Two-year wait before CJD alert

Thirty eight patients may have been at risk of contracting CJD during surgery in south Wales

Health chiefs have admitted they waited two years to contact 38 patients who are at risk of contracting Creutzfeldt-Jakob disease (CJD) after surgery.

Officials at Abertawe Bro Morganwg University Health Board (ABMU) discovered a patient was at “high risk” of developing the incurable brain condition in 2009 after surgery in 2007.

The instruments used in the operation were later deployed in a series of other surgical procedures, with doctors saying it was possible proteins which cause CJD were not killed by being sterilised.

Public Health Wales (PHW) said those affected were at “extremely low risk”, but confirmed it had only posted letters to them last Saturday, after it conducted an internal investigation.

Jorg Hoffman, consultant in communicable disease control, said there had only been six cases worldwide of any form of CJD being transmitted via surgery.

He said: “In this incident we do not have a single confirmed case of CJD. However, we do have one patient who was at high risk and 38 people at extremely low risk. We know all the surgical instruments used on this group of patients were cleaned, disinfected and sterilised normally. However, it is possible that the proteins which cause CJD, known as prions, survived these routine sterilisation procedures so an extremely small risk of transmission remains.”

The original operation involving the “index case” occurred in 2007 at one of ABMU’s four main hospitals in South Wales – Singleton and Morriston in Swansea, Neath Port Talbot and Princess of Wales Hospital in Bridgend.

Once the high risk of the patient was identified in 2009 – before another operation – PHW contacted the UK CJD incidents panel made up of experts from around the UK.

Health officials then investigated what instruments had been used in the original operation and their subsequent usage. It was in February this year that the panel said the health board should contact the 38 patients involved.

Of the 38 people who are at “low risk” – 37 were from Mid and West Wales and one was from North Wales.