Biological Hazards in Medical and Research Laboratories

October, 2010

What You Will Learn

This module gives an overview of how bacteria and viruses can cause injury, illness, or even death to medical laboratory workers.

Bacteria Exposure
The Centers for Disease Control (CDC) data indicates these bacteria have a high exposure potential in labs:

Mycobacterium tuberculosis Bacillus anthracis Bordetella pertussis Brucella sp.

Neisseria meningitis

Many labs also culture other types of dangerous bacteria.

Bacteria Exposure
In the lab bacteria can become airborne by:

Removing vacutainer caps Manipulation of cultures Centrifuge, test tube fractures/cracks

Bacteria Exposure - Tuberculosis

Present in sputum, gastric fluid, CSF, urine and

lesions of persons with active disease (not latent)

Bacilli survive in heat-fixed smears

Transmitted via airborne droplet from an infected

persons respiration, in preparation of frozen sections and in preparation of liquid cultures.

- Surveillance: PPD skin testing or blood assay based on laboratorys risk level.
- Prior vaccination with BCG not considered when interpreting PPD skin test. It is impossible to differentiate between BCG mediated response and latent infection.

Tuberculosis

90% of all persons infected with TB will never develop active TB TB infected or exposed people are NOT contagious Only contagious if they have ACTIVE TB disease

Source: CDC

Bacteria Exposure - Anthrax

Present in blood, skin lesion exudate,

CSF, pleural fluid, rarely in urine and feces

Aerosolized during handling Direct and indirect contact of intact or
Gram-positive anthrax bacteria (purple rods) in cerebrospinal fluid sample

broken skin with cultures and contaminated lab surfaces - Requires prompt diagnosis

- Vaccine is available

An Anthrax Infection Incident

Lab in Texas was processing environmental samples for anthrax in support of CDC bioterrorism investigation. A worker had cut his face shaving. The next day, he was moving vials containing aliquots of confirmed anthrax from the biological safety cabinet to a freezer in the next room. The worker did not use gloves. He washed his hands after handling the vials.

Within one day, his facial cut worsened on day 5, he was admitted to the hospital and treated for cutaneous anthrax.
Most likely source was the surface of the vials. No workers in the lab were immunized against anthrax.

Skin anthraxsource: CDC

From April 5, 2002 MMWR (Morbidity and Mortality Weekly Report from CDC)

Pertussis (whooping cough):

Hazard is aerosol generation during culture manipulation

Incidence on the rise see the latest report

May be mild or classic in adults

Most lab cases in research labs

A pertussis vaccine is now available for adults

Source: CDC

Brucellosis
One of the most commonly
Source: CDC

reported lab-associated bacterial infection

Present in blood, CSF, semen

and occasionally urine of infected persons

Transmitted through aerosols Reported cases of brucellosis - 2007

generating procedures

- No vaccine for humans,

treatment is with antibiotics
CDC recommendations for brucellosis lab exposure

N. Meningitis

Present in pharyngeal exudates, synovial fluid, urine, feces, CSF Aerosols from laboratory procedures on isolates Vaccine is available and recommended for lab workers routinely exposed. Post-exposure antibiotics
o

N. Meningitis bacteria

Rifampin or ciprofloxacin given orally; or

Ceftriaxone given IM

The use of post-exposure antibiotics have prevented outbreaks. Link to CDC webpage on meningitis

Meningitis Exposure Incidents

Two microbiologists contracted meningitis, both died. #1: 3 days before symptoms, the patient had prepared a gram stain from the blood culture of a patient who was subsequently shown to have meningococcal disease. The microbiologist had also handled and sub-cultured agar plates w/ CSF. At this lab, aspiration from blood culture bottles was performed at an open lab bench. #2: Microbiologist who worked at state public health lab and worked on several n meningitides isolates performed slide agglutination tests. Used BioSafety Level 2 precautions. In 15 years, there were 16 cases of meningitis in lab personnel, of which 50% were fatal.
From MMWR 2/22/02

Other Possible Pathogen Exposures

Fungal agents:

Coccidioimycosis and Histoplasmosis Hazard because spores are <5 microns and can be aerosolized and inhaled Spores resistant to drying and remain viable for long periods Both can be treated with antifungal drugs

Link to CDC webpage on coccidioidomycosis (Valley Fever) Link to CDC webpage on histoplasmosis Link to NIOSH document: Histoplasmosis protecting workers at risk

Other Possible Pathogen Exposure

Parasitic agents:
Intestinal (giardia, toxoplasmosis), tissue and

organs (trichinosis), blood (malaria)

Ingestion is primary hazard

Also can enter body through breaks in the skin

CDC webpage on parasitic diseases

CDC webpage in giardia

Other Possible Pathogen Exposure

Prions:
Transmissible spongiform encephalopathies Present in CNS of animals Resistant to conventional inactivation No known treatment Includes Creutzfeldt-Jakob disease

This tissue slide shows sponge-like lesions in the brain tissue of a classic CJD patient. This lesion is typical of many prion diseases.

Link to CDC Prion Diseases webpage

Other Possible Pathogen Exposures

Rickettsial Agents: Coxiella burnetti Q fever
High risk of lab infection o Aerosol and parenteral exposures
o

Rickettsia species

Typhus, reported in 57 lab-associated cases o Rocky mountain spotted fever, in 1976, 63 lab cases were reported, 11 were fatal o Aerosols and parenteral inoculation
o

CDC webpage on Q Fever

CDC webpage on Rickettsia

Virus Exposure
Some viruses are transmitted via aerosols such as:

Hantavirus lab infections have occurred during rodent handling Human herpes viruses Influenza Various pox viruses

Herpes viruses are ubiquitous primarily an opportunistic infection. Rarely, cytomegalovirus or Epstein-Barr may be transmitted in the lab. No documentation that influenza has been contracted in the lab as it also is ubiquitous in season. CDC lab management of agents associated with hantavirus interim biosafety guidelines -1994

Virus Exposure Blood/Body Fluids

Some pathogens are transmitted through

microorganisms contained in blood and other body fluids. Examples are:

Hepatitis B Virus (HBV)

Hepatitis C Virus (HCV)

Hepatitis D Virus (HDV) Human Immunodeficiency Virus (HIV)

Link to Exposure to Blood brochure

Virus Exposure Blood/Body Fluids

Blood includes:

Human blood Human blood components, such as packed cells and plasma Products made from human blood, such as:
Clotting agents for hemophilia Immune globulins including Rh factor immune globulins

Virus Exposure Blood/Body Fluids

Potentially infectious body fluids include:
Semen Vaginal secretions Pericardial fluid

Peritoneal fluid
Amniotic fluid Saliva in dental

Cerebrospinal fluid
Synovial fluid Pleural fluid

procedures

Virus Exposure Blood/Body Fluids

Other pathogens that can also be transmitted

through blood include:

Malaria Syphilis

Brucellosis
Leptospirosis Cruetzfeldt-Jakob Disease

Some fungi and ricketsii

Virus Exposure

Hepatitis A and E:
Fecally transmitted
Hepatitis A virus

We hear about it in the news when infected

restaurant workers may expose a community

Although high virus titers may be present in blood

during the incubation period, lab transmission not reported

Virus Exposure Blood/Body Fluids

Hepatitis B, C, and D
Transmitted via blood or other body
Healthy human liver
Copyright 1998 Trustees of Dartmouth College

fluids
Causes liver inflammation and/or

damage - mild to fatal

Can live in a dry environment > 7 days,
Hepatitis C liver

such as on countertop
Highest risk of transmission through

hollow bore needle stick

Virus Exposure Blood/Body Fluids

Hepatitis B, C, and D

Hepatitis B, active and passive vaccines available Hepatitis C, no vaccine available Hepatitis D, no vaccine available, however immunization against hepatitis B also protects against hepatitis D

Virus Exposure Blood/Body Fluids

Human Immunodeficiency Virus (HIV)
Attacks the human immune system Can live in a dry environment for only

a few hours
No vaccine available
Antiviral post-exposure prophylaxis

effective in reducing risk

HIV - seen as small spheres on the surface of white blood cells Reference: MMWR June 29, 2001/50(RR11);1-42

HIV Virus Exposure Routes

Parenteral
Needlestick Scalpel/glass cut

Mucous membrane

Mouth pipetting Eating, drinking in lab area Not wearing appropriate PPE Non-intact skin
Unguarded splash o Contact with contaminated surfaces o Not covering skin breaks
o

HIV Virus Exposure

Occupationally acquired HIV :
The CDC reports as of December 2001, 51 of the 57 cases of occupationally acquired HIV infection involved sharps injuries of which nearly half involved needles used in phlebotomy or blood sampling from a vascular line, with vacuum- tube device needles accounting for the largest number of these injuries. Other sharps injuries included broken glass from blood collection tubes and a needle for cleaning/dislodging debris in laboratory equipment.
Reference: Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel December, 2006

Lab Practices & Biosafety Guidelines

The Centers for Disease Control (CDC) has

guidelines to describe combinations of:

Laboratory Practices and Techniques
o Standard Practices o Special Practices

Safety Equipment Laboratory Facilities

CDC Laboratory Guidelines and Standards webpage CDC Biosafety Webpage includes a biosecurity online training course

CDC Biosafety Guidelines

These guidelines are called:
Biosafety in Medical and Biomedical Laboratories (BMBL - 5th edition)*

The guidelines describe four laboratory hazard

levels or Biosafety Levels (BSL)

* Some of the information in this module is derived from this document

Biosafety Guidelines
Biosafety Levels 1- 4 provide:
Increasing levels of personnel and

environmental protection
Guidelines for working safely in

microbiological and biomedical laboratories

Class I Biosafety Cabinet

(from CDC publication Selection,

Installation & Use of Biosafety Cabinets)

Biosafety Levels (BSL)

The Four Biosafety Levels are:

BSL1 - agents not known to cause disease (B. subtilis, E. coli). BSL2 - agents associated with human disease (hepatitis B, Salmonellae, Toxoplasma) BSL3 - indigenous/exotic agents associated with human disease and with potential for aerosol transmission (M. tuberculosis, C. burnetii). BSL4 - dangerous/exotic agents of life threatening nature (Marbug and Ebola virus).

DOSH Rules related to biological hazards

Occupational Exposure to Bloodborne Pathogens WAC 296-823
This rule provides requirements to protect

employees from exposure to blood or other potentially infectious materials, that may contain bloodborne pathogens.
The rule covers anticipated exposure, even

if no actual incidents have occurred.

Link to Online Training course on Bloodborne Pathogens

Other Related DOSH Rules & Directives

Protect Employees from Biological Agents 296-800-11045 refers to CDC guidelines Personal Protective Equipment,

296-800-160
Tuberculosis - WRD 11.35