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A dangerous first in AIDS transmission?

A dangerous first in AIDS transmission?

The Centers for Disease Control has just reported evidence indicating that for the first time a health care professional with AIDS has transmitted the causative virus to a patient during a medical procedure.(1)

The case involved a dentist with AIDS who, while wearing gloves and a mask, removed two teeth from a young woman. Two years later the woman developed AIDS.

Evidence from an epidemiological investigation and laboratory tests "is consistent with transmission" of the AIDS virus from the dentists to the woman, the CDC said.

Epidemiologists at the CDC said they presumed the dentist's blood had gone directly into the patient's open wound or had somehow contaminated the instruments used in the procedure. Tests of the molecular structure of the AIDS viruses cultured from the dentist and the patient were very similar, strongly signifying that the cases were linked.

Investigators ruled out as best they could that the woman had been infected in some other way, such as through sex with an HIV-infected partner. But the CDC said it could not prove that the virus had been transmitted between the dentist and the patient, or precisely how. "The possibility of another source of infection cannot be entirely excluded," it said.

The CDC report explained that the patient had two maxillary third molars extracted under local anesthesia in the dentist's office. The dentist had been diagnosed with AIDS three months earlier. Written documentation of the extraction procedure was limited.

The patient reported that she received no general anesthetic or sedative and the dentist wore gloves and a mask during the procedure. She did not recall, nor did review of the dental records reveal, any circumstances that would have exposed her to the dentist's blood (e.g., an injury to the dentist, such as a needlestick or cut with a sharp instrument).

While the CDC did not identify the state health department that reported the case and had charge of the investigation, a New York Times article(2) said it was Florida. The Florida Department of Health and Rehabilitative Services declined to comment because of a Florida law that prohibits discussion of AIDS cases.

While the mode of transmission from the dentist to the patient remains a mystery, the strongest evidence for the link comes from new DNA sequencing tests of the molecules in the AIDS viruses cultured from both individuals. The DNA tests were carried out at the CDC and the analyses done in collaboration with the Los Alamos National Laboratory. The viruses were found to be extremely close.

"Although the viral sequences from the dentist and the patient could be distinguished from each other, they were closer than what has been observed for pair-wise comparisons of sequences" selected at random, the CDC said.

The case is the first of possible transmission from a health professional to a patient among the more than 140,000 AIDS cases reported to the CDC since the epidemic was discovered in 1981. While the attendant risk is thus extremely low, the case seems certain to renew debate about what restrictions should be imposed on HIV-infected health care workers who perform surgery and other invasive procedures.

Currently the CDC's nonbinding guidelines, which will now be reevaluated, say the decision as to whether a health care worker with AIDS may continue to do these procedures should be made by the worker's personal physician and administrators of the hospital or clinic. The guidelines do not address such questions as these: Who has authority over infected dentists and doctors who practice in offices? Should all dentists and doctors who do invasive procedures be tested for the AIDS virus? Should those found to have the virus be required to tell their patients?

These questions cry for answers. After all, health professionals are supposed to be agents of healing, not couriers of death.

1. Centers for Disease Control. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 39(29): 489-493, 1990. 2. Altman, L.K. U.S. says study suggests dentist conveyed AIDS. N.Y. Times, p. A1, July 28, 1990.
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Title Annotation:dentist-to-patient transmission
Author:Fitzgibbon, Robert J.
Publication:Medical Laboratory Observer
Article Type:editorial
Date:Sep 1, 1990
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