VARIANT CREUTZFELDT-JACOB DISEASE (vCJD) AND GASTROINTESTINAL ENDOSCOPY

Can GI endoscopes transmit CJD? Human Transmissible Spongiform Encephalopathies (TSEs): 1.Human TSEs are neurological disorders caused by infectious proteins called prions. (Pathological Prions PrP sc scrapie associated prion protein- Normal prion protein PrP c )Human TSEs are neurological disorders caused by infectious proteins called prions. 2.Creutzfeldt-Jakob disease (CJD) and variant CJD (vCJD) are examples of TSEs. 3.vCJD may be caused by consuming beef products contaminated with the bovine spongiform encephalopathy (BSE) agent. 4.Both CJD and vCJD are fatal neurodegenerative diseases. A theoretical concern is that surgical instruments, including GI endoscopes, could become contaminated with prions diseases. Because prions exhibit remarkable resistance to conventional disinfection and sterilization methods patient-to-patient transmission of prion diseases via a contaminated surgical instrument is a potential concern.

Can GI endoscopes transmit CJD? In general, only surgical instruments and endoscopes in contact with: 1.“High-risk” tissues of “high-risk” patients might pose a risk of contamination with prions. 2.“High-risk” tissues are typically neurological and include the brain and spinal cord. 3.“High-risk” patients are those known to be (or suspected of being) infected with a prion disease.

Can GI endoscopes transmit CJD? To minimize the risk of transmission of vCJD during GI endoscopy, some guidelines in Europe recommend the following: 1.Do not perform GI endoscopy in patients with known vCJD. 2.When GI endoscopy is unavoidable, however, use an endoscope dedicated for vCJD patients. Alternatively, use an endoscope that is: 1.old or can be destroyed/incinerated after use; 2.or can be quarantined for use in the future exclusively on other vCJD patients.

Examinations via endoscopy should be avoided in patients with suspected or confirmed variant Creutzfeldt-Jakob disease (vCJD). If endoscopy is considered essential in such patients, either a dedicated endoscope should be used or an endoscope nearing the end of its life which can be reserved for use in similar patients. The vCJD prion is resistant to all forms of conventional sterilization. In particular, all accessible endoscope channels should be brushed with a disposable brush-tipped wire assembly designed for the purpose which has an appropriate length and diameter for each channel. W orld G astroenterology O rganization and OMED Practice Guideline: Endoscope Disinfection December 14, 2005

BSG GUIDELINES FOR DECONTAMINATION OF EQUIPMENT FOR GASTROINTESTINAL ENDOSCOPY The Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee (June 2014) The sporadic form of CJD affects approximately 1 person per million per annum worldwide. Variant CJD (vCJD) is an acquired form of CJD that was first reported in The incubation period for vCJD could be as long as 30 years: people might be infected while not showing any symptoms. vCJD can be transmitted via blood transfusion and could in theory be passed on by the re-use of surgical instruments. Endoscopy with biopsy have the potential to transmit the disease.

BSG GUIDELINES FOR DECONTAMINATION OF EQUIPMENT FOR GASTROINTESTINAL ENDOSCOPY The Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee (June 2014) It should be emphasised that aldehyde disinfectants, such as ortho- phthalaldehyde (OPA) and glutaraldehyde, fix protein, a property which may not only anchor prion protein within endoscope channels, but also render it more difficult to remove by other means. The use of these agents should be avoided when decontaminating endoscopes that have been used in patients with definite or suspected vCJD, or in patients considered to be at risk. Conventional sterilization methods cannot reliably destroy the infecting agent in vCJD. Every effort should be made to employ single-use equipment. Adequate funding must be available to endoscopy units for the purchase of single-use biopsy forceps, cytology brushes, guidewires and other accessories.

BSG GUIDELINES FOR DECONTAMINATION OF EQUIPMENT FOR GASTROINTESTINAL ENDOSCOPY The Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee (June 2014) The UK Advisory Committee for Dangerous Pathogens updated guidance states that quarantining of the endoscope is nowadays rarely necessary. If invasive endoscopy has been performed in any patient with or at increased risk of vCJD the endoscope used should be reprocessed singly before being quarantined. If a contamination risk is confirmed, the endoscope should be either destroyed or retained for dedicated re-use for the same patient.

It is recommended: 1.that single use disinfectants should be used for endoscopes that have been used in any “at risk” individual 2.that such endoscopes should be decontaminated separately from any other endoscope 3.that the endoscope washer disinfector should be put through an empty self-disinfection cycle after it has been used to decontaminate an endoscope that has been used in any “at risk” individual BSG GUIDELINES FOR DECONTAMINATION OF EQUIPMENT FOR GASTROINTESTINAL ENDOSCOPY The Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee (June 2014)

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Choice Framework for local Policy and Procedures (CFPP) – Decontamination of flexible endoscopes: Policy and management Although it is extremely unlikely that contamination of a second endoscope would occur in an EWD designed to decontaminate two scopes in a single chamber, it is recommended that, following invasive procedures in any patients with or at increased risk of human prion disease, flexible endoscopes should be reprocessed singly using a single-use, non-aldehyde- based disinfectant. New protein test system has been developed: the ninhydrin protein detection test. The ninhydrin test should be used with caution owing to its lack of sensitivity. Clean instruments are swabbed to pick up any non-visual proteins that may be present. The swab is then placed in the vial of ninhydrin reagent and incubated at 57°C.

Choice Framework for local Policy and Procedures (CFPP) – Decontamination of flexible endoscopes: Policy and management New protein test system has been developed: the ninhydrin protein detection test. The ninhydrin test should be used with caution owing to its lack of sensitivity. Clean instruments are swabbed to pick up any non-visual proteins that may be present. The swab is then placed in the vial of ninhydrin reagent and incubated at 57°C.

FRENCH DOCUMENT N°138/2001 (BELOW THE LINK): Circulaire DGS/5 C/DHOS/E 2 n° du 14 mars 2001 relative aux précautions à observer lors de soins en vue de réduire les risques de transmission d'agents transmissibles non conventionnels In the document the suggestion is one hour contact with hypoclorite. In the document the suggestion is one hour contact with hypoclorite. Groupe III Procédés d'efficacité importante Procédures physiques ou chimiques simples (20) Par ordre décroissant d'efficacité : 1. Immersion dans l'hypochlorite de sodium (21) pendant 1 heure. 2. Immersion dans la soude (22) pendant 1 heure. 3. Autoclavage à 134° C pendant 18 minutes en autoclave à charge poreuse. The premise is that we know that anything is effective against prion today, but we have to deal with tenders requirements. We’ll have a prion cycle available in our AERs running with Hypochlorite (in use concentration 3%) for one hour contact.