Infected Provider Update

CDC: French HIV surgical case will not affect U.S. policy on infected providers

New case may end ‘denial’ about Florida dental cluster

Though coinciding with calls to reopen Centers for Disease Control and Prevention guidelines on infected providers, the recent case of surgeon-to-patient HIV transmission in France heralds no immediate changes in U.S. policy, a top CDC official tells Hospital Infection Control.

"The fact that this is only the second health care worker in the history of the HIV epidemic who has been documented to have transmitted to a patient — plus the fact that of the 968 patients they tested, only one was found to be infected — supports our assessment that the risk of this is very small," says David Bell, MD, chief of the HIV infections branch in the CDC hospital infections program. "We don’t have any immediate plans to make any changes in recommendations based on this case."

French health officials announced in January that an orthopedic surgeon diagnosed with AIDS in 1994 apparently transmitted the virus to a patient during a surgical procedure in 1992 at a hospital near Paris. Typing of the viral strains of the patient and the surgeon to compare nucleotide sequences revealed that the viruses were so closely related genetically that the transmission was "highly probable," French officials concluded. The CDC regards the case as "completely verified," says Bell, considering the match with DNA sequencing and the epidemiology evidence.

"When you combine the clinical and epidemiologic investigation along with the laboratory investigation, it is very compelling," he says.

The case is significant in that the 1990 Florida case of transmission from a dentist to six patients is no longer the only reported incident of provider-to-patient HIV transmission.1-3 Though it formed the basis for current CDC guidelines on the issue, the controversial dental case spawned a variety of alternative theories in press coverage and medical meetings, such as the patients all having other risk factors or the dentist having infected them intentionally.4 Yet with more than 20 documented cases of provider-to-patient transmission of hepatitis B — not including several HBV transmission cases recently reported in the United Kingdom — some observers had predicted that another HIV transmission case would eventually occur. (See related story, p. 36.)

"We have always felt that although the risk of transmission is very low, it is not zero," Bell says. "Some people who may be less familiar with the epidemiology of bloodborne pathogen transmission in health care settings may have doubted that a case like the dentist could ever occur, and may have thought that the lack of subsequent reported cases casts doubt on even the dentist case. I think for those folks this new report may be a revelation that in fact these transmissions are possible."

Indeed, even some members of the infection control community have tended to view the Florida case as a "fluke," says William Schaffner, MD, professor of infectious disease and chairman of the department of preventive medicine at the Vanderbilt School of Medicine in Nashville.

"In my personal opinion there is a lot of denial," he says. "The first thing that this [French] episode may do is reduce that denial, and it may legitimize the results of the dental investigation."

Still, much more information is needed about the French case before it can be seriously considered for infection control implications in the United States, Schaffner notes.

"The news reports are provocative, but what the hospital epidemiology community will wait for is a definitive publication which examines all of the issues that surround this instance of transmission," he says. "When that is complete, that — along with the recent data from the United Kingdom on transmission of hepatitis B — could reopen this [guidelines] question."

Injury during procedure suspected

Though the case is expected to eventually be more completely described via publication in a peer-reviewed medical journal, initial reports from French health officials indicate the surgeon may have transmitted the virus during a prolonged orthopedic procedure of some 10 hours.

"We know that the patient had undergone a long procedure," Florence Lot, MD, epidemiologist at the National Public Health Center in Paris, tells Hospital Infection Control. "We [speculate] that the surgeon had an injury, but we have no information on that."

Indeed, a press release from the center stated that an assessment of surgical practices indicated that the surgeon experienced wounds or cuts during operations, and may have subsequently exposed patients to his blood. Noting that such injuries are common in orthopedic procedures, the French center reported there were no obvious breaches in infection control identified. Standard measures were in place for prevention of accidental exposures to blood, and for the treatment and sterilization of medical and surgical material, the center stated.

"The surgeon’s exposures seemed to be related more to orthopedic surgical techniques than to the practices of the surgeon himself," the report stated. In that regard, the 1991 CDC guidelines on the issue cite orthopedic procedures among the "exposure-prone" specialties with increased likelihood of suture needlesticks or other sharps injuries that could lead to transmission to patients.

Surgeon considered risk too low for testing

According to French officials, patient notification and testing in France began in October 1995, after the HIV-positive status of an orthopedic surgeon in Saint Germain en Laye (a suburb of Paris) was disclosed in the press. Review of the medical history of the surgeon suggests he was likely infected with HIV in May 1983. The diagnosis of HIV seropositivity and AIDS were made simultaneously in March 1994. The surgeon, who thinks he must have been occupationally infected during a procedure, considered the risk of transmission from patients to be too low to warrant HIV testing before 1994, according to French reports.

"He had never been tested — that’s what he said," Lot says. "There was no test in 1983, and he thought that the risk of transmission was so low that there was no problem."

Another factor that may have influenced transmission to the patient is that the surgeon’s HIV viral titer may have been particularly high, as the case occurred only two years before he was diagnosed with AIDS.

"The procedure on the patient was in 1992 and the surgeon was diagnosed with AIDS in 1994, so that is just a supposition," Lot says.

Overall, the investigation has identified 3,004 patients who underwent at least one invasive procedure by the surgeon. Of the 2,458 patients that have been successfully contacted, testing has been done on 968. Though only one case has been documented, it remains possible that more transmission occurred, because only 32% of the surgeon’s patients who underwent invasive procedures have been tested. Meanwhile, the French Ministry of Heath has formed an advisory committee to consider recommendations for prevention of HIV transmission from health care workers to patients. The case has raised the initial question of whether French health care workers who perform invasive procedures should be tested for HIV, Lot concedes.

"It’s under discussion, but for the moment there are no official recommendations," Lot says.

CDC guidelines concluded the risk does not warrant mandatory testing, recommending instead that health care workers voluntarily assess their HIV and HBV e-antigen status. Those infected should then consult expert medical review panels to discuss under what conditions they could continue practice.

While the French HIV case and the new reports of HBV transmission in the U.K. do not necessarily warrant any immediate changes in U.S. infection control policy, they do underscore that the CDC’s 1991 guidelines are becoming increasingly dated, says David Fleming, MD, state epidemiologist at the Oregon Health Department in Portland.

Prior to announcement of the French case, Fleming and other members of the CDC Hospital Infection Control Practices Advisory Committee (HICPAC) requested the agency update the guidelines. CDC officials say the matter has been under discussion, but there will be no update unless warranted by new scientific data. (See related story in Hospital Infection Control, February 1997, p. 17.)

ADA doesn’t provide full protection

The specter of state and federal legislative action — primarily targeting workers infected with HIV — has been cited as a potential hazard of reopening the issue. And even with the 1992 passage of the Americans with Disabilities Act, health care workers fired after discovery of their infection face an uphill battle convincing courts they pose little threat to patients, legal observers note. (See related story, p. 38.) Indeed, some could take the view that the recent report of HIV transmission in France warrants restrictive measures in addition to those currently proposed by the CDC. On the contrary, the case emphasizes how rare such an event is, Fleming notes.

"In my mind it was just a matter of time before another instance after the Florida dentist would be documented," he says. "The fact that people have been looking very hard for years confirms how low this risk is. I would hope that reopening the recommendations would result in national and state policies that would reduce the risk of discrimination against HIV-infected health care workers."

In addition, the CDC guidelines do not address hepatitis C virus, which, unlike HBV, has no vaccine and is more transmissible than HIV per exposure incident.

"My concern is that there is an inconsistency that people could appropriately call us on," Fleming says. "You have two diseases — HIV and HBV — for which you recommend similar kinds of restrictions. There is a third disease — HCV — which by most people’s accounting would fall intermediately between those two diseases as far as risk of transmission and seriousness of disease. Yet that has been excluded from these recommendations. In order for the recommendations to have internal validity, hepatitis C needs to be addressed."

The 1991 guidelines also are problematic in that they advise health care workers to confidentially report to expert review panels, but also to inform patients before continuing invasive procedures. As written, the CDC guidelines state that circumstances for continuing practice would include "notifying prospective patients of the health care worker’s seropositivity before they undergo exposure-prone invasive procedures." It is unlikely that anyone following such a provision would be able to continue a medical practice, Fleming says.

"I personally think that the recommendation about prospective informed consent is not workable and not indicated by the available data," he says.

Indeed, as a practical matter, the idea of disclosing a bloodborne infection with any hopes of continuing a medical practice is tantamount to "career suicide," says Eddie Hedrick, BS, MT (ASCP), CIC, infection control manager at the University of Missouri Hospital and Clinics in Columbia. Under that hospital’s policy, infected health care workers are encouraged to voluntarily come forward for confidential medical review, and are assured of alternative job assignments if it is determined their current role is inappropriate, he says.

"We reassure them they are not going to commit career suicide," he says. "The institution will stand behind them and either get them into an academic position or something else. If you don’t make a commitment to that first, nobody is going to come forward, and most people aren’t going to come forward anyway."

Quit chasing down pathogens

Indeed, rather than trying to add HCV-infected workers to the guidelines — and inevitably those infected with some other pathogen down the road — Hedrick argues it is better to focus efforts on ensuring that health care workers who perform invasive procedures have good overall infection control measures and medical competence.

"We could keep adding to this list for 40 years," he says. "My approach to this is, I don’t care what disease the person has, I care how they practice. I think what we need to be doing is looking at the practice of surgery in general to see what can be altered. For example, blunted [suture] needles are a good idea." (See related story, p. 43.)

Though no proponent of legislative solutions to medical problems, Hedrick says it might be time to mandate HBV immunization for U.S. surgeons, as has been done in the UK.

"It is a benefit for both the surgeon and the patient," he says. "I am not big on legislation, but in that case I could buy it. I think the public has a legitimate right to ask that that be done."

References

1. Centers for Disease Control. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990; 39:489-493.

2. Centers for Disease Control. Update: Transmission of HIV infection during an invasive dental procedure — Florida. MMWR 1991; 40:21-33.

3. Centers for Disease Control and Prevention. Update: Investigations of persons treated by HIV-infected health care workers — United States. MMWR 1993; 42:329-331;337.

4. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40:1-9.