Ethical analysis of communicating the risk of iatrogenic Creutzfeldt-Jakob disease.

To the Editor—The University of Michigan Health System Adult Ethics Committee recently convened to discuss whether 57 patients should be informed of possible exposure to classic Creutzfeldt-Jakob disease (CJD) after a neurosurgical patient was suspected of contracting CJD. Current routine sterilization procedures are believed to be ineffective against prions; thus, subsequent neurosurgical patients were potentially at risk of contracting CJD from contaminated instruments. Although eventually the patient definitively tested negative for CJD, the committee's discussion raised several key issues regarding communication of the risk of iatrogenic transmission of prion disease. The majority of known cases of iatrogenic transmission of sporadic CJD have been from the use of human growth hormone or from dural grafts, with over 100 known cases by each route of transmission. The posttransplant incubation period before CJD develops ranges from 2 to 30 years.' Iatrogenic transmission of CJD from surgical instruments has been documented in only 6 cases since 1950. The evidence for many of these cases of transmission was largely circumstantial: an iatrogenic origin was presumed when a patient was readmitted to the hospital with neurological deterioration 18-24 months after surgery. The average time from presumed exposure to symptomatic disease was 18 months; however, cases with longer incubation periods may remain unrecognized. Although the Centers for Disease Control and Prevention estimate that fewer than 1% of cases of sporadic CJD can be attributed to contaminated surgical instruments, a recent population-based study suggests that the percentage may be as high as 18%. Of note, the literature suggests that the development of symptoms may be significantly more rapid after iatrogenic transmission than would be expected in sporadic cases.