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CDC weighs stronger AIDS precautions.

CDC weighs stronger AIDS precautions

The Federal Centers for Disease Control (CDC) is now reconsidering the adequacy of existing guidelines to protect medical professionals and patients from bloodborne infectious diseases. A report, which may emerge this spring, is expected to address a number of weighty issues such as mandatory HIV testing for health care workers.

Pressures to revise existing policies had been building for several months. One of the most significant events was the AIDS death last November of Rudolph Almaraz, M.D., a Johns Hopkins Hospital breast cancer specialist who operated on approximately 1,800 patients after becoming infected with HIV.

Two of those former patients filed suit against Johns Hopkins and the Almaraz estate, alleging failure to disclose the surgeon's infection before he operated on the plaintiffs. According to hospital officials, the surgeon told neither the facility nor his patients of his status, despite their attempts to confirm or dismiss rumors.

Hopkins officials further demanded that the Government move to help fill what they termed a "policy vacuum" on management of HIV-infected health care workers.

In another case, a Florida dentist allegedly infected three patients with the AIDS virus before dying of the disease. One of the patients recently received a $1 million malpractice settlement. Some experts believe medical insurers may soon demand HIV testing to limit their liability exposure. They say it will take only a few more million-dollar awards to infected patients before companies that write malpractice policies insist on HIV testing as a precondition for coverage.

In late January, CDC released a draft report estimating that 13 to 128 Americans have been infected with the AIDS virus by their surgeons or dentists since 1981.

More specifically, CDC estimates that 336 HIV-infected surgeons transmitted the virus to 3 to 28 patients during invasive procedures and that some 1,248 infected dentists transmitted HIV to 10 to 100 patients during tooth extractions, oral surgery, or other invasive procedures.

The report also addressed transmission of hepatitis B virus, estimating that 124,000 of the nation's surgeons and 166,000 dentists are HBV-infected. But while HBV infection is of great concern, particularly within the clinical laboratory community, the nature of the AIDS epidemic has tended to dominate discussions about the need for additional precautionary guidelines.

Those discussions swung into high gear in late February at an open two-day meeting sponsored by the CDC in Atlanta. About 90 organizations or individuals presented comments. A majority suggested that no Federal policy change is warranted. A spokesman from the American Public Health Association, for example, said that any policy changes should be based on "science instead of fear and prejudice."

Appearing at the meeting was John Bryan, M.D., a pathologist at Emory University Hospital who spoke on behalf of the College of American Pathologists (CAP) and the American Society of Clinical Pathologists (ASCP).

According to Bryan, "The CAP and ASCP oppose mandatory testing of health care workers because we believe that if universal precautions are taken by health care workers, the possibility of transmission of the [AIDS] virus to patients is virtually nonexistent."

The spokesman explained that wide-scale testing would present problems because of the very nature of current tests. The original goal of the ELISA test was to insure a safe blood supply, thereby halting the spread of AIDS, Bryan noted. And for that reason, the test is sensitive rather than specific and gives false-positive results.

The Western blot test may confirm the presence of HIV antibody, indicating HIV infection, or it may be negative, indicating the ELISA was a false positive. But Bryan said the complexity of reading the Western blot is cause for concern. "When these tests are applied to low-risk populations with a low prevalence of disease, a major problem with false-positive results may occur," he explained.

ASCP and CAP also oppose mandatory HIV testing because it could "seriously curtail availability of health care workers in high-risk professions, such as the clinical laboratory field," according to Bryan.

As an alternative, the pathology groups support voluntary HIV testing of health workers that would guarantee informed consent, confidentiality, and appropriate counseling. Should the worker test positive, such programs would assist in making arrangements for early treatment interventions.

Officials believe the voluntary approach will be most productive because it will encourage early entry of HIV and HBV seropositive workers into local counseling, and promote education, behavior modification, and infection control responses.

In addition, Bryan urged that enforcement of existing universal precautions should be strengthened, and that greater emphasis should be placed on surveillance and case detection of HIV transmission at the local level.

Finally, Bryan said ASCP and CAP oppose practice restrictions based on procedure. Any restrictions should be related to high-risk circumstances or demonstrated transmission, and, if imposed, should be subject to periodic review of their continuing need, he stated.

Other delegates to the meeting addressed the responsibilities of infected providers and the reliability of CDC's transmission risk estimates.

Representing the American Medical Association, Nancy Dickey, M.D., stated the official AMA view: "Physicians who are HIV-positive have an ethical obligation to avoid any professional activity that has an identifiable risk of transmission of the infection to a patient. Or they may proceed with the patient's informed consent."

Before reaffirming that policy in Atlanta, Dickey said AMA gave careful consideration to the consequences or "ripple effects" of its position. Some observers have suggested, for example, that the policy may be taken as tacit approval for mandatory testing.

Dickey stated, however, that mandatory HIV testing for health workers "would be no more successful or cost-effective than mandatory testing for marriage license applicants." Two states enacted such requirements but later repealed them because of the low incidence of infection. Health care workers would need to be tested periodically, and even then, some of those infected would register negative because they had not yet seroconverted, she observed.

Dickey said the AMA sees other complications with mandatory HIV testing. "When the very low probability of a surgeon acquiring AIDS from an infected patient is multiplied by the even lower probability that the same physician would then transmit the infection to a patient, the risk to patients of becoming infected is virtually immeasurable, much lower than the risk that an already-infected surgeon would transmit the disease."

CDC's report estimates the risk of an HIV-infected physician's transmitting the virus during surgery is anywhere from 1 in 41,667 to 1 in 416,667. But several meeting attendees said any such estimates may be flawed because only sketchy data exist on how often doctors injure themselves and how often the injuries result in blood-to-blood contact.

Dickey added that calculations on the number of HIV-positive doctors may be off because they hinge on estimates such as the number of Americans infected with the virus, thus multiplying the chance of error.

To improve understanding, the spokesperson reported that AMA has formed a task force on the personal and educational needs of HIV-infected doctors. Working with a group at Yale University, the task force will address current resources available, new resources needed, specific projects appropriate for AMA, and potential roles for organized medicine and others.

Following the Feb. 21-22 meeting, CDC allowed a 30-day period for commenters to submit formal remarks. Officials said they would then consider the recommendations and determine what, if any, changes in Federal policy might be appropriate. It was unclear at this writing how long the process might take.

In the meantime, it's also uncertain what if any additional action may take place at the state level. New York State, with the most AIDS cases in the country, has already chosen not to wait for CDC. Instead, the state has issued guidelines by which infected providers need not tell patients of their status and may continue to perform invasive procedures.

The New York State Health Commissioner said that health professionals at risk for AIDS should be tested for their own benefit but should be able to continue all practices for which they are qualified.

Officials said New York has no regulations that would prohibit physicians from practicing unless their performance or judgment had been impaired by alcohol or drug abuse. The state health department developed its own guidelines on infected health care workers after several hospitals requested guidance.
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Title Annotation:Centers for Disease Control
Publication:Medical Laboratory Observer
Date:Apr 1, 1991
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