that others may be exposed to blood or high-risk body fluids from that student. The
committee will weigh the risks and benefits to both the HIV-infected student and to others. The
committee will re-evaluate such students periodically as deemed necessary by the State
Epidemiologist.
General Infection Control Principles
Some students may be unknowingly infected with HIV or other bloodborne pathogens such as
hepatitis B (HBV) or hepatitis C (HCV) viruses. Alternatively, the student’s parents/guardians
may choose (as is their right) not to inform the school of such infection. These pathogens may
be present in blood or other high-risk body fluids. Thus, all schools, regardless of whether
students with HIV infection or other bloodborne pathogens are known to be in attendance, must
develop and adopt routine procedures for the safe handling of blood, blood containing secretions
and high-risk body fluids.
Healthcare workers use “Standard precautions” in the care of all patients.12 The use of Standard
precautions indicates that healthcare workers are operating under the assumption that all patient
blood, secretions and excretions may be infectious, whether known to be or not. The general
principles of Standard Precautions apply in the school setting as well. These precautions, which
include the use of barriers such as gloves to prevent skin or mucous membrane exposure to blood
should be observed. Gloves should be used when there is any possibility of exposure to blood or
high-risk body fluids. Hands (and other parts of the body) should be washed immediately after
contact with blood even when gloves have been worn.
Federal and Minnesota Occupational Safety and Health Administration (OSHA) standards
require education about bloodborne pathogens and how to avoid exposure to blood or body fluids
for those employees who may be exposed.13,14 Gloves should be readily available in the event
that an injury with bleeding occurs which requires intervention or any time there is a potential for
exposure, such as cleaning a blood spill.
In addition, schools are required have a protocol in place to ensure that employees and students
who sustain significant occupational exposures to blood or body fluids have access to prompt
evaluation and treatment of such exposures as well as counseling and follow-up.15
Surfaces soiled with blood or body fluids should be promptly cleaned and then disinfected (with
at least 30 seconds of contact) with disinfectants, such as a household bleach (sodium
hypochlorite) solution that is freshly mixed daily and diluted 1/4 cup bleach to one gallon water.
Because sodium hypochlorite can be inactivated by blood and other substances, it is
recommended that visibly soiled surfaces by cleaned prior to using bleach. Disposable towels or
tissues should be used whenever possible and disposed of properly, and mops should be rinsed in
the disinfectant.
HIV-infected students may have compromised immune systems. Immunocompromised persons
are at increased risk of developing severe complications from infections such as pnuemococcal
infections, chickenpox, cytomegalovirus, tuberculosis, herpes simplex, and measles. Students
may have a greater risk of encountering these infectious agents in school than in the home.
Thus, assessment of the risk of unrestricted school attendance for the immunocompromised
student is best made by the student’s physician who is aware of his/her immune status. Schools
should have a protocol for informing families when a significant communicable disease (e.g.,
chickenpox, etc.) has been identified in a student. The families of students who are at risk for
complications from such infections may then consult with their child’s physician about any
necessary actions to take after an exposure.
References
1. American Academy of Pediatrics. Issues Related to Human Immunodeficiency Virus
Transmission in Schools, Child Care, Medical Settings, the Home, and Community
(RE9838) 1999.
http://www.aap.org/policy/re9838.html
2. Centers for Disease Control and Prevention (CDC). Recommendations of the U.S.
Public Health Service Task Force on the Use of Zidovudine to Reduce Perinatal
Transmission of Human Immunodeficiency Virus. MMWR 1994; 43:1-20.
3. Centers for Disease Control and Prevention (CDC). US Public Health Service
Recommendations for Human Immunodeficiency Virus Counseling and Voluntary
Testing for Pregnant Women. MMWR 1995; 44:1-15.
4. Centers for Disease Control and Prevention (CDC). Perspectives in Disease Prevention
and Health Promotion Update: Universal Precautions for Prevention of Transmission of
Human Immunodeficiency Virus, Hepatitis B Virus, and Other Blood-borne Pathogens in
Health Care Settings. MMWR 1988; 37:377-82, 387-88.
5. American Academy of Pediatrics. Human Immunodeficiency Virus Infection.
Report of the Committee on Infectious Diseases, Red Book 2000: 325-350.
6. Minnesota Department of Health (MDH). Summary of Nine Studies That Demonstrate
Lack of HTLV-III Transmission Among Family Member Contacts of HTLV-III Positive
Persons. MDH Disease Prevention and Control Newsletter, Vol. 12, No. 8, October
1985.
7. Rogers, M. F., White, C. R. Sanders, R., et al. Lack of Transmission of Human
Immunodeficiency Virus From Infected Children to Their Household Contacts.
Pediatrics 1990; 85:210-14.
8. Friedland, G., Kahl, P., Saltzman, B., et. al. Additional Evidence for Lack of
Transmission of HIV Infection by Close Interpersonal (Casual) Contact. AIDS 1990;
4:639-44.
9. Centers for Disease Control and Prevention (CDC). HIV Transmission Between Two
Adolescent Brothers With Hemophilia. MMWR 1993; 42:948-51.
10. Fitzgibbon, J. E., Gaur, S., Frenkel, L. D., et. al. Transmission From One Child to
Another of Human Immunodeficiency Virus Type 1 With a Zidovudine-resistance
Mutation. New England Journal of Medicine 1993; 329:1835-41.
11. Belec, L., Mohamed, A. S., Trutwin, M. C., et. al. Genetically Related Human
Immunodeficiency Virus Type 1 in Three Adults of a Family With No Identified Risk
Factor for Intrafamilial Transmission. Journal of Virology 1998; 72:5831-39.
12. Garner, J.S., Hospital Infection Control Practices Advisory Committee (HICPAC).
Guideline for Isolation Precautions in Hospitals. Infection Control and Hospital
Epidemiology. 1996; 17:53-80. (See Attachment 1)
13. OSHA. Occupational Safety and Health Administration/Bloodborne Pathogens.
http://www.osha-slc.gov/SLTC/bloodbornepathogens/index.html
14. Centers for Disease Control and Prevention (CDC). Exposure to Blood: What Healthcare
Workers Need to Know.
http://www.cdc.gov/ncidod/hip/BLOOD/exp_blood.htm
15. Centers for Disease Control and Prevention (CDC). Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to Hepatitis B, Hepatitis C,
and HIV and Recommendations for Postexposure Prophylaxis. MMWR June 29, 2001;
50(RR11): 1-42.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
Other Related American Academy of Pediatrics Policy Statements
1. Education of Children With Human Immunodeficiency Virus Infection (RE9950) 2000.
http://www.aap.org/policy/re9950.html
2. Human Immunodeficiency Virus and other Blood-borne Viral Pathogens in the Athletic
Setting (RE9821) 1999. http://www.aap.org/policy/re9821.html
3. Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Education in
Schools (RE9741) 1998. http://ww.aap.org/policy/re9741.html
4. Guidelines for Urgent Care in School (RE9193) 1990.
http://www.aap.org/policy/o3376.html
Attachment 1: Garner, J.S., Hospital Infection Control Practices Advisory
Committee (HICPAC). Guideline for Isolation Precautions in Hospitals. Infection
Control and Hospital Epidemiology. 1996; 17:53-80.*
*Although written for hospitals, this guideline may be modified for use in other settings.
Standard Precautions
Use Standard Precautions, or the equivalent, for the care of all patients.
A. Handwashing
(1) Wash hands after touching blood, body fluids secretions, excretions, and
contaminated items, whether or not gloves are worn. Wash hands immediately
after gloves are removed, between patient contacts, and when otherwise
indicated to avoid transfer of microorganisms to other patients or environments.
It may be necessary to wash hands between tasks and procedures on the same
patient to prevent cross-contamination of different body sites.
(2) Use a plain (nonantimicrobial) soap for routine handwashing.
(3) Use an antimicrobial agent or a waterless antiseptic agent for specific
circumstances (e.g., control of outbreaks or hyperendemic infections), as defined
by the infection control program. (See Contact Precautions for additional
recommendations on using antimicrobial and antiseptic agents.)
B. Gloves
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids,
secretions, excretions, and contaminated items. Put on clean gloves just before touching
mucous membranes and nonintact skin. Change gloves between tasks and procedures on
the same patient after contact with material that may contain a high concentration of
microorganisms. Remove gloves promptly after use, before touching noncontaminated
items and environmental surfaces, and before going to another patient, and wash hands
immediately to avoid transfer of microorganisms t other patients or environments.
C. Mask, Eye Protection, Face Shield
Wear a mask and eye protection or a face shield to protect mucous membranes of the
eyes, nose and mouth during procedures and patient-care activities that are likely to
generate splashes or sprays of blood, body fluids, secretions, and excretions.
D. Gown
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling
of clothing during procedures and patient-care activities that are likely to generate
splashes or sprays of blood, body fluids, secretions, or excretions. Select a gown that is
appropriate for the activity and amount of fluid likely to be encountered. Remove a
soiled gown as promptly as possible, and wash hands to avoid transfer of microorganisms
to other patients or environments.
E. Patient-Care Equipment
Handle used patient-care equipment soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures,
contamination of clothing, and transfer of microorganisms to other patients and
environments. Ensure that reusable equipment if not used for the care of another patient
until it has been cleaned and reprocessed appropriately. Ensure that single-use items are
discarded properly.
F. Environmental Control
Ensure that the hospital has adequate procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other
frequently touched surfaces, and ensure that these procedures are being followed.
G. Linen
Handle, transport, and process used linen soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures and
contamination of clothing and that avoids transfer of microorganisms to other patients
and environments.
H. Occupational Health and Bloodborne Pathogens
(1) Take care to prevent injuries when using needles, scalpels, and other sharp
instruments or devices; when handling sharp instruments after procedures; when
cleaning used instruments; and when disposing of used needles. Never recap
used needles, or otherwise manipulate them using both hands, or use any other
technique that involves directing the point of a needle toward any part of the
body; rather, use either a one-handed “scoop” technique or a mechanical device
designed for holding the needle sheath. Do not remove used needles from
disposable syringes by hand, and do not bend, break, or otherwise manipulate
used needles by hand. Place used disposable syringes and needles, scalpel
blades, and other sharp items in appropriate puncture-resistant containers, which
are located as close as practical to the area in which the items were used, and
place reusable syringes and needles in a puncture-resistant container for transport
to the reprocessing area.
(2) Use mouthpieces, resuscitation bags, or other ventilation devices as an
alternative to mouth-to-mouth resuscitation methods in areas where the need for
resuscitation is predictable.