Are staff required to wear gloves when collecting blood donations from healthy donors? -revisted

A patient reports that he was shocked to read on the CBBS web site that some blood donation centers in California do not require staff to wear new gloves for each blood donation procedure (see discussion: HERE). He asks "Why wouldn't you try to protect the patient/blood donor from contamination from the employee's hands, while also protecting the employee from contact with patient blood?" He asks for clarification of the CDC guidelines on universal precautions in the blood donation/phlebotomy setting. He states that his understanding is that "OSHA's requirements are more lax, but they are only concerned with worker safety, not patient safety."

Paul V. Holland, MD, Clinical Professor of Medicine and Pathology at UC Davis Medical Center and Scientific Director of the Delta Blood Bank (both in California) comments that it is understandable that a patient (such as the individual who initiated this discussion) might be confused about the need to wear gloves when collecting blood from a healthy blood donor versus collecting a blood sample from a patient for testing or a unit of blood from a patient for autologous (self) use. Dr. Holland states that "It is important to keep in mind that the healthy donor denies risk factors for blood tranmitted infections like HIV, the virus of AIDS, and hepatitis viruses like B and C, while patients are much more likely to have those infections." Dr. Holland also explains that "when collecting autologous blood from a patient for their use at a later time, staff would wear gloves and change them between each such patient. This is primarily for the protection of the staff since the venipuncture site would be treated with alcohol and iodine, usually after a soap scrub to reduce the chance of introducing bacteria on the skin into the blood bag which is to be returned to that patient should it be needed (for example) during a major surgical procedure. Such patients may be taken as autologous "donors" for their own transfusions, without being asked about risk factors for HIV and hepatitis and taken regardless of their test results, even if positive for these viruses."

Dr. Holland continues that community blood donors are donating blood to be transfused into patients (and not back into themselves). He says that "Donors are volunteers, not paid, and donate to help others, not to cause them any disease. The risk today that an asymptomatic blood donor, usually a repeat donor these days, will transmit HIV is less than 1 in 3,000,000 units; the chance of carrying the hepatitis C virus(HCV) on the order of 1 in a 1,000,000 with all the testing we are doing now for antigens, antibodies and even the genetic bits of these viruses. Thus, a volunteer donor recruited to help someone, asked at least 44 intrusive questions, and tested extensively, is very unlikely to be carrying HIV or HCV. It is not an OSHA requirement for staff at donor centers to wear gloves when taking blood from healthy donors. Patients have a higher chance of carrying HIV or HCV even than the general population. Patients are people who are ill and seek medical attention. For example, while about 2% of Americans are infected with HCV, a patient coming in to a hospital, for example, an emergency room, is much more likely than this to be carrying HCV, let alone HIV or HBV."

Finally, he comments that "In thinking about the risk of becoming infected with HIV from a healthy blood donor, I brought the following to the attention of OSHA several years ago when they were suggesting that staff drawing healthy blood donors wear gloves, as staff had to when taking blood from (sick) patients. About 1 in a hundred thousand volunteer donors who come in to donate these days is infected with HIV, without knowing it or denying the risk factors for getting this virus of AIDS. Our tests pick up most of these people and we destroy their blood when found to be positive (and we notify them). About once every 10,000 phlebotomies, a staff member will stick themselves after withdrawing the (initially) sterile needle from the donor's arm. If that donor has HIV and the staff member sticks himself/herself, there is a 1 in 333 chance he/she will get infected with HIV. The chance that all three things would happen is infinitessimal. You multiply the risks which are less than winning the lottery. Even with millions of donors being bled each year, this will only happen about once every 100 years! This convinced OSHA that it was not necessay for staff bleeding healthy, volunteer donors to wear gloves, unless they wanted to do so."

Editor's Note: A review of the 2001 e-Network Forum discussion: Should staff who collect blood donations wear gloves? may also be of interest.

ADDENDA Aug. 2, 2005

1. Dr. Jon Rosenberg of the California Department of Health Services Division of Communicable Disease Control (attribution used with permission) reports that California colleagues should be aware of the actual language of the California OSHA Bloodborne Pathogen Standard in regard to the use of gloves in voluntary blood donation centers, since it is not a blanket exemption from the use of gloves. He points out that according to California Code of Regulations (CCR) Title 8 Section 5193(d)(4)(G)4, if an employer in a volunteer blood donation center judges that routine gloving for all phlebotomies is not necessary then the employer shall:
   1. Periodically reevaluate this policy;
   2. Make gloves available to all employees who wish to use them for phlebotomy;
   3. Not discourage the use of gloves for phlebotomy; and
   4. Require that gloves be used for phlebotomy in the following circumstances:
      1. When the employee has cuts, scratches, or other breaks in his or her skin;
      2. When the employee judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative source individual; and
      3. When the employee is receiving training in phlebotomy.

Dr. Rosenberg comments that if gloves are worn they should be changed between patient contacts for purposes of consistency. If there is virtually no risk of infection from contact with donor’s blood, as Dr. Holland argues, then gloves need not be worn. When they are worn, whether for one of the three required reasons above or an employee’s choice, it is implied that there is a perceived risk to the phlebotomist, and thus one to the subsequent donors if gloves are not changed, and those subsequent donors would be justified in expressing their concern over this discrepancy.

ADDENDA Aug. 15, 2005

2. The patient who initiated this discussion offers the following additional perspectives, having read the comments above. He says: "Dr. Holland writes that blood donors are likely to be healthy. That presumes that donors answer questions honestly, that they know their risks, and that they will not donate if they have risk factors for bloodborne viruses. When employers or places of worship hold blood drives, for example, there is social pressure to participate and donate blood, even if a volunteer has risk factors. Some people may even donate blood as a means of checking their status. Although the questionnaires given to blood donors are certainly important, history has shown us that these questions alone do not screen out all donors with HIV and especially HCV. The concept behind Universal Precautions is that anyone may have a bloodborne illness and should be treated as though he or she does. Under that protocol, a distinction should not be made between blood donors (presumed to be healthy) and patients (presumed to be infected), as I understand it."
   
   He adds that he appreciated the explanation of the risk factors for HIV transmission in this setting.
   
   He continues asking, "wouldn't the bigger risk be hepatitis transmission between donor/patient and health care worker? Are health care workers with hepatitis C, for example, allowed to perform procedures without gloves? Do you routinely test all health care personnel for HCV, HBV, etc., and repeat these tests annually? If a worker decides not to wear gloves, does anyone routinely and consistently check the worker's hands for "cuts, scratches, or other breaks in his or her skin"? Are these employees required to wash hands between procedures?"
   
   Finally, he concludes saying: "Frankly, it seems easier and safer to require new gloves for each procedure. Certainly, blood donors and patients alike are likely to prefer it, and health care workers will be better protected."

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Ira A. Shulman, MD
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