Letters

Evidence of a CJD epidemic may still be missed

EDITORThe United Kingdom faces the possibility of an epidemic of new variant Creutzfeldt-Jakob disease as a result of bovine spongiform encephalopathy,¹ but the referral of brain tissue to neuropathologists to determine the cause of degenerative diseases of the brain has virtually stopped. Public concerns over the retention of tissues for investigation after postmortem examination make it is easy to see how this has happened.²

In the United Kingdom most postmortem examinations on adults are performed because they are directed by law. The main reason is to ascertain a natural medical cause of death for certification, thereby removing the need for an inquest. In the past, retaining the brain for examination was a routine part of the practice of pathologists, but it is now clear that many relatives of the deceased person may not have been aware of this. Because of concerns over the legitimacy of organ retention the true cause of a degenerative brain disease is now hardly ever being established after a postmortem examination, even though the brain has been examined by the inadequate method of slicing during the necropsy. Simply certifying that a person has died of a disease such as pneumonia, in the face of a decline as a result of a degenerative brain disease, is giving a mechanism of death rather than its true cause. This has implications for estimating misclassification rates in epidemiological studies.³ I suspect that many families will be concerned that they were not given the opportunity to benefit from appropriate investigations. Guidelines from the Royal College of Pathologists (www.rcpath.org) will be released soon, but medical and public confidence has already been lost.

So far, the cases of new variant Creutzfeldt-Jakob disease have been in a distinct subset of the population.¹ We have no knowledge of the ways in which new variant Creutzfeldt-Jakob disease may become manifest, especially in elderly people. Unless a positive statement is made to reassure the public, medicolegal authorities, and pathologists, the situation of "not looking" will prevail and we run the risk of missing any emerging epidemic.

James Lowe, professor. 
School of Clinical Laboratory Sciences, Division of Pathology, University of Nottingham Medical School, Nottingham NG7 2UH james.lowe{at}nottingham.ac.uk

Competing interests: Professor Lowe recieves funding from the UK Department of Health for surveillance of the incidence of Creutzfeldt-Jakob disease. He is a member of the council of the Royal College of Pathologists and has contributed to the formulation of its document Guidelines for the Retention of Tissues at Post-mortem Examination.