DENTISTS DO NOT GET OCCUPATIONAL AIDS: AN OPEN LETTER TO THE PROFESSION

AN EVIDENCE-BASED STUDY ON THE AIDS EPIDEMIC IN DENTISTRY

By E. J. Neiburger DDS
Director -Center for Dental AIDS Research

The greatest impact that dentistry has experienced in the last decades of the 20th century has been concerns about infection control.
This was primarily due to fears about the occupational transmission of HIV/AIDS.

Billions of dollars and millions of person-hours were devoted to this issue because of extrapolations of approximately 100 medical (not dental) HIV transmission cases reported world wide.(1)

As a result, thousands of allergic emergencies and some deaths (e.g.latex anaphylaxis) have resulted from staff and patient exposures to protective devices recommended for the prevention of transmission of this single terrifying disease.

With all the panic and publicity surrounding the great FAIDS (fear of AIDS) epidemic of the late 1980's and early 1990's one critical fact is often missed.

There are (and never have been) any documented cases of dental workers getting occupational HIV/AIDS. (1, 2). Our profession has spent billions of dollars and person-hours on questionable disposables, research, training, legislation, regulation and litigation in an effort to prevent a disease that has never occurred occupationally in dental workers.

There are, however, a reported seven "possible" non-documented cases of occupationally acquired dental HIV/AIDS which are continuously referenced as the only “solid” evidence that HIV/AIDS is a serious concern for dentistry.

This paper will examine the scientific aspects of these cases and how “soft” this “solid” evidence really is .(1)

PANIC---THE DR. ACER CASE

The one issue that threw the nation into a panic and damned dentistry in the mind of the public was the Dr.David Acer case where an AIDS infected Florida dentist ( using recommended Universal Precautions) was alleged to have transmitted the virus to 5 (later 6) of his dental patients. (3-5).

The Centers for Disease Control (CDC), a division of the U.S. Public Health Service under the Secretary of the U.S. Department of Health and Human Services, mishandled the scientific, statistical and media aspects of this case causing wide spread confusion.(4,5).

The “infected patients”, were finally identified with high risk behaviors and in a following governmental investigation, the U.S. General Accounting Office (GAO) reported:

“...CDC could not identify, on the basis of its investigation, exactly how HIV was transmitted to the 5 patients.” “...this case provides little specific information to advance an understanding of how to prevent such occurrences in the future.”

Litigation, big-buck settlements, unremitting media publicity and panic muddied the issue and established the public’s perception (as well as many in the profession) that dental care could easily transmit HIV/AIDS.(1-5)

Serious questions were asked about the conclusions the CDC made in this case but they fell on deaf ears.(3-6)

The GAO and other agencies recommended that the Acer case be considered an anomaly and not be used for policy decisions. Unfortunately the “horse was out of the barn” and the Acer case became the symbol of AIDS dangers; not the exception that it really was.

As time went on, the public and dental media expanded the concept that “AIDS is everywhere”.

Numerous gay rights and AIDS organizations, in an effort to avoid the stigma and discrimination surrounding AIDS being a “gay only disease,” fostered, with the help of the government and a few dental groups, the faulty concept that AIDS could affect everyone equally; heterosexuals and homosexuals alike.

As the FRAIDS panic spread, bizarre predictions appeared such as with TV host Oprah Winfrey’s 2-17-87 “Women living with AIDS” show where Oprah stated “by 1990, twenty percent of heterosexuals will be dead of AIDS”.

A 1991 Gallup Poll reported that Americans (and their political representatives) believed that AIDS (which killed approximately 25,000 that year) was eight times more important than cancer (which killed 900,000+ people in 1991).

This alarmist climate resulted in heavy pressure on the dental profession to show that the public was “safe” in the dental office and numerous laws, regulations and procedures were enacted to give this appearance.(1-7)

Many dental journals and supply manufacturers saw a boom in disposables advertising and sales. Self proclaimed “experts” and infection control organizations proliferated, generating millions of dollars in educational schemes.

Dental offices were awash in latex, wrappers and sterilants.

The U.S. Surgeon General, C. Everitt Koop publicly stated, “Getting AIDS from a Health Care worker is essentially nil.” Using a few occupational seroconversions among the world’s non-dental health care workers as a rational, the CDC supported draconian governmental regulatory measures which gave an opposite message.(1-5)

The Surgeon general’s advice was ignored by the media and public.(7)

Gradually the panic diffused and dissipated as FRAIDS fatigue and clearer minds prevailed. The constant media attention became old and boring. The public saw that, in spite of the doomsayers and activists’ predictions, very few people were going to die of AIDS; especially middle class, heterosexuals.

AIDS was not a disease of average Americans.(3-7)

Serious questions about the Acer case, the effectiveness of Universal Precautions, the CDC’s accuracy, rampant fraud/waste in many AIDS organizations and the obvious miniscule dangers of AIDS transmission caused many exhausted people to calm down and take a second look at the situation(3-5).

In the 1990’s annual AIDS case numbers began to significantly fall.(1,5,8)

AIDS was clearly identified as a preventable and treatable, chronic disease predominately affecting homosexuals, IV drug users and their sex partners.

New medications made AIDS a “tolerable” disease, cleared out hospital wards and allowed many of the infected, who otherwise would have quickly died, to live relatively comfortable, productive lives.

The epidemic was over and dentistry, with the exception of the Acer case, had not been implicated.

POLITICS AND MONEY WARP SCIENCE

The Atlanta based CDC is the nation’s main broker for AIDS epidemiology data and related health information.

It is, by its nature and history, a politically involved government organization.(4-6,9)

The CDC made serious errors in the analysis of the Acer case(4,5,10,11).

The organization routinely “amends” their statistics on HIV/AIDS and in some cases, exaggerates the dangers.(11,12)

For example, the CDC, in its main publication, Morbidity and Mortality Weekly Report (MMWR), published the total of AIDS cases for 1995 as 68,367 (MMWR (1-12-96 p.23), then published

71,547 ( MMWR 8-20-96 p.749) and 71,210 (MMWR 1-1-97 p.1138)...all three sets of data for the same year (1995).

The CDC treats AIDS as its golden child. No other disease has its cumulative, multi-decade case totals routinely published nor has the “data tortured” classification of the “25 to 44 year old group” which was selected to show the worse statistical expression of the AIDS epidemic.(13) It is not used for any other human disease category.

This lacks scientific reliability.

In 1996, the CDC was taken to task in Congressional hearings accusing the organization of exaggerating the risks of AIDS and inflating case numbers in order to increase funding.(4,/a>9)

In one exchange, the U.S. Department of Health and Human Services Director, Secretary Shalala, was asked by a Congressional investigator (Mr. Istook),

“ But I still don’t understand why you were telling this committee about an increase in AIDS and trying to dramatize increases when actually the reports from the CDC show fewer cases and that the increase you talk about is due to a change in definition.”(14)

The Secretary responded by stating, “I deny my testimony was inaccurate”.(14)

Incidentally, it was Secretary Shalala who in a news conference in 1984, announced: the discovery of the AIDS virus by NIH sponsored Dr. Gallo, that HIV was the sole cause of AIDS and a vaccine would be ready by 1986.

None of these statements proved true.

The CDC has often been involved in shady situations involving money and scandal.

The famous head of the CDC, Surgeon General C. Everett Koop, invented Universal Precautions (recommending glove, mask and eye ware for health care workers during all patient contacts).(5)

It was based on the Hadler Hepatitis B infection report (a case about an oral surgeon who transmitted Hepatitis B to patients) which was later found to be scientifically flawed (incorrect HBV incubation periods were used). (15)

In late 1999, Dr. Koop was exposed in what was reported as a million dollar “financial arrangement” with a latex glove maker (WRP Corp), the attempted suppression of government action responding to the erupting latex allergy epidemic and a failing web site (Dr. Koop Life Care Corp.) which sold stock to the public.(16,17)

Recent CDC scandals over misuse of funding (18), the unexpected resignation of its director (19), the retraction of its recommendation for an anti-AIDS cream, nonoxynol-9, (it increased the AIDS transmission rate, not reduced it(20), the feeble attempt to boost AIDS case numbers with a new AIDS designation (AIDS-Opportunistic Illnesses) (21) and the latest Surgeon General’s condemnation (after the 9-11 and anthrax attacks) that the “Atlanta labs are a national disgrace” (22), placed a cloud over the integrity of the policies and scientific methodology used at the CDC.

In an effort to reduce criticism in an often no-win situation, the CDC began a program that exerted great efforts to avoid embarrassing questions and admissions.

One way of doing this was to use “unpublished data” to substantiate “scientific” conclusions/recommendations and when questioned, to refuse researchers requests to examine the non-referenced data by claiming coverage under the Public Health Service Act. Section 301(d) of the Act allows the organization to avoid releasing data under the guise of protecting individuals’ privacy.(23)

It is important for health care providers to carefully examine the scientific basis of governmental mandates and recommendations and not blindly follow edicts that may be more politically than scientifically inspired.

THE MANY DEFINITIONS OF AIDS: CONFUSION

The AIDS of 1984 is different from the AIDS of 2004.

It differs by definition which has changed numerous times.

AIDS is truly a “political” disease.

The definition of AIDS differs from country to country.

In the U.S. there were major changes in the definition in 1987, 1992, 1993 and 2000. Each of these changes resulted in the inclusion of increasingly more ill individuals to the point that AIDS is really a collection of 25+ immunodeficient diseases.(5)

The 1993 definition change caused an almost doubling of yearly AIDS case numbers in one week.

After a year or so the case numbers came crashing down and in a fit of spin doctoring, the CDC refers to the episode as a “temporary distortion”. (24)

In 1987 the CDC defined AIDS as:

“Human Immunodeficiency Virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), is transmitted through....”(25)

By 1998 the CDC changed its definition:

“Acquired immunodeficiency syndrome (AIDS) is a group of diseases or conditions which are indicative of severe immunosuppression related to infection with the Human Immunodeficiency Virus (HIV).”(26)

These definitions all related to serologic HIV testing.

A different set of classifications were reserved by the World Health Organization (WHO) for third world countries without the means to do accurate lab HIV testing.

In 1992, WHO devised a definition of AIDS involving a combination of major (weight loss, diarrhea, fever, etc.) and minor signs (cough, dermatitis, herpes zoster, etc.).

If you had two major and one minor sign, you had “AIDS”.(27)

Unfortunately these signs are also present in TB, malaria, cancer, malnutrition, parasite infestation and a whole host of other “natural” background diseases that occur in many of the poor folk in third world countries.(28)

You do not have to be HIV positive to have “AIDS”.(5,29)

Since AIDS receives more funding than the above diseases, there is a strong financial pressure for impoverished health departments to diagnose more cases of “AIDS”.

Thus we are faced with the CDC and WHO, political organizations with an unimpressive record of counting statistics and some serious deficiencies in the analysis and interpretation of AIDS data. It is unfortunate, but this is the best epidemiology we have today. We must be very careful in what data we accept as accurate and factual.

PEOPLE LIE: AIDS RESEARCH IS OFTEN BASED ON BAD DATA

Much of AIDS epidemiology is unreliable.

It depends on patient interviews where carefully positioned questions attempt to get truthful responses.

Most AIDS data relies on the accuracy and truthfulness of those interviewed.(2-5)

Unfortunately, people lie. They especially lie about their sex-lives (5,30-35 ) and illegal activities (e.g. IV drug use)(36,37). Some even lie so that they can get to participate in vaccine trials.(38)

Numerous studies have shown that that people initially lie but often recant upon pressure.(30,31,33,35,37)

Some people do not.

A number of studies illustrate these phenomena. Castro et al. found that 75% of HIV positive individuals reporting no high risk behavior later admitted that they lied.(31). In a CDC study of heterosexually acquired AIDS patients, 9% later admitted they were homosexuals.(33). Cochran and Mays found 47% of individuals with sexually transmitted disease lied about their behavior: 20% said they would lie about being HIV positive.(35)

In a U.S. government study of 12,329 AIDS patients claiming “undetermined” risk factors, follow up interviews discovered that all but 491 individuals (3.9%) really participated in high risk behavior.(30) Healthcare workers were found to be no more truthful in telling the facts about their private activities.(37)

Why would someone lie that they caught HIV/AIDS occupationally when, in truth, it was from high risk behavior? The answer is simple. If you claim to have been infected with HIV/AIDS occupationally, you get sympathy from your family and community, disability payments, legal protection and other secondary benefits. If you admit your AIDS came from high risk behavior (e.g. anal intercourse with homosexual men, drugs) you get thrown out of the house, divorced, jailed, fired from your job and generally stigmatized. That is why people lie about AIDS and we should be very suspicious of any stories claiming non-risk sources of occupationally involved AIDS infection. In many of these cases, the CDC took subjects’ claims at face value in absence of other scientific facts.(4-6 ) This “soft” data forms the basis of the CDC’s determinations in the Seven possible dental (occupational) AIDS transmission cases.

LIMITED TESTING ACCURACY

AIDS is diagnosed in the industrial nations with a series of blood tests. Usually an ELISA survey test and, if needed, a confirming Western Blot test. Both tests require a sophisticated lab and well trained technicians.

Even though tests are considered accurate, false positives do occur. Kleinman, in a study of 5 million samples, found a 4.8% false positive rate for HIV (Western Blot) tests when compared to the much more accurate (and expensive) HIV-1RNA PCR test.(39)

The study found HIV tests to have a specificity of 100% and a sensitivity of 98%.

Another study found that numerous conditions like liver disease, drug abuse, pregnancy, hemodialysis, transfusions, etc. will give a false positive HIV test results.(40 )

Thus it is possible to be diagnosed as being HIV positive and having AIDS yet never be sick from the disease. This may explain the numerous HIV positive“non-reactors” who, unless they take the toxic antiviral drugs, have no observed problem with their health.(5,41 )

Because of these reasons, dentists must be skeptical of anecdotal reports and cautious in extrapolating rare reports of occupational HIV/AIDS transmission “cases”.

THE SEVEN DENTAL WORKERS WITH “POSSIBLE” OCCUPATIONALLY ACQUIRED HIV

The CDC, in several years of “HIV/AIDS Surveillance Report” issues, stated that there were seven dental workers who are “possible” cases of occupational HIV/AIDS transmission. (42).

The designation, “possible” is defined as, “These healthcare workers have been investigated and are without identifiable behavioral or transfusion risks: each reported percutaneous or mucocutaneous occupational exposures to blood or body fluids or laboratory solutions containing HIV, but HIV seroconversion specifically resulting form an occupational exposure was not documented.”(42-44) In this often quoted data, there are no sources referenced.

The last possible occupational case was recorded in 1995.(44)

With no further cases reported, the CDC stopped publishing this category of health care “infection” in 2001.(1)

In 1999, the CDC changed the total number, removing one case; thus reporting a new total of 6 “possible” cases of dental worker occupational exposure. (45).

Dr. H. Gayle, Director of the CDC’s National Center for HIV, STD and TB Prevention explained that this change was because, “...CDC surveillance data are always presented as ‘provisional’ in these reports... further investigation showed the dental worker had other (behavioral or transfusion-related) risk factors...”.(46)

The subject had lied to investigators.

After several years of inquiry through innumerable phone calls, Freedom of Information Act (FOIA) requests, litigation and Congressional/government inquiry (9,14,46,47-52), the following data describing the “possible” occupational transmissions in dental workers was received from the government and is presented:

Of the seven (six) dentists classified as “possible” occupational HIV/AIDS transmission, three were general practitioners, one a periodontist, one a pedodontist and two were dental students.

Five had AIDS, two were HIV positive but had no symptoms.(52)

Three dentists were mentally impaired. The seven performed 22,134 procedures on 6,740 patients with no HIV/AIDS being transferred to or from the operators (DNA studies).(52)

Dentist 1. The first case was reported by Klein et al and used by OSHA to extrapolate the dangers of AIDS transmission to dental workers.(2,5,48). Klein found a male dentist who tested HIV positive and denied high risk behavior in a survey of 1,309 dental staff. He lived among and treated New York City “village” patients; a high AIDS risk population. He intermittently used protective equipment. His wife refused to be tested. HIV exposure could not be documented and the CDC authors freely made an assumption; that if the dentist did contract HIV occupationally, then Universal Precautions would have prevented transmission.(48)

The problem with this study is that it was based on an unproved assumption (the dentist got HIV occupationally from his patients) with no other supporting evidence concerning false positive testing or other high-risk causes (e.g. bisexual contacts, drugs, etc.). Investigators took his word as fact. OSHA based its decision to include dental workers in its 1991 Blood Borne Pathogen Rule on this one case describing it as proof of...”a risk of dental professionals acquiring HIV”.(2) There is no science supporting this conclusion. It was a guess.

The 12-6-91 Federal Register (Bloodborne Pathogen Rule p.64021) contains one reference of “further evidence” involving two seroconverted dental workers, among a group of 69 health care workers, with no identifiable risk for infection.(2@ OSHA considers these cases “less complete” and states, “ it is reasonable to assume that at least some of them resulted from occupational exposure.” but gives no scientific references to support this claim.(2)

A 1992 report in MMWR mentions these two dentists and states they worked in a correctional facility (treating high risk patients), experienced needle sticks from equipment used on unidentified patients and died before HIV –DNA studies and in depth interviews could be done.(49) Since there was little information on these two dentists (e.g. their potential high risk behavior), occupational transmission could not be ruled out by CDC staffers and thus they were classified as “possible”.(2,,(49),50)

This “possible” designation is problematic because “possible” is often extended to “probable”, then “most likely” and finally being assumed as “actually happened” classifications: data torturing often seen in other government publications with a political bias.(4)

Dentists 4 ,5 & 6 (including perhaps dentists 1-3). The CDC, after years of numerous calls and an ignored FOIA request from the American Association of Forensic Dentists, reconsidered its decision and provided more data on “possible” occupational seroconversion cases in 1996 and later, 2003. This change of heart may have been encouraged by pressure of a high ranking Congressional committee chairman (John Porter, MC) during funding hearings. The CDC provided a single “scientific” document in the form of a short abstract from the 1995 meeting of the American Association of Public Health Dentistry. This was the “hard scientific” data the CDC supplied to Congress (and the FOIA requests) on the “possible” dental occupational seroconversions.(51)

The objectives were “To describe demographic characteristics and exposure to HIV among dental workers (DW) reported to the CDC through 1994.” The summary of the report stated:

“Six Dental Workers (DW) reported without a specific risk had occupational exposures that were possibly associated with HIV transmission: three of those reported percutaneous exposure to patient’s blood or body fluids, although the patients were not known to be HIV-infected.  Conclusions:  Almost all of the DWs reported to the CDC with AIDS had behavior risks for HIV infection. Adherence to universal precautions by DWs is recommended.”(52)

This report states that “almost” all the possible cases of DWs seroconverting had high risk behavior, a proven source of HIV/AIDS infection unrelated to dentistry. The first dentist would not admit high risk behavior. There were no examples of individuals who did not have this probable cause of infection. When asked how accurate this data was in supporting the “possible” designation, one CDC official stated, “the scientific evidence is not very ‘hard’”. There are no documented cases of occupational HIV/AIDS transmission. There are no “probable” cases and the six dentists classified in the “possible” designation appears arbitrary, lacking any scientific veracity.

So where do we stand on the potential of dental workers (dentists, assistants, etc.) of acquiring HIV/AIDS professionally? AIDS/HIV seroconversion rates of dentists have been studied for over 20 years. There is no dependable scientific evidence to substantiate that dental workers are or have been in ANY danger. The historical odds of a dental worker acquiring HIV/AIDS occupationally is zero. This is supported by the facts that in billions of dental patient contacts there have never been any documented cases of occupational HIV/AIDS infection in dentistry anywhere in the world since AIDS was discovered. It appears that the CDC’s proposed seven (six) possible cases of dental worker infection are based on scant, unscientific, poorly substantiated and unreliable/data.

Because of the politics, panic, exaggerations, denials, scandals, redefinitions and unscientific epidemiology which form the basis of the governments dental-related recommendations/ regulations (not to mention an ignorant and fear crazed populace), dentistry has spent billions of dollars, person hours and lives lost on infection control schemes addressing the prevention of a disease that does not affect dental personnel.

Because of the lack of demonstrative infection transmission over the 20-plus years of AIDS (before and after the advent of Universal Precautions), we are faced with one humbling conclusion. The dental profession has been duped. Dental workers do not get occupational HIV/AIDS.

The FRAIDS epidemic in dentistry fueled an extreme infection control movement that was not warranted nor supported by the alleged science identifying a hazard. It has not significantly reduced the already small infection transmission rates of other diseases. Vast resources were diverted from the population’s health care and livelihoods to address a “chicken little” disaster that never existed. Now that mythology and fear has somewhat abated, our profession should carefully re-examine the research and evidence available and produce clear, practical standards on disinfection, sterilization and patient treatment that more accurately reflect the objective scientific realities of HIV/AIDS hazards in dentistry. We should be skeptical of any alarmist’s tales. Dentistry should not continue the fear and hype that has been embarrassing the dental community and enriching hucksters and false prophets since the 1980’s.

I would recommend the following measures:

1. Cease confusing the CDC’s “six possible” occupational dental cases as fact. It is at best, an unsubstantiated guess. Carefully investigate the CDC’s data and publicize the scientific findings.

2. Do not believe everything government tells you. Require the CDC to provide full documentation (e.g. web) on all its data and decision making processes. Be skeptical and demand hard scientific proof for regulations.

3. Allow the dental workers the option of choosing what protective equipment and measures they will use on a case by case basis utilizing their professional judgment. The existing broad governmental mandates (e.g. Universal-Standard Precautions are unsupportable.

4. Establish a mechanism to insure accuracy in future infectious disease reporting and recommendations outside of the CDC (e.g. independent review panel, firing untruthful employees).

5. Insist on objectivity, accuracy and balance in dental organizations and publications.

6. Don’t be so gullible and easily lead.

It is time for a change.

REFERENCES

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2. Department of Labor-OSHA. Occupational exposure to bloodborne pathogens: final rule. Federal Register 1991;57 (235):64005-64157.

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51. Klevens, M. C., Ciesielski et al. AIDS cases in dental workers. 1995. Presented at the Annual Meeting of the American Association of Public Health Dentistry. October. Abstract 77.

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Copyright 2003 by E. Neiburger and the Center for Dental AIDS Research.

Permission to republish is granted to anyone who wishes to print this document provided that a copy of the article is mailed to E. Neiburger, CDAR. 1000 North Ave. Waukegan IL 60085 USA

This article was published in the January '04 issue of the Journal of the American Association of Forensic Dentists, vol. 26, no. 1-3, 2004