Health Security

Volume 17, Number 5, 2019 ª Mary Ann Liebert, Inc.

DOI: 10.1089/hs.2019.0057

Survey of Suspected Laboratory-Acquired Infections

and Biosafety Practices in Research, Clinical,
and Veterinary Laboratories in Karachi, Pakistan

Shamsul Arfin Qasmi and Bilal Ahmed Khan

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Laboratory-acquired infections (LAIs), an occupational illness, are defined as all infections acquired through laboratory or
laboratory-related activities. A report published in 1898 described an LAI resulting from Corynebacterium diphtheriae being
transmitted through mouth pipetting. Despite all efforts, LAIs continue, especially in developing countries like Pakistan, which
has been fighting to curb many infectious diseases. As reflected in the published literature, the biosafety culture is severely
lacking in many laboratories, and there are no data available from Pakistan on LAIs. Our objective was to ascertain the
frequency and rate of LAIs in various labs with versatile portfolios in relation to biosafety and biosecurity practices in Karachi.
Ours is a descriptive multicenter cross-sectional study conducted in 30 laboratories located in Karachi from November 2017 to
April 2018. Data were collected from laboratories including the university hospital labs, research labs, animal labs, and
biomedical labs. Out of 30 facilities, half (n = 15) were clinical/biomedical laboratories, 16.6% (n = 5) were university hospital
laboratories, 26.6% (n = 8) were R&D laboratories, and 6.6% (n = 2) were animal laboratories. Needle stick was found to be
the most common injury, followed by animal bite/scratch, cut on mucous membrane, falling of personnel, and burn injury.

Keywords: Laboratory-acquired infections, Aerosols, Occupational health

L aboratory-acquired infections (LAIs) are an occu-

pational illness and are defined as infections acquired
through laboratory-related activities. They have been occur-
ring since the beginning of work with infectious agents,1 but
epidemiologic investigation of LAIs has begun relatively re-
cently. The first report of an LAI resulting from Cor-
ynebacterium diphtheriae was published in 1898, when the
bacterium was transmitted through mouth pipetting.2 The
first survey of LAIs was carried out in Europe in 1915 by
Kisskalt, who reported 50 cases of typhoid fever that resulted
in 6 fatalities. Most of these infections were transmitted by
mouth pipetting. In 1929, Kisskalt reported 83 more cases of
LAIs, 59 of which were lab-acquired typhoid. Mouth pipet-
ting was again found to be the most common route of these
transmitted infections.2 In 1976, Pike et al published the
largest survey of LAI; they reported 4,079 LAIs caused by
159 infectious agents, which resulted in approximately 173
deaths. More than half of these LAIs were reported as being
caused by only 10 infectious agents.3 Since this study, many
surveys have been conducted that reported LAIs from various
bacteria, viruses, parasites, and fungi. In the United Kingdom,
enteric infections, such as shigellosis, and tuberculosis were
found to be the most common LAIs in clinical laboratory
workers.4,5 The Flemish environmental agency in Belgium

Shamsul Arfin Qasmi, PhD, is a Professor, Department of Pathology, Fazaia Ruth Pfau Medical College, Karachi, Pakistan. Bilal
Ahmed Khan, MPhil, is an Assistant Professor, Department of Molecular Pathology, Dow University of Health Sciences, Karachi,
Pakistan.

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 QASMI AND KHAN

conducted a survey in 2006, which reported 2 LAIs from
Listeria monocytogenes and Brucella melitensis. This was fol-
lowed by another survey in Belgium from 2007 to 2012, which
reported 140 LAIs.6
Laboratory-acquired infections can occur by exposure to
or inhalation of an agent, contact with mucous membrane, or
percutaneous inoculation, but in most cases, the actual cause
remains uncertain. Therefore, the significant increase in work
with pathogenic organisms and the emergence of infectious
diseases make LAIs a global health security concern.
Since an infected laboratory worker can be an index pa-
tient for a new epidemic,7 many biosafety guidelines have
been developed as well as sophisticated containment equip-
ment to prevent LAIs.8 Despite these efforts, LAIs continue
to occur and cannot be ignored, especially in developing
countries like Pakistan, which has been fighting to curb in-
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tion of the data and statistics to generate the numeric de-
scription of the data. Bar graphs and pie charts show the
relative number of participants in each category (by re-
porting the percentages/counts within each category). The
graphs were made to provide visual comparisons between
the different variables. A descriptive analysis provides a de-
tailed report of the percentages and frequencies of all the
categorical variables in the study.
Results
Laboratory Affiliations
Of the 30 facilities that were included in the survey, 50%
(n = 15) were clinical/biomedical laboratories, 16.6% (n = 5)
were university hospital laboratories, 26.6% (n = 8) were

fectious diseases. As reflected in the published literature, the research and development (R&D) laboratories, and 6.6%
biosafety culture is severely lacking in many laboratories,9-11 (n = 2) were animal laboratories. Clinical and biomedical
and no data are available from Pakistan on this topic. laboratories have the same status, while university hospital
Therefore, this study was conducted to identify and as- laboratories are associated with inhouse healthcare labora-
certain the incidence of LAIs, to develop indigenous data, tories whose main patients are inpatients in the hospital.
and to review protocols followed in response to incidents
in research, veterinary, and clinical laboratories. This study
will serve as a starting point to understanding the spectrum Biosafety Levels Surveyed
of problems; to designing and implementing policies and In cross tabulation analyses, the survey team found that
training programs that can mitigate risks in handing, most laboratories were designated as biosafety level 2 (BSL-
transportation, and storage of infectious pathogens; and to 2), across the 4 types of facilities surveyed. Among clinical/
propagating a culture of safety in Pakistan. biomedical labs, 6.7% were BSL-1, 73.3% were BSL-2,
6.7% were BSL-3, and 13.3% of the facilities have both
BSL-2 and -3 labs. In university hospital labs, 80% were
Methodology BSL-2, and 20% of the facilities have both BSL-2 and -3
laboratories. All of the animal laboratories were BSL-2,
A comprehensive questionnaire composed of 64 questions was keeping in mind the risk groups with their biosafety and
designed under the guidance of technical experts in microbi- biosecurity challenges. In R&D laboratories, 87.5% of the
ology and biorisk management from Pakistan and the United facilities were BSL-2, and 12.5% were BSL-3 (Table 1).
States. The questionnaire was formulated to assess the biosafety
measures in place, compliance with standard operating proce- Table 1. Biosafety Level of Laboratories Surveyed:
dures (SOPs) and international guidelines, microorganisms Cross Tabulation
or toxins handled, availability and use of personal protective
equipment (PPE) and other containment measures, emergency Biosafety Level (BSL)
preparedness, suspected LAIs, and possible route of exposure in
laboratories with diverse portfolios. The survey was conducted BSL-1 BSL-2 BSL-3 BSL-2 and -3 Total
1 11 1 2 15
by a research associate under the supervision of the principal
6.7% 73.3% 6.7% 13.3% 100.0%
investigator among the 30 laboratories in Karachi, Pakistan.
100.0% 45.8% 50.0% 66.7% 50.0%
The laboratories were selected by a cluster random sampling 0 4 0 1 5
method. The data were obtained from laboratory staff and 0.0% 80.0% 0.0% 20.0% 100.0%
recorded by the research associate under the supervision of the 0.0% 16.7% 0.0% 33.3% 16.7%
principal investigator. Data were then entered and statistically 0 2 0 0 2
analyzed using SPSS version 20 by a biostatistician. 0.0% 100.0% 0.0% 0.0% 100.0%
The data consisted of categorical variables, mostly of the 0.0% 8.3% 0.0% 0.0% 6.7%
nominal and ordinal type. Each category in the variable was 0 7 1 0 8
separated from the other. Descriptive statistics were recorded 0.0% 87.5% 12.5% 0.0% 100.0%
in percentages and frequencies for categorical data. Cross 0.0% 29.2% 50.0% 0.0% 26.7%
1 24 2 3 30
tabulations were done between different categorical vari-
3.3% 80.0% 6.7% 10.0% 100.0%
ables for finding comparisons between different variables.
100.0% 100.0% 100.0% 100.0% 100.0%
Bar graphs and pie charts were created as a visual presenta-

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 LABORATORY-ACQUIRED INFECTIONS IN PAKISTAN

Table 2. Types of Services Provided by the Surveyed Facilities In 43.3% of the facilities, management has stated a com-
mitment but does not have clearly defined roles, while in
Services Frequency, No. (%)
10% of the facilities, management has not made a com-
Pathology /histopathology 13 (43.3) mitment to biosafety (Figure 1).
Virology 4 (13.3)
Molecular diagnostics 17 (56.7)
Clinical pathology (hematology/ 20 (66.7)
biochemistry) International Biosafety Guidelines
Cell culture 9 (30) Regarding biosafety policies and guidelines, 50% (n = 15) of
Bacteriology 25 (83.3) the laboratories follow World Health Organization (WHO)
Serology 22 (73.3) guidelines,12 26.7% (n = 8) follow Biosafety in Micro-
Toxicology 3 (10) biological and Biomedical Laboratories (BMBL) guide-
In vitro research 7 (23.3) lines,13 and 1 (3.3%) has its own policies; 16.7% (n = 5)
Other 3 (10)
do not follow any biosafety policies or guidelines (Figure 2). It
was interesting to find in cross tabs distribution that 80% of the
clinical/biomedical labs follow WHO laboratory biosafety
Laboratory-related Activities guidelines, while 20% do not follow any biosafety guidelines.
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Data regarding the type of services provided by the labo-
ratories revealed that 83.3% (n = 25) of the laboratories
were doing bacteriology, 73.3% (n = 22) were doing se-
rology, 66.7% (n = 20) were doing clinical pathology, and
56.7% (n = 17) were doing molecular diagnostics. Only
13.3 % (n = 4) were dealing with virology, 30% (n = 9) with
cell culture, and 10% (n = 3) with toxicology (Table 2).
Safety Culture
To prevent exposure to potentially infectious material and
to prevent LAIs, it is important to determine the level of
biorisk management implementation. We found that
46.6% of the facilities have clearly defined the roles and
responsibilities for implementation of biosafety practices.
Of the university hospital labs, 80% follow BMBL guidelines,
while the remaining 20% follow other guidelines (mostly
WHO). Half of the animal labs follow the WHO biosafety
manual, while 50% do not follow any specific guidelines. Of
the R&D labs, 25% follow WHO laboratory biosafety
guidelines, 50% follow BMBL, 3.3% follow their own labo-
ratory’s SOPs, and 16.7% follow various biosafety policies or
did not have any prior knowledge of biosafety policies and
guidelines (Figure 2).
Biosafety Officer
The placement of a biosafety officer in a facility is important
for safeguarding the employees, as it ensures labs adhere to
biosafety practices. We found that 70% of the facilities have

Figure 1. Level of biorisk management in place in various institutions

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Figure 2. Biosafety guidelines followed by institutions

assigned the responsibility of a biosafety officer in their insti- do not have any warning signs outside of their laboratories.
tute, while only 3.3% also have assigned responsibility to Regarding the availability and use of primary containment
different related personnel. While 80% of the facilities have biosafety cabinets (Class II), the questionnaire showed that
assigned the role of biosafety officer to laboratory managers and in 10% of the laboratories, primary containment biosafety
13.3% to a scientific manager, 86.7% of facilities have assigned cabinets did not exist at all, while in 30% of the laboratories
the role of biosafety officer to microbiologists, and 70% of the primary containment biosafety cabinets were present, but
facilities have given this role to pathologists (Table 3). The they were used only periodically; in 60% of the laborato-
biosafety officer is responsible for promoting a culture of safety ries, primary containment biosafety cabinets (Class II) were
according to his or her expertise in biosafety and biosecurity, used consistently (Figure 3). However, the proper annual
which enables a facility or institute to curb the unintentional or field certification for biosafety cabinets as per the NSF 49
intentional misuse or exposure of potentially infectious mate- standard were not done in the facilities, as NSF-certified
rial and to prevent incidents in the laboratory environment. professionals are not currently available and trained in
Pakistan. This function is currently performed by engineers
referred by the vendors of biosafety cabinets.
Biosafety Facilities
The study found that 86.6% (n = 26) of the laboratories
have posted biohazard signs, while 13.3% (n = 4) of the labs Personal Protective Equipment
Assessments regarding the compliance with biosafety
measures revealed that in 50% of the facilities there is strict
Table 3. Assignment of Roles and Responsibilities Related
to Biosafety and Biosecurity compliance with biosafety measures, while in 43.3% of the
facilities biosafety measures are often not put into practice,
Designated Personnel in and in 6.6% biosafety measures are not respected at all.
the Surveyed Institutes Frequency, No. (%) Forty percent of the laboratories have active personal pro-
Biosafety officer 21 (70) tective equipment (PPE) programs (eg, lab coats, gowns,
Biosecurity officer 1 (3.3) gloves, face masks) with clearly defined procedures; 53.3%
Laboratory manager 24 (80) have some procedures regarding PPE but lack oversight in
Scientific manager 4 (13.3) implementation; and 6.6% of laboratories have limited
Microbiologist 26 (86.7) resources for PPE. Proper use of PPE can be effective in
Pathologist 21 (70) limiting the incidents of LAIs if used and maintained
Laboratory workforce 3 (10)
properly.

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Figure 3. Biosafety compliance and equipment decontamination procedures in laboratories

Equipment Decontamination the bloodborne pathogen standard of the US Occupational

Safety and Health Administration (OSHA, 1910:1030),
It was observed that equipment maintenance or repair is
while 23.3% were not following it, and 30% of the facilities
not up to standard, and it was seen that in BSL-2 labora-
were not even familiar with it. Table 4 shows the prevailing
tories there is no decontamination prior to maintenance or
status of occupational health programs in these facilities.
repair of laboratory equipment. Among the 30 surveyed
Increased awareness is an immediate need, in addition to
laboratories, 11 were not following decontamination pro-
some regulatory intervention.
cedures for maintenance and repair, and among them 9
were BSL-2 laboratories. Twelve laboratories were follow-
ing decontamination procedures but do not validate it;
among them 11 were BSL-2 facilities. In addition, in 7
remaining laboratories, of which 4 were BSL-2, there was Table 4. Occupational Health Program Activities Required
proper decontamination prior to maintenance and repair by the Institution
(Figure 3). This could important in preventing LAIs if done
properly before maintenance. Activities Frequency, No. (%)
Annual medical examination 7 (23.3)
Vaccination 15 (50)
Serum banking 0 (0)
Occupational Health Reporting of illness 29 (96.7)
Assessment of the occupational health programs of insti- Baseline medical examination 29 (96.7)
tutes reveals that 23.3% of facilities have protocols for Other 1 (3.3)
annual medical examination of employees, 50% provide OSHA bloodborne pathogens standard (1910:1030)
vaccinations, and 96.7% conduct baseline medical exami- Follows OSHA bloodborne 7 (23.3)
nations and require employees to report illnesses. However, pathogens standard
none of the institutes has any system for serum banking. Does not follow OSHA 14 (46.7)
Data regarding preventive measures against bloodborne bloodborne pathogens standard
Not familiar with this term 9 (30.0)
pathogens show that 46.6% of the facilities were following

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Figure 4a.

Volume 17, Number 5, 2019

Risk assessment strategy

Figure 4b. Incidence response plan

377
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Table 5. Procedure Performed in Institution Producing Aerosols and Droplets

Yes No
Procedure No. % No. %
Pouring, splitting, or decanting liquid specimens 28 (93.3) 2 (6.7)
Removing caps or swabs from culture containers 26 (86.7) 4 (13.3)
Spilling infectious material 22 (73.3) 8 (26.7)
Preparing smears, performing heat fixing, staining slides 27 (90) 3 (10)
Performing serology, rapid antigen tests, wet preps, and slide agglutinations 26 (86.7) 4 (13.3)
Throwing contaminated items into biohazardous waste 25 (83.3) 5 (16.7)
Aspirating and transferring body fluids 21 (70) 9 (30)
Separating needles from syringe 23 (76.7) 7 (23.3)
Subculturing and streaking culture media 27 (90) 3 (10)
Mixing, blending, grinding, shaking, and vortexing specimens or cultures 29 (96.7) 1 (3.3)

Risk Assessment cut on mucous membrane (3.3%), and falls and burn in-
juries (3.3%). Subcutaneous needlestick injury was the
Seventy percent of facilities were not aware of the importance
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most common needlestick injury in 60% of the facilities,

of risk assessments; 30% have protocols for risk assessment
before starting any new procedure or on a routine basis, and
they have SOPs for risk assessment before adopting new
procedures, which is mostly done by committees or profes-
sionals such as an infection control committee (13.3%), a
biosafety officer (6.6%), or a microbiologist, pathologist, lab
manager, or institutional biosafety committee (3.3%). A
total of 63.3% of the institutes report having policies and
procedures in place for incidence reporting that are strictly
followed; 30% have policies but they are often not followed,
while 6.6% of the institutes do not have any policies for
incident reporting. In 23.3% of the facilities, incidents were
first reported to a biosafety officer and supervisor, followed
by the head of the department (16.6%), an infection control
committee (10%), and the lab manager and pathologist
(6.6%). However, in 23.3% of the facilities, no follow-up
steps are taken, while 76.6% provide immediate medical
surveillance and generate a report, 66.7% also do follow-up
check-ups, and 63.3% take corrective measures. This could
result in prolonged absence of an individual from duty and
have an effect on his or her economic well-being.
In all of the BSL-1 laboratories, there is no SOP for risk
assessment; 70.8% of the BSL-2 laboratories, 50% of the BSL-
3 laboratories, and 66.7% of the facilities that have both
BSL-2 and BSL-3 laboratories have no SOP for risk assess-
ment before adopting new procedures (Figures 4a and 4b).
Procedure Performed
More than 90% of the institutes perform a variety of pro-
cedures (Table 5) that generate aerosols and droplets, such as
mixing/vortexing (96.7%), as well as separating needles from
syringes (76.7%), decanting liquid specimens (93.3%), and
spilling infectious material (73.3%).
Laboratory Incidents
Needlestick was found to be the most common injury in
76.7% institutes, followed by animal bite/scratch (13.3%),
while for rest of the facilities, the site of the needlestick
injury was not determined (Table 6).
Standard Operating Procedures
Assessment of SOPs for needlestick injury show that in
60% of the institutes, there is an SOP for needlestick injury
that is strictly followed, while 23.3% of the institute have
an SOP but it is often not followed; in 16.7% of the in-
stitutes, there is no SOP at all (Figure 5).
Transmission Routes
In the laboratories visited, 33 cases of suspected LAIs were
reported. Of these 33 cases, 13.3% were transmitted by
inhalation and percutaneous inoculation; for 83.3% of the
cases, transmission routes were unknown as there was no
proper system in place to determine the transmission routes
of LAIs. Data regarding the potential causes of suspected
LAIs in the surveyed facilities revealed that no or low
compliance with biosafety measures was the cause of LAIs
in 23.3% of cases. Causes included lack of knowledge re-
garding the biorisk related to an activity, lack of attention,
a too heavy workload (in 6.7% cases), and not enough
training (in 13.3% of cases) (Table 7). In addition, 73.3%
of the participants said that the cause of suspected LAIs is
unknown, which reflects a lack of training of participants.
Table 6. Most Common Injuries in the Institution
Injuries Frequency No. (%)
Needlestick injury 23 (76.7)
Eye injury 2 (6.7)
Animal bite/scratch 4 (13.3)
Cut on the mucous membrane 1 (3.3)
Falling 1 (3.3)
Burn injury 1 (3.3)
Aerosol

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Figure 5. Presence and compliance with SOP for responding to a needlestick injury in various institutions

Incident Reporting
Data regarding activities that resulted in suspected LAIs
reveal that 5 of the individuals received an LAI by needle-
stick injury and 1 from subculturing in a microbiology lab.
Table 7. Transmission Routes and Potential Causes of LAIs
In 5 individuals it was proven that the infection was work-
related based on an investigation done in their respective Route Frequency, No. (%)
laboratories. In the case of 26.6% suspected LAIs, the in- Unknown 25 (83.3)
fection was not transmitted to another person, while for
Inhalation 4 (13.3)
73.3% it was not known whether it was transmitted to
another person or not. Percutaneous inoculation 4 (13.3)
Pathogenic strain was identified in only a few cases of Contact with mucous membranes 0
inhalation as Mycobacterium tuberculosis. Percutaneous in- Ingestion 0
fections were mainly hepatitis C; others were not identified, Potential causes of LAIs
because for LAIs there was no protocol in place for incident
Unknown 22 (73.3)
reporting and further investigation up to the level of or- No compliance to biosafety measure 7 (23.3)
ganism identification. This needs to be addressed properly Lack of knowledge regarding the biorisk 2 (6.7)
to ensure the safety of people working in laboratories and to related to activity
examine the risk group for that organism, which will help in Lack of appropriate containment device 0
developing proper preventive and treatment modalities for Failure of containment device 0
a functional and effective medical surveillance program. Not enough training 4 (13.3)
In 12.5% of the R&D laboratories, there is no policy for Lack of attention 2 (6.7)
incident reporting. However, 26.7% of clinical laborato- Lack of space 0
ries, 60% of the university hospital laboratories, and 25% Too much workload 2 (6.7)
Other 0
of the R&D laboratories have procedures for incident

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Figure 6. Procedure/policy followed by institutes for incident reporting

reporting, but they are not strictly followed. In 73.3% of
the clinical laboratories, 40% of the university hospital
laboratories, and 62.5% of the R&D laboratories, there is
a strict policy for incident reporting (Figure 6).
Individual Vulnerability
The most vulnerable individuals identified in the laboratory
environment in this survey were pathologists, laboratory
technicians, researchers, and housekeepers (Table 8).
Exposure
In 16.6% of the LAIs, there were no reported physical
disabilities or severe illnesses in the infected individuals,
while 10% of the LAI cases caused a reported physical
disability or severe illness for more than 20 days. No fa-
talities have been reported in relation to LAIs in any in-
stitute. In 10% of the facilities, exposure to LAIs has been
reported, while in 26.7% of the laboratories, infection was
reported postexposure, which may be due to inappropriate
biosafety measures resulting in inadequate reporting of
incidents (Figure 7).
Medical Surveillance
Overall, 40% of the clinical laboratories, 60% of the uni-
versity hospital laboratories, and 12.5% of the R&D lab-
oratories have functional medical surveillance programs,
while none of the animal facilities have any medical sur-
veillance program in place (Figure 8).

Table 8. Healthcare Professionals Infected with LAIs

Discussion
Vulnerable Laboratory Number of Individuals
Professionals With Known LAIs
Laboratory-acquired infections can occur is any facility that
Pathologist 2 deals with biological agents. However, determining the
Laboratory technicians 2 source of LAIs can be difficult without an effective system
Researcher 1
in place to investigate LAIs,14 which is also the case for our
Housekeeping staff 1
surveyed facilities, since most of them do not have effective

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Figure 7. Days of disability and reporting of exposure in in-
stitutions
protocols to determine LAIs. Laboratory-acquired infec-
tions are an important public health concern globally, since
infected workers can further spread an infection into the
community and become the source of future outbreaks.
Laboratory-acquired infections are often not reported or
are underreported, because having an incidence of LAI can
affect the reputation of the organization, and the organi-
zation could face negative consequences.15 This is also re-
flected in our results, as this study identified only a few
reported LAIs. Another reason for underreported LAIs
could be that the organizations we surveyed were dealing
with risk group 2 organisms in most of the labs, in contrast
to the facilities studied by Pike et al,3 where most of the
organisms were from risk group 3—that is, the LAIs from
risk group 2 had occurred but they were not documented
since these infections cause mild to moderate diseases that
sometimes do not show obvious clinical manifestations or
are delayed. The signs and symptoms often go unnoticed,
because the laboratory professionals are mostly not edu-
cated about the signs and symptoms of the diseases caused
by the pathogens they are working with.
In addition, risk assessment is a joint effort and needs
input from different stakeholders in the lab, while our re-
Volume 17, Number 5, 2019
QASMI AND KHAN
sults show that only 1 individual at a time was involved in
risk assessment; this compromises risk assessment by lim-
iting it to a single person’s knowledge and experience rather
than the actual risk. It was also noted that the presence of
SOPs did not ensure compliance, which reflected gaps in
administration and leadership. Thus, when an infection
occurs, it fails to be linked with the pathogens in the labs. It
is evident that some of the LAIs, especially those that do not
cause severe diseases, remain unnoticed and are not re-
ported due to inadequate biosafety protocols in the labo-
ratories.13
The most common routes of LAIs are percutaneous in-
oculation (needlestick, broken glass, animal bites or scrat-
ches), inhalation (aerosols), ingestion (eg, by smoking,
eating, aspiration through a pipette), direct contact be-
tween contaminated surfaces (gloves, hands), and through
mucous membranes.16 Therefore, the route of transmission
and minimal infective dose for infection should be the
focuses while doing the risk assessment to prevent and
control infections in laboratory workers.17 Historically,
inhalation has been the most common route for transmis-
sion of LAIs.3 However, in our study transmission routes
for most of the LAIs were unknown, which may indicate an
inhalation route, while for a few cases, inhalation and
percutaneous inoculation by needlestick injury were iden-
tified as a result of lack of biosafety compliance and
training.
In our surveyed laboratories, most of the LAIs were re-
ported from the microbiology labs, while many surveys
have been conducted that reported various LAIs from
different bacteria, viruses, and parasites and fungi. In the
United Kingdom, enteric infections such as shigellosis and
tuberculosis have been found to be the most common LAIs
in clinical laboratory workers.4,5 Another survey from
1994-95 reported the predominance of gastrointestinal
infections (shigellosis).18 A clinical laboratory survey in
Utah from 1978 to 1992 also reported shigellosis as the
most common LAI.19 These reports show a changing
pattern of LAIs from early reports with the predominance
of enteric infections. A 2000 study reported Brucella spp.,
Mycobacterium tuberculosis, Salmonella spp., Shigella spp.,
Escherichia coli 0157:H7, Francisella tularensis, hepatitis B
virus (HBV), human immunodeficiency virus (HIV),
hepatitis C virus (HCV), and the dimorphic fungi as the
most common organisms involved in LAIs.20 The Amer-
ican Society for Microbiology (ASM) sponsored an online
survey in 2002-2004 of clinical laboratories; 33% of the
participating laboratories reported at least 1 LAI. They also
reported shigellosis, salmonellosis, and brucellosis as the
3 most common organisms for LAIs.21 The Baron and
Miller survey in 2008 also reported Shigella, Brucella,
Staphylococcus aureus, and Salmonella as the main agents of
LAIs.20 In 2009 Singh et al reviewed the previous surveys
and found that among bloodborne pathogens, HIV, HBV,
and HCV are the major causes of LAI among viral infec-
tions, while dimorphic fungi caused the largest number of
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Figure 8. Existence of functional medical surveillance program in the surveyed laboratories
LAI in fungal infections.20 However, the LAIs reported in
our study are not from these enteric bacteria. The differ-
ence could be the ineffective system for the determination
of LAIs as described. This study provides the pilot data to
identify the gaps for implementation of a biorisk man-
agement system to safeguard laboratory workers from LAIs
and highlights the critical need for reporting and investi-
gating infections in lab professionals.
Conclusion
We believe that this was the first-ever study focused on LAIs
in Karachi, Pakistan. This study has identified the gaps in
the biosafety and biosecurity practices in various laborato-
ries, including human, animal, and research, biomedical,
and university hospital laboratories. These data will help
us to focus on standard microbiological practices, special
practices, use of PPEs, primary barriers, and facility design
in identifying the root causes of LAIs and why they have not
received enough attention in Pakistan.
In this survey most of the laboratories were affiliated with
academic or university facilities and are dealing with bac-
teriology. Most of the laboratories have started a commit-
ment to the implementation of biosafety in the facility and
382
are following WHO or BMBL as guidelines. However,
commitment to laboratory biosecurity is extremely low in
most of the facilities, and they lack proper occupational
health and medical surveillance programs. There is a serious
gap in the risk assessment strategy that must be addressed
before adopting any diagnostic/research processes in the
laboratories surveyed.
We have also found serious gaps in effective SOPs to
determine and regulate LAIs. Inhalation and percutaneous
inoculation were found to be the major source of LAIs, and
most of the LAIs were caused by HCV and Mycobacterium
tuberculosis, which is highly endemic in our country. Most
of the clinical and university hospitals have BSL-2 labora-
tories. University hospital laboratories were found to be the
most committed to biosafety management. The WHO
biosafety manual was followed in most of the clinical lab-
oratories, while most of the university hospitals follow
BMBL guidelines for biosafety. In light of our findings, we
would recommend the following:
 Develop and implement guidelines for labs to imple-
ment a medical surveillance program for staff.
 Use a data driven approach to making policy and
smart investments to lab biorisk management capacity
and biosafety competence of lab professionals.
Health Security

 Formulate and carry out a national-level program so
that sensitization with reference to LAIs is prioritized,
and conduct workshops at frequent intervals to bridge
this gap.
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Manuscript received May 1, 2019;
revision returned June 18, 2019;
accepted for publication July 1, 2019.
Address correspondence to:
Shamsul Arfin Qasmi, PhD
Professor
Department of Pathology
Fazaia Ruth Pfau Medical College
Karachi, Pakistan
Email: saqshamsularfin@gmail.com
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