Friday, August 13, 2010

Creutzfeldt-Jakob disease (CJD) biannual update 13 August 2010 UK Iatrogenic CJD Incidents Report

Emerging Infections/CJD Published on: 13 August 2010

Next update: 12 February 2011

Last updated: 13 August 2010, Volume 4 No 32 (PDF file, 280 KB)

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Emerging Infections Emerging Infections Summary (July 2010)

CJD Creutzfeldt-Jakob disease (CJD) biannual update (2010/2)

Emerging Infections Summary (July 2010)

The Emerging Infections and Zoonoses Section (EIZ) at the HPA Centre for Infections uses an integrated horizon scanning approach which combines information on both human and animal health, in order to identify and assess outbreaks and incidents of new and emerging infectious diseases reported nationally and internationally. A wide variety of sources are scanned and the information gathered is logged daily. This is then used to produce a monthly Emerging Infections Summary that covers those incidents or events which might pose a public health threat to the UK population.

Recent topics have included polio resurgence in Tajikistan, Q fever in the Netherlands, Hantavirus in Germany, and a newly emerging disease of uncertain aetiology in cattle, bovine neonatal pancytopenia, in Europe.

The summary is produced for the Chief Medical Officer's National Expert Panel for New and Emerging Infections and, in addition to panel members, is circulated within the HPA, to the Department of Health, and to animal health colleagues. The summaries are published each month on the HPA website [1].

References 1. Emerging Infections Monthly Summaries, HPA website: Home › Topics › Infectious Diseases › Infections A-Z › Emerging Infections ›Emerging Infections Monthly Summaries.

Creutzfeldt-Jakob disease (CJD) biannual update (2010/2)

This six-monthly report provides an update on reports of incidents of potential iatrogenic (healthcare-acquired) exposure to CJD, and on the National Anonymous Tonsil Archive. The data are correct as of 13 July 2010.

For numbers of CJD case reports, readers should consult data provided by the national CJD Surveillance Unit (NCJDSU), Edinburgh [1]. The latest yearly analysis of vCJD reports (onsets and deaths) is also available from the NCJDSU website [2].

Reports of incidents of potential iatrogenic exposure to CJD via surgery: 2000 to 30 June 2010

A surgical incident occurs when a patient with or at risk of CJD has undergone surgery without the appropriate infection control guidance being followed [3]. This could happen if a patient undergoes surgery during the incubation period of CJD, or because information about CJD risk factors is not available at the time of surgery. If this happens, surgical instruments that may be contaminated with the infectious agent that causes CJD, could pose a transmission risk when they are reused on other patients.

Advice has been issued for the six surgical incidents that were reported to the CJD Incidents Panel in the first six months of 2010 (01/01/2010 to 30/06/2010). Table 1 shows the number of CJD surgical incidents reported to the CJD Incidents Panel from 2000 to 30 June 2010 by the diagnosis of the index patient. As shown in the table, 46% of surgical incidents result from surgery on index cases diagnosed with sporadic CJD.

Information about the CJD Incidents Panel can be found on the HPA website [4].

Table 1: CJD Surgical Incidents (n=417) reported to the CJD Incidents Panel (which have been closed, or where advice has been issued) by diagnosis of index patient: 2000 to 30 June 2010 Incident type 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 First half 2010 Total % of total incidents

Sporadic (possible, probable or definite) 7 19 22 24 16 18 31 17 21 14 2 191 46%

vCJD (possible, probable or definite) 6 14 22 5 4 1 2 – 1 – 56 13%

Familial (including 'at risk' familial) – 2 7 1 3 7 – 2 1 27 6%

'At risk' vCJD blood component recipient – 3 10 6 1 – 20 5%

'At risk' - vCJD plasma product recipient – 1 2 – 10 18 9 8 6 8 1 63 15%

Asymptomatic vCJD infection – 1 – 1 – 2 <1%

At risk' - other – 2 1 2 4 – 1 13 3%

CJD type unclear/ CJD unlikely 1 – 4 1 2 – 10 2%

Not CJD 2 1 4 7 1 – 3 – 26 6% Other – 1 2 1 – 1 7 2% No longer considered 'at-risk' – 1 – 1 – 2 <1%%

Total 16 38 56 50 45 56 63 27 33 27 6 417 100%


If the investigation of a surgical incident identifies any instruments that are considered to be potentially contaminated with the infectious agent, and that could still pose an infection risk to other patients, the Panel advises that these instruments should be removed from general use or refurbished. These instruments may be quarantined, kept for exclusive use on the index patient, refurbished (endoscopes only), destroyed, or sent for research (to the Surgical Instruments Store held by the Health Protection Agency, Porton Down).


Since 2000 there have been 83 incidents in which instruments have been permanently removed from general use or refurbished (endoscopes only). In the first half of 2010, four incidents have resulted in the Panel advising Trusts to remove instruments from general use (either destroying them, keeping them for sole use on the index patient or sending them to the instrument research repository) or to refurbish them (endoscopes only).

Surgical incidents resulting in At Risk patients

The Panel may advise contacting and informing patients of their possible exposure to CJD following a surgical incident. These patients should be considered ‘at-risk of CJD for public health purposes' and are asked to take certain precautions (ie not to donate blood, other tissues or organs, and to inform their medical and dental carers prior to any invasive procedures) in order to reduce the risk of transmitting the CJD agent.

The diagnosis of the index patient; the timing of the procedure relative to the development of clinical CJD; the tissue that instruments were in contact with during the procedure on the index patient; and the number of cycles of re-use and decontamination the instruments have been through following the procedure on the index case; all influence the possible risk to subsequent patients.

The threshold level of risk at which patients are considered to be ‘at risk' of CJD is 1%, in addition to the background risk experienced by the UK population. This risk is based on risk assessment models, using precautionary assumptions. The 1% threshold level is used as a cut off for implementing public health precautions, and is not intended to be a precise measure of an individual patient's risk. A similar threshold is used for identifying other patients who have been exposed to possible CJD risks following surgical, blood, plasma and tissue incidents.

Since 2000 to 30 June 2010, there have been 24 surgical incidents, in which the Panel has advised that 156 patients should be considered to have an increased risk of CJD.

Patient denotifications

Following changes in the assessment of tissue infectivity, the Panel has advised that 38 patients in 14 surgical incidents who were originally considered (and notified) as being at risk of CJD should no longer be considered at risk, and should be denotified. In November 2005, gastrointestinal endoscopies without invasive procedures were reclassified as low risk procedures, and advice was issued to denotify two patients in one surgical incident. In 2006, anterior eye was reclassified as a ‘medium low' risk tissue. This led to a change in advice as only the first patient on whom instruments were used following an anterior eye procedure was to be considered as having an increased risk of CJD. Previously this had applied to the first two patients exposed to such instruments. This resulted in the Panel advising that 16 patients in 7 incidents should be denotified. In 2009, the anterior eye was further reclassified as a low risk tissue. Following this change, the Panel advised that 20 patients should be denotified.

There are eleven remaining surgical incidents in which 118 patients are still considered to be at risk of CJD. Currently, 57 of these at risk patients have been notified that they are at risk of CJD. Local decisions have been taken not to notify 4 patients in these incidents. The Panel is currently advising on two other incidents in which approximately 40 at risk patients are to be advised that they have an increased risk of CJD (these two incidents are not included in Table 2).


Table 2: Surgical At Risk patients still identified as being at risk by the Panel by procedure on the index patient Diagnosis of index patient Procedure on index patient Number of Incidents Patients identified as ‘at increased risk' Patients who died before being notified Local decision not to notify patient Notified patients

Sporadic Brain biopsy 2 28 2 1 25

Variant Appendectomy 1 2 – 2 –

Variant Endoscopy 1 – 1 –

Asymptomatic infected vCJD Endoscopy 1 4 1 – 3

At risk Variant Endoscopy 3 12 4 – 8

At risk Familial Neurosurgery 1 31 10 – 21

Total 9 78 17 4 57


Reports of Blood Incidents 1 January 2010 to 30 June 2010:

The diagnosis in 2009 of a vCJD case, who had previously received blood transfusions, resulted in 10 individuals being identified as alive and at risk of vCJD. Two of these individuals had donated blood to the case, and eight others had received blood components from these two donors. Nine of these patients were notified of their exposure and asked to follow public health advice. A local decision was taken not to notify the 10th recipient.

Six monthly update on the National Anonymous Tonsil Archive: End of June 2010

The National Anonymous Tonsil Archive (NATA) continues to receive approximately 250 tonsil pairs per week (Figure 1). The archive had received a total of 87, 721 tonsil pairs up to the end of June 2010 from hospitals in England and Scotland . A further 3,000 tonsil pairs have been received from the Medical Research Council Prion Unit at the Institute for Neurology, National Hospital for Neurology and Neurosurgery. Therefore the total number of tonsil pairs in the archive was 90,721. The number of collection forms that were completed but no tonsil tissue collected was 2,480 (1,625 due to patient objection and 855 due to clinical pathology being requested).

Out of the 100 NHS Hospital Trusts that perform over 200 tonsillectomies per year in England , 91 have been recruited and are currently sending tonsil pairs to NATA on a regular basis. There are 120 hospitals sites within these trusts taking part in NATA. At present, approximately 50,000 tonsillectomies are performed annually in England . Figure 2 shows the number of tonsil pairs received from each Strategic Health Authority.

Figure 1: Number of tonsil pairs collected for NATA quarterly (Q1, 2004 to Q2 2010)

Just over 5,000 tonsillectomies are performed in Scotland each year. The project in Scotland , where there are 14 hospitals that each carry out more than 200 tonsillectomies per year, is being coordinated by Health Protection Scotland. All fourteen of these hospitals have been recruited and are collecting tonsils for NATA. The tonsil tissue is being transported to the Health Protection Agency in Colindale for inclusion in the archive. Figure 3 shows all hospitals in England and Scotland currently recruited in the study.

Figure 2: Tonsils pairs collected by Strategic Health Authority ( January 2004 to June 2010)

Figure 3: NHS Trusts and Scottish Hospitals currently collecting and sending tonsil tissue to the archive June 2010

References

1.The National Creutzfeldt-Jakob Disease Surveillance Unit, The University of Edinburgh . CJD statistics. Available at: http://www.cjd.ed.ac.uk/figures.htm.

2. The National Creutzfeldt-Jakob Disease Surveillance Unit, The University of Edinburgh . Incidence of variant Creutzfeldt-Jakob Disease Onsets and Deaths in the UK January 1994 – December 2006.Edinburgh: NCJDSU, 2 February 20. Available at: http://www.cjd.ed.ac.uk/vcjdqdec06.htm.

3. Transmissible spongiform encephalopathy agents: safe working and the prevention of infection. The ACDP TSE Working Group. http://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm.

4. HPA CJD Incidents Panel [online]. London : HPA. Available at:

http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1204031511121.


http://www.hpa.org.uk/hpr/infections/ei_cjd.htm




Monday, August 9, 2010


National Prion Disease Pathology Surveillance Center Cases Examined (July 31, 2010)


http://prionunitusaupdate2008.blogspot.com/2010/08/national-prion-disease-pathology.html


Thursday, August 12, 2010

Seven main threats for the future linked to prions

http://prionpathy.blogspot.com/2010/08/seven-main-threats-for-future-linked-to.html


http://prionpathy.blogspot.com/


Friday, November 30, 2007

CJD QUESTIONNAIRE USA CWRU AND CJD FOUNDATION

http://cjdquestionnaire.blogspot.com/


Thursday, August 12, 2010

USA Blood products, collected from a donor who was at risk for vCJD, were distributed July-August 2010


http://creutzfeldt-jakob-disease.blogspot.com/2010/08/usa-blood-products-collected-from-donor.html


Saturday, July 17, 2010


Variant Creutzfeldt-Jakob disease Ironside JW., Haemophilia. 2010 Jul;16 Suppl 5:175-80 REVIEW ARTICLE


http://vcjdtransfusion.blogspot.com/2010/07/variant-creutzfeldtjakob-disease.html


Thursday, July 08, 2010


Nosocomial transmission of sporadic Creutzfeldt-Jakob disease: results from a risk-based assessment of surgical interventions Public release date: 8-Jul-2010


http://creutzfeldt-jakob-disease.blogspot.com/2010/07/nosocomial-transmission-of-sporadic.html


Tuesday, March 16, 2010


Transmissible Spongiform Encephalopathy Agents: Safe Working and the Prevention of Infection: Part 4 REVISED FEB. 2010


http://creutzfeldt-jakob-disease.blogspot.com/2010/03/transmissible-spongiform-encephalopathy.html


Thursday, January 28, 2010


Multiorgan Detection and Characterization of Protease-Resistant Prion Protein in a Case of Variant CJD Examined in the United States


http://creutzfeldt-jakob-disease.blogspot.com/2010/01/multiorgan-detection-and.html


Communicated by: Terry S. Singeltary Sr.

[In submitting these data, Terry S. Singeltary Sr. draws attention to the steady increase in the "type unknown" category, which, according to their definition, comprises cases in which vCJD could be excluded.

The total of 26 cases for the current year (2007) is disturbing, possibly symptomatic of the circulation of novel agents. Characterization of these agents should be given a high priority. - Mod.CP]

http://pro-med.blogspot.com/2007/11/proahedr-prion-disease-update-2007-07.html


http://www.promedmail.org/pls/askus/f?p=2400:1001:6833194127530602005::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1010,39963


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


PLEASE SEE AND LISTEN TO VIDEO WAY BACK, toward the bottom of this url ; Monday, July 27, 2009 U.S.A. HIDING MAD COW DISEASE VICTIMS AS SPORADIC CJD ? Jeff Schwann 26 year old cjd victim USA, and please tell me why USA media did not pick this video up and run it on every evening broadcast across the USA $$$


http://creutzfeldt-jakob-disease.blogspot.com/2009/07/usa-hiding-mad-cow-disease-victims-as.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



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



Sunday, July 11, 2010

CJD or prion disease 2 CASES McLennan County Texas population 230,213 both cases in their 40s

http://creutzfeldt-jakob-disease.blogspot.com/2010/07/cjd-2-cases-mclennan-county-texas.html



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



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



my comments to PLosone here ;


http://www.plosone.org/annotation/listThread.action?inReplyTo=info%3Adoi%2F10.1371%2Fannotation%2F04ce2b24-613d-46e6-9802-4131e2bfa6fd&root=info%3Adoi%2F10.1371%2Fannotation%2F04ce2b24-613d-46e6-9802-4131e2bfa6fd



Saturday, June 13, 2009

Monitoring the occurrence of emerging forms of Creutzfeldt-Jakob disease in the United States 2003 revisited 2009

http://cjdusa.blogspot.com/2009/06/monitoring-occurrence-of-emerging-forms.html



Meeting of the Transmissible Spongiform Encephalopathies Committee On June 12, 2009 (Singeltary submission)

http://tseac.blogspot.com/2009/05/meeting-of-transmissible-spongiform.html



Saturday, January 16, 2010


Evidence For CJD TSE Transmission Via Endoscopes 1-24-3 re-Singeltary to Bramble et al

Evidence For CJD/TSE Transmission Via Endoscopes

From Terry S. Singletary, Sr flounder@wt.net 1-24-3

I have researched human/animal TSEs now for over 5 years due to the death of my Mother from the Heidenhain Variant Creutzfeldt Jakob disease, one of six - known - variants of the infamous 'sporadic' CJD.

I did a little survey several years ago about CJD and ENDOSCOPY in 2001, and then went there again when another article was released recently. However, they seemed to only be concerned with the vCJD strain and risk from endoscopy equipment.

My concerns are if vCJD can be transmitted by blood, and there are now 6 variants of the infamous sporadic CJDs that they are documenting to date, how do they know that none of these 6 variants will not transmit the agent (prion) via blood?...especially since the sporadic CJDs are the only ones documented to date to transmit via the surgical arena and now that the CWD is spreading more and more, who knows about the cattle?

I would always read this study and it would bring me back to reality as to how serious/dangerous this agent is in the surgical/medical arena. You might want to read this short abstract from the late, great Dr. Gibbs twice, and let it really sink in. And please remember while reading some of these transmission studies, that most all, if not ALL these agents transmit freely to primates. Humans, of course, are primates.

Regarding claims that:

'Well, it has never been documented to transmit to humans."

There are two critical factors to think about:

A. CJD/TSEs in the USA are NOT reportable in most states and there is NO CJD/TSE questionnaire for most victims and their families, and the one they are now issuing asks absolutely nothing about route and source of the (prion) agent, only how the disease was diagnosed. Furthermore, the elderly are only very rarely autopsied, ie looking for Alzheimer's or 'FAST Alzheimer's' OR prion disease-related factors and phenomena, such as heart failure caused by disease.

B. It is unethical and against the law to do transmission studies of TSEs to humans, they are 100% FATAL.

I suggest you read these case studies about medical arena CJD transmission very carefully:

snip...see full text ;


Saturday, January 16, 2010

Evidence For CJD TSE Transmission Via Endoscopes 1-24-3 re-Singeltary to Bramble et al

Evidence For CJD/TSE Transmission Via Endoscopes

From Terry S. Singletary, Sr flounder@wt.net 1-24-3


http://creutzfeldt-jakob-disease.blogspot.com/2010/01/evidence-for-cjd-tse-transmission-via.html




TSS

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Friday, February 19, 2010

Creutzfeldt-Jakob disease (CJD) biannual update (2010/1)

Emerging infections/CJD

Creutzfeldt-Jakob disease (CJD) biannual update (2010/1)

This six-monthly report provides an update on reports of incidents of potential iatrogenic (healthcareacquired) exposure to CJD via surgery, and on the National Anonymous Tonsil Archive. Data are correct as of 26 January 2010.

For numbers of CJD case reports, readers should consult data provided by the national CJD Surveillance Unit (NCJDSU), Edinburgh [1]. The latest yearly analysis of vCJD reports (onsets and deaths) is also available from the NCJDSU website [2].

Reports of incidents of potential iatrogenic exposure to CJD via surgery:

2000 to 31 December 2009

Since the previous update report [3], 19 surgical incidents were reported – between 1 July and 31 December 2009 – bringing the total number reported since 2000 to 407 (table 1). A surgical incident occurs when a patient undergoes surgery but is only identified as having CJD or being at risk of CJD at a later date. This means that the ACDP TSE Working Group infection control guidelines would not have been followed. The surgery carried out on an index patient with, or at risk of CJD, may result in contamination of the instruments with abnormal prion protein. Table 1 shows the number of CJD surgical incidents reported to the CJD Incidents Panel from January 2000 to 31st December 2009 by the diagnosis of the index patient. Information about the CJD Incidents Panel can be found on the HPA website [4].

Table 1. Closed CJD Surgical Incidents (n=407) reported to the CJD Incidents Panel, by diagnosis of index patient: 1 January 2000 to 30 June 2009

Incident type 2000 2001 2002 2003 2004 2005 2006 2007 2008 First half 2009 Total

1. Sporadic (possible, probable or definite) 7 19 22 24 16 18 31 17 21 11 186(46%)

2. vCJD (possible, probable or definite) 6 14 22 5 4 1 2 – 1 1 56(14%)

3. Familial including 'at risk' familial – 2 2 7 1 3 7 – 2 2 26(6%)

4. 'At risk' vCJD blood component recipient – – – – 4 10 6 1 – – 21(5%)

5. 'At risk' - vCJD plasma product recipient – 1 2 – 10 18 9 8 6 8 62(15%)

6. 'At risk' - other – – 2 2 1 2 4 – – 1 12(3%)

7. CJD type unclear/ CJD unlikely 1 1 4 1 1 2 – – – 10(2%)

8. Not CJD 2 1 4 7 7 1 1 – 3 – 26(6%)

9.Other – – 1 1 1 2 1 – – – 6(1%)

10. No longer considered 'at-risk' – – 1 – – – – 1 – – 2(0%)

Total 16 38 56 50 45 56 63 27 33 23 407(100%)

Investigation of surgical incidents may result in advice to remove surgical instruments from clinical use (to quarantine, destroy, or donate for research). Such advice is generally only given for instruments considered to be potentially contaminated with the CJD agent that have not undergone a certain number of cycles of use and decontamination since their use on an index patient. Hospitals are asked to consider sending any instruments to be permanently removed from use to the Surgical Instrument Store (held by the Health Protection Agency, Porton Down) for research. Since 2000, there have been 46 incidents in which instruments were permanently removed from use.

The Panel may advise contacting and informing some patients of their possible exposure to CJD in a surgical incident. Such advice is generally only given for patients who have definitely been exposed to potentially contaminated instruments which have been used on risk tissues in certain index patients. The Panel may advise that some of these patients should be considered „at-risk of CJD for public health purposes' and asked to take certain precautions (ie, not to donate blood or other tissues and to inform their medical and dental carers prior to any invasive procedures) in order to reduce the risk of transmitting the CJD agent further. Since 2000, 22 incidents have given rise to such advice. There are currently nine incidents in which 77 patients have been categorised as „at-risk' by the Panel, according to the current risk assessment. Seven of these patients died before notification. A total of 31 patients are currently notified of their „at-risk' status. Notifications are pending for another 31 patients. Three patients have not been notified due to local, clinical decisions.

The Panel has revised its advice on endoscopy and anterior eye patients. This has led to patients being denotified in 2006 and 2009. This resulted in reclassification of 38 patients from the „at-risk' category; 32 in anterior eye surgery, two in invasive endoscopy.

Table 2. Panel advice to inform patients that they are ‘at-risk' of CJD/vCJD: 1 January 2000 to 30 June 2009

Diagnosis of index patient Procedure on index patient Number of Incidents Alive 'at-risk' Died before notification Total Notified Not notified Total

Sporadic CJD Brain biopsy 2 20 1* 21 2 28

vCJD Appendectomy 1 – 2* 2 – 2

Endoscopy and GI surgery 2† 3 1 ** 4 1 5

'At risk' vCJD Endoscopy and GI surgery 4 8 30** 38 4 42

Total – 9 31 34 65 7 77

*Local decision not to notify.

† The index patient in one of these incidents was a haemophiliac plasma product recipient with evidence of vCJD infection.

** Notification pending.

National anonymous tonsil archive for studies of detectable abnormal prion protein

The National Anonymous Tonsil Archive (NATA) continues to receive approximately 250 tonsil pairs per week (figure 1). The archive had received a total of 81,604 tonsil pairs up to the end of December 2009 from hospitals in England and Scotland. A further 3,000 tonsil pairs have been received from the Medical Research Council Prion Unit at the Institute for Neurology, National Hospital for Neurology and Neurosurgery. Therefore the total number of tonsil pairs in the archive was 84,604. The number of collection forms that were completed but no tonsil tissue collected was 2,395 (1,565 due to patient objection and 830 due to clinical pathology being requested).

Out of the 100 NHS Hospital Trusts that perform over 200 tonsillectomies per year in England, 91 have been recruited and are currently sending tonsil pairs to NATA on a regular basis. There are 120 hospitals sites within these trusts taking part in NATA. At present, approximately 50,000 tonsillectomies are performed annually in England. Figure 2 shows the number of tonsil pairs received from each Strategic Health Authority.

Figure 1. Number of tonsil pairs collected for NATA quarterly: Q1 2004 – Q4 2009

Just over 5,000 tonsillectomies are performed in Scotland each year. The project in Scotland, where there are 14 hospitals that each carry out more than 200 tonsillectomies per year, is being coordinated by Health Protection Scotland. All fourteen of these hospitals have been recruited and are collecting tonsils for NATA. The tonsil tissue is being transported to the Health Protection Agency in Colindale for inclusion in the archive. Figure 3 shows all hospitals in England and Scotland currently recruited in the study.

Figure 2. Tonsils pairs collected by Strategic Health Authority, January 2004 - December 2009

Figure 3. NHS Trusts and Scottish Hospitals currently collecting and sending tonsil tissue to the archive December 2009

Testing of homogenates of the tonsil tissue from the archive began at the end of January 2007. Two enzyme immunoassays (EIAs) are being used for the initial screening of the homogenates for the presence of abnormal prion protein. These EIAs allow the identification of any tonsils that need to be investigated further by the more specific tests of Western blotting (WB) and immunohistochemistry (IHC) [5].

References

1. The National Creutzfeldt-Jakob Disease Surveillance Unit, The University of Edinburgh. CJD statistics. Available at: http://www.cjd.ed.ac.uk/figures.htm.


2.The National Creutzfeldt-Jakob Disease Surveillance Unit, The University of Edinburgh. Incidence of variant Creutzfeldt-Jakob Disease Onsets and Deaths in the UK January 1994 - December 2006. Edinburgh: NCJDSU, 2 February 2007. Available at: http://www.cjd.ed.ac.uk/vcjdqdec06.htm.


3. HPA. Biannual CJD update (2009/1). Health Protection Report [serial online] 2009; 3(27): Emerging Infections/CJD. Available at: http://www.hpa.org.uk/hpr/archives/2009/hpr2709.pdf.


4. HPA. CJD Incidents Panel [online]. London: HPA, 2010. Available at: http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1204031511121.


5. Spongiform Encephalopathy Advisory Committee. Combining evidence from tissue surveys to estimate the prevalence of subclinical vCJD. London: SEAC, 2008. Available at: http://www.seac.gov.uk/papers/paper100-2.pdf.


Health Protection Report Vol 4 No. 7 - 19 February 2010


http://www.hpa.org.uk/hpr/archives/2010/hpr0710.pdf





Iatrogenic CJD knows NO age group, TSE knows no boundaries. I propose as with Aguzzi, Asante, Collinge, Caughey, Deslys, Dormont, Gibbs, Gajdusek, Ironside, Manuelidis, Marsh, et al and many more, that the world of TSE Transmissible ...


http://bse-atypical.blogspot.com/2010/01/14th-international-congress-on.html




Saturday, January 16, 2010

Evidence For CJD TSE Transmission Via Endoscopes 1-24-3 re-Singeltary to Bramble et al


http://creutzfeldt-jakob-disease.blogspot.com/2010/01/evidence-for-cjd-tse-transmission-via.html




Monday, July 20, 2009

Pre-surgical risk assessment for variant Creutzfeldt-Jakob disease (vCJD) risk in neurosurgery and eye surgery units


http://vcjdtransfusion.blogspot.com/2009/07/pre-surgical-risk-assessment-for.html




[2] UK: SEAC position statement on dentistry Date: Sat 30 Jun 2007 Source: Position Statement vCJD and Dentistry, Spongiform Encephalopathy Advisory Committee (SEAC) Update, June 2007 [edited]





Position Statement vCJD and Dentistry ------------------------------------- Issue ----- 1. The Department of Health (DH) asked SEAC to advise on the findings of preliminary research aimed at informing estimates of the risk of variant Creutzfeldt-Jakob Disease (vCJD) transmission via dentistry.

Background ---------- 2. Prions are more resistant than other types of infectious agents to the conventional cleaning and sterilization practices used to decontaminate dental instruments (1). Appreciable quantities of residual material may remain adherent to the surface after normal cleaning and sterilization (2). Therefore, if dental tissues are both infectious and susceptible to infection, the dental instruments are a potential mechanism for the secondary transmission of vCJD. Dentistry could be a particularly significant route of transmission for the population as a whole, due to the large number of routine procedures undertaken and also because dental patients have a normal life expectancy.

This is in contrast with other transmission routes, such as blood transfusion and neurosurgery, where procedures are often carried out in response to some life-threatening condition. Additionally, the ubiquity of dental procedures and the lack of central records on dental procedures means that should such transmission occur, then it would be difficult to detect and control.

3. No cases of vCJD transmission arising from dental procedures have been reported to date (3). Previous DH risk assessments (4,5) have focused on 2 possible mechanisms for the transfer of vCJD infectivity via dental instruments; accidental abrasion of the lingual tonsil and endodontic procedures that involve contact with dental pulp. In considering these assessments, SEAC agreed that the risk of transmission via accidental abrasion of the lingual tonsil appears very low. However, the risk of transmission via endodontic procedures may be higher and give rise to a self sustaining vCJD epidemic under circumstances where (i) dental pulp is infective, (ii) transmission via endodontic instruments is efficient and (iii) a large proportion of vCJD infections remain in a subclinical carrier state (SEAC 91, February 2006). In light of this, SEAC advised that restricting endodontic files and reamers to single use be considered (6). SEAC recommended reassessment of these issues as new data emerge.

New research ------------ 4. Preliminary, unpublished results of research from the Health Protection Agency, aimed at addressing some of the uncertainties in the risk assessments, were reviewed by SEAC (SEAC 97, May 2007). The prion agent used in these studies is closely related to the vCJD agent. This research, using a mouse model, shows that following inoculation of mouse-adapted bovine spongiform encephalopathy (BSE) directly into the gut, infectivity subsequently becomes widespread in tissues of the oral cavity, including dental pulp, salivary glands and gingiva, during the preclinical as well as clinical stage of disease.

5. It is not known how closely the level and distribution of infectivity in the oral cavity of infected mice reflects those of humans infected with vCJD, as there are no comparable data from oral tissues, in particular dental pulp and gingiva, from human subclinical or clinical vCJD cases (7). Although no abnormal prion protein was found in a study of human dental tissues, including dental pulp, salivary glands and gingiva from vCJD cases, the relationship between levels of infectivity and abnormal prion protein is unclear (8). Infectivity studies underway using the mouse model and oral tissues that are presently available from human vCJD cases will provide some comparable data. On the basis of what is currently known, there is no reason to suppose that the mouse is not a good model for humans in respect to the distribution of infectivity in oral tissues. Furthermore, the new data are consistent with published results from experiments using a hamster scrapie model (9).

6. A 2nd set of experiments using the same mouse model showed that non-invasive and transient contact between gingival tissue and fine dental files contaminated with mouse-adapted BSE brain homogenate transmits infection very efficiently. It is not known how efficient gingival transmission would be if dental files were contaminated with infectious oral tissues and then subsequently cleaned and sterilized, a situation which would more closely model human dental practice. Further studies using the mouse model that would be more representative of the human situation, comparing oral tissues with a range of doses of infectivity, cleaned and sterilized files and the kind of tissue contact with instruments that occurs during dentistry, should be considered.

7. SEAC considered that the experiments appear well designed and the conclusions justified and reliable, while recognizing that the research is incomplete and confirmatory experiments have yet to be completed. It is recommended that the research be completed, submitted for peer-review and widely disseminated as soon as possible so others can consider the implications. Nevertheless, these preliminary data increase the possibility that some oral tissues of humans infected with vCJD may potentially become infective during the preclinical stage of the disease. In addition, they increase the possibility that infection could potentially be transmitted not only via accidental abrasion of the lingual tonsil or endodontic procedures but a variety of routine dental procedures.

Implications for transmission risks ----------------------------------- 8. The new findings help refine assumptions made about the level of infectivity of dental pulp and the stage of incubation period when it becomes infective in the risk assessment of vCJD transmission from the reuse of endodontic files and reamers (10). For example, if one patient in 10 000 were to be carrying infection (equivalent to about 6000 people across the UK, the best current estimate (11), the data suggest that in the worst case scenario envisaged in the risk assessment, reuse of endodontic files and reamers might lead to up to 150 new infections per annum. It is not known how many of those infected would go on to develop clinical vCJD. In addition, transmission via the reuse of endodontic files and reamers could be sufficiently efficient to cause a self-sustaining vCJD epidemic arising via this route.

9. These results increase the importance of obtaining reliable estimates of vCJD infection prevalence. Data that will soon be available from the National Anonymous Tonsil Archive may help refine this assessment and provide evidence of the existence and extent of subclinical vCJD infection in tonsillectomy patients. Further data, such as from post mortem tissue or blood donations, will be required to assess prevalence in the general UK population (12).

10. Recent guidance issued by DH to dentists to ensure that endodontic files and reamers are treated as single use (13) is welcomed and should, as long as it is effectively and quickly implemented, prevent transmission and a self-sustaining epidemic arising via this route. However, the extent and monitoring of compliance with this guidance in private and National Health Service dental practice is unclear.

11. The new research also suggests that dental procedures involving contact with other oral tissues, including gingiva, may also be capable of transmitting vCJD. In the absence of a detailed risk assessment examining the potential for transmission via all dental procedures, it is not possible to come to firm conclusions about the implications of these findings for transmission of vCJD. However, given the potential for transmission by this route, serious consideration should be given to assessing the options for reducing transmission risks, such as improving decontamination procedures and practice or the implementation of single use instruments.

12. The size of the potential risk from interactions between the dental and other routes of secondary transmission, such as blood transfusion and hospital surgery, to increase the likelihood of a self-sustaining epidemic is unclear.

13. It is likely to be difficult to distinguish clinical vCJD cases arising from dietary exposure to BSE from secondary transmissions via dental procedures, should they arise, as a large proportion of the population is likely both to have consumed contaminated meat and undergone dentistry.

However, an analysis of dental procedures by patient age may provide an indication of the age group in which infections, if they occur, would be most likely to be observed. Should the incidence of clinical vCJD cases in this age group increase significantly, this may provide an indication that secondary transmission via dentistry is occurring. Investigation of the dental work for these cases may provide supporting data. There is no clear evidence, to date, based on surveillance or investigations of clinical vCJD cases, that any vCJD cases have been caused by dental procedures, but this possibility cannot be excluded.

Conclusions ----------- 14. Preliminary research findings suggest that the potential risk of transmission of vCJD via dental procedures may be greater than previously anticipated. Although this research is incomplete, uses an animal model exposed to relatively high doses of infectivity, and there are no data from infectivity studies on human oral tissues, these findings suggest an increased possibility that vCJD may be relatively efficiently transmitted via a range of dental procedures. Ongoing infectivity studies using human oral tissues and the other studies suggested here will enable more precise assessment of the risks of vCJD transmission through dental procedures.

15. Guidance was issued to dentists earlier this year [2007] recommending that endodontic files and reamers be treated as single use, which, provided this policy is adhered to, will remove any risk of a self-sustaining epidemic arising from reuse of these instruments. To minimize risk, it is critical that appropriate management and audit is in place, both for NHS and private dentistry.

16. It is also critical that a detailed and comprehensive assessment of the risks of all dental procedures be conducted as a matter of urgency. While taking into account the continuing scientific uncertainties, this will allow a more thorough consideration of the possible public health implications of vCJD transmission via dentistry and the identification of possible additional precautionary risk reduction measures. The assessment will require continued updating as more evidence becomes available on the transmissibility of vCJD by dental routes, and on the prevalence of infection within the population. A DH proposal to convene an expert group that includes dental professionals to expedite such an assessment is welcomed. Given the potential for transmission via dentistry, consideration should be given to the urgent assessment of new decontamination technologies which, if proven robust and effective, could significantly reduce transmission risks.

References ---------- (1) Smith et al. (2003) Prions and the oral cavity. J. Dent. Res. 82, 769-775. (2) Smith et al. (2005) Residual protein levels on reprocessed dental instruments. J. Hosp. Infect. 61, 237-241. (3) Everington et al. (2007) Dental treatment and risk of variant CJD - a case control study. Brit. Den. J. 202, 1-3. (4) Department of Health. (2003) Risk assessment for vCJD and dentistry. (5) Department of Health (2006) Dentistry and vCJD: the implications of a carrier-state for a self-sustaining epidemic. Unpublished. (6) SEAC (2006) Position statement on vCJD and endodontic dentistry . (7) Head et al. (2003) Investigation of PrPres in dental tissues in variant CJD. Br. Dent. J. 195, 339-343. (8) SEAC 90 reserved business minutes. (9) Ingrosso et al. (1999) Transmission of the 263K scrapie strain by the dental route. J. Gen. Virol. 80, 3043-3047. (10) Department of Health (2006) Dentistry and vCJD: the implications of a carrier-state for a self-sustaining epidemic. Unpublished. (11) Clarke & Ghani (2005) Projections of future course of the primary vCJD epidemic in the UK: inclusion of subclinical infection and the possibility of wider genetic susceptibility R. J. Soc. Interface. 2, 19-31. (12) SEAC Epidemiology Subgroup (2006) position statement of the vCJD epidemic . (13) DH (2007) Precautionary advice given to dentists on re-use of instruments .

-- Communicated by Terry S. Singletary, Sr.

******


http://www.promedmail.org/pls/otn/f?p=2400:1001:19224::::F2400_P1001_BACK_PAGE,F2400_P1001_ARCHIVE_NUMBER,F2400_P1001_USE_ARCHIVE:1001,20070702.2112,Y




http://promedmail.oracle.com/pls/otn/f?p=2400:1001:1843502045853916::::F2400_P1001_BACK_PAGE,F2400_P1001_ARCHIVE_NUMBER,F2400_P1001_USE_ARCHIVE:1001,20070702.2112,Y






Monday, December 31, 2007

Risk Assessment of Transmission of Sporadic Creutzfeldt-Jakob Disease in Endodontic Practice in Absence of Adequate Prion Inactivation


http://creutzfeldt-jakob-disease.blogspot.com/2007_12_01_archive.html





Subject: CJD: update for dental staff Date: November 12, 2006 at 3:25 pm PST

1: Dent Update. 2006 Oct;33(8):454-6, 458-60.

CJD: update for dental staff.



http://seac992007.blogspot.com/2008/06/seac-2008-one-hundredth-meeting-of.html






Friday, July 24, 2009

UW Hospital and Clinics Addresses Creutzfeldt-Jakob Disease Risk

PLEASE SEE ;

Pre-surgical risk assessment for variant Creutzfeldt-Jakob disease (vCJD) risk in neurosurgery and eye surgery units

Hospitals should already be using a questionnaire in Annex J of the ACDP TSE Working Group Infection Control guidance to find out whether any patients who are about to undergo any surgery or endoscopy may be at increased risk of being infected with CJD. If a patient is found to have an increased risk of CJD prior to their surgery or endoscopy then special infection control precautions may need to be taken.

Annex J of the TSE Infection Control guidance has recently been revised, and now advises that patients who are due to have high risk surgery [1] or neuro-endoscopy should be asked an additional question: whether they have received transfusions of blood or blood components from 80 or more donors since 1980. This is because these patients may have an increased risk of being infected with variant CJD (vCJD).

On 16 July 2009 the HPA wrote to the chief executives of NHS trusts asking them to ensure that the guidance is implemented. Detailed information and tools for implementing the guidance can be downloaded from the links below.

If you have any queries about the implementation of the guidance, please contact the HPA Centre for Infections CJD Section at mhtml:%7B33B38F65-8D2E-434D-8F9B-8BDCD77D3066%7Dmid://00000260/!x-usc:mailto:cjd@hpa.org.uk or on 020 8327 6074/6411.

Background information on this new pre-surgical assessment is contained in this Letter to chief executives - July 2009 (PDF, 73 KB) written to all hospitals in England.

The new version of Annex J of the TSE Infection Control Guidance contains new question for patients undergoing high risk surgery and neuro-endoscopy. These questions should be used to assess patients' CJD risk factors.

Clinicians carrying out the new pre-surgical assessment should read Pre-surgical assessment Information for healthcare staff - July 2009 (PDF, 163 KB) This vCJD Algorithm for per-surgical roles - July 2009 (PDF, 28 KB) shows suggested roles and responsibilities for infection control teams, surgical teams and blood transfusion specialists.

Information on patients' transfusion histories should be collected using the Highly transfused vCJD risk assessment form - July 2009 (Word Document, 328 KB) This form is also available as a vCJD risk assessment spreadsheet - July 2009 (Excel Spreadsheet, 2.7 MB). This may help calculate the number of blood donors to a patient. The form may be posted or emailed to the HPA Centre for Infections CJD Section mhtml:%7B33B38F65-8D2E-434D-8F9B-8BDCD77D3066%7Dmid://00000260/!x-usc:mailto:cjd@hpa.org.uk.

Blood transfusion laboratories may wish to use this draft Letter to other blood laboratories - July 2009 (Word Document, 31 KB) when collecting transfusion information from other hospitals.

Pre-surgical assessment teams and patients may wish to read this vCJD Information for presurgical patients - July 2009 (PDF, 29 KB) about this new pre-surgical assessment.

[1] High risk surgery is defined as surgery involving any of the following organs or tissues (high risk tissues): brain, spinal cord, cranial nerves (specifically the entire optic nerve and only the intercranial components of the other cranial nerves), cranial nerve ganglia, posterior eye (specifically the posterior hyaloid face, retina, retinal pigment epithelium, choroid, subretinal fluid, optic nerve) and pituitary gland.

Letter to chief executives - July 2009 (PDF, 73 KB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247469060207




Pre-surgical assessment Information for healthcare staff - July 2009 (PDF, 163 KB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247469061870




vCJD Algorithm for per-surgical roles - July 2009 (PDF, 28 KB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247469062057




Highly transfused vCJD risk assessment form - July 2009 (Word Document, 328 KB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247469062225




Letter to other blood laboratories - July 2009 (Word Document, 31 KB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247469062420




vCJD Information for presurgical patients - July 2009 (PDF, 29 KB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247469062586




vCJD risk assessment spreadsheet - July 2009 (Excel Spreadsheet, 2.7 MB) Added/updated: 16 July 2009


http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247728926790




full text ;



http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1247469069188




http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1247728926790




see also ;

Friday, July 17, 2009

Revision to pre-surgical assessment of risk for vCJD in neurosurgery and eye surgery units Volume 3 No 28; 17 July 2009


http://creutzfeldt-jakob-disease.blogspot.com/2009/07/revision-to-pre-surgical-assessment-of.html




Tuesday, August 12, 2008

Biosafety in Microbiological and Biomedical Laboratories Fifth Edition 2007 (occupational exposure to prion diseases)


http://creutzfeldt-jakob-disease.blogspot.com/2008/08/biosafety-in-microbiological-and.html




Thursday, January 29, 2009

Medical Procedures and Risk for Sporadic Creutzfeldt-Jakob Disease, Japan, 1999-2008 (WARNING TO Neurosurgeons and Ophthalmologists) Volume 15, Number 2-February 2009 Research


http://creutzfeldt-jakob-disease.blogspot.com/2009/01/medical-procedures-and-risk-for.html




SEE FULL TEXT ;


Friday, July 24, 2009

UW Hospital and Clinics Addresses Creutzfeldt-Jakob Disease Risk


http://creutzfeldt-jakob-disease.blogspot.com/2009/07/uw-hospital-and-clinics-addresses.html



http://creutzfeldt-jakob-disease.blogspot.com/2009/07/uw-hospital-warning-53-patients-about.html




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




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





CJD


http://creutzfeldt-jakob-disease.blogspot.com/





Sunday, February 14, 2010


[Docket No. FSIS-2006-0011] FSIS Harvard Risk Assessment of Bovine Spongiform Encephalopathy (BSE)



http://bseusa.blogspot.com/2010/02/docket-no-fsis-2006-0011-fsis-harvard.html




Friday, January 29, 2010


14th International Congress on Infectious Diseases H-type and L-type Atypical BSE January 2010 (special pre-congress edition)


http://bse-atypical.blogspot.com/2010/01/14th-international-congress-on.html





TSS

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Monday, February 01, 2010

Import Alert 57-20 and 84-03 Human Dura Mater and risk factors there from due to Creutzfeldt Jakob Disease (CJD)

Import Alert 57-20

(Note: This import alert represents the Agency's current guidance to FDA field personnel regarding the manufacturer(s) and/or products(s) at issue. It does not create or confer any rights for or on any person, and does not operate to bind FDA or the public).

Import Alert # 57-20 Published Date: 10/02/2009 Type: DWPE

Import Alert Name: "Imported Dura Mater Regulated Under Section 361 Of The Public Health Service Act (PHS Act)"

Reason for Alert: Human cells, tissues, and cellular and tissue-based products (HCT/Ps), particularly HCT/Ps such as dura mater that are closely associated with the central nervous system, may transmit some human transmissible spongiform encephalopathies (TSEs) such as CJD and vCJD. Currently, FDA does not recommend testing for human TSEs such as CJD and vCJD and there are no FDA-approved donor screening tests.

However, manufacturers must screen donors of dura mater by reviewing the donor?s relevant medical records for risk factors for and clinical evidence of TSE, including vCJD and CJD ((? 1271.75(a)). Such factors include residence in a country where there is a geographic risk of BSE and, related, vCJD. In addition, manufacturers must perform an adequate assessment for donors of dura mater to detect evidence of TSE (? 1271.85(e)).

Guidance: Districts may detain without physical examination all imported Dura Mater due to the possible risk of CJD and vCJD transmission.

1. Districts may request documents to determine if entries of dura mater are:

a. Imported from a country of geographical risk of BSE (See the updated list below for your reference);

b. Imported following transshipment from a country of geographical risk of BSE.

2. Dura mater that is directly imported from a country of geographical risk of BSE or imported following transshipment from a country of geographical risk of BSE may be refused entry.

3. Districts encountering Dura Mater that is not directly imported from a country of geographical risk of BSE, or imported following transshipment from a country of geographical risk of BSE should contact OCBQ/DCM, Import/Export Staff to determine admissibility.

Countries List Based on Geographic Risk of BSE:

Albania(AL), Andorra (AD), Austria(AT), Belgium(BE), Bosnia-Herzegovina (BA), Bulgaria(BG), Croatia(HR), Czech Republic(CZ), Denmark(DK), Finland(FI), France(FR), Germany(DE), Greece (GR), Hungary(HU), Ireland(IE),Israel(IL), Italy(IT), Japan (JP), Liechtenstein (LI), Luxembourg(LU), Macedonia(MK), Monaco (MC), Netherlands(NL), Norway(NO), Oman (OM), Poland(PL), Portugal(PT), Romania(RO), San Marino(SM), Slovak Republic(SK), Slovenia(SI), Spain(ES), Sweden(SE), Switzerland(CH), United Kingdom (GB), and Yugoslavia(YU).

Product Description: Dura Mater

Charge: "This Human Cell, Tissue, and Cellular and Tissue-Based Product is in violation of section 361 of the Public Health Service Act." OASIS charge code - TISSUE

Countries (AL) ALBANIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(AD) ANDORRA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(AT) AUSTRIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(BE) BELGIUM

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(BA) BOSNIA-HERCEGOVINA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(BG) BULGARIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(HR) CROATIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(CZ) CZECH REPUBLIC

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(DK) DENMARK

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(FI) FINLAND

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(FR) FRANCE

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(DE) GERMANY

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(GR) GREECE

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(HU) HUNGARY

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(IE) IRELAND

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(IL) ISRAEL

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(IT) ITALY

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(JP) JAPAN

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(LI) LIECHTENSTEIN

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(LU) LUXEMBOURG

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(MK) MACEDONIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(MC) MONACO

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(NL) NETHERLANDS

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(NO) NORWAY

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(OM) OMAN

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(PL) POLAND

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(PT) PORTUGAL

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(RO) ROMANIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(SM) SAN MARINO

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(SK) SLOVAKIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(SI) SLOVENIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(ES) SPAIN

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(SE) SWEDEN

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(CH) SWITZERLAND

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(GB) UNITED KINGDOM

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized

(YU) YUGOSLAVIA

(57 T - - 01) Dura Mater (Human Dura Mater)

(84 L - - EM) Dura Mater, Human, Lyophilized


http://www.accessdata.fda.gov/cms_ia/importalert_158.html



Import Alert 84-03

(Note: This import alert represents the Agency's current guidance to FDA field personnel regarding the manufacturer(s) and/or products(s) at issue. It does not create or confer any rights for or on any person, and does not operate to bind FDA or the public).

Import Alert # 84-03 Published Date: 10/02/2009 Type: DWPE Import Alert Name: "Lyodura (Dura Mater)"

Reason for Alert: A recent reported case of Creutzfeldt Jakob Disease (CJD) in a 28 year old patient who had received a human dura mater graft indicates that the graft may have been the source of this always fatal disease. The woman died 22 months after receiving the lyophilized, irradiated human cadaveric dura mater graft. The dura mater used in the graft was packaged in October 1982 under lot #2105 by B. Braun Melsungen AG of West Germany, shipped to Tri Hawk International, Inc., Montreal, Quebec, Canada and sold to Saint Francis Hospital, Hartford, Connecticut, on April 4, 1985.

This is the first known case of CJD transmission associated with a dura mater graft. Present methods of sterilizing the dura mater do not completely inactivate the CJD agent.

The dura mater is manufactured by the West German firm under the trade name Lyodura. Although the material is primarily used in neurosurgery, it is also used in orthopedic, otologic, dental, urologic, gynecologic, and cardiac surgical procedures.

We have been unable to determine the total number of packages of Lyodura that were imported into the United States because the Canadian distributor failed to maintain adequate records of distribution for all lots which may have been distributed by mail to hospitals in the United States and Canada.

As stated in the FDA Safety Alert which issued April 28, 1987, we strongly recommend that users of dura mater choose only products from known sources which retrieve, process and handle the material according to guidelines such as those of the American Association of Tissue Banks.

Guidance: Detain all shipments of Lyodura (dura mater) received from Tri Hawk International, Inc., Montreal, Quebec, Canada, or from B. Braun Melsungen AG of West Germany.

Alert your local Customs office to be aware of this import alert and to monitor mail shipments for this product.

Product Description: Lyodura

Charge: "The article is subject to refusal of admission pursuant to section 801(a)(1) in that it appears to be adulterated under section 501(h), because the methods and controls used for the storage and distribution of Lyodura (dura mater) are not in conformance with current good manufacturing practice requirements under section 520(f)(1)."

OASIS charge code - DEVICE GMP

List of firms and their products subject to Detention without Physical Examination (DWPE) under this Import Alert (a.k.a. Red List)

(14415) Tri Hawk International IncDate Published : 09/16/2009 1570 Rue Bane , Saint-Laurent, QC CA 84 - - - -- Neurological Date Published: 09/16/2009

(3002806469) B. Braun MelsungenDate Published : 09/16/2009 Carl Braun Strasse 1 , Melsungen, DE 84 - - - -- Neurological Date Published: 09/16/2009

-

http://www.accessdata.fda.gov/cms_ia/importalert_232.html




also see North America BSE GBR risk factor for Canada, USA, and Mexico ;


The most recent assessments (and reassessments) were published in June 2005 (Table I; 18), and included the categorisation of Canada, the USA, and Mexico as GBR III. Although only Canada and the USA have reported cases, the historically open system of trade in North America suggests that it is likely that BSE is present also in Mexico.


http://www.oie.int/boutique/extrait/06heim937950.pdf




Tutogen Medid,U.S.,Inc.

December 9,2002

Dockets Management Branch (HFA-305)

Food and Drug Administration 5630 Fishers Lane, Rm. 1061 Rockville, MD 20852

RE: Docket No. 02D-0266, CBER 150. Draft Guidance for Industry: Preventive Measures to Reduce the Possible Risk of Transmission of Creutzfeldt-Jakob disease (CID) and Variant Creutzfeldt-Jakob Disease (vCJD) by Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps); Availability. Pages 42789--42790 FR Dot. 02- 158981

Tutogen Medical Inc. ("Tutogen") appreciates the opportunity to comment on the draft document issued by the FDA in June 2002 entitled: "Preventive Measures to Reduce the Possible Risk of Transmission of Creutzfeldt-Jakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD) by Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps) " In particular, we wish to use this venue to respond to your request for data assessing the impact of the recommendations contained therein to reduce the risk of CJD and vCJD on the availability of HCT/P.

snip...

1. # of Tissue Banks reporting 63

2. # of tissue donors recovered (HCT/P domw population) 18,021

3. # of Bone allografts dlstributed in U.S. 675,370

4. Volume of Skin grafts distributed in U.S. 11,222 ft2

1Excerpt Corn "Background" statement contained in the American Association of Tissue Banks Membership Directory 2001-2002.

snip...

II. Impact of donor deferral upon the availability of HCT/ps: During the year 2001, Tutogen processed 3,500 donors recovered by our contract recovery agencies from various locations including Europe. In the 12 months from July 1, 200l to June 30, 2002, Tutogen distributed a total of 21,639 musculoskeletal allograft products to patients in the U.S. Based upon the data above, this represents approximately 3% of the total number of bone allograft products distributed by AATB accredited Banks in the United States.

The implementation of the FDA's proposed guidance would immediately reduce the number of available HCT/P donors by approximately 10% in the U.S. due to country of origin exclusion. The direct impact to Tutogen would be an approximate 50% reduction in our donor base or approximately 10,820 musculoskeletal allograft products. Therefore, the impact of this proposal from the FDA upon Tutogen would be greater than upon any other U.S. based tissue bank. Among the remaining 16,271 HCT/P donors (approximately) recovered by other AATB accredited organizations annually, a large percentage would be eliminated under the proposed FDA rule that would disqualify any donor who has visited a listed country for a cumulative period of 6-months or more. Not only would frequent travelers be considered deferred donors, but a large share of military veterans and their immediate family members due to being stationed overseas. Tutogen does not have verifiable data concerning these figures, however, it is not inconceivable that this would adversely impact the donor pool by at least an additional 6% or more, based on the blood bank industry experience, this would translated to a 976 HCT/P donors. The combination of Tutogen's and the rest of the tissue banks would total approximately 2,726 HCT/P donors. .

III. Musculoskeletal allografl tissue has been scientijiiaUy classified as low risk for CVZWCJD transmission. As with other AATB certified organizations, Tutogen allograft products are used across a multitude of medical applications. Currently, none of Tutogen HCT/Ps in the United States are so-called high-risk tissue such as dura mater or corneas (refer to Appendix 1).

Not all tissue has the same infectivity risk. The HCT/Ps utilized by Tutogen in allografi products, distributed in the US, are classified as Category IV tissue (i.e., "No detectible @Jo-) infectivity") by the World Health Organization in its March 19972 study. Tutogen has not processed or distributed in the United States high-risk Category II tissue such as dura mater since June 2000. Tutogen has never processed or distributed comeal tissue. Therefore the effect of any donor deferral ruling by the FDA on HCT/Ps limited to high-risk Category II tissue, will not have any effect upon Tutogen's ability to continue providing HCT/Ps in the United States as shown in the table above.

2 World Health Organization, Emerging and other Communicable Diseases Report of a WHO consultation on medicinal and other products in relation to human and animal transmissible Spongiform Encephalophathies.

2

IK Tutoplast safe@ claims are supported by a long-hktory (25 consecutive years) of successful allograft implants:

Tutogen HCT/Ps are recovered following a very stringent donor selection criterion in accordance with AATB standards and FDA regulations. The current industry standard concerning CJD significantly reduces the risk of harvesting tissue from a potentially infected HCT/P donor. All Tutogen HCT/Ps are processed using a proprietary system known as the Tutophst 8 process. Tutogen's single donor tissue processing methods (no pooling of donors) have been shown to ensure viral/bacterial inactivation in controlled studies. The Tutopht 8 process has been validated, specifically for the inactivation of prions and other transmissible agents. Two independent studies have confirmed that the Tutophst 8 process is capable of removing infectious Prion agents from sol? tissue as a result of treating soft tissue with sodium hydroxide. '4

Recommendations:

Tutogen recognizest hat the spread of bovine spongiform encephalopathy, or mad cow disease, has prompted debate concerning the possible modification of recent deferral criteria Tutogen urges the FDA to continue inviting scientists, physicians and patient groups to participate in this policy discussion. Physicians must be given accurate information about the benefits and risks, both real and theoretical associatedw ith HCT/P transplantations o that they can effectively educate every patient when an HCT/P transplant is needed.

While Tutogen also recognizes that studies about the potential for transmission of TSEs in animal models continue, however, evidence is still lacking of such transmission among patients who have received human tissues, blood transfusions and clotting factor concentrates. Tutogen respectfully requests that the Food and Drug Administration, before any final ruling, address issues sited herein, by limiting its definition of deferred donor to those cases where high-risk Category II tissue is being implanted (e.g., dura mater, corneas), and/or to those cases where tissue recovery and processing methods being used pose additional risks.

Conclusion:

The very low incidence of human CJDMXD and our current screening criterion already poses a low risk that an infected donor may enter the process. The Centers for Disease Control and Prevention reports that the incidence of CJD is one case per million people each year. 3Robert Koch Institut in Berlin (Department of the German FederalI nstitute of Health) Diringer H, Braig H, Infectivity of unconventional viruses in duramater,The Lancet, February 25, 1989 4L aboratorieso f RBM, Ivrea, Italy and expert opinion by Dr. Masullo (NurosurgeonM) asullo, 1994, Estimate of the theoretical risk of transmission of Creutzfeld-Jacob Disease by human duramater grafts manufactured by the Tutoplast process.R MB, Studienbericht1, 994, Determination of the clearance factor for unconventional slow viruses during the processing of duramater.

3

Based upon the track record of safety, quality, and clinical effkacy of TutopZast@ and the product approval protocols adhered to by Tutogen, and already audited by the FDA, relating to the import of HCT/Ps into the U.S. from Europe, we do not believe that there is any additional risk associated with HCT/Ps recovered and processed by Tutogen. Given the scientific data available today, Tutogen does not believe that a blanket ruling to defer HCT/P donors from specific counties would reduce CJD and vCJD risk in cases where a validated recovery and processing procedure is being used. Indeed, the impact of a deferred donor ruling as presently proposed would significantly reduce the availability of HCT/Ps in the United States (up to 20% or more based upon the data contained herein) without a commensurate and measurable risk reduction in CJD and vCJD transmission.

Very truly yours,

Wade S, Tetsuka

Tutogen Medical U.S., Inc. General Manager

P.J. Pardo Tutogen Medical U.S., Inc. Director, Regulatory Affairs/ Quality Management

Appendix 1: Tutoplast@P rocessedA llografks Distributed

Spinal / Trauma Sulzer SpineTech, Minneapolis MN Ophthalmology IOP, Inc., Costa Mesa, CA ENT Urology Mentor Corp., Santa Barbara, CA Dental Sulzer Dental, Carlsbad, CA Spinal Fusion, ACL, Rotator Cuff repair Glaucoma patch, eyebrow slings, enucleation wraps, poterior segment, eyelid spacers Tymp~oplasty, CholesteomaR esection Pelvic Floor repair, urinary incontinence Peridontal implants Femur, Ulna, Radius, Humurous with cuff, anterior cruciate ligament. Sclera, Pericardium, Fascia Lata Sclera, Pericardium, Fascia Temporalis Fascia Lata, Pericardium,D ermis Cancellousb onec hips from femur, ulna, radius 4,000 grafh 8,000 grafts 2,000 grafls 9,000 grafts 17,000 grafts


http://www.fda.gov/ohrms/DOCKETS/dailys/02/Dec02/121002/02d-0266.pdf




Monday, August 31, 2009

HUMAN BODY PARTS FOR SALE TO THE HIGHEST BIDDER Inside a Creepy Global Body Parts Business SPIEGEL ONLINE - News - International ~~ August 28 2009

42.90 Euros Per Arm

Inside a Creepy Global Body Parts Business By Martina Keller and Markus Grill


see full text ;


http://creutzfeldt-jakob-disease.blogspot.com/2009/08/human-body-parts-for-sale-to-highest.html




Update: Creutzfeldt-Jakob Disease Associated with Cadaveric Dura Mater Grafts --- Japan, 1979--2003 MMWR Weekly December 5, 2003 / 52(48);1179-1181

http://www2.niddk.nih.gov/AboutNIDDK/CommitteesAndWorkingGroups/HGH_CJD_Dec_11_2003_TAB_A.htm



Thursday, October 23, 2008

Creutzfeldt-Jakob Disease Associated with Cadaveric Dura Mater Grafts - Japan, 1979-2008 : UPDATE


http://creutzfeldt-jakob-disease.blogspot.com/2008/10/creutzfeldt-jakob-disease-associated.html



http://www.wellsphere.com/cjd-article/medical-procedures-and-risk-for-sporadic-creutzfeldt-jakob-disease-japan-1999-2008-warning-to-neurosurgeons-and-ophthalmologi/641229



Thursday, January 29, 2009

Medical Procedures and Risk for Sporadic Creutzfeldt-Jakob Disease, Japan, 1999-2008 (WARNING TO Neurosurgeons and Ophthalmologists) Volume 15, Number 2-February 2009 Research

http://creutzfeldt-jakob-disease.blogspot.com/2009/01/medical-procedures-and-risk-for.html



Wednesday, August 12, 2009

Unique clinicopathological features and PrP profiles in the first autopsied case of dura mater graft-associated Creutzfeldt-Jakob disease

http://creutzfeldt-jakob-disease.blogspot.com/2009/08/unique-clinicopathological-features-and.html



Sunday, May 10, 2009

Meeting of the Transmissible Spongiform Encephalopathies Committee On June 12, 2009 (Singeltary submission)

http://tseac.blogspot.com/2009/05/meeting-of-transmissible-spongiform.html



SEE 2001 SUBMISSION BELOW ;

Freas, William TSS SUBMISSION

Page 1. J Freas, William From: Sent: To: Subject: Terry S. Singeltary

Sr. [flounder@wt.net] Monday, January 08,200l 3:03 PM freas ...


http://www.fda.gov/ohrms/dockets/ac/01/slides/3681s2_09.pdf



Thursday, January 28, 2010

Multiorgan Detection and Characterization of Protease-Resistant Prion Protein in a Case of Variant CJD Examined in the United States


http://creutzfeldt-jakob-disease.blogspot.com/2010/01/multiorgan-detection-and.html



Saturday, June 13, 2009

Monitoring the occurrence of emerging forms of Creutzfeldt-Jakob disease in the United States 2003 revisited 2009


http://cjdusa.blogspot.com/2009/06/monitoring-occurrence-of-emerging-forms.html



*** 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



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



Sunday, January 17, 2010

Human tissue, recovered from a donor history indicated increased risk factors for Creutzfeldt-Jacob disease Lions Eye Bank


http://creutzfeldt-jakob-disease.blogspot.com/2010/01/human-tissue-recovered-from-donor.html



Saturday, January 16, 2010

Evidence For CJD TSE Transmission Via Endoscopes 1-24-3 re-Singeltary to Bramble et al


http://creutzfeldt-jakob-disease.blogspot.com/2010/01/evidence-for-cjd-tse-transmission-via.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



my comments to PLosone here ;


http://www.plosone.org/annotation/listThread.action?inReplyTo=info%3Adoi%2F10.1371%2Fannotation%2F04ce2b24-613d-46e6-9802-4131e2bfa6fd&root=info%3Adoi%2F10.1371%2Fannotation%2F04ce2b24-613d-46e6-9802-4131e2bfa6fd





Friday, January 29, 2010

14th International Congress on Infectious Diseases H-type and L-type Atypical BSE January 2010 (special pre-congress edition)


http://bse-atypical.blogspot.com/2010/01/14th-international-congress-on.html




TSS

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