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NHS failed to sterilise surgical instruments contaminated with 'mad cow' disease

Regular sterilisation procedure wasn't suitable for the task, says leading specialist

The NHS has failed to use an effective method of sterilising surgical instruments contaminated with the human form of “mad cow” disease because it did not fit in with its established washing procedures, a leading specialist in variant Creutzfeldt-Jakob disease (vCJD) claimed yesterday.

The result is that hundreds of people have had their lives blighted by surgery performed with instruments possibly contaminated the prion protein responsible for vCJD said Professor John Collinge, director of the Medical Research Council’s Prion Unit at University College London.

Professor Collinge led one of a number of research groups that came up with novel ways of destroying the lethal prion protein, which sticks to the stainless steel of surgical instruments like superglue and can survive the high temperatures of hospital autoclaves.

However, in evidence to the House of Commons science and technology committee, Professor Collinge said that he was astonished and disappointed that the Department of Health and the NHS failed to adopt any of the suggestions for decontaminating surgical instruments.

“The solution we developed was a combination of enzymes and detergents, if you like a sort of bespoke biological washing powder which very effectively prion-decontaminated metal surfaces,” Professor Collinge said.

It was one of several decontamination procedures developed by a number of research groups sponsored by the health department over a decade ago to find ways of making surgical instruments safe, he said.

“Neither this nor the other products that were available – I think there were three – have ever been taken up by the NHS. They simply haven’t been used. These issues have been bounced around various committees to my and other peoples’ great frustration,” Professor Collinge said.

“It’s perhaps not surprising given that the NHS is notoriously resistant to change and to introducing new methodologies,” he said.

“Absolutely nothing has happened despite all this research and all this effort. Currently several hundred people have been notified that they have been exposed to [potentially contaminated] surgical instruments,” he told the committee.

“We’re blighting these peoples’ lives and all this has been avoidable for some years by applying this research. I find it quite extraordinary that the system just does not work,” he said.

“They’ve had to be notified that they’ve had a significant exposure to prions because they are expected to take precautions. They are not allowed to be blood donors and if they go on to have surgery they have to notify the surgeons that they are high risk individuals.

“Needless to say this has a major effect on their lives and needless to say it makes me very angry because all of this was avoidable,” he added.

DuPont, an American chemicals company, worked out a way of manufacturing Professor Collinge’s product as a 50C pre-soak for surgical instruments, but because this would involve changing the standard procedures for how medical devices were sterilised, NHS hospitals refused to adopt it, Professor Collinge claimed.

“What we had developed was seen to be inconvenient…The NHS didn’t buy a single unit of the product so was it surprising that the manufacturer just walked away?” he said.

“It was extraordinary [that] it was discussed in I don’t know how many committees and subcommittees when patients are being put in this position and having their lives blighted. It’s disgraceful,” he told the committee.

About 200 hospital patients have been told that they have been exposed to the vCJD prion through instruments that were used on other patients who subsequently died of the brain disease. Three out of the 177 people in the UK who have died of vCJD received contaminated blood, and the rest are assumed to have been infected by meat or meat products contaminated with bovine spongiform encephalopathy (BSE).

A spokesman for the Department of Health said that Professor Collinge’s research group has received £18m for various research projects and that DuPont’s prion inactivation product has been reviewed twice by Public Health England’s Rapid Review Panel, which established “gaps” in DuPont’s application.

Roland Salmon, the joint chairman of the government’s advisory sub-committee on dangerous pathogens, defended the Department of Health’s stance on introducing new ways of sterilising surgical instruments.

“I don’t think it’s fair on the department [of health] to say that nothing was done…they did institute a number of improvements,” Dr Salmon said.

“It’s perfectly true they haven’t introduced specific products…the barrier had been I’ve told with having a product composed in such a way that it can be introduced into what is an industrialised process in a cycle,” he said.

How vCJD can be contracted

Almost all of the 177 cases of vCJD – the human form of “mad cow” disease – have been contracted through eating contaminated meat or meat products before the introduction of controls to limit the spread of bovine spongiform encephalopathy (BSE) from cattle to people.

Three of these deaths, however, are believed to have resulted from blood donors infected with vCJD, but showing no clinical symptoms. There is one further case of a person who died of something else but who was shown at post-mortem to be infected following a blood transfusion.

There are fears of secondary infections from asymptomatic carriers in the population. Latest estimates suggest that up to one in 2,000 people in Britain could be carriers of vCJD.

Because the prion protein responsible for vCJD is found in a wide range of tissues, such as spleen, tonsils and appendix, the fear is that asymptomatic carriers may spread the infection to others through contaminated surgical instruments and blood donations.