1. Exposure to Infectious Agents in Health Protection Agency Laboratories Presented by Frances Knight and Ian Bateman

2. HEALTH PROTECTION AGENCY formed April 2003 CMO – Getting ahead of the curve formed from PHLS, CAMR, National Focus joined in 2004 by NRPB around 3000 staff 3 major centres, 79 sites 1500 staff work in microbiology

3. Diphtheria infection in member of staff HPA Board requested review Investigate laboratory exposures to infectious agents Review adequacy of actions to prevent infections in staff Recommend improvements Identify issues of wider relevance BACKGROUND

4. TERMS OF REFERENCE –examine laboratory acquired infections and incidents of exposure to infectious agents during laboratory work –identify number of incidents over 2 years and the circumstances in which they arose –review immediate and underlying causes –review lessons learned –review actions taken and whether they were adequate –determine further steps to ensure this area of risk is adequately controlled –final report for the HPA Board –make recommendations for further action

5. FINDINGS (1) 78 recorded incidents Hazard Group 1 (1) Hazard Group 2 (40) Hazard Group 3 (32) Hazard Group 4 (2) Not known (3) 6 LAIs (Salmonella Typhimurium, Shigella sonnei (2 cases), Corynebacterium diphtheriae, Salmonella Agona and Neisseria meningitidis ) Full recovery, no transmission to others

6. FINDINGS (2) 70% - SPILLS, BREAKAGES AND LEAKS 13% - SHARPS 11% - NO MSC/GENERATION OF AEROSOLS

7. REVIEW OF SPECIFIC INCIDENTS LAI – Corynebacterium diphtheriae LAI – Salmonella Agona Mycobacterium tuberculosis – dropped culture Mycobacterium tuberculosis – dropped swab LAI - Neisseria meningitidis

8. UNDERLYING CAUSES staffing levels off-site training competence communication immunisation status accommodation pressures

9. ACTION PLAN (1) Increased vigilance and awareness ­keep biological safety high on the agenda Communicate findings via cascade ­targeting key groups Improved risk assessment ­especially resource/space Standard arrangements ­incident reporting, investigation & analysis System for communicating lessons learned ­including pan-HPA communication of HSE visit findings Better and more consistent CL3 training

10. ACTION PLAN (2) ­review practices against HSAC, ACDP, etc ­processing at wrong containment levels ­create environment for open reporting ­frequency of CL2 and CL3 incidents ­monitor progress against action plans ­share findings across microbiology + HSE