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To the Editor: Health care workers who spend time in developing countries are at increased risk of infectious diseases from occupational exposure to bloodborne pathogens (BBPs) due to lack of personal protective equipment, inadequate sharps protection, and reuse of products designed for single use.¹ US-based volunteer organizations that send medical volunteers to developing countries are not required to comply with the safety and health regulations formulated by the Occupational Health and Safety Administration(OSHA) (J. Howard, California Division of Occupational Safety and Health, written communication, March 6, 2002). We surveyed US volunteer health care organizations that provide medical care in developing countries with higher than average worldwide prevalence of human immunodeficiency virus (HIV) to assess their BBP practices and policies.

Methods
We surveyed 124 US-based nongovernmental volunteer health care organizations listed by the International Medical Volunteer Association that provide direct medical care in countries with a prevalence of HIV infection greater than 1%.² Responses were obtained from individuals within each organization who stated they were knowledgeable or responsible for their organization's BBP practices and policies. The survey contained 4 demographic questions about organizational structure, and 5 questions relating to policies for prevention of potential exposure to BBP.

Results
Of the 90 (73%) organizations that responded, 72 stated they send volunteers with risk of BBP exposure to countries with HIV prevalence greater than 1% (median number of exposed workers, 17; range, 1-1000). Only 25 (35%) of the 72 organizations had a formal policy for protection of workers from exposure to blood and body fluids and one fourth required proof of hepatitis B immunization from volunteers. Thirty (43%) organizations had no formal policies or procedures to protect volunteers from BBP exposure. Organizations with formal BBP policies were more likely to have reported volunteer percutaneous injuries in the past (7/24 with formal policy vs 4/46 with no policy). Large organizations (more than 100 potentially exposed volunteers annually) were more likely to have a formal BBP policy than smaller organizations (8/13 larger organizations vs 14/43 smaller organizations).

Comment
The majority of US organizations sending volunteer health care workers to countries with high endemic rates of HIV do not have formal policies or procedures for volunteer protection. There may be significant underreporting of percutaneous injuries within these organizations, since only 11 of 72 reported previous percutaneous injuries.

We suggest that volunteer organizations examine their occupational safety policies, and that all should establish policies and recommended practices to protect volunteers from BBP exposure. An appropriate and cost-effective starting point for health behavior education in these organizations could be the provision of the Centers for Disease Control and Prevention's Universal Precautions guideline,³ the revised OSHA standard on needlestick and other sharps injuries to all volunteers,⁴ as well as hepatitis B immunization.

Alice Edler, MD
Department of Anesthesiology
Stanford University School of Medicine
Stanford, Calif

Margaret A. Olsen, PhD, MPH
Division of Infectious Diseases
Washington University School of Medicine
St Louis, Mo

M. C. E. Mbwille, ADAS
Mbeya Consultant Hospital
Mbeya, Tanzania

1. Sagoe-Moses C, Pearson RD, Perry J, Jagger J. Risks to health care workers in developing countries. N Engl J Med. 2001;345:538-540. FREE FULL TEXT 2. International Medical Volunteers Association. Available at: http://www.imva.org. Accessibility verified April 18, 2002. 3. Centers for Disease Control and Prevention. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR Morb Mortal Wkly Rep. 1988;37:377-388. PUBMED 4. Occupational exposure to bloodborne pathogens; Needlestick and other sharps injuries; Final Rule, 66 Federal Register. 5317 (2001) (codified at 29 CFR 1910). Available at: http://www.osha-slc.gov/FedReg_osha_data/FED20010118A.html. Accessibility verified April 18, 2002.

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2002;288:166.