California Pathologists Balk on Performing CJD Autopsies

By Gary Finch

A recent study that focused in part on the reluctance of pathologists to perform autopsies on CJD cases was conducted by the California Emerging Infections Program. The results, or specifically, the objections of pathologists, should interest embalmers.

First, some background. CJD surveillance reports rely on autopsies and neuro-pathologic evaluation. The 1990–2000 CJD autopsy rates in California were 21%. Most neurologists were comfortable diagnosing CJD (83%), but few pathologists felt comfortable diagnosing CJD (35%) or performing an autopsy (29%).

In California, CJD is not reportable. Since 1999, the California CJD Surveillance Project of the California Emerging Infections Program, a collaboration of the California Department of Health Services and the U.S. Centers for Disease Control and Prevention, has conducted enhanced surveillance for classic and variant CJD.

Currently, pathologic review of brain tissue obtained by biopsy or autopsy is the only means of confirming a diagnosis of CJD. Autopsy remains the preferred method for obtaining tissue, as brain biopsy can result in serious complications (e.g., brain hemorrhage or abscess formation) and may not yield adequate amounts of tissue for analysis. The main role of a brain biopsy is to exclude other potentially treatable conditions.

This study describes results from analysis of California mortality data from 1990 through 2000. It also summarizes responses generated from a statewide survey of neurologists and pathologists regarding the challenges to diagnosing CJD and variant CJD, including obtaining an autopsy in suspected cases.

From July to December 2002, questionnaires regarding experience with diagnosing CJD were sent to 1,241 California neurologists identified as members of the American Academy of Neurology and 574 pathologists identified as members of the California Society of Pathologists and the American Association of Neuropathologists. Most neurologists felt comfortable clinically recognizing classic CJD. The most commonly cited barrier to obtaining autopsy was family reluctance to give consent.

A majority of pathologists were uncomfortable doing an autopsy on a CJD case. Their reasons ranged from infection control concerns (77%), lack of experience (62%), and institutional limitations (53%). Less than half of the respondents reported that confirming the diagnosis of CJD or ruling out variant CJD was an important reason to pursue an autopsy.

Consensus opinion of Compliance Plus: If 53% of pathology labs are not fit to handle CDJ, it stands to reason that nearly 100% of funeral home labs would be lacking.

Compliance Plus – Opinion on Embalming CJD Cases

We share in the opinion from the World Health Organization and Centers for Disease Control that posted remains should not be embalmed.

We further contend that non-posted cases are also high risk, since the trocar is likely to come into contact with spinal fluid. We note that the World Health Organization requires a special autoclave (one that heats about 20 degrees more than a conventional autoclave) and that to our knowledge, no funeral home has this type of autoclave.

We are aware of posted articles appearing in publications from Dodge Chemical Company and Embalmers Supply Company (ESCO) that promote safe practices for injecting CJD cases. We take note of all the extra precautions they require, such as covering the table with plastic to protect it. It is our consensus opinion that any requirement to cover the prep room table or floor shows that the promoter is aware that this is a high risk procedure. In our opinion, funeral homes do not charge enough to cover high risk procedures; embalmers are not paid enough to engage in them, and they should not.

For further information, call our office.