Exposure to Infectious Exposure to Infectious Agents in Health Protection Agents in Health Protection Agency LaboratoriesAgency LaboratoriesPresented by Presented by
Frances Knight and Ian BatemanFrances Knight and Ian Bateman
HEALTH PROTECTION AGENCYHEALTH PROTECTION AGENCY
• formed April 2003
• CMO – Getting ahead of the curve
• formed from PHLS, CAMR, National Focus
• joined in 2004 by NRPB
• around 3000 staff
• 3 major centres, 79 sites
• 1500 staff work in microbiology
• Diphtheria infection in member of staff
• HPA Board requested review
• Investigate laboratory exposures to infectious agents
• Review adequacy of actions to prevent infections in staff
• Recommend improvements
• Identify issues of wider relevance
BACKGROUNDBACKGROUND
TERMS OF REFERENCETERMS OF REFERENCE
– examine laboratory acquired infections and incidents of exposure to infectious agents during laboratory work
– identify number of incidents over 2 years and the circumstances in which they arose
– review immediate and underlying causes
– review lessons learned
– review actions taken and whether they were adequate
– determine further steps to ensure this area of risk is adequately controlled
– final report for the HPA Board
– make recommendations for further action
FINDINGS (1)FINDINGS (1)
78 recorded incidents
• Hazard Group 1 (1)• Hazard Group 2 (40)• Hazard Group 3 (32)• Hazard Group 4 (2)• Not known (3)
6 LAIs (Salmonella Typhimurium, Shigella sonnei (2 cases),
Corynebacterium diphtheriae, Salmonella Agona and Neisseria
meningitidis )
Full recovery, no transmission to others
FINDINGS (2)FINDINGS (2)
• 70% - SPILLS, BREAKAGES AND LEAKS
• 13% - SHARPS
• 11% - NO MSC/GENERATION OF AEROSOLS
REVIEW OF SPECIFIC REVIEW OF SPECIFIC INCIDENTSINCIDENTS
• LAI – Corynebacterium diphtheriae
• LAI – Salmonella Agona
• Mycobacterium tuberculosis – dropped culture
• Mycobacterium tuberculosis – dropped swab
• LAI - Neisseria meningitidis
UNDERLYING CAUSESUNDERLYING CAUSES
• staffing levels
• off-site training
• competence
• communication
• immunisation status
• accommodation pressures
ACTION PLAN (1)ACTION PLAN (1)
Increased vigilance and awareness
keep biological safety high on the agenda
Communicate findings via cascade
targeting key groups
Improved risk assessment
especially resource/space
Standard arrangements
incident reporting, investigation & analysis
System for communicating lessons learned
including pan-HPA communication of HSE visit findings
Better and more consistent CL3 training
ACTION PLAN (2)ACTION PLAN (2)
review practices against HSAC, ACDP, etc
processing at wrong containment levels
create environment for open reporting
frequency of CL2 and CL3 incidents
monitor progress against action plans
share findings across microbiology + HSE