UW Hospital and Clinics Addresses Creutzfeldt-Jakob Disease Risk
MADISON - On Monday, July 20, UW Hospital and Clinics received a confirmed diagnosis of likely-sporadic Creutzfeldt-Jakob Disease (CJD) in a patient who underwent brain surgery at our hospital on June 11.
During a press conference held by UW Hospital and Clinics following the confirmed diagnosis, Senior Vice President for Medical Affairs and Associate Dean for Hospital Affairs Carl Getto explained, "Our primary concern is to ensure our patients are fully aware and informed about this extremely rare occurrence."
CJD is an extremely rare and progressive neurological disease that affects approximately one person per million per year worldwide. It can be transmitted by direct contact of brain tissue or spinal cord fluid from an infected person with brain tissue or spinal cord fluid of another individual.
CJD was not suspected at the time of the June 11 surgery to remove a brain tumor. When the patient's condition deteriorated rapidly in the weeks following surgery, additional tests were performed, and CJD was confirmed.
"In this case, the individual had a space occupying lesion, which provided the diagnosis for why the symptoms might have been occurring. That is why CJD was not considered a possibility at the time of the surgery," explained UW Health infectious disease physician Nasia Safdar, MD
Because the means of CJD transmission are specific and limited, staff are not at risk. From the patient perspective, there has not been a single reported case worldwide of CJD transmission by surgical instruments since 1976, when current sterilization and processing techniques were adopted. Nevertheless, the infectious agents in CJD – called prions – are considered more resistant than other organisms to standard disinfectants and sterilization procedures
"Although the likelihood of CJD transmission is virtually non-existent," said Getto, "we have taken immediate and extraordinary aggressive measures to ensure that all surgical instruments used during this procedure are re-sterilized according to CJD-specific sterilization processes as recommended by the Centers for Disease Control."
In addition, UW Hospital and Clinics leaders are taking the following steps:
- Notifying through a letter and personal phone call from medical staff a subset of 53 neurosurgery patients who underwent within-brain and spinal cord procedures between June 11 and July 20
- Conducting surgery with instruments that were definitely not affected by the June 11 procedure
- Resterilizing and reprocessing all other instruments using enhanced sterilizing techniques and disinfecting agents, per Centers for Disease Control recommendations
"We have notified 53 neurosurgery patients and offered them our assistance, information and reassurance. These surgical patients were only those who were undergoing surgery within the brain," explained Getto.
The 53 patients will have a follow up appointment with their neurosurgeon and be offered an appointment with a neurologist. If further neurologic or psychologic care is necessary, UW Hospital and Clinics will provide the necessary resources to the patients.
Other hospitals in the U.S. have experienced similar situations, including Tulane Medical Center, Emory Healthcare and Froedtert.
"We are confident that we have followed standard procedures and followed the best procedures recommended to us," concluded Getto. "Our processes are exactly what you should expect from a quality hospital."
Common Concerns Related to Creutzfeldt-Jakob Disease
In addition, Dr. Safdar addresses common concerns in the video FAQs below.
What is the risk of patient exposure to Creutzfeldt-Jakob Disease?
Why is exposure risk so low?
Why is UW Hospital notifying patients of the risk?
What are the symptoms of Creutzfeldt-Jakob Disease?
Are current patients at risk for Creutzfeldt-Jakob Disease?
What should patients who may have been exposed do?
Has possible Creutzfeldt-Jakob Disease exposure occurred at other hospitals?
How many people in other hospitals have developed Creutzfeldt-Jakob Disease?
Whom should I contact at UW Hospital if I have concerns?
Date Published: 08/04/2009