Low-incidence, high-consequence pathogens

Clinical Laboratory Biosafety Gaps: Lessons Learned from Past Outbreaks Reveal a Path to a Safer Future

Patient care and public health require timely, reliable laboratory testing. However, clinical laboratory professionals rarely know whether patient specimens contain infectious agents, making ensuring biosafety while performing testing procedures challenging. The importance of biosafety in clinical laboratories was highlighted during the 2014 Ebola outbreak, where concerns about biosafety resulted in delayed diagnoses and contributed to patient deaths. This review is a collaboration between subject matter experts from large and small laboratories and the federal government to evaluate the capability of clinical laboratories to manage biosafety risks and safely test patient specimens. We discuss the complexity of clinical laboratories, including anatomic pathology, and describe how applying current biosafety guidance may be difficult as these guidelines, largely based on practices in research laboratories, do not always correspond to the unique clinical laboratory environments and their specialized equipment and processes. We retrospectively describe the biosafety gaps and opportunities for improvement in the areas of risk assessment and management; automated and manual laboratory disciplines; specimen collection, processing, and storage; test utilization; equipment and instrumentation safety; disinfection practices; personal protective equipment; waste management; laboratory personnel training and competency assessment; accreditation processes; and ethical guidance. Also addressed are the unique biosafety challenges successfully handled by a Texas community hospital clinical laboratory that performed testing for patients with Ebola without a formal biocontainment unit. The gaps in knowledge and practices identified in previous and ongoing outbreaks demonstrate the need for collaborative, comprehensive solutions to improve clinical laboratory biosafety and to better combat future emerging infectious disease outbreaks.

Nipah virus: a potential pandemic agent in the context of the current severe acute respiratory syndrome coronavirus 2 pandemic

For centuries, zoonotic diseases have been responsible for various outbreaks resulting in the deaths of millions of people. The best example of this is the current coronavirus disease 2019 (COVID-19) pandemic. Like severe acute respiratory syndrome coronavirus, Nipah virus is another deadly virus which has caused several outbreaks in the last few years. Though it causes a low number of infections, disease severity results in a higher death rate. In the context of the recent COVID-19 pandemic, we speculate that many countries will be unable to deal with the sudden onset of such a viral outbreak. Thus, further research and attention to the virus are needed to address future outbreaks.

Late incidence of SARS-CoV-2 infection in a highly-endemic remote rural village. A prospective population-based cohort study

Data on SARS-CoV-2 transmission in rural communities is scarce or non-existent. A previous cross-sectional study in middle-aged and older adults enrolled in the Atahualpa Project Cohort demonstrated that 45% of participants had SARS-CoV-2 antibodies, 77% of whom were symptomatic. Here, we assessed the incidence of SARS-CoV-2 infection in the above-mentioned rural population. One month after baseline testing, 362 of 370 initially seronegative individuals were re-tested to assess incidence of seroconversion and associated risk factors. Twenty-eight of them (7.7%) became seropositive. The overall incidence rate ratio was 7.4 per 100 person months of potential virus exposure (95% C.I.: 4.7-10.2). Six seroconverted individuals (21.4%) developed SARS-CoV-2-related symptomatology. The only covariate significantly associated with seroconversion was the use of an open latrine. Predictive margins showed that these individuals were 2.5 times more likely to be infected (95% C.I.: 1.03-6.1) than those using a flushing toilet. Therefore, along one month, approximately 8% of seronegative individuals became infected, even after almost half of the population was already seropositive. Nevertheless, a smaller proportion of incident cases were symptomatic (21% versus 77% of the earlier cases), and no deaths were recorded. Whether this decreased clinical expression resulted from a lower viral load in new infections cannot be determined. Increased seroconversion in individuals using latrines is consistent with a contributory role of fecal-oral transmission, although we cannot rule out the possibility that latrines are acting as a proxy for poverty or other unknown interacting variables.

Application of the Incident Command System to the Hospital Biocontainment Unit Setting

High-consequence pathogens create a unique problem. To provide effective treatment for infected patients while providing safety for the community, a series of 10 high-level isolation units have been created across the country; they are known as Regional Ebola and Special Pathogen Treatment Centers (RESPTCs). The activation of a high-level isolation unit is a highly resource-intensive activity, with effects that ripple across the healthcare system. The incident command system (ICS), a standard tool for command, control, and coordination in domestic emergencies, is a command structure that may be useful in a biocontainment event. A version of this system, the hospital emergency incident command system, provides an adaptable all-hazards approach in healthcare delivery systems. Here we describe its utility in an operational response to safely care for a patient(s) infected with a high-consequence pathogen on a high-level isolation unit. The Johns Hopkins Hospital created a high-level isolation unit to manage the comprehensive and complex needs of patients with high-consequence infectious diseases, including Ebola virus disease. The unique challenges of and opportunities for providing care in this high-level isolation unit led the authors to modify the hospital incident command system model for use during activation. This system has been tested and refined during full-scale functional and tabletop exercises. Lessons learned from the after-action reviews of these exercises led to optimization of the structure and implementation of ICS on the biocontainment unit, including improved job action sheets, designation of physical location of roles, and communication approaches. Overall, the adaptation of ICS for use in the high-level isolation unit setting may be an effective approach to emergency management during an activation.

Macacine Herpesvirus 1 Antibody Prevalence and DNA Shedding among Invasive Rhesus Macaques, Silver Springs State Park, Florida, USA

We compiled records on macacine herpesvirus 1 (McHV-1) seroprevalence and, during 2015–2016, collected saliva and fecal samples from the free-ranging rhesus macaques of Silver Springs State Park, a popular public park in central Florida, USA, to determine viral DNA shedding and perform sequencing. Phylogenetic analysis of the US5 and US5-US6 intragenic sequence from free-ranging and laboratory McHV-1 variants did not reveal genomic differences. In animals captured during 2000–2012, average annual seroprevalence was 25% ± 9 (mean ± SD). We found 4%–14% (95% CI 2%–29%) of macaques passively sampled during the fall 2015 mating season shed McHV-1 DNA orally. We did not observe viral shedding during the spring or summer or from fecal samples. We conclude that these macaques can shed McHV-1, putting humans at risk for exposure to this potentially fatal pathogen. Management plans should be put in place to limit transmission of McHV-1 from these macaques.

Survey of rabies vaccination status of Queensland veterinarians and veterinary students

BACKGROUND

To determine the rabies vaccination status of Queensland veterinarians and veterinary students and their perception of zoonotic risk from Australian bat lyssavirus (ABLV).

DESIGN

Cross-sectional questionnaire surveys.

METHODS

Questionnaires were sent by post in 2011 to veterinary surgeons registered in Queensland, to final-year veterinary students at James Cook University via SurveyMonkey® in 2013 and to final-year veterinary students at James Cook University and University of Queensland via SurveyMonkey® in 2014.

RESULTS

The response rate for registered veterinarians was 33.5% and for veterinary students 33.3% and 30% in 2013 and 2014, respectively. Of the 466 registered veterinary surgeons, 147 (31.5%) had been vaccinated, with 72 (15.5%) currently vaccinated. For veterinary students the rabies vaccination rate was 20.0% (4/20) and 13.0% (6/46) in the 2013 and 2014 surveys, respectively. More than 95% of veterinary students had received the mandatory Q fever vaccine. Both veterinarians and students regarded bats and horses as high-risk species for zoonoses.

CONCLUSIONS

Queensland veterinarians and veterinary students have low levels of protection against ABLV. Although incidents of ABLV spilling over from a bat to a domestic mammal are likely to remain rare, they pose a significant human health and occupational risk given the outcome of infection in humans is high consequence. Principals of veterinary practices and veterinary authorities in Australia should implement a policy of rabies vaccination for clinical staff and veterinary students.

Management of arthropod vector data - Social and ecological dynamics facing the One Health perspective

Emerging infectious diseases (EIDs) are spread by direct and/or indirect contacts between a pathogen or parasite and their hosts. Arthropod vectors have evolved as excellent bloodsuckers, providing an elegant transportation mode for a wide number of infectious agents. The nature of pathogen and parasite transfer and the models used to predict how a disease might spread are magnified in complexity when an arthropod vector is part of the disease cycle. One Health is a worldwide strategy for expanding interdisciplinary collaborations and communications in all aspects of health care for humans, animals and the environment. It would benefit from a structured analysis to address vectoring of arthropod-borne diseases as a dynamic transactional process. This review focused on how arthropod vector data can be used to better model and predict zoonotic disease outbreaks. With enhanced knowledge to describe arthropod vector disease transfer, researchers will have a better understanding about how to model disease outbreaks. As public health research evolves to include more social-ecological systems, the roles of society, ecology, epidemiology, pathogen/parasite evolution and animal behavior can be better captured in the research design. Overall, because of more collaborative data collection processes on arthropod vectors, disease modeling can better predict conditions where EIDs will occur.

Difficulties experienced by veterinarians when communicating about emerging zoonotic risks with animal owners: the case of Hendra virus

BACKGROUND

Communication skills are essential for veterinarians who need to discuss animal health related matters with their clients. When dealing with an emerging zoonosis, such as Hendra virus (HeV), veterinarians also have a legal responsibility to inform their clients about the associated risks to human health. Here we report on part of a mixed methods study that examined the preparedness of, and difficulties experienced by, veterinarians communicating about HeV-related risks with their clients.

METHODS

Phase 1 was an exploratory, qualitative study that consisted of a series of face-to-face, semi-structured interviews with veterinary personnel from Queensland, Australia (2009-10) to identify the barriers to HeV management in equine practices. Phase 2a was a quantitative study that surveyed veterinarians from the same region (2011) and explored the veterinarians' preparedness and willingness to communicate about HeV-related risks, and the reactions of their clients that they experienced. The second study included both multiple choice and open-ended questions.

RESULTS

The majority of the participants from Phase 2a (83.1%) declared they had access to a HeV management plan and over half (58.6%) had ready-to-use HeV information available for clients within their practice. Most (87%) reported "always or sometimes" informing clients about HeV-related risks when a horse appeared sick. When HeV was suspected, 58.1% of participants reported their clients were receptive to their safety directives and 24.9% of clients were either initially unreceptive, overwhelmed by fear, or in denial of the associated risks. The thematic analysis of the qualitative data from Phases 1 and 2a uncovered similar themes in relation to HeV-related communication issues experienced by veterinarians: "clients' intent to adhere"; "adherence deemed redundant"; "misunderstanding or denial of risk"; "cost"; "rural culture"; "fear for reputation". The theme of "emotional state of clients" was only identified during Phase 1.

CONCLUSION

Warning horse owners about health and safety issues that may affect them when present in a veterinary work environment is a legal requirement for veterinarians. However, emerging zoonoses are unpredictable events that may require a different communication approach. Future training programs addressing veterinary communication skills should take into account the particular issues inherent to managing an emerging zoonosis and emphasise the importance of maintaining human safety. Veterinary communication skills and approaches required when dealing with emerging zoonoses should be further investigated.

Health professionals' experiences of tuberculosis cohort audit in the North West of England: a qualitative study

OBJECTIVES

Tuberculosis cohort audit (TBCA) was introduced across the North West (NW) of England in 2012 as an ongoing, multidisciplinary, systematic case review process, designed to improve clinical and public health practice. TBCA has not previously been introduced across such a large and socioeconomically diverse area in England, nor has it undergone formal, qualitative evaluation. This study explored health professionals' experiences of the process after 1515 cases had been reviewed.

DESIGN

Qualitative study using semistructured interviews. Respondents were purposively sampled from 3 groups involved in the NW TBCA: (1) TB nurse specialists, (2) consultant physicians and (3) public health practitioners. Data from the 26 respondents were triangulated with further interviews with key informants from the TBCA Steering Group and through observation of TBCA meetings.

ANALYSIS

Interview transcripts were analysed thematically using the framework approach.

RESULTS

Participants described the evolution of a valuable 'community of practice' where interprofessional exchange of experience and ideas has led to enhanced mutual respect between different roles and a shared sense of purpose. This multidisciplinary, regional approach to TB cohort audit has promoted local and regional team working, exchange of good practices and local initiatives to improve care. There is strong ownership of the process from public health professionals, nurses and clinicians; all groups want it to continue. TBCA is regarded as a tool for quality improvement that improves patient safety.

CONCLUSIONS

TBCA provides peer support and learning for management of a relatively rare, but important infectious disease through discussion in a no-blame atmosphere. It is seen as an effective quality improvement strategy which enhances TB care, control and patient safety. Continuing success will require increased engagement of consultant physicians and public health practitioners, a secure and ongoing funding stream and establishment of clear reporting mechanisms within the public health system.

The L, M, and S Segments of Rift Valley Fever Virus MP-12 Vaccine Independently Contribute to a Temperature-Sensitive Phenotype

Rift Valley fever (RVF) is endemic to Africa, and the mosquito-borne disease is characterized by "abortion storms" in ruminants and by hemorrhagic fever, encephalitis, and blindness in humans. Rift Valley fever virus (RVFV; family Bunyaviridae, genus Phlebovirus) has a tripartite negative-stranded RNA genome (L, M, and S segments). A live-attenuated vaccine for RVF, the MP-12 vaccine, is conditionally licensed for veterinary use in the United States. MP-12 is fully attenuated by the combination of the partially attenuated L, M, and S segments. Temperature sensitivity (ts) limits viral replication at a restrictive temperature and may be involved with viral attenuation. In this study, we aimed to characterize the ts mutations for MP-12. The MP-12 vaccine showed restricted replication at 38°C and replication shutoff (100-fold or greater reduction in virus titer compared to that at 37°C) at 39°C in Vero and MRC-5 cells. Using rZH501 reassortants with either the MP-12 L, M, or S segment, we found that all three segments encode a temperature-sensitive phenotype. However, the ts phenotype of the S segment was weaker than that of the M or L segment. We identified Gn-Y259H, Gc-R1182G, L-V172A, and L-M1244I as major ts mutations for MP-12. The ts mutations in the L segment decreased viral RNA synthesis, while those in the M segment delayed progeny production from infected cells. We also found that a lack of NSs and/or 78kD/NSm protein expression minimally affected the ts phenotype. Our study revealed that MP-12 is a unique vaccine carrying ts mutations in the L, M, and S segments.

IMPORTANCE

Rift Valley fever (RVF) is a mosquito-borne viral disease endemic to Africa, characterized by high rates of abortion in ruminants and severe diseases in humans. Vaccination is important to prevent the spread of disease, and a live-attenuated MP-12 vaccine is currently the only vaccine with a conditional license in the United States. This study determined the temperature sensitivity (ts) of MP-12 vaccine to understand virologic characteristics. Our study revealed that MP-12 vaccine contains ts mutations independently in the L, M, and S segments and that MP-12 displays a restrictive replication at 38°C.

Emerging and Reemerging Viral Diseases

An emerging infectious disease (EID) is defined as a disease caused by a pathogen that has not been observed previously within a population or geographic location. Viruses are a major cause of EIDs, particularly −ssRNA viruses. Many variables are involved in the emergence or reemergence of viruses. These can be classified into human factors, environmental/ecological factors, and viral factors and include urbanization, globalization, weather and climate change, and the genetic composition of the virus. The great majority of emerging viral diseases are zoonoses, notably transmitted by arthropods and nonhuman mammals. Flaviviruses include several notable vector-transmitted viruses, while rodents and bats are thought to be the natural reservoirs of arenaviruses and filoviruses, respectively. This chapter discusses several notable outbreaks of emerging and reemerging viruses, including the 2014–15 outbreak of Ebolavirus in West Africa.

Management of the slowly emerging zoonosis, Hendra virus, by private veterinarians in Queensland, Australia: a qualitative study

Background

Veterinary infection control for the management of Hendra virus (HeV), an emerging zoonosis in Australia, remained suboptimal until 2010 despite 71.4% (5/7) of humans infected with HeV being veterinary personnel or assisting a veterinarian, three of whom died before 2009. The aim of this study was to identify the perceived barriers to veterinary infection control and HeV management in private veterinary practice in Queensland, where the majority of HeV outbreaks have occurred in Australia.

Results

Most participants agreed that a number of key factors had contributed to the slow uptake of adequate infection control measures for the management of HeV amongst private veterinarians: a work culture characterised by suboptimal infection control standards and misconceptions about zoonotic risks; a lack of leadership and support from government authorities; the difficulties of managing biosecurity and public health issues from a private workforce perspective; and the slow pattern of emergence of HeV. By 2010, some infection control and HeV management changes had been implemented. Participants interviewed agreed that further improvements remained necessary; but also cautioned that this was a complex process which would require time.

Conclusion

Private veterinarians and government authorities prior to 2009 were unprepared to handle new slowly emerging zoonoses, which may explain their mismanagement of HeV. Slowly emerging zoonoses may be of low public health significance but of high significance for specialised groups such as veterinarians. Private veterinarians, who are expected to fulfil an active biosecurity and public health role in the frontline management of such emerging zoonoses, need government agencies to better recognise their contribution, to consult with the veterinary profession when devising guidelines for the management of zoonoses and to provide them with greater leadership and support. We propose that specific infection control guidelines for the management of slowly emerging zoonoses in private veterinary settings need to be developed.

Hendra virus in Queensland, Australia, during the winter of 2011: veterinarians on the path to better management strategies

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We surveyed private equine veterinarians about their use of personal protective equipment when examining healthy, sick and dead horses.

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Practices had official Hendra virus management guidelines and a dedicated field kit available but no standardised management protocols.

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Not all participants used all possible personal protective equipment when attending horses, regardless of health status.

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Personal protective equipment usage increased when the likelihood of a horse being infected with the zoonosis Hendra virus increased.

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Those who had dealt with horses suspected of or were trained in Hendra virus management were more likely to use appropriate protective equipment.

Following the emergence of Hendra virus (HeV), private veterinarians have had to adopt additional infection control strategies to manage this zoonosis. Between 1994 and 2010, seven people became infected with HeV, four fatally. All infected people were at a higher risk of exposure from contact with horses as they were either veterinary personnel, assisting veterinarians, or working in the horse industry. The management of emerging zoonoses is best approached from a One Health perspective as it benefits biosecurity as well as a public health, including the health of those most at risk, in this case private veterinarians. In 2011 we conducted a cross-sectional study of private veterinarians registered in Queensland and providing veterinary services to horses. The aim of this study was to gauge if participants had adopted recommendations for improved infection control, including the use of personal protective equipment (PPE), and the development of HeV specific management strategies during the winter of 2011. A majority of participants worked in practices that had a formal HeV management plan, mostly based on the perusal of official guidelines and an HeV field kit. The use of PPE increased as the health status of an equine patient decreased, demonstrating that many participants evaluated the risk of exposure to HeV appropriately; while others remained at risk of HeV infection by not using the appropriate PPE even when attending a sick horse. This study took place after Biosecurity Queensland had sent a comprehensive package about HeV management to all private veterinarians working in Queensland. However, those who had previous HeV experience through the management of suspected cases or had attended a HeV specific professional education programme in the previous 12 months were more likely to use PPE than those who had not. This may indicate that for private veterinarians in Queensland personal experience and face-to-face professional education sessions may be more effective in the improvement of HeV management than passive education via information packages. The role of different education pathways in the sustainable adoption of veterinary infection control measures should be further investigated.