Laboratory-acquired infections and pathogen escapes worldwide between 2000 and 2021: a scoping review

Laboratory-acquired infections (LAIs) and accidental pathogen escape from laboratory settings (APELS) are major concerns for the community. A risk-based approach for pathogen research management within a standard biosafety management framework is recommended but is challenging due to reasons such as inconsistency in risk tolerance and perception. Here, we performed a scoping review using publicly available, peer-reviewed journal and media reports of LAIs and instances of APELS between 2000 and 2021. We identified LAIs in 309 individuals in 94 reports for 51 pathogens. Eight fatalities (2·6% of all LAIs) were caused by infection with Neisseria meningitidis (n=3, 37·5%), Yersinia pestis (n=2, 25%), Salmonella enterica serotype Typhimurium (S Typhimurium; n=1, 12·5%), or Ebola virus (n=1, 12·5%) or were due to bovine spongiform encephalopathy (n=1, 12·5%). The top five LAI pathogens were S Typhimurium (n=154, 49·8%), Salmonella enteritidis (n=21, 6·8%), vaccinia virus (n=13, 4·2%), Brucella spp (n=12, 3·9%), and Brucella melitensis (n=11, 3·6%). 16 APELS were reported, including those for Bacillus anthracis, SARS-CoV, and poliovirus (n=3 each, 18·8%); Brucella spp and foot and mouth disease virus (n=2 each, 12·5%); and variola virus, Burkholderia pseudomallei, and influenza virus H5N1 (n=1 each, 6·3%). Continual improvement in LAI and APELS management via their root cause analysis and thorough investigation of such incidents is essential to prevent future occurrences. The results are biased due to the reliance on publicly available information, which emphasises the need for formalised global LAIs and APELS reporting to better understand the frequency of and circumstances surrounding these incidents.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Foot and Mouth Disease Virus

Introduction

Foot and mouth disease (FMD) is a highly contagious infection of cloven-hoofed animals. The Biosafety Research Road Map reviewed scientific literature regarding the foot and mouth disease virus (FMDV). This project aims to identify gaps in the data required to conduct evidence-based biorisk assessments, as described by Blacksell et al., and strengthen control measures appropriate for local and national laboratories.

Methods

A literature search was conducted to identify potential gaps in biosafety and focused on five main sections: the route of inoculation/modes of transmission, infectious dose, laboratory-acquired infections, containment releases, and disinfection and decontamination strategies.

Results

The available data regarding biosafety knowledge gaps and existing evidence have been collated. Some gaps include the need for more scientific data that identify the specific safety contribution of engineering controls, support requirements for showering out after in vitro laboratory work, and whether a 3- to 5-day quarantine period should be applied to individuals conducting in vitro versus in vivo work. Addressing these gaps will contribute to the remediation and improvement of biosafety and biosecurity systems when working with FMDV.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Crimean Congo Haemorrhagic Fever Virus and Lassa Virus

Introduction

Crimean Congo Hemorrhagic Fever (CCHF) virus and Lassa virus (LASV) are zoonotic agents regarded as high-consequence pathogens due to their high case fatality rates. CCHF virus is a vector-borne disease and is transmitted by tick bites. Lassa virus is spread via aerosolization of dried rat urine, ingesting infected rats, and direct contact with or consuming food and water contaminated with rat excreta.

Methods

The scientific literature for biosafety practices has been reviewed for both these two agents to assess the evidence base and biosafety-related knowledge gaps. The review focused on five main areas, including the route of inoculation/modes of transmission, infectious dose, laboratory-acquired infections, containment releases, and disinfection and decontamination strategies.

Results

There is a lack of data on the safe collection and handling procedures for tick specimens and the infectious dose from an infective tick bite for CCHF investigations. In addition, there are gaps in knowledge about gastrointestinal and contact infectious doses for Lassa virus, sample handling and transport procedures outside of infectious disease areas, and the contribution of asymptomatic carriers in viral circulation.

Conclusion

Due to the additional laboratory hazards posed by these two agents, the authors recommend developing protocols that work effectively and safely in highly specialized laboratories in non-endemic regions and a laboratory with limited resources in endemic areas.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Mpox/Monkeypox Virus

Introduction

The virus formerly known as monkeypox virus, now called mpoxv, belongs to the Orthopoxvirus genus and can cause mpox disease through both animal-to-human and human-to-human transmission. The unexpected spread of mpoxv among humans has prompted the World Health Organization (WHO) to declare a Public Health Emergency of International Concern (PHEIC).

Methods

We conducted a literature search to identify the gaps in biosafety, focusing on five main areas: how the infection enters the body and spreads, how much of the virus is needed to cause infection, infections acquired in the lab, accidental release of the virus, and strategies for disinfecting and decontaminating the area.

Discussion

The recent PHEIC has shown that there are gaps in our knowledge of biosafety when it comes to mpoxv. We need to better understand where this virus might be found, how much of it can spread from person-to-person, what are the effective control measures, and how to safely clean up contaminated areas. By gathering more biosafety evidence, we can make better decisions to protect people from this zoonotic agent, which has recently become more common in the human population.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Zoonotic Avian Influenza and Mycobacterium tuberculosis

Introduction

The Biosafety Research Road Map reviewed the scientific literature on a viral respiratory pathogen, avian influenza virus, and a bacterial respiratory pathogen, Mycobacterium tuberculosis. This project aims at identifying gaps in the data required to conduct evidence-based biorisk assessments, as described in Blacksell et al. One significant gap is the need for definitive data on M. tuberculosis sample aerosolization to guide the selection of engineering controls for diagnostic procedures.

Methods

The literature search focused on five areas: routes of inoculation/modes of transmission, infectious dose, laboratory-acquired infections, containment releases, and disinfection and decontamination methods.

Results

The available data regarding biosafety knowledge gaps and existing evidence have been collated and presented in Tables 1 and 2. The guidance sources on the appropriate use of biosafety cabinets for specific procedures with M. tuberculosis require clarification. Detecting vulnerabilities in the biorisk assessment for respiratory pathogens is essential to improve and develop laboratory biosafety in local and national systems.

Stability of SARS-CoV-2 variants of concern (Delta and Omicron) on surfaces at room temperature

Surfaces contaminated with infectious SARS-CoV-2 particles have the potential to cause human infection and any increase in surface survivability of a SARS-CoV-2 variant may increase its prevalence over other variants. This study investigated whether there were differences in surface persistence between Delta and Omicron variants leading to Omicron's dominance globally. Stainless steel coupons were inoculated with suspensions of either Delta or Omicron variant and exposed to typical environmental conditions within a containment level 3 laboratory. Coupons were recovered at different timepoints and enumerated using plaque assay. Both variants were recoverable for >48 h on the coupons. Omicron showed a greater reduction of viability after 48 h compared to Delta with a 20-fold decrease versus 15-fold respectively, but this difference was not statistically significant (p = 0.424). These results indicate that Omicron's surface persistence is unlikely to contribute to it becoming the dominant variant over Delta.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Shigella spp

Introduction

Shigella bacteria cause shigellosis, a gastrointestinal infection most often acquired from contaminated food or water.

Methods

In this review, the general characteristics of Shigella bacteria are described, cases of laboratory-acquired infections (LAIs) are discussed, and evidence gaps in current biosafety practices are identified.

Results

LAIs are undoubtedly under-reported. Owing to the low infectious dose, rigorous biosafety level 2 practices are required to prevent LAIs resulting from sample manipulation or contact with infected surfaces.

Conclusions

It is recommended that, before laboratory work with Shigella, an evidence-based risk assessment be conducted. Particular emphasis should be placed on personal protective equipment, handwashing, and containment practices for procedures that generate aerosols or droplets.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Bacillus anthracis and Brucella melitensis

Introduction

Brucella melitensis and Bacillus anthracis are zoonoses transmitted from animals and animal products. Scientific information is provided in this article to support biosafety precautions necessary to protect laboratory workers and individuals who are potentially exposed to these pathogens in the workplace or other settings, and gaps in information are also reported. There is a lack of information on the appropriate effective concentration for many chemical disinfectants for this agent. Controversies related to B. anthracis include infectious dose for skin and gastrointestinal infections, proper use of personal protective equipment (PPE) during the slaughter of infected animals, and handling of contaminated materials. B. melitensis is reported to have the highest number of laboratory-acquired infections (LAIs) to date in laboratory workers.

Methods

A literature search was conducted to identify potential gaps in biosafety and focused on five main sections including the route of inoculation/modes of transmission, infectious dose, LAIs, containment releases, and disinfection and decontamination strategies.

Results

Scientific literature currently lacks information on the effective concentration of many chemical disinfectants for this agent and in the variety of matrices where it may be found. Controversies related to B. anthracis include infectious dose for skin and gastrointestinal infections, proper use of PPE during the slaughter of infected animals, and handling contaminated materials.

Discussion

Clarified vulnerabilities based on specific scientific evidence will contribute to the prevention of unwanted and unpredictable infections, improving the biosafety processes and procedures for laboratory staff and other professionals such as veterinarians, individuals associated with the agricultural industry, and those working with susceptible wildlife species.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in Human and Veterinary Laboratories

Introduction

Lack of evidence-based information regarding potential biological risks can result in inappropriate or excessive biosafety and biosecurity risk-reduction strategies. This can cause unnecessary damage and loss to the physical facilities, physical and psychological well-being of laboratory staff, and community trust. A technical working group from the World Organization for Animal Health (WOAH, formerly OIE), World Health Organization (WHO), and Chatham House collaborated on the Biosafety Research Roadmap (BRM) project. The goal of the BRM is the sustainable implementation of evidence-based biorisk management of laboratory activities, particularly in low-resource settings, and the identification of gaps in the current biosafety and biosecurity knowledge base.

Methods

A literature search was conducted for the basis of laboratory design and practices for four selected high-priority subgroups of pathogenic agents. Potential gaps in biosafety were focused on five main sections, including the route of inoculation/modes of transmission, infectious dose, laboratory-acquired infections, containment releases, and disinfection and decontamination strategies. Categories representing miscellaneous, respiratory, bioterrorism/zoonotic, and viral hemorrhagic fever pathogens were created within each group were selected for review.

Results

Information sheets on the pathogens were developed. Critical gaps in the evidence base for safe sustainable biorisk management were identified.

Conclusion

The gap analysis identified areas of applied biosafety research required to support the safety, and the sustainability, of global research programs. Improving the data available for biorisk management decisions for research with high-priority pathogens will contribute significantly to the improvement and development of appropriate and necessary biosafety, biocontainment and biosecurity strategies for each agent.

Infection-competent monkeypox virus contamination identified in domestic settings following an imported case of monkeypox into the UK

An imported case of monkeypox was diagnosed in December 2019 in a traveller returning from Nigeria to the UK. Subsequently, environmental sampling was performed at two adjoining single-room residences occupied by the patient and their sibling. Monkeypox virus DNA was identified in multiple locations throughout both properties, and monkeypox virus was isolated from several samples 3 days after the patient was last in these locations. Positive samples were identified following the use of both vacuum and surface sampling techniques; these methodologies allowed for environmental analysis of potentially contaminated porous and non-porous surfaces via real-time quantitative reverse transcriptase PCR analysis in addition to viral isolation to confirm the presence of infection-competent virus. This report confirms the potential for infection-competent monkeypox virus to be recovered in environmental settings associated with known positive cases and the necessity for rapid environmental assessment to reduce potential exposure to close contacts and the general public. The methods adopted in this investigation may be used for future confirmed cases of monkeypox in order to establish levels of contamination, confirm the presence of infection-competent material and to identify locations requiring additional cleaning.

Microbial Aerosols Generated from Standard Microbiological Laboratory Procedures

Background:

Modern microbiology laboratories are designed to protect workers and the environment from microbial aerosols produced during microbiological procedures and accidents. However, there is only limited data available on the aerosols generated from common microbiology procedures.

Methods:

A series of common microbiological procedures were undertaken with high concentration spore suspensions while air samplers were operated to sample the aerosols generated. Surface contamination from droplets was visualized using sodium fluorescein within the suspension. A total of 36 procedures were studied using different sample volumes (0.1–10 mL) and two spore suspension titers (10⁷ and 10⁹ colony forming units [cfu]/mL).

Results:

The aerosol concentrations generated varied from 0 to 13,000 cfu/m³. There was evidence to suggest that titer, volume, and poor use of equipment were significant factors in increased aerosol generation from some of the procedures. A risk assessment undertaken using the data showed that any aerosol generated from these processes would be contained within a correctly operating biological safety cabinet. Therefore, with these procedures, the operator and the environment would not require any additional protective measures such as respiratory protective equipment or a negative pressure laboratory to prevent aerosol exposure or release.

Conclusions:

Aerosol generation from common laboratory processes can be minimized by reducing sample volumes and concentrations if possible. Training laboratory staff in good microbiological techniques would further mitigate aerosols generated from common laboratory processes.

Biosafety and biosecurity requirements for Orientia spp. diagnosis and research: recommendations for risk-based biocontainment, work practices and the case for reclassification to risk group 2

Scrub typhus is an important arthropod-borne disease causing significant acute febrile illness by infection with Orientia spp.Using a risk-based approach, this review examines current practice, the evidence base and regulatory requirements regarding matters of biosafety and biosecurity, and presents the case for reclassification from Risk Group 3 to Risk Group 2 along with recommendations for safe working practices of risk-based activities during the manipulation of Orientia spp. in the laboratory.We recommend to reclassify Orientia spp. to Risk Group 2 based on the classification for RG2 pathogens as being moderate individual risk, low community risk. We recommend that low risk activities, can be performed within a biological safety cabinet located in a Biosafety Level (BSL) 2 core laboratory using standard personal protective equipment. But when the risk assessment indicates, such as high concentration and volume, or aerosol generation, then a higher biocontainment level is warranted. For, the majority of animal activities involving Orientia spp., Animal BSL 2 (ABSL2) is recommended however where high risk activities are performed including necropsies, Animal BSL (ABSL3) is recommended.

Hazard Group 3 agent decontamination using hydrogen peroxide vapour in a class III microbiological safety cabinet

AIMS

This study investigated the efficacy of hydrogen peroxide vapour (HPV) at inactivating hazard group 3 bacteria that have been presented dried from their growth medium to present a realistic challenge.

METHODS AND RESULTS

Hydrogen peroxide vapour technology (Bioquell) was used to decontaminate a class III microbiological safety cabinet containing biological indicators (BIs) made by drying standard working suspensions of the following agents: Bacillus anthracis (Ames) spores, Brucella abortus (strain S99), Burkholderia pseudomallei (NCTC 12939), Escherichia coli O157 ST11 (NCTC 12079), Mycobacterium tuberculosis (strain H37Rv) and Yersinia pestis (strain CO92) on stainless steel coupons. Extended cycles were used to expose the agents for 90 min. The HPV cycle completely inactivated B. anthracis spores, B. abortus, B. pseudomallei, E. coli O157 and Y. pestis when BIs were processed using quantitative and qualitative methods. Whilst M. tuberculosis was not completely inactivated, it was reduced by 4 log₁₀ from a starting concentration of 10⁶ colony-forming units.

CONCLUSIONS

This study demonstrates that HPV is able to inactivate a range of HG3 agents at high concentrations with associated organic matter, but M. tuberculosis showed increased resistance to the process.

SIGNIFICANCE AND IMPACT OF THE STUDY

This publication demonstrates that HPV can inactivate HG3 agents that have an organic load associated with them. It also shows that M. tuberculosis has higher resistance to HPV than other agents. This shows that an appropriate BI to represent the agent of interest should be chosen to demonstrate a decontamination is successful.

Sampling and inactivation of wet disseminated spores from flooring materials, using commercially available robotic vacuum cleaners

AIMS

Four commercially available robotic vacuum cleaners were assessed for sampling efficiency of wet disseminated Bacillus atrophaeus spores on carpet, polyvinyl chloride (PVC) and laminate flooring. Furthermore, their operability was evaluated and decontamination efficiency of one robot was assessed, using a sodium hypochlorite solution.

METHODS AND RESULTS

In an environmental chamber, robots self-navigated around 4 m² of flooring containing a single contaminated 0·25 m² tile (c. 10⁴ spores per cm² ). Contamination levels at predetermined locations were assessed by macrofoam swabs (PVC and laminate) or water soluble tape (carpet), before and after sampling. Robots were dismantled postsampling and spore recoveries assessed. Aerosol contamination was also measured during sampling. Robot sampling efficiencies were variable, however, robots recovered most spores from laminate (up to 17·1%), then PVC and lastly the carpet. All robots spread contamination from the 'hotspot' (all robots spread <0·6% of the contamination to other areas) and became surface contaminated. Spores were detected at low levels during air sampling (<5·6 spores per litre). Liquid decontamination inactivated 99·1% of spores from PVC.

CONCLUSIONS

Robotic vacuum cleaners show promise for both sampling and initial decontamination of indoor flooring.

SIGNIFICANCE AND IMPACT OF THE STUDY

In the event of a bioterror incident, e.g. deliberate release of Bacillus anthracis spores, areas require sampling to determine the magnitude and extent of contamination, and to establish decontamination efficacy. In this study, we investigate robotic sampling methods against high concentrations of bacterial spores applied by wet deposition to different floorings, contamination spread to other areas, potential transfer of spores to the operators and assessment of a wet vacuum robot for spore inactivation. The robots' usability was evaluated and how they can be employed in real life scenarios. This will help to reduce the economic cost of sampling and the risk to sampling/decontamination teams.

Persistence of influenza on surfaces

BACKGROUND

Close contact transmission (either direct or large droplet/droplet nuclei) is considered the main driver of influenza outbreaks but there is limited information regarding the role of fomites in transmission.

AIM

To investigate the surface stability of influenza strains and thereby the role of fomites in transmission.

METHODS

The viability and quantitative reverse transcription-polymerase chain reaction (qt-RT-PCR) signal of five influenza strains (A/PR/8/34/H1N1, A/Cal/7/09/H1N1, A/Cal/4/09/H1N1, A/Sol/54/06/H1N1, and A/Bris/59/07/H1N1) seeded on to three surfaces (cotton, microfibre, and stainless steel) were assessed over time. Coupons of material were seeded with 10μL of a 10⁶-10⁸pfu/mL suspension of cell culture-derived virus stock supplemented with 0.3% bovine serum albumin. Coupons were assayed by plaque assay and qt-RT-PCR at 1, 24h, and weekly for seven weeks using a vortex-mixing elution method.

FINDINGS

Viable virus was detected from coupons for up to two weeks (stainless steel) and one week (cotton and microfibre), whereas detection of viruses by PCR was made for the entire seven-week study period. No strain differences were found. Ninety-nine percent reduction values (as a function of the seeding stock) were determined to be 17.7h for cotton (R²=0.86), 34.3h for microfibre (R²=0.80), and 174.9h for stainless steel (R²=0.98).

CONCLUSION

Viable influenza was recovered from surfaces for up to two weeks. By contrast, influenza could be detected by PCR for more than seven weeks. These results have important implications for determining infection control protocols, cleaning regimes and sampling methods in healthcare settings.

Is there an infection risk when playing drums contaminated with Bacillus anthracis?

AIMS

This study aims to investigate the aerosol release of a Bacillus anthracis spore surrogate from two different types of drums while playing, by; (i) quantifying the number of spores aerosolized during playing; (ii) investigating spore recovery from drums over long time periods, and (iii) measuring differences between (i) and (ii) for two different drums types.

METHODS AND RESULTS

Two African drums were contaminated with Bacillus atrophaeus spores then sampled and played by hand over a number of days. During playing three air samplers were used to collect any aerosols generated, the choice of air samplers (Casella slit sampler, all glass impinger and six-stage Andersen sampler) allowed for characterization of the aerosols produced.

CONCLUSIONS

Spore contamination of drums was found to be long-lasting with a small percentage of the spores being detached and aerosolized during drumming. The results of these studies have been used for a quantitative risk assessment of playing drums contaminated with B. anthracis spores.

SIGNIFICANCE AND IMPACT OF THE STUDY

This demonstrates that the risk of inhalational exposure while playing drums contaminated with the levels linked to the US and UK cases is very low and that the resulting cases of inhalational anthrax can be explained by being unusual events involving highly susceptible persons.

Biofilm formation in an experimental water distribution system: the contamination of non-touch sensor taps and the implication for healthcare

Hospital tap water is a recognised source of Pseudomonas aeruginosa. U.K. guidance documents recommend measures to control/minimise the risk of P. aeruginosa in augmented care units but these are based on limited scientific evidence. An experimental water distribution system was designed to investigate colonisation of hospital tap components. P. aeruginosa was injected into 27 individual tap 'assemblies'. Taps were subsequently flushed twice daily and contamination levels monitored over two years. Tap assemblies were systematically dismantled and assessed microbiologically and the effect of removing potentially contaminated components was determined. P. aeruginosa was repeatedly recovered from the tap water at levels above the augmented care alert level. The organism was recovered from all dismantled solenoid valves with colonisation of the ethylene propylene diene monomer (EPDM) diaphragm confirmed by microscopy. Removing the solenoid valves reduced P. aeruginosa counts in the water to below detectable levels. This effect was immediate and sustained, implicating the solenoid diaphragm as the primary contamination source.

Responding to biological incidents--what are the current issues in remediation of the contaminated environment?

Since 2000 there have been a number of biological incidents resulting in environmental contamination with Bacillus anthracis, the causative agent of anthrax. These incidents include the US anthrax attacks in 2001, the US and UK drumming incidents in 2006-2008 and more recently, anthrax contamination of heroin in 2009/2010 and 2012/2013. Remediation techniques used to return environments to normal have varied between incidents, with different decontamination technologies being employed. Many factors need to be considered before a remediation strategy or recovery option can be implemented, including; cost, time (length of application), public perception of risk, and sampling strategies (and results) to name a few. These incidents have demonstrated that consolidated guidance for remediating biologically contaminated environments in the aftermath of a biological incident was required. The UK Recovery Handbook for Biological Incidents (UKRHBI) is a project led by Public Health England (PHE), formerly the Health Protection Agency (HPA) to provide guidance and advice on how to remediate the environment following a biological incident or outbreak of infection, and is expected to be published in 2015.

Whispering gallery mode diamond resonator

We demonstrate a nearly spherical diamond whispering gallery mode resonator with quality factor (Q factor) Q=2.4×10(7) limited by material loss approaching α=4×10(-3) cm(-1). The Q factor does not depend on the wavelength: it is approximately the same at 1319 and 1550 nm. Resonators with this range of Q (<10 MHz at 1550 nm wavelength) are attractive for laser locking and stabilization. Applications such as stable compact optical comb generators as well as Raman optical frequency shifters will be feasible with further improvement of the material.

Influenza aerosols in UK hospitals during the H1N1 (2009) pandemic--the risk of aerosol generation during medical procedures

BACKGROUND

Nosocomial infection of health-care workers (HCWs) during outbreaks of respiratory infections (e.g. Influenza A H1N1 (2009)) is a significant concern for public health policy makers. World Health Organization (WHO)-defined 'aerosol generating procedures' (AGPs) are thought to increase the risk of aerosol transmission to HCWs, but there are presently insufficient data to quantify risk accurately or establish a hierarchy of risk-prone procedures.

METHODOLOGY/PRINCIPAL FINDINGS

This study measured the amount of H1N1 (2009) RNA in aerosols in the vicinity of H1N1 positive patients undergoing AGPs to help quantify the potential risk of transmission to HCWs. There were 99 sampling occasions (windows) producing a total of 198 May stages for analysis in the size ranges 0.86-7.3 µm. Considering stages 2 (4-7.3 µm) and 3 (0.86-4 µm) as comprising one sample, viral RNA was detected in 14 (14.1%) air samples from 10 (25.6%) patients. Twenty three air samples were collected while potential AGPs were being performed of which 6 (26.1%) contained viral RNA; in contrast, 76 May samples were collected when no WHO 2009 defined AGP was being performed of which 8 (10.5%) contained viral RNA (unadjusted OR = 2.84 (95% CI 1.11-7.24) adjusted OR = 4.31 (0.83-22.5)).

CONCLUSIONS/SIGNIFICANCE

With our small sample size we found that AGPs do not significantly increase the probability of sampling an H1N1 (2009) positive aerosol (OR (95% CI) = 4.31 (0.83-22.5). Although the probability of detecting positive H1N1 (2009) positive aerosols when performing various AGPs on intensive care patients above the baseline rate (i.e. in the absence of AGPs) did not reach significance, there was a trend towards hierarchy of AGPs, placing bronchoscopy and respiratory and airway suctioning above baseline (background) values. Further, larger studies are required but these preliminary findings may be of benefit to infection control teams.

Laboratory methods for assessing vaccine potency retained in aerosol outputs from nebulizers: application to World Health Organization measles aerosol project

BACKGROUND

Laboratory methods for measuring vaccine potency of nebulized aerosol are required to support clinical trials of measles aerosol vaccination.

METHODS

Measles vaccine containing the Edmonston Zagreb virus strain was reconstituted in sodium fluoride as tracer and nebulized from three devices. Emitted aerosol was collected using an impinger. Aliquots were removed from the impinger chamber for vaccine virus plaque assay and for fluoride measurement to determine aerosol output.

RESULTS

Vaccine potency retention results were adjusted to take into account the effect of aerosol output on estimates. Adjusted potency of nebulized vaccine ranged from 88% to 102%.

CONCLUSIONS

New laboratory methods to measure aerosol vaccine potency retention were reliable and accurate. The results demonstrated that Edmonston Zagreb vaccine remains robust during aerosolisation and imply that this is a viable candidate for further evaluation in the measles aerosol project.

Hospital and community acquired infection and the built environment--design and testing of infection control rooms

Negative-pressure isolation rooms are required to house patients infected with agents transmissible by the aerosol route in order to minimise exposure of healthcare workers and other patients. Housing patients in a separate room provides a barrier which minimises any physical contact with other patients. An isolation room held at negative pressure to reduce aerosol escape and a high air-change rate to allow rapid removal of aerosols can eliminate transmission of infectious aerosols to those outside the room. However, badly designed and/or incorrectly operating isolation rooms have been shown to place healthcare workers and other patients at risk from airborne diseases such as tuberculosis. Few standards are available for the design of isolation rooms and no pressure differential or air-change rates are specified. Techniques such as aerosol particle tracer sampling and computational fluid dynamics can be applied to study the performance of negative-pressure rooms and to assess how design variables can affect their performance. This should allow cost-effective designs for isolation rooms to be developed. Healthcare staff should be trained to understand how these rooms operate and there should be systems in place to ensure they are functioning correctly.

Nuclear and cytosolic calcium are regulated independently

Nuclear calcium (Ca(2+)) regulates a number of important cellular processes, including gene transcription, growth, and apoptosis. However, it is unclear whether Ca(2+) signaling is regulated differently in the nucleus and cytosol. To investigate this possibility, we examined subcellular mechanisms of Ca(2+) release in the HepG2 liver cell line. The type II isoform of the inositol 1,4,5-trisphosphate (InsP(3)) receptor (InsP(3)R) was expressed to a similar extent in the endoplasmic reticulum and nucleus, whereas the type III InsP(3)R was concentrated in the endoplasmic reticulum, and the type I isoform was not expressed. Ca(2+) signals induced by low InsP(3) concentrations started earlier or were larger in the nucleus than in the cytosol, indicating higher sensitivity of nuclear Ca(2+) stores for InsP(3). Nuclear InsP(3)R channels were active at lower InsP(3) concentrations than InsP(3)R from cytosol. Enriched expression of type II InsP(3)R in the nucleus results in greater sensitivity of the nucleus to InsP(3), thus providing a mechanism for independent regulation of Ca(2+)-dependent processes in this cellular compartment.

Cytotoxic T-cell activity is not detectable in Venezuelan equine encephalitis virus-infected mice

Previously published research has established that the immune response to the Venezuelan equine encephalitis virus (VEEV) vaccine strain TC-83 is Th 1-mediated, with local activation of both CD4+ and CD8+ T cells. This suggests that cytotoxic lymphocytes CTL may play a role in protection against virulent VEEV. Studies involving a variety of immunisation schedules with either TC-83 or strain CAAR 508 (serogroup 5) of VEEV, and six different haplotypes of mice, failed to reveal functional CTL activity against VEEV-infected targets in secondary antigen-stimulated lymphocyte cultures from either the draining lymph nodes (LN) or spleen. Nor were VEEV-specific CTL detected after immunisation of mice (three haplotypes) with recombinant vaccinia viruses (VV) expressing either the non-structural (nsP1-4) or the structural (C-E3-E2-6K-E1) genes of TC-83. Reciprocal experiments in which mice were immunised with TC-83, and their lymphocytes tested against VV recombinant-infected targets also failed to detect CTL activity. These data suggest that VEEV infection of mice does not elicit detectable CTL activity, and that CTL are unlikely to play a role in protection against virulent VEEV.

Co-immunisation with a plasmid DNA cocktail primes mice against anthrax and plague

The protective antigen (PA) of Bacillus anthracis and the V antigen of Yersinia pestis are potent immunogens and candidate vaccine sub-units. When plasmid DNA encoding either PA or V antigen was used to immunise the Balb/c mouse, a low serum IgG titre was detected (log (10)1.0 or less) which was slightly increased by boosting with plasmid DNA. However, when mice immunised with plasmid DNA were later boosted with the respective recombinant protein, a significant increase in titre (up to 100-fold) was observed. Mice primed with a combination of each plasmid and boosted with a combination of the recombinant proteins, were fully protected (6/6) against challenge with Y. pestis. This compared favourably with mice primed only with plasmid DNA encoding the V antigen and boosted with rV, which were partially protected (3/6) against homologous challenge or with mice primed and boosted with plasmid DNA encoding the V antigen which were poorly protected (1/6). Combined immunisation with the two plasmid DNA constructs followed by boosting with a combination of the encoded recombinant proteins enhanced the protective immune response to Y. pestis compared with priming only with plasmid DNA encoding the V antigen and boosting with rV. This enhancement may be due to the effect of CpG motifs known to be present in the plasmid DNA construct encoding PA.

SHP-2 complex formation with the SHP-2 substrate-1 during C2C12 myogenesis

Myogenesis is a highly ordered process that involves the expression of muscle-specific genes, cell-cell recognition and multinucleated myotube formation. Although protein tyrosine kinases have figured prominently in myogenesis, the involvement of tyrosine phosphatases in this process is unknown. SHP-2 is an SH2 domain-containing tyrosine phosphatase, which positively regulates growth and differentiation. We show that in C2C12 myoblasts, SHP-2 becomes upregulated early on during myogenesis and associates with a 120 kDa tyrosyl-phosphorylated complex. We have identified that the 120 kDa complex consists of the SHP-2 substrate-1 (SHPS-1) and the Grb2-associated binder-1 (Gab-1). SHPS-1, but not Gab-1, undergoes tyrosyl phosphorylation and association with SHP-2 during myogenesis, the kinetics of which correlate with the expression of MyoD. Either constitutive expression or inducible activation of MyoD in 10T½ fibroblasts promotes SHPS-1 tyrosyl phosphorylation and its association with SHP-2. It has been shown that p38 mitogen-activated protein kinase (MAPK) activity is required for the expression/activation of MyoD and MyoD-responsive genes. Inhibition of p38 MAPK by SB203580 in differentiating C2C12 myoblasts blocks MyoD expression, SHPS-1 tyrosyl phosphorylation and the association of SHPS-1 with SHP-2. These data suggest that SHPS-1/SHP-2 complex formation is an integral signaling component of skeletal muscle differentiation.

Microbial aerosols in general dental practice

OBJECTIVE

To measure the concentration of microbial aerosols in general dental practices and to use this information to carry out quantitative microbiological risk assessments.

METHODOLOGY

Microbial air sampling was carried out continuously during 12 treatment sessions in 6 general dental practices in the South West of England.

RESULTS

The microbial aerosol concentration in treatment rooms was generally less than 10(3) colony forming units per cubic metre of air (cfu x m(-3)). However, in 6 out of the 12 visits, at least one peak concentration with much higher numbers of bacteria was detected. The peak concentrations were associated with increased recoveries of presumptive oral streptococci suggesting these aerosols originated from the mouths of patients. These aerosol peaks dissipated within 30 minutes and no dissemination into waiting areas was detected. The peak concentrations were associated with mechanical scaling procedures (47% of procedures giving rise to a peak) and to a lesser extent by cavity preparation (11%). No aerosolised blood was detected.

CONCLUSIONS

The data have been used to generate a framework for quantifying risk of exposure of staff to aerosolised microbial pathogens in general dental practice. For example, dentists and their assistants may have a slightly higher risk of exposure to Mycobacterium tuberculosis than the general public. The use of face seal masks that have been shown to protect against aerosolised micro-organisms may reduce this exposure.

An immunological profile of Balb/c mice protected from airborne challenge following vaccination with a live attenuated Venezuelan equine encephalitis virus vaccine

The live attenuated vaccine strain of Venezuelan equine encephalitis virus (VEEV), TC-83, protects mice against challenge (subcutaneous and aerosol) with virulent VEEV but is not suitable for widescale human use. Elucidation of the immune response profile of protected mice should assist in the development of an improved vaccine. We determined the optimum dose of TC-83 required to consistently protect Balb/c mice from airborne challenge with the virulent Trinidad Donkey strain of VEEV and studied the development of humoral and cellular immune responses in protected mice between 6 h and 21 days post-vaccination. The most dramatic immune responses occurred in draining lymph nodes 24 h following vaccination with increased levels of activated B cells and T cells of both CD4(+) and CD8(+) subtypes. Activated monocyte/macrophages and natural killer cells were also seen between 6 h and 7 days post-vaccination. Serum contained detectable VEEV-specific IgG on day 5 post-vaccination with titres continuing to rise on days 7, 14 and 21. Isotypes of IgG measured on days 7 and 21 were predominantly of the IgG2a subclass, indicating that the immune response was Th1-mediated. Cytokine mRNA was quantified by RT-PCR and revealed production of the Th1 cytokine IFN-gamma and the inflammatory cytokine TNF-alpha, whereas the Th2 cytokine IL4 was not detected above control levels at any of the time points studied. This data describes key cellular immune responses at early times post-vaccination and is consistent with previous data demonstrating protection against aerosol challenge with VEEV in the absence of detectable levels of specific IgG or IgA antibody.

Survival of mycobacterial species in aerosols generated from artificial saliva

Tuberculosis is transmitted primarily by the aerosol route and the aim of this study was to measure the ability of pathogenic mycobacteria to survive in aerosols generated from artificial saliva. Aerosols of Mycobacterium avium, Mycobacterium intracellulare and Mycobacterium tuberculosis were generated and maintained in air under controlled conditions using a Henderson apparatus and a rotating drum. There were no differences in aerosol survival between the three species, and all had a poor survival rate over a period of 1 h. These data confirm epidemiological studies that close and prolonged contact with a TB patient is required for transmission of infection.

Microbial biofilm formation and contamination of dental-unit water systems in general dental practice

Dental-unit water systems (DUWS) harbor bacterial biofilms, which may serve as a haven for pathogens. The aim of this study was to investigate the microbial load of water from DUWS in general dental practices and the biofouling of DUWS tubing. Water and tube samples were taken from 55 dental surgeries in southwestern England. Contamination was determined by viable counts on environmentally selective, clinically selective, and pathogen-selective media, and biofouling was determined by using microscopic and image analysis techniques. Microbial loading ranged from 500 to 10(5) CFU. ml(-1); in 95% of DUWS water samples, it exceeded European Union drinking water guidelines and in 83% it exceeded American Dental Association DUWS standards. Among visible bacteria, 68% were viable by BacLight staining, but only 5% of this "viable by BacLight" fraction produced colonies on agar plates. Legionella pneumophila, Mycobacterium spp., Candida spp., and Pseudomonas spp. were detected in one, five, two, and nine different surgeries, respectively. Presumptive oral streptococci and Fusobacterium spp. were detected in four and one surgeries, respectively, suggesting back siphonage and failure of antiretraction devices. Hepatitis B virus was never detected. Decontamination strategies (5 of 55 surgeries) significantly reduced biofilm coverage but significantly increased microbial numbers in the water phase (in both cases, P < 0.05). Microbial loads were not significantly different in DUWS fed with soft, hard, deionized, or distilled water or in different DUWS (main, tank, or bottle fed). Microbiologically, no DUWS can be considered "cleaner" than others. DUWS deliver water to patients with microbial levels exceeding those considered safe for drinking water.

Differential role of beta(1C) and beta(1A) integrin cytoplasmic variants in modulating focal adhesion kinase, protein kinase B/AKT, and Ras/Mitogen-activated protein kinase pathways

The integrin cytoplasmic domain modulates cell proliferation, adhesion, migration, and intracellular signaling. The beta(1) integrin subunits, beta(1C) and beta(1A), that contain variant cytoplasmic domains differentially affect cell proliferation; beta(1C) inhibits proliferation, whereas beta(1A) promotes it. We investigated the ability of beta(1C) and beta(1A) to modulate integrin-mediated signaling events that affect cell proliferation and survival in Chinese hamster ovary stable cell lines expressing either human beta(1C) or human beta(1A). The different cytodomains of either beta(1C) or beta(1A) did not affect either association with the endogenous alpha(2), alpha(V), and alpha(5) subunits or cell adhesion to fibronectin or TS2/16, a mAb to human beta(1). Upon engagement of endogenous and exogenous integrins by fibronectin, cells expressing beta(1C) showed significantly inhibited extracellular signal-regulated kinase (ERK) 2 activation compared with beta(1A) stable cell lines. In contrast, focal adhesion kinase phosphorylation and Protein Kinase B/AKT activity were not affected. Selective engagement of the exogenously expressed beta(1C) by TS2/16 led to stimulation of Protein Kinase B/AKT phosphorylation but not of ERK2 activation; in contrast, beta(1A) engagement induced activation of both proteins. We show that Ras activation was strongly reduced in beta(1C) stable cell lines in response to fibronectin adhesion and that expression of constitutively active Ras, Ras 61 (L), rescued beta(1C)-mediated down-regulation of ERK2 activation. Inhibition of cell proliferation in beta(1C) stable cell lines was attributable to an inhibitory effect of beta(1C) on the Ras/MAP kinase pathway because expression of activated MAPK kinase rescued beta(1C) antiproliferative effect. These findings show that the beta(1C) variant, by means of a unique signaling mechanism, selectively inhibits the MAP kinase pathway by preventing Ras activation without affecting either survival signals stimulated by integrins or cellular interactions with the extracellular matrix. These findings highlight a role for beta(1)-specific cytodomain sequences in maintaining an intracellular balance of proliferation and survival signals.

Gene gun mediated vaccination is superior to manual delivery for immunisation with DNA vaccines expressing protective antigens from Yersinia pestis or Venezuelan Equine Encephalitis virus

Plasmids expressing the V antigen of Yersinia pestis or the E2 glycoprotein of Venezuelan Equine Encephalitis (VEE) virus were used to vaccinate mice by intra-dermal or intra-muscular injection, or by particle-mediated bombardment using the Helios gene gun. After two immunizations, groups of mice which had received 4 microg doses of plasmid DNA using the gene gun had IgG levels which were higher than in other groups manually immunised with 12-fold more plasmid DNA. The immunoglobulin isotype profile was predominantly IgG1 following inoculation with either plasmid. Our results indicate that gene gun mediated vaccination can be used to increase the magnitude of the immune response to both bacterial and viral antigens expressed by plasmid DNA.

Anaphylaxis during caesarean section in a patient with undiagnosed placenta accreta: it never rains but it pours!

Published guidelines exist for the management and investigation of suspected anaphylactic reactions associated with anaesthesia. We report a woman who had a life-threatening anaphylactic reaction during caesarean section under spinal anaesthesia, complicated by undiagnosed placenta accreta. We discuss the particular problems of the case and the practical difficulties of testing survivors of anaphylaxis: despite following the recommendations, we have been unable to identify the cause.

Expression of a recombinant form of the V antigen of Yersinia pestis, using three different expression systems

Yersinia pestis, the causative organism of plague, produces V antigen (LcrV), a bifunctional protein with regulatory and virulence roles that has been shown to be highly protective against a plague challenge. A combined sub-unit vaccine, comprising recombinant V and Fraction 1 antigens is currently being developed. We report here the expression and purification of recombinant V antigen (rV) using three different expression systems: the N-terminal GST fusion pGEX-5X-2 and pGEX-6P-2 systems from Pharmacia Biotech, and the C-terminal CBD fusion (IMPACT I) system from New England Biolabs. After cleavage from the carrier protein, the yields of rV were 25 mg l(-1) (pGEX-5X-2), 31 mg l(-1) (pGEX-6P-2) and 0.75 mg l(-1) (IMPACT I). All of the recombinant proteins were immunogenic in mice, although there were some differences in their protective efficacy against subcutaneous challenge with Y. pestis. Whilst rV antigen derived from the IMPACT I and pGEX-6P-2 systems and given in two immunising doses protected fully against challenge with 1 x 10(7) colony forming units (cfu) of Y. pestis, there was breakthrough in protection against 1 x 10(5) cfu of Y. pestis in animals immunised twice with rV from the pGEX-5X-2 system. From this study, the pGEX-6P-2 has been selected for the production of rV as a vaccine component. The pGEX-6P-2 system utilises a GST tagged PreScission Protease (a recombinant human rhinovirus 3C protease) to cleave the fusion protein, thereby allowing efficient removal of the enzyme from the final product. In addition, the enzyme is not of animal origin, therefore making it suitable for vaccine production.

Presentation of protective antigen to the mouse immune system: immune sequelae

Protective antigen (PA), the major protective component of the existing vaccine, is a potent immunogen. Protective antigen in alhydrogel induced a high serum IgG titre (> log10 4) in both the C57B16 and Balb/c mouse and the predominant subclass of antibody induced was IgG1, indicating that the response to PA was predominantly Th2 directed. When plasmid DNA encoding PA was used to immunize the Balb/c mouse, a low serum IgG titre was detected (</=log10 1), which was slightly increased by boosting with plasmid DNA. However, when mice immunized with plasmid DNA were later boosted with rPA, a significant and rapid increase in titre (up to threefold) was observed. Priming mice with PA-encoding plasmid DNA may be a mechanism of enhancing and accelerating the immune response to PA.

Recombinant vaccinia viruses protect against Clostridium perfringens alpha-toxin

Recombinant vaccinia viruses that expressed the nontoxic C-domain of Clostridium perfringens alpha-toxin were constructed. The J2R (thymidine kinase [TK] gene) and B13R (serpin 2 [SPI-2] gene) loci were used as insertion sites for the clostridial DNA, and expression of the foreign protein was measured in each case. A double recombinant that encoded the alpha-toxin truncate at the B13R locus and the protective antigen of Bacillus anthracis at the J2R locus was also constructed. Although differences in expression of the alpha-toxin C-domain were recorded, all of the vaccinia recombinants protected mice against a lethal challenge with alpha-toxin demonstrating that a recombinant vaccinia virus can be used to provide protection against a toxin challenge that is known to be solely antibody mediated.

Improved protection against Venezuelan equine encephalitis by genetic engineering of a recombinant vaccinia virus

An improved vaccine is needed against Venezuelan equine encephalitis (VEE) virus because the existing live attenuated vaccine, TC-83, causes a high incidence of adverse effects, and the Formalin-inactivated vaccine, C-84, does not protect against airborne infection. A recombinant vaccine had previously been constructed in which the VEE structural proteins were expressed by vaccinia virus. Although protection against subcutaneous challenge with VEE was achieved, the vaccine had limited efficacy against aerosolized virus. We made a similar construct (WR100) and compared its performance with that of a recombinant vaccinia virus which had been altered in two ways (WR103) in order to improve its performance as a vaccine: a synthetic promoter was inserted upstream of the VEE coding sequence to increase the amount of VEE proteins produced, and a single nucleotide in the E2 glycoprotein gene was altered to enhance immunogenicity. The WR103 virus expressed greater amounts of VEE proteins on the surface of infected cells than did WR100, and this difference was found to correspond to a 3.5-fold increase in VEE protein production. Sera from mice immunized with WR103 contained elevated levels of antibody to VEE, and enhanced protection against subcutaneous challenge with the pathogenic Trinidad donkey strain was achieved. This altered construct could form the basis for a better vaccine against VEE.

Protection against herpes B virus infection in rabbits with a recombinant vaccinia virus expressing glycoprotein D

Herpes B virus infects naturally monkeys of the macaque genus in whom it can cause recurrent oral and genital lesions. However, when the virus infects humans it causes a neurological illness with a high case fatality rate. Successful treatment is possible but this depends on diagnosis prior to the onset of respiratory arrest, and fatalities over the last 10 years have been the result of late or no diagnostic data on which to base anti-viral intervention. An effective vaccine would be an ideal way to combat the risk of herpes B virus disease in humans working with potentially infected monkeys or their tissues. A recombinant vaccinia virus expressing herpes B virus glycoprotein D (gD) was constructed and rabbits inoculated with the chimeric virus were tested for immunoglobulin responses to herpes B virus by virus neutralisation, ELISA and Western blot analyses. Anti-gD humoral responses were detected in all vaccinated animals by ELISA and Western blot but neutralising antibody was not detected prior to challenge with herpes B virus. Non-vaccinated rabbits died within 8 days of challenge while 10/11 vaccinated animals were protected against herpes B virus disease. No antibodies to herpes B virus proteins other than gD were detectable in surviving animals, suggesting minimal herpes B virus replication post challenge. Autopsies were carried out on 4/10 rabbits which had remained healthy at 31 days post challenge and the dorsal root ganglia adjacent to the inoculation site were removed. Attempts to detect herpes B virus DNA by PCR followed by hybridisation proved negative suggesting protection against latent herpes B virus infection.

Airborne movement of anthrax spores from carcass sites in the Etosha National Park, Namibia

Tests for airborne movement of anthrax spores downwind from three heavily contaminated carcass sites were carried out under a range of wind conditions. Anthrax spores were detected in just three of 43 cyclone or gelatin filter air samples taken at distances of 6, 12 and 18 m from the sites. In addition, nine positives resulted during sampling sessions in which the site was mechanically disturbed, with a further five positives being found in sessions subsequent to those in which the site had been disturbed. The three positive samples not related to man-made disturbance were associated with the highest winds experienced during the study. Despite colony counts exceeding 100 on the culture plates in three instances, calculations showed that these represented very low worst case probable spore inhalation rates for animals or humans exposed to such levels. The low number of positives, the clear pattern of rapidly declining numbers of anthrax spores with distance downwind from the centres of the sites apparent on settle plates, and the persisting levels of contamination despite wind and rain, collectively suggest that the anthrax spores were associated with fairly heavy particles, although this was not seen by electron microscopy on soil samples from the sites. Overall, the findings are interpreted as indicating that it is very unlikely that Etosha animals contract anthrax by the inhalation route while simply in transit near or across a carcass site. The significance of the observations in relation to weather conditions in the Etosha, other studies on particulate aerosols in the region, and reports of long-distance airborne movement of microbes, is discussed.

Epidermal growth factor receptor and the adaptor protein p52Shc are specific substrates of T-cell protein tyrosine phosphatase

T-cell protein tyrosine phosphatase (TCPTP) exists as two forms generated by alternative splicing: a 48-kDa endoplasmic reticulum (ER)-associated form (TC48) and a 45-kDa nuclear form (TC45). To identify TCPTP substrates, we have generated substrate-trapping mutants, in which the invariant catalytic acid of TCPTP (D182) is mutated to alanine. The TCPTP D182A substrate-trapping mutants were transiently overexpressed in COS cells, and their ability to form complexes with tyrosine-phosphorylated (pTyr) proteins was assessed. No pTyr proteins formed complexes with wild-type TCPTP. In contrast, TC48-D182A formed a complex in the ER with pTyr epidermal growth factor receptor (EGFR). In response to EGF, TC45-D182A exited the nucleus and accumulated in the cytoplasm, where it bound pTyr proteins of approximately 50, 57, 64, and 180 kDa. Complex formation was disrupted by vanadate, highlighting the importance of the PTP active site in the interaction and supporting the characterization of these proteins as substrates. Of these TC45 substrates, the approximately 57- and 180-kDa proteins were identified as p52Shc and EGFR, respectively. We examined the effects of TC45 on EGFR signaling and observed that it did not modulate EGF-induced activation of p42Erk2. However, TC45 inhibited the EGF-induced association of p52Shc with Grb2, which was attributed to the ability of the PTP to recognize specifically p52Shc phosphorylated on Y239. These results indicate that TC45 recognizes not only selected substrates in a cellular context but also specific sites within substrates and thus may regulate discrete signaling events.