Investigations of Patients of
Health Care Workers Infected with HIV: The Centers for Disease
Control and Prevention Database
 Laurie
M. Robert; Mary E. Chamberland; Jennifer L. Cleveland; Ruthanne
Marcus; Barbara F. Gooch; Pamela U. Srivastava; David H. Culver;
Harold W. Jaffe; Donald W. Marianos; Adelisa L. Panlilio; and
David M. Bell
http://www.annals.org/cgi/content/full/122/9/653
1
May 1995 | Volume 122 Issue 9 | Pages 653-657
Objective:
To assess
the risk for transmission of the human
immunodeficiency virus (HIV) from an infected health care worker
to patients.
Design:
Survey of
investigators from health departments, hospitals, and
other agencies who had elected to notify patients who had
received care from health care workers infected with HIV.
Measurements:
Information
was collected about infected health care workers,
their work practices, their patients' HIV test
results, procedures that they did on those of their patients
who were tested for HIV, and patient notification
procedures.
Results:
As of 1
January 1995, information about investigations of 64
health care workers infected with HIV was reported to
the Centers for Disease Control and Prevention; HIV test results
were available for approximately 22 171 patients of 51 of
the 64 health care workers. For 37 of the 51 workers,
no seropositive patients were reported among 13 063
patients tested for HIV. For the remaining 14 health
care workers, 113 seropositive patients were reported
among 9108 patients. Epidemiologic and laboratory
follow-up did not show any health care worker to have been a
source of HIV for any of the patients tested.
Conclusion:
Despite
limitations, these data are consistent with previous
assessments that state that the risk for transmission
of HIV from a health care worker to a patient is very small.
These data also support current recommendations that state
that retrospective patient notification need not be
done routinely.
The risk for
transmission of the human immunodeficiency virus
(HIV) from a health care worker infected with HIV to patients
has not been well quantified. After publication of the
reports of the transmission of HIV from an infected
dentist to six patients in a Florida dental practice
[1, 2], many health
departments, hospitals, and other agencies began
investigations of health care workers infected with
HIV and notified patients who had received care from
these workers. In many investigations, the Centers
for Disease Control and Prevention (CDC) provided epidemiologic
and laboratory assistance. Only a minority of these
investigations have been published
[3-20]. We summarize
the results of all published and unpublished
investigations of which the CDC is aware, excluding
the investigation of the previously described Florida
dental practice
[1, 2].
Methods
In March 1992, the CDC developed a database to monitor the
results of retrospective investigations of health
care workers infected with HIV. All of these
investigations included the notification of patients,
with the exception of the investigations of three
U.S. Navy dentists; in these three cases, investigators reviewed
the HIV testing records of military personnel treated by
the dentists
[14]. We surveyed
persons responsible for conducting these
investigations (such as health department officials, hospital
and clinic administrators, and prison officials) to
collect information about the infected health care
workers, their practices, their patients' HIV test
results, the procedures they did on the tested
patients, and patient-notification procedures. All of
the health care workers had practiced in the United States,
except for two who had practiced in the United Kingdom and
one who had practiced in Australia.
The scope
and comprehensiveness of the investigations varied
widely. In a few instances, investigators developed a careful
protocol with which to conduct patient notification and
follow-up studies. In some situations, officials
elected to notify patients but not to offer HIV
testing; in others, testing was not well monitored
and the number of patients tested could only be approximated.
In still other investigations, no data about HIV test
results were collected.
Patients
were notified if they had been treated during periods
that were established by the investigators on the basis of
various factors, including the health care worker's
medical history, the length of time the health care
worker had been in a particular practice, the
procedures the health care worker did, and the
availability of patient records.
Results
As of 1 January 1995, information was available for 61 health
care workers from 24 states, one U.S. territory, and the
U.S. Department of Defense; 2 workers from the United
Kingdom; and 1 worker from Australia. Eight
investigations (13%) began in 1987-1990; 47 (73%)
began in 1991; 6 (9%) began in 1992; 2 (3%) began in
1993; and 1 (2%) began in 1994.
Profile of the Health Care Workers Infected with HIV
The 64
health care workers comprised 29 dentists (45%); 4 dental
students (6%); 10 surgeons (16%) whose specialties
included general, thoracic, breast, trauma, and
orthopedic surgery; 4 obstetricians (6%); 12
nonsurgical physicians (19%) specializing in family
practice, internal medicine, pediatrics, emergency
medicine, or anesthesia; 2 surgical technicians (3%); 1 medical
student (2%); 1 dental assistant (2%); and 1 podiatrist
(2%). Six of the 64 health care workers were
residents or fellows during the period for which the
data were collected.
The
health care worker's medical condition while providing care
to patients was not systematically reported. Eleven health
care workers were known to have been asymptomatic
while practicing. Three dentists were reportedly
mentally impaired while practicing; one family
practitioner did procedures with weeping dermatitis
of his hands
[6].
Patient Notification and Testing Procedures
In 53 of
the 64 investigations (83%), decisions about the notification
of patients were made in consultation with a review panel.
Panels may have included a representative from a
state or local health department (74%), a physician
specializing in infectious diseases or a hospital
epidemiologist (47%), a hospital attorney (28%), a
hospital administrator (26%), a health care worker in the
same specialty as the worker infected with HIV (28%), the
infected worker's personal physician (25%), an
infection control practitioner (21%), a dental or
medical school dean (19%), and a member of a state
licensing board (2%). In 42% of the investigations,
other persons, such as faculty members, ethicists, chiefs of
staff, and corrections personnel, were included on review
panels.
In 14
investigations, patients were notified only if they had
had invasive procedures, as defined by the investigators,
during the period when the health care worker was
thought to have been infected. In 1 investigation,
patients were notified only if they had had a
procedure done while the health care worker had had a
specific medical condition (severe dermatitis of the hand)
that may have placed his patients at an increased risk for
acquiring HIV
[6]. In 41
investigations (64%), patients were notified by
letter. Although the media publicized 91% of all investigations,
this publicity was the only form of notification in 30% of
the investigations. Patients were offered HIV
counseling and testing in 55 (86%) of the 64
investigations. Dedicated testing sites or times were
established in 39 investigations.
Results of HIV Testing
Results
from HIV tests were available for patients of 51 of
the 64 health care workers; test results were not collected
for the patients of 13 health care workers. None of the
patients of these 13 workers identified him- or
herself to health officials as being seropositive for
HIV.
As of 1
January 1995, approximately 22 171 patients of 51 health
care workers had been tested. Tested patients represent
17% of all patients treated by 45 of the 51 health
care workers (information not available for 6
workers). For 37 health care workers, no seropositive
patients were reported among 13 059 persons tested.
Seventeen of these 37 workers were dentists, 4 were
dental students, 8 were nonsurgical physicians, 5 were
surgeons, 2 were obstetricians, and 1 was a podiatrist.
For the remaining 14 workers, 113 seropositive
patients were identified among 9108 patients known to
have been tested. The number of patients infected
with HIV per health care worker ranged from 1 to 41 (Table
1).
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Table 1. Patients Seropositive for HIV from the Practices of
Health Care Workers Infected with HIV, January 1995
Table 1. Patients
Seropositive for HIV from the Practices of Health Care Workers
Infected with HIV, January 1995
Follow-up of Patients Infected with HIV
Epidemiologic and laboratory follow-up has been completed for
110 of the 113 seropositive patients
Table 2: Twenty-eight
were documented as having been infected before
receiving care from the infected health care worker;
62 had established risk factors (as defined by the
CDC acquired immunodeficiency syndrome [AIDS] case
definition) for acquiring HIV; 15 did not have clearly
established risks but had had opportunities for potential
exposure to HIV, such as multiple sex partners or
exchange of sex for money or drugs; and 5 had no
identified risk. Of these 5, 1 had had only a single
diagnostic examination by a dentist infected with HIV
[7]. The remaining 4
had been treated by a dentist who practiced in an
inner-city area with a high prevalence of HIV
infection
[8].
Table 2.
Epidemiologic and Laboratory Follow-up of Patients Infected
with HIV, January 1995*
Table 2.
Epidemiologic and Laboratory Follow-up of Patients Infected with
HIV, January 1995*
Genetic
sequence analysis was done on HIV strains from three
health care workers and 30 of their patients who were
seropositive, including 3 of the 5 patients who had
no identified risk and 13 of the 15 patients (87%)
with potential but undocumented risks for exposure.
Sequencing was done by the CDC
[7, 8] for
all but 1 of the 30 patients
[12]. In no instances
were the viral strains of patients and health care
workers found to be related
[7, 8, 12] (Table
2). Sequencing was not done for the
remaining seropositive patients because either they or the
health care worker had died before a blood sample
could be collected, had refused to provide a blood
sample, or had been lost to follow-up.
Procedures Done on Patients Tested for HIV
Data
about the number and types of procedures done by health
care workers were available for 9160 patients from the
practices of seven dentists
[4, 5, 7, 9, 18], two
surgeons
[12, 13], two
obstetricians, and one family practitioner
[6]. Results of HIV
tests were available for 4245 (46%) of these patients;
these 4245 patients were 19% of all patients with
known HIV test results.
Dental Procedures
Three of
the seven dentists practiced general dentistry; one
specialized in periodontics; one specialized in pediatric
dentistry; and two were students. Five of the
dentists had AIDS; two were infected with HIV but did
not have symptoms. During the period under
investigation, these seven dentists treated an estimated
6740 patients. Data on a total of 22 134 procedures were
available for 3813 patients; HIV test results were
reported for 1826 (48%) of these patients (Table
3). Of the 1826 patients, 21% to 41% had
had one or more procedures, such as oral surgery, restorative
procedures, or crown and bridge work, that may have
required the administration of local anesthetic or
that could have caused patient bleeding.
Table 3. Number and
Type of Dental Procedures Done in the Practices of Seven
Dentists Infected with HIV*
Table 3. Number and Type
of Dental Procedures Done in the Practices of Seven Dentists
Infected with HIV*
Obstetric and Surgical Procedures
Information on procedures was available for three physicians
who did obstetric or gynecologic surgical procedures on a
total of 1899 women; HIV test results were known for
832 (44%) of these women (Table
4). One of the physicians was infected with
HIV but was asymptomatic; another was symptomatic but did
not have AIDS; and the third had an AIDS-defining
illness and weeping dermatitis of the hand
[6]. In two of the
investigations, patients were classified only once
into a mutually exclusive listing of procedures;
therefore, the total number of procedures done for
patients with HIV test results is unknown. Overall, 46%
of all women who had had either major gynecologic surgery
or vaginal or cesarean deliveries were tested.
Table 4.
Number and Type of Obstetric and Gynecologic Procedures from
the Practices of Three Health Care Workers Infected with HIV*
Table 4. Number and
Type of Obstetric and Gynecologic Procedures from the Practices
of Three Health Care Workers Infected with HIV*
Data on
procedures have been published for a breast surgeon
with AIDS and an orthopedic surgeon infected with HIV
[12, 13].
Results of HIV tests were known for 1587 (46%) of the 3448
patients in these two investigations who had had an
invasive procedure.
Discussion
We have summarized the largest existing database on
retrospective evaluations of patients who have been
treated by health care workers infected with HIV.
Excluding the previously described Florida dental
practice
[1, 2], no cases of
transmission of HIV have been documented among
approximately 22 171 patients tested. These results
are consistent with previous assessments by the CDC,
which concluded that the risk for transmission of HIV
from a health care worker to a patient during an invasive
procedure is very small
[21-23].
Our data
have important limitations, however, which are due
primarily to difficulties in obtaining test results, records,
and blood specimens. Results of HIV testing are known for
only about 17% of patients who were treated by the
infected health care workers during the periods under
investigation. Data on procedures are available for
only 19% of the patients with known test results;
thus, it is not known how many of the remaining
patients tested for HIV had had invasive procedures and possible
contact with the blood of a health care worker. In most
cases, the stage of the health care worker's HIV
infection during the time the worker did procedures
is not known—for example, it is not often known
whether the worker had developed AIDS, the stage of
infection at which the titer of HIV in the blood is
highest and the risk for transmission might be increased
[24, 25]. Finally,
even a study population of 22 171 patients might lack
sufficient statistical power to detect a low-frequency
event, especially if, as seems likely, the risk for
transmission is greatest for only a subset of health
care workers or procedures
[21, 22, 26]. In view
of the great heterogeneity of procedures and health
care workers summarized here, we have refrained from
using these data to calculate numerical estimates of the mean
or confidence intervals for the risk for transmission of
HIV from workers to patients, either collectively or
for individual specialties. These limitations
notwithstanding, it seems likely that if HIV were
easily transmitted from health care worker to
patient, evidence of such transmission would have been detected
in these investigations, particularly in situations in
which a health care worker's altered mental status or
breach of infection control practices was noted
[6, 8].
Many of
these retrospective investigations involved intensive
effort and the expenditure of substantial resources by
hospitals, state and local health departments, and
the CDC
[6, 12, 13].
Failure to find additional instances of transmission to
patients supports recommendations by the CDC and
others that state that retrospective patient
notification need not be done routinely, but should
be considered on a case-by-case basis, taking into
account an assessment of risks, confidentiality issues, and
available resources
[6, 21, 26, 27].
Author and Article Information
From the National Center for Infectious Diseases and the
National Center for Preventive Services of the Centers for
Disease Control and Prevention, Atlanta, Georgia.
Requests for Reprints: Laurie M. Robert, MS, Hospital
Infections Program, Mailstop E-68, Centers for Disease Control
and Prevention, 1600 Clifton Road, Atlanta, GA 30333.
Acknowledgments: The authors thank Robert Comer, Nancy
Bringman Taylor, Audrey Smith Rogers, Paul Arnow, Russell
Martin, William Wolverton, Paul Silverman, Richard Danila,
Robert Scott, Jenice Longfield, Kevin Gipson, William Hall, Bob
Greenlee, Kim Callanan, R. Lynn Browder, Bobby Jones, Gordon
Dickinson, Don Conner, Rebecca Meriwether, M. Geoffrey Smith,
Patricia Checko, Mary Lou Fleissner, Sean Flood, Perry Smith,
Calvin Linnemann Jr., Karen Chapman, Harold Laswell, Stacey
Bourgeois, Michael Heuer, Georgia Thomas, Ban Mishu Allos, Mark
Miller, Karen Smalley, Ronald Altman, Rick Reich, James Cottone,
John Weston, Beverly Dahan, Bryan Bartlett, Reginald Finger,
Patricia Starr, Karen Adams, Shirley Crawshaw, Mark Bek, Kholoud
Porter and Jeff Jones for supplying data; Penny McKibben for
assistance with data management; and Sara Critchley for
assistance with tables. Data from investigations in the United
Kingdom and Australia were provided by the Communicable Disease
Surveillance Centre, London, and Sydney and New South Wales
health authorities.
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