James C. Eisenach, M.D., Editor

Fatal Extraction. By Mark Carl Rom. San Francisco, Jossey-Bass Inc., 1997. Pages: 226. Price:$23.00.

In July 1990, the Centers for Disease Control and Prevention (CDC) announced that evidence from a recent investigation was consistent with the first case of human immunodeficiency virus (HIV) transmission from a health care worker to a patient. When Kimberly Bergalis, a college student, was diagnosed as HIV-positive, repeated questioning by public health officials identified no behavioral risk factors for the infection. The review of her medical history revealed that in 1987 she had two wisdom teeth extracted by her dentist, Dr. David Acer, who had previously been diagnosed with AIDS. Subsequently epidemiologic investigation of five other HIV-positive patients indicated that they had undergone dental procedures performed by Dr. Acer. Sequencing of viral DNA from Dr. Acer's patients demonstrated that the virus infecting these patients was most likely the same as that found in a blood sample taken from Dr. Acer and was different from other strains isolated from randomly selected, HIV-infected people in the community. Therefore officials from the CDC concluded that the most likely source of Kimberly Bergalis's infection was from Dr. Acer, although the exact mechanism for the transmission was unknown. Although this was the only cluster of health care worker-to-patient transmissions of HIV in the United States, the report concerning Kimberly Bergalis and Dr. Acer immediately set off public debate on the effectiveness of existing safeguards of the public's health, whether it was appropriate for HIV-positive health care workers to practice, and the public's right to know the HIV status of their physicians. Opinion polls showed strong public sentiment toward implementation of measures believed to protect patients from HIV-positive health care workers. Congressional representatives began to get involved as their constituents demanded federal measures to ensure their safety.

Mark Carl Rom, currently assistant professor of government and public policy at Georgetown University and Robert Wood Johnson Scholar in health policy research at the University of California, Berkley, served as the principal General Accounting Office investigator of the CDC's investigation of the HIV transmissions. In this capacity, he was charged by the US Congress to review the CDC's investigation. He therefore had access to CDC documents that chronicled the events and information substantiating the conclusion that the most likely explanation for the infections was exposure to Dr. Acer's blood at the time of the dental extractions. In Fatal Extraction, Mark Rom has put together a detailed analysis of the data, shows the difficulties facing CDC officials in reaching their conclusion about the source of Kimberly Bergalis's infection, and describes the complexities of formulating recommendations for preventing further health care personnel-to-patient transmissions.

Once the CDC announced that HIV had likely been transmitted from an infected health care worker to a patient, multiple public health policy issues resulted. Was there significant risk for disease transmission when patients are cared for by HIV-positive health care workers? How great was the risk, and could its magnitude be correctly assessed when there had only been one cluster of infections? If HIV-positive personnel continued to practice, should their practice be limited, and who should decide what procedures could be performed? If there are restrictions placed on HIV-infected health care workers, must all personnel be tested for HIV, and is it necessary for them to inform patients of their HIV status because this would jeopardize the future of their practice? Do patients known to be HIV-positive have to disclose their HIV status to their physicians? These were some of the difficult topics debated by CDC officials in trying to formulate new recommendations to prevent HIV transmission to patients. Any new practice recommendations had to protect patients from infection but also had to protect the rights of health care personnel. In July 1991, the CDC published their recommendations for preventing HIV transmission to patients.

Although there was input from expert consultants, from concerned citizens, and from organizations representing health care workers, the CDC recommendations were controversial and not readily accepted. Because the CDC was established as a federal agency for monitoring the health of the US population, it was granted no regulatory or enforcement powers, and therefore, it is only able to make recommendations, which may not be accepted by the medical community and not implemented. This was the case with the HIV recommendations because they did not completely satisfy the public or organizations representing health care workers. As a result, the issues have been taken to the legislative and judicial branches of the federal and state governments in an attempt to clarify the situation. Rom crystalizes the salient points in each side's argument and concludes his book with his personal recommendation for what should have been done to resolve the controversies.

The book clearly presents information about the Bergalis investigation as it unfolded for officials at the CDC and the difficulties that they had in dealing with the implications of this case. It is well written with extensive references to primary data sources. The book is worthwhile reading for anyone interested in the epidemiology of HIV transmission in the health care setting, the details of the CDC's role in this area of health policy, or the challenges associated with making public health decisions regarding HIV. The HIV epidemic has had a profound effect on many aspects of life in the United States and has been a stimulus for examination of public health policy. This book chronicles the debate and reminds us of the enormous challenge of protecting the health and rights of patients and health care personnel.

Arnold J. Berry, M.D., M.P.H.

Professor of Anesthesiology; Emory University School of Medicine; Atlanta, Georgia 30322;arnold_berry@emory.org