Mix-up will reignite row over surgical instruments

A mix-up at a Middlesbrough hospital that may have exposed up to 29 people to Creutzfeldt-Jakob disease (CJD) reignited the argument last night over the equipment and procedures used to contain the illness.

The Department of Health introduced tight guidelines demanding improved hygiene and sterilisation of surgical instruments in hospitals three years ago following the emergence of variant CJD (vCJD).

The move was made after scientists discovered a theoretical risk that the infective agent that causes the human form of BSE could be passed on during surgery.

Researchers warned that prions, the protein particles thought to be responsible, might be transferred during procedures, in particular those on the tonsils and the brain.

It was during brain surgery at Middlesbrough General Hospital that the instruments at the centre of last night's health alert were first used on a patient who was subsequently found to be suffering from CJD.

The prions that cause the disease lurk in particular types of tissue found not only in the tonsils and brain but also the spleen, appendix, part of the intestines and the back of the eye.

In order to minimise the risk, a £25m project to provide disposable surgical instruments – the only way to eliminate the risk of CJD infection – for tonsil removal operations was introduced by the Department of Health. But late last year the scheme was abandoned after it was found that one woman had died and 18 had been hurt as a result of errors in the use of the throw-away kit.

The problems were caused by an electrical tool used to cauterise incisions during the surgery that health chiefs found was being used at excessive temperatures, causing post-operative bleeding.

A Department of Health spokesman said last December: "Single-use instruments represent a real risk to patients, compared with a theoretical risk of transmission of vCJD. Given this balance of risks, we have decided that surgeons can return to using reusable equipment which should be sterilised in the normal way."

The decision leaves health professionals with a dilemma in their efforts to control the spread of CJD, a wasting disease of the brain that causes personality change, loss of body function and eventually death. There is no known cure or treatment.

Under NHS procedures, all surgical instruments are washed and heat-treated for 15 minutes at 121C. There is also a method under which equipment is heated to 134C for three minutes. The problem is that no matter how much they are heated, the prions that cause vCJD cannot be destroyed by sterilisation.

Instead, government advisers say a combination of careful washing of all equipment to sluice away the microscopic infective particles followed by sterilisation should be enough to minimise the risk.

A random check of hospitals two years ago found that standards of hygiene were often poor, with some instruments still stained with blood after sterilisation and tracing of equipment used in specific operations difficult.

About 6.5 million operations are carried out in hospitals in England each year, but the Department of Health points out that most will not involve tissues identified as carrying prions.

The Government said last year that each of England's 249 hospitals had brought sterilisation procedures up to an acceptable level. Further tightening of procedures, under which instruments used in CJD "danger areas" are put through the washing and heating 10 times, are being brought in.

WHAT IS CJD?

Creutzfeldt-Jakob Disease, named after two German scientists who diagnosed it in the 1920s, was until recently just one of a number of horribly disabling but obscure brain diseases. The "classic" form, also known as sporadic CJD, strikes men and women from all ethnic groups, generally between the ages of 50 and 75. One in a million people are affected every year, meaning up to 70 cases a year in Britain. The trigger for it is the prion, a pathogen which turns benign protein molecules into infectious ones, which attack the brain, making small holes in the tissue, giving it a sponge-like appearance. This causes a decline from early symptoms such as insomnia to rapidly progressing dementia, involuntary movement and a fatal coma. Symptoms can take years to emerge.

But it was the appearance eight years ago of a different form of the disease, variant or vCJD, which turned the illness into a medical and political phenomenon. It was found to affect much younger people, on average aged around 27, and develop a pattern of destruction in the brain different from sporadic CJD, but similar to the brains of cows infected with bovine spongiform encephalopathy or BSE. The most likely source of vCJD is exposure to the agent that causes BSE. So far, 117 people in the UK have died from vCJD.