Annex H
After Death
H.1 On the death of a patient defined in Table 4a in Part 4 of this guidance, the removal of the deceased from the ward, community setting or hospice, to the mortuary, should be carried out using normal infection control measures. It is recommended that the deceased is placed in a body bag, which should be labelled as High-Risk or Danger of Infection prior to transportation to the mortuary, in line with normal procedures for deceased patients where there is a known infection risk. An infection control notification sheet should be completed and given to the undertakers concerned with the deceased. (A specimen sheet, similar to that included in the Health Services Advisory Committee guidance on “Safe working and prevention of infection in the mortuary and post-mortem room” (second edition, 2202) (HMSO. ISBN 07176 2293 2) is included at the end of this Annex).
Post-mortem examination
H.2 Post-mortem examinations are required in order to confirm a clinical diagnosis and the cause of death in patients with suspected CJD, vCJD or any other form of human prion disease. However, such procedures have the potential to expose pathologists and anatomical pathology technologists (APTs) to tissues containing high levels of infectivity. The following paragraphs give advice on basic precautions for safe working. Further advice is given in the Health Services Advisory Committee publication "Safe working and the prevention of infection in the mortuary and post mortem room" (second edition, 2002). Specific information on neuropathological post-mortems in CJD cases has been published (1).
H.3 Only fully trained, competent staff should undertake any necessary post-mortem examination on patients defined in Table 4a. At least two people should be present during the examination: the pathologist assisted by one senior APT, with another APT (if required) to aid in the labelling of containers for tissue samples. Observers should be prohibited from entering the post-mortem room and should only observe via video or from a separate viewing gallery. APTs and others attending out of necessity should be fully trained, competent, understand all of the procedures for such post- mortem examinations, and made aware of the relevant history of the patient.
H.4 Post-mortem examinations on CJD cases can be undertaken in any mortuary subject to local risk assessment; however, if available, a “high-risk” post-mortem suite should be used. If a general post-mortem suite is used, the CJD post-mortem should not be performed while other post-mortems are in progress. Additionally, appropriate care should be taken to minimise contamination of the working environment.
H.5 In order to minimise contamination of the working environment, the examination may be carried out with the deceased in an open body bag with absorbent wadding alongside the body, to retain the body fluids. Examination of the brain is essential in a case of suspected CJD or vCJD, and absorbent wadding can be placed underneath Published: 2 June 2003 Updated: May 2010 the head to contain the spread of blood when the scalp is reflected and CSF when the skull is opened. If preferred, the entire head can be enclosed within a large plastic bag during use of a bone saw to open the cranium. A hand saw or electric saw can be used, but if an electric saw is used then it should be a dedicated saw and only used for known or suspected CJD/vCJD. There should be no vacuum unit attached to the saw. The use of a bag to enclose the head during the opening of the skull and/or removal of the brain is an optional technique, but requires experience for optimal results. If a polythene bag is used, it should be fitted over the head and neck of the deceased, and a saw introduced through a hole in the bag, which may then be sealed with tape as necessary. The polythene bag (if used) and any soiled wadding should be incinerated after the post-mortem.
H.6 Any mortuary undertaking a CJD autopsy should be prepared to perform a full autopsy and to freeze samples of brain and other tissues for biochemical evaluation for PrPSc. If local facilities cannot or are not prepared to do this, or do not have the expertise or equipment to sample and store the frozen tissues, then the deceased should be moved to a regional centre where the required experience and facilities exist. Advice on autopsy protocols and arrangements for refund of any removal costs for CJD post-mortems are made through the National CJD Surveillance Unit – see below for further details: National CJD Surveillance Unit, University of Edinburgh Western General Hospital Edinburgh EH4 2XU UK Tel: 0131 537 1980
Personal Protective Equipment
H.7 Disposable protective clothing should be worn during the post-mortem, including a theatre suit, gown or preferably a full disposable coverall, apron, hat, double gloves, and a full face visor or splash guard mask with visor which completely encloses the operator's head to protect the eyes and mouth. A full hood with batterypowered ventilation may also be suitable. Consideration should be given to the use of hand protection, such as armoured or cut-resistant gloves. Care should be taken when reconstructing in respect of needle stick injuries. The APT must not be rushed and be given sufficient time to perform this task safely.
H.8 Disposable mortuary instruments should be used wherever possible, and be incinerated after use. If it is not feasible to use all disposable instruments due to some not being available in a disposable format then, a set of dedicated instruments for use in ALL definite, probable, possible or at risk cases is recommended. Manual or electric saws may be used. Although the former do not create aerosols and are easier to decontaminate after use, they may present a greater risk of injury. If an electric saw is used, it is advisable to have a dedicated saw for the same reasons as Published: 2 June 2003 Updated: May 2010 above. Instruments and mortuary working surfaces should be decontaminated following the guidance in Annex C. The deceased should be washed in accordance with local protocols.
H.9 In some instances, the relatives of the deceased may request that the body is dressed in clothes prior to viewing at the mortuary or at the funeral directors. This is best achieved at the end of the post-mortem, when the body can be dried and dressed and then placed in a clean body bag prior to viewing.
Anatomy and pathology teaching
H.10 Anatomy departments are advised not to accept for teaching or research purposes, bodies, body parts or organs from any patients defined in Table 4a. Departments should produce local policies to identify who is responsible for checking whether a potential donor may be in one of the defined categories. The extent of the checks necessary will vary with circumstances, but would normally include checking with those responsible for the donation and the medical staff involved in the care of the donor.
Undertakers and embalmers
H.11 The undertakers should receive an infection control notification sheet (see specimen form at the end of this Annex), appropriately completed, before handling the deceased. Concern about possible unknown CJD cases does not warrant a level of precaution for undertakers handling intact bodies other than those used generally for all work of this nature. Dressing and cosmetic work on deceased patients from this risk group may be undertaken if the usual precautions routinely used when dealing with the dead are observed.
H.12 When the diagnosis of CJD or vCJD is known or suspected it is advisable to avoid embalming procedures. When embalming is required by the family, because of the need to preserve the deceased’s appearance for some time, or if the deceased is to be transported outside the UK, then it should be carried out in a facility that is fit for purpose and where the staff are trained, competent and qualified to do so. Single use needles should be used in embalming procedures. All embalmers should perform risk assessments of their premises to establish if they can facilitate embalming onsite, or if their company would need to refer any such request to a specialist establishment.
H.13 The embalming process involves replacing the deceased's blood with a fixative that often includes a dye in order to counter the paleness of the deceased's appearance. The process involves inserting a cannula into an artery (similar to a central line), usually the common carotid, and slowly perfusing the tissues with this fixative. An instrument known as a trocar is used to remove gas and excess fluids from the thoracic and abdominal cavities, prior to injecting fluid into them. A hypodermic syringe is used to inject any tissues that have received insufficient fluid from the arterial injection. A deceased patient who has undergone a post-mortem examination will be subject to a different procedure, which generally involves reopening the body, via the PM incisions, and locating and using the arteries inside the deceased.
Published: 2 June 2003 Updated: May 2010
Funerals and cremations Viewing the deceased
H.14 Relatives, friends or carers of the deceased may wish to view or have some final contact with the deceased. Such viewing and possible superficial contact, such as touching or kissing, need not be discouraged even if a post-mortem has taken place. Body bags may be rolled down temporarily to allow superficial contact; there is no need to deny the relatives, friends or carers this opportunity if a post-mortem examination has been performed.
Return of tissues, blocks, slides etc.
H.15 If consent has been obtained for the retention of tissue for teaching, research and other scheduled purposes, none of the tissues retained following the post mortem examination are required to be disposed of. If this is not the case, following a request from relatives, friends, carers or a person in a Qualifying Relationship (2) decisions about whether tissues, blocks, slides etc of a patient defined in Table 4a can be returned, should be made on the basis of an assessment of the risks. Respectful disposal of tissue by the hospital may be preferable. Each establishment will have their chosen method of respectful disposal, which should be in keeping with the Human Tissue Authority’s Code of Practice. If a risk assessment indicates that these items may be returned, this is best done via the funeral director. If return is not possible, families should have the reasons explained to them. Any retained items from such situations should only be returned, with information relating to the potential risks from the material (e.g. infection or chemical exposure), so that relatives can consider all the risks before selecting the most appropriate option for immediate respectful disposal. Care must be taken to ensure confidentiality in all dealings between funeral directors and a patient’s relatives.
Environmental concerns
H.16 There is no need to discourage burial of a patient with known or suspected CJD or vCJD, and no special arrangements for burial are required. Similarly, there is no need for any extra precautions to be taken for cremation.
Transporting the deceased
H.17 No additional precautions are needed for transporting the body within the UK. If there is a need to transport the body internationally, it will be necessary to comply with the IATA Restricted Articles Regulations. Any additional requirements of the individual carrier should be discussed on a case-by-case basis. The deceased will normally be required to have been embalmed prior to transport and a Notification of Infection form, to replace the usual free from infection form, must also be produced.
Exhumation
H.18 A Home Office licence is required before exhumation can take place. Those involved with such a procedure should follow normal standard practice for exhumations.
Acknowledgments
Published: 2 June 2003 Updated: May 2010
The ACDP TSE Working Group are grateful to the Association for Anatomical Pathology Technology, the British Institute of Embalmers, Professor Sebastian Brandner, Imperial College London and Mrs Linda McCardle, National CJD Surveillance Unit, Edinburgh, for their valuable contribution to this guidance. References 1. Ironside JW, Bell JE. The “high-risk” neuropathological autopsy in AIDS and Creutzfeldt-Jakob Disease: principles and practice. Neuropathol Appl Neurobiol. 1996; 22:388-93. 2. Human Tissue Act 2004, Code of Practice on Consent, www.hta.gov.uk
Published: 2 June 2003 Updated: May 2010
Specimen Infection Control Notification Sheet
Name of deceased:
…………………………………………………………
Date and time of death:
……………………………………………………
Source hospital and ward:
…………………………………………………
The deceased’s remains are a potential source of infection: YES / UNKNOWN (see note 1 below) (ring as appropriate) If YES (see note 2 below), the remains present an infectious hazard of transmission by: (ring as appropriate): Inoculation Aerosol Ingestion Instructions for handling remains (If YES above, tick as appropriate): Body bagging Embalming presents high risk Signed: (Note 3)
…………………………………………..
Print name
………………………………………………..
On behalf of:
………………………………….…
(hospital / mortuary / General Practitioner)
Notes
Note 1: Not all infected patients display typical symptoms, therefore some infections may not have been identified at the time of death.
Note 2: In accordance with health and safety law and the information provided in the Health Services Advisory Committee guidance Safe working and the prevention of infection in the mortuary and postmortem room (Second edition 2002).
Note 3: In hospital cases, the doctor certifying death, in consultation with ward nursing staff, is asked to sign this Notification sheet; Where a post-mortem examination has been undertaken, the pathologist is asked to sign this Notification Sheet; In non-hospital situations, the doctor certifying death is asked to sign this Notification Sheet.
Published: 2 June 2003 Updated: May 2010
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_116540.pdf
Tuesday, June 1, 2010
USA cases of dpCJD rising with 24 cases so far in 2010
http://cjdtexas.blogspot.com/2010/06/usa-cases-of-dpcjd-rising-with-24-cases.html
Thursday, May 27, 2010
Guidance for Industry: Revised Preventive Measures to Reduce Possible Risk of Transmission of CJD and vCJD by blood and blood products; Availability
[Federal Register: May 27, 2010 (Volume 75, Number 102)] [Notices] [Page 29768-29769] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr27my10-66]
http://vcjdtransfusion.blogspot.com/2010/05/guidance-for-industry-revised.html
Tuesday, May 11, 2010
Current risk of iatrogenic Creutzfeld-Jakob disease in the UK: efficacy of available cleaning chemistries and reusability of neurosurgical instruments
http://creutzfeldt-jakob-disease.blogspot.com/2010/05/current-risk-of-iatrogenic.html
Monday, October 19, 2009
Atypical BSE, BSE, and other human and animal TSE in North America Update October 2009
http://bse-atypical.blogspot.com/2009/10/atypical-bse-bse-and-other-human-and.html
CJD TEXAS 38 YEAR OLD FEMALE WORKED SLAUGHTERING CATTLE EXPOSED TO BRAIN AND SPINAL CORD MATTER
>>> Up until about 6 years ago, the pt worked at Tyson foods where she worked on the assembly line, slaughtering cattle and preparing them for packaging. She was exposed to brain and spinal cord matter when she would euthanize the cattle. <<<
Irma Linda Andablo CJD Victim, she died at 38 years old on February 6, 2010 in Mesquite Texas Irma Linda Andablo CJD Victim, she died at 38 years old on February 6, 2010 in Mesquite Texas.She left 6 Kids and a Husband.The Purpose of this web is to give information in Spanish to the Hispanic community, and to all the community who want's information about this terrible disease.-
Physician Discharge Summary, Parkland Hospital, Dallas Texas Admit Date: 12/29/2009
Discharge Date: 1/20/2010
Attending Provider: Greenberg, Benjamin Morris;
General Neurology Team: General Neurology Team
Linda was a Hispanic female with no past medical history presents with 14 months of incresing/progressive altered mental status, generalized weakness, inability to walk, loss of appetite, inability to speak, tremor and bowel/blader incontinence.She was, in her usual state of health up until February, 2009, when her husbans notes that she began forgetting things like names and short term memories. He also noticed mild/vague personality changes such as increased aggression. In March, she was involved in a hit and run MVA,although she was not injured. The police tracked her down and ticketed her. At that time, her son deployed to Iraq with the Army and her husband assumed her mentation changes were due to stress over these two events. Also in March, she began to have weakness in her legs, making it difficult to walk. Over the next few months, her mentation and personality changes worsened, getting to a point where she could no longer recognized her children. She was eating less and less. She was losing more weight. In the last 2-3 months, she reached the point where she could not walk without an assist, then 1 month ago, she stopped talking, only making grunting/aggressive sounds when anyone came near her. She also became both bowel and bladder incontinent, having to wear diapers. Her '"tremor'" and body jerks worsened and her hands assumed a sort of permanent grip position, leading her family to put tennis balls in her hands to protect her fingers. The husband says that they have lived in Nebraska for the past 21 years. They had seen a doctor there during the summer time who prescribed her Seroquel and Lexapro, Thinking these were sx of a mood disorder. However, the medications did not help and she continued to deteriorate clinically. Up until about 6 years ago, the pt worked at Tyson foods where she worked on the assembly line, slaughtering cattle and preparing them for packaging. She was exposed to brain and spinal cord matter when she would euthanize the cattle. The husband says that he does not know any fellow workers with a similar illness. He also says that she did not have any preceeding illness or travel.
http://www.recordandoalinda.com/index.php?option=com_content&view=article&id=19:cjd-english-info&catid=9:cjd-ingles&Itemid=8
>>> Up until about 6 years ago, the pt worked at Tyson foods where she worked on the assembly line, slaughtering cattle and preparing them for packaging. She was exposed to brain and spinal cord matter when she would euthanize the cattle. <<<
please see full text ; Monday, March 29, 2010 Irma Linda Andablo CJD Victim, she died at 38 years old on February 6, 2010 in Mesquite Texas
http://creutzfeldt-jakob-disease.blogspot.com/2010/03/irma-linda-andablo-cjd-victim-she-died.html
CJD TEXAS 38 YEAR OLD FEMALE WORKED SLAUGHTERING CATTLE EXPOSED TO BRAIN AND SPINAL CORD MATTER
http://cjdtexas.blogspot.com/2010/03/cjd-texas-38-year-old-female-worked.html
USA sporadic CJD cases rising ;
There is a growing number of human CJD cases, and they were presented last week in San Francisco by Luigi Gambatti(?) from his CJD surveillance collection. He estimates that it may be up to 14 or 15 persons which display selectively SPRPSC and practically no detected RPRPSC proteins.
http://www.fda.gov/ohrms/dockets/ac/06/transcripts/1006-4240t1.htm
http://www.fda.gov/ohrms/dockets/ac/06/transcripts/2006-4240t1.pdf
CJD USA RISING, with UNKNOWN PHENOTYPE ; 5 Includes 41 cases in which the diagnosis is pending, and 17 inconclusive cases; 6 Includes 46 cases with type determination pending in which the diagnosis of vCJD has been excluded.
http://www.cjdsurveillance.com/pdf/case-table.pdf
Friday, February 05, 2010 New Variant Creutzfelt Jakob Disease case reports United States 2010 A Review
http://vcjd.blogspot.com/2010/02/new-variant-creutzfelt-jakob-disease.html
Saturday, January 2, 2010 Human Prion Diseases in the United States January 1, 2010 ***FINAL***
http://prionunitusaupdate2008.blogspot.com/2010/01/human-prion-diseases-in-united-states.html
Archive Number 20100405.1091 Published Date 05-APR-2010 Subject PRO/AH/EDR> Prion disease update 1010 (04)
snip...
[Terry S. Singeltary Sr. has added the following comment:
"According to the World Health Organisation, the future public health threat of vCJD in the UK and Europe and potentially the rest of the world is of concern and currently unquantifiable. However, the possibility of a significant and geographically diverse vCJD epidemic occurring over the next few decades cannot be dismissed
The key word here is diverse. What does diverse mean? If USA scrapie transmitted to USA bovine does not produce pathology as the UK c-BSE, then why would CJD from there look like UK vCJD?"
http://www.promedmail.org/pls/apex/f?p=2400:1001:568933508083034::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,82101
see mad cow feed ban violations ;
Monday, March 8, 2010 UPDATE 429,128 lbs. feed for ruminant animals may have been contaminated with prohibited material Recall # V-258-2009 Greetings,
I got a follow on this in the mail this past Saturday in the mail. thought some might be interested in the following ;
DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Food and Drug Administration Rockville MD 20857
Terry Singeltary P.O. box 42. Bacliff, TX USA 77518
Dear Requestor
In reply refer to: F2009-7430
http://madcowfeed.blogspot.com/2010/03/update-429128-lbs-feed-for-ruminant.html
Tuesday, March 2, 2010
Animal Proteins Prohibited in Ruminant Feed/Adulterated/Misbranded Rangen Inc 2/11/10 USA
http://madcowfeed.blogspot.com/2010/03/animal-proteins-prohibited-in-ruminant.html
Monday, March 1, 2010
ANIMAL PROTEIN I.E. MAD COW FEED IN COMMERCE A REVIEW 2010
http://madcowfeed.blogspot.com/2010/03/animal-protien-ie-mad-cow-feed-in.html
FRIENDLY FIRE AND OR PASS IT FORWARD MODE OF TRANSMISSION
Sunday, January 17, 2010 CJD Following up: Patients never contracted brain disorder UW Hospital patients
http://creutzfeldt-jakob-disease.blogspot.com/2010/01/cjd-following-up-patients-never.html
Terry S. Singeltary Sr.
P.O. Box 42
Bacliff, Texas USA 77518