Probable Transmission of HIV from an Orthopedic Surgeon to a Patient in France

Since the beginning of the AIDS epidemic, transmission of HIV from an infected health care worker to patients has been reported only once (1). To better quantify the risk that patients may become infected with HIV during invasive procedures, several investigations of patients exposed to an infected health care worker have been undertaken. In 1995, the Centers for Disease Control and Prevention (CDC) summarized the results of all published and unpublished investigations (2). Of 22 171 patients tested who were treated by 51 HIV-infected health care workers, 113 HIV-positive patients were reported, but epidemiologic and laboratory follow-up did not show that a health care worker was the source of HIV infection for any of the patients. We report on an epidemiologic investigation that supports transmission of HIV from an orthopedic surgeon to a patient during surgery. Methods History In July 1995, a French medical newspaper reported that an orthopedic surgeon practicing in the hospital of Saint-Germain-en-Laye (a public hospital in the Paris suburbs) had been accidentally infected with HIV while performing surgery 12 years earlier. In September 1995, the surgeon asked the hospital director to screen all of his former patients and informed the press of his request. In October 1995, the French Ministry of Health offered HIV testing to patients who had been operated on by the surgeon. An epidemiologic investigation was initiated that included review of the surgeon's medical history, assessment of the surgeon's practices and comparison with the practices of other surgeons and the infection-control personnel of the hospital, and identification and HIV testing of patients on whom the surgeon had performed an invasive procedure. Medical Evaluation of the Surgeon An infectious disease specialist and a medical epidemiologist interviewed the surgeon by using an unpublished CDC questionnaire (Risk ascertainment questionnaire for adult/adolescent HIV/AIDS cases reported without risk information, 1994). The questionnaire inquires about all known avenues of exposure to HIV to determine the most likely date of infection. A medical epidemiologist interviewed the surgeon's health care providers to obtain the surgeon's medical history. Evaluation of the Surgeon's Practices Two infection-control physicians interviewed the surgeon to review operating room practices. Information was collected on blood exposures, surgical procedures, and infection-control precautions. The surgeon's practices were compared with those of all of the other surgeons of the hospital (1 orthopedic surgeon and 11 other surgeons), who were interviewed by using the same questionnaire. In addition, the disinfection and sterilization procedures of the operating room were evaluated by interviewing an operating room nurse, the head nurse, and the pharmacist in charge of sterilizing the surgical and medical devices of the hospital. Identification and Evaluation of Patients at Risk An information center with a toll-free telephone number was set up at the hospital on 19 October 1995. The center handled telephone calls, identified and notified patients at risk, managed consultations, and received exposed patients for counseling and HIV testing. Patients at risk were defined as those on whom the surgeon had performed an invasive procedure during the period from the presumed date of his infection until he ceased practicing surgery. An invasive procedure was defined as a procedure involving an open wound or incision in the skin. Patients at risk were identified from surgical reports that the surgeon had signed as the responsible surgeon or co-surgeon and that specified an invasive procedure. Patients were sent a letter informing them they had been operated on by the unnamed HIV-infected surgeon. The letter discussed the low risk for HIV infection in this context and suggested that patients make an appointment with their physician or call the toll-free telephone number. For patients whose letters were returned as undeliverable, attempts were made to obtain the current address from the hospital's admission department and, if necessary, from the French national health insurance system. A second letter was sent to all nonresponders. The content of this letter was more specific; it offered free counseling and HIV testing at the information center. At the hospital laboratory, enzyme-linked immunosorbent assay was used to test serum samples for antibody to HIV-1. Patients who wanted to be tested by their own physician were asked to report the results to the information center. All general practitioners and private laboratories of the district were asked to report the HIV serology results of exposed patients who had been tested outside the hospital laboratory (with the consent of the patients). A computerized database of all patients at risk was created with the agreement of the French National Committee on Information and Privacy. Procedures were classified into three categories according to the risk for exposure: major surgery (prosthetic joint replacement, spine procedures, open reduction of fracture, ligamentoplasty of knee or ankle, amputation, osteotomy, or arthrotomy), medium surgery (hardware removal), and minor surgery (arthroscopy, resection of cysts, exploration of cuts, whitlow, punctures, and operations on metatarsi or metacarpi). If a patient had undergone more than one procedure within the same category of exposure, the date of the most recent procedure was taken as the date of exposure. For patients who had undergone procedures within different categories, the date of the procedure that carried the highest risk for exposure was taken as the date of exposure. With the agreement of the French National Committee on Information and Privacy, all untested patients were matched by date of birth, first name, and initial of last name to the national mandatory AIDS case registry to identify any former patients who were reported to have AIDS and had no other identified risk factors. HIV-Positive Patient and Molecular Investigation An infectious disease specialist interviewed the one identified HIV-positive patient about risk factors for HIV infection and a potential seroconversion syndrome. The patient's surgical record, the operating room register, and the ward logbook were reviewed for possible patient exposure to the blood of the surgeon or another health care worker. The national reference center for virology and immunology of human retroviruses performed molecular analysis to compare viral sequences from the surgeon and the HIV-positive patient. At different dates, blood samples were collected with consent from the surgeon (November 1995 and September 1996) and his patient (February 1996). After amplification by using polymerase chain reaction, the env and gag sequences from the viral genomes were cloned and sequenced. Phylogenetic analysis was performed by using the software package Phylip (Department of Genetics, University of Washington, Seattle, Washington). Pairwise evolutionary distances were estimated by using the Kimura two-parameter model. Phylogenetic trees were constructed by the neighbor-joining and maximum likelihood methods. The phylogenetic relations among the sequences obtained from the surgeon and the patient were determined. Representative sequences of different HIV-1 subtypes were used for comparison. Details of these methods have been published elsewhere. (3). Results Medical Evaluation of the Surgeon The 53-year-old surgeon received a diagnosis of AIDS in March 1994, when he presented with HIV encephalopathy. At that time, his CD4 cell count was 46 cells/mL. He had stopped performing surgery in October 1993 because of depression, but he was not tested for HIV at that time. At the time of the interview in January 1996, the surgeon did not present with any further neurologic disorders and had been receiving triple therapy (zidovudine, dideoxycytidine, and ritonavir) for 10 months. The surgeon was married, had only heterosexual contacts with his wife, denied using injection drugs, never received a blood transfusion, and traveled only to various European countries. He had been vaccinated against hepatitis B, tested negative for hepatitis C, and had no history of sexually transmitted diseases. He reported that in May 1983, he had a needlestick injury while operating on a patient who had received multiple transfusions and whose HIV serologic status was not known. This patient later died. Thirty days after the needlestick, the surgeon developed a febrile illness characterized by fatigue, weight loss, and rashsymptoms consistent with the HIV seroconversion syndromethat resulted in interruption of his normal activities. In 1988, the surgeon had diarrhea lasting 4 months. Stool cultures tested positive only for Aeromonas hydrophila. In November 1992, viral pneumonitis was diagnosed. Bronchoscopy showed reactive mucous membranes; biopsy and bronchoalveolar lavage were not done. Evaluation of the Surgeon's Practices The surgeon had been practicing as an orthopedic specialist in the same hospital since 1970. He had never received specific training about universal precautions but was aware of their principles. The surgeon reported frequent opportunities for blood exposures, as well as frequent actual blood exposures (Table). For example, he often tightened suture wires with his fingers and sometimes tied sutures with the needle still attached. Although his fingers sometimes directed the needle, he did not report digital palpation of the needle tip while suturing. However, he did report using digital palpation of the needle tip during placement of bone pins. He used metallic wires for tendinous sutures and mentioned that his fingers were sometimes confined with sharp objects in a blind cavity. Table. Surgical Techniques and Occupational Blood Exposure of the HIV-Infected Surgeon and the Other Surgeons of the Hospital The surgeon reported that percutaneous injuries