7. Telegram From the Department of State to the Medical Collective1
173962. Subject: Acquired Immune Deficiency. For Regional Medical Officers and Foreign Service nurses.
1. The ICD–9–CM does not have a number specifically set aside for this disorder. After consulting with the National Center for Health Statistics, M/MED designates the following numbers as the codes for human T lymphotrophic virus/lymphadenopathy associated virus, (HTLV III/LAV) infections:
—279.191 HTLV III/LAV infection
—279.192 HTLV III/LAV infection with immunodeficiency
Other manifestations such as lymphadenopathy, infectious complications or tumors will be coded according to the established ICD–9–CM numbers. For example, a patient with HTLV III/LAV infection, lymphadenopathy, and Kaposi’s sarcoma would be 291.191, 785.6, and M9140/3.
2. The documents that follow represent the Office of Medical Service’s approach to this problem and current policy:
A. AIDS: The facts—RMO’s and State Department nurses are to distribute this information to all Department of State health program beneficiaries in their regions. Administrative notices and post newsletters should be used to disseminate this information as quickly as possible.
1. In areas of the world where the virus is highly prevalent, RMO’s and nurses are instructed to discuss the prevention of HTLV III/LAV infection with all new arrivals. This may be accomplished in small group sessions and/or individually. Marine Security Guards represent a special group for which emphasis and repetition of the message in the strongest terms possible, is necessary.
A. Areas of the world in which the HTLV III/LAV infection appears more prevalent
(1) All of Sub Saharan Africa except South Africa
(3) Any country that, in the opinion of State Department medical personnel, has a significant incidence of HTLV III/LAV, or provides unique opportunities for exposure.[Page 19]
2. Health units should incorporate information about prevention of AIDS infection, in the health and medical information handbook. In addition, in countries where the incidence of infection is high, information about HTLV III/LAV infections should be provided in the Post Report as well.
B. The policy for HTLV III/LAV positive individuals indicates the Department’s intention to provide these patients the same standards of care and benefits as is provided other illnesses. It should be noted that this disease, like any other potentially serious illness, may affect the medical clearance. For example, patients with evidence of immunodeficiency will be restricted to positions within the United States.
C. The policy for screening emergency blood donors includes a list of problems that could adversely affect either the donor or recipient. Donors will be asked to review this list and decide for themselves whether or not to donate.
This policy should be used in all posts whenever emergency donation of blood for members of the embassy community is required. This policy is not necessary in areas where the blood banking facilities are deemed adequate.
3. Document 1—AIDS: The Facts
A newly recognized disease, termed acquired immune deficiency syndrome (AIDS), has been increasing in incidence in several parts of the world. The name AIDS is derived from the suppressive affect on the body’s immune system by the recently discovered virus, human T lymphotrophic virus or lymphadenopathy-associated virus (HTLV III or LAV). This organism attacks the cells in the body that protect against many parasitic, fungal and bacterial infections.
It is believed that the virus has been present, and causing disease, in central Africa for a number of years. About 5 years ago AIDS began to appear in the homosexual population in the United States. It may have been introduced directly from a source in Zaire but is more likely to have passed through patients in Haiti. Since that time over 10,000 cases and over 5,000 deaths have occurred. The number of cases is expected to double by the end of 1985 and again in 1986 bringing the total number of expected AIDS cases in the United States to 40,000 by the end of 1986. The incidence of the disease amongst single men in the United States is, at present, 8.5 cases/100,000 people. To give some perspective, the incidence of pulmonary tuberculosis is about 13 cases/100,000 population in the United States.
The complex course of this disease is gradually becoming clear. The virus is present in saliva, semen and in the blood of an infected person. Sexual contact, receipt of blood products containing the virus, spread to a fetus through the placenta, and exposure through intravenous drug abuse have been the major means of infection in the United States. Sexual spread of disease has been primarily through homosexual [Page 20]contact, but it is now apparent that this disease is also spread through heterosexual exposure.
The disease manifests itself as:
1. An asymptomatic carrier state. The patient has antibodies to the HTLV III/LAV virus but has no manifestations of disease.
2. An asymptomatic to mildly symptomatic state with a measurable decrease in the body’s defenses against infection.
3. A symptomatic illness with the patient developing enlarged lymph nodes, decreased immunity and other symptoms.
4. The fully manifested disease with immune deficiency, development of unusual types of cancers, increased susceptibility to infections with uncommon organisms and an inexorably fatal course (AIDS).
The proportion of people who are infected with the virus and progress to the rapidly fatal AIDS is estimated to be 6 to 19. Those infected with this virus, even in its mildest form, carry the organism and are apparently capable of spreading the disease for long periods.
Prevention by avoidance of the common sources of infection is the most effective approach to the control of this problem. Studies of disease patterns indicate that the commonest means of spread is sexual and that the more promiscuous a person, the greater the possibility of encountering and being infected with the virus that causes AIDS.
Another source of infection in the United States has been through contaminated blood products. The majority of cases of transfusion-caused HTLV III/LAV virus infection occurred in the period between 1979 and 1983. It was not yet appreciated that there was a viral cause that could be spread through transfusion. In 1983 a voluntary program to encourage blood donors to evaluate their risks was initiated. Donors were asked not to donate if they fell into one of the high risk groups. The self-deferral program has worked and the incidence of transfusion transmitted infection has markedly declined.
It should be pointed out that very close interpersonal contact of any sort with a person infected with HTLV III/LAV virus may carry a risk. While the definition of close contact is inexact, for the purpose of defining the risk of infection with the HTLV III/LAV virus, it is considered to be contact with the body fluids of another person. Such contact may occur during sexual intimacy and “intimate” kissing. Sharing personal implements such as a razor or toothbrush may provide a risk as well.
High risk groups for the transmission of the HTLV III/LAV virus:
1. Sexually active homosexual and bisexual men with multiple sex partners.
2. Present or past abusers of intravenous drugs.[Page 21]
3. Patients who have been transfused with blood or blood products (such as hemophiliacs).
4. Sexual partners of persons with AIDS or persons in groups at high risk for AIDS (including prostitutes).
In March of 1985 the Public Health Service licensed a new test to identify the presence of antibodies to the AIDS virus in blood. The presence of antibodies means that the person tested has been exposed to the virus. It is not yet clear whether the person will develop AIDS or even the extent to which he or she is infectious. The test, while quite accurate, is not infallible. Three to six percent of those with the viral infection will not be diagnosed by the test (false negative). On the other hand, over half of the estimated one person in a hundred found to have antibodies to the virus, will be shown not to have the infection (false positive).
The importance of the test is that scientists can now begin to study questions that remain unanswered about the virus that causes AIDS. Until this time diagnosis only occurred after the person’s immune system was destroyed. It is hoped that with earlier diagnosis, it will be possible to develop treatment that can prevent the destruction of the immune system and even prevent infection.
Implications for the Foreign Service:
AIDS is a worldwide phenomenon. The disease has been diagnosed throughout Europe, in parts of Africa, Asia, and Latin America. There is some risk of infection throughout the world, particularly for those in the high risk groups outlined above.
The Office of Medical Services is monitoring the AIDS situation carefully. The risk factors for infection are no different for Foreign Service personnel than for other people. The major manner of spread is sexual intimacy. The chance of contracting the virus increases with multiple sexual partners, particularly those identified to be in high risk groups. There is increasing evidence that heterosexual transmission is an important means of spread with obvious implications concerning prostitutes. The other major risk to Foreign Service personnel and their families is acquiring infection from contaminated blood products, needles, etc. In this regard it should be noted that the processing of pooled blood plasma for gamma globulin sterilizes that product which is, therefore, safe to use. At posts at which there is a higher occurrence of the infection in the local population, use of local medical and dental facilities should be monitored and controlled carefully by the medical staff. To provide further protection, guidelines for the use of blood products for all Foreign Service personnel stationed abroad have been developed and are being disseminated to the Department’s medical staff. In places where blood banking follows international standards [Page 22]and where there is a risk of the HTLV III/LAV infection, blood donated for transfusion is now, or soon will be, tested for the virus. In other areas it is recommended that blood for emergency transfusions be obtained from members of the embassy community at that location and that the donors review the reasons for deferral before donating.
To assist employees and their dependents who, for any reason, are concerned, the Office of Medical Services, as part of its periodic examination program will test, on request, any beneficiary of the Department’s health program. Such requests must be supported by the recommendation of the Regional Medical Officer or the examining physician. To eliminate the possibility of false positive results, further testing will be arranged for any patient whose initial test is positive. All results, and, indeed the testing process itself, will be considered confidential medical information whose only purpose is to assure that patients receive optimal care.
Since knowledge about AIDS and the implications of HTLV III/LAV infection is growing daily, our concept of this problem will likely be modified in the months to come.
For further information contact the Office of Medical Services, Deputy Medical Director, (202) 632–3485 or your Regional Medical Officer.
4. Document 2—Policy for HTLV III/LAV Positives
Individuals who demonstrate evidence of exposure to the human T lymphotrophic virus or lymphadenopathy associated virus (HTLV III/LAV) as evidenced by a positive enzyme linked immunosorbent assay (ELISA) are at risk of progression to symptomatic states. These states may include the fully manifested disease AIDS (acquired immune deficiency syndrome) with all of its devastating complications, or the partially manifested problem, AIDS related complex (ARC). Such patients present grave management problems for the Foreign Service medical program. For example, it is not in the best interest of individuals or of the Foreign Service to maintain proven immunocompromised people in an overseas setting where adequate follow-up observation and care are unavailable. In an overseas setting these patients would have greater exposure to opportunistic infections that often prove fatal. The purpose of this policy is to establish basic guidelines for the management of such patients.
Mandatory testing for HTLV III/LAV virus is neither desirable or possible. For patients with signs and symptoms consistent with HTLV III/LAV infection, such testing is clearly indicated and encouraged. For people who are concerned for any number of reasons that they have a risk of infection, ELISA testing is also justified. The Department [Page 23]will offer the test to any beneficiary of its health program who desires to have it, based on the recommendation of the Regional Medical Officer and/or examining physician. Because of the difficulties in actual performance of the test and the expense of the required equipment, the ELISA (enzyme-linked immunosorbent assay) cannot be performed at any but a few of our overseas posts. Therefore, M/MED and private laboratories in CONUS will provide most of the testing resources. This testing can most conveniently be performed as part of the biennial clearance examination done in Washington D.C.
What course of action should be taken if someone is found to be positive or has equivocal results on ELISA testing?
A. Perform the western blot assay, immunofluorescence, radioimmunoprecipitation, or other confirmatory test. The choice of confirmatory test will depend on availability. At present the western blot assay is the preferred approach.
B. All individuals with a confirmed positive ELISA will be returned to CONUS for further testing and evaluation.
C. When confirmatory testing is positive and after consultation with the patient, intimate personal contacts should be urged to undergo similar testing.
A. When an individual is found to be positive by the above criteria, a complete history and physical examination shall be done. Special attention will be given to symptoms which might relate to progression of this illness: fever, chills, night sweats, weight loss, anorexia, unusual lymphadenopathy, or any other symptoms or signs known to be related to this disorder.
B. Further laboratory testing is recommended to establish baseline immunologic status.
1. Complete blood count with differential count of WBC’s
2. Measurement of the absolute numbers of T–4 lymphocytes
3. Measurement of the T–4/T8 ratio
4. Titers for CMV, hepatitis B, E–B virus and toxoplasmosis
5. Skin testing to establish whether the patient is reactive to common antigens
A. If a significant degree of immunoincompetence can be objectively demonstrated, i.e., T–4/T–8 ratio less than 0.5 or an absolute T–4 count of less than 400 cells/MM3, these individuals are at risk of opportunistic infections. They should, therefore, remain in CONUS until more is known about the course of HTLV III/LAV infection or until they are no longer at risk.[Page 24]
B. If an individual has antibodies to HTLV III/LAV positive, but has no evidence of immunosuppression and is asymptomatic, it is recommended that the individual receive counseling and then be allowed to return to post.
A. The individual shall be counseled and instructed about the virus and referred for treatment as required.
B. He/she will be advised:
1. Not to donate blood or plasma, sperm, body organs, or other tissues.
2. To inform physicians and dentists of the positive HTLV III/LAV test.
3. To limit sexual contacts and be frank with sexual partners about steps to be taken to prevent spread of the virus. Use of condoms is recommended.
4. That the virus has been found in saliva and it is possible that it will be spread by open mouth “french” kissing.
5. That there is no evidence that the virus can be spread through casual kissing or other casual social contacts such as hugging or that contact with clothing and other items cause spread of the infection.
6. That toothbrushes, razors or other personal implements should not be shared.
7. If the person is a woman with a positive antibody test or the sexual partner of a man with a positive antibody test, it is advisable to avoid pregnancy or to postpone pregnancy until more is learned. Some infants have developed AIDS from their infected mothers.
8. Not to receive live virus vaccines such as measles, mumps, rubella, yellow fever and polio vaccines.
A. Because of the political, social, and emotionally charged nature of this illness, medical confidentiality is of paramount importance. The medical record should be available only to those health care providers who have direct responsibility for care. A coding system by number or letter to record these actual diagnoses in the record should be used rather than direct language. For example, reactivity should be referred to simply as HTLV III/LAV positive or HTLV III/LAV negative. AIDS related complex would be ARC with a list of the related symptoms. AIDS itself might be identified as HTLV III/LAV positive with a list of the identifying features such as a pneumocystis or M. TB. (avian) etc.
5. Document 3—Recommendations for Screening Volunteer Emergency Blood Donors When Blood is Required for Life Threatening Conditions[Page 25]
Use of blood obtained from emergency blood donors should be considered only in the rare instance when the need for blood is considered life saving, e.g. severe blood loss resulting from traumatic injury, ruptured ectopic pregnancy, etc., and the practices of the local blood facilities are not considered adequate to ensure safety. In many instances the use of blood volume expanders, i.e., crystalloides (1/6 molar lactate or normal saline) and colloids (albumin) to maintain an adequate circulating blood volume will preclude the need for whole blood.
Blood borne diseases can be transmitted from a blood donor to a recipient. Well documented evidence exists for transmission of a variety of blood borne diseases including hepatitis B, malaria, and more recently the acquired immune deficiency syndrome (AIDS) caused by a retrovirus named the human T-lymphotropic virus type III (HTLV III).
Screening procedures to identify individuals at risk for transmitting blood-borne disease include a careful interview for disease related risk factors in the potential donor and in some instances laboratory tests to detect antibodies to the disease causing agent in the donated blood. Examples of the latter are the serological test for antibodies to hepatitis B, syphilis and the newly developed enzyme-linked immunosorbent assay (ELISA) test for antibodies to HTLV III. These tests must be performed each time a unit of blood is donated, i.e., individuals who were seronegative on a previous test can subsequently convert to a seropositive state.
When blood is required for life threatening conditions at overseas post locations where the opportunity or capability does not exist for serological screening of blood, the Office of Medical Services recommends that the potential donor be carefully interviewed/examined using the following guidelines:
Potential donors should be only those persons for whom the health unit has medical records including blood group and type. These donors should be provided with the following list of reasons for not giving blood.
If potential donors decide from this list that they are not an acceptable donor, they need not proceed further with the interview. The following groups of people are deferred:
1. Persons under 17 years of age.
2. Persons with a known history of hepatitis are permanently deferred.[Page 26]
3. Persons with history of recent onset of night sweats, unexplained fever or weight loss, lumps in the neck, armpits or groin or discolored areas of skin or mouth.
4. Persons taking antibiotics for infections.
5. Persons taking penicillin or sulfa drugs prophylactically.
6. Persons who have received transfusions of whole blood or blood fractions, e.g., fibrinogen, cryoprecipitate, fresh frozen plasma during the last six years. (Gamma globulin and serum albumin are safe.)
7. Persons taking insulin or taking tuberculosis medication for active disease.
8. Women who are pregnant.
9. Persons with coronary artery disease manifested by myocardial infarct or angina pectoris.
10. Persons with a confirmed diagnosis of cancer, leukemia or established bleeding disorder such as hemophilia are permanently deferred. (Persons with history of completely excised and cured skin cancer are acceptable as donors.)
11. According to the U.S. Centers for Disease Control, individuals who may be considered to be at increased risk of acquired immune deficiency syndrome (AIDS) include:
(A) Sexually active homosexual and bisexual men
(B) Present or past intravenous drug abusers
(D) Sexual partners of the above individuals, including prostitutes, are at increased risk for AIDS
Persons who have had sexual contact with any of the above groups are deferred.
Persons of the appropriate blood group and type who are acceptable as donors should sign the statement:
“I am not a member of any of the groups listed as not acceptable as donors and voluntarily donate my blood for use as deemed advisable.”
1. Record donor’s name, age and date of birth.
2. Record donor’s weight, temperature, pulse and blood pressure. Donors with a systolic pressure over 180 mm mercury or a diastolic blood pressure over 100 mm of mercury are deferred.
3. Record donor’s hematocrit. If hematocrit is below 34, defer donation.
4. Arm inspection: Donors with skin diseases at the phlebotomy site and/or such disease generalized to such an extent as to create a risk of contamination of blood, such as multiple boils, are deferred.[Page 27]
A copy of the signed statement/examination should be placed in the medical record of the donor and the recipient.
The blood obtained from acceptable donors should be carefully cross matched with the recipients blood to ensure blood group and type compatibility.
- Source: Department of State, Subject Files, Other Agency and Channel Messages and Substantive Material—World Health Organization (WHO), 1985, Lot 89D136, 83 HLTH WHO Programs AIDS. Unclassified. Sent through MED Channel. Drafted by Goff and approved by Dustin.↩