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

person’s respiration, in preparation of frozen sections
and in preparation of liquid cultures.
 Tuberculosis
- Surveillance: PPD skin testing or blood assay based on laboratory’s 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.
– 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 Gram-positive anthrax
bacteria (purple rods) in
– Direct and indirect contact of intact or 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.
Skin anthrax-
• Within one day, his facial cut worsened … on day 5, he source: CDC

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.

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.
N. Meningitis bacteria
– Post-exposure antibiotics
o Rifampin or ciprofloxacin given orally; or
o 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
o High risk of lab infection
o Aerosol and parenteral exposures

– Rickettsia species
o 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

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  Pericardial fluid

 Vaginal secretions  Peritoneal fluid
 Cerebrospinal fluid  Amniotic fluid
 Synovial fluid  Saliva in dental
 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

Copyright 1998 Trustees of Dartmouth College

Hepatitis B, C, and D
– Transmitted via blood or other body Healthy human liver
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
o Unguarded splash
o Contact with contaminated surfaces
o Not covering skin breaks
 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