Newsday - November 5, 1991
Laurie Garrett - Staff Writer
A consensus of the medical and public health communities is "essential for our ability to do our jobs," CDC Director Dr. William Roper said at a news conference capping a day-long meeting at which only the American Medical Association supported the federal guidelines, signed into law last week.
Issued in July, the guidelines call for identifying "exposure-prone" medical procedures. Health-care workers involved in such procedures should be tested for the human immunodeficiency virus, which causes AIDS, and if found positive, refrain from such procedures or inform their patients.
Yesterday's meeting was called by the CDC to get advice from the nation's leading medical authorities on which procedures should be classified "exposure-prone." The agency is scheduled to issue its definition by Nov. 15.
But almost all the organizations announced they would not assist in the preparation of such a list because there is insufficient scientific data available to determine how HIV might be transmitted in medical settings. Doctors' skills vary dramatically, so that "what is safe in one physician's hands might be dangerous in another's," according to a representative of the 35 groups.
The groups also argued that the risk of HIV transmission during practice was "extremely low, approaching zero" and strict adherence to safety precautions should eliminate most of that "infinitesimally small" risk.
New York State Health Department nurse Linda Chiarello accused the CDC of relying on a policy that is "diagnosis-driven," rather than based on the nature of interactions between health-care workers and patients. A focus on the latter means steps are taken to decrease risks for both patients and their health providers through safety precautions.
"What our state needs and what the nation needs is a prevention policy," New York Department of Health's Dr. Lloyd Novick declared. "But in New York we've chosen not to label procedures as exposure-prone. We think that any procedure where there's blood and body fluid interchanging between patients and health-care workers poses the potential of transmitting HIV."
New York's policy calls for strict adherence to safety procedures in all medical and dental practice, with special attention to any procedures that involve exposure to blood. There is no requirement that physicians tell their status to patients, and HIV-positive health-care workers may continue on the job as long as their involvement in invasive procedures is closely monitored by a local medical review board.
There has been only one case of a dentist giving HIV to his patients - and the mode of transmission remains a mystery. The CDC used data on another virus, hepatitis B, as the basis for the recommendations about exposure-prone procedures. By examining which procedures led to hepatitis B transmission, the CDC reached its tentative exposure-prone list that includes most major surgery.
Dr. June Osborn, chair of the National Commission on AIDS, questioned the hepatitis model, noting the number of hepatitis B viruses per droplet of blood in transmission cases averaged between 1 million and 100 million. In contrast, HIV has not been found in concentrations of more than 10,000 viruses per droplet of blood, and is usually inside cells, rather than floating freely in the blood. That means, she said, hepatitis B is likely to pose a threat in far more medical circumstances than HIV.
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