Connecticut health officials said Friday that two patients treated at a VA hospital in West Haven could have been exposed to a rare, deadly brain disease from potentially contaminated surgical equipment that was also used in New Hampshire and Massachusetts.
The two are in addition to 13 patients in the other states who are already reported at risk of developing Creutzfeldt-Jakob disease, an incurable illness marked by rapid mental deterioration that resembles dementia.
Connecticut’s Department of Public Health said in a statement that New Hampshire health officials notified the agency on Aug. 29 about the potential patient exposure.
“The risk of transmission of [Creutzfeldt-Jakob] to the two patients at the VA is considered very low. The general public and any other patients at the VA Hospital and their employees are not at any risk,” it said.
The VA Connecticut Healthcare System said in a statement that both patients, who underwent surgery in late May and early June, had been notified.
On Wednesday, Catholic Medical Center in Manchester, N.H., reported that eight of its patients might have been exposed to the disease during brain surgery from equipment used in May on another patient who did not show symptoms of the illness until August.
Standard methods for sterilizing surgical equipment before every operation do not completely protect against the rare disease, specialists said.
A device used in the May operation was rented from Minneapolis-based Medtronic, and then sent to the Connecticut VA hospital and to Cape Cod Hospital in Hyannis.
The Medtronic device, a metal frame and brace used to pinpoint an area for surgery with as little disruption as possible to the surrounding tissue, was used on five Cape Cod Hospital spine-surgery patients as well as the two in Connecticut.
The eight Catholic Medical Center patients were potentially exposed to the disease by other instruments that had also been used in the original May surgery, hospital officials said.
Tests are being conducted on tissue samples taken after the May patient died last month. Results are not due back for about a month. Creutzfeldt-Jakob disease can be definitively diagnosed only after death.
Similar events have occurred at other hospitals.
Last year, 11 patients at Greenville Health System in South Carolina were potentially exposed to Creutzfeldt-Jakob through instruments used on a patient who was later diagnosed with the disease.
To date, none of the 11 are known to have developed the disease, according to a statement from Dr. Angelo Sinopoli, the hospital’s chief medical officer.
Sinopoli said the hospital’s sterilization policies and procedures met all federal recommendations, but “in an abundance of caution” it consulted with a center that specializes in Creutzfeldt-Jakob disease and decided to increase the sterilization temperature and length of sterilization on all surgical instruments.
“We believe that the risk to those patients is extremely small and probably zero,” he said.
Another case happened in 2004 at Emory University Hospital in Atlanta, where staffers notified 98 brain and spine surgery patients that they might have been exposed to the rare disease after a surgery patient was diagnosed with Creutzfeldt-Jakob.
In 2001, the Joint Commission, an organization that accredits hospitals, issued an advisory noting two separate incidents at hospitals in which a total of 14 patients were possibly exposed to the rare disease through instruments used during brain surgery.
The commission recommended that hospitals establish clear policies for disinfecting or disposing of instruments used in neurosurgery in general, and when Creutzfeldt-Jakob is suspected or confirmed.
It also suggested that hospitals quarantine neurosurgery instruments that have been used on patients who have an unclear diagnosis, until a diagnosis can be confirmed.