Biological Safety Manual - Chapter 08: Agent Summary Statements (Section I: Bacterial Agents)

University-Policy EHS---Biological-Safety-Manual Export-Controls

Introduction

Agent: Bacillus anthracis
Agent: Bordetella pertussis
Agent: Brucella species
Agent: Burkholderia mallei
Agent: Burkholderia pseudomallei
Agent: Campylobacter (C. jejuni subsp. jejuni, C. coli, C. fetus subsp. fetus, C. upsaliensis)
Agent: Chlamydia psittaci (Chlamydophila psittaci), C. trachomatis, C. pneumoniae (Chlamydophila pneumoniae)
Agent: Neurotoxin Producing Clostridia species
Agent: Clostridium tetani and Tetanus toxin
Agent: Corynebacterium diphtheria
Agent: Francisella tularensis
Agent: Helicobacter species
Agent: Legionella pneumophila and Other Legionella-Like Agents
Agent: Leptospira
Agent: Listeria monocytogenes
Agent: Mycobacterium leprae
Agent: Mycobacterium tubercolosis complex
Agent: Mycobacterium spp. Other Than M. tubercolosiscomplex and M. leprae
Agent: Neisseria gonorrhoeae
Agent: Neisseria meningitides
Agent: Salmonella serotypes, Other Than S. typhi
Agent: Salmonella typhi
Agent: Shiga toxin (Verocytotoxin)-Producing Escherichia coli
Agent: Shigella
Agent: Treponema pallidum
Agent: Vibrio enteritis species (V. cholerae, V. parahaemolyticus)
Agent: Yersinia pestis
References
Section Ia: Policy For Laboratory Personnel Who Are Working With Neisseria meningitidis

Agent: Bacillus anthracis

Bacillus anthracis, a gram-positive, non-hemolytic, and non-motile bacillus, is the etiologic agent of anthrax, an acute bacterial disease of mammals, including humans. Like all members of the genus Bacillus, under adverse conditions B. anthracis has the ability to produce spores that allow the organism to persist for long periods until the return of more favorable conditions. Reports of suspected anthrax outbreaks date back to as early as 1250 BC. The study of anthrax and B. anthracis in the 1800s contributed greatly to our general understanding of infectious diseases. Much of Koch’s postulates were derived from work on identifying the etiologic agent of anthrax. Louis Pasteur developed the first attenuated live vaccine for anthrax.

Most mammals are susceptible to anthrax; it mostly affects herbivores that ingest spores from contaminated soil and, to a lesser extent, carnivores that scavenge on the carcasses of diseased animals. Anthrax still occurs frequently in parts of central Asia and Africa. In the United States, it occurs sporadically in animals in parts of the West, Midwest and Southwest.

The infectious dose varies greatly from species to species and is route-dependent. The inhalation anthrax infectious dose (ID) for humans primarily has been extrapolated from inhalation challenges of nonhuman primates (NHP) or studies done in contaminated mills. Estimates vary greatly but the medium lethal dose (LD) is likely within the range of 2,500-55,000 spores.¹ It is believed that very few spores (10 or less) are required for cutaneous anthrax.²

Occupational Infections

Occupational infections are possible when in contact with contaminated animals, animal products or pure cultures of B. anthracis, and may include ranchers, veterinarians and laboratory workers. Numerous cases of laboratory-associated anthrax (primarily cutaneous) have been reported.^3,4 Recent cases include suspected cutaneous anthrax in a laboratory worker in Texas and a cutaneous case in a North Dakota male who disposed of five cows that died of anthrax.^5,6

Natural Modes of Infection

The clinical forms of anthrax in humans that result from different routes of infection are:

cutaneous (via broken skin)
gastrointestinal (via ingestion)
inhalation anthrax

Cutaneous anthrax is the most common and readily treatable form of the disease. Inhalation anthrax used to be known as “Woolsorter disease” due to its prevalence in textile mill workers handling wool and other contaminated animal products. While naturally occurring disease is no longer a significant public health problem in the United States, anthrax has become a bioterrorism concern. In 2001, 22 people were diagnosed with anthrax acquired from spores sent through the mail, including 11 cases of inhalation anthrax with five deaths and 11 cutaneous cases.⁷

Laboratory Safety and Containment Recommendations

B. anthracis may be present in blood, skin lesion exudates, cerebrospinal fluid, pleural fluid, sputum, and rarely, in urine and feces. The primary hazards to laboratory personnel are; direct and indirect contact of broken skin with cultures and contaminated laboratory surfaces, accidental parenteral inoculation and rarely, exposure to infectious aerosols. Efforts should be made to avoid production of aerosols by working with infectious organisms in a BSC. In addition, all centrifugation should be done using aerosol-tight rotors that are opened within the BSC after each run.

BSL-2 practices, containment equipment, and facilities are recommended for activities using clinical materials and diagnostic quantities of infectious cultures. ABSL-2 practices, containment equipment and facilities are recommended for studies utilizing experimentally infected laboratory rodents. BSL-3 practices, containment equipment, and facilities are recommended for work involving production quantities or high concentrations of cultures, screening environmental samples (especially powders) from anthrax-contaminated locations, and for activities with a high potential for aerosol production. Workers who frequently centrifuge B. anthracis suspensions should use autoclavable aerosol-tight rotors. In addition, regular routine swabbing specimens for culture should be routinely obtained inside the rotor and rotor lid and, if contaminated, rotors should be autoclaved before re-use.

Special Issues

Vaccines

A licensed vaccine for anthrax is available. Guidelines for its use in occupational settings are available from the ACIP.^8,9 Worker vaccination is recommended for activities that present an increased risk for repeated exposures to B. anthracis spores including:

work involving production quantities with a high potential for aerosol production
handling environmental specimens, especially powders associated with anthrax investigations
performing confirmatory testing for B. anthracis, with purified cultures
making repeated entries into known B. anthracis-spore-contaminated areas after a terrorist attack
work in other settings in which repeated exposure to aerosolized B. anthracis spores might occur

Vaccination is not recommended for workers involved in routine processing of clinical specimens or environmental swabs in general diagnostic laboratories.

Select Agent

B. anthracis is a select agent requiring registration with CDC and/or USDA for possession, use, storage and/or transfer. See Appendix F for additional information.

Transfer of Agent

Importation of this agent may require CDC and/or USDA importation permits. Domestic transport of this agent may require a permit from USDA/APHIS/VS. A Department of Commerce (DoC) permit may be required for the export of this agent to another country. See Appendix C for additional information.

Agent: Bordetella pertussis

Bordetella pertussis, an exclusively human respiratory pathogen of worldwide distribution, is the etiologic agent of whooping cough or pertussis. The organism is a fastidious, small gram-negative coccobacillus that requires highly specialized culture and transport media for cultivation in the laboratory. Its natural habitat is the human respiratory tract.

Occupational Infections

Occupational transmission of pertussis has been reported, primarily among healthcare workers.^10-16 Outbreaks, including secondary transmission, among workers have been documented in hospitals, long-term care institutions, and laboratories. Nosocomial transmissions have been reported in healthcare settings. Laboratory-acquired pertussis has been documented.^17,18

Natural Modes of Infection

Pertussis is highly communicable, with person-to-person transmission occurring via aerosolized respiratory secretions containing the organism. The attack rate among susceptible hosts is affected by the frequency, proximity, and time of exposure to infected individuals. Although the number of reported pertussis cases declined by over 99% following the introduction of vaccination programs in the 1940s, the 3- to 4-year cycles of cases have continued into the post-vaccination era.^19-21

Laboratory Safety and Containment Reccomendations

The agent may be present in high levels in respiratory secretions, and may be found in other clinical material, such as blood and lung tissue in its infrequent manifestation of septicemia and pneumonia, respectively.^22,23 Because the natural mode of transmission is via the respiratory route, aerosol generation during the manipulation of cultures and contaminated clinical specimens generates the greatest potential hazard.

BSL-2 practices, containment equipment, and facilities are recommended for all activities involving the use or manipulation of known or potentially infectious clinical material and cultures. ABSL-2 practices and containment equipment should be employed for housing experimentally infected animals. Primary containment devices and equipment, including biological safety cabinets, safety centrifuge cups or safety centrifuges should be used for activities likely to generate potentially infectious aerosols. BSL-3 practices, containment equipment, and facilities are appropriate for production operations.

Special Issues

Vaccines

Pertussis vaccines are available but are not currently approved or recommended for use in persons over six years of age. Because this recommendation may change in the near future, the reader is advised to review the current recommendations of the ACIP published in the Morbidity and Mortality Weekly Report (MMWR) and at the CDC Vaccines and Immunizations website for the latest recommendations for adolescents and adults.

Transfer of Agent

Importation of this agent may require CDC and/or USDA importation permits. Domestic transport of this agent may require a permit from USDA/APHIS/VS. A DoC permit may be required for the export of this agent to another country. See Appendix C for additional information.

Agent: Brucella species

The genus Brucella consists of slow-growing, very small gram-negative coccobacilli whose natural hosts are mammals. Seven Brucella species have been described using epidemiologic and biological characteristics, although at the genetic level all brucellae are closely related. B. melitensis (natural host: sheep/goats), B suis (natural host: swine), B. abortus (natural host: cattle),B. canis (natural host: dogs), and B. “maris” (natural host: marine mammals) have caused illness in humans exposed to the organism including laboratory personnel.^24,25 Hypersensitivity to Brucella antigens is a potential but rare hazard to laboratory personnel. Occasional hypersensitivity reactions to Brucella antigens occur in workers exposed to experimentally and naturally infected animals or their tissues.

Occupational Infections

Brucellosis has been one of the most frequently reported laboratory infections in the past and cases continue to occur.^26-28 Airborne and mucocutaneous exposures can produce LAI. Accidental self-inoculation with vaccine strains is an occupational hazard for veterinarians.

Natural Modes of Infection

Brucellosis (Undulant fever, Malta fever, Mediterranean fever) is a zoonotic disease of worldwide occurrence. Mammals, particularly cattle, goats, swine, and sheep act as reservoirs for brucellae. Multiple routes of transmission have been identified, including direct contact with infected animal tissues or products, ingestion of contaminated milk, and airborne exposure in pens and stables.

Laboratory Safety and Containment Recommendations

Brucella infects the blood and a wide variety of body tissues, including cerebral spinal fluid, semen, pulmonary excretions, placenta, and occasionally urine. Most laboratory associated cases occur in research facilities and involve exposures to Brucella organisms grown in large quantities or exposure to placental tissues containing Brucella. Cases have occurred in clinical laboratory settings from sniffing bacteriological cultures²⁹ or working on open bench tops.³⁰ Aerosols from, or direct skin contact with, cultures or with infectious clinical specimens from animals (e.g. blood, body fluids, tissues) are commonly implicated in human infections. Aerosols generated during laboratory procedures have caused multiple cases per exposure.^30,31 Mouth pipetting, accidental parenteral inoculations, and sprays into eyes, nose and mouth result in infection. The infectious dose of Brucella is 10-100 organisms by aerosol route and subcutaneous route in laboratory animals.^32,33

BSL-2 practices, containment equipment, and facilities are recommended for routine clinical specimens of human or animal origin. Products of conception containing or believed to contain pathogenic Brucella should be handled with BSL-3 practices due to the high concentration of organisms per gram of tissue. BSL-3 and ABSL-3 practices, containment equipment, and facilities are recommended, for all manipulations of cultures of pathogenic Brucellaspp. listed in this summary, and for experimental animal studies.

Special Issues

Vaccines

Human Brucella vaccines have been developed and tested in other countries with limited success. A human vaccine is not available in the United States.³⁴

Select Agent

Brucella abortus, Brucella melitensis, and Brucella suis are select agents requiring registration with CDC and/or USDA for possession, use, storage and/or transfer. See Appendix F for additional information.

Transfer of Agent

Agent: Burkholderia mallei

Burkholderia mallei (formerly Pseudomonas mallei) is a non-motile gram-negative rod associated with glanders, a rare disease of equine species and humans. While endemic foci of infection exist in some areas of the world, glanders due to natural infection is extremely rare in the United States.

Occupational Infections

Glanders occurs almost exclusively among individuals who work with equine species and/or handle B. mallei cultures in the laboratory. B. mallei can be very infectious in the laboratory setting. The only reported case of human glanders in the United States over the past 50 years resulted from a laboratory exposure.³⁵ Modes of transmission may include inhalation and/or mucocutaneous exposure.

Natural Modes of Infection

Glanders is a highly communicable disease of horses, goats, and donkeys. Zoonotic transmission occurs to humans, but person-to-person transmission is rare. Clinical glanders no longer occurs in the Western Hemisphere or in most other areas of the world, although enzootic foci are thought to exist in Asia and the eastern Mediterranean.³⁶ Clinical infections in humans are characterized by tissue abscesses and tend to be very serious.

Laboratory Safety and Containment Recommendations

B. mallei can be very hazardous in a laboratory setting. In a pre-biosafety era report, one-half of the workers in a B. malleiresearch laboratory were infected within a year of working with the organism.³⁷ Laboratory-acquired infections have resulted from aerosol and cutaneous exposure.^37,38 Laboratory infections usually are caused by exposure to bacterial cultures rather than to clinical specimens. Workers should take precautions to avoid exposure to aerosols from bacterial cultures, and to tissues and purulent drainage from victims of this disease.

Primary isolations from patient fluids or tissues may be performed with BSL-2 practices, containment equipment, and facilities in a BSC. Procedures must be performed under BSL-3 containment whenever infectious aerosols or droplets are generated, such as during centrifugation or handling infected animals, or when large quantities of the agent are produced. Procedures conducted outside of a BSC (centrifugation, animal manipulation, etc.) that generate infectious aerosols require respiratory protection. Sealed cups should be used with all centrifuges and these should be opened only inside a BSC. Gloves should be worn when working with potentially infectious material or animals. Animal work with B. mallei should be done with ABSL-3 practices, containment equipment, and facilities.

Special Issues

Select Agent

B. mallei is a Select Agent requiring registration with CDC and/or USDA for possession, use, storage and/or transfer. See Chapter 14 for additional information.

Transfer of Agent

Agent: Burkholderia pseudomallei

Burkholderia pseudomallei (formerly Pseudomonas pseudomallei) is a motile gram-negative, oxidase-positive rod that is found in soil and water environments of equatorial regions, including Southeast Asia, Northern Australia, Central America and South America. This organism is the causative agent of melioidosis, an unusual bacterial disease characterized by abscesses in tissues and organs. Victims of the disease frequently exhibit recrudescence months or years after the initial infection.

Occupational Infections

Melioidosis is generally considered to be a disease associated with agriculture; however, B. pseudomallei can be hazardous for laboratory workers. There are two reports of melioidosis in laboratory workers who were infected by aerosols or via skin exposure.^39,40 Laboratory workers with diabetes are at increased risk of contracting melioidosis.⁴¹

Natural Modes of Infection

While primarily a disease found in Southeast Asia and Northern Australia, melioidosis can occasionally be found in the Americas.⁴² Natural modes of transmission include the exposure of mucous membranes or damaged skin to soil or water containing the organism, the aspiration or ingestion of contaminated water, or the inhalation of dust from contaminated soil. In endemic areas 5-20% of agricultural workers have antibody titers to B. pseudomallei, in the absence of overtdisease.⁴³

Laboratory Safety

B. pseudomallei can cause a systemic disease in human patients. Infected tissues and purulent drainage from cutaneous or tissue abscesses can be sources of infection. Blood and sputum also are potential sources of infection.

Containment Recommendations

Work with clinical specimens from patients suspected of having melioidosis and of B. pseudomallei cultures may be performed with BSL-2 practices, containment equipment, and facilities. Work should be done in a BSC. Gloves always should be worn when manipulating the microorganism. In cases where infectious aerosols or droplets could be produced, or where production quantities of the organism are generated, these procedures should be confined to BSL-3 facilities with all pertinent primary containment against escape of aerosols. Respiratory protection must be used if the microorganism is manipulated outside of a BSC, such as during centrifugation or handling infected animals. Sealed cups should be used in all centrifuges and these should be opened only in a BSC. Animal studies with this agent should be done at ABSL-3.

Special Issues

Select Agent

B. pseudomallei is a Select Agent requiring registration with CDC and/or USDA for possession, use, storage and/or transfer. See Chapter 14 for additional information.

Transfer of Agent

Agent: Campylobacter (C. jejuni subsp. jejuni, C. coli, C. fetus subsp. fetus, C. upsaliensis)

Campylobacters are curved, S-shaped, or spiral rods associated with gastrointestinal infections (primarily C. jejuni subsp. jejuni and C. coli), bacteremia, and sepsis (primarily C. fetus subsp. fetus and C. upsaliensis). Organisms are isolated from stool specimens through the use of selective media, reduced oxygen tension, and elevated incubation temperature (43°C).

Occupational Infections

These organisms rarely cause LAI, although laboratory-associated cases have been documented.^44-47Experimentally infected animals also are a potential source of infection.⁴⁸

Natural Modes of Infection

Numerous domestic and wild animals, including poultry, pets, farm animals, laboratory animals, and wild birds are known reservoirs and are a potential source of infection for laboratory and animal care personnel. While the infective dose is not firmly established, ingestion of as few as 500-800 organisms has caused symptomatic infection.^49-51 Natural transmission usually occurs from ingestion of organisms in contaminated food or water and from direct contact with infected pets, farm animals, or infants.⁵²

Laboratory Safety

Pathogenic C. sp. may occur in fecal specimens in large numbers. C. fetus subsp. Fetus may also be present in blood, exudates from abscesses, tissues, and sputa. The primary laboratory hazards are ingestion and parenteral inoculation of C. jejuni. The significance of aerosol exposure is not known.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for activities with cultures or potentially infectious clinical materials. ABSL-2 practices, containment equipment, and facilities are recommended for activities with naturally or experimentally infected animals.

Special Issues

Transfer of Agent

Agent: Chlamydia psittaci (Chlamydophila psittaci), C. trachomatis, C. pneumoniae (Chlamydophila pneumoniae)

Chlamydia psittaci, C. pneumoniae (sometimes called Chlamydophila psittaciand Chlamydophila pneumoniae) and C. trachomatisare the three species ofChlamydia known to infect humans. Chlamydiae are nonmotile, gram-negative bacterial pathogens with obligate intracellular life cycles. These three species of Chlamydia vary in host spectrum, pathogenicity, and in the clinical spectrum of disease. C. psittaci is a zoonotic agent that commonly infects psittacine birds and is highly pathogenic for humans. C. trachomatisis historically considered an exclusively human pathogen and is the most commonly reported bacterial infection in the United States. C. pneumoniae is considered the least pathogenic species, often resulting in subclinical or asymptomatic infections in both animals and humans.

Occupational Infections

Chlamydial infections caused by C. psittaci and C. trachomatis lymphogranuloma venereum (LGV) strains were at one time among the most commonly reported laboratory-associated bacterial infections.²⁶ In cases reported before 1955,⁴ the majority of infections were psittacosis, and these had the highest case fatality rate of laboratory acquired infectious agents. The major sources of laboratory-associated psittacosis are contact with and exposure to infectious aerosols in the handling, care, or necropsy of naturally or experimentally infected birds. Infected mice and eggs also are important sources of C. psittaci. Most reports of laboratory-acquired infections with C. trachomatis attribute the infection to inhalation of large quantities of aerosolized organisms during purification or sonification procedures. Early reports commonly attributed infections to exposure to aerosols formed during nasal inoculation of mice or inoculation of egg yolk sacs and harvest of chlamydial elementary bodies. Infections are associated with fever, chills, malaise, and headache; a dry cough is also associated with C. psittaci infection. Some workers exposed to C. trachomatis have developed conditions including mediastinal and supraclavicular lymphadenitis, pneumonitis, conjunctivitis, and keratitis.⁵³Seroconversion to chlamydial antigens is common and often striking although early antibiotic treatment may prevent an antibody response.

Laboratory-associated infections with C. pneumoniae have been reported.⁵⁴ Exposed workers were asymptomatic and infection was diagnosed by serology. The route of infection was attributed to inhalation of droplet aerosols created during procedures associated with culture and harvest of the agent from cell culture.

With all species of Chlamydia, mucosal tissues in the eyes, nose, and respiratory tract are most often affected by occupational exposures that can lead to infection.

Natural Modes of Infection

C. psittaci is the cause of psittacosis, a respiratory infection that can lead to severe pneumonia requiring intensive care support and possible death. Sequelae include endocarditis, hepatitis, and neurologic complications. Natural infections are acquired by inhaling dried secretions from infected birds. Psittacine birds commonly kept as pets (parrots, parakeets, cockatiels, etc.) and poultry are most frequently involved in transmission. C. trachomatis can cause a spectrum of clinical manifestations including genital tract infections, inclusion conjunctivitis, trachoma, pneumonia in infants, and LGV. The LGV strains cause more severe and systemic disease than do genital strains. C. trachomatis genital tract infections are sexually transmitted and ocular infections (trachoma) are transmitted by exposure to secretions from infected persons through contact or fomite transmission. C. pneumoniae is a common cause of respiratory infection; up to 50% of adults have serologic evidence of previous exposure. Infections with C. pneumoniaeare transmitted by droplet aerosolization and are most often mild or asymptomatic, although there is a body of evidence associating this agent with chronic diseases such as atherosclerosis and asthma.

Laboratory Safety

C. psittaci may be present in the tissues, feces, nasal secretions and blood of infected birds, and in blood, sputum, and tissues of infected humans. C. trachomatis may be present in genital, bubo, and conjunctival fluids of infected humans. Exposure to infectious aerosols and droplets, created during the handling of infected birds and tissues, are the primary hazards to laboratory personnel working with C. psittaci. The primary laboratory hazards of C. trachomatis and C. pneumoniae are accidental parenteral inoculation and direct and indirect exposure of mucous membranes of the eyes, nose, and mouth to genital, bubo, or conjunctival fluids, cell culture materials, and fluids from infected cell cultures or eggs. Infectious aerosols, including those that may be created as a result of centrifuge malfunctions, also pose a risk for infection.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for personnel working with clinical specimens and cultures or other materials known or suspected to contain the ocular or genital serovars (A through K) ofC. trachomatis or C. pneumoniae.

BSL-3 practices, containment equipment, and facilities are recommended for activities involving the necropsy of infected birds and the diagnostic examination of tissues or cultures known to contain or be potentially infected with C. psittaci strains of avian origin. Wetting the feathers of infected birds with a detergent-disinfectant prior to necropsy can appreciably reduce the risk of aerosols of infected feces and nasal secretions on the feathers and external surfaces of the bird. Activities involving non-avian strains of C. psittaci may be performed in a BSL-2 facility as long as BSL-3 practices are followed, including but not limited to the use of primary containment equipment such as BSCs. ABSL-3 practices, containment equipment, and facilities and respiratory protection are recommended for personnel working with naturally or experimentally infected caged birds.

BSL-3 practices and containment equipment are recommended for activities involving work with culture specimens or clinical known to contain or be potentially infected with the LGV serovars (L1 through L3) of C. trachomatis. Laboratory work with the LGV serovars of C. trachomatis can be conducted in a BSL-2 facility as long as BSL-3 practices are followed when handling potentially infectious materials, including but not limited to use of primary containment equipment such as BSCs.

Gloves are recommended for the necropsy of birds and mice, the opening of inoculated eggs, and when there is the likelihood of direct skin contact with infected tissues, bubo fluids, and other clinical materials.

ABSL-2 practices, containment equipment, and facilities are recommended for activities with animals that have been experimentally infected with genital serovars of C. trachomatis or C. pneumoniae.

BSL-3 practices, containment equipment, and facilities are indicated for activities involving any of these species with high potential for droplet or aerosol production and for activities involving large quantities or concentrations of infectious materials.

Special Issues

Transfer of Agent

Agent: Neurotoxin-producing Clostridia species

Clostridium botulinum, and rare strains of C. baratii and C. butyricum, are anaerobic spore- forming species that cause botulism, a life-threatening food-borne illness. The pathogenicity of these organisms results from the production of botulinum toxin, one of the most highly potent neurotoxins currently recognized. Purified botulinum neurotoxin is a 150 kDa protein that acts selectively on peripheral cholinergic nerve endings to block neurotransmitter release.⁵⁵ The principal site of action is the neuromuscular junction, where blockade of transmission produces muscle weakness or paralysis. The toxin also acts on autonomic nerve endings where blockade of transmission can produce a variety of adverse effects. The toxin may also contain associated proteins that may increase its size to as high as 900 kDA.

Occupational Infections

There has been only one report of botulism associated with handling of the toxin in a laboratory setting.⁵⁶ However, concerns about potential use of the toxin as an agent of bioterrorism or biological warfare have led to increased handling of the substance by investigators studying mechanism of action and/or developing counter measures to poisoning.⁵⁷

Natural Modes of Infection

Botulinum toxin occurs in seven different serotypes (A to G), but almost all naturally occurring human illness is due to serotypes A, B, E, and F.⁵⁸ Botulism occurs when botulinum toxin is released into circulation following ingestion of preformed toxin. However animal studies have shown that botulism may occur through inhalation of preformed toxin. Use of appropriate personal protective equipment should prevent potential exposure through mucus membranes. Symptoms and even death are possible by accidental injection of botulinum toxin. Risk to toxin exposure is dependent on both route of exposure and toxin molecular weight size. Exposure to neurotoxin producing Clostridia species does not cause infection; however in certain rare circumstances (Infant Botulism, Wound Botulism, and Adult colonization), the organism can colonize the intestinal tract and other sites and produce toxin. In Wound Botulism, exposure to toxin is caused by introduction of spores into puncture wounds and in situ production by the organism. Infants less than 1 year of age may be susceptible to intestinal colonization and develop the syndrome of Infant Botulism as a result of in situ production of toxin. Similarly to Infant Botulism, ingestion of spores by adults with a compromised gastrointestinal tract (GI), such as following GI surgery or long-term administration of antibiotics, may increase risk for intestinal infection and in situ production of toxin. See the C. botulinum Toxin Agent Summary Statement and Chapter 17 for additional information.

Laboratory Safety

Neurotoxin producing Clostridia species or its toxin may be present in a variety of food products, clinical materials (serum, feces) and environmental samples (soil, surface water).⁵⁹ In addition, bacterial cultures may produce very high levels of toxin.⁶⁰ In healthy adults, it is typically the toxin and not the organism that causes disease. Risk of laboratory exposure is due to the presence of the toxin and not due to a potential of infection from the organisms that produce the toxin. Although spore-forming, there is no known risk to spore exposure except for the potential for the presence of residual toxin associated with pure spore preparations. Laboratory safety protocols should be developed with the focus on prevention of accidental exposure to the toxin produced by these Clostridia species.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for activities that involve the organism or the toxin⁶¹ including the handling of potentially contaminated food. Solutions of sodium hypochlorite (0.1%) or sodium hydroxide (0.1N) readily inactivate the toxin and are recommended for decontamination of work surfaces and for spills. Autoclaving of contaminated materials also is appropriate.

Additional primary containment and personnel precautions, such as those recommended for BSL-3, should be implemented for activities with a high potential for aerosol or droplet production, or for those requiring routine handling of larger quantities of the organism or of the toxin. ABSL-2 practices, containment equipment, and facilities are recommended for diagnostic studies and titration of toxin.

Special Issues

Vaccines

A pentavalent (A, B, C, D and E) botulinum toxoid vaccine (PBT) is available through the CDC as an Investigational New Drug (IND). Vaccination is recommended for all personnel working in direct contact with cultures of neurotoxin producing Clostridia species or stock solutions of Botulinum neurotoxin. Due to a possible decline in the immunogenicity of available PBT stocks for some toxin serotypes, the immunization schedule for the PBT recently has been modified to require injections at 0, 2, 12, and 24 weeks, followed by a booster at 12 months and annual boosters thereafter. Since there is a possible decline in vaccine efficacy, the current vaccine contains toxoid for only 5 of the 7 toxin types, this vaccine should not be considered as the sole means of protection and should not replace other worker protection measures.

Post-Exposure Treatment

An equine antitoxin product is available for treatment of patients with symptoms consistent with botulism. However, due to the risks inherent in equine products, treatment is not provided as a result of exposure unless botulism symptoms are present.

Select Agent

Neurotoxin producing Clostridia species are Select Agents requiring registration with CDC and/or USDA for possession, use, storage and/or transfer. See Chapter 14 for additional information.

Transfer of Agent

Agent: Clostridium tetani and Tetanus toxin

Clostridium tetani is an anaerobic endospore-forming gram-positive rod found in the soil and an intestinal tract commensal. It produces a potent neurotoxin, tetanospasmin, that causes tetanus, an acute neurologic condition characterized by painful muscular contractions. Tetanospasmin is an exceedingly potent, high molecular weight protein toxin, consisting of a heavy chain (100kD) subunit that binds the toxin to receptors on neuronal cells and a light chain (50kD) subunit that blocks the release of inhibitory neural transmitter molecules within the central nervous system. The incidence of tetanus in the United States has declined steadily since the introduction of tetanus toxoid vaccines in the 1940s.⁶²

Occupational Infections

Although the risk of infection to laboratory personnel is low, there have been five incidents of laboratory personnel exposure recorded.⁴

Natural Modes of Infection

Contamination of wounds by soil is the usual mechanism of transmission for tetanus. Of the 130 cases of tetanus reported to CDC from 1998 through 2000, acute injury (puncture, laceration, abrasion) was the most frequent predisposing condition. Elevated incidence rates also were observed for persons aged over 60 years, diabetics, and intravenous drug users.⁶³When introduced into a suitable anaerobic or microaerophilic environment, C. tetani spores germinate and produce tetanospasmin. The incubation period ranges from 3 to 21 days. The observed symptoms are primarily associated with the presence of the toxin. Wound cultures are not generally useful for diagnosing tetanus.⁶⁴

Laboratory Safety

The organism may be found in soil, intestinal, or fecal samples. Accidental parenteral inoculation of the toxin is the primary hazard to laboratory personnel. Because it is uncertain if tetanus toxin can be absorbed through mucous membranes, the hazards associated with aerosols and droplets remain unclear.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for activities involving the manipulation of cultures or toxin. ABSL-2 practices, containment equipment, and facilities are recommended for animal studies.

Special Issues

Vaccines

The vaccination status of workers should be considered in a risk assessment for workers with this organism and/or toxin. While the risk of laboratory-associated tetanus is low, the administration of an adult diphtheria-tetanus toxoid at 10-year intervals further reduces the risk to laboratory and animal care personnel of toxin exposures and wound contamination, and is therefore highly recommended.⁶² The reader is advised to consult the current recommendations of the ACIP. ⁶⁵

Transfer of Agent

Agent: Corynebacterium diphtheria

Corynebacterium diphtheriae is a pleomorphic gram-positive rod that is isolated from the nasopharynx and skin of humans. The organism is easily grown in the laboratory on media containing 5% sheep blood. C. diphtheriaeproduces a potent exotoxin and is the causative agent of diphtheria, one of the most wide-spread bacterial diseases in the pre vaccine era.

Occupational Infections

Laboratory-associated infections with C. diphtheriae have been documented, but laboratory animal-associated infections have not been reported.^4,66 Inhalation, accidental parenteral inoculation, and ingestion are the primary laboratory hazards.

Natural Modes of Infection

The agent may be present in exudates or secretions of the nose, throat (tonsil), pharynx, larynx, wounds, in blood, and on the skin. Travel to endemic areas or close contact with persons who have returned recently from such areas, increases risk.⁶⁷ Transmission usually occurs via direct contact with patients or carriers, and more rarely, with articles contaminated with secretions from infected people. Naturally occurring diphtheria is characterized by the development of grayish-white membranous lesions involving the tonsils, pharynx, larynx, or nasal mucosa. Systemic sequelae are associated with the production of diphtheria toxin. An effective vaccine has been developed for diphtheria and this disease has become a rarity in countries with vaccination programs.

Laboratory Safety

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for all activities utilizing known or potentially infected clinical materials or cultures. ABSL-2 facilities are recommended for studies utilizing infected laboratory animals.

Special Issues

Vaccines

A licensed vaccine is available. The reader is advised to consult the current recommendations of the ACIP. ⁶⁷ While the risk of laboratory-associated diphtheria is low, the administration of an adult diphtheria-tetanus toxoid at 10-year intervals may further reduce the risk of illness to laboratory and animal care personnel.⁶⁷

Transfer of Agent

Agent: Francisella tularensis

Francisella tularensis is a small gram-negative coccobacillus that is carried in numerous animal species, especially rabbits, and is the causal agent of tularemia (Rabbit fever, Deer fly fever, Ohara disease, or Francis disease) in humans. F. tularensis can be divided into three subspecies, F. tularensis (Type A), F. holarctica (Type B) and F. novicida, based on virulence testing, 16S sequence, biochemical reactions and epidemiologic features. Type A and Type B strains are highly infectious, requiring only 10-50 organisms to cause disease. Subspecies F. novicida is infrequently identified as the cause of human disease. Person-to-person transmission of tularemia has not been documented. The incubation period varies with the virulence of the strain, dose and route of introduction but ranges from 1-14 days with most cases exhibiting symptoms in 3-5 days.⁶⁸

Occupational Infections

Tularemia has been a commonly reported laboratory-associated bacterial infection.⁴ Most cases have occurred at facilities involved in tularemia research; however, cases have been reported in diagnostic laboratories as well. Occasional cases were linked to work with naturally or experimentally infected animals or their ectoparasites.

Natural Modes of Infection

Tick bites, handling or ingesting infectious animal tissues or fluids, ingestion of contaminated water or food and inhalation of infective aerosols are the primary transmission modes in nature. Occasionally infections have occurred from bites or scratches by carnivores with contaminated mouth parts or claws.

Laboratory Safety

The agent may be present in lesion exudates, respiratory secretions, cerebrospinal fluid (CSF), blood, urine, tissues from infected animals, fluids from infected animals, and fluids from infected arthropods. Direct contact of skin or mucous membranes with infectious materials, accidental parenteral inoculation, ingestion, and exposure to aerosols and infectious droplets has resulted in infection. Infection has been more commonly associated with cultures than with clinical materials and infected animals.⁶⁹

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for activities involving clinical materials of human or animal origin suspected or known to contain F. tularensis. Laboratory personnel should be informed of the possibility of tularemia as a differential diagnosis when samples are submitted for diagnostic tests. BSL-3 and ABSL- 3 practices, containment equipment, and facilities are recommended for all manipulations of suspect cultures, animal necropsies and for experimental animal studies. Preparatory work on cultures or contaminated materials for automated identification systems should be performed at BSL-3. Characterized strains of reduced virulence such as F. tularensis Type B (strain LVS) and F. tularensis subspnovicida (strain U112) can be manipulated in BSL-2. Manipulation of reduced virulence strains at high concentrations should be conducted using BSL-3 practices.

Special Issues

Select Agent

BSL-3 practices, containment equipment, and facilities are required for laboratory activities in the propagation and manipulation of cultures of any of the subspecies of the M. tuberculosis complex and for animal studies using experimentally or naturally infected NHP. Animal studies using guinea pigs or mice can be conducted at ABSL-2.¹¹¹ BSL-3 practices should include the use of respiratory protection and the implementation of specific procedures and use of specialized equipment to prevent and contain aerosols. Disinfectants proven to be tuberculocidal should be used. See Chapter 10 for additional information.

Manipulation of small quantities of the attenuated vaccine strain M. bovisBacillus Calmette- Guérin (BCG) can be performed at BSL-2 in laboratories that do not culture M. tuberculosis and do not have BSL-3 facilities. However, considerable care must be exercised to verify the identity of the strain and to ensure that cultures are not contaminated with virulent M. tuberculosisor other M. bovis strains. Selection of an appropriate tuberculocidal disinfectant is an important consideration for laboratories working with mycobacteria. See Chapter 10 for additional information.

Special Issues

Surveillance

Annual or semi-annual skin testing with purified protein derivative (PPD) of previously skin-test-negative personnel can be used as a surveillance procedure.

Vaccines

The attenuated live BCG, is available and used in other countries but is not used in the United States for immunization.

Transfer of Agent

Agent: Mycobacterium spp. other than M. tuberculosis Complex and M. Leprae

More than 100 species of mycobacteria are recognized. These include both slowly growing and rapidly growing species. In the past, mycobacterial isolates that were not identified as M. tuberculosis complex were often called atypical mycobacteria, but these are now more commonly referred to as nontuberculous mycobacteria or mycobacteria other than tuberculosis. Many of the species are common environmental organisms, and approximately 25 of them are associated with infections in humans. A number of additional species are associated with infections in immunocompromised persons, especially HIV-infected individuals. All of these species are considered opportunistic pathogens in humans and none are considered communicable. Mycobacteria are frequently isolated from clinical samples but may not be associated with disease. The most common types of infections and causes are:

pulmonary disease with a clinical presentation resembling tuberculosis caused by M. kansasii, M. avium, and M. intracellulare
lymphadenitis associated with M. avium and M. scrofulaceum
disseminated infections in immunocompromised individuals caused by M. avium
skin ulcers and soft tissue wound infections including Buruli ulcer caused by M. ulcerans, swimming pool granuloma caused by M. marinum associated with exposure to organisms in fresh and salt water and fish tanks, and tissue infections resulting from trauma, surgical procedures, or injection of contaminated materials caused by M. fortuitum, M. chelonei, and M. abscesens

Occupational Infections

Laboratory-acquired infections with Mycobacterium spp. other thanM. tuberculosis complex have not been reported.

Natural Modes of Infection

Person-to-person transmission has not been demonstrated. Presumably, pulmonary infections are the result of inhalation of aerosolized bacilli, most likely from the surface of contaminated water. Mycobacteria are widely distributed in the environment and in animals. They are also common in potable water supplies, perhaps as the result of the formation of biofilms. The source of M. avium infections in immunocompromised persons has not been established.

Laboratory Safety

Various species of mycobacteria may be present in sputa, exudates from lesions, tissues, and in environmental samples. Direct contact of skin or mucous membranes with infectious materials, ingestion, and accidental parenteral inoculation are the primary laboratory hazards associated with clinical materials and cultures. Aerosols created during the manipulation of broth cultures or tissue homogenates of these organisms also pose a potential infection hazard.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for activities with clinical materials and cultures ofMycobacteria spp. other than M. tuberculosis complex. Clinical specimens may also contain M. tuberculosis and care must be exercised to ensure the correct identification of cultures. Special caution should be exercised in handling M. ulcerans to avoid skin exposure. ABSL-2 practices, containment equipment, and facilities are recommended for animal studies. Selection of an appropriate tuberculocidal disinfectant is an important consideration for laboratories working with mycobacteria. See Chapter 10 for additional information.

Special Issues

Transfer of Agent

Agent: Neisseria gonorrhoeae

Neisseria gonorrhoeae is a gram-negative, oxidase-positive diplococcus associated with gonorrhea, a sexually transmitted disease of humans. The organism may be isolated from clinical specimens and cultivated in the laboratory using specialized growth media.¹¹²

Occupational Infections

Laboratory-associated gonococcal infections have been reported in the United States and elsewhere.^113-116 These infections have presented as conjunctivitis, with either direct finger-to-eye contact or exposure to splashes of either liquid cultures or contaminated solutions proposed as the most likely means of transmission.

Natural Modes of Infection

Gonorrhea is a sexually transmitted disease of worldwide importance. The 2004 rate of reported infections for this disease in the United States was 112 per 100,000 population.¹¹⁷ The natural mode of infection is through direct contact with exudates from mucous membranes of infected individuals. This usually occurs by sexual activity, although newborns may also become infected during birth.¹¹²

Laboratory Safety

The agent may be present in conjunctival, urethral and cervical exudates, synovial fluid, urine, feces, and CSF. Accidental parenteral inoculation and direct or indirect contact of mucous membranes with infectious clinical materials are known primary laboratory hazards. Laboratory-acquired illness due to aerosol transmission has not been documented.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for all activities involving the use or manipulation of clinical materials or cultures. Gloves should be worn when handling infected laboratory animals and when there is the likelihood of direct skin contact with infectious materials. Additional primary containment and personnel precautions such as those described for BSL- 3 may be indicated when there is high risk of aerosol or droplet production, and for activities involving production quantities or high concentrations of infectious materials. Animal studies may be performed at ABSL-2.

Special Issues

Transfer of Agent

Agent: Neisseria meningitides

Neisseria meningitidis is a gram-negative coccus responsible for serious acute meningitis and septicemia in humans. Virulence is associated with the expression of a polysaccharide capsule. Thirteen different capsular serotypes have been identified, with types A, B, C, Y, and W135 associated with the highest incidence of disease. The handling of invasive N. meningitidis isolates from blood or CSF represents an increased risk to microbiologists.^118,119

Occupational Infections

Recent studies of LAI and exposures have indicated that manipulating suspensions of N. meningitidis outside a BSC is associated with a high risk for contracting meningococcal disease.¹¹⁹Investigations of potential laboratory-acquired cases of meningococcal diseases in the United States showed a many-fold higher attack rate for microbiologists compared to that of the United States general population age 30-59 years, and a case fatality rate of 50%, substantially higher than the 12-15% associated with disease among the general population. Almost all the microbiologists had manipulated sterile site isolates on an open laboratory bench.¹²⁰ While isolates obtained from respiratory sources are generally less pathogenic and consequently represent lower risk for microbiologists, rigorous protection from droplets or aerosols is mandated when microbiological procedures are performed on all N. meningitidis isolates, especially on those from sterile sites.

Natural Modes of Infection

The human upper respiratory tract is the natural reservoir for N. meningitidis. Invasion of organisms from the respiratory mucosa into the circulatory system causes infection that can range in severity from subclinical to fulminant fatal disease. Transmission is person-to-person and is usually mediated by direct contact with respiratory droplets from infected individuals.

Laboratory Safety

N. meningitidis may be present in pharyngeal exudates, CSF, blood, and saliva. Parenteral inoculation, droplet exposure of mucous membranes, infectious aerosol and ingestion are the primary hazards to laboratory personnel. Based on the mechanism of natural infection and the risk associated with handling of isolates on an open laboratory bench, exposure to droplets or aerosols of N. meningitidis is the most likely risk for infection in the laboratory.

Containment Recommendations

Specimens for N. meningitidis analysis and cultures of N. meningitidis not associated with invasive disease may be handled in BSL-2 facilities with rigorous application of BSL-2 standard practices, special practices, and safety equipment. All sterile-site isolates of N. meningitidis should be manipulated within a BSC. Isolates of unknown source should be treated as sterile- site isolates. If a BSC is unavailable, manipulation of these isolates should be minimized, primarily focused on serogroup identification using phenolized saline solution while wearing laboratory coat, gloves, and safety glasses or full face splash shield. BSL-3 practices and procedures are indicated for activities with a high potential for droplet or aerosol production and for activities involving production quantities or high concentrations of infectious materials. Animal studies should be performed under ABSL-2 conditions.

Special Issues

Vaccines

The quadrivalent meningococcal polysaccharide vaccine, which includes serogroups A, C, Y, and W-135, will decrease but not eliminate the risk of infection, because it is less than 100% effective and does not provide protection against serogroup B, which caused one-half of the laboratory-acquired cases in the United States in 2000.^118,120 Laboratorians who are exposed routinely to potential aerosols of N. meningitidis should consider vaccination.^118,121,122

Transfer of Agent

Agent: Salmonella Serotypes, other than S. Typhi

Salmonellae are gram-negative enteric bacteria associated with diarrheal illness humans. They are motile oxidase-negative organisms that are easily cultivated on standard bacteriologic media, although enrichment and selective media may be required for isolation from clinical materials. Recent taxonomic studies have organized this genus into two species, S. enterica and S. bongori, containing more than 2500 antigenically distinct subtypes or serotypes.¹²³ S. enterica contains the vast majority of serotypes associated with human disease. S. enterica serotypes Typhimurium and Enteritidis (commonly designated S. Typhimurium and S. Enteritidis) are the serotypes most frequently encountered in the United States. This summary statement covers all pathogenic serotypes except S. Typhi.

Occupational Infections

Salmonellosis is a documented hazard to laboratory personnel.^4,26,124-125 Primary reservoir hosts include a broad spectrum of domestic and wild animals, including birds, mammals, and reptiles, all of which may serve as a source of infection to laboratory personnel. Case reports of laboratory-acquired infections indicate a presentation of symptoms (fever, severe diarrhea, abdominal cramping) similar to those of naturally-acquired infections, although one case also developed erythema nodosum and reactive arthritis.^126,127

Natural Modes of Infection

Salmonellosis is a foodborne disease of worldwide distribution. An estimated 5 million cases of salmonellosis occur annually in the United States. A wide range of domestic and feral animals (poultry, swine, rodents, cattle, iguanas, turtles, chicks, dogs, cats) may serve as reservoirs for this disease, as well as humans.¹²⁸ The most common mode of transmission is by ingestion of food from contaminated animals or contaminated during processing. The disease usually presents as an acute enterocolitis, with an incubation period ranging from 6 to 72 hours.

Laboratory Safety

The agent may be present in feces, blood, urine, and in food, feed, and environmental materials. Ingestion or parenteral inoculation are the primary laboratory hazards. The importance of aerosol exposure is not known. Naturally or experimentally infected animals are a potential source of infection for laboratory and animal care personnel, and for other animals.

Containment Recommendations

Strict compliance with BSL-2 practices, containment equipment, and facilities are recommended for all activities utilizing known or potentially infectious clinical materials or cultures. This includes conducting procedures with aerosol or high splash potential in primary containment devices such as a BSCs or safety centrifuge cups. Personal protective equipment should be used in accordance with a risk assessment, including splash shields, face protection, gowns, and gloves. The importance of proper gloving techniques and frequent and thorough hand washing is emphasized. Care in manipulating faucet handles to prevent contamination of cleaned hands or the use of sinks equipped with remote water control devices, such as foot pedals, is highly recommended. Special attention to the timely and appropriate decontamination of work surfaces, including potentially contaminated equipment and laboratory fixtures, is strongly advised. ABSL-2 facilities and practices are recommended for activities with experimentally infected animals.

Special Issues

Transfer of Agent

Agent: Salmonella Typhi

Recent taxonomic studies have organized the genus Salmonella into two species, S. enterica and S. bongori, containing more than 2500 antigenically distinct subtypes or serotypes.¹²³ S. enterica contains the vast majority of serotypes associated with human disease. S. enterica serotype Typhi, commonly designated S. Typhi, is the causative agent of typhoid fever. S. Typhi is a motile gram-negative enteric bacterium that is easily cultivated on standard bacteriologic media, although enrichment and selective media may be required for isolation of this organism from clinical materials.

Occupational Infections

Typhoid fever is a demonstrated hazard to laboratory personnel.^4,129,130 Ingestion and less frequently, parenteral inoculation are the most significant modes of transmission in the laboratory. Secondary transmission to other individuals outside of the laboratory is also a concern.¹³¹ Laboratory-acquired S. Typhi infections usually present with symptoms of septicemia, headache, abdominal pain, and high fever.¹²⁹

Natural Modes of Infection

Typhoid fever is a serious, potentially lethal bloodstream infection of worldwide distribution. Humans are the sole reservoir and asymptomatic carriers may occur. The infectious dose is low (<103 organisms) and the incubation period may vary from one to six weeks, depending upon the dose of the organism. The natural mode of transmission is by ingestion of food or water contaminated by feces or urine of patients or asymptomatic carriers.¹²³

Laboratory Safety

The agent may be present in feces, blood, gallbladder (bile), and urine. Humans are the only known reservoir of infection. Ingestion and parenteral inoculation of the organism represent the primary laboratory hazards. The importance of aerosol exposure is not known.

Containment Recommendations

Strict compliance with BSL-2 practices, containment equipment, and facilities are recommended for all activities utilizing known or potentially infectious clinical materials or cultures. This includes conducting procedures with aerosol or high splash potential in primary containment devices such as a BSCs or safety centrifuge cups. Personal protective equipment should be used in accordance with a risk assessment, including splash shields, face protection, gowns, and gloves. The importance of proper gloving techniques and frequent and thorough hand washing is emphasized. Care in manipulating faucet handles to prevent contamination of cleaned hands or the use of sinks equipped with remote water control devices, such as foot pedals, is highly recommended. Special attention to the timely and appropriate decontamination of work surfaces, including potentially contaminated equipment and laboratory fixtures, is strongly advised. BSL-3 practices and equipment are recommended for activities likely to produce significant aerosols or for activities involving production quantities of organisms. ABSL-2 facilities, practices and equipment are recommended for activities with experimentally infected animals. ABSL-3 conditions may be considered for protocols involving aerosols.

Special Issues

Laboratory Safety

The agent may be present in materials collected from cutaneous and mucosal lesions and in blood. Accidental parenteral inoculation, contact with mucous membranes or broken skin with infectious clinical materials are the primary hazards to laboratory personnel.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for all activities involving the use or manipulation of blood or other clinical samples from humans or infected rabbits. Gloves should be worn when there is a likelihood of direct skin contact with infective materials. Periodic serological monitoring should be considered in personnel regularly working with these materials. ABSL-2 practices, containment equipment, and facilities are recommended for work with infected animals.

Special Issues

Vaccines

Vaccines are currently not available for use in humans.

Transfer of Agent

Agent: Vibrio enteritis species (V. cholerae, V. parahaemolyticus)

Vibrio species are straight or curved motile gram-negative rods. Growth of Vibrio species is stimulated by sodium and the natural habitats of these organisms are primarily aquatic environments. Although 12 different Vibrio species have been isolated from clinical specimens, V. cholerae and V. parahaemolyticus are the best-documented causes of human disease.¹⁴⁸Vibrios may cause either diarrhea or extraintestinal infections.

Occupational Infections

Rare cases of bacterial enteritis due to LAI with either V. cholerae or V. parahaemolyticus have been reported from around the world.⁴ Naturally and experimentally infected animals¹⁴⁹ and shellfish^150,151are potential sources for such illnesses.

Natural Modes of Infection

The most common natural mode of infection is the ingestion of contaminated food or water. The human oral infecting dose of V. cholerae in healthy non-achlorhydric individuals is approximately 106-1011 colony forming units,¹⁵² while that of V. parahaemolyticus ranges from 105-107 cells.¹⁵³ The importance of aerosol exposure is unknown although it has been implicated in at least one instance.¹⁴⁹ The risk of infection following oral exposure is increased in persons with abnormal gastrointestinal physiology including individuals on antacids, with achlorhydria, or with partial or complete gastrectomies.¹⁵⁴

Laboratory Safety

Pathogenic vibrios can be present in human fecal samples, or in the meats and the exterior surfaces of marine invertebrates such as shellfish. Other clinical specimens from which vibrios may be isolated include blood, arm or leg wounds, eye, ear, and gall bladder.¹⁴⁸ Accidental oral ingestion of V. cholerae or V. parahaemolyticus principally results from hands contaminated from the use of syringes or the handling of naturally contaminated marine samples without gloves.

Containment Recommendations

Special Issues

Vaccines

The reader is advised to consult the current recommendations of the ACIP published in the MMWR for vaccination recommendations against V. cholera. There are currently no human vaccines against V. parahaemolyticus.

Transfer of Agent

Agent: Yersinia pestis

Yersinia pestis, the causative agent of plague, is a gram-negative, microaerophilic coccobacillus frequently characterized by a “safety pin” appearance on stained preparations from specimens. It is nonmotile and nonsporulating. There are three biotypes of Y. pestis, differentiated by their ability to ferment glycerol and reduce nitrate. All three biotypes are virulent. The incubation period for bubonic plague ranges from two to six days while the incubation period for pneumonic plague is one to six days.

Agent Summary Statements – Bacterial Agents

Pneumonic plague is transmissible person-to-person;¹⁵⁵ whereas bubonic plague is not. Laboratory animal studies have shown the lethal and infectious doses of Y. pestis to be quite low (less than 100 colony forming units).¹⁵⁶

Occupational Infections

Y. pestis is a documented laboratory hazard. Prior to 1950, at least 10 laboratory-acquired cases were reported in the United States, four of which were fatal.^4,157 Veterinary staff and pet owners have become infected when handling domestic cats with oropharyngeal or pneumonic plague.

Natural Modes of Infection

Infective fleabites are the most common mode of transmission, but direct human contact with infected tissues or body fluids of animals and humans also may serve as sources of infection.

Primary pneumonic plague arises from the inhalation of infectious respiratory droplets or other airborne materials from infected animals or humans. This form of plague has a high case fatality rate if not treated and poses the risk of person-to-person transmission.

Laboratory Safety

The agent has been isolated, in order of frequency of recovery, from bubo aspirate, blood, liver, spleen, sputum, lung, bone marrow, CSF, and infrequently from feces and urine, depending on the clinical form and stage of the disease. Primary hazards to laboratory personnel include direct contact with cultures and infectious materials from humans or animal hosts and inhalation of infectious aerosols or droplets generated during their manipulation. Laboratory and field personnel should be counseled on methods to avoid fleabites and accidental autoinoculation when handling potentially infected live or dead animals.

Containment Recommendations

BSL-2 practices, containment equipment, and facilities are recommended for all activities involving the handling of potentially infectious clinical materials and cultures. In addition, because the infectious dose is so small, all work, including necropsies of potentially infected animals should be performed in a BSC. Special care should be taken to avoid generating aerosols or airborne droplets while handling infectious materials or when performing necropsies on naturally or experimentally infected animals. Gloves should be worn when handling potentially infectious materials including field or laboratory infected animals. BSL-3 is recommended for activities with high potential for droplet or aerosol production, and for activities involving large scale production or high concentrations of infectious materials. Resistance of Y. pestis strains to antibiotics used in the treatment of plague should be considered in a thorough risk assessment and may require additional containment for personal protective equipment. For animal studies, a risk assessment that takes into account the animal species, infective strain, and proposed procedures should be performed in order to determine if ABSL-2 or ABSL-3 practices, containment equipment, and facilities should be employed. BSL-3 facilities and arthropod containment level 3 practices are recommended for all laboratory work involving infected arthropods.¹⁵⁸ See Chapter 15 for additional information on arthropod containment guidelines.

Special Issues

Select Agent

Yersinia pestis is an HHS Select Agent requiring registration with CDC for the possession, use, storage and transfer. See Chapter 14 for further information.

Transfer of Agent

References

Inglesby TV, O'Toole T, Henderson DA, et al. Anthrax as a biological weapon. JAMA. 2002;287:2236-52.
Watson A, Keir D. Information on which to base assessments of risk from environments contaminated with anthrax spores. Epidemiol Infect. 1994;113:479- 90.
Ellingson HV, Kadull PJ, Bookwalter HL, et al. Cutaneous anthrax: report of twenty-five cases. JAMA.1946;131:1105-8.
Pike RM. Laboratory-associated infections: summary and analysis of 3,921 cases. Hlth Lab Sci1976;13:105-14.
Centers for Disease Control and Prevention. Suspected cutaneous anthrax in a laboratory worker--Texas, 2002. MMWR Morb Mortal Wkly Rep. 2002;51:279- 81.
Centers for Disease Control and Prevention. Human anthrax associated with an epizootic among livestock---North Dakota, 2000. MMWR Morb Mortal Wkly Rep. 2001;50:677-80.
Jernigan DB, Raghunathan PS, Bell BP, et al. Investigation of bioterrorism related anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis. 2002;8:1019-28.
Centers for Disease Control and Prevention. Notice to readers: use of anthrax vaccine in response to terrorism: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2002;51:1024-6.
Centers for Disease Control and Prevention. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2000;49(RR15):1-20.
Addiss DG, Davis JP, Meade BD, et al. A pertussis outbreak in a Wisconsin nursing home. J Infect Dis. 1991;164:704-10.
Christie CD, Glover AM, Willke MJ, et al. Containment of pertussis in the regional pediatric hospital during the greater Cincinnati epidemic of 1993. Infect Control Hosp Epidemiol. 1995;16:556-63.
Kurt TL, Yeager AS, Guenette S, et al. Spread of pertussis by hospital staff. JAMA. 1972;221:264-7.
Linnemann CC Jr, Ramundo N, Perlstein PH, et al. Use of pertussis vaccine in an epidemic involving hospital staff. Lancet. 1975;2:540-3.
Shefer A, Dales L, Nelson M, et al. Use and safety of acellular pertussis vaccine among adult hospital staff during an outbreak of pertussis. J Infect Dis. 1995;171:1053-6.
Steketee RW, Wassilak SG, Adkins WN, et al. Evidence for a high attack rate and efficacy of erythromycin prophylaxis in a pertussis outbreak in a facility for the developmentally disabled. J Infect Dis. 1988;157:434-40.
Weber DJ, Rutala WA. Management of healthcare workers exposed to pertussis. Infect Control Hosp Epidemiol. 1994;15:411-5.
Beall B, Cassiday PK, Sanden GN. Analysis of Bordetella pertussis isolates from an epidemic by pulsed-field gel electrophoresis. J Clin Microbiol. 1995;33:3083- 6.
Burstyn DG, Baraff LJ, Peppler MS, et al. Serological response to filamentous hemagglutinin and lymphocytosis-promoting toxin of Bordetella pertussis. Infect Immun. 1983;41:1150-6.
Farizo KM, Cochi SL, Zell ER, et al. Epidemiological features of pertussis in the United States, 1980-1989. Clin Infect Dis. 1992;14:708-19.
Guris D, Strebel PM, Bardenheier B, et al. Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996. Clin Infect Dis. 1999;28:1230-7.
Tanaka M, Vitek CR, Pascual FB, et al. Trends in pertussis among infants in the United States, 1980-1999.JAMA.2003;290:2968-75.
Janda WM, Santos E, Stevens J, et al. Unexpected isolation of Bordetella pertussis from a blood culture. J Clin Microbiol. 1994;32:2851-3.
Centers for Disease Control and Prevention. Fatal case of unsuspected pertussis diagnosed from a blood culture – Minnesota, 2003. MMWR Morb Mortal Wkly Rep. 2004;53:131-2.
Morisset R, Spink WW. Epidemic canine brucellosis due to a new species, Brucella canis. Lancet.1969;2:1000-2.
Spink WW. The nature of brucellosis. Minneapolis: The University of Minnesota Press; 1956.
Miller CD, Songer JR, Sullivan JF. A twenty-five year review of laboratory acquired human infections at the National Animal Disease Center. Am Ind Hyg Assoc J. 1987;48:271-5.
Olle-Goig J, Canela-Soler JC. An outbreak of Brucella melitensis infection by airborne transmission among laboratory workers. Am J Publ Hlth 1987;77:335-8.
Memish ZA, Mah MW. Brucellosis in laboratory workers at a Saudi Arabian hospital. Am J Infect Control. 2001;29:48-52.
Grammont-Cupillard M, Berthet-Badetti L, Dellamonica P. Brucellosis from sniffing bacteriological cultures. Lancet. 1996;348:1733-4.
Huddleson IF, Munger M. A study of an epidemic of brucellosis due to Brucella melitensis. Am J Public Health. 1940;30:944-54.
Staszkiewicz J, Lewis CM, Coville J et al. Outbreak of Brucella melitensis among microbiology laboratory workers in a community hospital. J Clin Microbiol. 1991;29:278-90.
Pardon P, Marly J. Resistance of normal or immunized guinea pigs against a subcutaneous challenge of Brucella abortus. Ann Rech Vet. 1978;9:419-25.
Mense MG, Borschel RH, Wilhelmsen CL, et al. Pathologic changes associated with brucellosis experimentally induced by aerosol exposure in rhesus macaques (Macaca mulatto). Am J Vet Res. 2004;65:644-52.
Madkour MM. Brucellosis: overview. In: Madkour MM, editor. Madkour's Brucellosis. 2nd ed. Germany: Berlin Springer Verlag; 2001.
Centers for Disease Control and Prevention. Laboratory-acquired human glanders-- Maryland, May 2000. MMWR Morb Mortal Wkly Rep. 2000;49:532-5.
Glanders. In: Chin J, Ascher M, editors. Control of communicable diseases. Washington, DC: American Public Health Association; 2000. p. 337-8.
Howe C, Miller WR. Human glanders: report of six cases. Ann Intern Med. 1947;26:93-115.
Srinivasan A, Kraus CN, DeShazer D, et al. Glanders in a military research microbiologist. N Engl J Med. 2001;345:256-8.
Green RN, Tuffnell PG. Laboratory acquired melioidosis. Am J Med. 1968;44:599-605.
Schlech WF 3rd, Turchik JB, Westlake RE, Jr., et al. Laboratory-acquired infection with Pseudomonas pseudomallei (melioidosis). N Engl J Med. 1981;305:1133-5.
Dance DA. Ecology of Burkholderia pseudomallei and the interactions between environmental Burkholderia spp. and human-animal hosts. Acta Trop. 2000;74:159-68.
Dorman SE, Gill VJ, Gallin JI, et al. Burkholderia pseudomallei infection in a Puerto Rican patient with chronic granulomatous disease: case report and review of occurrences in the Americas. Clin Infect Dis. 1998;26:889-94.
Melioidosis. In: Chin J, Ascher M, editors. Control of communicable diseases. Washington, DC: American Public Health Association. 2000. p. 335-7.
Masuda T, Isokawa T. Kansenshogaku Zasshi. [Biohazard in clinical laboratories in Japan]. J. Jpn Assoc Infect Dis. 1991;65:209-15.
Oates JD, Hodgin UG, Jr. Laboratory-acquired Campylobacter enteritis. South Med J. 1981;74:83.
Penner JL, Hennessy JN, Mills SD, Bradbury WC. Application of serotyping and chromosomal restriction endonuclease digest analysis in investigating a laboratory-acquired case of Campylobacter jejuni enteritis. J Clin Microbiol 1983;18:1427-8.
Prescott JF, Karmali MA. Attempts to transmit Campylobacter enteritis to dogs and cats. Can Med Assoc J. 1978;119:1001-2.
Young VB, Schauer DB, Fox JG. Animal models of Campylobacter infection. In: Nachamkin I, Blaser MJ, editors. Campylobacter. 2nd ed. Washington, DC: ASM Press; 2000.
Robinson DA. Infective dose of Campylobacter jejuni in milk. Brit Med J (Clin Res Ed). 1981;282:1584.
Black RE, Levine MM, Clements ML, et al. Experimental Campylobacter jejuni infections in humans. J Infect Dis. 1988;157:472-9.
Black RE, Perlman D, Clements ML, et al. Human volunteer studies with Campylobacter jejuni. In: Nachamkin I, Blaser MJ, Tompkins LS, editors. Campylobacter jejuni: Current status and future trends. Washington, DC: ASM Press. 1992. p. 207-15.
Nachamkin I, Blaser MJ, Tompkins LS. Campylobacter jejuni: current status and future trends. Washington, DC: ASM Press; 1992.
Bernstein DI, Hubbard T, Wenman W, et al. Mediastinal and supraclavicular lymphadenitis and pneumonitis due to Chlamydia trachomatis serovars L1 and L2. N Eng J Med. 1984;311:1543-6.
Hyman CL, Augenbraun MH, Roblin PM, et al. Asymptomatic respiratory tract infection with Chlamydia pneumoniae TWAR. J Clin Microbiol. 1991;29:2082-3.
55. Simpson LL. Identification of the major steps in botulinum toxin action. Ann Rev Pharmacol Toxicol. 2004;44:167-93.
Holzer VE. Botulismus durch inhalation. Med Klin. 1962;57:1735-8.
Arnon SS, Schecter R, Inglesby TV, et al. Botulinum toxin as a biological weapon. JAMA. 2001;285:1059-70.
Hatheway CL. Botulism: The current state of the disease. Curr Topics Microbiol Immunol. 1995:55-75.
Smith LDS, Sugiyama H. Botulism: the organism, its toxins, the disease. 2nd ed. Balows A, editor. Springfield (IL): Charles C Thomas; 1988.
Siegel LS, Metzger JF. Toxin production by clostridium botulinum type A under various fermentation conditions. Appl Environ Microbio; 1979;38:600-11.
Maksymowych AB, Simpson LL. A brief guide to the safe handling of biological toxins. In: Aktories K, editor. Bacterial toxins. London: Chapman and Hall; l997. p. 295-300.
Centers for Disease Control and Prevention. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1991;40(RR10):1-28.
Centers for Disease Control and Prevention. Tetanus surveillance-United States, 1998-2000. MMWR Surveill Summ. 2003;52(SS-3):1-8.
Onderdonk A, Allen SD. Clostridium. In: Murray PR, Barron EJ, Pfaller M, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 574-86.
Centers for Disease Control and Prevention. Recommended childhood and adolescent immunization schedule--United States, January-June 2004. MMWR Morb Mortal Wkly Rep. 2004;53:Q1-4.
Geiss HK, Kiehl W, Thilo, W. A case report of laboratory-acquired diphtheria. Euro Surveill. 1997;2:67-8.
Centers for Disease Control and Prevention. Fatal respiratory diphtheria in a U.S. traveler to Haiti-Pennsylvania, 2003. MMWR Morb Mortal Wkly Rep. 2004; 52:1285-6
Dennis DT. Tularemia. In: Cohen J, Powderly WG, editors. Infectious diseases. Vol II. 2nd ed. Edinburgh: Mosby; 2004. p. 1649-53.
Burke DS. Immunization against tularemia: analysis of the effectiveness of live Francisella tularensis vaccine in prevention of laboratory-acquired tularemia. J Infect Dis. 1977;135:55- 60.
Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet. 1984;1:1311-5.
Schauer DB. Enterohepatic Helicobacter species. In: Mobley HLT, Mendz GL, Hazell SL, editors. Helicobacter pylori: physiology and genetics. Washington, DC: ASM Press. 2001. p. 533-48.
Versalovic J, Fox JG. Helicobacter. In: Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 915-28.
Marshall BJ, Armstrong JA, McGechie DB, et al. Attempt to fulfill Koch's postulates for pyloric Campylobacter. Med J Aust. 1985;142:436-9.
Matysiak-Budnik T, Briet F, Heyman M, et al. Laboratory-acquired Helicobacter pylori infection. Lancet. 1995;346:1489-90.
Mitchell HM. Epidemiology of infection. In: Mobley HLT, Mendz GL, Hazell SL, editors. Helicobacter pylori: physiology and genetics. Washington DC: ASM Press. 2001. p. 7-18, 90.
Perez-Perez GI. Accurate diagnosis of Helicobacter pylori. Culture, including transport. GastroenterolClin North Am. 2000;29:879-84.
Stout JE, Yu VL. Legionellosis. N Engl J Med. 1997;337:682-7.
Stout JE, Rihs JD, Yu VL. Legionella. In: Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 809-23.
Benin AL, Benson RF, Beser RE. Trends in legionnaires' disease, 1980-1998: declining mortality and new patterns of diagnosis. Clin Infect Dis. 2002;35:1039- 46.
Yu VL, Plouffe JF, Pastoris MC, et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey. J Infect Dis. 2002;186:127-8.
Fields BS, Benson RF, Besser RE. Legionella and legionnaires' disease: 25 years of investigation. Clin Microbiol Rev. 2002;15:506-26.
Centers for Disease Control and Prevention (CDC). 1976. Unpublished data. Center for Infectious Diseases. HEW, Public Health Service.
Friedman H, Yamamoto Y, Newton C, et al. Immunologic response and pathophysiology of Legionella infection. Semin Respir Infect. 1998;13:100-8.
Fabbi M, Pastoris MC, Scanziani E, et al. Epidemiological and environmental investigations of Legionella pneumophila infection in cattle and case report of fatal pneumonia in a calf. J Clin Microbiol. 1998;36:1942-7.
Muder RR, Yu VL, Woo A. Mode of transmission of Legionella pneumophila. A critical review. Arch InternMed. 1986;146:1607-12.
Lowry PW, Tompkins LS.Nosocomial legionellosis:a review of pulmonary and extrapulmonary syndromes. Am J Infect Control. 1993;21:21-7.
Levett PN. Leptospira and Leptonema. In: Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 929-36.
Barkin RM, Guckian JC, Glosser JW. Infection by Leptospira ballum: a laboratory-associated case. South Med J. 1974;67:155 passim.
Bolin CA, Koellner P. Human-to-human transmission of Leptospira interrogans by milk. J Infect Dis. 1988;158:246-7.
Stoenner HG, Maclean D. Leptospirosis (ballum) contracted from Swiss albino mice. AMA Arch Intern Med. 1958;101:606-10.
Schuchat A, Swaminathan B, Broome CV. Epidemiology of human listeriosis. Clin Microbiol Rev.1991;4:169-83.
Armstrong D. Listeria monocytogenes. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practices of infectious diseases. 4th ed. NY: Churchill Livingstone. 1995. p. 1880-85.
McLauchlin J, Low JC. Primary cutaneous listeriosis in adults: an occupational disease of veterinarians and farmers. Vet Rec. 1994;135:615-7.
Ortel S. Listeriosis during pregnancy and excretion of listeria by laboratory workers. Zentralbl Bakteriol [Orig. A]. 1975;231:491-502.
Centers for Disease Control and Prevention. Update: foodborne listeriosis-United States, 1988-1990.MMWR Morb Mortal Wkly Rep. 1992;41:251,257-8.
Ryser ET, Marth EH, editors. Listeria, Listeriosis, and food safety. 2nd ed. New York: Marcel Dekker,1999.
Gellin BG, Broome CV. Listeriosis. JAMA. 1989;261:1313-20.
Walsh GP, Storrs EE, Burchfield HP, et al. Leprosy-like disease occurring naturally in armadillos. J Reticuloendothel Soc. 1975;18:347-51.
Donham KJ, Leininger JR. Spontaneous leprosy-like disease in a chimpanzee. J Infect Dis. 1977;136:132-6.
Meyers WM, Walsh GP, Brown HL, et al. Leprosy in a mangabey monkey-- naturally acquired infection. Int J Lepr Other Mycobact Dis. 1985;53:1-14.
Marchoux PE. Un cas d'inoculation accidentelle du bacilli de Hanson en pays non lepreux. Int J Lepr. 1934;2:1-7.
Parritt RJ, Olsen RE. Two simultaneous cases of leprosy developing in tattoos. Am J Pathol.1947;23:805-17.
Grist NR, Emslie JA. Infections in British clinical laboratories, 1982-3. J Clin Pathol. 1985;38:721-5.
Muller HE. Laboratory-acquired mycobacterial infection. Lancet. 1988;2:331.
Pike RM, Sulkin SE, Schulze ML. Continuing importance of laboratory-acquired infections. Am J Public Health Nations Health. 1965;55:190-9.
Reid DD. Incidence of tuberculosis among workers in medical laboratories. Br Med J. 1957;(5035):10-4.
Kaufmann AF, Andersone DC. Tuberculosis control in nonhuman primates. In: Montali RJ, editor. Mycobacterial infections of zoo animals. Washington, DC: Smithsonian Institution Press. 1978. p. 227-34.
Allen BW. Survival of tubercle bacilli in heat-fixed sputum smears. J Clin Pathol. 1981;34:719-22.
Smithwick RW, Stratigos CB. Preparation of acid-fast microscopy smears for proficiency testing and quality control. J Clin Microbiol. 1978;8:110-1.
Oliver J, Reusser TR. Rapid method for the concentration of tubercle bacilli. Am Rev Tuberc.1942;45:450-2.
Richmond JY, Knudsen RC, Good RC. Biosafety in the clinical mycobacteriology laboratory. Clin Lab Med. 1996;16:527-50.
Janda WM, Knapp JS. Neisseria and Moraxella catarrhalis. In: Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 585-608.
Diena BB, Wallace R, Ashton FE, et al. Gonococcal conjunctivitis: accidental infection. Can Med Assoc J. 1976;115:609-12.
Malhotra R, Karim QN, Acheson JF. Hospital-acquired adult gonococcal conjunctivitis. J Infect. 1998;37:305.
Bruins SC, Tight RR. Laboratory acquired gonococcal conjunctivitis. JAMA. 1979;241:274.
Zajdowicz TR, Kerbs SB, Berg SW, et al. Laboratory-acquired gonococcal conjunctivitis: successful treatment with single-dose ceftriaxone. Sex Transm Dis. 1984;11:28-9.
Centers for Disease Control and Prevention [https://www.cdc.gov/]. Atlanta: The Centers; [updated 2006 April]. Gonorrhea – CDC Fact Sheet; [about five screens]. Available from: https://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm
Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWRRecommRep.2000;49(RR-7):1-10.
Boutet R, Stuart JM, Kaczmarski EB, et al. Risk of laboratory-acquired meningococcal disease. J Hosp Infect. 2001;49:282-4.
Centers for Disease Control and Prevention. Laboratory-acquired meningococcal diseases-- United States, 2000. MMWR Morb Mortal Wkly Rep. 2002;51:141-4.
Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 1997;46(RR18):1-35.
Centers for Disease Control and Prevention. Laboratory-acquired meningococcemia-- California and Massachusetts. MMWR Morb Mortal Wkly Rep. 1991;40:46-7,55.
Bopp CA, Brenner FW, Fields PI, et al. Escherichia, Shigella, and Salmonella. In: Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 654-71.
Grist NR, Emslie JA. Infections in British clinical laboratories, 1984-5. J Clin Pathol. 1987;40:826-829.
Nicklas W. Introduction of salmonellae into a centralized laboratory animal facility by infected day-old chicks. Lab Anim. 1987;21:161-3.
Steckelberg JM, Terrell CL, Edson RS. Laboratory-acquired Salmonella typhimurium enteritis: association with erythema nodosum and reactive arthritis. American J Med. 1988;85:705-7.
Baumberg S, Freeman R. Salmonella typhimurium strain LT-2 is still pathogenic for man. J Gen Microbiol. 1971;65:99-100.
Salmonellosis. In: Chin J, Ascher M, editors. Control of communicable diseases. Washington, DC: American Public Health Association. 2000. p. 440-4.
Blaser MJ, Hickman FW, Farmer JJ 3rd. Salmonella typhi: the laboratory as a reservoir of infection. J Infect Dis. 1980;142:934-8.
Grist NR, Emslie JA. Infections in British clinical laboratories, 1984-5. J Clin Pathol. 1987;40:826-829.
Sewell DL. Laboratory-associated infections and biosafety. Clin Microbiol Rev. 1995;8:389-405.
Centers for Disease Control and Prevention. Typhoid immunization recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep.1994;43(RR14):1-7.
Laboratory acquired infection with Escherichia coli O157. Commun Dis Rep CDR Wkly 1994;4:29.
Escherichia coli O157 infection acquired in the laboratory. Commun Dis Rep CDR Wkly 1996;6:239.
Booth L, Rowe B. Possible occupational acquisition of Escherichia coli O157 infection. Lancet.1993;342:1298-9.
Burnens AP, Zbinden R, Kaempf L, et al. A case of laboratory-acquired infection with Escherichia coli O157:H7. Zentralbl Bakteriol. 1993;279:512-7.
Rao GG, Saunders BP, Masterton RG. Laboratory-acquired verotoxin producing Escherichia coli (VTEC) infection. J Hosp Infect. 1996;33:228-30.
Spina N, Zansky S, Dumas N, et al. Four laboratory-associated cases of infection with Escherichia coli O157:H7. J Clin Microbiol. 2005;43:2938-9.
Chin J. Diarrhea caused by Escherichia coli. In: Chin J, ed. Control of Communicable Diseases. 17th ed. Washington, DC: American Public Health Association; 2000. p. 155- 65.
Nielsen EM, Skov MN, Madsen JJ, et.al. Verocytotoxin-producing Escherichia coli in wild birds and rodents in close proximity to farms. Appl Envrion Microbiol. 2004;70:6944-7.
Mermel LA, Josephson SL, Dempsey J, et al. Outbreak of Shigella sonnei in a clinical microbiology laboratory. J Clin Microbiol. 1997;35:3163-5.
Walker D, Campbell D. A survey of infections in United Kingdom laboratories, 1994-1995. J Clin Pathol. 1999;52:415-8.
Parsot C, Sansonetti PJ. Invasion and the pathogenesis of Shigella infection. Curr Top Microbiol Immunol. 1996;209:25-42.
National Research Council. Zoonoses. In: Occupational health and safety in the care and use of research animals. Washington, DC: National Academy Press. 1997. p. 65-106.
Norris SJ, Pope V, Johnson RE, et al. Treponema and other human host associated spirochetes. In: Murray PR, Barron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press. 2003. p. 955-71.
Fitzgerald JJ, Johnson RC, Smith M. Accidental laboratory infection with Treponema pallidum, Nichols strain. J Am Vener Dis Assoc. 1976;3:76-8.
Magnuson HJ, Thomas EW, Olansky S, et al. Inoculation syphilis in human volunteers. Medicine. 1956;35:33-82.
Farmer JJ, Janda JM, Birkhead K. Vibrio. In: Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Washington DC: ASM Press. 2003. p. 706- 18.
Sheehy TW, Sprinz H, Augerson WS, et al. Laboratory Vibrio cholerae infection in the United States. JAMA. 1966;197:321-6.
Lee KK, Liu PC, Huang CY. Vibrio parahaemolyticus infectious for both humans and edible mollusk abalone. Microbes Infect. 2003;5:481-5.
Morris JG Jr. Cholerae and other types of vibriosis: a story of human pandemics and oysters on the half shell. Clin Infect Dis. 2003;37:272-80.
Reidl J, Klose KE. Vibrio cholerae and cholera: out of the water and into the host. FEMS Microbiol Rev. 2002;26:125-39.
Daniels NA, Ray B, Easton A, et al. Emergence of a new Vibrio parahaemolyticus serotype in rawoysters. JAMA. 2000;284:1541-5.Erratum in: JAMA 2001;285:169.
American Public Health Association. Cholera and other vibrioses. In: Heymann HL, editor. Control of communicable diseases. 18th ed. Baltimore (MD): United Book Press, Inc. 2004. p. 103-15.
Dennis DT, Gage, KL. Plague. In: Cohen J, Powderly WG, editors. Infectious diseases. Vol II. 2nd ed. Edinburgh: Mosby; 2004. p. 1641-8.
Russell P, Eley SM, Bell DL, et al. 1996. Doxycycline or ciprofloxacin prophylaxis and therapy against Yersinia pestis infection in mice. J Antimicrobial Chemother. 1996;37:769-74.
Burmeister RW, Tigertt WD, Overholt EL. Laboratory-acquired pneumonic plague. Report of a case and review of previous cases. Ann Intern Med. 1962;56:789-800.
Higgs S. Arthropod containment guidelines. Vector-Borne and Zoonotic Diseases. 2003;3:57-98.Antigenic groups designated A, B, and C refer to the original comprehensive and unifying serogroups established by Casals, Brown, and Whitman based on cross-reactivity among known arboviruses (2,21). Group A viruses are members of the genus Alphavirus, group B belong to the family Flaviviridae, and Group C viruses are members of the family Bunyaviridae.

Section Ia: Policy for Laboratory Personnel Who Are Working With Neisseria Meningitidis

Policy Statement

This policy addresses the procedures required by the University to reduce the risk of exposure to Neisseria Meningitidis for laboratory personnel who work with this infectious agent. This policy also reinforces the University requirements of strict adherence to Standard Precautions for all personnel in laboratories, as adherence to Standard Precautions is the most effective way to prevent exposure and transmission.

Definitions

Standard Precautions are the minimum prevention measures that apply to all laboratory work. These evidence-based practices are designed to protect laboratory personnel from exposure to infectious agents. Standard Precautions include:
1. hand hygiene
2. use of personal protective equipment (e.g., gloves, gowns, eye protection), depending on the anticipated exposure
3. safe sharps procedures
4. safe handling of potentially contaminated equipment or surfaces in the laboratory environment
Neisseria meningitidis is a bacterium that causes meningococcal disease. About 10% of people have this type of bacteria in the back of their nose and throat with no signs or symptoms of disease. However, sometimes the bacteria can invade the body causing certain illnesses, known as meningococcal disease. N. meningitidis is the major cause of infectious morbidity and mortality globally, and is responsible for epidemics in Africa and in Asia. In the United States, 1000 to 2600 cases of N. meningitidis infection occur annually; most cases are sporadic.

Audience

Laboratory personnel who manipulate N. meningitidis or work in labs that manipulate N. meningitidis are covered by this Policy.

Reason for Policy

Recent laboratory-acquired infections as reported by the Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA) reflect the need for the University to address the potential risks associated in working with N. meningitidis and preventative measures used to mitigate those risks.

Roles and Responsibilities

UNC’s Environmental, Health, and Safety’s Biological Safety section and the University Employee Occupational Health Clinic are responsible for the administration of this Policy as it pertains to employees of the University. Final responsibility for compliance with this Policy, including the authorization of temporary or permanent work restrictions for faculty and/or staff, lies with the Dean of the appropriate professional school.

Contacts

Daniel Eisenman
Biological Safety Officer
The University of North Carolina at Chapel Hill
Campus Box 7470
Chapel Hill, NC 27599-7470
P: 919-962-5722
eisenman@ehs.unc.edu

James Hill, MD, MPH
Medical Director, University Employee Occupational Health Clinic
The University of North Carolina at Chapel Hill
UEOHC 145 N. Medical Drive
Chapel Hill, NC 27599
P: 919-966-9579
james_hill@med.unc.edu

Prevention

Vaccine

Three meningococcal vaccines are licensed in the United States, one polysaccharide vaccine (MPSV4) and two conjugate vaccines. One of the conjugate vaccines uses diphtheria toxoid as the protein carrier (MCV4-DT) and the other uses CRM197(MCV4-CRM) as the protein carrier. All three vaccines cover meningococcal serogroup A, C, W-135, and Y strains but not serogroup B strains, which are a common cause of meningococcal disease in the United States. In general, conjugate vaccines are preferred over polysaccharide vaccine. However, MCV4-DT is licensed only for persons 2 through 55 years old and MCV4-CRM for persons 11-55 years old. Vaccine effectiveness for the included serogroups is generally considered to be about 75%-90%. For adults, a single dose of vaccine is required with a second dose 5 years later among persons who remain at high risk. For information on the most commonly reported adverse events for MCV4-DT, MCV4-CRM, and MPSV4 and the medical contraindications, which include, depending on the vaccine, and allergic reaction to previous vaccine administration or vaccine components, see the Vaccine Information Sheet.

Vaccination will not be offered to those individuals over the age of 55. However post-exposure prophylaxis will be offered to anyone potentially exposed to N. meningitidis with consent.

Chemoprophylaxis

Antibiotic chemoprophylaxis with rifampin, ciprofloxacin, or ceftriaxone is available for the prevention of meningococcal disease following known high- risk exposures. Laboratory personnel with high-risk exposure, regardless of immunization status, should contact University Employee Occupational Health Clinic (UEOHC) at 919-966- 9119 immediately for evaluation for the need for chemoprophylaxis.

Laboratory Hazards and Communicability

Use of N. meningitidis is restricted to Biosafety Level 2 or Animal Biosafety Level 2 (BSL-2/ABSL-2) facilities with strict adherence to BSL-2/ABSL-2 engineering practices and personal protective equipment. All work with liveN. meningitidisorganisms must be done in a biosafety cabinet.

N. meningitidis can be transmitted in a laboratory setting through needlesticks, droplet exposure to the mucous membranes and poor adherence to biosafety precautions. Many of the cases of laboratory transmission have occurred while working with live N. meningitidis on an open bench. Use of a certified biological safety cabinet is required for manipulation of N. meningitidis.

Employees at Risk

Handling of the N. meningitidis agent and/or research animals experimentally infected with N. meningitidis creates the highest risk of exposure and potential infection. Due to the presence of engineering controls, personal protective equipment and work practices, employees entering areas where N. meningitidis is utilized are at less risk of infection.

Guidelines

Principal Investigators (PIs)

Registration/Notification

All Principal Investigators (PI’s) using N. meningitidis must register the agent in the Schedule F section of their laboratory safety plan.
Biosafety Level 2 practices, containment equipment and EHS-approved BSL2/ABSL2 facilities are required for all activities involving the use or manipulation of N. meningitidis and infected animals. Handling of N. meningitidis must be conducted in a biosafety cabinet.
Laboratories shall be inspected by EHS at least annually to verify appropriate BSL-2 containment and practices.
All individuals who directly handle a) cultures or b) animals contaminated or infected with non-attenuated N. meningitidis strains that infect humans must be medically screened by UEOHC for contraindications to N. meningitidisexposure and/or N. meningitidis vaccine. Vaccination is offered to individuals seeking to handle N. meningitidis or infected animals at the University of North Carolina. Proof of vaccination or written declination is required prior to working with N. meningitidis. Vaccination is provided at no cost to the employee.
Visitors are not permitted to handle N. meningitidis or infected animals at the University of North Carolina unless they have demonstrated proficiency at BSL-2 practices and have documented evidence of vaccination.
It shall be the responsibility of the Principal Investigator and/or individuals responsible for control of access to a N. meningitides facility to assure that individuals with potential N. meningitides exposure are enrolled in the occupational health requirements of this SOP, and are vaccinated before initial handling of N. meningitidis.
Laboratory personnel must wear personal protective equipment (lab coat, gloves, eye protection, and N95) when handling N. meningitidis and all manipulations of N. meningitidis must be performed in a biosafety cabinet. Personnel entering BSL2 containment facilities must abide by the PPE requirements for the specific facility as established by EHS. Refer to the University of North Carolina Biosafety Manual Chapter 4, Section 1 for more details on Biosafety level 2 requirements.
Anyone experiencing signs or symptoms of N. meningitidis (severe headache, stiff neck, fever) should contact University Employee Occupational Health Clinic (M-F 8:30 a.m. – 4:30 p.m., 919-966-9119). The PI must notify EHS. Notification should be made to the local health department within 24 hours of positive test results.

0 reviews

Print Article

Updating...

Biological Safety Manual - Chapter 08: Agent Summary Statements (Section I: Bacterial Agents)

Introduction

Table of Contents

Agent: Bacillus anthracis

Occupational Infections

Natural Modes of Infection

Laboratory Safety and Containment Recommendations

Special Issues

Vaccines

Select Agent

Transfer of Agent

Agent: Bordetella pertussis

Occupational Infections

Natural Modes of Infection

Laboratory Safety and Containment Reccomendations

Special Issues

Vaccines

Transfer of Agent

Agent: Brucella species

Occupational Infections

Natural Modes of Infection

Laboratory Safety and Containment Recommendations

Special Issues

Vaccines

Select Agent

Transfer of Agent

Agent: Burkholderia mallei

Occupational Infections

Natural Modes of Infection

Laboratory Safety and Containment Recommendations

Special Issues

Select Agent

Transfer of Agent

Agent: Burkholderia pseudomallei

Occupational Infections

Natural Modes of Infection

Laboratory Safety

Containment Recommendations

Special Issues

Select Agent

Transfer of Agent

Agent: Campylobacter (C. jejuni subsp. jejuni, C. coli, C. fetus subsp. fetus, C. upsaliensis)

Occupational Infections

Natural Modes of Infection

Laboratory Safety

Containment Recommendations

Special Issues

Transfer of Agent

Agent: Chlamydia psittaci (Chlamydophila psittaci), C. trachomatis, C. pneumoniae (Chlamydophila pneumoniae)

Occupational Infections

Natural Modes of Infection

Laboratory Safety

Containment Recommendations

Special Issues

Transfer of Agent

Agent: Neurotoxin-producing Clostridia species

Occupational Infections

Natural Modes of Infection

Laboratory Safety

Containment Recommendations

Special Issues

Vaccines

Post-Exposure Treatment

Select Agent

Transfer of Agent

Agent: Clostridium tetani and Tetanus toxin

Occupational Infections

Natural Modes of Infection

Laboratory Safety

Containment Recommendations

Special Issues

Vaccines

Transfer of Agent

Agent: Corynebacterium diphtheria

Occupational Infections

Natural Modes of Infection

Laboratory Safety

Containment Recommendations

Special Issues