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

Pyramid of Safety (after Heinrich, 1931)

200-600 Unreported Occurrences

30 Reportable Incidents

10 Accidents

1 Fatality

2

 

Error    

Infec*on  

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

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

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

4

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

5

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

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 !

6

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 !

7

11

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  

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

Biological Safety Cabinets

Rusnak, J. et al. (USAMRIID) Biosec. Bioterr.: biodefense strategy, practice, science. 2:281-93.

9

Influence of BSC on LA Tularemia

10

11

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

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)

15

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.

16

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

17

Recent Tragedy

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

18

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%)

19

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.

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

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

21

26

Published in 2009.

All fungus culture plates taped after inoculation

•  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

23

Recommendations •  Train workers; retain high index of suspicion •  Tape suspicious plates immediately •  Limit the sniffing

24

•  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

•  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

Recommendations •  Engineering controls: automatic faucets, gloves

worn on bench, tape suspicious plates, plastic shields, incinerator burners, alcohol gel, etc.

26

Recommendations •  Do not trust automated instruments or kits

with unusual, slower-growing isolates

27

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

28

Barriers to Enhancing Worker Safety

I didn’t think about it

29

Also available online: http://www.cdc.gov/biosafety/publications/bmbl5/BMBL.pdf

30

CDC Biosafety Infographic

www.cdc.gov/phpr/documents/BSL_infographic_final.pdf

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

31

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

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

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

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

32