AIDS Exposure Advisory to EMS
Guidance Letter to EMS Agencies and Personnel
- Guidance Letter to First Responders Regarding Occupational Exposure to HIV (PDF, 1.94MB, 4pg.)
August 1, 2008
The purpose of this letter is to clarify current New York State (NYS) provisions for sharing of confidential information in cases of occupational potential exposure to HIV; to ask that you review and update applicable policies and procedures and to request your help in making sure that emergency responders know the steps to be taken in such situations.
Although preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired Human Immunodeficiency Virus (HIV) infection, appropriate post exposure management is an important element of workplace safety. Each emergency response agency is required to have plans in place for post exposure management. In cases of significant exposure, seeking medical treatment immediately is crucial. NYS Department of Health (NYSDOH) guidelines recommend that post exposure prophylaxis (PEP) should be initiated as soon as possible, ideally within 2 hours and generally no later than 36 hours post-exposure. Emergency responders should go to the nearest emergency room for evaluation of exposure.
We are writing at this time due to changes to the federal law that previously governed the manner in which response agencies could seek information. As background, the original Ryan White law sections 2681-2690, passed in 1990 (public law 101-381, section 411) containing emergency response provisions for notification of possible exposure to infectious diseases, were not included in the 2006 Reauthorization. These provisions required emergency response employers (i.e., fire departments, police departments, emergency medical services) to have a "designated officer" to field calls from employees regarding possible exposures to communicable diseases and obtain the disease status of the patients in those exposures from the medical facility providing treatment to that patient. This language was included in subsequent reauthorizations of the Ryan White law until 2006, when public law 109-415 eliminated them.
Despite these changes to the federal law, emergency response agencies can still access HIV test results on patients when there has been a bona fide risk exposure. NYS regulations now govern the manner in which disclosure of the HIV status of a patient may be made to emergency responders. Section 63.8(m) of Title 10 of the New York Codes, Rules and Regulations (enclosed) provides for disclosure in such instances. Section 63.8(m) differs from the previous federal law as follows:
- The federal law required disclosure to a "designated officer" of the emergency response employer. Under Part 63.8(m), such disclosure may be made to the physicians or other medical providers of the emergency responders.
- The federal law did not require knowledge of the HIV status of the emergency responder for disclosure of the patient's HIV status. NYS regulations for disclosure require that the emergency responder's status is HIV-negative. If the emergency responder's HIV status is unknown, an HIV test must be offered and administered with consent of the emergency responder.
Therefore, the following steps are now required when a significant risk exposure occurs:
- An incident report documenting the details of the exposure, including witnesses to the incident, if any, is on record with supervisory staff.
- A request for disclosure of the patient's HIV status is made to the patient's physician or to the medical provider designated by the hospital or clinic to which the patient is brought. This request may be made by the exposed person (EMS provider) or by his or her physician as soon as possible after the alleged exposure if a decision relating to the initiation or continuation of post-exposure prophylactic treatment is being considered.
- The medical provider of the EMS provider or the medical provider designated by the hospital or clinic must review, investigate and evaluate the incident and certify that:
- the information is necessary for immediate decisions regarding initiation or continuation of post-exposure prophylactic treatment for the EMS provider; and
- the EMS provider's status is either HIV negative or unknown and that if the patient's status is unknown, the EMS provider has consented to an HIV test; and
- if the EMS provider's test result becomes known as positive prior to the receipt of the patient's HIV status, no disclosure of the patient's HIV status will be made to the EMS provider.
- Documentation of the request is placed in the medical record of the EMS provider.
- If the patient's physician or the medical provider designated by the hospital or clinic determines that a risk of transmission has occurred or is likely to have occurred in the reasonable exercise of his/her professional judgment, the patient's physician or medical provider designated by the hospital or clinic may release the HIV status of the patient, if known. The patient's physician or medical provider in the hospital or clinic may consult with the local director or commissioner of public health to determine whether a risk of transmission exists. If consultation occurs, both the medical provider of the hospital or clinic and the local director or commissioner of public health must be in agreement if the HIV information is to be disclosed. In the disclosure process the name of the patient shall not be provided to the EMS provider. Redisclosure of the HIV status of the source is prohibited except when made in conformance with Public Health Law Article 21, Title III.
In addition to the above, the NYSDOH recommends that, if the patient's HIV status is not known, consent of the patient be obtained for a rapid HIV test. Rapid test results are usually available within 30 minutes of testing. Rules regarding confidentiality and consent for testing are identical to those for other HIV tests. A form, titled "Informed Consent to Perform a Confidential HIV Test and Authorization for Release of HIV-related Information for Purposes of Providing Post-exposure Care to a Health Care Worker Exposed to a Patient's Blood or Body Fluids" (DOH- 4054, Rev 8/05) is enclosed. This form is available at the NYSDOH web site at: Informed Consent to Perform HIV Testing and Authorization for Release of HIV-related Information . The EMS providers' medical provider could request that the hospital try to secure a rapid HIV test of the patent.
An informational slide set has been developed by the Department to aid emergency response agencies in implementing the above provisions. It is available on-line at: Bureau of EMS Updates and Announcements.
At this time, your organization should review and update its policies and procedures to ensure that they are in compliance with section 63.8(m) and notify individual emergency responders of the procedures to be followed in cases of possible exposure. Specific questions should be directed as follows:
- Emergency medical response organizations should contact the NYSDOH Bureau of Emergency Medical Services at: (518) 402-0996, Ext. 2.
- Police agencies should contact the NYS Police, Bureau of Municipal Police, at (518) 457-2667.
- Fire Departments should contact the NYS Department of State, Office of Fire Prevention and Control at (518) 474-6746.
NYSDOH AIDS Institute recommendations for PEP following occupational exposure are based on careful review of available studies and constitute the considered opinion of expert HIV clinicians. They are available for review on the NYSDOH HIV Guidelines Website at HIV Clinical Resourse. In addition, clinical assistance is available through the NYSDOH HIV Clinical Education Initiative's PEP, Testing & Diagnosis Center of Excellence (212-604-2980). This Center provides education and technical assistance to providers regarding PEP. This Center operates the PEP Line (1-888-448-4911), a 24-hour provider consultation line for the management of PEP.
Enclosed for your reference are copies of Part 63.8(m) and a letter from the Department to hospitals in NYS that notifies them of the status of the federal law and applicable NYS regulations. Your attention to this matter is appreciated.
Edward G. Wronski
Bureau of Emergency Medical Services