Measles outbreak in western Sydney

acceptable to Dr Black. However, a clear and most extensive risk profile assessment failed to identify traditional modes of sexual or other transmission. All surgical and infection control procedures undertaken by the surgeon were meticulously assessed and no identifiable failures were evinced. HIV transmission has not been reported in this health care setting in any country with universal precautions in place. A number of possibilities could have explained the patient-to-patient transmission. The most scientifically understandable mechanism would have been through the use of multidose vials, which were reported not to have been used by the surgeon, although they were widely used in clinical practice in 1989. The expert panelthose involved in assessing this most tragic case, as well as the Medical Tribunal that evaluated the situation failed to pinpoint the failure in infection control. It is, however, recognised in many situations of nosocomial transmission that the precise mode of transmission in a clinical setting (e.g., for hepatitis B) may never be traced. Dr Black reports that the guidelines have now been changed. In fact they have been extended to include office practice, and clarified with respect to voluntary self-identification of HIV and hepatitis status of health-care workers involved in exposureprone procedures. The guiding principles of infection control have not changed compliance must. I share Dr Black's dissatisfaction with not being able to firmly clarify events that took place in November 1989.