Fifty-three patients at the University of Wisconsin Hospital were informed last week that there is an “extremely low risk” they may have been infected by a fatal brain disease know as Creutzfeldt-Jakob Disease.

After a woman in her 50s, who recently died of CJD, had brain surgery at UW Hospital in June 2009, there was a 40-day window where 53 other patients were possibly infected. The doctors did not suspect CJD at the time because they believed a tumor to be the cause of her symptoms, according to a statement released by UW Hospital.

“In this case, the individual had a space occupying lesion, which provided the diagnosis for why the symptoms might have been occurring. That is why CJD was not considered a possibility at the time of the surgery,” Nasia Safdar, UW Health infectious disease physician said in a statement.

Weeks after the surgery the woman’s condition declined greatly, and at that point more tests were administered and CJD was confirmed.

Although doctors at the UW Hospital say they had no reason to diagnose the woman with CJD at the time, Florence Kranitz, president of the Creutzfeldt-Jakob Disease Foundation, believes CJD should always be considered during exploratory brain surgery.

“In a perfect world whenever they are doing brain surgery they should consider that CJD is a possibility,” Kranitz said. “Unfortunately it didn’t happen and people were involved and the concern is there.”

According to Lisa Brunette, spokesperson for UW Hospital, the procedures they use will not be changed from previous methods. In cases where the patient is known to have CJD, they would use disposable instruments during brain surgery and then throw them away, but continue to use normal instruments and normal sterilization on brain surgery patients without known CJD.

In this particular case the instruments went through the Center for Disease Control’s recommended method of heightened sterilization, but were not thrown away like some other hospitals would do.

“As far as non-disposable instruments, we take our cue from the Center for Disease Control and the fact that in 33 years of experience across the world that a case of transmission of CJD through neuro-surgical instruments that are cleaned and disinfected the standard way has just never happened,” Brunette said.

As of now, no legal action has been taken against the UW Hospital and they are currently providing counseling to the affected patients.

Kranitz said she thinks, even after counseling, there could still be hardships for the 53 patients, such as their inability to donate blood and the ethical responsibility to disclose they have been exposed to the disease, which might lead them to denial of medical care.

She added UW should provide them with any future care they might need. According to Brunette, UW always provides medical care to someone with an infectious disease such as CJD and she does not believe hospitals would turn these patients away.

Stephanie Marquis, spokesperson for the Wisconsin Department of Health Services, said the hospital did what it was supposed to do by reporting the incident to their department and informing the patients of the situation.

Marquis also said the federal government has the right to have their division further investigate the situation if they choose to do so.

“They should learn from this experience, and to say, ‘continue with business as usual,’ well unfortunately business as usual means there is a possibility that there is going to be another exposure,” Kranitz said.