CJD Overview Bob Will, National CJD Surveillance Unit, Edinburgh, UK Associazione Italiana...
-
Upload
darrell-newton -
Category
Documents
-
view
227 -
download
0
Transcript of CJD Overview Bob Will, National CJD Surveillance Unit, Edinburgh, UK Associazione Italiana...
CJD Overview Bob Will, National CJD Surveillance Unit, Edinburgh, UK
Associazione Italiana Encefalopatie da Prion
Milano 3 Ottobre 2009
Questions
• What is the origin of infection in CJD?• Is there a link to scrapie in sheep?• What are the clinical and pathological
characteristics of CJD?• What are the epidemiological characteristics
of CJD?
SYSTEMATIC STUDIES OF CJD WORLDWIDECountry Period Incidence:
cases/million Country Period Incidence:
cases/million
Austria 1969-1985 1986-1994 1995-2001
0.18 0.67 1.15
Italy 1958-1971 1993-2001
0.05 1.10
Australia 1970-1980 1987-1996 1997-2001
0.66 1.07 1.39
Japan 1975-1977 1985-1996
0.45 0.58
Chile 1955-1972 1973-1977 1978-1983
0.10 0.31 0.69
Netherlands New Zealand
1993-2001 1989-1989
1.00
0.88 Czechoslovakia 1972-1986 0.66 Slovakia 1993-2001 1.17
France 1968-1977 1978-1982 1993-2001
0.34 0.58 1.52
Switzerland
1995-2001
1.50
Germany
1979-1990 1993a-2001
0.31 1.14
UK 1964-1973 1970-1979 1980-1984 1985-1989 1993-2001
0.09 0.31 0.47 0.46 0.99
Israel 1963-1972 1963-1987
0.75 0.91
US 1973-1977 1983-1990b 1991-1998b
0.26 1.10 1.10
a Extrapolated from part-year data b Age-adjusted to the standard US projected 2000 population
AUTHOR METHOD RISK FACTORS
Bobowick et al. (1973) 38 “selected” cases; healthy controls. None.
Kondo & Kuroiwa (1982) Population study: 60 cases, healthy controls
trauma in males.
Kondo (1985) 88 autopsied cases; autopsied controls
organ resection.
Davanipour et al (1985) 26 cases; 40 controls trauma or surgery to head or neck;
other trauma; surgery needing sutures; tonometry
Davanipour et al (1985) 26 cases; 40 controls roast pork, ham, underdone meat, hot dogs.
Davanipour et al (1985) 26 cases; 40 controls contact with fish, rabbits, squirrels.
Harries-Jones et al (1980) 92 cases; 184 controls Herpes Zoster; keeping cats; contact with pets other than cats/dogs; dementia in family
Van Duijn et al (1998) 405 cases; 405 controls consumption of raw meat; consumption of brain; frequent exposure to leather products, exposure to fertilizer consisting of hoof and horn.
Collins et al (1999) 241 cases; 784 controls number of surgical procedures; residence or employment on a farm or market garden.
Ward et al (2002) 326 cases; 326 controls surgery, especially in females; ear piercing, psychiatric consultation.
SIGNIFICANT RISK FACTORS IN CONTROLLED STUDIES
HUMAN TSEs (Prion diseasesHUMAN TSEs (Prion diseases
DISEASE CAUSE
Sporadic Creutzfeldt-Jakob disease (CJD)
Unknown
Iatrogenic CJD Kuru
Human to human transmission
Variant CJD Transmission of BSE to humans
Familial CJD Gerstmann-Straussler syndrome Fatal Familial Insomnia
Mutations of prion protein gene
SPORADIC CJD : EEGPERIODIC TRIPHASIC DISCHARGES
• 60-80% SENSITIVITY(TESTING POLICY)
• ? SPECIFICITY (? 74%)(CONTEXT DEPENDENT)
• ‘SUBJECTIVITY’ OF REPORTING
NO EEG CRITERIA PROSPECTIVELY VALIDATED IN LARGE NUMBERS OF CASES
CSF Analysis
Dr Alison Green, The National CJD Surveillance Unit ECDC funded meeting, 10 th March 2009
sCJD AD vCJD SpCJD
14-3-3 Western Blot
FIGURE 2
Sporadic CJD0.00 - 0.500.51 - 1.001.01 - 1.50
Genetic CJD0.00 - 0.100.11 - 0.150.16 - 0.80
Iatrogenic CJD0.01 - 0.050.070.17
0.00 Variant CJD0.000.050.20
MORTALITY RATES PER COUNTRY - (EUROCJD) 1993-2000)
IATROGENIC CREUTZFELDT-JAKOB DISEASE WORLDWIDE
Mode of infection
No. of patients
Agent entry
into brain
Mean incubation period (range)
Clinical signs on presentation
Corneal transplant 2 Optic nerve 18, 320 mo Dementia, cerebellar
Stereotactic EEG 2 Intra-cerebral 16, 20 mo Dementia, cerebellar
Neurosurgery 4 Intra-cerebral 17 mo (12-28) Visual/dementia/cerebellar
Dura mater graft 209 Cerebellar surface 11 yr (1.5-23) Cerebellar (visual, dementia)
Growth hormone 203 Hematogenous(?) 15 yr (4-36) Cerebellar
Gonadotrophin 4 Hematogenous (?) 13 yr (12-16) Cerebellar
Blood transfusion 3 (+1) Hematogenous 6.5, 7.5, 8.5 yr Sensory, psychiatric
DURA MATER CASES WORLDWIDE SHOWN BY YEAR OF OPERATION AND YEAR OF ONSET OF SYMPTOMS FOR CJD
0
2
4
6
8
10
12
14
16
18
20
69 - - - 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96
Year
Operation Onset
Mean incubation period from operation to onset of symptoms: 6.8 years (range 1-16)
THE HUMAN PRION PROTEIN GENE Mutations and polymorphisms
• Clinical diagnosis
• Screening of family members
• Pre-natal testing
• Influence on phenotype
‘BSE posed the greatest political and economic challenge to the EU since its foundation’
The specified bovine offal ban UK Dec 1989/ Jan1990
The UK BSE epidemic
DIFFERENCES BETWEEN SPORADICAND VARIANT CJDDIFFERENCES BETWEEN SPORADICAND VARIANT CJD
SPORADIC CJD VARIANT CJD
Mean age at death 66 years 29 years
Median duration of illness
4 months 13 months
Thalamic MRI high signal
Caudate/Putamen 60%
Pulvinar
90%
EEG "Typical" 70% "Typical" 0%
Neuropathology Plaques
10%
Florid plaques 100%
0
20
40
60
80
100
120
140
160
180
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85-8
9
90+
sCJD vCJD
AGE AT DEATH FOR SPORADIC CJD CASES AND vCJD CASES BY 5-YEAR AGE GROUP
Age Group
Nu
mb
er o
f ca
ses
ResultsTemporal distribution of vCJD cases in France and UK
10 0 0
1 1 1 20
2
7
4 4
0
810 11
14
17
29
24
16
13
4
9
5
20
0
5
10
15
20
25
30
35
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
year of onset
num
ber o
f cas
es
vCJD in France
vCJD in UK
According to the year of onset, the number of vCJD cases in France reached a peak of incidence in 2004, five years after the peak observed in the UK in 1999
YEAR OF ONSET OF ILLNESS OF vCJD WORLDWIDE Year
Onset
UK France Ireland Italy USA Canada Saudi Arabia
Japan Nether-lands
Portugal
Spain
1994 8 1
1995 10
1996 11
1997 14
1998 17 1
1999 29 1 1
2000 24 1
2001 17 2 1 1 1 1
2002 14
2003 5 2 1
2004 9 7 2 1 1 1
2005 5 4 1 1 1
2006 3 4 1 1 1
2007 1 3
2008 2 2 1
Total 169 25 4 1 3 1 1 1 3 2 5
CHARACTERISTICS OF TSEs
• Prolonged incubation periods.• Uniformly fatal neurological diseases.• Causal agents (prions) resistant to
sterilisation.• No serological test for infection.• Infection may be present in tissues (LRS)
during the incubation period.
0
10
20
30
40
50
60
70
80
9096-1
96-3
97-1
97-3
98-1
98-3
99-1
99-3
00-1
00-3
01-1
01-3
02-1
02-3
03-1
03-3
04-1
04-3
05-1
05-3
06-1
06-3
07-1
Donation (RBC)Donoronset
Donordeath
vCJD case(Case 1)
vCJD case(Case 3)
Transfusion to recipient
Donation 1 (RBC)Donoronset
Donordeath
Recipientonset
Recipientdeath
Transfusion to recipient Recipientonset
Recipientdeath
Pre-clinical infection(Case 2)
Donoronset
DonordeathDonation (RBC)
RBC=red blood cells
Transfusion to recipient Recipient death
Years shown by quarter
vCJD case(Case 4)
Donation 2 (RBC)
Transfusion to recipient
Donoronset
Donordeath
Recipientonset
Recipientdeath
There is no evidence of transmission of any form of CJD through:
• Social contact• Treating minor injuries• Occupational contact• Maternal transmission• Sexual transmission• General surgery
Number of Reported BSE cases,vCJD Deaths (Probable & Definite) and vCJD Onsets
in the EC & the UK 1988-2008
0
5
10
15
20
25
30
35
40
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Year
No
. BS
E c
ases
('0
00s)
0
5
10
15
20
25
30
35
40
45
50
No
. vC
JD d
eath
s UK BSE cases('000s)
UK vCJD deaths
EC BSE cases(x 100)
EC vCJD deaths