Israeli HIV+ surgeon cleared to continue work

Provider-to-patient transmission exceedingly rare

In a case that recalls the national hue and cry of the Florida HIV dental outbreak in the early 1990s, investigators have determined that HIV provider-to-patient infections remain exceedingly rare.

A cardiothoracic surgeon in Israel specializing in open-heart procedures was found to be HIV positive in January 2007 during evaluation for fever of recent onset. The duration of infection was unknown. A lookback investigation of patients operated on by the infected surgeon during the preceding 10 years was conducted under the auspices of the Israel Ministry of Health to determine whether any surgeon-to-patient HIV transmission had occurred. Of 1,669 patients identified, 545 (33%) underwent serologic testing for HIV antibody. All results were negative. "The results of this investigation add to previously published data indicating a low risk for provider-to-patient HIV transmission," the Centers for Disease Control and Prevention reported.1

After considering the clinical details of the surgeon's case, the published literature on HIV transmission from infected health-care workers to patients, and the findings of this lookback investigation, a review panel recommended allowing the resumption of work, with no restrictions on the types of procedures the surgeon could perform, provided the surgeon met the following conditions:

1) instruction by infection-control personnel at the surgeon's hospital regarding safe practices, including adherence to standard precautions and hand hygiene requirements, double-gloving during all surgery, and immediate reporting of any cuts in gloves or fingersticks, plus agreement by the surgeon to abide by these practices;

2) routine health-care follow-up at three month intervals, including measurement of CD4 T-cell count and HIV RNA; and

3) adherence to a prescribed antiretroviral regimen, maintenance of good health, and continued CD4 T-cell level >200 cells/µL, with HIV RNA below the threshold of detection.

On the basis of the published literature, the panel did not require notification of prospective patients of the surgeon's HIV status because of the extremely low likelihood of transmission to patients if the conditions for resuming surgery were met, the CDC concluded.

The conditions were consistent with the recommendations contained in the position paper of the Society for Healthcare Epidemiology of America in 1997. By agreement with the surgeon and the administration at the hospital of current employment, an infection-control physician on the hospital's staff familiar with the case was charged with ensuring compliance with these conditions. As of June 2008, none of the 1,669 patients included in the initial contact list was listed in the national HIV registry.

In the early 1990s, CDC reported on six patients infected by a Florida dentist. Subsequently, only three additional cases have been reported: 1) probable transmission from an orthopedic surgeon to a patient in France; 2) probable transmission from a nurse to a patient, also in France; and 3) probable transmission from a gynecologist to a patient during a cesarean delivery in Spain4 In 1991, CDC issued guidelines to prevent transmission of HIV and hepatitis B virus (HBV) to patients, which required health-care workers infected with either of these viruses to refrain from performing exposure-prone procedures before obtaining counsel from a review panel and to notify prospective patients of the health-care worker's seropositivity before performing exposure-prone invasive procedures5 The guidelines provide general characteristics of exposure-prone procedures, which include digital palpation of a needle tip in a body cavity or the simultaneous presence of the health-care worker's fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site. Although medical organizations and institutions are advised to identify specific procedures falling into this category, the guidelines include cardiothoracic procedures among the types of invasive surgical procedures that should be considered exposure-prone. Regarding retrospective notification of patients who have had exposure-prone procedures performed on them by infected health-care workers, the guidelines note that more data are needed to determine the risk for transmission during such procedures, and notification should be considered on a case-by-case basis, taking into consideration an assessment of specific risks, confidentiality issues, and available resources.

During the 17 years since the CDC guidelines were issued, data based on published lookback investigations of bloodborne pathogen outbreaks and mathematical modeling indicate that the risk for transmission of HIV from an infected surgeon to a patient is considerably lower than that for HBV or HCV. Regarding cardiothoracic surgery specifically, previous lookback studies have revealed transmission of HBV and HCV but no transmission of HIV. Moreover, the degree of blood infectivity of HIV carriers has been shown to vary, in part, as a function of viral load, which can now be rendered undetectable via use of antiretroviral regimens that were unavailable at the time the guidelines were issued.

"The data in this and other studies published since the CDC guidelines of 1991, considered together, argue for a very low risk for provider-to-patient HIV transmission in the present era and could form the basis for national and international public health bodies to consider issuing revised guidelines for medical institutions faced with HIV infection in a health-care worker performing exposure-prone procedures," the CDC concluded.

Reference

  1. Centers for Disease Control and Prevention. Investigation of patients treated by an HIV-infected cardiothoracic surgeon — Israel, 2007. MMWR 2009; 57(53):1413-1415.D4+ Recovery in HIV-1 Infected Patients is Independent of Class of Antiretroviral Therapy.