Preventing accidental transmission of human transmissible spongifom encephalopathies

Mapping Biological Risks Related to Necropsy Activities: Old Concerns and Novel Issues for the Safety of Health Professionals

Nowadays only a few studies on biological and environmental risk among healthcare workers are available in literature. The present study aims to assess the health operator’s risk of contact with microorganisms during necropsy activities, to evaluate the efficiency of current protections, to identify possible new sources of contact, and to point out possible preventive measures. In addition, considering the current pandemic scenario, the risk of transmission of SARS-CoV-2 infection in the dissection room is assessed. The objectives were pursued through two distinct monitoring campaigns carried out in different periods through sampling performed both on the corpses and at the environmental level.

Reference Jitter Values for Concentric Needle Electrode of Orbicularis Oculi and Frontalis Muscles Using Voluntary Activation Method in Sudanese Population

Single fibre electromyography is the most sensitive neurophysiological test for the diagnosis of neuromuscular junction disorders, particularly myasthenia gravis. The study aimed at establishing concentric needle (CN) normal jitter values for voluntarily activated orbicularis-oculi (V-OOc) & Frontalis (V-FRO) muscles in Sudanese population. 57 healthy volunteers (20 males & 37 females) were included in the study (mean Age 43.6 ± 14.2 years, range 18–70 years). V-OOc and V-FRO were tested in the same individual using CN. Jitter values were expressed as the mean consecutive difference (MCD) of 30 potential pairs in microseconds. The mean jitter, mean individual fibre pairs jitter & mean outliers jitter values with (upper 95% Confidence Limit-CL) for [OOc] were [26.9 ± 3.3 (31.97), 26.1 ± 8.9 (41.8) & 38.5 ± 5.7 (49.0) µs] & for [FRO] were [27.1 ± 3.0 (31.32), 26.4 ± 9.4 (42.9) & 39.9 ± 5 (49.2) µs] respectively. The suggested practical upper limits for mean jitter & for outliers were (32, 49 µs) for OOc & (31, 49 µs) for FRO. Our CN-jitter values were within the range of the few published studies. The study was unique in that it established and compared between CN reference jitter values of two voluntarily activated facial muscles (V-OOc & V-FRO) in the same individual in large number of healthy subjects.

Strain Typing of Prion Diseases Using In Vivo Mouse Models

Transmissible spongiform encephalopathies (TSE) or prion diseases exhibit strain variation, a phenomenon that has been studied extensively in mouse bioassays. Despite the introduction of many rapid in vitro systems, bioassays remain a key tool in defining prion strains and their ability to transmit disease in vivo. Prion strains can be characterized by a range of phenotypic characteristics such as incubation period, vacuolar pathology, and distribution of the abnormal form of PrP following experimental transmission of the agent into a panel of mice (transgenic or wild type). Interpretation of these characteristics requires considerable experience and an understanding of the procedures used to define them. This chapter reviews the techniques used in strain typing of prion diseases from inoculum preparation and pathological studies to data interpretation alongside an extensive troubleshooting guide.

Assessment of safety and efficiency of nitrogen organic fertilizers from animal-based protein hydrolysates--a laboratory multidisciplinary approach

BACKGROUND

Protein hydrolysates or hydrolysed proteins (HPs) are high-N organic fertilizers allowing the recovery of by-products (leather meal and fluid hydrolysed proteins) otherwise disposed of as polluting wastes, thus enhancing matter and energy conservation in agricultural systems while decreasing potential pollution. Chemical and biological characteristics of HPs of animal origin were analysed in this work to assess their safety, environmental sustainability and agricultural efficacy as fertilizers. Different HPs obtained by thermal, chemical and enzymatic hydrolytic processes were characterized by Fourier transform infrared spectroscopy and sodium dodecyl sulfate polyacrylamide gel electrophoresis, and their safety and efficacy were assessed through bioassays, ecotoxicological tests and soil biochemistry analyses.

RESULTS

HPs can be discriminated according to their origin and hydrolysis system by proteomic and metabolomic methods. Three experimental systems, soil microbiota, yeast and plants, were employed to detect possible negative effects exerted by HPs. The results showed that these compounds do not significantly interfere with metabolomic activity or the reproductive system.

CONCLUSION

The absence of toxic and genotoxic effects of the hydrolysates prepared by the three hydrolytic processes suggests that they do not negatively affect eukaryotic cells and soil ecosystems and that they can be used in conventional and organic farming as an important nitrogen source derived from otherwise highly polluting by-products.

Ocular Tonometry and Sporadic Creutzfeldt - Jakob Disease (sCJD): A Confirmatory Case-Control Study

AIMS

To evaluate the hypothesis that sporadic Creutzfeldt-Jakob disease (sCJD) may be transmitted through ocular tonometry.

BACKGROUND

The infectious agent of sCJD may be present in the cornea prior to clinical symptoms. Cornea infectiousness has been documented by cornea transplants in guinea pigs and humans. sCJD is resistant to complete inactivity by conventional sterilization techniques. Thus contact tonometry equipment is not disinfected sufficiently to kill sCJD. We previously hypothesized that contact tonometry is a sCJD risk factor.

STUDY DESIGN

Population-based case-control study.

PLACE AND DURATION OF STUDY

Department of Neurology, School of Medicine, Loma Linda University, Loma Linda, CA, USA; 4 years.

METHODOLOGY

An 11-state case-control study of pathologically confirmed definite sCJD cases, individually matched controls, and a sample of control surrogates was conducted. Ocular tonometry histories were obtained from case-surrogates, controls, and a sample of control-surrogates.

RESULTS

The odds ratio (OR) for ever vs never having had an ocular tonometry test was statistically significant for matched and unmatched analyses for 15 through 3 years prior to disease onset, using both control self-responses and control surrogates: ORs were ∞ and 19.4 with 1-sided P-values <0.0001 and 0.003 and ORs=∞ and 11.1 with 1-sided P-values <0.003 and 0.02, respectively. ORs increased as the number of tonometry tests increased during this age period: trend test, 2-sided P-value < 0.0001. For ≥5 vs <5 tonometry tests, the OR was 5.8 (unmatched) and 3.7 (matched), 2-sided P-value<0.00005. Respondents generally could not specify the type of tonometry. There was no indication of increased tonometry testing among cases within 2 years of disease onset.

CONCLUSIONS

The a priori hypothesis was supported. Contact tonometry, preferred by ophthalmologists, may be capable of transmitting sCJD. Consideration should be given to using disposable instrument covers after each use. The use the disposable covers or non-contact tonometry is preferable in the absence of effective disinfectant processes at this time.

Availability of manufacturers' information on efficacy and compatibility of detergents used for cleaning dental instruments

AIM

To review physico-chemical data supplied for commercially available detergents marketed for manual and/or ultrasonic cleansing of reusable dental instruments.

METHOD

Manufacturers/suppliers of commercially available detergents for manual or ultrasonic cleaning of dental instruments within primary dental care were invited to supply product information. A structured questionnaire requested details on a range of physical and chemical properties for each detergent.

RESULTS

Seventeen detergent manufacturers/suppliers, encompassing 31 commercially available detergents were identified. Ten of the 17 manufacturers provided information on 23 (74%) of the detergent formulations. Nine detergents were of neutral pH, ten mild alkalis (pH 7.5-10.5) and four strong alkalis (pH >10.5). Sixteen detergents were recommended for ultrasonic and manual cleaning, four stated ultrasonic use and three manual only. Ten detergents cited enzymatic activity as their main mode of action, but only six manufacturers provided detailed information. Four detergents recommended by manufacturers as suitable for manual washing had a strong alkaline pH (>10.5), presenting chemical hazards to users. Two strong alkaline detergents did not warn users of potential adverse effects of such alkaline solutions (corrosion) upon aluminium containing instruments. Only one detergent had investigated the potential toxicity of detergent residuals remaining on instruments after reprocessing.

CONCLUSION

It has proven challenging to collate physico-chemical data on detergents suitable for use in manual and/or ultrasonic cleaning of dental instruments in general dental practice. Standardisation of information on the nature and efficacy of dental detergents in a readily accessible form would be beneficial to dental practice.

An investigation into the impact of safety features on the ergonomics of surgical scalpels

In the case of surgical scalpels, blade retraction and disposability have been incorporated into a number of commercial designs to address sharps injury and infection transmission issues. Despite these new designs, the traditional metal reusable scalpel is still extensively used and this paper attempts to determine whether the introduction of safety features has compromised the ergonomics and so potentially the take-up of the newer designs. Examples of scalpels have been analysed to determine the ergonomic impact of these design changes. Trials and questionnaires were carried out using both clinical and non-clinical user groups, with the trials making use of assessment of incision quality, cutting force, electromyography and video monitoring. The results showed that ergonomic performance was altered by the design changes and that while these could be for the worse, the introduction of safety features could act as a catalyst to encourage re-evaluation of the ergonomic demands of a highly traditional product.

Bovine spongiform encephalopathy

Bovine spongiform encephalopathy is an infectious disease of cattle that is transmitted through the consumption of meat-and-bone meal from infected cattle. The etiologic agent is an aberrant isoform of the native cellular prion protein that is a normal component of neurologic tissue. There currently are no approved tests that can detect BSE in live cattle.

Single-fiber EMG with a concentric needle electrode: validation in myasthenia gravis

We performed a retrospective study to validate whether a disposable concentric needle electrode (CNE) can be used in place of a single-fiber (SF) electrode for jitter measurements in myasthenia gravis (MG). Normal values for voluntary contraction of orbicularis oculi (OO) and extensor digitorum communis (EDC) were collected from 20 healthy subjects. The method was validated by a retrospective analysis of 56 consecutive MG patients, the "gold standard" being a positive acetylcholine receptor (AChR) antibody titer at the time of the electrophysiological (electromyography) study and the clinical diagnosis. Receiver operating characteristic (ROC) curves were constructed to define maximal sensitivity and specificity of the technique. The sensitivity was 96.4% (95% confidence interval 87.5%-99.6%), with no false-positive results, similar to traditional SF EMG and confirming that the disposable CNE is a justifiable alternative.

Prions: Who Should Worry about Them?

Prion diseases, also called transmissible spongiform encephalopathies (TSEs), are a family of neurodegenerative disorders affecting both humans and animals. They are caused by the accumulation of an abnormal form of a protein known as prion that results in neuronal death and a characteristic spongiform appearance of the brain tissue. Human prion diseases can be sporadic, acquired or hereditary. Acquired prion diseases have been linked to entering contaminated food into the human food chain, failure to completely disinfect or sterilize contaminated surgical instruments, patients receiving tissues and organs from infected donors, recipients of blood and other biological contaminated products, and potentially to cross infection in dental procedures. At present, there is unfortunately no efficient therapy that can be administered to clinically infected patients with prion diseases. Moreover, there are no simple diagnostic tests that can be used to show the agent of transmissible spongiform encephalopathy during the preclinical phase of the disease. Therefore, to prevent the spread of this emerging infectious agent it is necessary to implement several health control strategies and maintain surveillance for subclinical infections.

The origin of bovine spongiform encephalopathy: the human prion disease hypothesis

The cause of the original case or cases of bovine spongiform encephalopathy (BSE) remains an enigma. Sheep scrapie or a previously undetected sporadic bovine transmissible spongiform encephalopathy (TSE) have long been considered as candidates, but no convincing evidence to support these proposals has come to light. We present a new theory, with three related hypotheses: (1) that BSE was acquired from a human TSE (prion disease); (2) that the route of infection was oral, through animal feed containing imported mammalian raw materials contaminated with human remains; and (3) that the origin was the Indian subcontinent, from which large amounts of mammalian material were imported during the relevant time period. Human remains are known to be incorporated into meal made locally, and may still be entering exported material. Further investigations are needed into the sources of animal by-products used in animal feed manufacture, and into the the transmissibility of human TSEs to cattle.

Tissue Safety in View of CJD and Variant CJD

Epidemiological studies on human transmissible spongiform encephalopathies (Creutzfeldt-Jakob Disease, CJD) have shown that the agent could be transmitted by highly infectious tissues like brain, spinal cord or retina and medicinal products derived from these tissues (i.e. human growth hormone, dura mater). A few cases of transmission of CJD by neurosurgical instruments have been reported. The transmission of the agent of variant CJD, which is suspected to be transmitted by BSE-contaminated food, by blood transfusion implies that in contrast to the agent of classical CJD this agent can also be transmitted by organs and tissues other than nerve tissues. Health authorities have implemented guidelines to reduce the risk of transmission of human and animal TSE by human and veterinary medicinal products. The high resistance of TSE agents against physical or chemical treatment hamper the development of highly efficient inactivation steps in the production of medicinal products. Donor selection is considered as an efficient measure to reduce the risk of TSE transmission. However, the development of rapid, sensitive and specific diagnostic test systems is urgently required to test blood, organs and tissue of donors.

Lymphocyte contamination of laryngoscope blades - a possible vector for transmission of variant Creutzfeldt-Jakob disease

Variant Creutzfeldt-Jakob disease (vCJD) is associated with extensive prion infection of lymphoreticular tissues during the prolonged asymptomatic incubation period. Instruments exposed to infected tissues of preclinically infected individuals during medical or surgical procedures represent a potential risk of iatrogenic transmission of vCJD prions. We assessed the frequency of contamination with lymphoid tissue of single-use laryngoscope blades used for tracheal intubation for general anaesthesia. Using a cyto-centrifugation technique, lymphocytes were detected from 30% of laryngoscope blades studied. As prions resist routine sterilisation procedures, the use of non-disposable laryngoscope blades poses a risk of transmitting vCJD from patient to patient. The use of such instruments should be abandoned and disposable alternatives used.

Decontamination of surgical instruments from prion proteins: in vitro studies on the detachment, destabilization and degradation of PrPSc bound to steel surfaces

Effective reprocessing of surgical instruments ensuring elimination of inadvertent contamination with infectious agents causing transmissible spongiform encephalopathies (TSEs) is essential for the prevention of iatrogenic transmission of Creutzfeldt-Jakob disease (CJD) or its new variant (vCJD) from asymptomatic carriers. In a search for effective yet instrument-friendly and routinely applicable reprocessing procedures, we used an in vitro carrier assay to assess the decontamination activity exerted by different reagents on pathological prion protein (PrP(Sc)), the biochemical marker for TSE infectivity, attached to steel surfaces. In this assay, steel wires were contaminated with 263K scrapie brain homogenate and reprocessed for decontamination by exposure to several different test reagents. Residual contamination with PrP(Sc) and its protease-resistant core PrP27-30, still present after reprocessing on the wire surface or in the cleaning solution, was monitored by sensitive Western blot detection without or after proteinase K digestion. Using this approach, various reagents and processing conditions were screened for both their efficacy of decontamination and their active principles, such as detachment, destabilization or degradation of surface-bound prion protein. This revealed that, under appropriate conditions, relatively mild reagents such as 0.2 % SDS/0.3 % NaOH (pH 12.8), a commercially available alkaline cleaner (pH 11.9-12.2), a disinfectant containing 0.2 % peracetic acid and low concentrations of NaOH (pH 8.9) or 5 % SDS (pH 7.1) exert potent decontaminating activities on PrP(Sc)/PrP27-30 attached to steel surfaces. For in vivo validation, wires reprocessed in these reagents have been implanted into reporter animals in ongoing experiments.