Biological and Clinical Sciences Research Journal
ISSN: 2708-2261
DOI: https://doi.org/10.47264/bcsrj0201008
Biol. Clin.
Sci. Res. J., Volume, 2021: e008
BIOSAFETY AND BIOSECURITY OF LAB AND HOSPITAL ACQUIRED
INFECTIONS
ISHAQUE
S, ARSHAD A, *HAIDER MA, FATIMA F
1Department of Biotechnology, Kinnaird College for
Women, Lahore, Pakistan
2Institute
of Molecular Biology and Biotechnology, University of Lahore, Lahore, Pakistan
*Corresponding author: maounh07@gmail.com
Abstract: Microbes have the ability to transmit and reproduce.
Pathogenic microbes when released and spread in the environment can cause
infectious diseases. This release can be natural, accidental, or intentional.
Whatever might be the cause of release it can cause devastation and destruction
of not just human health but the entire system of the affected region. It is,
therefore, very important to handle these microbes with utmost precautions to
avoid any such situation. When released either intentionally or accidentally
the best response is to limit its transmission by adopting preventive measures.
Most of the lab acquired infections (LAIs) are bacterial and viral in nature.
Infectious agents having a potential hazard to cause LAIs are bacillus
anthracis, Francisella tularensis, Brucella spp., yersinia pestis, smallpox,
VHF agents, and botulinum. Small doses of these agents can be controlled under
BSL2 while dealing with large quantities requires BSL3 practices.
Hospital-Acquired infections (HAIs) can be transmitted via direct or indirect
contact, droplet transmission, and air. Pathogens encountered causing HAIs are
usually bacteria, viruses, and mites. The transfer of pathogenic agents in
healthcare personnel can be avoided by treating them with vaccines whenever
such a risk is expected. They should also be given PPEs and trained to use them
in an effective manner. All the hygiene and sterilization procedures should be
strictly followed. The cleansing of surgical instruments and the physical
environment in hospitals is also very important to prevent HAIs.
Keywords:
infectious diseases, pathogens, bacterial, viral, lab acquired infections, Spanish flu
Introduction
Nearly, 1400 species of microbes are
known to be of possible threat to humans (Taylor et al., 2001). Release of microbes in the environment causes the
epidemic. This release can be as a result of natural mechanism, unintentional release or intentional release. The epidemic of diseases caused by
infectious agents has been recorded since 500BC when a typhoid fever likes
unknown disease ‘the plague of Athens’ killed almost 100,000 people. The
history of Europe has a number of incidents of plagues ranging from Antonine plague that killed 30% of its population to the
Black Death that finished 70% of the population. This left the cities deserted
and whose record was only found through archeology (Morens
et al., 2009; Eitzens
and Takafyuji, 1997). An epidemic that crosses
boundaries and occurs worldwide, effects people on
large scale is a pandemic.” This is how pandemic is defined internationally
(Harris, 2000). The pandemic of
influenza, AIDS, severe acute respiratory syndrome (SARS), plague, west Nile
disease, cholera, small pox etc. are the well-known pandemics of human history
(Qiu and Chu 2019). Among these
influenza has been the worst of all the pandemics. Since 1500s this pandemic
occurs periodically three times in a century i.e. more or less after every 10
to 15 years (Qiu and Chu 2019). During the 20th
century the 1st pandemic was in the year 1918 to 1919 which was
named as Spanish flu, this pandemic destroyed the lives of more than 20 million
people (Morens et
al., 2009). This according to WHO is the most severe pandemic of the world
history (WHO, 2011). Then second pandemic named Asian flu was in 1957 to 1958,
killed almost million deaths and then again in 1968-1969 in Hong Kong occurred third pandemic of influenza and almost one million
people died of it (Qiu and Chu 2019).
Of the 21st century major
epidemic outbreaks were hanta virus pulmonary syndrome, H5N1 influenza, the
Middle East respiratory syndrome, H1N1 influenza and the Ebola virus disease (Gostin et al.,
2006). Ebola caused the death of more than 11,000 (Maurice, 2016). In 21st
century the first influenza pandemic was of H1N1virus of 009 which killed more
than 18000 people worldwide. Microbial forensics deals with bioterrorism by
first identifying the source of
disease causing biological agent and then associating that act of release to a
specific individual or group. Microbial forensics need to improve its
competence so that differentiation among unintentional release, natural
outbreaks and bio crimes can be done. It must provide satisfactory quality
evidence to carry out legal proceedings (Carus,
2001). Examples of events of bioterrorism
include the use of smallpox on South American groups in 15th century with
clothes contaminated by variola (Eitzen
et al., 1997; Christopher et al., 1997). Also smallpox was used in
French-Indian war on the native Indian groups that were unfriendly with British
(Christopher et al., 1997; Henderson,
et al., 1999).
During the World War 1, some say
that Germans sent cattle and horses infected with B. anthracis and P. pseudomallei to USA and other
countries (Eitzen et
al., 1997; Stockholm et al.,
1994). The ‘unit 731’ of Japanese bio-warefare
program used to test the prisoners of war with pathogenic agents like Yersinia pestis, Shigella spp, Vibrio cholera, Neisseria meningitides,
B. anthracis
(Eitzen et al.,
1997). Due to this testing almost 10,000 prisoners died between 1932 and 1945,
these were the prisoners of World War 2 (Riedel, 2004). In April 1979, the
anthrax epidemic started spreading in a city of Russia called Sverdlovsk. Death
of livestock started happening in that area. Human anthrax cases there were as
result of eating the meat of infected livestock. When investigated by US and
European intelligence, they characterized it as the accident release of spores
of anthrax (Riedel, 2004).
Before March 1995, using the anthrax and botulin toxin three unsuccessful bioterrorism attempts were
made by cult in Japan and before that in 1992 the members of cult made another
bioterrorism attempt using Ebola virus in Zaire (Christopher et al., 1997; Caudle, et al., 1997). But no sufficient
evidence was collected by Japanese intelligence, only little information
collected was made available to public (Riedel, 2004). During 2001 in US the
attack by letters of anthrax was another example of bioterrorism. All the
current cases at that time were as a result of indirect or direct contact with
these letters (Lin et al., 2016). Due
to all such attempts of bioterrorism it becomes difficult to differentiate if
the epidemic is naturally occurring or an act of bioterrorism (Riedel, 2004).
Either the outbreak is accidental or intentional; in both the cases it is
important to identify the source
of release to ensure public health safety by stopping the further release of
microbe. Formation of federal bureau investigation in united stated began
microbial forensics in 1990s. The unit called hazardous materials response unit
(HMRU) was made to deal with events suspected of bioterrorism. Forensics must
be able to answer leader’s questions such as the source of biological agent,
law enforcement and public health by help of forensic science. The information
should be of such evidence that is acceptable by the audience as well (Riedel,
2004).
World’s economy and region’s stability both gets effected by the spread of
these infectious diseases since these communicable agents easily cross
boundaries, as happened earlier in case of HIV, H5N1, H1N1, SARS epidemic and
Spanish flu pandemic (Lin et al.,
2016; Davies, 2013). Apart from economy and health, pandemics also influence
social behavior, political moments, transport, education, agriculture, tourism,
animal health and financial sector (Davies, 2013). The certain characteristics
that must be present in a biological agent to cause pandemic or to act as an
agent of bioterrorism are its pathogenicity, possibly
high mortality rate and its ability to cause such an infectious disease that is
difficult to treat. Other characters may include its ability to reproduce and
spread rapidly and its stability under normal conditions. Communication is of
great importance in the prevention and control of pandemics (Philip, 2002). The number of people it would affect would greatly depend
upon its route of transmission.
Definitely if the agent is airborne is would affect greater number of people in
small period of time (Philip,
2002). If the agent transmission is by
water or food then it would possibly affect specific groups of people. Other
routes of transmission may include blood, body fluids, some insect vectors and
medicines (Kruse et al., 1991).
Prevention of the spread of these biological agents depends upon its route of
transmission (Philip,
2002).
Lab-acquired
Infections
Mostly lab acquired
infections are due to isolates of new infectious agents shown from experience (Kruse et
al., 1991). The factor that risk of infectious agent exposure to lab
workers is negligible as compared to other health care workers groups (HCW),
but that risk is greater in employees of clinical and research laboratories
rather than in the general population. It suggests that unique risks are often
linked with the laboratory workspace. At first, it was observed that
laboratory-acquired infections are mainly due to bacteria, rickettsia
and viruses. Many of these agents were transferred by air so it led to the use
and development of biosafety cabinets with laminar
flow and HEPA filters. According to this observation, it was thought again that
lab associated infections are mostly because of the viruses which transfer
mostly through contact and not by bacteria (Kiley, 1992).
Laboratory safety practices
with specific agents
(i)
Bacillus
anthracis
Bacillus
anthracis is bacterial specie
which is present in many clinical samples, including cerebrospinal fluid (CSF),
blood, pleural fluid, wound exudates, sputum and infrequently in urine and
feces. The major hazards to lab personnel are indirect or direct contact of infectious
inoculation culture with intact or broken skin. Screening of
environmental samples lead to the hazard of aerosol infections exposure.
To control the spread of culture and clinical specimen of Bacillus anthracis, BSL2 practices along
with containment facilities and equipment are enough. But if we are working
with high loads of cultures for which there is high potential of aerosol
spread, including suspect powder, then we apply BSL3 conditions (Lin et
al., 2016; David, 2003).
(ii)
Francisella tularensis
F.
tularensis
is commonly spread through air and an easy cause for lab acquired infections. Francisella tularensis is
nearly present in all clinical specimens. However, in most cases, large amount
of liquid cultures of Francisella
tularensis
are handled in research facilities. Hazards include accidental ingestion of the
culture, direct contact of infectious culture with the mucous membranes or
skin. Manipulation of cultures can be exposed through the air in the form of
droplets and can cause infection. Among all the biggest risk to lab workers
comes with the manipulation of cultures. For the safe handling of Francisella tularensis,
practices of BSL2 and containment equipment is suitable but more accurate with
BSL3 when handling cultures (Gilchrist
et al., 1992; Lin et al., 2016; David,
2003).
(iii)
Brucella spp.
The most vulnerable
laboratory-acquired infection reported is the infection of Brucellosis because
only a small dose of it can cause infection. The sources of Brucellosis spread
include blood, semen, CSF fluid and seldom, urine. Hazards associated with the
spread of this infectious agent are either the direct contact or indirect
contact of Brucellosis with mucous membrane or skin, or accidental ingestion of
air droplets generated during culture manipulation. Laboratory safe handling is
working with Brucellosis in BSL2 and clinical safe handling in BSL3 are
recommended (Lin et al., 2016; David,
2003).
(iv)
Yersinia
pestis
Y.
pestis is not a usual cause
of lab acquired infections. The chances of its spread are rare. Samples of Yersinia pestis include
blood, CSF fluid, feces, sputum, urine and bubo fluid. Hazard of Yersinia pestis spread
to lab personnel include exposure to infectious aerosols or droplets of
manipulated cultures, accidental ingestion or inoculation and direct contact of
infectious cultures with skin or mucous membrane. With small sample sizes, BSL2
is recommended for the safe handling of Yersinia pestis but at large samples sizes with high potential
of spread through air droplets, BSL3 practices are recommended to carry out (Gilchrist et al., 1992; Lin et al.,
2016; David, 2003).
(v)
Smallpox virus
Smallpox virus has a very high potential of
spread to lab personnel therefore, very high precautions are undertaken for its
safety. The main sources of smallpox virus are respiratory excretions and
tissues and smallpox lesion crusts or fluids. The primary hazards include
exposure not infectious aerosol dispersal, accidental ingestion or parenteral inoculation, or direct or indirect contact with
broken skin or mucous membrane. At clinical level, if there are mild or high
symptoms of smallpox present in a patient, doctors should immediately contact
state health department prior to collect the specimen. The lab personnel who is previously vaccinated against small should only be
allowed to collect samples. Testing of patients with very high risk and
potential of smallpox should be done by National laboratory of D level. BSL2
conditions are enough for testing patients with low risks of smallpox
infection. In any case smallpox is not identified by testing, immediately
contact with local or state level health departments (Lin et
al., 2016; David, 2003).
(vi)
VHF agents
Hemorrhagic fevers
also pose greater risks of lab acquired infections to the lab personnles. Samples of this infectious agent are urine,
blood, semen, throat and respiratory excretions. Infectious aerosol exposure,
unintentional ingestion or parenteral inoculation and
exposure of mucous membrane with infectious air droplets are primary hazards of
spread of VHF agents. Safe handling of VHF agents is carried out with BSL3
practices and appropriate PPEs to lab personnel. After consultation, specimen
from patients suspected with VHF agents should be send to National Laboratory
for testing procedures (Lin
et al., 2016; David,
2003).
(vii)
Botulism
Botulinum
also poses a threat to lab infections. Sources are feces, serum, environmental
samples, gastric juice and food. Primary hazards include direct contact of
mucous membrane or broken skin with botulinum toxins
and through the ingestion of toxins along the respiratory tract. Safe handling
of botulinum toxins is carried out in BSL2 with a
face shield or mask. Manipulated cultures are treated under BSL3 (Gilchrist et al., 1992; Lin et al.,
2016; David, 2003).
Management of
laboratory accidents
A safety plan is the most careful approach to identify the potential
hazards and risks of laboratory accidents and exposures to infectious agents. Thus, minimizing the cause of lab accidents or potential exposure
(Gilchrist et al., 1992). All
the management and control programs are planned according to that infectious
agent while keeping in view all its risk assessments (David, 1995). If there occur an accidental exposure, it should be reported
immediately to the safety officer and the supervisor. After the accident,
instant medical care is sent to give first aid to lab personnel and to control
the exposure of the infectious agent. Following are the investigation of the
accident to determine the risk factor and source of exposure, specially, in the
case blood borne pathogens. On the subject of risk assessment of infection,
confidential medical consultation with the employee is arranged so to get more
information about the potential of transmission of infection to the family
members, future supervision and medication, the need of prophylaxis and helpful
actions that could be taken in the future to prevent the accidental exposure of
infectious material. If the patient is infected with the blood borne pathogen
e.g. HIV virus or any type of hepatitis virus, the action plan is dependent on
the status and level of infection of the patient. Employee health manual should
cover the management plan of already occurred lab accidents and also the
expected future lab exposures based on the frequency of that infectious agent
to cause disease in population and also its types which are under use in
industrial and research projects (David, 1995).
Hospital-acquired
Infections
Hospital
acquired infections (HAIs) is an important safety issue for health stability
givers and their patients. Considerations of being unhealthy, death rates,
longer stay at hospitals, and thus the increased costs are also important in
this regard. Therefore, measures should be taken to make the health care
institutions as safe as they possibly could be by getting rid of such
infections (Plowman et al., 1999; Wenzel, 1995).
HAIs are caused by a variety of sources. These include viruses, other
microorganisms such as bacteria and fungi as the possible factors. Significant
reasons that cause vulnerability to HAIs are the instruments used for cannulation, drug delivery for therapy and contact with
infectious fluids from the patient’s body during supportive healthcare
procedures. The Centers for Disease Control and Prevention (CDC) has given an
alarming approximate figure of two million people being affected by HAIs each
year out of which almost 100,000 lose their lives due to it (Deoine et
al., 2009).
Sources of infectious
agents
The factors causing
infections are usually traced back to human sources, but physical environment
also plays a considerable role in transmission. Human carriers and sources
include. Patients, health care providers, family members and other visitants.
These sources may be carrying infections in active form, or the pathogens may
be harboring in the incubation time in them or they may be acutely or
chronically affected by those pathogens which are deposited in their
respiratory system or gut. The naïve set of disease-causing organisms in such
tracts may also be a factor in causing HAIs (Siegel et al., 2007).
Modes of Transmission
and their control
Direct contact
transmission
As mentioned
previously the infected fluids from a patient’s body can infect the healthcare
providers. Blood or other such fluids can meet the patient via mucous membrane
(Rosen 1997)
or exposed areas such as cuts and wounds on the skin (Beltrami et al., 2003). Mites from the body of a patient
suffering scabies are transmitted to the skin surface of a healthcare provider
by just a direct contact with the patient’s skin for example the on contact
without gloves (Obasanjo et al., 2001;
Andersen et al., 2000).
Similarly, a caregiver can be infected with whitlow on hand or fingers after
direct handling of an HSV patient when giving oral treatment to a patient
especially in the absence of gloves. On the other hand, HSV can be transferred
to a patient from the pathogen carrying hands of a caregiver with no gloves and
contamination with herpetic whitlow (Avitzur and
Amir, 2002).
Indirect contact
transmission
Infections can spread
by the hands of health caregivers if they do not follow the proper hand hygiene
procedures between treating more than one patient. Pathogens from one patient
may be transmitted to the other by the contaminated hands or healthcare
instruments of the healthcare personnel (Duckro et al., 2005).
The healthcare devices are another factor of indirect contact transmission
leading to HAIs. These can include temperature monitoring thermometers, glucose
measuring apparatus etc. If these instruments have come into contact with an
infected person and are contaminated with the patient’s body fluids such as
blood or saliva and then they are not properly sanitized before being used for
other patients they can definitely transmit the pathogens from one patient to
the other (Brooks et al., 1992).
Moreover, patients in early ages may exchange toys in the pediatric spaces.
These toys if contaminated can become a reason for the spread of diseases
especially those associated with respiratory tracts. They may contain viruses
such as RSV (respiratory syncytial virus) or
infectious bacteria such as Pseudomonas aeruginosa
and many others (Agerton et al., 1997; Hall
and Douglas, 1980). Healthcare devices such as stethoscope
and other surgical apparatus can carry and transmit pathogens if not properly
cleansed and sterilized before use from one patient to another. Some of these
might have manufactural shortcomings that inhibit
efficient disinfection processes and thus are a potential tool of transmission
of HAIs (Srinivasan et
al., 2003).
Droplet Transmission
Pathogen containing
droplets that can be inhaled are generated during coughing, sneezing or simply
talking of a patient (Papineni and Wolfenden, 1997; Wells, 1934). They can also be produced
during oral procedures such as suction, endotracheal
procedures, cough treatments, chest therapies and cardiopulmonary processes (Loeb et
al., 2004) Epidemiological researches prove this method of
transmission via droplets (Gilchrist
et al., 1992; Fowler et al., 2004).
Other experimental studies and aerosol science have also mounted evidence
proving such transmission (Gehanno et al., 1999).
Conventionally, the region of high risk is within 3 feet of the infected
patient and this is based on epidemiological and experimental researches of
some infections (Valenzuela
et al., 1991; Bassinet et al., 2004).
Using face masks within this distance and otherwise around patients has proved
to be useful in getting rid of such transfers of HAIs via droplets. In the
light of above facts, it is important to wear face masks with 6 to 10 feet or
while entering the vicinity of an infected patient especially when the risk of
such virulent pathogenic infections is inevitable (Feigin et al., 1982)
Some of the disease causing pathogens that are transferred by this method include
Neisseria meningitidis
(Dick et al., 1992; Duguid,
1946), Rhinovirus (Papineni and
Rosenthal, 1997), Bordetella pertussis (Christie et al., 1995), group A streptococcus (Hamburger and Robertson, 1948), Mycoplasma pneumonia (Steinberg
et al., 1969),
influenza (Weinstein et al., 2003) and adenovirus (Musher, 2003), SARS
related corona virus (SARS-CoV) etc. (Seto et al., 2003; Varia
et al., 2003)
Airborne Transmission
Pathogens and other
infectious agents can spread through long distances by the movements of air
particles and waves. These pathogens may then be inspired by the vulnerable
persons who do not have any direct contact with the infected patient (Coronado et al., 1993; Bloch et al.,
1985). This type of transfer of pathogens can only be stopped by
using particular air treating and ventilating methods such as AIIRs to inhibit
the spread and removal of such disease-causing pathogens (LeClair et
al., 1980). The pathogens which can be removed via this procedure
include Rubeola virus. Other infectious agents that
can be stopped include Mycobacterium tuberculosis (Riley et
al., 1959; Beck-Sague et al., 1992), measles (86) as well as the chickenpox
virus called Varicella-zoster virus (87). Moreover,
respiratory protective equipment that is certified by NIOSH such as N95 or a
better respirator is endorsed for the healthcare providers who enter AIIR so
that infections with pathogenic agents such as Mycobacterium tuberculosis can
be prevented (GiHaleylchrist et al., 1989).
Response to bioterrorism
Various
bioterrorism events in the past enabled the scientist and researchers devise an
effective way to deal with bioterrorism attack. This response includes two
steps (Erenler et al., 2018) early detection
of the biological agent, (Vatansever et al., 2013) emergency role
of various healthcare and laboratory departments (Erenler et al.,
2018).
Detection
Various
methods of decontamination and detection have been developed and applied
recently due to which this step has shown significant progress (Vatansever et al., 2013). Huge burden
may rise on the healthcare system since many people can get infected in quite a
small period of time (Keim et al., 1999). Know how
about the biological agents to the professionals of healthcare are stimulated
by the US Center of Disease Control as this would help escape the logistic
problems and the problem of lack of resources and medication. A new program is
been made ‘bioterrorism preparedness and response program’ in association of
the government organizations and the healthcare staff for the immediate
response and detection in case of a bio crime act (Vatansever
et al., 2013). Preservation
of adequate resources, starting immediate appropriate response and the
possibility of occurrence of minimal causalities are all dependent on the early
detection of bio crime. Sometimes the symptoms of biological agent used in bio
crime are similar to everyday disease symptoms and can be mistaken with them
that is way enough knowledge about warfare agents is very essential (Busl et al., 2012). Determination
of a bio crime agent has a strong relationship with the maintenance of
suspicion strong index (Kman et al., 2012). Existence of
these agents is rapidly and accurately determined these days because of the
newly developed technologies. These new techniques and technologies are easy to
use, portable and are efficient enough to detect multiple agents at a time to
identify the bioterrorism agent in small amounts is also very important and for
this the development of sensor based on nucleic acid are under research (Thavaselvam et al., 2010).
Responsibilities
of emergency sectors
A
safe communication between the infectious disease workers,,
infection control workers and emergency room staff in the hospitals should be
developed by the advisory of health network and regular meetings should be
conducted to share the current situation information and the effective response
that should be opted. New programs to cope up with the situation should be
formed (Thavaselvam et al., 2010). Training of
the health workers by various training programs would increase the number of
people that would deal with the emergency and would prove useful (Olson et al., 2010). The condition
of developing countries is the worst when such infection spread and so there is
a greater need to increase the emergency personnel. Training may be given
either online or in person (Chandler et al., 2008). Funding,
space and staff needed to cope up with the emergency must be asked from general
public that is capable. Keeping in context the type of outbreak help should be
asked from other sectors such as police, intelligence, forensics, law
enforcement agencies and customs. These should work in collaboration with
environmental, public, social and animal health organizations (Posid et al., 2013). Simultaneously
the scientist and researchers should start working on the development of
vaccines and antibody serum as these two are most effective treatments in case
of infectious diseases (Martensson et al., 2010).
Conclusion
Once
these infectious agents get spread, no one can determine the destruction it
would cause so it is best to safely handle these agents by various methods
discussed above so that its chances of release are minimized. If an epidemic
has spread, the immediate preventive measures one can take is to minimize its
transmission by adopting various methods depending upon its route of
transmission. Obviously it is impossible to prevent the initial cases of the
epidemic because of the lack of information but once the preventive measures
become defined by the researches, the spread can become limited by the
responsible and mature public response.
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