# Petition for Writ of Certiorari — Bragdon v. Abbott

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## Record

- **Collection:** Supreme Court brief
- **Document type:** Petition for Writ of Certiorari
- **Published:** January 1, 1998
- **Citation:** 524 U.S. 624

## Text

EEO eee — — eee
Supreme Court. U.S. | —
PILED

» 97. 15 6 JUL 21 1997

fick OF THE CLERK

In The

Supreme Court of the United States

October Term 1997

RANDON BRAGDON, D. M. D.,

Petitioner,
v.

SIDNEY ABBOTT ET AL.,
Respondents.

On Petition for a Writ of Certiorari to the United States
Court of Appeals for the First Circuit.

PETITION FOR WRIT OF CERTIORARI

JOHN W. MCCARTHY, ESQUIRE
Counsel of Record

BRENT A. SINGER, ESQUIRE
RUDMAN & WINCHELL

Post Office Box 1401

84 Harlow Street

Bangor, Maine 04402-1401
Phone: (207) 947-4501

Attorneys for Petitioner

APPELLATE SERVICE: CURRY & TAYLOR (215) 241-9764

ee ee

i
QUESTIONS PRESENTED

1. Is reproduction a major life activity within the
meaning of the Americans with Disabilities Act (ADA), 42
U.S.C. §§ 12101-12213?

2. Are asymptomatic individuals infected with HIV per
se disabled within the meaning of the ADA?

3. When deciding under title III of the ADA whether a
private health care provider must perform invasive procedures
on an infectious patient in his office, should courts defer to the
health care provider’s professional judgment, as long as it is
reasonable in light of then-current medical knowledge?

4. What is the proper standard of judicial review under
title III of the ADA of a private health care provider's
judgment that the performance of certain invasive procedures
in his office would pose a direct threat to the health or safety
of others?

5. Did petitioner, Randon Bragdon, D.M.D., raise a
genuine issue of fact for trial as to whether he was warranted
in his judgment that the performance of certain invasive
procedures on a patient in his office would have posed a direct
threat to the health or safety of others?

LIST OF PARTIES

The parties below were plaintiff/appellee Sidney
Abbott, plaintiff/appellee the Maine Human Rights
Commission, intervenor United States of America, and
defendant/appellant Randon Bragdon, D.M.D.

An amicus brief was filed by the Association of State
and Territorial Health Officials, the American Public Health

Association, the Association of State and Territorial Dental
Directors, the Rhode Island Department of Health, the
Department of Public Health, Commonwealth of
Massachusetts, and the Bureau of Health of the Maine
Department of Human Services. The American Dental
Association also filed an amicus brief.

iii
TABLE OF CONTENTS
Page
QUESTIONS PRESENTED .....ccccccccccsccccecs: i
, 5 i
OPINIONS BELOW AND JURISDICTION .......... l
RELEVANT STATUES AND REGULATIONS ...... l
STATEMENT OF nc 2
REASONS FOR GRANTING THE Wilk 4

I. BECAUSE THERE IS A CONFLICT AMONG
THE CIRCUITS ON THE REOCCURRING
QUESTION OF WHETHER REPRODUCTION IS
A MAJOR LIFE ACTIVITY UNDER THE ADA,
AND BECAUSE THIS QUESTION RAISES A
SIGNIFICANT AND CHALLENGING PURE
ISSUE OF LAW UNDER AN IMPORTANT CIVIL
RIGHTS STATUTE, THE COURT SHOULD
ENE DEEEBOUEEEEE, 0.2). Breaches in infection control
and other dental office practices to explain these
transmissions could not be identified.

0 Conclusion: Although the specific incident that
resulted in HIV transmission to these patients remains
uncertain, the epidemiologic evidence supports direct
dentist-to-patient transmission rather than = a
patient-topatient route.

In July 1990, the Centers for Disease Control (CD(.)
published the first of a series of reports describing human
immunodeficiency virus (HI\) transmission from a health
care worker to a patient (1-3). No case of such
transmission had been previously reported, although
transmission of another blood-borne pathogen, hepatitis
B virus (HBV), from infected health care workers to
patients has been well documented, and the theoretic
possibility that HIV transmission could also Occur had
been previously acknowledged (4-6). These reports
intensified the ongoing debate concerning whether HIV
and HBV-infected health care workers should do invasive
medical and dental procedures. Resolution of this
question has been hampered by the lack of accurate
quantitation of the risk for transmission and also by
misinformation and misconceptions regarding the likely
mechanism of HIV transmission in the dental practice.
We review updated epidemiologic findings which
led to the conclusion that five patients of a dentist with
the acquired immunodeficiency syndrome (AIDS) were
infected with HIV during their dental care. We also
discuss the possible mechanisms of disease transmission.

li3a

Methods

The investigation began when a young woman
without identified risk factors for HIV infection (Patient
A) was reported to have AIDS. During a routine health
department follow-up interview, Patient A provided the
name of her dentist who, 2 years previously, had
extracted her maxillary third molars. She was aware that
the dentist had become ill and suspected that he might
have AIDS. The dentist was known to the Florida
Department of Health and Rehabilitative Services
investigator as a previously reported AIDS case.

After publication of a report describing the
possible HIV transmission to Patient A, the dentist
publicly requested that his former patients seek HIV
testing. The dentist was no longer in practice, and he
could not provide a complete list of his former patients.
However, a partial list was compiled from names
provided by insura nce companies, Medicaid records,
billing and other records from the practice, and from
other dental offices in the area. Patients who had not been
tested for HIV at the local county public health unit were
notified by the Florida Department of Health and
Rehabilitative Services. By the end of 1991. 2 of the
approximately I 100 former patients tested were found to
be HIV-seropositive (Patients B and C).

A fourth paticot (Patient D) was identified by
confidentially matching the names of the former patients
to the state's reported AIDS cases. Three former patients
(Patients E, G, and I) notified the Ct)(. that they were
infected with HIV An-other patient (Patient F) was
identified during the epidemeio-logic investigation of
Patient E. which occurred between November 1987 and
June 1989, included one examination, two prophylaxes,
two cosmetic bondings, and one visit for extraction of her

lida

maxillary third molars (Table 2). The patient recalled
that the dentist wore gloves and a mask during the
procedures. Dental x-rays taken during the spring of 1990
showed no additional extractions.

Medical records indicated that 4 weeks after the
dental extraction, she was evaluated for a sore throat. She
was afebrile, and her ulcerated tonsils and anterior
cervical lymph nodes were moderately enlarged. The
diagnosis was pharyngitis and aphthous ulcers; no
indication exists that an acute retroviral syndrome was
considered. She was diagnosed with oral candidiasis in
May 1989 (17 months after the extraction) and with AIDS
in December 1989 (24 months after the extraction), when
she developed Pneumocystis carinii pneumonia. At that
time, she was first tested for HIV antibody and was found
to be seropositive.

Patient B reported that her only sex partner since
1978 was her husband, who tested seronegative for HIV.
She denied injecting drugs.

Her 21 dental visits, between December 1987 and
July 1989, included four extractions (see Table 2). Other
procedures included three prophylaxes, three periodontal
scalings, one examination, two restorative fillings, and ten
fixed and removable prosthodontics. She recalled that the
dentist wore gloves and a mask. She also recalled cutting
her tongue on a tooth that was "sharply filed" during
preparation for a bridge; however, she was unaware of
any injury that the dentist may have sustained at that
time.

Patient C denied having sex with men and
injecting drugs. He reported multiple heterosexual
partners but could name only 14 former female sex
partners since 1978, and he was unaware that any were
infected with HIV. Nine of these former partners were
located and were found to be HIV seronegative The

115a

possibility that Patient C had engaged in high-risk
behaviors was raised durin: interviews and record
reviews; however, behavioral exposures to HIV could not
be documented.

He made 14 visits to the dental office between
December 1984 and May 1989; the procedures included
two extractions, two examinations, six restorative fillings,
four prophylaxes, one periodontal scaling and one
cosmetic bonding (see Table 2). Nine of these visits,
including both of the extractions, occurred in 1984 and
1985, before the dentist began to wear gloves routinely
(Figure 1). The patient did recall that the dentist wore
gloves and a mask during his visits in 1988 and 1989.

Patient D, a man who had behavioral risks for
HIV infection, was diagnosed with AIDS in 1989. He had
18 visits to the dental office between June 1985 and May
1989. The procedures included five examinations, five
extractions, six prophylaxes, two periodontal scalings,
four removable prosthodontics, and two _ restorative
fillings.

Patient E denied injecting drugs. Of her ten known
sex partners since 1978, two had died from
non-HIV-related causes and were not known to be at risk
for HIV infection. Each of the remaining eight was tested
for HIV antibody; one was seropositive. This man
(Pa-tient F) had other risk factors for HIV infection and
was also a patient of the dentist. Patient E reported
infrequent sexual contact with Patient F, the last contact
occurring in the fall of 1988. Because of her concern
about Patient F's high-risk behavior, she was first tested
for HIV antibody in October 1988. Patient E was
seropositive, whereas Patient F was seronega-tive

Billing records and receipts indicated that Patient
E made 14 visits to the dentist between June 1988 and
December 1988 (see Table 2). The procedures included

la

four examinations and radiographs, two prophylaxes, two
root canal therapies, one restorative filling, six fixed
prosthodontics, and one fluoride treatment. She reported
that the dentist wore gloves and a mask during her visits.

Patient F tested negative for HIV antibody in
October and December 1988, but he tested positive during
the epidemiologic follow-up investigation in December
1990.

In September 1989, his medical records indicate a
I- Week history of sore throat, loose stools, and headache;
other symptoms included decreased appetite, fatigue,
myalgia, and an earache. He had a temperature of 38.1
*C and tender anterior cervical adenopathy; his
leukocyte count was 3300/[{u]L, and he had a lymphocyte
count of 693/[u|L. A diagnosis of tonsillitis was made, and
a throat culture yielded "normal respiratory flora.“ No
HIV-antibody test was done at that time, nor does any
indication exist that an acute retroviral syndrome was
considered. This illness occurred approximately 1 year
after Patient F's last reported dental appointment
(August 1988) and his last sexual contact with Patient E
(Autumn 1988) and 9 months after his last negative HIV
antibody test (December 1988).

Review of Patient Fs medical and other records
established a history of behavioral risk factors for HIV
infection. Only one dental visit was documented by billing
records, although he reported five or six visits during
July and August 1988 for examination, radio-graphs,
prophylaxis,extraction, restorative fillings, and root canal
therapy.

Patient G denied, since 1978, sex with men and
injecting drugs. He first tested positive for HIV during
screening for plasma donation in November 1990. He had
been HIV seronegative when he donated blood in 1986,
and his two reported female sex partners since 1986 were

117a

HIV seronegative

Patient G's dental records could not be located,
but records from an alcohol rehabilitation facility
documented two visits in July 1988 for root canal therapy
and a restorative filling (see Table 2). He could not recall
whether the dentist wore gloves or a mask.

Patient H has acknowledged behavioral risks for
HIV infection. He made three visits to the dentist between
September 1985 and July 1986 for prophylaxes,
examination, and gingivectomy.

With the exception of patients E and F, none of
these patients named each other as a sex partner, and all
denied sexual contact with the dentist. For all of the
patients, local anesthesia _was the only anesthetic
administered, and none could recall an injury to the
dentist that would have exposed them to his blood (for
example, a needlestick or a cut with a sharp instrument).

Laboratory Findings on Patients

The nucleotide sequences of the C2-V3 domain of
the viruses from Patients A, B, C, E, and G were closely
related to those of the dentist's virus. The average
nucleotide variation ranged from 3.4% to 4.9% (50), a
range similar to those previously observed for HIV
strains from persons whose infections were known to be
epidemiologically linked (7-9). In contrast, the viruses
from Patients D, F, and H, each of whom had high-risk
behaviors, were not closely related to the dentist's virus,
and differed by 13.6% and 10.7% for Patients D and F,
respectively (50). This degree of genetic difference has
been found among strains of HIV that were
epide-miologically unrelated. Preliminary analysis
indicates that the virus from Patient H is also not closely

118a

related to that of the dentist. No instance of comparable
viral sequence relatedness was identified among the
viruses from the 35 local controls (50). The HIV strains
from patients A, B, C, E, and G were significantly closer
in their DNA sequences to the dentist's virus than control
patients (P = 6 x 10-[6], Wilcoxon rank-sum test) (50).

An unusual pattern or signature of eight
noncontiguous amino acids encoded by V3 nucleotides
was found in the dentist's virus. The viruses from Patients
A, B, C, E, and G, had at least 7 of the 8 signature amino
acids. This degree of agreement was not found in the
viruses from the dental patients with behavioral risks
for HIV infection, the local controls, or a reference set of
sequences from 32 HIV-I strains (P = 8 x 10-[6], Wilcoxon
rank-sum test) (50). This finding, together with the
genetic distance analysis, suggests that the virus from the
dentist and those from Patients A, B, C, E, and G formed
a clusterof genetically similar strains that were distinct
from the viruses of the patients with identified risks for
HIV infection and from the viruses of 35 local control
patients.

Interview with the Dentist

The dentist recalled having sustained needlestick
injuries from anesthetic needles before he was diagnosed
with HIV infection, but did not recall sustaining any
percutaneous injuries after learning he was HIV positive.

The dentist reported nonoccupational exposures to
HIV, and he believed that he had been infected through
these exposures, although the exact time of infection
remains unknown. He was unaware that any of his
patients were infected with HIV, although he suspected
that as many as ten patients may have been at risk for

119a

HIV infection. He denied sexual contact with any of his
patients.

Medical History of the Dentist

Review of the dentist's medical records showed
that he was diagnosed with symptomatic HIV infection in
late 1986 and with AIDS in September 1987, as indicated
by a biopsy result diagnostic of Kaposi sarcoma of the
palate and a CD4 + lymphocyte count of 190/[u]L.
Zidovudine therapy was begun in early November 1987
but was discontinued from 16 December through 23
December 1987 because of neutropenia (see Figure 1). It
was then continued at different doses throughout the time
he remained in clinical practice.

In May 1988, examination of the palate showed
purplish discoloration of the mucosa of the entire hard
palate without ulceration or exophytic growth. The
remainder of his physical examination was
unremarkable. From 6 June through 20 June 1988, he
received a total of 2750 rads of radiation therapy to his
palate. This treatment resulted in mucositis at the end of
therapy. By 6 July 1988, the palatal lesions had regressed,
and the mucositis reaction had subsided. According to his
medical records and interviews with his health care
providers, he remained relatively asymptomatic except
for fatigue until March 1989, when several lesions
indicative of Kaposi sarcoma were noted on his abdomen
and thorax. In June 1989, he was hospitalized with a
presumptive diagnosis of P. carinii pneumonia. According
to medical records, in the summer of 1989 his cutaneous
Kaposi sarcoma lesions were treated with liquid nitrogen,
and he reported that he used an electrocautery unit kept
at his home to self-cauterize some of the lesions. In the

120a

summer of 1989, he stopped practicing dentistry. During
the time he was in practice, his medical records did not
indicate thrombocytopenia or any other bleeding
disorder, hand dermatitis, injury, or dementia. No
indication of peripheral neuropathy was present,
although no record of a detailed neurologic examination
or testing for neurologic dysfunction was found in the
medical records.

In October 1989, the Kaposi sarcoma progressed
to involve his lungs, and he was treated with
alpha-interferon and chemotherapy. He died in
September 1990.

The Dental Practice

The dentist had a general practice at one location
from 1981 to 1989. He was in solo practice except from
September 1985 through February 1986, when he had an
associate. In the summer of 1989, the office was sold to
another dentist. The patient records were dispersed and
many office records, such as appointment books, were
discarded. The office was rernodeled, and most of the
dental equipment was replaced. The office staff stated
that there had been no electrocautery unit in his office
practice.

All 16 persons identified as having been employed
in the dental practice, including receptionists, hygienists,
and assistants, were located and interviewed. All tested
seronegative for HIV antibody. Staff members were not
aware of any patients who were known to be infected with
HIV or of any who had been sex partners of the dentist.

Staff members reported that since 1987, the dentist
had received one prophylactic treatment from the
hygienist and on one or two occasions had had an

121a

unspecified liquid medication placed on a palatal lesion
. ing a cotton-tipped applicator that was then discarded.
To the knowledge of staff members, the dentist received
no other treatment and did not perform any treatment on
himself in his office.

Infection Control Practices

Barrier precautions were fully introduced into the
practice by early 1987; all staff with patient contact wore
latex gloves and surgical masks for patient-care activities
when appropriate. On most occasions, gloves were
changed and hands were washed between patient
contacts. Occasionally, however, gloves were washed
rather than changed. Masks reportedly were changed
infrequently. No staff member reported noticing any
dermatitis or other lesions visible on the dentist or
witnessing the dentist sustain a percutaneous injury
during patient treatment.

By 1987, all surgical instruments used in the
practice were autoclaved; other heat-tolerant instruments
were autoclaved when time and instrument supply
allowed or were immersed in a 2% glutaraldehyde
solution for varying periods, usually of at least 20 minutes
duration. Dental equipment such as prophylaxis angles
and air and water syringe tips were either wiped with
alcohol or immersed in 2% glutaraldehyde after each
patient encounter. Some disposable items, such as saliva
ejectors, high-speed evacuation tubes, and prophylaxis
cups, were occasionally reused after being immersed in
2% glutaraldehyde, usually for at least 20 minutes.
Hand-pieces were wiped with alcohol after each patient
encounter; water lines were not flushed between patients.

The dental practice had no written infection
control protocol or consistent pattern for operatory

122a

cleanup and instrument reprocessing. No office protocol
existed for reporting or recording injuries such as
needlesticks or other percutaneous injuries involving
sharp instruments or devices.

Only local anesthetic was used in this practice, and
anesthetic needles were either recapped by the dentist
using a two-handed technique or remained uncapped and
were recapped by the assistant on completion of the
dental procedure. By 1983, only single-use disposable
anesthetic carpules and disposable needles were used.
Staff members reported no instance in which a needle or
carpule was reused on different patients; however, the
same needle was routinely used multiple times on the
same patient when multiple injections of local
anesthetic were required. The dentist did not document
his use of local anesthetic in patient records.

Days of Shared Visits

On four occasions, two of the five infected patients
whose viruses were related to that of the aentist were seen
in the dental office on the same day (see Table 2, Figure
1). Those with shared visit days included Patients A, B, C,
and E; Patient G did not share any visit days with the
othe four patients.

The five patients made a total of 48 visits to the
dental office from November 1987 until the close of
practice in July 1989. To examine the likelihood that the
five patients shared visit days, conditional probabilities
were calculated based on the number of visits made by
each patient between November 1987 and July 1989, the
interval during which at least two of these five HIV.
infected persons were patients of the dentist. The
probabilities were calculated assuming that visits

123a

occurred during days on which the dentist's office was
open, without allowing multiple visits for the same patient
on the same day. These shared-visit days probably
occurred by chance alone (P > 0.2). Because appointment
books no longer existed, neither the order nor the time of
day could be determined for any of the shared-visit days.

Patients A and B were seen on 17 December 1987
(see Table 2). Patient A had two extractions while
receiving local anesthetic. Patient B was examined for a
toothache, and a radiograph was taken; no invasive
procedures were done, although she had an extraction 4
days later. No indication exists that a handpiece was used
on either of these patients on this day.

On 11 July 1988, Patient B had periodontal scaling
and an extraction. Patient E had a crown placed on a
maxillary bicuspid tooth. Patient B received local
anesthetic, but we could not determine whether an
anesthetic was used for placement cf Patient E's crown
because the tooth had previously had a completed root
canal. It is unlikely that instruments used for the
periodontal scaling and extraction would also be used to
place a crown.

On 29 August 1988, Patient B had a bridge placed,
and Patient E had plastic restorations placed on two
maxillary anterior teeth. Although it is probable that
local anesthetic was used on both patients on this day, the
other instrumentation would differ. We could not
determine whether the dental handpiece was used during
the placement of the bridge; however, it would have been
used for the restorations on patient E.

On 20 January 1989, Patients B and C had
prophylaxes. Patient B's prophylaxis was done by
thedental hygienist; however, we could not determine
whether Patient C's prophylaxis was performed by the
dentist or by the hygienist. It is unlikely that either

Aa

patient had local anesthetie administered on that day.

Discussion

The findings of this investigation led us to
conclude that five patients of a dentist with AIDS became
infected with HIV during their dental care. We support
this conclusion because the five patients had no other
confirmed exposures to HIV; all had invasive procedures
done by the dentist; and DNA sequence analyses of the
HIV strains from these five patients indicate a high
degree of similarity among the strains and that which
infected the dentist. These HIV strains were distinct from
those infecting the three patients in the practice who had
identified risk factors for HIV infection and from 35
HIV-infected persons residing in the same geographic
area.

Our investigation is the first to report the
transmission of HIV to patients during receipt of health
care, although HIV transmission from infected patients to
health care workers is well documented (10-12). In
addition, transmission of HBV, another blood-borne
virus, from infected health care workers to patients has
been reported repeatedly since the early 1970s. More than
330 cases of HBV transmission from health care workers
to patients occurring during invasive procedures have
been reported (13-32) (Shapiro CN, CDC, unpublished
data). Virtually all cases have involved clusters associated
with care by 33 HBV-infected health care workers,
including 9 dentists and 20 surgeons. Although
percutaneous transfer of blood was the most likely
mechanism of HBV transmission from health care worker
to patient, the specific incident which resulted in
transmission was not identified in any of the 33 episodes

125a

investigated.

In none of these studies involving an HBV-infected
surgeon or dentist was patient-to-patient transmission of
HBV believed to have been a mechanism of transmission.
However, in other health care settings, patient-to-patient
transmission of HBV has been attributed to contaminated
common-source vehicles, including jet guns, multidose
vials of heparin and local anesthetic, and fingerstick
devices (33-36).

Although the precise circumstances or mechanism
of HIV transmission in this Florida dental office remains
unclear, the preponderance of data support direct
dentist-to-patient transmission rather than a
patient-to-patient route. The dentist continued to do
many invasive procedures after he was diagnosed with
AIDS. This period includes the interval during which his
zidovudine was discontinued and during which a course
of radiation therapy was administered. All five patients
had invasive procedures done after the dentist was
diagnosed with AIDS and had evidence of severe
immunosuppression. Low CD4 + lymphocyte counts are
associated with higher viral titers in the blood (37) and
therefore could be associated with an increased likelihood
of transmission if an injury to the dentist occurred. In
addition, interviews with the dentist's health care
providers and his office staff indicated that, after he was
diagnosed with AIDS, he frequently experienced fatigue,
a factor which may have increased the likelihood of
injury.

There were multiple opportunities for the dentist
to have injured himself during invasive procedures done
on these patients, especially during periods of fatigue and
ill health. In a survey of self-reported sharps injuries in
89 dentists, 32% reported 2 or more per month, and 3%
indicated more than 15 such injuries per month (38).

126a

Another survey of 1132 dentists found a median of one
sharps injury per month (39). Further, although
undocumented, the possibility that the dentist had a
peripheral neuropathy cannot be ruled out; peripheral
nervous system dysfunction has been noted in 9% to 35%
of patients with AIDS (40-43).

All five patients received multiple injections of
local anesthetic, and a sharps iniury during anesthetic
administration could have resulted in contamination of
the syringe apparatus with the dentist's blood, after
which additional anesthetic may have been injected into
the same patient. A sharps injury could also result in
direct contact of the dentist's blood with the patient's
inflamed or nonintact oral tissues during the invasive
procedures. Although the dentist began to routinely wear
gloves in 1987, gloves do not prevent most injuries caused
by sharp instruments.

Human immunodeficiency virus does not remain
viable for extended periods outside the body, and it is
susceptible to commonly used germicides, including those
used in the practice (4). Interviews of staff members
indicate that, before use on patients, all instruments were
cleaned and reprocessedby methods known to inactivate
HIV, although these methods may not comply with
recommendations designed to kill more resistant
organisms.

If contaminated instruments or equipment are
assumed to be the principal factor in these transmissions,
one would expect to see a clustering of patient
appointments. Although some shared-visit days were
documented, these probably occurred by chance alone.
Additionally, the procedures done on these shared visit
days probably did not involve the use of the same
instruments on more than one of the infected patients.
Questions have been raised about the possible role of the

127a

dental handpiece in these transmissions. It is unlikely that
a high-speed dental handpiece was used on both patients
on any of the shared-visit days, and, to date, no studies
have confirmed the transmission of blood-borne viruses
such as HIV or HBV through the dental handpiece or
other dental equipment.

The dentist denied having sex with any of his
patients. One HIV-infected person subsequently
contacted the CDC and reported having had sex with the
dentist in the early 1980s and occasionally receiving
dental care from this dentist before moving from the area
in 1985. However, no patient records exist to confirm
these data. No other persons who were both sex partners
and patients of the dentist have been identified.

The possibility that these infections were
intentionally transmitted has been hypothesized.
Interviews with family, staff, health care providers,
patients, and others who knew the dentist have not
provided any support for this hypothesis. The dentist
initially cooperated with our investigation and provided a
blood specimen for genetic sequencing to be compared
with patients“ specimens. Additionally, most of the
procedures done by the dentist were routinely observed
by staff, all patients were awake during the procedures,
and no unusual behavior was noted or suspected by either
patients or staff members.

Some have hypothesized that the dentist might
have had an exceptionally high titer of virus or an easily
transmittable strain of HIV. The titer of HIV in the
dentist's blood obtained in March 1990 is eurrenth be-
ing determined, although it is unclear how accurately this
result would reflect the viral titer in his blood between
1987 and 1989. Strain-speciſie virulence factors for HIV
transmission have not been identified; further, no
evidence was found to suggest HIV transmission from

128a

these patients to their sex partners.

The five patients identified in our investigation
remain the only reported cases of HIV transmission from
an infected health care worker to patients during invasive
procedures. Results from six other studies of patients
exposed to HIV-infected surgeons or dentists have not
shown transmission (44-49). Of the 1246 patients of these
health care workers who are known to have been tested,
one was positive for HIV infection; however, this patient
had behavioral risks for HIV infection and was probably
infected before his surgical procedure
(48).

The risk for transmission of blood-borne
infections, including HBV and HIV, from an infected
health care worker to a susceptible patient during an
invasive dental or surgical procedure may depend on
several factors, including the type of procedure, the
infection control precautions, and the individual
technique of the health care worker. The relative
importance of these and perhaps other factors in
predicting the risk for such transmission is poorly
understood and requires further study.

Currently available information indicates that
when health care workers adhere to recommended
infection control procedures, the risk for transmitting
HBY from an infected health care worker to patients is
small, and the risk for transmitting HIV is probably even
smaller. These small risks should not deter patients from
seeking necessary surgical or dental care.

atients Identified in the Dental

Table 1. Characteristics of the Dentist and the HIV-infected P

Practice*

.
=
ods
=
—
oL

=
0
12
2 2
—
Zé
= 8
58 2
sé
5
-

Negative

Negative
Not Done

Not Done

Negative

rease.

225a

(The American Journal of Medicine Volume 80)

Frequency of Nonparenteral Occupational Exposures to
Blood and Body Fluids Before and After Universal
Precautions Training

BARBARA J. FAHEY, B S. N., DELORIS E. KOZIOL,
Ph.D., STEVEN M. BANKS, Ph.D., DAVID K.
HENDERSON, MD. . Bethesda, Mar) land

PURPOSE: During annual periods before and after
Universal Precautions training, ve compared the
frequency of health care workers self-reported cutaneous
exposures to blood and various substances from any
patient and from patients presum infected with human
immunodefici virus pe 1 (HIV-1).

SUBJECTS AND METHODS: Self-reported cutaneous
exposures to blood, sputum, urine, feces, and other body
— were evaluated separately in 559 workers
d the first survey and 269 workers. during the

RESULTS: Mean annual blood exposures decreased from
35.8 to 18.1, and mean annual exposures to all substances
decreased from 77.8 to 40.0 (p <0.001 for both

determinations).

R * *

\SIONS: These data that Universal Precautions
8 decreased but did not eliminate
cutaneous exposures to blood and body substances, The
results further suggest that the risk for HIV-1 infection
associated with cutaneous exposures is substantially lower
than the risk associated with parenteral exposures.

R * *

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385014_0110%3A02. Public record. Not legal advice.