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Ellen Jo Baron, Ph.D., D(ABMM) Professor Emerita Stanford Univ. Med. School
Biosafety in the Clinical Lab: Brucella, Coccidioides, and
Mindfulness Handled a specimen from a patient with monkeypox without PPE
Executive Director of Medical Affairs Cepheid
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Pyramid of Safety (after Heinrich, 1931)
200-600 Unreported Occurrences
30 Reportable Incidents
10 Accidents
1 Fatality
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Error
Infec*on
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HHS CDC Tier 1 Select Agent List • Tier 1 agents: Ebola, Marburg viruses,
Variola minor and Variola major viruses, Francisella tularensis, Yersinia pestis, Bacillus anthracis, Burkholderia mallei and B. pseudomallei, Foot-and-mouth disease virus, rinderpest virus, Botulinum neurotoxin and neurotoxin-producing strains of C. botulinum
• Recent Deletions: Herpes B virus, Coccidioides sp., South American Genotypes of EEEV, Staphylococcal enterotoxins
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Brucella Exposure in Stanford Lab
• Mexican woman, ill for months
• Blood cultures – Day 2 “gram-variable rods”
• Plates showed at Plate Rounds Day 4
Yagupsky & Baron. 2005. Emerging Infect. Dis. 11:1180.
(http://www.cdc.gov/ncidod/EID/vol11no08/04-1197.htm) 3
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Brucella
• Beaumont Hospital, Michigan 1988 • 8 Employees became ill 1.5-5 months later • Blood cultures positive in 5 of 8 • Subsequently a CDC microbiologist
working with these isolates developed brucellosis
• Naroibi and Oxford, UK labs - 1992 • Pus and blood cultures (4 d) yielded gr- cb • API 20 NE identified as M. phenylpyruvica • 3 months later, lab tech developed brucellosis • 5 months later, another tech became ill • Cultures handled on open bench • ? Sniffing
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Brucella • Nice, France, 1996 – 3 cases attributed to
sniffing plates • Synovial and tissue samples, 79 yo woman • Cultures on chocolate (4 d) grew gr-cb • 3 techs “smelt” plates • 2-4 months later, 2 developed night sweats or
mild fatigue and positive serology, one had fevers and positive blood cultures
• Beaumont Hospital, Royal Oak, MI, 1997 • Blood cultures (2 d) grew gr-cb • Colonies on chocolate only at 48 h • 3 techs worked on cultures, 2 sniffed plates • All 3 were given prophylaxis
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Sniffing – Really such a risky practice?
Organism CFU/meter3
Neisseria meningitidis 0 Streptococcus pneumoniae 0
Burkholderia pseudomallei 6.25
Bacillus sp. 6.25
Pseudomonas aeruginosa 6.25
Staphylococcus aureus 12.5
Escherichia coli 6.25
Candida albicans 0
Bacteroides fragilis 0
• Fresh overnight cultures on blood agar • Air sampled (40 liters/min) 2 cm above plate surfaces for 4 min • CFU determined per m3
Barkham & Taylor. 2002. JCM 40:3877. 6
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Sniffing – Really such a risky practice? • Fresh overnight cultures on blood agar • Air sampled (40 liters/min) 2 cm above plate surfaces for 4 min • CFU determined per m3
Barkham & Taylor. 2002. JCM 40:3877.
1 sniff = 50-200 ml air 6,000-7,000 sniffs required to inhale 12.5 CFU Conclusion – Low Risk !
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Ann Robinson Data on Sniffing - unpublished
• Disposable filter unit with 0.2 micron filter connected to a lab bench vacuum.
• Plate medium containing a lawn of organisms positioned ~0.5 cm above filter unit.
• Vacuum applied for 1 and 3 min to each test organism.
• E. coli, Staphylococcus aureus, and Neisseria meningitidis on blood or chocolate agar plates.
• Filters removed and placed on chocolate agar plate and incubated for 48 h.
• No organisms were recovered from any of the filters.
Sacred Heart Med. Ctr., Spokane, WA
Conclusion – Low Risk !
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Biological agent Infectious dose Route of inoculation Escherichia coli 108 Inges*on Escherichia coli O157: H7 10 Inges*on Campylobacter jejuni ≤ 500 Inges*on Treponema pallidum 57 Intradermal Francisella tularensis 10 Inhala*on, Inges*on Bacillus anthracis ~8000 spores? Inhala*on, Inges*on Mycobacterium tuberculosis & bovis <10 Inhala*on Coxiella burne<i 10 Inhala*on Salmonella typhi 105 Inges*on Shigella flexneri 180 Inges*on Vibrio cholerae 108 Inges*on Yersinia pes<s 100 – 500 Inges*on, Inhala*on Smallpox virus (V. major) 10 -‐ 100 Inges*on, Inhala*on (rare) Poliovirus 2 Inges*on Influenza A2 virus <790 Inhala*on Venezuelan encephali*s virus 1 Subcutaneous Hepa**s A virus 10 -‐ 100 Inges*on, intravenous Adenovirus >150 Intranasal Respiratory syncy*al virus >100 -‐ 640 Intranasal Plasmodium falciparum 10 Intravenous Histoplasma capsulatum 10 (mice) Inhala*on
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Lab-acquired infections (LAI) - USAMRIID
• 234 persons working 1989-2002 had only 5 LAIs
• 1943 – 1969 data analyzed; BSCs in 1949 • Vaccines not available for agents tested • 423 LAIs experienced • Agents: B. anthracis, Y. pestis, B. mallei, F. tularensis, Brucella, Coxiella, VEE, Chlamydia psittaci, botulism, Staph SEB • Tularemia 15/yr; Brucella 13/yr; Q fever
3/yr • 80% infections occurred in scientists
Rusnak, et al. 2004. Biosecurity and bioterrorism: biodefense strategy, practice, and science. 2:281-93 8
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Biological Safety Cabinets
Rusnak, J. et al. (USAMRIID) Biosec. Bioterr.: biodefense strategy, practice, science. 2:281-93.
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Influence of BSC on LA Tularemia
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Shapiro & Schwartz. 2002. JCM 40:2278-81.
Francisella tularensis Boston Med. Center, 2002 • 43 yo man with opacified left hemithorax, rapidly
progressive pneumonia, died within 2 days • Lab and autopsy service not notified of Med.
Service suspicion of tularemia • Multiple positive cultures worked up on bench • 12 lab employees exposed; 11 given prophylaxis • No illness developed
12
One theme: Failure of clinicians to notify lab when they suspect high risk agent
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Survey of healthcare workers: UK
• 1994-95 (Walker & Campbell) ~25,000 workers § 397 clinical labs in UK surveyed § 9 infections § 18/100,000 workers infections § Shigella (4), E.coli O157 (1), HCV (1),
GI virus (1), TB (1), Rat-bite fever (1)
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0%10%20%30%40%50%60%70%80%
Exposures Infections Noincidents
BigSmall
Baron Uncontrolled Survey - 2005 • 88 facilities responded; 53 big, 32 small, 3 ref • 38 (43%) = NO exposures (15 big; 23 small) • 21 (24%) = Exposures (17 big; 4 small) • 29 (33%) = Infections (24 big; 5 small)
ClinMicroNet directors webgroup. J.M. Miller, coordinator ASM Division C webgroup. D. Wiedbrauk, coordinator.
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Baron Survey – Infecting Organisms
Organism Number % from big labs Shigella 15 87% Brucella 7 100% Salmonella 6 83% Staph aureus 6 (5 MRSA) 83% N. meningitidis 4 50% E.coli O157:H7 2 100% Coccidioides 2 100% C. difficile 1 0 B. anthracis 1 Research
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Recent Tragedy
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Neisseria meningitidis risk to lab workers
Sejvar, J. et al. 2005. JCM 43:4811-14.
• Survey of lab-acquired cases since 1985 • 3000 N. mening. reported per year, handled
by ~3 technicians (9000 exposures/year) • 16 cases total, 9 grp. B & 7 grp. C (6 in U.S.) • 8 fatalities, 3 grp. B and 5 grp. C • At risk procedures = subcultures, serotyping,
examining plates – no BSC (94%) • 3 additional cases reported 2002
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Neisseria meningitidis risk to lab workers
Sejvar, J. et al. 2005. JCM 43:4811-14.
• Attack rate =
General pop’n 13/100,000 Age 30-59 0.3/100,000
• Attack rate microbiologists (Age 30-59) =
20/100,000 At risk procedures = subcultures, serotyping, examining plates without BSC (94%)
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So. California Kaiser, 2003
• 47 yr. old, diabetes • Died of multi-organ
system failure 3 days after admission
• 17 workers exposed • Cultures grew Burkholderia
pseudomallei • 17 workers exposed
MMWR. Oct. 29, 2004. p. 988-90.
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Baron Survey – Risk of Infection
Organism Risk/100,000 Microbiol.
Risk/100,000 25-64 y.o.
Brucella 641 0.08 Coccidioides 13.7 12 C. difficile 0.2 8* E.coli O157:H7 8.3 0.96 N. meningitidis 25.3 0.62 Salmonella 1.5 17.9* Shigella 6.6 6.6
Baron, E.J. & J.M. Miller. Bacterial and fungal infections among diagnostic laboratory workers: evaluating the risks. Diagn Microbiol Infect Dis. 2008 Mar;60(3):241-6. Epub 2007 Nov 8. 20
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Stanford Lab, Palo Alto, CA - 2004 • 3 lab workers called in with GI disease • Subsequently cultures yielded S. sonnei • Patient culture handled previous week • PFGE patterns
identical for 1 worker’s isolate and the patient strain
• 2 technol and one lab assistant
in 2006: another Shigella infection
in a CLS Remodeled handwashing sink with automatic eye faucet- 2004
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Published in 2009.
All fungus culture plates taped after inoculation
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• Prevention better than response (tape plates) § Freeze plate and examine frozen mass
• Cover spill with paper towels and bleach • Close windows (seal off from outside) • Hold breath and evacuate the room • Remove labcoats right before leaving • Wash skin surfaces with soap and water • Call HazMat or designated safety officer • Wait 1-2 hours before starting decontam • May require hydrogen peroxide vapor (p-
formaldehyde vapor is second choice) • Get baseline serum to store • Treat exposed personnel with itra- or
fluconazole for 6 weeks
Recommendations summary
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Recommendations • Train workers; retain high index of suspicion • Tape suspicious plates immediately • Limit the sniffing
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• Establish guidelines for use of BSC § Slow growth on
BAP, no growth on Mac
§ Gram-neg diplococci from blood or CSF
• Immunize for Hepatitis B, C, and N.meningitidis
Recommendations
25
Employer should offer immunizations for FREE
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• California lab shut down after young researcher dies while on personal crusade to find vaccine for meningitis
• Richard Din, 25, died about 17 hours after handling a deadly bacteria
• Din, a biology major, has been trying to find a vaccine for a rare strain of meningitis
• The researcher's co-workers have described him as 'fastidious' in his work
• About 70 people who came in contact with Din have been given antibiotics
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Recommendations • Engineering controls: automatic faucets, gloves
worn on bench, tape suspicious plates, plastic shields, incinerator burners, alcohol gel, etc.
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Recommendations • Do not trust automated instruments or kits
with unusual, slower-growing isolates
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Recommendations • In endemic areas, assign immunocom-
promised workers to different job categories • In high-risk situations, vaccinate workers for
additional agents (viruses, Coxiella, etc.) • Constantly remind
clinicians and pathologists to notify lab if risk of bad bug
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Barriers to Enhancing Worker Safety
I didn’t think about it
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Also available online: http://www.cdc.gov/biosafety/publications/bmbl5/BMBL.pdf
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CDC Biosafety Infographic
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www.cdc.gov/phpr/documents/BSL_infographic_final.pdf
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http://www.cdc.gov/mmwr/pdf/other/su6002.pdf
Judy R. Delany, Michael A. Pentella, Joyce A. Rodriguez, Kajari V. Shah, Karen P. Baxley, David E. Holmes
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J. Michael Miller, Ph.D. Rex Astles, Timothy Baszler, Kimberle Chapin, Roberta Carey, Lynne Garcia, Larry Gray, Davise Larone, Michael Miller, Michael Pentella, Ann Pollock, Daniel S. Shapiro, Elizabeth Weirich, and Danny Wiedbrauk.
30 http://www.cdc.gov/mmwr/pdf/other/su6101.pdf
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Tenets of Safe Practices • Use a Class IIA2 biological safety cabinet • Wash hands frequently • Use appropriate disinfectants including
1:10 household bleach • Use formal risk assessment for activities • Develop written safety protocols • Negative airflow into the laboratory • Use PPE when needed. Get trained! • Know your role in the safety of your
laboratory
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Culture of Safety
A work environment where all employees accept the responsibility and accountability for the safety of their co-workers and where management leads the effort.
J. Michael Miller Former CDC Associate Director for Laboratory Science for the National Center for Emerging and Zoonotic Infectious Diseases
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Creating an Environment of Safety
• Constant mindfulness • Team participation
(peer safety audit) • Managers reinforce
concepts to everyone • Opinion leaders must
take the lead • Start each meeting with a
safety message – rotate the responsibility
? Put on your gloves
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