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Letters to the Editor

El American College of Surgeons Issues Position Statement on Surgeons and HIV Infection Chicago -The American College of Surgeons reported in October of 1991 that its Board of Regents has approved a position statement on the issue of HIV infection and the surgical team. The statement was officially released on October 21, during the College’s annual Clinical Congress in Chicago. Developed through the College’s Board of Governors’ Subcommittee on AIDS, the statement includes specific recommendations to guide surgeons in such areas as rendering care to HIV-infected patients and implementing infection control standards, including the use of universal precautions and scientifically accepted infection control practices. Since its inception in October 1989, the Subcommittee on AIDS has spent a considerable amount of time and thought in preparing the statement entitled, “The Surgeon and HIV Infection.” A major component of the statement addresses the guidelines published by the Centers for Disease Control (CDC) on July 12, 1991. The College believes that the CDC guidelines are flawed, because in formulating them, “the CDC ignored the overwhelming testimony of the scientific community, and the fact that all currently available data indicate that transmission from [health care] provider to patient in a hospital setting is so far, a purely hypothetical event. ” Furthermore, the College is dismayed that insurers, licensing bodies, government agencies, and legislative bodies may propose regulations based on the CDC guidelines, because such actions are “not based on direct scientific data; they are not cost-effective; they are intrusive to the extreme; and they are unable to achieve their desired intent.” With regard to the CDC’s intent to publish a list of “risk-prone” procedures, the College believes that such an effort would be “irrelevant and counterproductive,” because such procedures “cannot be defined in any scientific or rational way.” The College points out that “since no procedure other than dental extraction has ever beerr shown to result in HIV transmission, this is the only procedure that can be logically called ‘risk-prone.“’ The College concedes that although it is conceivable that HIV transmission from health care provider to patient may take place in the future, “this risk appears so low that costly measures such as testing and limiting work are not justified.” Given this extremely low risk, the College believes that the best strategy for surgeons to employ in protecting patients from accidental exposure is to conduct surgical prac-

tice in such a way as to continue to minimize the risk of HIV infection by enforcing a high standard of infection control and universal precautions. The College firmly believes that basic epidemiological research related to HIV transmission in the health care environment needs to be continued, and recognizes that its current recommendations may need to be revised in the future based on newly acquired information. The College further advises any concerned bodies who wish to enact regulatory measures on this issue to base their actions “on documented scientific data, not on unfounded hysteria.” In addition, the College strongly supports general public information efforts, based on fact, to clarify the issue of HIV transmission in the health care setting. The American College of Surgeons is a scientific and educational association of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of surgical patients. The College is dedicated to the ethical and competent practice of surgery. The College has over 51,000 members, making it the largest association of surgeons in the world. The College’s achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. Note: The College’s position statement enumerating its specific recommendations on the surgeon and HIV infection follows.

THE SURGEON AND HIV INFECTION STATEMENT

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In 1980, a new blood-borne viral infection was identified. Since that time, this newly discovered infection and its clinical entity (AIDS) has become a subject of major public and professional interest. Unfortunately, this serious infectious disease has attained a sociopolitical status that is resulting in some unusual reactions with significant consequences, particularly for the surgical community. Important virological information has evolved from laboratory studies. However, important epidemiological information has not been easily accessible because of barriers to testing and because of the stigma and profound social and economic consequences that result when an individual tests positive. Consequently, important data for decision making are not fully available. Because the disease is blood-borne and transmissible, and because of the nature of surgical work, a concerned surgical community has become involved

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and has offered leadership in developing improved surgical techniques and procedures, and enhanced sterile surgical barriers. Surgeons are at risk for exposure to the HIV virus in their daily endeavors and are concerned about this risk. Patients are increasingly concerned about their risk of exposure to HIV infection from blood transfusions, other patients, health care workers, and from their surgeons. We would emphasize that to date, there have been no documented incidents of transmission of the HIV Gus from a surgeon to a patient, and no transmission of the virus to a patient in a sterile operating room environment. This area has been investigated carefully, and despite testing of thousands of patients of HIV-infected surgeons, no evidence of transmission has been found. Reasons for this low risk are readily available and include routine utilization of sterile surgical technique, to which has been added universal precautions. The surgical team is continually aware of the dangers of transmission of any infection, not just the HIV virus; out of this concern has evolved what is known as the “surgical conscience.” In addition, we now know that the blood concentration of viral particles in patients who are infected with HIV is low, and the virus is easily killed. Surgical barriers and surgical techniques should be further developed whenever possible to avoid intraoperative injury and to further diminish any possible risk of transmission. Health care workers are known to have a minimal risk of acquiring HIV injection from patients; however, this risk is much greater than the extremely remote possibility of transmission @ patients. The only identified HIV transmission from a health care worker to a patient occurred in a dentist’s office in Florida. Although not conclusively proven, it almost certainly occurred from contaminated instruments that were not adequately disinfected or sterilized between patient visits. The differences between sterile technique in a dentist’s office and that in a surgical environment are enormous, and they must be differentiated in any epidemiologic analysis. Guidelines published on July 12, 1991, by the Centers for Disease Control (CDC) and now widely distributed, are based on data that are not applicable to the surgical community; yet insurers, licensing bodies, government agencies, legislative bodies, and others are proposing rules based on these guidelines that will dramatically increase the cost of medical care and have a significant impact on the surgical community. We deplore these actions because they are not based on direct scientific data; they are not costeffective; they are intrusive to the extreme; and they are unable to achieve their desired intent. Moreover, “risk-prone procedures” cannot be defined in any sci-

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entific or rational way. Since no procedure other than dental extraction has ever bin shown to result in HIV transmission, this is the only procedure that can logically be called “risk-prone.” We feel that such a categorization would be irrelevant and counterproductive. In formulating these guidelines, the CDC ignored the overwhelming testimony of the scientific community, and the fact that all currently available data indicate that transmission from provider to patient in a hospital setting is, so far, a purely hypothetical event. While basic clinical and epidemiological research continues, a number of issues remain unresolved. Until answers based on scientific data are forthcoming, broad regulatory efforts are unreasonable and, as proposed, will unquestionably have a negative impact on the availability of health care for HIVinfected patients. In the strongest terms, we urge that epidemiologic testing and analysis be made the highest priority by the CDC, in order to answer unresolved questions. The surgical community emphasizes that available scientific data indicate that transmission of HIV infection from physician, surgeon, or nurse to a patient has never been documented. Conceivably some cases of HIV may be transmitted from health care workers to patients at some future date, but this risk appears so low that costly measures such as testing and limiting work are not justified. Our paramount concern is to continue to minimize this risk. We believe that enforcing a high standard of infection control and universal precautions remains the best strategy for protecting patients from accidental exposure. Present recommendations unsubstantiated by scientific data have created an unhealthy atmosphere of doubt in the minds of the patient and the public regarding the problems of HIV transmission. Any regulatory efforts by concerned bodies should be based solely on documented scientific data, not on unfounded hysteria. Public information efforts to clarify the problem, based on fact, could be most helpful in improving the situation. Based on data that are currently available, we make the following recommendations: 1. Surgeons have the same ethical obligations to render care to HIV-infected patients that they have to care for other patients. 2. Surgeons should utilize the highest standards of infection control, involving the most effective known sterile barriers, universal precautions, and scientifically accepted infection control practices. This practice should extend to all sites where surgical care is rendered. 3. To date, there have been no documented incidents

Letters to the Editor

of transmission of HIV from a surgeon to a patient, and no transmission of the virus to a patient in a sterile operating room environment. Therefore, HIV-infected surgeons may continue to practice and perform invasive procedures unless there is clear evidence that a significant risk of transmission of infection exists through an inability to meet basic infection-control procedures and unless the surgeon is functionally unable to care for patients. These determinations are to be made by the surgeon’s personal physician or an institutional panel so designated for confidential counseling.

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4. Various College committees should continue to consider the concerns and problems of HIVinfected surgeons and their families in their deliberations. These recommendations are based on currently available knowledge. Ongoing, continuing research is encouraged, and modification of these recommendations may be necessary in the future, based on newly acquired information. The College strongly supports continuing basic and epidemiological research related to this subject.

American College of Surgeons issues position statement on surgeons and HIV infection.

497 Letters to the Editor El American College of Surgeons Issues Position Statement on Surgeons and HIV Infection Chicago -The American College of S...
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