Labs urged to boost worker safety measures

CDC: Incident tracking option on the way

For weeks, 25-year-old Richard Din worked long hours in the lab, hoping for a research breakthrough. At the VA Medical Center in San Francisco, he was a research laboratory associate on a project to develop a vaccine against Neisseria meningitides serogroup B. But instead of saving lives, Din became a victim of the deadly organism.

Soon after he came home from work one day last spring, he complained of headache, fever and chills. He developed a rash and lost consciousness in the car on the way to the hospital. He died about 17 hours after his first symptoms appeared.1

This meningitis case highlights the serious risks that face lab workers in both clinical and research labs. In a 2005 report, researchers from the Centers for Disease Control and Prevention in Atlanta identified six cases of laboratory-acquired meningitis, with a fatality rate significantly higher than for community-acquired cases.2 Other deadly organisms also transmitted to workers in a lab include plague (Yersinia pestis)and Brucella.3,4

No one knows the actual number of laboratory-acquired infections — or lab exposures — because there is no national reporting system. A Biosafety Blue Ribbon Panel of experts representing all laboratory disciplines advised CDC to create a surveillance system and to promote a "culture of safety" in the nation's diagnostic labs.5 In response to their concerns, the CDC and National Institutes of Health are working on an online, voluntary, non-punitive reporting system which may be available later next year.

"Working in the microbiology laboratory is inherently risky because we work with live, virulent infectious agents. We do that every day, 24 hours a day, and we do everything we can to protect our patients, ourselves, our coworkers and our families from [being exposed]," says Michael Miller, PhD, D(ABMM), former associate director for laboratory science at the CDC's National Center for Emerging and Zoonotic Infectious Diseases and now a private clinical microbiology laboratory consultant based in Dunwoody, GA.

Miller led a writing team of experts to produce the new "Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories." The document provides detailed information on analyzing hazards and reducing risk. "We think that these guidelines fill a gap that hasn't been filled for quite some time," he says.

Lack of training raises risk

Infection with a deadly organism remains rare, but poor infection control and safety compliance can lead to outbreaks that affect even the children of laboratory workers. From August 20, 2010 and June 29, 2011, surveillance of foodborne disease picked up clusters that were related to a strain of Salmonella Typhimurium associated with clinical and training microbiology laboratories. In 38 states, 109 people were infected with the lab-linked strain X of S. Typhimurium.5

Further investigation pointed to some specific risk factors. Labs with Salmonella illness generally had less biosafety training. They also had problems ensuring compliance with some lab policies, such as the prohibition on using cell phones or other handheld devices in the lab, a survey found.

"Training is the first thing that gets cut [to save money]," says Terry Jo Gile, MT(ASCP), MA, Ed, a laboratory safety consultant based in North Fort Myers, FL, known as "the safety lady." "If [laboratory managers] take the time to do the training they would save a lot of time in the long run, including visits to the employee health department."

For example, lab workers become complacent about what they wear, she says. "We find that people are not wearing the right personal protective equipment," she says. Clogs may be acceptable footwear in other parts of the hospital, but in the lab, the foot needs to be completely covered, she notes. Lab coats need to be made out of approved materials, and employees need to use appropriate personal protective equipment.

Under the new Hazard Communications Standard of the U.S. Occupational Safety and Health Administration, lab employees need to be trained to recognize the safety pictograms and to become familiar with the new material data sheets.

In working with biological samples, employees need to fully understand the importance of safety precautions, says Christina Dillard, assistant director of the Laboratory Safety Institute in Natick, MA, which provides training and audits of lab safety programs.

"I go into too many labs [where employees] do not know the difference between a biosafety cabinet and a standard laminar flow hood," she says, noting that the laminar flow hoods can blow contaminated air onto the employee.

Meanwhile, specimens containing infectious agents don't have a skull and cross bones on the label to remind employees that they are potentially deadly. "A sample of meningitis didn't come in a labeled container that said, 'This is how it could hurt you.' It's a training issue," Dillard says.

Tracking system a year away

Although there is no surveillance data, laboratory exposures appear to be commonplace. In a 2002-2004 online survey of clinical laboratory directors, a third reported a lab-acquired infection. Shigella, which causes fever, diarrhea and stomach cramps, was the most frequent. Lab workers also are vulnerable to bloodborne pathogen exposures. Lab workers comprised one-fourth of the 32 health care workers identified as having acquired HIV in an occupational transmission between 1981 and 1992.5

CDC recognizes the lack of data, including research related to laboratory incidents and lab-associated infections.

"Any laboratory director you talk to can give you anecdotal stories, which can be very powerful. But what we really need is standardized collected data," says Nancy E. Cornish, MD, medical officer with CDC's Division of Laboratory Science and Standards.

The questionnaire will seek exposure incidents as well as near-misses, says Paul Meechan, PhD, MPH, CBSP, director of the CDC Office of Safety, Health and Environment. They will collect information on the type of injury, any resulting disease process and treatment, last biosafety training, and the lab actions taking place when the incident occurred.

"We're trying to find the key questions to ask that [will best] modify behavior or engineering to reduce exposures and incidents," says Meechan. "We're very careful about the types of data we collect so we don't end up with anything that will identify an institution or an area specifically."

Lab safety experts look forward to data that will help focus efforts to protect employees. "We definitely need a better surveillance system," says Dillard. "Without having a better system of capturing what can go wrong in the labs, we can't prevent it."

Document your risk analysis

By tracking incidents (including near-misses) at your facility, you can target your riskiest practices. Risk assessment is the centerpiece of a safety program, according to the guidelines for safe work practices.

It's vital not only to identify the hazardous materials, but to recognize the activities that could lead to exposure, the guidelines state. The safety program should prioritize them based on the likelihood and consequences of an exposure and establish controls to minimize risk.

"Every laboratory should have a risk analysis done and documented," says Miller. "If it's done appropriately, the risk analysis will recognize where those risks are within the laboratory, whether it's an aerosol or a simple risk of tripping over a rug."

When new tests are introduced to the lab, they must be accompanied by a risk analysis, he says. (See box, below.) And sometimes risks change in the midst of a work process. "When we receive spinal fluid for analysis and the gram stain suggests this could contain Neisseria meningitides, that [sample] should be moved into a biosafety cabinet," he says.

Safety rules are often common sense, but training gives them context and emphasis. "One of the key rules of prevention in terms of laboratory acquired infection is still handwashing," says Miller. "Wash your hands over and over again. Don't just use the hand gels. In fact, the gels don't work for some things. Hand-washing should be foremost in the protection in lowering risk."

Foster a culture of safety

The safety culture of a lab can be a life or death matter. In a 2009 case, a University of Chicago researcher became infected with an attenuated strain of Y. pestis and died about a week after he developed fever, body aches and a cough. A review found that the researcher — and other laboratory staff — had failed to attend required biosafety courses. The researcher also didn't consistently wear gloves while handling the Y. pestis cultures.3

The new guidelines on safe work practices state that they were drafted, in part, to "encourage laboratorians to create and foster a culture of safety in their laboratories."

That is a never-ending quest, says Dan Scungio, MT (ASCP), SLS, CQA (ASQ), laboratory safety officer at Sentara Healthcare in Norfolk, VA.

Scungio observes the practices in the labs to assess the culture. "You can always tell when people don't feel comfortable with [protective equipment]," he says. "You could tell people were scrambling to put on gloves but they didn't know where they were. If you spend enough time hanging around you're going to see the level of the culture."

He also drafts short surveys to ask employees what they feel about the level of safety in the lab.

"To change the safety culture, one of the first steps is to find your champions. Find the people who are most interested in it and let them be safety coaches and start working with them individually or as a team," he says.

He meets monthly with about 30 safety coaches and asks them to provide safety education to their co-workers. With their help, he also tracks injuries and exposures.

"A couple of years ago we were seeing a large number of injuries in the histology area with people getting cut with cryostat or microtome blades," he says.

He was able to purchase magnetic implements that allowed lab workers to pull the blades out with the magnet rather than by hand. He also purchased special forceps that could be used to handle the blade. The injuries dropped dramatically.

But much of lab safety involves a day-to-day awareness of safe practices.

"People who are interested in changing culture never give up," he says. "A good safety coach never goes away. Even if you have to say the same thing every day, you are making a difference."

References

1. Miller G. Death of California researcher spurs investigation. Science Insider May 4, 2012. Available at http://news.sciencemag.org/scienceinsider/2012/05/death-of-california-researcher.html. Accessed on Sept. 6, 2012.

2. Sejvar JJ, Johnson D, Popovic T, et al. Assessing the risk of laboratory-acquired meningococcal disease. J Clin Microbiol 2005;43:4811–4814.

3. Centers for Disease Control and Prevention. Fatal laboratory-acquired infection with an attenuated Yersinia pestis strain – Chicago, Illinois, 2009. MMWR 2011;60:201-205.

4. CDC. Laboratory-acquired brucellosis – Indiana and Minnesota, 2006. MMWR 2008;57:39-42.

5. Singh K. Laboratory-acquired infections. Clin Infect Dis 2009;49:142-147.

 

What led to lab death remains a mystery

Culture of safety can prevent exposures

More than 100 names appear on a virtual "memorial wall" on the website of the Laboratory Safety Institute, including high school and college students killed in explosions or electrocutions, researchers who died of plague and ebola, and even Marie Curie, who famously died after long-term exposure to radiation.

Richard Din is at the top of the list, the most recent addition. After his death from Neisseria meningitides, which he had been working with in the lab, the San Francisco VA Medical Center sought to detect the cause of his exposure and improve the lab's safety practices.

They never figured out how he became infected.

"There's no evidence that he did anything outside of laboratory routine practice," says Harry Lampiris, MD, chief of infectious disease at the San Francisco VA Medical Center. "At the end of the day, it's a mystery.

"He had only been working in the lab for about six months," Lampiris adds. "We tried hard to get to the question of whether he did something to increase his risk. He didn't disclose anything to friends, coworkers didn't observe anything."

However, the San Francisco VA Medical Center undertook a review of "all the potential microbiologically transmissible agents that we work with in all our research laboratories," he says.

The hospital also beefed up its lab safety and training. Lab workers should be aware of the signs and symptoms of early infection with an organism such as N. meningitides and should seek antibiotic prophylaxis if there's an exposure, he says.

Clinical laboratories operate under the standard of "universal precautions. Any specimen could be high risk," Lampiris says.

Reporting of exposures, incidents such as spills, and near-misses is important to maintaining a culture of safety, he says. "Laboratory safety is everyone's responsibility. If there's any kind of breach, lab employees feel they can report it to the [principle investigator] with no risk of recrimination," Lampiris says.

 

Laboratory job safety analysis

The Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories provide detailed information on potentially hazardous activities in the lab and suggest ways to protect employees from harm. Here is an excerpt on conducting a job safety analysis (See table, below.):

"One way to initiate a risk assessment is to conduct a job safety analysis for procedures, tasks, or activities performed at each workstation or specific laboratory by listing the steps involved in a specific protocol and the hazards associated with them and then determining the necessary controls, on the basis of organism suspected. Precautions beyond the standard and special practices for Biosafety Level-2 may be indicated in the following circumstances:

• Test requests for suspected Mycobacterium tuberculosis or other mycobacteria, filamentous fungi, bioterrorism agents, and viral hemorrhagic fevers

• Suspected high-risk organism (such as Neisseria meningitides)

• Work with animals

• Work with large volumes or highly concentrated cultures

• Compromised immune status of staff

• Training of new or inexperienced staff

• Technologist preference.