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Guidance issued on reducing risk of CJD transmission

Measures relate to use of surgical instruments

Jo Carlowe

Wednesday, 22 January 2020

The National Institute for Health and Care Excellence (NICE) has today published final guidance on reducing the risk of transmission of Creutzfeldt-Jakob disease (CJD) from surgical instruments. 

Although there has been no reported case of CJD being surgically transmitted, NICE states that special safety measures are needed for instruments that are used on tissues that have a high risk of containing prions. 

NICE reviewed its 2006 interventional procedures guidance on patient safety and reduction of risk of transmission of Creutzfeldt–Jakob disease (CJD) via interventional procedures. It said that those born after 1996, undergoing an interventional procedure, had to have their own set of neuroendoscopes and reusable surgical instruments. Those born after 1996 should not have come into contact with meat from infected cattle entering the food chain.

In updating the guidance, NICE’s independent interventional procedures committee considered the findings of a report from the School of Health and Related Research (ScHARR) and the opinions of the CJD advisory committee members. It also considered the cost-effectiveness of potential management strategies to reduce the risk of transmission of CJD.

The guidance is specifically for interventional procedures on tissues considered at high risk of transmitting CJD. These are: intradural surgery on the brain (including the pituitary gland) and spinal cord, neuroendoscopy, and surgery on the retina or optic nerve.

The recommendations include:

  • Ensuring all surgical instruments that have come into contact with high-risk tissues during an interventional procedure are kept moist until decontamination. This improves the efficacy of the decontamination process and is highly cost effective.
  • Surgical instruments that come into contact with high-risk tissues must not be moved from one set to another and must remain within their individual sets.
  • Supplementary instruments that have come into contact with high-risk tissues must remain within the individual set to which they have been introduced.
  • Rigid neuroendoscopes (rather than flexible neuroendoscopes) should be used if possible.

The committee said the evidence on cost effectiveness does not support: 

  • Using sets of single-use instruments to reduce the risk of CJD transmission
  • Introducing systems to maintain separate sets of neuroendoscopes and reusable surgical instruments for use on high-risk tissues for people born after 1996.

The updated guidance reaffirms previous recommendations made in 2006 around having a separate pool of neuroendoscopes and reusable surgical instruments for high-risk procedures. However, there is now no longer a requirement to have separate sets of neuroendoscopes and reusable surgical instruments for use on high-risk tissues for people born after 1996.

The committee’s recommendations do not apply to any interventional procedures carried out on patients already known to have or thought to be at increased risk of CJD as defined by the Advisory Committee on Dangerous Pathogens and Spongiform Encephalopathies Advisory Committee. 

For these patients, the guidance on transmissible spongiform encephalopathy agents, safe working and the prevention of CJD, part 4 must be followed. The guidance on transmissible spongiform encephalopathy agents, safe working and the prevention of CJD, part 4 must also be followed when the risk of CJD cannot be ascertained by questioning the patient or when a diagnosis of CJD cannot be excluded.

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