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Lauwers E, Lalli G, Brandner S, Collinge J, Compernolle V, Duyckaerts C, Edgren G, Haïk S, Hardy J, Helmy A, Ivinson AJ, Jaunmuktane Z, Jucker M, Knight R, Lemmens R, Lin IC, Love S, Mead S, Perry VH, Pickett J, Poppy G, Radford SE, Rousseau F, Routledge C, Schiavo G, Schymkowitz J, Selkoe DJ, Smith C, Thal DR, Theys T, Tiberghien P, van den Burg P, Vandekerckhove P, Walton C, Zaaijer HL, Zetterberg H, De Strooper B. Potential human transmission of amyloid β pathology: surveillance and risks. Lancet Neurol 2020; 19:872-878. [PMID: 32949547 DOI: 10.1016/s1474-4422(20)30238-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 01/05/2023]
Abstract
Studies in experimental animals show transmissibility of amyloidogenic proteins associated with prion diseases, Alzheimer's disease, Parkinson's disease, and other neurodegenerative diseases. Although these data raise potential concerns for public health, convincing evidence for human iatrogenic transmission only exists for prions and amyloid β after systemic injections of contaminated growth hormone extracts or dura mater grafts derived from cadavers. Even though these procedures are now obsolete, some reports raise the possibility of iatrogenic transmission of amyloid β through putatively contaminated neurosurgical equipment. Iatrogenic transmission of amyloid β might lead to amyloid deposition in the brain parenchyma and blood vessel walls, potentially resulting in cerebral amyloid angiopathy after several decades. Cerebral amyloid angiopathy can cause life-threatening brain haemorrhages; yet, there is no proof that the transmission of amyloid β can also lead to Alzheimer's dementia. Large, long-term epidemiological studies and sensitive, cost-efficient tools to detect amyloid are needed to better understand any potential routes of amyloid β transmission and to clarify whether other similar proteopathic seeds, such as tau or α-synuclein, can also be transferred iatrogenically.
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Affiliation(s)
- Elsa Lauwers
- VIB-KU Leuven Center for Brain and Disease Research, KU Leuven, Leuven, Belgium; Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Giovanna Lalli
- UK Dementia Research Institute, University College London, London, UK
| | - Sebastian Brandner
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK; Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London National Health Service Foundation Trust, London, UK
| | - John Collinge
- Medical Research Council Prion Unit at UCL, Institute of Prion Diseases, University College London, London, UK
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross-Flanders, Mechelen, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Charles Duyckaerts
- Institut du Cerveau et de la Moelle épinière, Sorbonne University, INSERM, CNRS UMR, Paris, France; Laboratoire de Neuropathologie Raymond Escourolle, Hôpital de la Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, Paris, France
| | - Gustaf Edgren
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Stéphane Haïk
- Institut du Cerveau et de la Moelle épinière, Sorbonne University, INSERM, CNRS UMR, Paris, France; Laboratoire de Neuropathologie Raymond Escourolle, Hôpital de la Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, Paris, France; Cellule Nationale de Référence des maladies de Creutzfeldt-Jakob, Hôpital de la Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, Paris, France
| | - John Hardy
- UK Dementia Research Institute, University College London, London, UK; Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK; Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, University College London, London, UK; National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK; Institute for Advanced Study, The Hong Kong University of Science and Technology, Hong Kong Special Administrative Region, China
| | - Adel Helmy
- Department of Clinical Neuroscience, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Adrian J Ivinson
- UK Dementia Research Institute, University College London, London, UK
| | - Zane Jaunmuktane
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK; Queen Square Brain Bank for Neurological Disorders, Queen Square Institute of Neurology, University College London, London, UK; Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London National Health Service Foundation Trust, London, UK
| | - Mathias Jucker
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; German Center for Neurodegenerative Diseases, Tübingen, Germany
| | - Richard Knight
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK; National Creutzfeldt-Jakob Disease Research and Surveillance Unit, Western General Hospital, Edinburgh, UK
| | - Robin Lemmens
- VIB-KU Leuven Center for Brain and Disease Research, KU Leuven, Leuven, Belgium; Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - I-Chun Lin
- UK Dementia Research Institute, University College London, London, UK
| | - Seth Love
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Simon Mead
- Medical Research Council Prion Unit at UCL, Institute of Prion Diseases, University College London, London, UK
| | - V Hugh Perry
- UK Dementia Research Institute, University College London, London, UK
| | - James Pickett
- Alzheimer's Society, London, London, UK; Epilepsy Research UK, London, UK
| | - Guy Poppy
- Biological Sciences, University of Southampton, Southampton, UK
| | - Sheena E Radford
- Astbury Centre for Structural Molecular Biology, School of Molecular and Cellular Biology, University of Leeds, Leeds, UK
| | - Frederic Rousseau
- VIB-KU Leuven Center for Brain and Disease Research, KU Leuven, Leuven, Belgium; Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | | | - Giampietro Schiavo
- UK Dementia Research Institute, University College London, London, UK; Department of Neuromuscular Disorders, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Joost Schymkowitz
- VIB-KU Leuven Center for Brain and Disease Research, KU Leuven, Leuven, Belgium; Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Dennis J Selkoe
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Colin Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Dietmar R Thal
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium; Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Theys
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Pierre Tiberghien
- Etablissement Français du Sang, La Plaine St Denis, France; Unité Mixte de Recherche, INSERM, Université de Franche-Comté, Besançon, France
| | - Peter van den Burg
- European Blood Alliance, Brussels, Belgium; Department of Transfusion Medicine, Sanquin, Amsterdam, Netherlands
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Blood Services, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Clare Walton
- Alzheimer's Society, London, London, UK; Multiple Sclerosis International Federation, London, UK
| | - Hans L Zaaijer
- Department of Blood-borne Infections, Sanquin, Amsterdam, Netherlands
| | - Henrik Zetterberg
- UK Dementia Research Institute, University College London, London, UK; Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK; Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bart De Strooper
- VIB-KU Leuven Center for Brain and Disease Research, KU Leuven, Leuven, Belgium; Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium; UK Dementia Research Institute, University College London, London, UK.
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Stevenson M, Uttley L, Oakley JE, Carroll C, Chick SE, Wong R. Interventions to reduce the risk of surgically transmitted Creutzfeldt-Jakob disease: a cost-effective modelling review. Health Technol Assess 2020; 24:1-150. [PMID: 32122460 PMCID: PMC7103914 DOI: 10.3310/hta24110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Creutzfeldt-Jakob disease is a fatal neurological disease caused by abnormal infectious proteins called prions. Prions that are present on surgical instruments cannot be completely deactivated; therefore, patients who are subsequently operated on using these instruments may become infected. This can result in surgically transmitted Creutzfeldt-Jakob disease. OBJECTIVE To update literature reviews, consultation with experts and economic modelling published in 2006, and to provide the cost-effectiveness of strategies to reduce the risk of surgically transmitted Creutzfeldt-Jakob disease. METHODS Eight systematic reviews were undertaken for clinical parameters. One review of cost-effectiveness was undertaken. Electronic databases including MEDLINE and EMBASE were searched from 2005 to 2017. Expert elicitation sessions were undertaken. An advisory committee, convened by the National Institute for Health and Care Excellence to produce guidance, provided an additional source of information. A mathematical model was updated focusing on brain and posterior eye surgery and neuroendoscopy. The model simulated both patients and instrument sets. Assuming that there were potentially 15 cases of surgically transmitted Creutzfeldt-Jakob disease between 2005 and 2018, approximate Bayesian computation was used to obtain samples from the posterior distribution of the model parameters to generate results. Heuristics were used to improve computational efficiency. The modelling conformed to the National Institute for Health and Care Excellence reference case. The strategies evaluated included neither keeping instruments moist nor prohibiting set migration; ensuring that instruments were kept moist; prohibiting instrument migration between sets; and employing single-use instruments. Threshold analyses were undertaken to establish prices at which single-use sets or completely effective decontamination solutions would be cost-effective. RESULTS A total of 169 papers were identified for the clinical review. The evidence from published literature was not deemed sufficiently strong to take precedence over the distributions obtained from expert elicitation. Forty-eight papers were identified in the review of cost-effectiveness. The previous modelling structure was revised to add the possibility of misclassifying surgically transmitted Creutzfeldt-Jakob disease as another neurodegenerative disease, and assuming that all patients were susceptible to infection. Keeping instruments moist was estimated to reduce the risk of surgically transmitted Creutzfeldt-Jakob disease cases and associated costs. Based on probabilistic sensitivity analyses, keeping instruments moist was estimated to on average result in 2.36 (range 0-47) surgically transmitted Creutzfeldt-Jakob disease cases (across England) caused by infection occurring between 2019 and 2023. Prohibiting set migration or employing single-use instruments reduced the estimated risk of surgically transmitted Creutzfeldt-Jakob disease cases further, but at considerable cost. The estimated costs per quality-adjusted life-year gained of these strategies in addition to keeping instruments moist were in excess of £1M. It was estimated that single-use instrument sets (currently £350-500) or completely effective cleaning solutions would need to cost approximately £12 per patient to be cost-effective using a £30,000 per quality-adjusted life-year gained value. LIMITATIONS As no direct published evidence to implicate surgery as a cause of Creutzfeldt-Jakob disease has been found since 2005, the estimations of potential cases from elicitation are still speculative. A particular source of uncertainty was in the number of potential surgically transmitted Creutzfeldt-Jakob disease cases that may have occurred between 2005 and 2018. CONCLUSIONS Keeping instruments moist is estimated to reduce the risk of surgically transmitted Creutzfeldt-Jakob disease cases and associated costs. Further surgical management strategies can reduce the risks of surgically transmitted Creutzfeldt-Jakob disease but have considerable associated costs. STUDY REGISTRATION This study is registered as PROSPERO CRD42017071807. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Lesley Uttley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jeremy E Oakley
- School of Mathematics and Statistics, University of Sheffield, Sheffield, UK
| | - Christopher Carroll
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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