SAFETY GUIDELINES FOR PRION DISEASES


	SAFETY GUIDELINES FOR PRION DISEASES Daron Davis¹, Ruth Carrico², Joseph C Parker³ 1 University of Kentucky Medical Center, ²Infection Control, University of Louisville Hospital, ³ Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine TABLE OF CONTENTS 1. Purpose 2. Policy statements 3. Nursing care: 4. Postmortem examination 5. References 1. PURPOSE The following represents the guidelines for the safety of staff during the treatment and care of a patient with known or suspected prion diseases as well as the precautions should be considered during the postmortem examination. The following disorders are known to be Prion diseases of Humans: Creutzfeldt-Jakob Disease Atypical Variant of Creutzfeldt-Jakob Disease, Bovine Spongiform Encephalopathy (BSE) Gerstmann-Straussler-Scheinker Disease Fatal Familial Insomnia Progressive Subcortical Gliosis Kuru Inclusion Body Myositis Consideration should be given to limiting the autopsy to the brain. The method chosen for post mortem exam will be at the discretion of the prosector. NO postmortem examamination will be performed without prior authorization for cremation of all suspected or known cases of human prior disease. The Infection Control Department is available to assist with family questions. 2. POLICY STATEMENTS All patients within the specified groups will be cared for utilizing the following policy as a guide: The Infection Control office must be notified immediately upon presumptive or confirmed diagnosis of a transmissible spongiform encephalopathy including CJD or its variants (see purpose outlining target population). Meticulous universal precautions will be utilized during all care or interaction with these patients. Special attention should be paid to all neural tissue and fluids. All post mortem exams performed on a patient with known or suspected CJD must follow the accompanying procedure and the Infection Control office must be notified. No post mortem exam will be performed without the written consent of the family to cremate the body after the procedure. Recognizing that research is essential, the hospital will work with researchers requesting assistance in obtaining tissue for study. Fresh frozen tissue is used for molecular genetic testing to determine the specific mutation along the prion gene. Tissue may be forwarded to the appropriate institution by express carrier using the guidelines provided by the CDC for transporting these agents and with prior written approval by authorized personnel at the receiving institution stating that they agree to accept the materials. When the body of a patient with known or suspected CJD is sent to a funeral home, efforts will be made to provide information to that funeral home regarding precautions needed. The Infection Control Department should provide this information and assistance. All specimens obtained from a patient with known or suspected CJD/ GSS must be labeled *"CJD- Biohazardous"* (See example below.) Any exposure to the blood or body fluids of a patient with known or suspected CJD must be reported to the Employee Health Nurse as is standard procedure. If neurosurgical procedures are performed prior to death, the Infection Control Nurse must be notified prior to that procedure in order to work with the respective surgeon, Director of Surgical Services, and the Department of Nursing for the provision of patient care and environmental safety. The departments of neurology and/or neurosurgery are resources regarding patient care and safety issues. 3. NURSING CARE All nursing care will be provided using universal precautions as is the standard procedure. In the event neurologic and/or opthalmic procedures are performed, special precaution needs will be individualized for that patient after consultation with resource departments such as Infection Control, Neurology and Pathology. 4. POSTMORTEM EXAMMINATION The body will be received in the anatomic pathology area by the Department of Pathology only if placed in two (2) heavy plastic body bags of the type used in disaster corpse recovery. These bags are available in the pathology area. The outer bag must be clearly labeled as a biohazard and indicate the suspected infectious agent or suspected diagnosis. (See the example below). NO Power Saws or Drills will be used under any circumstances during the autopsy. Preparations for the exam prior to opening the body bags will include the following: seal the autopsy table drain. cover with the following items with durable, heavy gauge, sheet polyethylene available by calling the anatomic pathology department: the autopsy table or gurney covered with sufficient plastic to reach the floor any prep table, cart or other surface to be used for autopsy utensils or specimen containers an area of floor at least ten feet by ten feet (10' x 10') beneath the head of the autopsy table or gurney. cover any exposed equipment, supplies or other work areas (use discretion, if any item is within a reasonable immediate radius, cover it to prevent potential contamination. mix at least three (3) gallons of 2N Sodium Hydroxide (NaOH) solution in an unbreakable plastic container with a tight fitting lid. This is prepared by mixing 88 grams of NaOH pellets per liter of water. For 3 gallons, you will need at least one kilogram (1.0 Kg.) of NaOH. Use this container for contaminated instruments. prepare a trash receptacle for use; double bag with large, red, heavy duty, biohazard bags. the following autopsy instruments will be needed (use stainless steel or disposable where possible): hammer, one (1) skull chisel, one (1) calvarium breakers, two (2) scalpel handle and blade, one (1) manual calvarial saw, one (1) blunt ended scissors, one (1) toothed forceps, one (1) syringe 10 cc, one (1) spinal needle 18 ga. 4 inch, one (1) chest tube clamps or large hemostats, (12) large autopsy brain knife, one (1) disposable tight capped CSF containers, two (2) obtain the following supplies for procedural use: disposable sharps container, preferably with a large, unobstructed opening one plastic (preferably unbreakable) brain jar 2/3 filled with 10% neutral buffered formalin large ziplock specimen bags, six (6) cardboard sheet cut to fit into the large ziplock bags, one (1) towels or absorbent underpads, twelve (12) autopsy head rest (must be able to withstand soak in NaOH) polyethylene sheet six feet by ten feet (6' x 10'), one (1) arrange and assemble instruments on a towel in working proximity on a plastic covered table. lock the Autopsy Suite doors prior to opening the body bags. mark and label all containers (brain jars, waste containers, sodium hydroxide instrument baths, etc.) as biohazardous containers and note the suspected agent. Four individuals only, will be allowed in the autopsy suite during the proceedings. One clean circulator One assistant The primary prosector Attending pathologist Personal Protective Equipment (PPE) includes the following: First Layer No street clothes. Dress in scrubs and don shoe covers. Put on first set of forearm covers and surgical gloves. Kevlar gloves should be available and, if worn, done so under surgical gloves. Second Layer disposable waterproof gown another pair of shoe covers, forearm covers and a second pair of surgical gloves Third Layer surgical head cover (2) surgical mask full face eye shield The bagged body will be placed on the covered autopsy table or left on a stable plastic covered gurney. Place the large sheet of plastic (10' x 10') on the floor under the head of the table on which the patient rests. Place the waste receptacles (biohazard trash can and NaOH) and work table holding the instruments on the perimeter of the plastic sheet. Open the body bags. Check the deceased for any jewelry and for the presence of a subcutaneous cardiac pacemaker and remove these objects. Place them in clean autoclave safe bags. This will remove the necessity of the funeral personnel to open the body bags after completion of the autopsy and before cremation. Place the 6' x 10' plastic sheet around the head of the autopsy table inside the inner body bag and under the head of the deceased. Use hemostat clamps to secure the plastic. Place the head on a headrest and towels in sufficient quantities around the head to absorb all blood and CSF. Cover the neck and chest of the deceased with several absorbent underpads. The plastic encircling the head, underpads over the thorax and towels about and under the head will be folded into the inner body bag at the completion of the brain extraction. Reflect the scalp in the usual manner. Manually saw the calvarium. Hint: to open the calvarium requires only that the outer table be cut and scored along the desired line prior to utilizing the chisel and hammer to complete the calvarial removal. Use the chisel and hammer to complete the calvarial separation. Use a wet towel to prevent splatter and aerosolization while sawing and using the hammer and chisel. Place the skull breakers along the calvarial cut at each side of the forehead and exert a twisting motion. Work completely around the skull until the calvarial cap is free. [Not necessarily part of the routine procedure, but potentially useful for research studies, use the spinal needle and syringe, aspirate ventricular CSF and place in the collection tubes taking care to keep all fluid inside the tubes]. Extract the brain in the usual manner being particularly aware of the sharp calvarial bone edges. When the dissectionist is finished using an instrument, place the instrument in the 2N NaOH solution container. A wire basket or other container should be inside the NaOH in order to facilitate safe removal of the instruments after sufficient soak time has elapsed. For sharps, discard immediately into the impervious sharps container once the sharp has served its purpose. Remove one cerebral hemisphere and make multiple coronal slices. Lay the slices on the cardboard sheet in anterior to posterior order and seal in ziplock specimen bag. Place sequentially in two (2) clean ziplock specimen bags. Freeze at -70°C. Have the clean circulating person open the brain jar with formalin and take several steps back. Place the remaining cerebrum, cerebellum and brain stem in the formalin. Formalin does not reduce the infectivity of the tissue but, in fact, stabilizes the prion protein making it much more difficult to denature and destroy the infectivity. Replace the lid on the jar and place the jar in a biohazard bag. Replace the calvarium and return the scalp to its normal position over the skull. Do not stitch the scalp together. Remove the head block and place in 2N NaOH solution. Fold all plastic sheeting, towels, etc. around the head of the deceased into the inner body bag. Have the clean circulating person don a pair of disposable gloves and zip the bag closed, then remove that pair of gloves and discard into the biohazard trash. Zip close the outer body bag. (If the body is on a gurney, roll the gurney away to a clean area.) Place all remaining instruments in the 2N NaOH solution and seal the lid on the container. Gently place all disposable plastic, towels, underpads, etc. into the center of the plastic on the floor. While standing on the plastic covered floor, remove the apron, outer layer of gloves, forearm coverings, shoe covers, and bunny suit tossing them gently to the middle of the plastic. Step off the plastic as you remove the shoe covers with the clean foot. Gather the corners of the plastic and fold inward. Place in a double biohazard bag cinching the top of each bag individually. Clearly mark for incineration and the biohazard agent. Contact Facilities Management for assistance with appropriate disposal for incineration. The instruments will be soaked in 2N NaOH for at least one hour, rinsed with water or saline, and autoclaved for at least one (1) hour at 134°C at pressure of at least 30 lbs/in², then scrubbed and sent to SPD for routine processing. If the autopsy table or other surface is contaminated, it will be thoroughly cleansed with 2N NaOH solution and the affected area allowed to sit covered with the solution for one (1) hour. After use of 2N NaOH, the solution can be carefully discarded into the sewer system followed by copious amounts of water. Appropriate PPE must be worn during this disposal to prevent accidental splash and exposure to the skin and eyes by this base solution. Preparation of tissue blocks for Histology Processor must dress and prepare a work area prior to removal of the fixed brain from formalin. Cover all work surfaces with polyethylene plastic sheeting and some towels to absorb fluids. Wearing appropriate PPE, cut the brain coronally from anterior to posterior. Be sure to take two (2) sections each of the caudate nucleus and putamen with adjacent insular cortex, thalamus and cerebellum. Take sections from all cerebral lobes plus the hippocampus and amygdala. Tissue blocks are prepared after fixation for a minimum of 48 hours in fresh formalin, then transferred to undiluted reagent grade (95-100%) formic acid for one hour, and returned to fresh formalin for 48 hours. (Tissues handled in this manner have been shown to not transmit prion diseases to laboratory animals.) Tissue block processing is then handled by the technician. The blocks and slides will be processed in a dedicated tissue processor or manually in separate containers which can be cleansed in 2N NaOH and then autoclaved at least one (1) hour at 134°C at pressure of at least 30 lbs/in². Do not commingle this glassware with the histology lab’s other glassware; retain it sequestered for future use. Tissue sections will be cut on a dedicated microtome used only for prion disease cases. (This equipment should be so marked.) All contaminated disposable items and discarded tissues will be clearly marked as contaminated with Creutzfeldt-Jakob disease or other prion diseases and placed in doubled biohazard bags and incinerated. Tissue blocks once cut, will be placed in two (2) clean ziplock bags, clearly identified as biohazard and sealed. Blocks should then be taken to the appropriate place for storage. Store all reusable equipment clean and covered. Solvents and liquids will be sequestered and disposed of by incineration. Specimen processing (other than histologic processing): Specimen processing other than histologic processing should utilize the same precautions as those outlined above. Reagents and glassware should utilize the same disposal and reprocessing procedures. All specimen must be appropriately labeled indicating the infectious agent and, if kept, be double bagged. All trash generated through the processing must also be double bagged and labeled for incineration. Questions should be referred to Infection Control and the appropriate laboratory resource. 5. REFERENCES 1. Budka H.et al. Tissue handling in suspected Creutzfeldt-Jakob disease (CJD) and other human spongiform encephalopathies (Prion diseases). Brain Pathology 5:319-322, 1995. 2. Steelman, VM. Creutzfeldt-Jakob disease: Recommendation for infection control. Am J Infect Control. 22:312-318, 1994. (Note: this older reference makes use of 1N NaOH, a practice that has been supplanted by the recommended use of 2N NaOH.) Provided by: Dr Jospeh C parker A.J. Miller Professor and Chairman Dept of Pathology and Laboratory Medicine University of Louisville Louisville, Kentucky Tel: 502-852-5341 Fax: 502-852-8299

SAFETY GUIDELINES FOR PRION DISEASES

Daron Davis¹, Ruth Carrico², Joseph C Parker³

1 University of Kentucky Medical Center, ²Infection Control, University of Louisville Hospital, ³ Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine

TABLE OF CONTENTS

1. Purpose
2. Policy statements
3. Nursing care:
4. Postmortem examination
5. References

1. PURPOSE

The following represents the guidelines for the safety of staff during the treatment and care of a patient with known or suspected prion diseases as well as the precautions should be considered during the postmortem examination. The following disorders are known to be Prion diseases of Humans:

Creutzfeldt-Jakob Disease

Atypical Variant of Creutzfeldt-Jakob Disease, Bovine Spongiform Encephalopathy (BSE)

Gerstmann-Straussler-Scheinker Disease

Fatal Familial Insomnia

Progressive Subcortical Gliosis

Kuru

Inclusion Body Myositis

Consideration should be given to limiting the autopsy to the brain. The method chosen for post mortem exam will be at the discretion of the prosector.

NO postmortem examamination will be performed without prior authorization for cremation of all suspected or known cases of human prior disease. The Infection Control Department is available to assist with family questions.

2. POLICY STATEMENTS

All patients within the specified groups will be cared for utilizing the following policy as a guide:

The Infection Control office must be notified immediately upon presumptive or confirmed diagnosis of a transmissible spongiform encephalopathy including CJD or its variants (see purpose outlining target population).

Meticulous universal precautions will be utilized during all care or interaction with these patients. Special attention should be paid to all neural tissue and fluids.

All post mortem exams performed on a patient with known or suspected CJD must follow the accompanying procedure and the Infection Control office must be notified.

No post mortem exam will be performed without the written consent of the family to cremate the body after the procedure.

Recognizing that research is essential, the hospital will work with researchers requesting assistance in obtaining tissue for study. Fresh frozen tissue is used for molecular genetic testing to determine the specific mutation along the prion gene. Tissue may be forwarded to the appropriate institution by express carrier using the guidelines provided by the CDC for transporting these agents and with prior written approval by authorized personnel at the receiving institution stating that they agree to accept the materials.

When the body of a patient with known or suspected CJD is sent to a funeral home, efforts will be made to provide information to that funeral home regarding precautions needed. The Infection Control Department should provide this information and assistance.

All specimens obtained from a patient with known or suspected CJD/ GSS must be labeled "CJD- Biohazardous" (See example below.)

Any exposure to the blood or body fluids of a patient with known or suspected CJD must be reported to the Employee Health Nurse as is standard procedure.

If neurosurgical procedures are performed prior to death, the Infection Control Nurse must be notified prior to that procedure in order to work with the respective surgeon, Director of Surgical Services, and the Department of Nursing for the provision of patient care and environmental safety. The departments of neurology and/or neurosurgery are resources regarding patient care and safety issues.

3. NURSING CARE

All nursing care will be provided using universal precautions as is the standard procedure. In the event neurologic and/or opthalmic procedures are performed, special precaution needs will be individualized for that patient after consultation with resource departments such as Infection Control, Neurology and Pathology.

4. POSTMORTEM EXAMMINATION

The body will be received in the anatomic pathology area by the Department of Pathology only if placed in two (2) heavy plastic body bags of the type used in disaster corpse recovery. These bags are available in the pathology area. The outer bag must be clearly labeled as a biohazard and indicate the suspected infectious agent or suspected diagnosis. (See the example below).

NO Power Saws or Drills will be used under any circumstances during the autopsy.

Preparations for the exam prior to opening the body bags will include the following:

seal the autopsy table drain.

cover with the following items with durable, heavy gauge, sheet polyethylene available by calling the anatomic pathology department:

the autopsy table or gurney covered with sufficient plastic to reach the floor
any prep table, cart or other surface to be used for autopsy utensils or specimen containers
an area of floor at least ten feet by ten feet (10' x 10') beneath the head of the autopsy table or gurney.
cover any exposed equipment, supplies or other work areas (use discretion, if any item is within a reasonable immediate radius, cover it to prevent potential contamination.

mix at least three (3) gallons of 2N Sodium Hydroxide (NaOH) solution in an unbreakable plastic container with a tight fitting lid. This is prepared by mixing 88 grams of NaOH pellets per liter of water. For 3 gallons, you will need at least one kilogram (1.0 Kg.) of NaOH. Use this container for contaminated instruments.

prepare a trash receptacle for use; double bag with large, red, heavy duty, biohazard bags.

the following autopsy instruments will be needed (use stainless steel or disposable where possible):

hammer, one (1)
skull chisel, one (1)
calvarium breakers, two (2)
scalpel handle and blade, one (1)
manual calvarial saw, one (1)
blunt ended scissors, one (1)
toothed forceps, one (1)
syringe 10 cc, one (1)
spinal needle 18 ga. 4 inch, one (1)
chest tube clamps or large hemostats, (12)
large autopsy brain knife, one (1)
disposable tight capped CSF containers, two (2)

obtain the following supplies for procedural use:

disposable sharps container, preferably with a large, unobstructed opening

one plastic (preferably unbreakable) brain jar 2/3 filled with 10% neutral buffered formalin
large ziplock specimen bags, six (6)
cardboard sheet cut to fit into the large ziplock bags, one (1)
towels or absorbent underpads, twelve (12)
autopsy head rest (must be able to withstand soak in NaOH)
polyethylene sheet six feet by ten feet (6' x 10'), one (1)

arrange and assemble instruments on a towel in working proximity on a plastic covered table.

lock the Autopsy Suite doors prior to opening the body bags.

mark and label all containers (brain jars, waste containers, sodium hydroxide instrument baths, etc.) as biohazardous containers and note the suspected agent.

Four individuals only, will be allowed in the autopsy suite during the proceedings.

One clean circulator
One assistant
The primary prosector
Attending pathologist

Personal Protective Equipment (PPE) includes the following:

First Layer

No street clothes. Dress in scrubs and don shoe covers. Put on first set of forearm covers and surgical gloves. Kevlar gloves should be available and, if worn, done so under surgical gloves.

Second Layer

disposable waterproof gown

another pair of shoe covers, forearm covers and a second pair of surgical gloves

Third Layer

surgical head cover (2)

surgical mask

full face eye shield

The bagged body will be placed on the covered autopsy table or left on a stable plastic covered gurney. Place the large sheet of plastic (10' x 10') on the floor under the head of the table on which the patient rests. Place the waste receptacles (biohazard trash can and NaOH) and work table holding the instruments on the perimeter of the plastic sheet.

Open the body bags. Check the deceased for any jewelry and for the presence of a subcutaneous cardiac pacemaker and remove these objects. Place them in clean autoclave safe bags. This will remove the necessity of the funeral personnel to open the body bags after completion of the autopsy and before cremation.

Place the 6' x 10' plastic sheet around the head of the autopsy table inside the inner body bag and under the head of the deceased. Use hemostat clamps to secure the plastic. Place the head on a headrest and towels in sufficient quantities around the head to absorb all blood and CSF. Cover the neck and chest of the deceased with several absorbent underpads.

The plastic encircling the head, underpads over the thorax and towels about and under the head will be folded into the inner body bag at the completion of the brain extraction.

Reflect the scalp in the usual manner. Manually saw the calvarium. Hint: to open the calvarium requires only that the outer table be cut and scored along the desired line prior to utilizing the chisel and hammer to complete the calvarial removal. Use the chisel and hammer to complete the calvarial separation. Use a wet towel to prevent splatter and aerosolization while sawing and using the hammer and chisel.

Place the skull breakers along the calvarial cut at each side of the forehead and exert a twisting motion. Work completely around the skull until the calvarial cap is free. [Not necessarily part of the routine procedure, but potentially useful for research studies, use the spinal needle and syringe, aspirate ventricular CSF and place in the collection tubes taking care to keep all fluid inside the tubes]. Extract the brain in the usual manner being particularly aware of the sharp calvarial bone edges.

When the dissectionist is finished using an instrument, place the instrument in the 2N NaOH solution container. A wire basket or other container should be inside the NaOH in order to facilitate safe removal of the instruments after sufficient soak time has elapsed. For sharps, discard immediately into the impervious sharps container once the sharp has served its purpose.

Remove one cerebral hemisphere and make multiple coronal slices. Lay the slices on the cardboard sheet in anterior to posterior order and seal in ziplock specimen bag. Place sequentially in two (2) clean ziplock specimen bags. Freeze at -70°C. Have the clean circulating person open the brain jar with formalin and take several steps back. Place the remaining cerebrum, cerebellum and brain stem in the formalin. Formalin does not reduce the infectivity of the tissue but, in fact, stabilizes the prion protein making it much more difficult to denature and destroy the infectivity. Replace the lid on the jar and place the jar in a biohazard bag.

Replace the calvarium and return the scalp to its normal position over the skull. Do not stitch the scalp together.

Remove the head block and place in 2N NaOH solution. Fold all plastic sheeting, towels, etc. around the head of the deceased into the inner body bag. Have the clean circulating person don a pair of disposable gloves and zip the bag closed, then remove that pair of gloves and discard into the biohazard trash. Zip close the outer body bag. (If the body is on a gurney, roll the gurney away to a clean area.) Place all remaining instruments in the 2N NaOH solution and seal the lid on the container.

Gently place all disposable plastic, towels, underpads, etc. into the center of the plastic on the floor. While standing on the plastic covered floor, remove the apron, outer layer of gloves, forearm coverings, shoe covers, and bunny suit tossing them gently to the middle of the plastic. Step off the plastic as you remove the shoe covers with the clean foot. Gather the corners of the plastic and fold inward. Place in a double biohazard bag cinching the top of each bag individually. Clearly mark for incineration and the biohazard agent. Contact Facilities Management for assistance with appropriate disposal for incineration.

The instruments will be soaked in 2N NaOH for at least one hour, rinsed with water or saline, and autoclaved for at least one (1) hour at 134°C at pressure of at least 30 lbs/in², then scrubbed and sent to SPD for routine processing. If the autopsy table or other surface is contaminated, it will be thoroughly cleansed with 2N NaOH solution and the affected area allowed to sit covered with the solution for one (1) hour.

After use of 2N NaOH, the solution can be carefully discarded into the sewer system followed by copious amounts of water. Appropriate PPE must be worn during this disposal to prevent accidental splash and exposure to the skin and eyes by this base solution.

Preparation of tissue blocks for Histology

Processor must dress and prepare a work area prior to removal of the fixed brain from formalin. Cover all work surfaces with polyethylene plastic sheeting and some towels to absorb fluids. Wearing appropriate PPE, cut the brain coronally from anterior to posterior. Be sure to take two (2) sections each of the caudate nucleus and putamen with adjacent insular cortex, thalamus and cerebellum. Take sections from all cerebral lobes plus the hippocampus and amygdala. Tissue blocks are prepared after fixation for a minimum of 48 hours in fresh formalin, then transferred to undiluted reagent grade (95-100%) formic acid for one hour, and returned to fresh formalin for 48 hours. (Tissues handled in this manner have been shown to not transmit prion diseases to laboratory animals.) Tissue block processing is then handled by the technician. The blocks and slides will be processed in a dedicated tissue processor or manually in separate containers which can be cleansed in 2N NaOH and then autoclaved at least one (1) hour at 134°C at pressure of at least 30 lbs/in². Do not commingle this glassware with the histology lab’s other glassware; retain it sequestered for future use. Tissue sections will be cut on a dedicated microtome used only for prion disease cases. (This equipment should be so marked.) All contaminated disposable items and discarded tissues will be clearly marked as contaminated with Creutzfeldt-Jakob disease or other prion diseases and placed in doubled biohazard bags and incinerated. Tissue blocks once cut, will be placed in two (2) clean ziplock bags, clearly identified as biohazard and sealed. Blocks should then be taken to the appropriate place for storage. Store all reusable equipment clean and covered.

Solvents and liquids will be sequestered and disposed of by incineration.

Specimen processing (other than histologic processing):

Specimen processing other than histologic processing should utilize the same precautions as those outlined above. Reagents and glassware should utilize the same disposal and reprocessing procedures. All specimen must be appropriately labeled indicating the infectious agent and, if kept, be double bagged. All trash generated through the processing must also be double bagged and labeled for incineration. Questions should be referred to Infection Control and the appropriate laboratory resource.

5. REFERENCES

1. Budka H.et al. Tissue handling in suspected Creutzfeldt-Jakob disease (CJD) and other human spongiform encephalopathies (Prion diseases). Brain Pathology 5:319-322, 1995.

2. Steelman, VM. Creutzfeldt-Jakob disease: Recommendation for infection control. Am J Infect Control. 22:312-318, 1994.

(Note: this older reference makes use of 1N NaOH, a practice that has been supplanted by the recommended use of 2N NaOH.)

Provided by:

Dr Jospeh C parker
A.J. Miller Professor and Chairman
Dept of Pathology and Laboratory Medicine
University of Louisville
Louisville, Kentucky

Tel: 502-852-5341
Fax: 502-852-8299