dmcanzi@watserv1.waterloo.edu (David Canzi) (08/01/90)
Medical News for Week Ending July 29, 1990
Copyright 1990: USA TODAY/Gannett National Information Network
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July 24, 1990
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CFS TEST MAY BE DEVELOPED:
A test for chronic fatigue syndrome could be developed in the next few
months, says leading AIDS researcher Dr. Jay Levy of the University of
California, who has turned his attention to CFS. The test would identify a
specific immune system imbalance found in CFS patients and not in healthy
people. CFS symptoms include: crippling fatigue, weakness, foggy thinking,
sleep disturbances.
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July 25, 1990
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AIDS NOT PASSED FROM DOCTOR:
A Nashville, Tenn., surgeon with AIDS apparently infected none of the
hundreds of patients he operated on while infected, says a study in
Wednesday's Journal of the American Medical Association. A Vanderbilt
University School of Medicine researcher says the study provides some
reassurance for those who have worried about infected health care workers
passing the AIDS virus to patients.
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July 26, 1990
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AIDS SCREENING URGED:
Random testing at 26 U.S. hospitals found AIDS virus infections in every
community, says a study in Thursday's New England Journal of Medicine.
Infection levels varied widely, from 0.1 percent at some Western hospitals to
7.8 percent at a Newark, N.J., hospital. Study author Dr. Michael St. Louis
says the data should convince hospitals in high-risk areas to offer routine
AIDS virus screening.
HIV TO SPREAD AMONGST TEENS:
HIV is embedded in adolescent populations and may spread more widely among
teenagers, according to the National Research Council. They say that infection
rates vary substantially around the country. The Committee on AIDS Research
stresses the need for teenagers to receive specific information and assistance
to protect themselves against HIV infection.
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Center for Disease Control Reports
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Morbidity and Mortality Weekly Report
Thursday July 26, 1990
Possible Transmission of Human Immunodeficiency Virus to a Patient
during an Invasive Dental Procedure
CDC received a case report of acquired immunodeficiency syndrome (AIDS) in
a young woman for whom an epidemiologic investigation had not established a
source for her human immunodeficiency virus (HIV) infection (i.e., documented
behavioral or other risk factors, including intravenous (IV)-drug use, sex
with an HIV-infected person, or receipt of a blood transfusion or blood
components). However, investigation revealed that 24 months before her AIDS
diagnosis she had two teeth extracted by a dentist who had AIDS. Information
on the dental procedure was obtained from interviews with the patient and
reviews of her dental records and radiographs. This report summarizes the
epidemiologic and laboratory findings of the investigation.*
The patient had two maxillary third molars extracted under local
anesthesia in the dentist's office. The dentist had been diagnosed with AIDS 3
months before performing the procedure. Written documentation of the procedure
was limited. Review of the radiographs indicated that the maxillary third
molars were not impacted in bone. The patient reported that she received no
general anesthetic or sedative and that during the procedure the dentist wore
gloves and a mask. She did not recall, nor did review of the dental records
reveal, any circumstances that would have exposed her to the dentist's blood
(i.e., an injury to the dentist, such as a needlestick or cut with a sharp
instrument). The patient had not received dental care from this dentist before
the dental extractions.
Four weeks after the dental procedure, the patient sought medical
evaluation for a sore throat. Review of her medical records revealed that she
was afebrile, with moderately enlarged tonsils with ulcerations and moderately
enlarged nontender anterior cervical lymph nodes. Rash, generalized
lymphadenopathy, or fatigue were not reported or noted on the medical record.
A "strep antigen" test was negative. The patient was diagnosed with
pharyngitis and aphthous ulcers. Seventeen months after the procedure, she was
diagnosed with oral candidiasis; 24 months after the procedure, she was
diagnosed with Pneumocystis carinii pneumonia and was seropositive for HIV
antibody. The patient reported no previous test for HIV infection.
Multiple interviews of the patient and her family and friends by health
department staff and review of her medical and previous dental records did not
identify factors that may have potentially placed her at risk for HIV
infection. The patient reported no history of blood transfusions, IV-drug use,
acupuncture, tattoos, or artificial insemination. Additionally, she denied a
history of sexually transmitted diseases or pregnancies. VDRL and hepatitis B
serologies were negative. The patient has never been employed in a health-
care or other setting where she could have been exposed to HIV-infected blood
or other body fluids. She reported two boyfriends before her diagnosis of
AIDS; both were tested for HIV infection and were seronegative.
Blood specimens were obtained from the patient and the dentist. To
determine the relatedness of the HIV strains from both persons, DNA was
extracted from their peripheral blood mononuclear cells (PBMC). HIV sequences
encoding the variable regions (V3, V4, and V5) and a constant region (C3) of
the major external glycoprotein gp120 were selectively amplified using the
polymerase chain reaction (PCR) (1). Amplified HIV DNA was molecularly cloned,
and nucleotide sequences of multiple clones were determined. The relatedness
of the sequences was analyzed by several computer-based methods in
collaboration with Los Alamos National Laboratory.** This multifaceted
analysis showed a similarity between the sequences from the patient and the
dentist that was comparable to what has been observed for cases that have been
epidemiologically linked (Los Alamos National Laboratory, unpublished data).
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 taken from the other North American
isolates studied (3).
Reported by: Div of HIV/AIDS and Hospital Infections Program, Center for
Infectious Diseases; Dental Disease Prevention Activity, Center for Prevention
Svcs; National Institute for Occupational Safety and Health, CDC.
Editorial Note: The case reported here is consistent with transmission of HIV
to a patient during an invasive dental procedure, although the possibility of
another source of infection cannot be entirely excluded. No case of such
transmission has been previously described.
In this report, the possibility that the patient may have been infected
with HIV during the dental procedure is based on the following considerations:
1) the patient had an invasive procedure performed by a dentist with AIDS
(such procedures have been associated with transmission of hepatitis B virus,
which is also a bloodborne pathogen, to patients); 2) an epidemiologic
investigation did not identify any other risk factors or behaviors that may
have placed the woman at risk for HIV infection; and 3) viral DNA sequences
from the patient and the dentist were closely related. These three
considerations are discussed as follows.
First, although the dentist was infected with HIV, it is uncertain whether
the patient was exposed to the dentist's blood during the extraction
procedure. When interviewed more than 2 years after the procedure, the patient
recalled that the dentist wore gloves and a mask. The dental records
contained few details on the extraction procedure, but there was no mention of
any circumstances that may have exposed the patient to the dentist's blood.
Review of the dental records and radiographs suggest that the extraction
should have been uncomplicated.
The dentist recalled occasional needlesticks with narrow-gauge needles
used to administer local anesthetic. After the diagnosis of HIV infection,
however, the dentist did not recall sustaining a needlestick or cut resulting
in visible blood during a procedure. The dentist, who is negative for
hepatitis B surface antigen, is no longer in practice. Although the dentist
employed assistants, it could not be determined whether or to what extent the
dentist was assisted in the procedure reported here; it is not known whether
the assistants were tested for HIV infection. Details of the disinfection and
sterilization practices of the dental office are unknown.
Second, although multiple interviews with this patient and other persons
did not identify any established risk factors for HIV infection, such risk
factors involve sensitive personal behaviors that may not always be revealed
during interviews. In addition, the patient's HIV-infection status at the time
of the dental procedure is unknown. The possibility that the patient may have
been infected through another mode cannot be entirely excluded.
Third, the DNA sequence data indicate a high degree of similarity between
the HIV strains infecting the patient and the dentist. HIV-1 exhibits
considerable genetic variability, particularly in the selected regions of the
envelope gene tested. This property may be helpful in evaluating the
relatedness of viral strains isolated from different persons (2). However, use
of DNA sequencing for this purpose is new, and there is a paucity of sequence
data pertaining to the HIV-1 viruses of sex partners and other
epidemiologically related patients. The quantitative criteria for determining
epidemiologic linkage based on HIV sequences are just now being developed.
In addition, the occurrence of pharyngitis 4 weeks after the dental
procedure is consistent with an acute retroviral syndrome following HIV
infection. However, the symptoms in this patient did not include fever, rash,
or generalized lymphadenopathy, which have been described in most cases of
acute retroviral syndrome (4). Also, the time between the dental procedure and
the development of AIDS (24 months) was short; 1% of infected
homosexual/bisexual men and 5% of infected transfusion recipients develop AIDS
within 2 years of infection (5,6).
Prospective investigations of HIV transmission from patients to health-
care workers indicate that the risk for HIV transmission after percutaneous
exposure to HIV-infected blood averages 0.4% (7). Four investigations have
been reported that attempted to assess the risk of HIV transmission from
infected health-care workers to their patients (8-11). In the largest study,
616 patients who underwent surgery by a general surgeon during the 7 years
preceding his diagnosis of AIDS were tested for HIV antibody. One patient, an
IV-drug user, was positive for HIV antibody (8). Viral strains from the
patient and the surgeon were not characterized.
Transmission of hepatitis B virus (HBV), which has epidemiologic
transmission patterns similar to HIV, from health-care workers to patients
during invasive medical (primarily gynecologic surgery) and dental (primarily
oral surgery) procedures has been reported (12-15). The dental procedures in
which HBV was transmitted involved oral surgical procedures such as dental
extractions. In these reported instances, the dental workers did not routinely
wear gloves and were thought to have sustained puncture wounds or had skin
lesions or microlacerations that allowed virus to contaminate instruments or
open wounds of patients. Also, these health-care workers (when tested) have
been positive for hepatitis B e antigen, a marker that indicates very high
titers of virus in blood and correlates with increased transmissibility of
HBV.
Restrictions on patient care for health-care workers with HIV infection
have been considered by the American Medical Association (16), the American
Hospital Association (17), the American Dental Association (18), the American
College of Obstetricians and Gynecologists (19), the British government (20),
CDC (21), and other organizations. Although the specific recommendations of
these organizations vary to some extent, these recommendations generally have
stated that the risk, if any, of HIV transmission from health-care workers to
patients occurs during invasive procedures and that decisions regarding
restrictions of patient care by infected workers who perform such procedures
should be made on an individual basis.
The epidemiologic and laboratory findings in this investigation indicate
possible transmission of HIV from the dentist to the patient. Regardless of
the interpretation of the findings in this investigation, adherence to
universal precautions, including prevention of blood contact between health-
care workers and patients and proper sterilization and disinfection of
patient-care equipment, is important for prevention of transmission of
bloodborne pathogens in health-care settings (21-23). CDC is considering the
implications of this case in its review of the guidelines for prevention of
transmission of HIV and other bloodborne pathogens to patients during invasive
procedures.
References
1. Ou CY, Kwok S, Mitchell SW, et al. DNA amplification for direct detection
of HIV-1 in DNA of peripheral blood mononuclear cells. Science 1988;239:295-7.
2. Burger H, Belman A, Grimson R, et al. Long HIV-1 incubation periods and
dynamics of transmission within a family. Lancet 1990;336:134-6.
3. Myers G, Rabson AB, Josephs SE, Smith TF, Berzofsky JA, Wong-Staal F.
Human retroviruses and AIDS, 1989. Los Alamos, New Mexico: Los Alamos National
Laboratory, Theoretical Division, 1989.
4. Cooper DA, Gold J, MacLean P, et al. Acute AIDS retrovirus infection:
definition of a clinical illness associated with seroconversion. Lancet
1985;1:537-40.
5. Lifson AR, Hessol N, Rutherford G, et al. Natural history of HIV infection
in a cohort of homosexual and bisexual men: clinical and immunologic outcome,
1977-1990 (Abstract). Vol 1. VI International Conference on AIDS. San
Francisco, June 20-24, 1990:142.
6. Ward JW, Bush TJ, Perkins HA, et al. The natural history of transfusion-
associated infection with human immunodeficiency virus: factors influencing
the rate of progression to disease. N Engl J Med 1989;321:947-52.
7. Marcus R, the CDC Cooperative Needlestick Surveillance Group.
Surveillance of health care workers exposed to blood from patients infected
with the human immunodeficiency virus. N Engl J Med 1988;319:1118-23.
8. Mishu B, Schaffner W, Horan J, Wood L, Hutcheson R, McNabb P. A surgeon
with AIDS: lack of transmission to patients. JAMA 1990;264:467-70.
9. Sacks JJ. AIDS in a surgeon (Letter). N Engl J Med 1985;313:1017-8.
10. Armstrong FP, Miner JC, Wolfe WH. Investigation of a health-care worker
with symptomatic human immunodeficiency virus infection: an epidemiologic
approach. Military Med 1988;152:414-8.
11. Porter JD, Cruickshank JG, Gentle PH, Robinson RG, Gill ON. Management of
patients treated by a surgeon with HIV infection (Letter). Lancet
1990;335:113-4.
12. Welch J, Webster M, Tilzey AJ, Noah ND, Banatvala JE. Hepatitis B
infections after gynaecological surgery. Lancet 1989;1:205-7.
13. Shaw FE Jr, Barrett CL, Hamm R, et al. Lethal outbreak of hepatitis B in a
dental practice. JAMA 1986;255:3260-4.
14. Kane MA, Lettau LA. Transmission of HBV from dental personnel to patients.
J Am Dent Assoc 1985;110:634-6.
15. Ahtone J, Goodman RA. Hepatitis B and dental personnel: transmission to
patients and prevention issues. J Am Dent Assoc 1983;106:219-22.
16. American Medical Association. Ethical issues in the growing AIDS crisis:
Council on Ethical and Judicial Affairs. JAMA 1988;259:1360-1.
17. American Hospital Association. Management of HIV infection in the
hospital. 3rd ed. Chicago: American Hospital Association, 1988.
18. American Dental Association. Report of the Council on Ethics, Bylaws, and
Judicial Affairs: American Dental Association annual reports and resolutions.
Chicago: American Dental Association, 1990:147-9.
19. Committee on Ethics, The American College of Obstetricians and
Gynecologists. Human immunodeficiency virus infection: physicians'
responsibilities. Obstet Gynecol 1990;75:1043-5.
20. Department of Health and Social Security. AIDS: HIV-infected health care
workers--report of the recommendations of the Expert Advisory Group on AIDS.
London: Her Majesty's Stationery Office, 1988.
21. CDC. Recommendations for prevention of HIV transmission in health-care
settings. MMWR 1987;36(no. 2S).
22. CDC. Update: universal precautions for prevention of transmission of human
immuno deficiency virus, hepatitis B virus, and other bloodborne pathogens in
health-care settings. MMWR 1988;37:377-82,387-8.
23. CDC. Guidelines for prevention of transmission of human immunodeficiency
virus and hepatitis B virus to health-care and public safety workers. MMWR
1989;38(no. S-6).
* Single copies of this article will be available free until July 27, 1991,
from the National AIDS Information Clearinghouse, P.O. Box 6003, Rockville, MD
20850; telephone (800) 458-5231.
**Viral sequences obtained from the samples taken from the dentist and the
patient were shown to be distinct by the following criteria:
1. Each PBMC sample was split into two before extraction of DNA. PCR
amplification of human leukocyte antigen (DQ alpha) sequences was performed on
each sample. The sequences were the same between samples from the same person,
but the dentist and patient DNA samples were clearly different.
2. The average difference (4.6%, range: 2.0%-7.2%) between all viral V4-C3-V5
sequences present in the patient versus all those in the dentist was higher
than the average difference between the viral sequences present within the
dentist alone (3.5%, range: 1.2%-6.0%) and within the patient alone (2.0%,
range: 0.4%-3.6%).
3. Viral sequences in the patient possessed some unique substitutions not
found in the viral sequences from the dentist, and vice versa.
Viral sequences obtained from the samples taken from the dentist and the
patient were judged to be closely related by the following criteria:
1. Individual consensus sequences deduced from single base substitutions
(excluding insertions and deletions) in the patient's and dentist's viral
sequence sets over the V3-V4-C3-V5 regions of the envelope gene differed by
1.2%. Corresponding DNA regions from 17 other distinct North American isolates
gave pair-wise differences to the dentist's consensus viral sequence of 5.1%-
10.2%, with an average of 8.1%. Similarly, comparison of the patient's
consensus viral sequence to these 17 gave pair-wise differences of 5.9%-10.7%,
with an average of 8.8%. The range of all pair-wise differences among the 17
was 4.7%-12.9%, with an average of 9.2%.
2. Unique patterns of nucleotide substitutions not found in any other virus
isolate examined were shared between viral sequences found in the dentist and
patient.
3. The average difference (4.6%) between all of the patient's viral sequences
and all of the dentist's viral sequences over the V4-C3-V5 regions falls into
a class of differences (3.4%-5.8%) similarly determined for viruses from known
epidemiologically linked cases (2; Los Alamos National Laboratory, unpublished
data). These include two instances of sexual transmission, one instance of
perinatal transmission, and an instance in which a group of persons with
hemophilia became infected from a single batch of factor VIII concentrate.
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Volume 3, Number 28 July 29, 1990
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Editor: David Dodell, D.M.D.
St. Joseph's Hospital and Medical Center
10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA
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David Canzi