Case Raises New Fears on Spread of AIDS by Health-Care Workers : Medicine: The adequacy of prevention guidelines is questioned in the wake of a woman’s apparent infection by her dentist.
The report that a dentist with AIDS may have infected a young woman while removing two of her molars raised new concerns this week about the adequacy of guidelines for preventing the spread of the AIDS virus from health-care workers to patients.
Federal health officials said Friday that they expect to consider shortly whether they should tighten existing guidelines--for example, by identifying surgical procedures that are especially risky and recommending that infected surgeons not perform them.
But health experts emphasized that no radical changes in current practices, such as mandatory testing of health-care workers, are warranted by the case of the dental patient--the first in the 10-year AIDS epidemic suspected to be traceable to a health-care worker.
“All of us have a very emotional reaction to this,” said Dr. Julie Gerberding, an infectious-disease specialist at UC San Francisco. “No one likes to contemplate the fact that they could acquire some dreadful infection from their health-care provider. Hopefully, that can be tempered with a little bit of perspective.”
Health officials offer the following points:
Infection of patients by health-care workers can occur only during so-called invasive procedures, in which body tissues are penetrated by a surgical instrument. For transmission to take place, the infected surgeon or dentist’s body fluid must mix with the patient’s.
Even when that happens, the odds of infection appear to be low. Studies examining the risk to health-care workers from infected patients estimate that only 0.4% of all needle-sticks involving contaminated blood have resulted in infection.
Physicians, dentists and other workers already follow extensive infection-control guidelines requiring, for example, use of gloves, masks and gowns, never recapping needles, and immediate removal of contaminated equipment from areas being operated on.
Dr. Frank S. Rhame, an infectious-disease specialist at the University of Minnesota Hospital and director of the hospital’s AIDS virus clinic, has calculated the risk of surgeon-to-patient transmission at one in 100,000 to as little as one in a million operations.
“We are talking about a level of risk that we want to try and guarantee that is on the order of lightning striking,” said Mark Madsen, director of physician education for the California Medical Assn. “There’s really no way to guarantee risk-free living.”
The U.S. Centers for Disease Control reported Thursday that a dentist with AIDS appeared to have infected a patient. The CDC found no other way that the woman might have become infected, although investigators said another source “cannot be entirely excluded.”
The woman, who developed AIDS two years later, recalled that the dentist had worn gloves and a mask during the oral surgery, CDC officials said. Some officials speculated that the dentist might have accidentally stuck himself with a needle that he then used on the patient.
In part because of that case, the CDC has scheduled a meeting for mid-August in Atlanta at which representatives of medical groups, labor unions, public health organizations and others will discuss whether existing guidelines should be revised.
Two key questions are likely to arise at that meeting, a CDC official said. Should it be recommended that infected surgeons and dentists not perform invasive procedures? Or should they have to be screened before being allowed to do so?
The current CDC policy says the question of whether an infected health-care worker should continue to perform his or her usual duties “must be determined on an individual basis.” It leaves that decision to the worker’s physician or employing institution.
Many physicians say that policy is too vague--a problem they attribute to the difficulty of getting agreement on the subject. They say the CDC offers no guidance in determining who should continue to work and what procedures they might perform.
“The truth is, we have to do a better job of dealing with the issue,” said Dr. Neil Schram, a Los Angeles County internist who will take part in the August meeting. “Most organizations, so far, have tried to duck the issue.”
Some would like the CDC to identify surgical procedures that seem to pose the greatest risk of transmission. Past experience with hepatitis B, another blood-borne virus, indicates that a small number of operations are especially risky.
Vaginal hysterectomy and pelvic surgery are among the most hazardous, Rhame and others said. Those procedures involve manipulation of sharp surgical instruments inside body cavities, often “by feel” rather than in direct view of the surgeon.
A few medical groups have already adopted more explicit rules.
The California Medical Assn. last year approved a policy recommending that infected workers “exclude themselves or be excluded from performing” so-called exposure-prone procedures. Workers who continue to do those procedures “have an obligation to ensure they are free from infection,” the policy states.
At the University of Minnesota Hospital, where Rhame works, surgeons who have reason to suspect they might be infected are expected to get themselves tested. Those who are infected are barred from performing certain invasive procedures.
Rhame would also like the CDC to address what he called “the disclosure issue”: What is the obligation of an infected health-care worker to reveal his or her condition to a patient, either by volunteering the information or when asked?
“I think that the moral obligation to (reveal one’s) status is contingent on what the probability of transmission is,” Rhame said. A nurse, orderly, dietary worker or internist is not morally obliged to answer the question of whether he or she is infected.
On the other hand, a worker who accidentally sticks himself with a needle and then sticks a patient must tell the patient, Rhame said. At his hospital, the worker must then be tested for the AIDS virus and hepatitis B if he wants to remain employed.
Many health officials said the case of the dentist underlines, above all, the need for rigorous adherence to existing infection-control procedures. If closely followed, those procedures will protect patients and health-care workers alike, they said.
“The philosophy is that health-care workers should be encouraged to get themselves tested, in particular if they have non-occupational risks for infection,” said Gerberding of UC San Francisco. “And regardless of whether they know they are infected, they should practice a more rigorous standard of infection control in invasive procedures.”
