Iatrogenic Transmission Research Articles

Chapter 12 - Iatrogenic Creutzfeldt–Jakob disease

Iatrogenic transmission of Creutzfeldt-Jakob disease (CJD) has occurred through particular medical procedures. Among them, dura mater grafts and pituitary-derived growth hormone obtained from human cadavers undiagnosed as CJD are the most frequent sources of infection. Recent advances in our knowledge about dura mater graft- and human pituitary-derived growth hormone-associated CJD patients have revealed that the combination of the infected CJD strain and the PRNP genotype of the patient determines their clinical, neuropathologic, and biochemical features. In this chapter, we summarize the clinical, neuropathologic, biochemical, and diagnostic features of dura mater graft- and human pituitary-derived growth hormone-associated CJD patients for the appropriate diagnosis of iatrogenic CJD.

Infectivity in bone marrow from sporadic CJD patients.

Prion infectivity was recently identified in the blood of both sporadic and variant Creutzfeldt-Jakob disease (CJD) patients. In variant CJD (vCJD), the widespread distribution of prions in peripheral tissues of both asymptomatic and symptomatic patients is likely to explain the occurrence of the observed prionaemia. However, in sporadic CJD (sCJD), prion infectivity is described to be located principally in the central nervous system. In this study, we investigated the presence of prion infectivity in bone marrow collected after death in patients affected with different sCJD agents. Bioassays in transgenic mice expressing the human prion protein revealed the presence of unexpectedly high levels of infectivity in the bone marrow from seven out of eight sCJD cases. These findings may explain the presence of blood-borne infectivity in sCJD patients. They also suggest that the distribution of prion infectivity in peripheral tissues in sCJD patients could be wider than currently believed, with potential implications for the iatrogenic transmission risk of this disease. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

First outbreak and subsequent cases of Trypanosoma vivax in the state of Goiás, Brazil.

Trypanosomiasis caused by Trypanosoma vivax has increased the reports in Brazil in the last decade. An outbreak is herein first reported in the state of Goiás, from May 2016 to January 2017. The outbreak start occurred in the city of Ipameri (Goiás) after the introduction of 18 auctioned cows from the state of Minas Gerais. Direct parasitological test (blood smears) and polymerase chain reactions targeting the catL genes diagnosed T. vivax infection. Fifty six cows from a herd of 161 were infected; 12 died during the outbreak and 44 animals persistently positive (by blood smears) even after chemical treatment were discarded. After this first case, five other cases were detected in state of Goiás. The spread of this disease can be linked to the commercialization of animals carrying T. vivax, allied to the iatrogenic transmission practice, using a single needle and syringe for all cows, during oxytocin administration before each milking.

Distribution and Quantitative Estimates of Variant Creutzfeldt-Jakob Disease Prions in Tissues of Clinical and Asymptomatic Patients.

In the United-Kingdom, ≈1 of 2,000 persons could be infected with variant Creutzfeldt-Jakob disease (vCJD). Therefore, risk of transmission of vCJD by medical procedures remains a major concern for public health authorities. In this study, we used in vitro amplification of prions by protein misfolding cyclic amplification (PMCA) to estimate distribution and level of the vCJD agent in 21 tissues from 4 patients who died of clinical vCJD and from 1 asymptomatic person with vCJD. PMCA identified major levels of vCJD prions in a range of tissues, including liver, salivary gland, kidney, lung, and bone marrow. Bioassays confirmed that the quantitative estimate of levels of vCJD prion accumulation provided by PMCA are indicative of vCJD infectivity levels in tissues. Findings provide critical data for the design of measures to minimize risk for iatrogenic transmission of vCJD.

Validation of an improved Anaplasma antibody competitive ELISA for detection of Anaplasma ovis antibody in domestic sheep.

An accurate and simple-to-perform new version of a competitive ELISA (cELISA) kit that became commercially available in 2015 for testing of cattle for antibody to Anaplasma marginale was validated for detection of Anaplasma ovis antibody in domestic sheep. True positives and negatives were identified using nested PCR (nPCR) as the gold standard. Negative bovine control sera supplied with the kit were used to calculate % inhibition (%I), designated bovine control ELISA (BcELISA), and this was compared to %I calculated from negative ovine sera derived from hand-raised, pathogen-free sheep, designated ovine control ELISA (OcELISA). The receiver operating characteristics area under the curve was 1.0 with a p value <0.001 regardless of the source of the control sera. The cutoff values for negative BcELISA and OcELISA were <30%I and <27%I, respectively. Our work confirmed that this Anaplasma antibody cELISA kit version 2 can be used with the serum controls supplied in the kit to test for A. ovis antibody in domestic sheep. Furthermore, this work confirmed the historically high infection prevalence (>93%) at the U.S. Sheep Experiment Station (Dubois, Idaho), in spite of efforts to reduce the possibility for iatrogenic transmission there, suggesting high levels of tick-borne transmission.

Amyloid-\u03b2 accumulation in the CNS in human growth hormone recipients in the UK

Human-to-human transmission of Creutzfeldt–Jakob disease (CJD) has occurred through medical procedures resulting in iatrogenic CJD (iCJD). One of the commonest causes of iCJD was the use of human pituitary-derived growth hormone (hGH) to treat primary or secondary growth hormone deficiency. As part of a comprehensive tissue-based analysis of the largest cohort yet collected (35 cases) of UK hGH-iCJD cases, we describe the clinicopathological phenotype of hGH-iCJD in the UK. In the 33/35 hGH-iCJD cases with sufficient paraffin-embedded tissue for full pathological examination, we report the accumulation of the amyloid beta (Aβ) protein associated with Alzheimer’s disease (AD) in the brains and cerebral blood vessels in 18/33 hGH-iCJD patients and for the first time in 5/12 hGH recipients who died from causes other than CJD. Aβ accumulation was markedly less prevalent in age-matched patients who died from sporadic CJD and variant CJD. These results are consistent with the hypothesis that Aβ, which can accumulate in the pituitary gland, was present in the inoculated hGH preparations and had a seeding effect in the brains of around 50% of all hGH recipients, producing an AD-like neuropathology and cerebral amyloid angiopathy (CAA), regardless of whether CJD neuropathology had occurred. These findings indicate that Aβ seeding can occur independently and in the absence of the abnormal prion protein in the human brain. Our findings provide further evidence for the prion-like seeding properties of Aβ and give insights into the possibility of iatrogenic transmission of AD and CAA.

Transmission des lésions amyloïdes de la maladie d’Alzheimer : apports des modèles animaux

Transmission of amyloid lesions in Alzheimer’s disease : contributing data from animal models. Since the discovery of the transmissibility of prion diseases, other cerebral proteinopathies have been suspected to harbor similar transmissible properties. Alzheimer’s disease (AD) is characterized by the deposition of misfolded β-amyloid (Aβ) peptides and hyperphosphorylated Tau proteins, forming amyloid plaques and neurofibrillary tangles respectively in the brain. Although available epidemiological data suggest that AD is not transmitted between individuals, suspicion has recently been raised for iatrogenic β-amyloidosis transmission between humans. This suggests that Aβ misfolding and aggregation could occur through seeding and spreading mechanisms, virtually identical to those of prions. Here, we present a review of the literature focusing on the relevance of prion-like misfolding and aggregation mechanisms for Aβ in animal models.

An outbreak of HCV genotype 6a and 2a infection in South China: Confirmation of iatrogenic transmission by phylogenetic analysis of the NS5B region.

An outbreak of hepatitis C virus (HCV) infections, for which the risk factor was unknown, was previously identified in North Guangdong, China. In the present study, a total of 736 local residents were surveyed regarding their lifetime risk factors for HCV infection. Serum anti‑HCV antibodies and HCV RNA were examined to confirm infection. In the HCV‑positive samples, the core and nonstructural protein5B sequences were amplified, and phylogenetic analysis was performed to determine the association between HCV subtypes and transmission routes. A total of 374 individuals were positive for anti‑HCV antibodies. Blood transfusion, blood product transfusion, people who inject drugs and intravenous injection at a local clinic were identified as independent risk factors for HCV infection. Phylogenetic analysis revealed that the two predominant subtypes of HCV, 2a and 6a, were primarily focused in four homologous clusters. Patients with a history of intravenous injection at a local clinic were more likely to be found in the four clusters, compared with patients exposed to other risk factors. The present emergency retrospective survey showed a specific epidemiological feature of HCV infection in Zijin County and found genetic homology among individuals exposed to intravenous injection at a local clinic. Further evidence is required to confirm the causal association between the outbreak of HCV infection and intravenous injection.

A novel equine-derived pericardium membrane for dural repair: A preliminary, short-term investigation.

Background:A large variety of biological and artificial materials are employed in dural repair, each of them with major limitations. Autologous grafts have limited availability and require an additional incision and surgical time. Cadaveric preparations and heterologous materials entail the risk of iatrogenic transmission of prions, whereas synthetic substitutes have been reported to cause inflammatory reactions and graft rejection. An equine-derived pericardium membrane has been developed (Heart®, Bioteck, Vicenza, Italy) with mechanical and safety-related features that could make it suitable for neurosurgical application.Aims:This preliminary study aimed to evaluate the short-term safety and efficacy of the Heart® membrane in dural repair procedures following meningioma surgeries.Subjects and Methods:Medical records of patients who were surgically treated for an intracranial meningioma and underwent duraplasty with the Heart® membrane were reviewed retrospectively. The occurrence of any graft-related complications such as cerebrospinal fluid (CSF) leakage, postoperative hematoma, wound infection, meningitis, and neurological symptoms was analyzed.Results:Eight patients were identified as meeting the inclusion criteria. A watertight closure was achieved in all of them. Postoperatively, no patients exhibited CSF leak, cerebral contusion, hemorrhage, or wound infection. The 1-month radiological follow-up revealed no evidence of pseudomeningocele, wound breakdown, or meningitis. Neurologic complications were observed in three patients but not directly imputable to the dural substitute or its application.Conclusions:In all the patients, the pericardium membrane enabled achievement of a watertight dural closure without graft-related adverse events. Further investigations should be performed to assess medium- and long-term clinical outcomes in a larger set of patients.

Seroprevalence of parvovirus B19 infection in patients with beta thalassemia major in Fayoum University Hospital

Background and objectivesPatients with beta thalassemia major are at higher risk of acquiring reticulocytopenia, and cessation of erythropoiesis after exposure to parvovirus B19. The aim of the study was to detect the seroprevalence of parvovirus B19 infection in children with transfusion dependent beta-thalassemia major through the detection of its specific IgM and IgG in their sera by Enzyme-linked Immunosorbent Assay (ELISA) in the Pediatric Department of Fayoum University Hospital. Materials and methodsA cross sectional descriptive study was carried out from July to September 2013, in the Pediatric Department of Fayoum University Hospital in Egypt. A total of fifty-five children with beta-thalassemia major aged from 2 to 16years were enrolled in the study. All patients were subjected to history taking, examination and investigations including; Complete blood count, serum creatinine, blood urea, hepatitis B surface antigen (HBsAg), anti hepatitis C virus antibody (anti HCV), reticulocytic count, anti B19 IgM and IgG. ResultsAnti-B19 IgM antibodies (recent infection) were detected in 14.5% (8 patients), while anti B19 IgG antibodies (prior infection) were detected in 18.2% (10 patients) of transfusion dependent thalassemic patients. There was a significant statistical correlation between the history of other siblings with beta thalassemia major, the hepatitis C virus and hepatitis B virus infection regarding absent, prior and recent infection. ConclusionParvovirus B19 infection is detected in high rates among children with beta thalassemia major. Measures to avoid iatrogenic and nosocomial transmission have to be implemented including screening of donated blood for B19 especially blood given to patients with hematological disorders. Also data from this study support the need for introduction of an approved B19 vaccine that primarily protects children with thalassemia major against that infection.

Human prion diseases: surgical lessons learned from iatrogenic prion transmission.

The human prion diseases, or transmissible spongiform encephalopathies, have captivated our imaginations since their discovery in the Fore linguistic group in Papua New Guinea in the 1950s. The mysterious and poorly understood "infectious protein" has become somewhat of a household name in many regions across the globe. From bovine spongiform encephalopathy (BSE), commonly identified as mad cow disease, to endocannibalism, media outlets have capitalized on these devastatingly fatal neurological conditions. Interestingly, since their discovery, there have been more than 492 incidents of iatrogenic transmission of prion diseases, largely resulting from prion-contaminated growth hormone and dura mater grafts. Although fewer than 9 cases of probable iatrogenic neurosurgical cases of Creutzfeldt-Jakob disease (CJD) have been reported worldwide, the likelihood of some missed cases and the potential for prion transmission by neurosurgery create considerable concern. Laboratory studies indicate that standard decontamination and sterilization procedures may be insufficient to completely remove infectivity from prion-contaminated instruments. In this unfortunate event, the instruments may transmit the prion disease to others. Much caution therefore should be taken in the absence of strong evidence against the presence of a prion disease in a neurosurgical patient. While the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) have devised risk assessment and decontamination protocols for the prevention of iatrogenic transmission of the prion diseases, incidents of possible exposure to prions have unfortunately occurred in the United States. In this article, the authors outline the historical discoveries that led from kuru to the identification and isolation of the pathological prion proteins in addition to providing a brief description of human prion diseases and iatrogenic forms of CJD, a brief history of prion disease nosocomial transmission, and a summary of the CDC and WHO guidelines for prevention of prion disease transmission and decontamination of prion-contaminated neurosurgical instruments.

Zoonoses: infectious diseases transmissible between animals and humans

Written by an international, interdisciplinary team of physicians, veterinarians, virologists, medical microbiologists, and parasitologists, Zoonoses: Infectious Diseases Transmissible from Animals to Humans covers zoonotic pathogens as agents of emergence and reemergence of zoonotic diseases, opportunistic zoonotic infections, risks of iatrogenic transmission and xenotransplantation, imported zoonotic infections, food-borne zoonoses, transmissible spongiform encephalopathies, and of warfare. Zoonoses is a valuable physician's reference that covers all aspects of epidemiology, diagnosis and differential diagnosis as well as therapy and prophylaxis of zoonotic diseases caused by bacteria, viruses, parasites, and fungi.

Advanced tests for early and accurate diagnosis of Creutzfeldt-Jakob disease.

Early and accurate diagnosis of Creutzfeldt-Jakob disease (CJD) is a necessary to distinguish this untreatable disease from treatable rapidly progressive dementias, and to prevent iatrogenic transmission. Currently, definitive diagnosis of CJD requires detection of the abnormally folded, CJD-specific form of protease-resistant prion protein (PrP(CJD)) in brain tissue obtained postmortem or via biopsy; therefore, diagnosis of sporadic CJD in clinical practice is often challenging. Supporting investigations, including MRI, EEG and conventional analyses of cerebrospinal fluid (CSF) biomarkers, are helpful in the diagnostic work-up, but do not allow definitive diagnosis. Recently, novel ultrasensitive seeding assays, based on the amplified detection of PrP(CJD), have improved the diagnostic process; for example, real-time quaking-induced conversion (RT-QuIC) is a sensitive method to detect prion-seeding activity in brain homogenate from humans with any subtype of sporadic CJD. RT-QuIC can also be used for in vivo diagnosis of CJD: its diagnostic sensitivity in detecting PrP(CJD) in CSF samples is 96%, and its specificity is 100%. Recently, we provided evidence that RT-QuIC of olfactory mucosa brushings is a 97% sensitive and 100% specific for sporadic CJD. These assays provide a basis for definitive antemortem diagnosis of prion diseases and, in doing so, improve prospects for reducing the risk of prion transmission. Moreover, they can be used to evaluate outcome measures in therapeutic trials for these as yet untreatable infections.

Comparative assessment of the surveillance systems for equine infectious anaemia, equine viral arteritis and contagious equine metritis in France

Equine infectious anemia (EIA) is caused by a persistent lentivirus infection. Infected horses are lifelong reservoirs for vector mediated or iatrogenic transmission of EIA virus (EIAV). No vaccine is currently available or likely to become so. Therefore control of new cases depends upon the time honored strategy of serological identification of carriers and their disposition by quarantine and or slaughter. In the United States EIA prevalence has declined from 4% in 1972 when the control program began to its current prevalence of approximately 0.001%. The agar gel immunodiffusion (AGID) test has been the regulatory test since EIAV control program began 43 years ago. This 4,000 fold reduction in prevalence underscores the effectiveness of the AGID test but it has a couple of drawbacks: it requires 48 hours to read and is not as sensitive as newer serological tests. Alert clinicians, regulators and horse owners seek to implement and facilitate better management of outbreaks, pre purchase evaluations and import/ export requirements. To address the need for a faster and more sensitive assay we carried out this study to compare a USDAlicensed AGID test kit with a USDA-licensed modified indirect ELISA (MI-ELISA) kit. The serum sample from an EIAV carrier horse was serially diluted and used to determine the analytical sensitivity of each assay: the MI-ELISA was 4-fold more sensitive. A Center for Veterinary Biologics proficiency panel (validated by AGID test) of 20 samples was tested: there was 100% concordance between the two assays. Analytical time point samples from 6 experimentally infected horses were collect over a period 4 months (n¼100): analytical sensitivity of experimentally infected horses was comparable for the two assays. The two assays were used to test known weak positive samples collected from nine carrier horses: the AGID test detected only two but the MI-ELISA detected all nine (Table). Due to the speed (45 minutes) and significantly greater sensitivity of the MI-ELISA reflected in the results of this study, screening of routine samples with it and confirmation of positives by the regulatory assay, AGID test, would serve the needs of the equine industry for better and more rapid risk management. Comparison between the modified indirect enzyme-linked immunosorbent assay (MI-ELISA) and agar gel immunodiffusion (AGID) test in the sensitivity against the sera from weak EIA positive carriers

Susceptibility of porcine endogenous retrovirus to anti-retroviral inhibitors.

Porcine endogenous retrovirus (PERV) is an endogenous retrovirus that poses a risk of iatrogenic transmission in the context of pig-to-human xenotransplantation. The lack of a means to control PERV infection in the context of pig-to-human xenotransplantation is a major concern in the field. In this study, we set out to evaluate the ability of currently licensed anti-HIV drugs, and other types of anti-retroviral compounds, to inhibit PERV infection in vitro. We used target cells stably expressing one of the known PERV viral receptors, an infectious molecular clone, PERV-A 14/220, and at least one drug from each class of anti-retroviral inhibitors as well as off-label drugs shown to have anti-viral activities. The susceptibility of PERV-A 14/220 LacZ to the anti-retroviral drugs was determined from infected cells by histochemical staining. We extend the results of previous studies by showing that, in addition to raltegravir, dolutegravir is found to have a potent inhibitory activity against PERV replication (IC50 8.634 ±0.336 and IC50 3.06 ± 0.844 nM, respectively). The anti-HIV drug zidovudine (AZT) showed considerable anti-PERV activity with IC50 of 1.923 ±0.691 μM as well. The study results indicate that some of the licensed anti-retroviral drugs may be useful for controlling PERV infection. However, the efficacy at nanomolar concentrations put forward integrase inhibitors as a drug that has the potential to be useful in the event that xenotransplantation recipients have evidence of PERV transmission and replication.

Using shared needles for subcutaneous inoculation can transmit bluetongue virus mechanically between ruminant hosts.

Bluetongue virus (BTV) is an economically important arbovirus of ruminants that is transmitted by Culicoides spp. biting midges. BTV infection of ruminants results in a high viraemia, suggesting that repeated sharing of needles between animals could result in its iatrogenic transmission. Studies defining the risk of iatrogenic transmission of blood-borne pathogens by less invasive routes, such as subcutaneous or intradermal inoculations are rare, even though the sharing of needles is common practice for these inoculation routes in the veterinary sector. Here we demonstrate that BTV can be transmitted by needle sharing during subcutaneous inoculation, despite the absence of visible blood contamination of the needles. The incubation period, measured from sharing of needles, to detection of BTV in the recipient sheep or cattle, was substantially longer than has previously been reported after experimental infection of ruminants by either direct inoculation of virus, or through blood feeding by infected Culicoides. Although such mechanical transmission is most likely rare under field condition, these results are likely to influence future advice given in relation to sharing needles during veterinary vaccination campaigns and will also be of interest for the public health sector considering the risk of pathogen transmission during subcutaneous inoculations with re-used needles.

Mechanical transfer of Theileria orientalis: possible roles of biting arthropods, colostrum and husbandry practices in disease transmission.

BackgroundThe intracellular protozoal parasite Theileria orientalis has rapidly spread across South-eastern Australia, substantially impacting local cattle industries since 2006. Haemaphysalis longicornis appears to be a biological vector in the endemic regions. Mechanical transfer of blood by biting arthropods, in colostrum or iatrogenic transmission though husbandry procedures is another possible mode of transmission. This study assesses the risk of these mechanical modes of transmission.MethodsBlood was collected from a T. orientalis Ikeda positive Angus steer, and was inoculated into the jugular vein of 9 calves in 3 treatment groups, each with 3 animals. Calves in Group 1 received 10 ml of cryopreserved blood, while those in Groups 2 and 3 received 1 ml (fresh blood) and 0.1 ml (cryopreserved), respectively. An additional three animals remained as negative controls and the donor calf was also followed as a positive control. Blood was collected over 3 months, and analysed via qPCR for the presence of the parasite. Samples of the sucking louse Linognathus vituli were collected opportunistically from calves 5 months after inoculation and tested for T. orientalis. For the colostral transmission study, 30 samples of blood and colostrum were collected from cows at calving in an endemic herd. These samples along with blood from their calves were tested by qPCR for T. orientalis and for antibodies to the major piroplasm surface protein (MPSP).ResultsEight of the nine inoculated calves became positive for T. orientalis. The prepatent period of these infections was inversely correlated with inoculation dose. All negative control calves remained negative and the positive control calf remained positive.Samples of L. vituli tested positive for T. orientalis Ikeda, while some samples of colostrum were also shown to be qPCR and anti-MPSP positive. All calves in the colostral study tested qPCR negative although one was antibody-positive.ConclusionsT. orientalis is capable of being mechanically transferred by intravenous inoculation with small volumes of blood and is detectable up to 5 months post-infection. Animals infected by this means may play a significant role in the transmission of the disease by acting as asymptomatic carriers. Other modes of blood transfer, including biting arthropods and colostral transfer are also possible modes of disease transmission.

Commentary: Evidence for human transmission of amyloid-β pathology and cerebral amyloid angiopathy.

Commentary: Evidence for human transmission of amyloid-β pathology and cerebral amyloid angiopathy.

Epidemic History and Iatrogenic Transmission of Blood-borne Viruses in Mid-20th Century Kinshasa.

The human immunodeficiency virus type 1 (HIV-1) pandemic was ignited in Léopoldville (now known as Kinshasa), in the former Belgian Congo. Factors that jump-started its early expansion remain unclear. Nonlethal hepatitis C virus (HCV) and human T-cell lymphotropic virus (HTLV-1) can be used to investigate past iatrogenic transmission. We undertook a cross-sectional study of elderly inhabitants of Kinshasa, with serological assays, amplification, and sequencing. Risk factors were assessed through logistic regression. Phylogenetic methods reconstructed the genetic history of HCV. A total of 217 of 839 participants (25.9%) were HCV seropositive; 26 (3.1%) were HTLV-1-seropositive. Amplification products were obtained from 118 HCV-seropositive participants; subtypes 4k (in 47 participants) and 4r (in 38) were most common. Independent risk factors for HCV subtype 4r seropositivity were intramuscular tuberculosis therapy, intravenous injections at hospital A, intravenous injections before 1960, and injections at a colonial-era venereology clinic. Intravenous injections at hospital B and antimalarials were associated with HCV subtype 4k seropositivity. Risk factors for HTLV-1 seropositivity included intravenous injections at hospitals C or D and transfusions. Evolutionary analysis of viral sequences revealed independent exponential amplification of HCV subtypes 4r and 4k from the 1950s onward. Iatrogenic transmission of HCV and HTLV-1 occurred in mid-20th century Kinshasa, at the same time and place HIV-1 emerged. Iatrogenic routes may have contributed to the early establishment of the pandemic.

Epidemic History and Iatrogenic Transmission of Blood-borne Viruses in Mid-20th Century Kinshasa

Epidemic History and Iatrogenic Transmission of Blood-borne Viruses in Mid-20th Century Kinshasa