Miami Herald (MH) - Sunday, June 23, 1991
Herald Staff

Standing before an audience of more than 500 people at the seventh International Conference on AIDS in Florence, Italy, Harold Jaffe, one of the most respected epidemiologists at the U.S. Centers for Disease Control, had to admit defeat. He simply couldn't explain how Dr. David Acer infected five of his patients with the AIDS virus.

Jaffe said Acer, now deceased, would not cooperate with the investigation. Some key documents unaccountably turned up missing. People who might have the most vital information could not be found. When Acer died in September, he took a lot of secrets to his grave.

It remains the only known case of a health-care worker who transmitted AIDS to a patient. It raises urgent questions about the likelihood that dentists, surgeons and other health-care workers with AIDS might be infecting their patients.

In related developments:

* Acer kept his condition a closely guarded secret for years because he feared repercussions in "a judgmental town," according to AIDS Alert, a newsletter for health care workers.

* Newsweek said 90 percent of the people it polled for its July 1 edition feel that AIDS-infected medical workers should be required to disclose to patients and infected patients to health care workers that they have the deadly virus.

Jaffe, a quiet-spoken man with little round eyeglasses, delivered his conclusions Thursday.

It started 14 months ago when Kimberly Bergalis of Fort Pierce tested positive for the virus believed to cause AIDS, known as HIV (human immunodeficiency virus).

Subsequent investigation linked her infection to Acer. In genetic tests, virus samples from the 22-year-old woman matched almost perfectly with those from her dentist. Because no two AIDS viruses are identical, this strongly suggested that one person had infected the other, and because Acer's illness was far more advanced than Bergalis', presumably it was he who infected her.

At the time, it didn't look like much of a mystery. HIV is nowhere near as easily transmitted as airborne microbes like the flu virus, which can be passed on with a sneeze, a kiss or the sharing of eating utensils. In the absence of sex or needle-sharing, blood-to-blood contact would have been necessary for infection.

The most likely explanation: that the dentist cut himself while performing a tooth extraction and some of his contaminated blood dripped into the extraction wound.

The theory was seriously undermined a few months later when Barbara Webb, 65, a retired English teacher, came forward. After reading about Bergalis, Webb had herself tested and found that she had HIV infection. Her virus was virtually identical to the one that infected Acer and Bergalis.

Could Acer have cut himself twice, and both times dripped contaminated blood into the dental wounds of his patients? Possible, but unlikely.

Then health officials heard from a young man, Patient C. He was also HIV-positive, with no known risk factors other than having a dentist named David Acer. Investigators tested the virus in his body. It matched the others.

Concerned that this might be the start of a one-man mini-epidemic, state health officials started sending letters to Acer's patients -- he had more than 2,000. Meanwhile, the CDC matched the list of patients with a list of known AIDS patients in the state.

One name was found on both lists. Patient D.

But that man's virus didn't match the rest, and he had other risk factors, making it unlikely that his infection was related to those of the first three patients.

Patient E, a woman, was identified in December. She also was a patient of Acer, and her virus matched his. Her lover also was one of Acer's patients, and tests showed that he was infected with HIV, but his virus didn't match the others genetically. This suggested, surprisingly, that his infection was in no way related to those of either his dentist or his lover.

Finally, there was Patient G, a blood-plasma donor identified during routine screening. His dentist was Acer; his virus matched the dentist's and the others.

Acer had seven HIV-infected patients -- five with a virus that was almost identical to the one that was killing him.

All the patients had undergone tooth extractions or root canals -- procedures involving sharp instruments that could cut tissue in the mouth, leaving it open to contamination with infected blood, Jaffe said.

Acer didn't start using gloves until late 1987, when he was diagnosed with AIDS. But it was awfully hard to believe that -- five times -- Acer had injured himself so badly that his hand oozed with blood and that -- five times -- the blood had seeped into the wounds of his patients. Acer was one of the dentists used by Cigna Dental Health of Florida, and as such he would have undergone a routine inspection of his office and practice. But when the CDC asked Cigna Dental Health for their inspection report, it could not be found.

Another obstacle was finding Acer's sexual partners. Jaffe and his team wanted to know if they had the same virus Acer did. Though Acer's bisexuality was known, the CDC investigators were unable to identify any of his sexual partners.

In another paper presented in Italy, David M. Bell of the CDC calculated there was one chance in 42,000 of an infected surgeon giving the virus to a patient during an operation.

A patient would be two times more likely to die in an airplane crash or 42 times more likely to die in a car crash.

So the question remains: If the odds are so remote, how does the CDC explain the perplexing case of the Florida dentist?

"We can't," Bell said. "It's a mystery."
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