Miami Herald (MH) - Sunday, August 4, 1991
Linda Roach Monroe; Herald Health Writer

The issue is not so much the infection status of those who work in a medical office, experts say, but whether the office follows basic procedures to keep microbes from passing from one person to another.

"I say to the dentist, 'I know this may not seem realistic to you but I'm really concerned about these cases of AIDS transmission at the dental office, and I'd really like to know what you do in your practice to make sure this kind of transmission doesn't occur here,' " says Dr. Julie Gerberding, who oversees HIV prevention among workers at San Francisco General Hospital. The facility is a leader in AIDS treatment and prevention issues.

"I expect them to describe to me how they clean the instruments that go in my mouth, how they disinfect the instruments that they put in the (sterilizing) autoclave, what kind of infection control training they have had lately. And what kind of training has their staff had. Because I think in a lot of cases it's really the ancillary office staff that have the responsibility for cleaning equipment," Gerberding said.

"Then I watch and see what they do. And if I have any question or concerns along the way, I ask."

But the AIDS virus isn't the main reason health care consumers need to be concerned about infection control in doctor and dentist offices. If an office isn't run properly, a patient is more likely to come into contact with the hepatitis B virus than HIV, the AIDS virus.

Unlike the more common hepatitis A (the type usually involved in restaurant scares), hepatitis B is a liver infection that is not always curable. About 10 percent of people with hepatitis B develop a chronic form of the disease, which then progresses to cirrhosis, liver failure and death. An infected person also can be symptom-free yet able to infect others. The virus is spread much more easily than the AIDS virus, but also through blood or sexual activity.

Since the early 1970s, more than 300 U.S. patients have contracted hepatitis B from 20 infected health-care workers, according to the U.S. Centers for Disease Control. In 12 of the 20 infection clusters, the infected worker did not routinely wear protective gloves.

The cases spanned all types of health-care workers: nine dentists or oral surgeons, a general-practice physician, an inhalation therapist, a cardiopulmonary-bypass-pump technician, five obstetrician/gynecologists, and three cardiovascular surgeons. There have also been recent unpublished reports of transmission of hepatitis B in 1989 and 1990 from three doctors to patients during surgery.

These numbers compare to just five documented cases of HIV transmission from health care worker to patient, all of them from a single dentist, Dr. David Acer of Stuart. Acer died last year. Three other studies of 280 people treated by HIV-infected doctors or dentists found no transmission of HIV at all.

The Centers for Disease Control uses these studies to conclude that the risk of acquiring AIDS from a health care worker is even lower than the risk of patients giving it to their health care providers, which is 0.3 percent.

For hepatitis B, infection of medical workers by patients is 100 times more likely, at 30 percent for a single accident.

So why all the fear of HIV, and not of hepatitis B?

For one thing, AIDS remains incurable and fatal, while hepatitis B kills only about 10 percent of its victims and takes longer to do so.

For another, there is 23-year-old Kimberly Bergalis, near death, who was infected with HIV by Acer. Although no one is sure how Acer managed to infect five patients, Bergalis's painful, wasting ordeal, shared with the world through newspapers and TV, is a powerful and frightening symbol.

But the fact is that an informed patient can decrease the already minute risk of contracting AIDS during health-care procedures by simply being watchful and assertive.

Is the lab technician about to draw blood from you without washing his hands and donning new gloves? Say something.

Was the dental instrument unprotected or in a jumble of instruments in a drawer? It can't be sterile, so say something.

Is a hospital nurse about to tend to a loved one's intravenous line without washing hands and donning gloves? Say something. (Accredited hospitals are required to have gloves available in each patient room.)

That is the last line of defense, however. Better yet to follow Gerberding's example, and ask for specific information about the facility's infection precautions at the start of the visit. The response will either be reassuring or a red flag -- and will give the patient a sense of control over the situation instead of the helplessness that the Bergalis case has nurtured.

"I generally have zero fear of contracting HIV or any of the deadly viruses in the dentist's office," said Dr. Gabor Kellen, assistant professor of emergency medicine at Johns Hopkins Medical Institutions. Only a sloppy medical professional would be involved in unsterile practices, Kellen said.

But it was Kellen's own study in the emergency room at Johns Hopkins that points out that medical personnel aren't always as careful about infection control as they should be, particularly if they are rushed.

Kellen found that only 58 percent of the residents in the emergency room, 44 percent of the nursing staff, 38 percent of the doctors and 14 percent of the X-ray technicians observed what the CDC calls "universal precautions" against infection.

These involve wearing the proper gowns, masks and gloves while dealing with blood or conducting invasive procedures like suctioning or inserting tubes into the body.

In non-emergency situations, doctors and nurses theoretically have more time for taking infection precautions. But it is well-known that financially pressed hospitals have cut back on staff wherever possible, making staff more harried.

Hospital-acquired infections are common. They include a steady rise in the number of bloodstream infections in hospitals over the last decade.

Unpublished figures calculated by CDC found that, for every 1,000 patient-days on intravenous catheters in coronary and medical intensive-care units, there are 7.1 bloodstream infections, said Dr. Robert Gaynes, who oversees hospital infection surveillance for CDC.

In pediatric intensive-care units, the figure is 10.2 infections fer 1,000 patient-days on intravenous catheters.

The figures are constantly in flux because of disagreement over how they should be calculated, particularly since invasive procedures have increased dramatically in recent years, Gaynes said. Still, it is clear that hospital-caused infections are nine times as likely if a patient is on a ventilator or is catheterized, he said.

Denise Ricketts-Goombs, in charge of infection control for Humana Hospital-Cypress in Pompano Beach, noted that it is routine now for packs of disposable gloves to be in every patient's room. Hospital staff, from nurses to housekeepers, must attend a class in infection control annually. They hear one key message, she said: "You should treat each patient's blood and body fluids as infectious."

Consequently, patients' families that insists on strict adherence to infection precautions are on solid ground, even if they are annoying the staff.

Indeed, it is reluctance to rock the boat that keeps many people from asking their health care providers about infection precautions, Gerberding said.

"I think they're afraid of confronting the authority figure," she said. "And in dentistry it might be even more pronounced. Most people don't associate going to the dentist with a pleasant experience in the first place, so you're already feeling nervous about the encounter. So this whole business of the transmissions in Florida just adds to the anxiety."

Infection precautions need to be strictly observed even if the dentist or physician is among those who -- sensitized by the Bergalis story -- posts the results of his negative HIV test for patients to see.

A negative test is no guarantee because a person can carry the AIDS virus but test negative for several months after acquiring it. In addition, taking an AIDS test a month ago doesn't guarantee that the person didn't pick up the virus a week ago.

And even if the doctor is HIV-free, instruments contaminated by HIV-positive patients might transfer the virus to other patients.
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