When The Doctor Gets Infected

By Anastasia Toufexis

Many patients are eyeing their doctors and dentists with growing suspicion these days. The anxiety stems from reports of medical professionals' dying of AIDS and, most alarmingly, of a woman who claims to have been infected with the virus by her dentist during a tooth extraction. Amid the swelling concern and hyped press, the Centers for Disease Control is considering a controversial shift in policy that for the first time would recommend restrictions on health-care workers infected with the AIDS virus.

No one knows how many medical professionals harbor the blood-borne pathogen. But of the 153,000 reported cases of AIDS, about 4% have involved health-care workers, including 1,199 nurses, 679 physicians and 156 dentists and hygienists. Current CDC guidelines suggest that infected workers consult with peers about what duties to perform and that clinics and hospitals decide on a case-by-case basis what restrictions to impose in accordance with their state's rules and policies. Generally, HIV-infected staff members are allowed to practice freely as long as they follow standard infection-control techniques.

The revised guidelines under consideration are primarily aimed at the doctors, dentists, nurses and technicians who perform invasive procedures that require putting a hand holding a sharp instrument inside the body, a definition covering most surgical and dental activities. These operations carry the greatest risk of exposure to contaminated blood. The proposals call for such workers to be tested for HIV infection and, if they prove positive, to refrain from performing invasive procedures unless they have the informed consent of the patient or are faced with an emergency. The new policy would be voluntary, but medical institutions, already skittish about potential | lawsuits, could be expected to pressure their staffs to submit to testing and dismiss those who turn up positive.

The possibility of widespread HIV testing, bruited about for months, has stirred fierce opposition. The American Public Health Association, civil liberties groups and unions representing medical workers contend that a policy change at this time is misguided and scientifically unjustified. "The CDC is not focusing on public health," declares Ruth Finkelstein of the AIDS Action Council, a watchdog group. "It is focusing on public relations. The issue is being framed as one in which doctors are being irresponsible. The fact is that the public health risk from infected medical professionals is infinitesimal."

Several studies have tracked the patients of AIDS-infected doctors and dentists, but to date there has not been a single confirmed case of the virus' being transmitted from a health-care worker to a patient. The Florida incident involving Kimberly Bergalis, 22, who allegedly acquired the virus from her dentist, is still open to question. Federal investigators have not determined how she was exposed to the dentist's blood. Even if the Bergalis case is an instance of doctor-to-patient transmission, the risk is minute when compared with other medical dangers. Says Dr. Julie Gerberding, director of HIV prevention at San Francisco General Hospital: "The chance of a patient's dying from HIV infection from the care providers is many times less than the risk from hospital staph infection, anesthetic complications or treatment by an inexperienced surgeon."

In fact, there is a much greater chance of a medical worker's being infected by a patient than the reverse. So far, 40 such cases have been documented. Doctors and nurses routinely suffer needle sticks and scalpel nicks that expose them to patients' blood. If the new guidelines force health professionals to be tested for AIDS infection, it would seem only fair to test patients as well, a move that has been rejected by the general medical community as too intrusive and costly.

Firing infected doctors and nurses would destroy their reputations and livelihoods, even though they pose little risk to their patients. Such actions could thus provoke legal challenges. State laws and the Americans with Disabilities Act passed by Congress last year protect workers from discrimination based on handicaps that are not a significant threat to others.

Patient care would suffer too if infected workers are driven from practice. And what is a hospital to do every time an uninfected nurse or doctor suffers a scalpel cut? It can take six months or more for the AIDS virus to show up in tests. "Do they sit out those months?" asks Mark Barnes, policy director of the AIDS Institute, a branch of New York State's department of health. "In large urban settings you could have half the surgical staff waiting it out."

Critics argue that the best way to protect patients and medical workers is to improve infection-control techniques and equipment, something that is needed to guard against not only AIDS but also other potentially deadly blood- borne illnesses like hepatitis B. Basic precautionary measures call for workers exposed to contaminated blood to wear gowns, masks and latex gloves and to discard used syringes in special containers. Medical personnel would like to see continued development of needles that automatically sheathe themselves once they are withdrawn from the skin and flexible scalpels that minimize the chance of accidental cuts. Some operating-room teams have begun to wear protective space-suit-like outfits. Cost: $575 each.

The goal of a revised CDC policy is commendable enough: to rebuild the trust necessary between doctors and patients. But the agency may be in danger of overreacting. Pandering to fears rather than presenting facts is no way to cure public hysteria.

With reporting by Lee Griggs/San Francisco and Dick Thompson/Washington