october 31, 2011 anaheim, ca health watch and the glrce ...•β-thalassemia patients under...

Health Watch

and the GLRCE Emergency Response

An investigation of a fatal case of

laboratory-acquired septicemic plague.

ABSA

The 54th Annual Biological Safety Conference October 31, 2011

Anaheim, CA

Scope of Research Program

Two Campuses:

1. Howard T. Ricketts Regional Biocontainment

Laboratory

– On the DOE campus of Argonne National

Laboratories

2. University of Chicago-Hyde Park

2

Ricketts RBL

• Home of UC Select Agent Program

– Since January, 2010

• 5 Principal Investigators/~50 staff/1 ABSO

• Houses BSL2, BSL3 and ABSL3

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Yersinia sp. (SA and non-SA) Rickettsia sp. (SA and non-SA)

Bacillus sp. (SA and non-SA)

Coxiella sp. (non-SA)

Brucella sp. (SA)

Staphylococcus sp. (non-SA)

UC Hyde Park

• ~ 220 Principal Investigators

• ~ 350 protocols

• IBC annual workload

– ~50 new protocol submissions

– ~80 protocol re-submissions

– ~200 amendments

• Three IBC staff/One ABSO

4

UC Hyde Park

• One ABSL3 (Prion Disease)

• Remainder: BSL2, BSL2-enhanced, ABSL2

• Prior to January 2010, three of the BSL3/

ABSL3 programs now housed at Ricketts were

conducted in one BSL3 suite and two ABSL3

suites.

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UC Hyde Park Agents

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Viral Vectors Viruses (Replication-

competent)

Viruses

(Replication-

competent

Adenovirus (Replication-

defective) Herpes Simplex Virus 1 Dengue Virus

Adeno-Associated Virus

(Replication-defective) Epstein-Barr Virus Reovirus

Murine retroviruses

(Replication-

defective/amphotropic)

Influenza A Vaccinia Virus

(Attenuated)

Lentivirus (Replication-

defective) Influenza B Rotavirus

UC Hyde Park Agents

Bacteria

Salmonella

typhimurium

Coxiella burnettii

(vaccine strain)

Yersinia

pseudotuberculosis

Mycobacterium

avium

Staphylococcus

aureus

Yersinia

pseudotuberculosis

Listeria

monocytogenes

Enteropathogenic

E. coli

Listeria

monocytogenes

Bacteroides fragilis

Vibrio cholerae Serratia

marcescens

Yersinia

enterocolitica

Legionella

pneumophila

Shigella flexneri Klebsiella

pneumoniae

Pseudomonas

aeruginosa

7

Fungi

Aspergillus fumigatus Candida albicans

Agent Profile Forms

• Required for any pathogen or molecular vector

managed at BSL2/ABSL2 or above.

• Describe biological features of pathogen,

including source, susceptibility to disinfectants,

drug sensitivity, environmental stability, routes of

infection, BSL/PPE, treatment paradigm.

– Accompanies investigator to UCOM in the event of

an exposure

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Agent Profile Forms

9

Agent Profile Forms

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Occupational Health/Medical Assessment (pre-employment for BSL3/ABSL3)

• Occupational Medicine

– Health Questionnaire

– PFT as needed; Clearance for use of respiratory

protection (PAPR)

– Vaccination (e.g. influenza, AVA)

– Serological surveillance (very limited)

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Occupational Exposure

• Examples

– Needle stick, bite or scratch

– PIM splash into mucus membrane/exposed skin

– Aerosol exposure

– Medical Emergency within primary containment

– Disease symptoms exhibited by investigator

– Confirmed LAI

Occupational Exposure First Aid

Skin Contamination

• Proceed to Ante Room

• Disinfect by submersing or exposing the area with 70% alcohol for 10 minutes.

Needle Sticks, Contaminated Cuts and Animal Bites/Scratches

• If bleeding, squeeze out blood, spray with 70% alcohol

• Proceed to Ante Room

• Disinfect with iodine solution (povidone-idone) or peroxide for 20 minutes

• Wipe surrounding tissue with iodine solution or peroxide

Eye Contamination

• Proceed to nearest Eye Wash

• Flush eyes in eye wash for 15 minutes.

Aerosol Exposure

• Exit lab under normal SOP

Occupational Exposure First Aid

Exit under normal SOP

• Immediately after exiting, contact the University of Chicago

Occupational Medicine (UCOM) Bloodborne Pathogen/Needle

Stick hotline at ###-###-####, enter pager number ####,

followed by #.

• Notify PI, BSO, RO/ARO (SA) and supervisor

For Life Threatening Situations call 911.

Health Watch SOP

BSL3/ABSL3

Independent of known exposure event

If fever develops (oral temp 101.5o F) with or without

respiratory complaints or other disease symptoms

employee shall report the illness

Within 14 days of last entry into containment

Contact UCOM BBP/ID Hotline

Contact RO/ARO/PI

Assessment and Treatment provided by UCOM as

needed

Wallet Cards

Notification Name: Joe Kanabrocki

Biosafety Level 3 Agent(s):

Anthrax (Bacillus anthracis AMES strain)

Plague (Yersinia pestis CO92 and/or KIM strain)

Rickettsia (Rickettsia rickettsii)

Vaccinations Received: None

University Emergency Contact Number:

Outside Medical Center: ###-###-####, enter ####, followed by #

Medical Center: ###, enter ####, followed by #

Agent/Treatment Information:

www.phac-aspc.gc.ca/msds-ftss

http://www.phac-aspc.gc.ca/msds-ftss





Health Watch SOP

BSL2/ABSL2

Monitor health for disease symptoms;

Employee shall report the illness if disease symptoms

suggest LAI

Contact UCOM BBP/ID Hotline

Contact BSO/PI

Assessment and Treatment provided by UCOM as

needed

GLRCE Emergency Response:

An investigation of a fatal case of

laboratory-acquired septicemic plague.

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Septicemic plague –

sequence of events

September 13, 2009

• researcher dies in the Emergency Room of the University of Chicago

September 15, 2009

• blood cultures positive for Gram-negative rods and Gram-positive cocci

September 16, 2009

• memorial service at Bond Chapel

September 18, 2009

• Autopsy report by the University of Chicago: no obvious cause of death,

including no pulmonary pathology.

• Clinical microbiology reports Gram-negative rod preliminarily identified

as Yersinia pesudotuberculosis.

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sequence of events

September 18, 2009 (con’t):

• Case review determines that Deceased worked with Y.p. KIM D27, an attenuated, non-SA strain of Y.p. approved for work at BSL2. The Deceased’s lab bench, all research materials quarantined immediately.

• Finding reported to UC Admin, CDC, IDPH (Illinois), CDPH (Chicago), CDC SAP, NIH-NIAID, NIH-RAC, DOE, ANL (Argonne National Laboratories);

• UC Public Affairs issues press release;

• GLRCE Emergency Response Core identifies Gram-negative rods as the non-pigmented Yersinia pestis isolate UC91309 (PCR, Western blots); the Gram-positive cocci were identified as Streptococcus defecticus

20


sequence of events

September 18-19, 2009

• Infectious Diseases and UC Hospital Infection Control, together with CDPH, contact all lab contacts and patient contacts of the Deceased to offer tetracycline prophylaxis; approximately 100 persons offered antibiotics.

September 19, 2009:

• 8:00 AM conference call/data review with the CDC, IDPH, CDPH, UC Hospital IC, ID, ES, Risk Mgmt, GC, Microbiology and UC Administration.

• CDPH decision to close down lab bench pending data review & inspection of laboratory, scheduled for Monday, Sept. 21 at 1:00 PM.

21


sequence of events September 21, 2009

• CDC, CHPH, IDPH, County PH, OSHA, NIOSH, Chicago Police

Department arrive on-site for investigations, which continue through

Thurs., Sept 24. OSHA leaves after first day, returning Oct. 5. CPD

leaves after the first day.

September 22-24, 2009

• Investigations continue. Protocols and training records examined,

approx. 30 lab staff and maintenance workers interviewed by CDPH.

September 23, 2009

• Emergency Response Core animal experiments with non-pigmented

plague isolate indicate attenuation

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sequence of events September 24, 2009

• On-site investigation ends.

October-November, 2009: Investigation continues:

• Genome sequence for the plague isolate UC91309

• Genetic information for the deceased becomes available

• Genome sequence for the parent strain KIM D27 and laboratory records indicate that the deceased had constructed UC91309

October 16, 2009

• Formal incident report filed with NIH-OBA

August 2, 2010

• University of Chicago IRB, legal counsel, CDC as well as City and State Public Health Departments endorse submission case report

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sequence of events November 23, 2010

• UC provides an update report to the NIH Office of Biotechnology Activities

December 30, 2010

• Chicago Dept. of Public Health issues final investigation report.

February 25, 2011

• CDC publishes case report in Morbidity and Mortality Weekly

March 14, 2011

• U.S. Occupational Safety and Health Administration (OSHA) provides a final report to the UC, with recommendations but no citations.

– Incorporates December 18, 2009 final report and findings of NIOSH investigation

April 8, 2011

• NIH Office of Biotechnology Activities provides a report to the UC with a request for additional documentation.

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Investigation Findings: University of Chicago

• Characterization of clinical isolate:

– Microbial analysis

– Molecular analysis

– Virulence assessment

• Characterization of post-mortem specimens

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Wright-Giemsa staining of peripheral blood Safety-pin stained bacteria and leukemoid reaction

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Liver – hereditary hemochromatosis H&E and iron staining reveal intracellular iron deposits

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Lung -

intravascular Y. pestis Lillie-Twort Gram and HE stains

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Spleen Necrosis and immuno-histochemical

identification of Y. pestis

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UC91309 non-pigmented Y. pestis (V+, F1+)

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UC91309 genome sequence pgm and HPI are absent

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Yersiniabactin,

the iron scavenger of transferrin

Crosa and Walsh (2007) MMBR

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UC91309 harbors cat primers define the cat insertion site

on the chromosome

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Attenuation and iron-dependence of

UC91309 in Swiss -Webster mice

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Pathology of UC91309 infection

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Hereditary hemochromatosis

N.D. Andrews (2008) Blood 112:219

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Antemortem iron load in a patient with

septicemic plague

• serum ferritin 392,530 ng/ml (20-300) – a measure for liver iron storage

• total iron binding capacity 648 µg/dl (230-430) – a measure for the abundance of transferrin

• iron 541 μg/dl (40-160) – the amount of iron in the serum

• iron saturation 83.5% (14-50%) – the % amount of transferrin charged with iron

• liver iron 14,672 µg/g dry weight

Frank et al. (2010)

37

Yersiniosis and hemochromatosis

• β-thalassemia patients under deferoxamine therapy (streptomyces siderophore) are highly susceptible to Y. enterocolitica infection

• Patients with iron overload or secondary hemochromatosis due to blood transfusions receive deferoxamine treatment and this increases their susceptibility to Y. enterocolitica infection

• Hereditary hemochromatosis patients (HFE C282Y) display increased susceptibility towards Y. enterocolitica infection and liver abscesses even without deferoxamine

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Investigation Findings: Chicago Dept. of Public Health/CDC

• Case Report

• Epidemiological and Environmental

Investigation

• Laboratory and Pathologic Testing

39


• Case Report

– Deceased researcher was a 60 y/o, insulin-dependent

diabetic. Last day in lab was Sept. 4.

– Seen in outpatient clinic on Sept. 10, three days prior to

ER admission for fever, body aches and cough (3 days

duration).

– Subsequently seen in ER (Sept. 13) for fever, cough,

worsening shortness of breath.

– Patient expired in ER.

40


• Case Report

– Blood cultures yielded:

• Gram negative bacilli: ultimately determined to be Yersinia pestis

KIM D27 derivative (attenuated, non-SA)

• Gram positive cocci: ultimately determined to be a nutritionally

variant Streptocci (NVS).

– Autopsy:

• No signs of pneumonia, bowel perforation or endocarditis.

• Preliminary diagnosis of hereditary hemochromatosis.

– Later confirmed through genetic testing.

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• Epidemiological and Environmental Investigation

– Antibiotic prophylaxis offered to close contacts

• Inhalation exposure not ruled out at this time.

– Lab environment assessment revealed no deficiencies in lab

engineering controls; no history of work-related injuries or

illnesses.

– Training records revealed deficiencies in attendance of

required of some lab staff (including deceased)

– No reports of exposure incidents.

– Interviews with co-workers revealed inconsistent compliance

by deceased with lab PPE policies.

42



– PCR and microbiological testing confirmed pgm- genotype

and colony pigmentation (CDC).

– Antibiotic resistance testing confirmed presence of

chloramphenicol resistance gene.

– Virulence testing in mouse in vivo model confirmed “that

the strain with which the patient was infected was attenuated and

that no new virulence mechanisms were acquired by or engineered into

the infecting strain.”

43



– Histopathological examination ruled out pneumonic

plague as a cause of death; consistent with diagnosis of

septicemic plague.

– Histologic staining revealed abnormal iron deposits in the

liver.

– Post-mortem blood chemistries were consistent with UC

findings regarding elevated serum iron content.

44


• Conclusions:

– First known fatality from a lab-acquired infection with an

attenuated Y.p. strain.

– Findings are consistent with cause of death being septic shock

from Y.p. infection and inconsistent with pneumonic plague.

• Suggestive of a trans-dermal or mucosal route of infection.

• Inconsistent use of gloves could have resulted in an inadvertent

transdermal exposure.

– Severe outcome of infection with Y.p. (pgm-) was unexpected.

45


• Conclusions:

– NVS bacteremia cannot be excluded as a contributing factor

in the patient’s death.

– Animal studies have shown that virulence of Y.p. KIM D27

can be enhanced by simultaneous injection of iron into

experimental animals.

• Hemochromatosis-induced iron overload might have a similar effect.

– Diabetes is a known risk factor for increased severity and

complications from bacterial infections.

46


• Conclusions:

– Researchers working with attenuated Y. pestis and other

potentially infectious materials should always use at least BSL2

practices.

– Lab managers should ensure that staff adhere to

recommended biosafety practices.

– Institutional safety committees should implement and

maintain effective surveillance programs to identify and

monitor acute illness among lab workers.

– Health-care providers should routinely inquire about

occupational exposures when evaluating patients.

47

Investigation Findings: OSHA: Major Finding and Conclusion

“Apparent violations warranting citations

were not found during the inspection period.”

48

Investigation Findings: OSHA: Recommendations

1. Prior to start of work on an attenuated pathogen, identify all

know factors that could potentially enhance virulence and

be hazardous to workers. The principal investigator should

ensure that the attenuated strain remains attenuated.”

2. Implement a medical surveillance program to provide

confidential screening for personnel for the presence of, or

potential predisposition to, these factors.

3. Train laboratory personnel and supervisors to recognize the

signs and symptoms of the virulent form of the pathogen

being studied.

49


4. Educate workers and supervisors about the hazards in the

workplace and any potential risks and personal risk factors that

may cause injury or illness.

5. Train workers how to obtain medical evaluations for suspected

occupational exposures and illness, including access to medical

evaluation after work hours.

6. Encourage laboratory personnel to report immediately to a

supervisor any signs and symptoms of illness.

7. Train supervisors to authorize and arrange for immediate

medical evaluation for workers reporting any signs and

symptoms of illness.

50


8. Develop, implement and maintain an effective medical

evaluation program to identify, treat and track acute illness

among laboratory personnel.

9. Supervisors and managers should ensure that staff adheres

to recommended biosafety practices (Biosafety in

Microbiological and Biomedical Laboratories [BMBL], 5th Edition)

51

Investigation Outcomes

• CPD reports no evidence of criminal activity;

• CDC, CDPH, IDPH indicate that incident appears to be an isolated incident

with no threat to the public and no systemic issues identified;

• OSHA and NIOSH complete investigation issuing no citations or fines.

June 16, 2010

• NIH RAC debates applicability of NIH Guidelines Major Actions (III-A-1) clause

to attenuated Y. pestis strains.

– Lcr- are exempt

– Pgm- are NOT exempt, although CAM marker use is exempt.

52

Investigation Outcomes: UC Biosafety Program Enhancements

• Biosafety Office staffing increased from 2.0 to 3.5 FTE.

• Each investigator (PI, post-doc, student, tech) in the Dept. of

Microbiology has received a personalized biosafety manual:

– Agent Profile Forms for all pathogens present in work area.

• A written Code of Conduct has been established and each investigator

in the Dept. of Microbiology has signed this agreement.

• Includes provisions for peer reporting, self reporting.

• Includes commitment to adherence to established lab safety standards.

• Includes provisions for ethical conduct and scientific integrity.

• BSO/RO meets personally with all staff in SA program annually

53

Investigation Outcomes: UC Biosafety Program Enhancements

• Institutional BSL2 Biosafety Manual drafted. Will be distributed

during lab inspections and made available via web.

• Training module on peer reporting being developed for Biological

Sciences Division.

• Numerous biosafety training modules under development.

54

GLRCE

Emergency Response Core

• Mobilized immediately upon incident notification.

• Rapidly integrated and coordinated activities of institutional scientists and administration officials, local and Federal public health, law enforcement, regulatory and investigational agencies.

• Immediate and sustained communication with the public

• Evaluated institutional programs and implemented safety program enhancements.

• Performed incident review and response analysis; poised to share lessons learned.

55

Lessons Learned

• All investigators should inform their personal physician

about their work and hazardous materials, incl.

pathogens, with which they work.

• All investigators should be aware of their own health

status and about potential susceptibilities resulting

from illness, whether chronic or acute.

• All investigators should be aware of disease signs and

symptoms associated with pathogens with which they

work.

56

Lessons Learned

• All investigators should adhere to established biosafety

practices.

• Occupational Health Watch protocols should be

established to monitor for signs and symptoms of

disease, even in absence of known exposures.

• Mechanisms for reporting issues of non-compliance

should be established and training should be provided;

all investigators must commit to an ethical code of

conduct.

57

CREDITS GLRCE EMERGENCY RESPONSE

Olaf Schneewind, Julie Bubeck-Wardenberg (UC Dept. of Microbiology)

John Bivona (U of C Biosafety)

Karen Frank, Peter Pytel, John Hart (U of C Pathology)

Helene Louvel, Bill Blaylock, Nate Miller (U o fC Microbiology)

Stephen Weber (U of C Medicine)

Elizabeth Marland Glass (ANL)

Lauriane Quenee, Tim Hermanas, John Schramm (HTRL)

Paul Keim, Jim Tschupp (Translational Genomics Research Institute)

William Nierman (JCVI)

Wun-ju Shieh , Sherif Zaki (CDC)

Rona Hirschberg, Michael Schaefer (NIAID RCE)

58

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