Infectious diseases continue to be a leading cause of disease and death worldwide,

FEATURE ARTICLE Preventing Infections in Health Care Workers Linda Tietjen I nfectious diseases continue to be a leading cause of disease and death...
Author: Justin Johnson
1 downloads 3 Views 58KB Size
FEATURE ARTICLE

Preventing Infections in Health Care Workers Linda Tietjen

I

nfectious diseases continue to be a leading cause of disease and death worldwide, and health care workers are at risk of contracting these infections. The spread of infections within health facilities results in large part from the failure of health care workers to wash their hands before and after each patient contact—a lesson learned more than 100 years ago. The epidemic spread of bloodborne viral diseases, including hepatitis B and C, and human immunodeficiency virus (HIV), heightens the importance of working safely in a health care facility. Infection prevention strategies should focus on: • preventing the spread of infection by cross-contamination (person to person), and • protecting health care workers at all levels by providing a safer work environment.1 Most infections can be spread before symptoms are present. Therefore, exposure to any patient’s blood or other body fluid through needle sticks or other injuries and splashes into eyes and mouth (mucous membranes) increases the risk of exposure. Many health care workers are only vaguely aware of the risk they face while at work; some still believe that little can be done to protect them. This article focuses on what health care workers can do to protect themselves (and at the same time their clients) from exposure to infectious diseases. The specific decontamination, cleaning, disinfection, and sterilization procedures required to ensure facilities and equipment remain infection free are not specifically addressed Linda Tietjen (BSN, MPH) is Faculty Associate at the Johns Hopkins University School of Nursing and infection prevention consultant for the JHPIEGO Corporation. Volume 15, Number 4 December 1997

PATH (Program for Appropriate Technology in Health)

here. These procedures are nurses. In some countries “Most infectious agents are transmitted by summarized in Outlook, housekeeping staff have a contact with blood and body fluids and Volume 7, Number 2, a copy rate of needlestick of which is available from injuries second only to most infections can be spread before Outlook on request, and in operating room staff. This symptoms are present. Therefore, it is the manual Infection is due in large part to essential that health care workers treat all Prevention for Family used needles being Planning Service incorrectly discarded patients as if they are infected.” Programs,1 available from combined with houseJHPIEGO, Brown’s Wharf, 1615 Thames Street, keeping staff not being taught how to protect Suite 200, Baltimore, Maryland 21231, U.S.A. themselves.1 Compliance with infection prevention guidelines How Risky Is Health Care Work? can be strenghtened if there is consistent support for In a recent U.S. survey, only truck drivers and safety efforts by program managers. This includes laborers were reported to have higher on-the-job ensuring that identified deficiencies are corrected, accident rates than health care workers.2 While dangerous practices are eliminated, and staff are exposure to biologic agents and subsequent infection actively encouraged to suggest better safety practices. is not the only occupational hazard faced by health It also is important that supervisors regularly provide care workers, infections present the greatest risk, feedback and reward appropriate infection prevention especially those caused by bloodborne organisms. practices, and that role models, especially physicians Contact with blood and other body fluids is the most and other senior staff, support recommended infection common occupational risk faced by health care prevention practices and model appropriate behavior.7 workers. In the United States alone, more than Finally, educational programs geared at problem800,000 needlestick injures occur each year, despite solving—not just providing information—and continuing education and other efforts aimed at addressing psychosocial factors (minimizing stress, preventing them.3 Although there is a growing awareness of the Handwashing and Using Gloves: seriousness of HIV and hepatitis B and C and how Crucial for Any Health Care Worker these viruses are transmitted, many health care Routine handwashing for 10 to 15 seconds workers do not perceive themselves to be at risk. before and after patient contact may be the single Even those who know that precautions such as most important procedure in preventing infections. handwashing and using gloves are important do not Using soap and water when available or an alcohol/ use them regularly. This is in part due to the glycerin (waterless) handrub is effective. Health mistaken belief that HIV is largely confined to certain care workers in the United States have been found “at-risk” groups—sex workers, intravenous drug to wash their hands only 40 percent of the time, users, or homosexuals—and to urban areas. While even in intensive care units, where patients often this may have been true several years ago, in 1996 are most vulnerable and resistant organisms most WHO estimated that worldwide there were more than common.8 22.6 million people infected with the AIDS virus and Gloves should be worn by all health care that this virus is increasingly affecting the heteroworkers prior to contact with blood and other body sexual population as well as spreading to rural areas.4 fluids from any patient. This also includes the staff Other factors also contribute to the lack of compliwho clean up after a procedure and wash instruance, including the perception that health care ments. The type of glove used depends on the task. facilities are risky places to work and little can be Sterile gloves are required for surgery; inexpensive, done to make them safer, and the belief that there is a disposable exam gloves for performing pelvic examconflict of interest between providing the best patient inations; and thick utility gloves for washing instru5 care and protecting oneself from getting an infection. ments, cleaning up spills, and disposing of medical In many settings a lack of sufficient staff and inapprowaste. Gloves should be changed after each contact. priate staff mix to meet client needs magnifies the For example, after changing a dressing staff should 6 problem. remove their gloves and wash their hands before writing up notes or doing anything else. Making Infection Prevention Programs Work If surgical gloves are being reused (either Implementing effective strategies to ensure that sterile or high-level disinfected), operating room health care workers follow infection prevention staff should “double glove” for procedures where guidelines is crucial to preventing the spread of blood or body fluid contamination is routine (for infection. Education and other efforts intended to example, vaginal deliveries or Cesarean sections) make the health care facility safer should be directed because invisible tears can occur with reprocessing. to all health care workers—not just physicians and

2

OUTLOOK/Volume 15, Number 4

emotional strain, and interpersonal problems) can lead to better compliance and improved health worker safety.3 How Can Health Care Be Made Safer? Most infectious agents are transmitted by contact with blood and body fluids and most infections can be spread before symptoms are present. Therefore, it is essential that health care workers treat all patients as if they are infected. The barrier precautions described and illustrated on this page should be used routinely by all health care workers with all patients:9 Barrier precautions will provide sufficient protection when working with almost all patients. Isolate patients only if secretions (airborne) or excretions (urine or feces) cannot be contained. This would include, for example, patients who have active tuberculosis. Infection prevention precautions are a part of every procedure. In women’s health clinics, for example, gynecological procedures, even pelvic exams, can expose health workers to body fluids. Listed below are the specific infection prevention procedures that should be followed during a pelvic exam: • Wash hands thoroughly with soap and water before each examination. • When possible, have the client wash her genital area before doing the pelvic examination. • Use clean, high-level disinfected (or sterilized) instruments and surgical gloves (both hands). Alternatively, examination gloves can be used. • Properly dispose of waste material (gauze, cotton, and disposable gloves). • Decontaminate instruments and reusable items immediately after using them. • Wash hands thoroughly with soap and water after removing gloves. Finally, while not specifically a barrier precaution, when possible health care workers should take advantage of available immunizations, especially hepatitis B vaccine. Being vaccinated protects not only the health care worker but also fellow workers, patients, and the health care worker’s family. Summary It is increasingly important that health care workers know and use simple, inexpensive practices that can markedly reduce the risk of acquiring and spreading a serious, life-threatening disease. It is the responsibility of all health care workers to help create a safer environment for patients and fellow health care workers. 1. Tietjen, L.G. et al. Infection Prevention for Family Planning Service Programs. Durant, OK:Essential Medical Information Systems, Inc. (1992).

Protect Yourself Wash hands before and after each patient contact—this is the single most practical procedure for preventing cross-contamination (see box previous page.) Wear gloves before touching anything wet—broken skin, mucous membranes, blood or other body fluids (secretions or excretions), soiled instruments, gloves, and medical waste (see box previous page.) Use physical barriers (protective goggles, face masks and plastic aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated, for example, vaginal deliveries. Never eat, smoke, or put anything in your mouth in areas where blood might be present.

sharps disposal

Use safe work practices, such as safely passing sharp instruments; properly disposing of medical waste; and not recapping, breaking, or bending needles or disassembling syringes. Specific approaches to prevent needlestick injuries include: • Place puncture resistant containers for needles and other sharp instruments near the patient’s bed or examination tables. • Train all staff to immediately dispose of needles and syringes in sharps containers without recapping. (Attempting to recap accounts for one third of all needlesticks.)10 • If recapping must be done, train staff in the one-hand recapping technique illustrated here.

Illustrations from PATH’s bloodborne infection control program in Ukraine, January 1997. OUTLOOK/December 1997

3

2. US Department of Labor, Bureau of Labor Statistics. Current Population Survey, 1995 Annual Averages (1995). 3. Rogers, B. Health hazards in nursing and health care: an overview. American Journal of Infection Control 25:248-261 (1997). 4. XI International Conference on AIDS. The Status and Trends of the Global HIV/AIDS Pandemic: Final Report (July 7-12, 1996). 5. Gershon, R. Facilitator report: Bloodborne pathogens exposure among health care workers. American Journal of Industrial Medicine 29:418420 (1996). 6. Institute of Medicine. Nursing Staff in Hospitals and Nursing Homes—Is It Adequate? (1996). 7. Lipscomb, J. and Rosenstock, L. Health care workers: protecting those who protect our health. Infection Control Hospital Epidemiology 18: 397-399 (1997). 8. Griffin, K. They should have washed their hands. Health 82-90 (November/ December 1996). 9. Blumenthal, P. and McIntosh, N. Pocket Guide for Family Planning Service Providers (1996-1998) (1996). 10. Jagger, J. et al. Rates of needlestick injury caused by various devices in a university hospital. New England Journal of Medicine 5: 284-218 (1988).

PRODUCT NEWS

The Female Condom: For Women and Men

T

he female condom is the first barrier method that provides dual protection against pregnancy and sexually transmitted diseases (STDs) and is worn by women. It offers an additional contraceptive option to women and men, particularly those at risk of STD. The female condom is made from polyurethane plastic with a ring made from the same material at either end. The closed-end ring is used to insert the device into the vagina and to hold it in place at the cervix; the open-end ring stays outside the vagina after insertion and covers the external genital area (see illustration on right). The female condom was first marketed in Switzerland in 1992; as of 1996 it was available in 13 countries including several European nations, the United States, South Africa, Thailand, and Korea.1 Given the unmet contraceptive need and high rates of STDs, including human immunodeficiency virus (HIV), among women in many developing countries, there is renewed interest in the female condom among the international health community. A 60-country survey by UNAIDS estimated the global demand for female condoms (at affordable prices) at 13 million for 1998.2 Effectiveness in Pregnancy and STD Prevention The female condom is effective in preventing pregnancy when used correctly and consistently at

4

OUTLOOK/Volume 15, Number 4

every act of intercourse; with typical use, failure rates increase. One study estimates that about five percent of women always using the female condom correctly (perfect use) become pregnant during the first year. With typical (non-perfect) use for one year, the failure rate increases to 21 percent. 3 A study of 377 women from six U.S. and three Latin American sites reported a 6-month cumulative accidental pregnancy rate of 15 percent among typical users of the female condom (12.4 percent among U.S. women and 22.2 percent among Latin American women). Among perfect users of the female condom, the 6month failure rate dropped over threefold, to 4.3 percent (U.S. women 2.6 percent and Latin American women 9.5 percent).4 Six-month discontinuation rates were 55 percent for Latin American women and 32 percent for U.S. women. Few data are available on the degree of protection against STDs provided by the female condom. Use-effectiveness results from two studies are promising, however. In a U.S. study that examined the rate of recurrent vaginal trichomoniasis in 104 women who had been treated for the infection, the reinfection rate was zero among 20 perfect users of the female condom, about 15 percent among 34 nonperfect users, and 14 percent among 50 controls (nonusers) following a 45-day period.5 Laboratory studies have found that the female condom is impermeable to STD-causing organisms, including HIV. New evidence from a study of female sex workers in Thailand suggests that the availability of female condoms may reduce the rate of STDs in this population, presumably by reducing the number of unprotected sex acts. Female sex workers who were offered both female and male condoms had a 34 percent reduction in incidence of STDs and 25 percent reduction in the number of unprotected sex acts compared to their counterparts who were offered the male condom only.2 The female condom, when properly used, may offer better protection against transmission of some

Inserting the female condom. Illustration courtesy of Wisconsin Pharmacal, as published in Outlook, Volume 10, Number 2, September 1992.

TABLE 1 Summary of Selected Acceptability Studies in African Countries Country

Number of Participants

User Acceptability

Partner Acceptability

Kenya

100 women; 46 male partners

• 93% were always satisfied with female condom • 86% liked using it very much

• Men generally found female condom acceptable; one man reacted violently when a woman suggested using it

Malawi

57 couples; 46 CSWs†

• 95% of non-CSW women and 100% of CSWs liked female condom • 81% of study participants preferred female condom to male condom

• 96% of men liked female condom very much or fairly well • 67% preferred it to male condom; 93% said they would use it again

Uganda

100 CSWs; 90 urban and 30 rural women

• 90%-100% of CSWs, 90% of urban women, and 100% of rural women liked female condom very much or fairly well

• 90% of CSWs and rural women said their steady partners also liked it very well or fairly well

Zimbabwe

89 CSWs, 84 urban and 23 rural women

• More than 90% of all women liked it very much or fairly well • 66% of urban women, 100% of rural women, and 80% of CSWs preferred it to male condom

• More than 75% of urban and rural women said their steady partners liked it • About 75% of CSWs said their clients liked it



CSW = commercial sex worker

Adapted from WHO, 1997.1

STDs than male condoms. This is because the female condom covers more of the external genitalia than the male condom. In addition, the polyurethane female condom is sturdier and more resistant to breakage than male latex condoms.

also have often found that their partners like the female condom and prefer it to other methods (see Table 1). Anecdotal data from social marketing projects to date reveal that between 20 percent to 50 percent of purchasers of female condoms are men.7

User Perspectives Acceptability studies of the female condom have been conducted in both developed and developing countries, although generally with a small number of participants. While acceptability results have varied, women and men in many settings report liking the female condom “very much” or “fairly well” (see Table 1). When individuals are asked how the female condom compares to the male condom, as few as 40 percent and as many as 100 percent of women and men have stated they prefer the female condom to the male condom.1 The acceptability of the female condom is affected by its aesthetic qualities: a specific concern women often mention is the appearance and feel of the protruding outer ring.1, 6 Other concerns about the device have included: difficulty with insertion; inner ring causes pain for both partners; produces noise during sex; and the device can become compressed inside the vagina during intercourse.1 Is the female condom really a female-controlled method? A key reason for developing the method was to provide women with a barrier method they did not have to negotiate with their partner. While use of the female condoms generally is initiated by women, partner cooperation and willingness is essential for sustained and effective use. Partner resistance frequently is cited for non-use or discontinuation of use. On the other hand, women

Availability and Cost Issues While the female condom is not a perfect method, demand is strong among certain groups of women and men. Yet in developing countries, female condoms are not widely available. One way to increase access to female condoms is through social marketing. Until recently, social marketing of the female condom has been limited to small-scale efforts, generally with a focus on preventing STDs/HIV. For example, Population Services International (PSI) test-marketed a total of 96,000 female condoms in five countries in 1996—Bolivia, Haiti, Guinea, South Africa, and Zambia.7 The female condom was positioned as an effective alternative to the male condom to protect against both unintended pregnancies and STDs/HIV. It was made available in pharmacies and small general stores and through outreach workers. It was marketed mostly via interpersonal communication, with limited mass media support, and targeted primarily to sex workers and university students.7 A large-scale social marketing project in Zimbabwe launched in July 1997 promoted female condoms as the “care contraceptive sheath: for women and men.” The care condom has been made available through pharmacies and clinics in all major towns and cities of Zimbabwe at a price equivalent to about US$0.14 per condom. More than 100,000 were sold within the first four months.7 OUTLOOK/December 1997

5

The high cost of female condoms compared to male condoms is a barrier to use. When available through regular commercial channels in developing countries, the female condom costs between US$2 and $3—an unaffordable price for most women.1, 2, 8 UNAIDS has negotiated a preferential public sector price of about US$0.63 per condom, but this still is too expensive for many women around the world. Social marketing research results suggest that consumers were willing to purchase the female condom only at much lower prices, for example US$0.03 in Zimbabwe, $0.06 in Haiti, to $0.32 in Bolivia.1, 6, 7 These prices generally are still higher than the prices of male condoms, however. Because of its high cost, women reportedly often reuse the female condom (which is approved for a one-time use only). Reuse raises a number of concerns, including the potential for breakage, strength, permeability to microorganisms, and possible microbial contamination.1 Issues related to reuse currently are being investigated. Program Implications When used correctly and consistently, the female condom can be quite effective in preventing pregnancy and STDs. Increasing data on acceptability and demand for the device suggest that it can be acceptable to certain women and men. In order for the method to be made more accessible, the prices must be lowered and it must be promoted carefully. Given that men’s cooperation in its use is crucial, promoting the female condom to both women and men is important in many settings. It also is important to address user concerns about aesthetics and improper use of the female condom. As with all methods, women and men are more likely to understand and use the female condom properly when: method use is clearly explained by trained clinic or community-based workers; potential users are informed that it requires some practice to use comfortably; and support, counseling, consistent use, and follow-up are emphasized. Lastly, it is important that research on the effectiveness and acceptability of the female condom continues so that appropriate use can be further defined. 1. World Health Organization. The female condom: a review. Geneva. WHO/HRP/WOM/97.1 2. UNAIDS. The female condom and AIDS. UNAIDS point of view (April 1997). http://www.unaids.org/unaids/bpc/pointv/femalepv.pdf (October 24, 1997). 3. Trussell, J. et al. Comparative contraceptive efficacy of the female condom and other barrier methods. Family Planning Perspectives 26(2):66-72 (1994). 4. Farr, G. et al. Contraceptive efficacy and acceptability of the female condom. American Journal of Public Health 84(12):1, 960-964 (1994). 5. Soper, D.E. et al. Prevention of trichomoniasis by compliant use of the female condom. Sexually Transmitted Diseases 20(3):137-139 (1993). 6. Ray, S. et al. Acceptability of the female condom in Zimbabwe: positive but male centered responses. Reproductive Health Matters 5:494-503 (1995).

6

OUTLOOK/Volume 15, Number 4

7. Stallworthy, G. (Population Services International). Personal correspondence, October 24, 1997. 8. AIDSCAP. The female condom: from research to the marketplace (August 1997).

SAFETY

Vaginal Douching: Unnecessary and Potentially Harmful?

V

aginal douching—rinsing the vagina for hygiene, to ease symptoms of infection, or in an effort to prevent pregnancy—is an ancient practice performed by millions of women around the world. In the United States alone, it is estimated that more than 20 million women douche regularly either with a commercial or homemade preparation. Douching also is common among women in African and Asian cultures. In these cultures, dry substances, such as herbal leaves or powders, also are commonly used to treat symptoms of infection or for sexual enhancement (see box, page 7). Few studies have addressed the risks and benefits of douching, and the results of available studies have been inconsistent. A recent meta analysis of studies on douching published within the past 30 years indicates that frequent douching may be linked to adverse health effects. The meta analysis included primarily studies from the United States; some studies from Latin America were also included. All studies adjusted results for confounding factors such as number of sexual partners, marital status, and frequency of intercourse. The analysis found that douching once a week or more was associated with a significantly increased risk of pelvic inflammatory disease (PID) and a moderate risk of ectopic pregnancy. The analysis also found a somewhat increased risk of cervical cancer among women douching frequently, but this result was less clear.1 The implications of this meta analysis are important given that the practice is so common and that many health providers and women are largely unaware of potential risks associated with douching. Why do women douche? A U.S.-based study found that among urban women the most frequently cited reason given for douching was hygiene—to feel clean after sex and/or after menstruation.2 About half of the women in this U.S.-based study douched with a

commercial preparation, 30 percent used a home mixture of vinegar and water, 10 percent used water alone, and 10 percent used other preparations. Overall, douching was associated with three characteristics: lower socio-economic class, greater risk of STD, and symptoms suggestive of vaginal infection. Despite the perception that douching promotes genital hygiene, most health providers advise that douching is not necessary after a menstrual period or after sexual intercourse since the vaginal wall is self-cleansing. Unless a woman has a medical condition for which a clinician has specifically prescribed douche, the practice is unnecessary and may even be harmful. Possible Risks of Douching Although only two case-control studies during the past 30 years have specifically examined the issue, a link between douching and PID appears to be likely. Results from these studies—which controlled for potentially confounding factors including number of sexual partners—suggest that women who douche have a 73 percent increased risk of PID compared to women who do not douche.1 The pooled overall relative risk from these two studies was 1.73 (95% confidence interval [CI]=1.07 - 2.79). The more frequently a woman douched, the higher her risk of having PID. A possible mechanism for this increased risk is that douching helps pathogens ascend through the cervix to the uterus and fallopian tubes. More research is required before a cause-effect relationship is confirmed. The link between douching and ectopic pregnancy also appears to be supported by study results. Pooled results of five hospital-based case-control studies found that women who douched had a 76 percent increased risk of having an ectopic pregnancy compared with women who did not douche. 1 Again, these studies were controlled for confounding factors. Some researchers suggest that douching may be more likely to promote ascending infections at certain times of the menstrual cycle.1 Immediately after menses, the cervical os is small and contains a plug of thick, sticky mucus that blocks the passage of many pathogens. As ovulation approaches, the os opens and the mucus thins and washes away more easily. Therefore, researchers suggest that douching may be riskiest around the time of ovulation. Another influencing factor may be the pressure with which douche solution is applied. Since the 1930s, douching has been suggested as a possible risk factor for cervical cancer. Results of studies have been inconsistent, however. Pooled results of six population-based case-control studies found a weak overall association between douching

Dry Sex Practices: a Risk for STDs? Dry sex is a common cultural practice in many Southern, Central and West African countries. Dry sex refers to the practice of using herbs, pharmaceutical agents, absorbents such as cloth, or other substances to dry and tighten the vagina before intercourse. A wide variety of substances are commonly used including soaps, ground stones, toothpaste, and many kinds of herbs. Women engage in these practices for a variety of cultural reasons and often learn them from older women or family members, or as part of their initiation rite as young girls. The most common reason cited for dry sex is to enhance sexual pleasure for the male partner, but women also report using these herbs and substances to clean the vagina before or after sex and to treat symptoms of vaginal infection. Given the high incidence of sexually transmitted disease infection in these regions, researchers and AIDS prevention programs are interested in the effect of these substances on vaginal tissue and implications of their use on condom use. Some studies have shown an association between use of intravaginal substances and HIV; others have not. In Zaire, a study among 377 sex workers found that introduction of any product into the vagina was associated with HIV seropositivity (odds ratio 2.4; 95% CI = 1.2 - 4.8), although use of specific intravaginal agents for tightening the vagina was not.3 In general, the substances used to promote dry sex can cause vaginal inflammation, peeling of vaginal tissue, and penile or vaginal abrasion, all of which can increase risk of STD/HIV transmission. The herbs and other substances also may mask symptoms of existing STDs, thereby increasing the risk of HIV transmission. Dry sex practices also may affect condom use and effectiveness. In a study among HIV/AIDS peer educators in Zimbabwe, women reported that condoms often broke when used in conjunction with dry sex practices, either because the vagina was too tight, or possibly because of chemical or abrasive interaction with the substances.4 Even though only limited information is available, health providers working in regions where dry sex practices are common should be prepared to discuss these practices with their clients, and should advise clients that the practices may put them at increased risk of STDs.4

and cervical cancer (relative risk = 1.25, 95% CI = 0.99 - 1.59). A more significant association was found among women who douched at least once a week (adjusted relative risk = 1.86, 95% CI = 1.29 - 2.68). The possible biological mechanism for the link is unclear, however, and concern has been raised that douching may simply be a marker for other risk factors for cervical cancer, including HPV infection.1 Douching also can affect fertility. Among 849 married, parous women in the United States, douching resulted in reduced fertility.5 Women who douched were 30 percent less likely to become pregnant each month they attempted pregnancy. Young OUTLOOK/December 1997

7

women who douched had significantly greater reduction in fertility than older women. The mechanism for this reduced fertility is unclear, although altered vaginal pH or tissue changes have been suggested. Even though douching seems to result in reduced fertility, its effect is slight and it should not be relied upon to prevent pregnancy. Results of the few studies that have evaluated douching and risk of STD infection suggest that frequent douching may be associated with an increased risk of STDs and HIV, although it also is possible that women at risk of STDs are more likely to practice douching. In Indonesia, a study of 599 pregnant women attending a prenatal clinic found that the presence of STDs was associated with douching habits.6 Compared to women who never douched, women who always douched with a commercial preparation or with a traditional substance called betel leaf had a substantially increased risk of sexually transmitted disease (odds ratio 9.4, 95% CI=1.8 - 50.3). Douching with water only after sex was not associated with STD risk. Researchers also are evaluating a possible association between frequency and type of douche and HIV infection. In a study of 397 women referred to an STD clinic in the Central African Republic, women douching with a noncommercial traditional preparation were more likely to be infected with HIV than women who had never douched (odds ratio 1.7, 95%

ADVISORY BOARD •Giuseppe Benagiano, M.D., Director General, Italian National Institute of Health, Italy•Gabriel Bialy, Ph.D., Special Assistant, Contraceptive Development, National Institute of Child Health & Human Development, U.S.A. •Rebecca J. Cook, Professor, Faculty of Law, University of Toronto, Canada •Lawrence Corey, M.D., Professor, Laboratory Medicine, Medicine, and Microbiology and Head, Virology Division, University of Washington, U.S.A. •Horacio Croxatto, M.D., President, Chilean Institute of Reproductive Medicine, Chile •Judith A. Fortney, Ph.D., Corporate Director for Scientific Affairs, Family Health International, U.S.A. •John Guillebaud, M.A., FRCSE, MRCOG, Medical Director, Margaret Pyke Centre for Study and Training in Family Planning, U.K. •Atiqur Rahman Khan, M.D., Country Support Team, UNFPA, Thailand •Louis Lasagna, M.D., Sackler School of Graduate Biomedical Sciences, Tufts University, U.S.A. •Roberto Rivera, M.D., Corporate Director for International Medical Affairs, Family Health International, U.S.A. •Pramilla Senanayake, MBBS, DTPH, Ph.D., Assistant Secretary General, IPPF, U.K. •Melvin R. Sikov, Ph.D., Senior Staff Scientist, Developmental Toxicology, Battelle Pacific Northwest Labs, U.S.A. •Irving Sivin, M.A., Senior Scientist, The Population Council, U.S.A. •Richard Soderstrom, M.D., Clinical Professor OB/GYN, University of Washington, U.S.A. •Martin P. Vessey, M.D., FRCP, FFCM, FRCGP, Professor, Department of Public Health & Primary Care, University of Oxford, U.K.

© PATH (PROGRAM FOR APPROPRIATE TECHNOLOGY IN HEALTH). 1997. ALL RIGHTS RESERVED.

8

OUTLOOK/Volume 15, Number 4

CI=1.0 - 3.0). On the other hand, women douching with commercial antiseptics were less likely to be infected with HIV (odds ratio 0.6, 95% CI=0.4 - 0.9). In all analyses, researchers adjusted for potentially confounding factors such as marital status, number of sexual partners, and frequency of intercourse.3 Additional research is needed to confirm these results. Conclusion Although the data on the effects of douching are limited, it appears that douching may be more harmful than helpful. Frequent douching seems to be associated with a greater likelihood of STDs, PID, and ectopic pregnancy. Women who douche also experience reduced fertility. More research should be carried out to confirm findings, but in the meantime, women should be counseled that douching is not necessary and may be harmful. 1. Zhang, J. et al. Vaginal douching and adverse health effects: a meta analysis. American Journal of Public Health 87(7):1207-1211 (July 1997). 2. Rosenberg, M. et al. Vaginal douching. who and why? Journal of Reproductive Medicine 36(10):753-758 (October 1991). 3. Mann, J. et al., eds. AIDS in the World. Cambridge, Massachusetts: Harvard University Press (1992). 4. Civic, D. and Wilson, D. Dry sex in Zimbabwe and implications for condom use. Social Science Medicine 42(1): 91-98 (1996). 5. Baird, D.D. et al. Vaginal douching and reduced fertility. American Journal of Public Health 86(6):844-850 (June 1996). 6. Joesoef, M.R. et al. Douching and sexually transmitted diseases in pregnant women in Surabaya, Indonesia. American Journal of Obstetrics and Gynecology 174(1 Pt 1):115-119 (January 1996).

ISSN:0737-3732

Outlook is published by PATH in English and French, and is available in Chinese, Spanish, Portuguese, and Russian. Outlook features news on reproductive health products and drug regulatory decisions of interest to developing country readers. Outlook is made possible in part by a grant from the United Nations Population Fund. Content or opinions expressed in Outlook are not necessarily those of Outlook’s funders, individual members of the Outlook Advisory Board, or PATH. PATH is a nonprofit, international organization dedicated to improving health, especially the health of women and children. Outlook is sent at no cost to readers in developing countries; subscriptions to interested individuals in developed countries are US$40 per year. Please make checks payable to PATH. Editor: Jacqueline Sherris, Ph.D. PATH 4 Nickerson Street Seattle, Washington 98109-1699 U.S.A. Phone: 206-285-3500 Fax: 206-285-6619 E-mail: [email protected] URL: www.path.org The staff writers for this issue were Maggie Kilbourne-Brook and Tuong Nguyen. Production assistance was provided by Diane Lachman and Ginger Topel. In addition to selected members of Outlook’s Advisory Board, the following individuals reviewed this issue: Ms. M. Cabral, Ms. J. Cottingham, Mr. G. Stallworthy, Dr. G. Thomas, Dr. K. Vogelsong, and Dr. J. Zhang. Outlook appreciates their comments and suggestions. Printed on recycled paper

M

I

N

S

I

D

E

M

The Female Condom: For Women and Men. . . . . . . . . . . . . 4 Vaginal Douching: Unnecessary and Potentially Harmful? 6

OUTLOOK/December 1997

9

Suggest Documents