REVIEW

published: 28 April 2015

doi: 10.3389/fbioe.2015.00056

Biological risks and

laboratory-acquired infections: a
reality that cannot be ignored in
health biotechnology
Ana Cludia Coelho * and Juan Garca Dez

Department of Veterinary Sciences, Veterinary and Animal Science Center (CECAV), School of Agrarian and Veterinary
Sciences, University of Trs-os-Montes e Alto Douro, Vila Real, Portugal

Edited by:
Advances and research in biotechnology have applications over a wide range of areas,
Nisreen DaifAllah AL-Hmoud, such as microbiology, medicine, the food industry, agriculture, genetically modified organ-
Princess Sumaya University for
isms, and nanotechnology, among others. However, research with pathogenic agents,
Technology, Jordan
such as virus, parasites, fungi, rickettsia, bacterial microorganisms, or genetic modified
Reviewed by:
Kavita M. Berger, organisms, has generated concern because of their potential biological risk not only
American Association for the for people, but also for the environment due to their unpredictable behavior. In addition,
Advancement of Science, USA
Johannes Rath,
concern for biosafety is associated with the emergence of new diseases or re-emergence
University of Vienna, Austria of diseases that were already under control. Biotechnology laboratories require biosafety
Dana Perkins,
measures designed to protect their staff, the population, and the environment, which
US Department of Health and Human
Services, USA may be exposed to hazardous organisms and materials. Laboratory staff training and
*Correspondence: education is essential, not only to acquire a good understanding about the direct handling
Ana Cludia Coelho, of hazardous biological agents but also knowledge of the epidemiology, pathogenicity,
Department of Veterinary Sciences,
Veterinary and Animal Science Center and human susceptibility to the biological materials used in research. Biological risk can be
(CECAV), School of Agrarian and reduced and controlled by the correct application of internationally recognized procedures
Veterinary Sciences, University of
such as proper microbiological techniques, proper containment apparatus, adequate
Trs-os-Montes e Alto Douro (UTAD),
P.O. Box 1013, Vila Real 5001-801, facilities, protective barriers, and special training and education of laboratory workers. To
Portugal avoid occupational infections, knowledge about standardized microbiological procedures
[email protected]
and techniques and the use of containment devices, facilities, and protective barriers is
necessary. Training and education about the epidemiology, pathogenicity, and biohazards
Specialty section:
This article was submitted to of the microorganisms involved may prevent or decrease the risk. In this way, the
Biosafety and Biosecurity, a section of scientific community may benefit from the lessons learned in the past to anticipate future
the journal Frontiers in Bioengineering
and Biotechnology
problems.
Received: 21 November 2014 Keywords: biological risks, biosafety, biotechnology, laboratory-acquired infections, health
Accepted: 10 April 2015
Published: 28 April 2015
Citation:
Introduction
Coelho AC and Garca Dez J (2015)
Biological risks and Health biotechnology and bioengineering have recently undergone major advances in both human
laboratory-acquired infections: a
and animal medicine. They involve the study and manipulation of modified living organisms,
reality that cannot be ignored in health
biotechnology.
genetically modified organisms (GMOs), transgenic plants, animals or microorganisms, and the
Front. Bioeng. Biotechnol. 3:56. production of vaccines carried out in special laboratories with different biosafety and biosecurity
doi: 10.3389/fbioe.2015.00056 levels according to the pathogenicity of the organisms under study (Mattiasson, 2013) Since

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Coelho and Garca Dez Laboratory-acquired infections in health biotechnology

microorganisms and GMOs may be harmful or pathogenic to ani- promotes biosecurity by establishing rules and procedures for the
mals and humans, the possibility of enhanced virulence through safe transfer, handling, and use of GMOs (McKenzie and Ascen-
genetic manipulation or increased drug-resistance, among other cio, 2003). Since biotechnology could be a potential threat to the
routes, implies putting specific biosafety and biosecurity proce- population, the Biological Weapons Convention a multilateral
dures in place. To guarantee public health, every possible scenario disarmament treaty focused on the prohibition of biological and
of an outbreak arising through the release of a bio-hazard into the toxins weapons (Millett, 2006; Bakanidze et al., 2010) recognized
environment cannot be neglected (Nordmann, 2010). the application of biosafety and biosecurity measures as tools to
Biosecurity includes a set of preventive measures that vary prevent the development, acquisition, or use of biological and/or
according to the organisms which are under study. Biosafety toxins weapons. Biotechnology investigations have developed a
and biosecurity are terms which are frequently referred to with wide range of powerful tools and processes to improve human and
similar meanings in the literature. While the differences between animal health. Good laboratory practices regarding biosafety and
the two concepts have been specified academically, in practice, bioethics are essential measures to avoiding LAIs. Some publica-
when one is actually working hands-on in a laboratory it is more tions have evaluated the effectiveness of biosafety and biosecurity
difficult to draw such distinctions as referred by Daoust-Maleval measures in traditional laboratories (Kimman et al., 2008; Nasim
(2011). Moreover, Bakanidze et al. (2010) indicates that concepts et al., 2010). Monitoring laboratory infections is one of the most
of biosafety and biosecurity include several control measures that important methods of evaluating the effectiveness of containment
may overlap each other. To avoid misunderstanding, biosafety measures (McLean et al., 2002).
includes all the prevention measures carried out to avoid the infec-
tion with pathogenic organisms and/or toxins and their release to
the environment (OMS). In the other hand, biosecurity is referred Biological Risk Classification
to all the preventive measures to avoid or reduce the risk of trans-
Pathogenic microorganisms represent only a small proportion of
mission of infectious diseases in crops and livestock, quarantined
the biological hazards of concern in laboratory investigations.
pests, or GMOs (Baltz et al., 2010). The objective of this review
Their control importance is based on their potential threat to
is to highlight the main risks associated with biological investi-
humans, animal populations, and also agriculture. In addition,
gation in laboratory, the potential laboratory-acquired infections
they can be responsible for large-scale infections with huge eco-
(LAIs) by laboratory personnel, and suggested recommendations
nomic costs and environmental consequences (Bosia, 2008).
to avoid them.
In addition, new viruses are constantly emerging that threaten
the lives of humans and animals. All laboratory staff who work
Biotechnology in Health and Biosafety with biological samples are exposed to a number of infectious
materials and subject to risk from clinical specimens and cultures.
Advances and research in biotechnology have applications over Since hazardous agents can be transmitted in the laboratory by
a wide range of areas, such as microbiology, medicine, the food inhalation, inoculation, or through the skin, among others, it
industry, waste management, agriculture, GMOs, and nanotech- is necessary to know the characteristics of the agents in study
nology, among others (Thompson, 2007; Baltz et al., 2010; Bennett according to their risk to the health of laboratory staff, and to
et al., 2013). the human and animal population in case of an outbreak (Corrao
Biosafety cuts across different human and veterinary science. et al., 2012).
The first infectious diseases acquired in a laboratory were reported The World Health Organization (WHO) developed a system
at the time of Pasteur and Koch in 1890. However, several decades to classify microorganisms based on their danger to laboratory
passed before the connection between human diseases and the staff and the public (World Health Organization (WHO), 2004).
handling of pathogenic microorganisms was understood (Sulkin, Biological agents of risk group 1 include those unlikely to cause
1961; Traxler et al., 2013), and the implementation of protective disease in man, biological agents of risk group 2 include those that
measures against biological risks in humans was reported in the can cause disease in humans and pose a danger for workers with
literature (Sulkin, 1961; Pike, 1978; Collins and Kennedy, 1998). little chance of spreading among them or to the community. In
The first safety measures in microbiology laboratories that work addition, there is prophylaxis and effective treatment available to
with pathogenic microorganisms were implemented in North the community. Biological agents of risk group 3 include those that
America and the United Kingdom at the beginning of the 1970s. can cause serious illness in humans, represent a serious danger to
These measures included laboratory training and education about workers with risk of spreading to the community, and there is an
the correct use of personal protective equipment and physical effective treatment or prophylaxis. Finally, the biological agents of
containment measures designed to limit the potential spread of risk group 4 include those that can cause severe disease in humans
biological agents (Frommer et al., 1989). After that, safety mea- and represent a serious danger to workers, with likelihood of being
sures were applied in laboratories that work with GMOs. One spread to the community and there is usually no effective prophy-
of the most important considerations in the development and laxis or treatment (World Health Organization (WHO), 2004).
application of biotechnology is the maintenance of both biosafety However, there are other biological risk classifications by coun-
and biosecurity measures at high levels. The Cartagena Protocol try, based mainly on national policies. In the European Union,
on Biosafety is an international regulation of the use of GMOs Directive 2000/54/EC (2000) on the protection of workers from
resulting from modern biotechnology. This agreement, which risks through exposure to biological agents, the agents are classi-
focuses specifically on the transboundary movement of GMOs, fied into four risk groups based on the risk level of infection. In the

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Coelho and Garca Dez Laboratory-acquired infections in health biotechnology

United States, biological hazards are also classified into four risk (Casadevall and Imperiale, 2014). While GOF is associated with
groups, from minimal hazard (risk group 1) to those responsible the acquirement of a new activity or the enhancement, a previ-
for very serious diseases (risk group 4), as described by the Centers ous function, DUR, is associated with a misuse of science (Suk
for Disease Control and Prevention (CDC) (Center for Disease et al., 2011; Duprex et al., 2015). Research with highly pathogenic
Control and Prevention (CDC), 2009). In other countries such as microorganisms, like H5N1 influenza, anthrax among others,
Canada or Australia, pathogenic agents are also classified into four could derive into a serious biological threat to a population or
risk groups (NZS, 2002; PHAC, 2013). even terrorism (Resnik, 2010; Lipkin, 2012). Epidemics of pan-
Taking into account the pathogenic effects to humans and demic proportions or improved previous research to develop bio
the potential danger to the environment, the classification of weapons could be an uncontrollable risk for a population. As a
pathogenic agents as well as their containment measures should result, both GOF research and DUR must be regulated with strong
be undertaken with a single goal: to reduce all potential risks biosafety measures, restricted research, and specific policy as was
(Kimman et al., 2008). Moreover, investigation with infected recently discussed in Germany (Karberg, 2014).
transgenic animals that carry the genes of an infectious agent must
be subjected to a proper risk evaluation and also subject to correct
Vectors used in Gene Therapy
handling with specialized containment facilities and equipment.
Gene therapy, in vivo and ex vivo, use vectors classified as viral
The specialized containment can address the risks of aerosolized
or non-viral, which express the gene or genes of therapeutic
particles, such as in studies of tuberculosis or lymphocytic chori-
interest. Non-viral vectors include liposomes, naked DNA, and
omeningitis, and animals such as poultry infected with influenza
DNA-protein complexes (Doblhoff-Dier and Collins, 2001), while
(World Health Organization (WHO), 2004; OIE, 2012; Shinnick
viral vectors derived from viruses that are attenuated in order to
and Gilpin, 2012).
prevent destructive infection in target tissues. Non-viral vectors
are preferred from the biosafety point-of-view, although they are
Biological Risks to Health in Biotechnology less efficient than viral. Thus, viral vectors are usually used to avoid
Laboratories this disadvantage. The expression of the information encoded
in genes leads to functional modification of infected cells, and
There are many biological risks in health biotechnology, such the evaluation of these modifications are extremely complex and
as bacteria, viruses, rickettsiae, fungi, and parasites (Liberman incomplete when the modified cells belong to the host. The safety
et al., 1990; World Health Organization (WHO), 2004). Regard- of gene therapy vectors has been the focus of regulatory attention
ing biosafety and biosecurity in biomedical laboratories, there is by committees. They are required to assess the proportionality
great concern about new vaccines, diagnostic tools, or therapeutic between the magnitude of the risks and potential therapeutic
agents, some of which are made by genetic engineering (Doblhoff- benefits, as well as to monitor the occurrence of risks in the
Dier and Collins, 2001). Currently, a main concern of biosafety experiment once they have been approved (Verma and Somia,
is due to the emergence of new diseases or the re-emergence of 1997). Biosafety in laboratories with gene therapy manufacture
diseases that were already under control (Brown, 2004; Jones et al., must consider the staff and the patients that may be in contact. In
2008). In laboratories, there are many tasks that involve numerous addition, a comprehensive risk assessment of viral vectors must be
risks to the laboratory staff. Thus, any incident associated with a carried out.
given microbiological hazard is probably most likely to happen in Ideally, viral vectors should be designed only to act as trans-
a microbiology laboratory. However, incidents are not associated porters of the exogenous genetic material to avoid the develop-
to a single factor but the interaction of several of them (Sewell, ment of new replicative viral particles in transduced cells. Thus,
1995; Kozajda and Szadkowska-Stanczyk, 2010). it is understood that a viral vector cannot make any escape or
In the near future, advances in microbiology associated with reversion in virulent forms. The biohazard of these vectors is
biotechnology will increase the knowledge of viroids, viruses, and determined by their own biological risk to the laboratory staff, by
bacteria cells that carry novel genetic material, which has been the environment of the exogenous genes they carry and also by
modified or constructed through genetic engineering. Thus, new the tropism of the recombinant virus (Doblhoff-Dier and Collins,
concerns in biosecurity and environmental health will emerge. 2001).
Currently, there is an urgent demand for new vaccines against Gene therapy, due to its technical and ethical characteristics,
extremely hazardous pathogens such as Ebola (Levine et al., is regulated by law. In the United States, the National Institutes of
2014). The research will involve the manipulation of pathogenic Health (1999) and the Food and Drug Administration (1998) pub-
microorganisms that could have harmful effects on public health lished several guides to describe the main biosecurity measures
and the environment. To guarantee the biosafety of laboratory with which all laboratories must comply.
staff and the biosecurity measures of the facilities, the intrinsic and Utilization of retroviral vectors must be subjected to a previous
potentially harmful characteristics of all microorganisms under risk assessment. Since they are highly infectious and may infect
study must be identified. and propagate themselves in human cells, they may be considered
Although research in biotechnology is necessary, nowadays as an important biohazard to the laboratory staff (Thomas et al.,
there is a dilemma about the freedom or limitation of these 2003; Anson, 2004).
investigations. Thus, gain-of-function (GOF) research or dual use The principal biosafety concern when working with retro-
research (DUR) have arisen as an important concern, not only viruses is the chance of viruses entering the cells and tissues of lab-
among the scientific community but also among the population oratory personnel through skin lesions or by accident. The closer

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Coelho and Garca Dez Laboratory-acquired infections in health biotechnology

the contact the greater the risk, because retroviral particles are Xenotransplantation
extremely labile and short-lived. Even when using defective retro- Another possible biohazard in biotechnology is associated with
viruses that present a lower risk of infection, laboratory staff must xenotransplantation. This term includes any procedure that
be trained in virology and tissue culture (Le Duc et al., 2008). involves the transplantation, implantation, or infusion of human
Handling of animals infected with retroviruses, especially those cells, tissues, or organs from non-human animals (Yang and
that present a potential human cell risk, need high standards of Sykes, 2007). Nowadays, biotechnology companies develop genet-
biosecurity measures, particularly for avoiding potential animal ically engineered pigs to meet the demand for organs, which
escape and the spread of infection. Additionally, when handling are compatible with humans. Transgenic pigs have been adopted
infected animals extreme caution must be taken to avoid injuries as organ donors rather than primates, because of ethical objec-
through bites, clawing, or scratches. Laboratory staff should only tions to the use of primates (Lambrigts et al., 1998). Moreover,
be allowed to handle infected animals if they have specific training almost all primate species are protected. Since xenotransplanta-
and always under the supervision of a senior (Wolfensohn and tion may imply a potential zoonotical risk, donor animals must
Lloyd, 2013). not carry any potential zoonotical disease, with special care for
Regarding gene therapy, immunomodulation has arisen as immunosuppressed patients (Michaels et al., 1994). Potential
a new trend in biotechnology. It can be defined as therapeu- virus infections associated with xenotransplantation have been
tic procedures aimed at modifying the immune response (Gea- widely discussed by the scientific community (Tacke et al., 2000;
Banacloche, 2006). Research in immunomodulation is focused Fishman, 2014).
on correcting specific diseases or immuno-deficiencies such Furthermore, xenotransplantation has been criticized by the
as HIV, cancer, allergies, or inflammatory diseases among scientific community due to the risk of new viral infections
others. It consists in the hybridization of synthetic genetic with zoonotical characteristics that can infect the population
sequence in the organisms targeted to express or suppress spe- (Boneva and Folks, 2004). Viral infection from pig to human
cific genes in the host. Several oligonucleotides based on DNA cells, and also from xenotransplantation of baboon livers to
or RNA has been used, vaccination being the most effective humans, have been reported (Allan, 1998; Denner, 2008). The
immunomodulatory technique (Gea-Banacloche, 2006). How- DNA of the simian foamy virus (SFV) and the baboon endoge-
ever, the potential biological risk of immunomodulation is asso- nous virus (BaEV) have been observed in many tissues of
ciated with the uncertain hybridization and gene expression in patients. The presence of baboon mitochondrial DNA (evidence
the host, which may cause an adverse effect (Vo et al., 2006). of baboon cells) suggests that baboon leukocytes may carry latent
Thus, the main biosafety concern in the laboratory is associ- or active viral infections (Allan, 1998). Other works suggest
ated with accidental needlesticks that can cause unpredictable that pig endogenous retrovirus (PERV) can infect culture cells
responses in an organism. However, the utilization of oligonu- of human origin, and after completing its life-cycle in human
cleotides sequences of RNAi or siRNA increases the control cells it is able to infect other human cells (Patience et al.,
of the gene expression (Behlke, 2006), and further research is 1997). Because pigs present multiple copies of PERVs, breeding
necessary. PERV-free pigs is almost impossible (Boneva and Folks, 2004;
Denner and Tnjes, 2012).
Vaccines
The manufacture of vaccines based on viral or bacterial recom- Transportation of Infectious and Biological
binants are the most common approaches to live GMO vaccines, Material
and are sources of biological risk in biotechnology laboratories. Transportation and transfer of infectious and biological materi-
Several pathogens, including bacteria like Lactococcus lactis or als is an important biological risk and an occupational risk to
Salmonella Typhymurium have been used in the manufacture staff through improper packaging (Snyder, 2002; Kozajda et al.,
of recombinant vaccines (Robinson et al., 1997; Gomez-Duarte 2013). There are several guidelines concerning the transport of
et al., 1998). Recombinant viral vaccines are manufactured from infectious material (World Health Organization (WHO), 1997).
poxvirus, paramixovirus, adenovirus, or vaccinia virus, among Thus, shipping of biohazard material within and between facilities
others (Rotz et al., 2001). The large-scale manufacture of vac- must be carried out with extreme care. GMOs must be transported
cines, as well as other biological products, should be considered in securely sealed triple package systems to avoid any escape. In
as a potential occupational risk factor. Thus, the training and addition, the primary and secondary package must be previously
education of workers engaged in vaccine manufacture must be decontaminated (World Health Organization (WHO), 2012).
a priority (Doblhoff-Dier and Collins, 2001). There are some These units should ideally be placed within sturdy outer
biosafety guidelines about manufacture of recombinant vaccines, shipping containers. The removal of wastes and by-products
laboratory procedures, exposure of laboratory staff, or advice from genetic engineering labs requires comparable packaging
about outbreak, among others (Doblhoff-Dier and Collins, 2001; and container specifications. Furthermore, pathogenic or infec-
World Health Organization (WHO), 2004). For the most part, tious microorganisms must be wholly contained inside a sealed,
viral vectors for vaccine development have similar biosafety risks unbreakable primary container (World Health Organization
as gene therapy viruses, as we previously described. The major (WHO), 2012). Training and education in packing and ship-
differences in risk are associated with the antigens or immune ping hazardous laboratory material is necessary for all laboratory
enhancing components of the vaccine and challenge experiments staff (Biosafety in Microbiological and Biomedical Laboratories
(Vemula and Mittal, 2010). (BMBL), 2009; World Health Organization (WHO), 2012).

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Coelho and Garca Dez Laboratory-acquired infections in health biotechnology

Biosafety in Research with Experimental animals reports of the infection laboratory or by official investigation. The
Today, research with experimental animals must be carried underreporting of LAIs is widely acknowledged, and is ascribed
out according to specific policies to guarantee their protec- to the negative consequences for a company or authority to which
tion (Biosafety in Microbiological and Biomedical Laboratories the laboratory belongs (Sewell, 1995). On the other hand, several
(BMBL), 2009; Directive 2010/63/EU, 2010). However, their uti- reports about LAIs in traditional laboratories have been published
lization involving the use of hazardous biological agents also in the recent years (Britton et al., 2011; Riyesh et al., 2014).
represents an important biosafety issue. According to the potential The most common routes of infection are inhalation (particu-
risk, facilities at an animal laboratory are classified into three larly by aerosols), percutaneous inoculation (needlestick injuries,
categories as reported by the CDC (Biosafety in Microbiological broken glass injury, and/or animal bites or scratches), direct con-
and Biomedical Laboratories (BMBL), 2009), although several tact between contaminated surfaces (gloves, hands), and mucous
countries also present specific legislation. As previously described, membranes as well as through ingestion for example by smok-
it is necessary to identify the potential hazards associated with the ing, eating, or accidental aspiration through a pipette (Kozajda
animal species and the pathogens used (OIE, 2012). Moreover, it et al., 2013; Traxler et al., 2013).
is important to differentiate the zoonotical agents from the non- The risk assessment of the potential infection of laboratory staff
zonootical pathogens. The first represent a potential threat to the must consider the route of transmission and also the minimal
laboratory staff, whereas non-zoonotical pathogens, transgenic infective dose for humans, which varies according to the route of
animals, or GMOs inoculated in those animals are a threat to the inoculation (Johnson, 2003). The increased risk for microbiology
environment (Peeters, 2011). Although laboratory research with laboratory staff that do research with zoonotical agents has long
experimental animals involves a large variety of pathogenic organ- been recognized. Although LAIs caused by pathogenic bacteria
isms, such as bacteria, virus, parasites, or prions, among others, have been described as the most common, LAIs caused by viruses
reports on laboratory-acquired or zoonotical-acquired infection have arisen nowadays (Singh, 2011).
are scarce. To avoid potential LAIs and/or the escape of animals
used in research, animal facilities must meet specific require- Brucella spp.
ments. Operations with research animals must be carried out in Brucellosis has been reported as one of the most important LAIs
individually ventilated cages that guarantee isolation between ani- (Traxler et al., 2013).
mals and laboratory staff (Peeters, 2011). To improve the biosafety Most infections were acquired through workers being unaware
of the laboratory staff, workers needs to operate with personal pro- of contaminated cultures from clinical cases (Bouza et al., 2005;
tective equipment within facilities with an appropriate biosecurity Knudsen et al., 2013; Dentinger et al., 2014).
level. Moreover, in an animal facility, different types of wastes Brucellosis is still recognized as an important LAI (Knudsen
such as feces, bedding, manure, or carcasses must be appropriately et al., 2013), and outbreaks have been mainly associated with the
removed and processed (Schultz, 2004). improper use of the biological safety cabinets (BSC) and deficient
recognition of Brucella spp. isolated by laboratory staff (Bouza
et al., 2005; Dentinger et al., 2014). Brucella spp. belongs to risk
Laboratory-Acquired Infections group Level 3. In contrast, laboratory-acquired brucellosis is not
The term LAIs refer to all infections acquired through labora- always associated with an occupational accident but due to direct
tory work or laboratory-related activities with or without the contact, contamination of skin, splashing in the mucous mem-
onset of infections, and result from occupational exposure to branes or conjunctivae, or needlestick injuries (Kiel and Khan,
infectious agents (Pike, 1976; Wei et al., 2011). There are only 1993; Ergnl et al., 2004).
a few reports of laboratory acquired infections and accidents There have been reported cases of infections due to eating
with GMOs (Kimman et al., 2008). LAIs can occur in biologi- and drinking near a culture-processing bench, and the lack of
cal facilities such as microbiological or animal facilities during individual protection equipment when handling infectious mate-
research and investigations. In addition, the higher the biosecurity rial (Ergnl et al., 2004; Singh, 2009). Due to scarce reports
level of the laboratory, the stronger the biosafety and biosecurity about laboratory-acquired brucellosis, it is difficult to quan-
measures are. Although LAIs and outbreaks associated with risk tify (Knudsen et al., 2013) and difficult to assess, because of
group 4 are extremely rare, BSL-4 laboratories are necessary to a lack of surveillance and central reporting based mainly on
investigate new emerging diseases or bioterrorism threats (Nisii case reports. Unawareness of the pathogenicity of Brucella spp.
et al., 2013). Identification of a laboratory outbreak is difficult, and and deficient training in regard to handling biohazard materials
therefore training and education is necessary to avoid outbreaks may contribute to new outbreaks (Sam et al., 2012). Further-
(Risi et al., 2010). The determination of the source of infection in more, the low infectious dose of Brucella spp. can cause labora-
a laboratory worker can be difficult, because the etiological agent tory outbreaks that affect the laboratory staff, ranging 30100%
is sometimes present in the laboratory and outside the workplace (Yagupsky and Baron, 2005).
in the population as well.
In addition, LAIs are an important issue in regard to public Mycobacterium tuberculosis
health, because an infected worker could be a transmission risk Early surveys of laboratory acquired tuberculosis found three to
for other people. However, the literature about LAIs is quite nine times greater incidence of Mycobacterium tuberculosis among
scarce (Pike, 1978; Traxler et al., 2013). LAIs still occur, although laboratory personnel than in the general population (Singh, 2009).
comprehensive reports on LAIs are few, and based on internal However, laboratory-acquired tuberculosis is difficult to trace due

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Coelho and Garca Dez Laboratory-acquired infections in health biotechnology

to the environmental distribution of the pathogenic microorgan- Herwaldt, 2001; Kinoshita-Yanaga et al., 2009; Felinto de Brito
isms as well as the chronicity of infection, because infection could et al., 2012). The common route of parasitic LAIs has mainly
happen outside of the workplace (Collins and Grange, 1999). been associated with needlestick injuries, although other causes
The greatest risk of LAI for laboratory personnel who handle M. such as barehanded work or research in the open field have also
tuberculosis is associated with the generation of aerosols. More- been reported (Herwaldt, 2001). Training and education of the
over, M. tuberculosis is also characterized by a low infective dose laboratory staff is necessary to prevent laboratory accidents. Since
for humans (Center for Disease Control and Prevention (CDC), some parasitic diseases are characterized by a long asymptomatic
2009). There are reported cases of M. tuberculosis associated with period, laboratory staff that work with parasites should be tested
inadequate isolation procedures and high volumes of specimens periodically (Herwaldt, 2001). In addition, special cautions must
handled (Kao et al., 1997). To avoid possible LAI by M. tuberculo- be taken for women of childbearing age due to the congenital
sis, mycobacteria must be handled in class II or III BSC (Weinstein transmission characteristics of some protozoan parasites (Lopes
and Singh, 2009). et al., 2012).

LAIs Associated to Other Bacterial Agents Virus

Other bacterial agents have been associated with LAIs with lower Today, virus research is associated with wide applications in
frequency. Among them, Francisella tularensis is a zoonotical biotechnology, such as viral diseases, new vaccines, or GMOs. The
infection, usually presented as an ulceroglandular form but also as potential risk with virus has been previously described regard-
pneumonia. F. tularensis is characterized by its high infectivity via ing vaccine production, GMOs, or xenotransplantation. Research
aerosols and the severity of disease in humans. LAIs by F. tularen- about LAI via virus is scarce, although infections with human
sis have been reported in the literature, and are more frequently immunodeficiency haemorrhagic virus, West Nile Virus, Dengue,
associated with cultures than with clinical material or infected ani- or Marburg virus, among others, have been reported (Barry et al.,
mals (Shapiro and Schwartz, 2002; Singh, 2009). Since antibiotic 1995; Gaidamovich et al., 2000; Center for Disease Control and
therapy treatment presents some adverse effects, a combination of Prevention (CDC), 2002; Britton et al., 2011; Pavlin, 2014; Wei
vaccination and correct biosafety measures has been referred to as et al., 2014). Thus, appropriate biosafety and biosecurity measures,
the most valuable control tool (Lam et al., 2012). immune control strategies, training and education, and specific
Enterobacteriaceae group microorganisms such as Salmonella laboratory facilities are necessary to decrease the potential risk of
or Shigella have been reported as LAIs (Mermel et al., 1997; Baron LAIs and/or viral outbreaks (Lipsitch and Bloom, 2012).
and Miller, 2008). The increasing number of antimicrobial agent-
resistant pathogens may influence these infections. Thus, other Lessons Learned to Apply in the Future
pathogenic bacteria like Clostridium difficile, Escherichia coli, or At regional and international levels, a number of countries have
Klebsiella spp. have been related with LAIs (Coia, 1998; Bouza developed and adopted biosafety guidelines for biotechnology and
et al., 2005). bioengineering laboratories to guarantee the safety and decrease
the risk of an outbreak. Although, several biosecurity guidelines
Neisseria meningitidis and good laboratory practices manuals are available among these
Occupationally acquired meningococcal disease is unusual; how- laboratories, their recommendations and procedures are basically
ever, infection has been reported (Boutet et al., 2001; Sejvar et al., the same. At international level, agencies such as WHO, FAO,
2005; Miller, 2012). Good laboratory practice reduces the risk of OIE, national governments and other international agencies, and
transmission for laboratory workers (Sheets et al., 2014). Thus, biosafety associations published biosafety manuals and guidelines
training and correct handling of cultures in safety cabinets is in collaboration with expert groups to assist developing countries
fundamental because aerosol formation of isolates when working in the publication of their own biosafety manuals. Conferring
on an open laboratory bench could be a source of infection (Sejvar authority to laboratories and project supervisors is essential. Since
et al., 2005; Borrow et al., 2014). standards on biosafety and biosecurity vary according to the
In addition, laboratory personnel must use appropriate per- laboratory, institution, or even among countries (Le Duc et al.,
sonal protective equipment and meningococcal vaccination is rec- 2008; Lipsitch and Bloom, 2012), a homogenization of criteria is
ommended for staff that work with Neisseria meningitides (Sheets necessary to avoid discrepancies. Although the three international
et al., 2014). regulatory regimes, WHO, FAO, and OIE, have their own recom-
mendations, an integrative approach on biosafety and biosecurity
Parasites issues among them could improve the standardization of criteria
Parasitic infections have decreased in recent years. However, they (Sture et al., 2013).
have arisen due to the globalization of trade and travel (Jenkins It is necessary to control the ambient conditions, and the proce-
et al., 2012). Because of the increased interest in parasitic diseases, dures practiced by laboratory staff in the manipulation of genetic
research in both human and veterinary medicine, mainly in the of microorganisms should be in accordance with biosafety and
context of One Health (Oura, 2014), the potential exposure to biosecurity rules for personnel to avoid potential dissemination
parasites in the laboratory probably increases the risk for acquir- to the environment. Identification and characterization of poten-
ing parasitic infections. Parasitic LAIs by malaria, leishmaniasis, tial hazards related with the genetic manipulation techniques or
trypanosomiasis, toxoplasmosis, fascioliasis, or schistosomiasis research for which the risks are still unknown is also necessary.
among others have been reported (Herwaldt and Juranek, 1993; However, responsibilities are also imputed to the researchers,

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Coelho and Garca Dez Laboratory-acquired infections in health biotechnology

since conforming to codes of conduct and awareness of the risks specific pathogen, which is a real problem in a globalized world
and hazards involved are their responsibility. Moreover, institu- (Le Duc et al., 2008; Lipsitch and Bloom, 2012).
tions are also responsible for providing the technical and human Laboratory-acquired infections are still a real threat in tra-
resources required to ensure compliance with all biosafety and ditional microbiology and clinical laboratories. Reports about
biosecurity measures (Hackney et al., 2012). biotechnology and bioengineering laboratory accidents and infec-
Research that involves pathogenic organisms must be carried tions are scarce compared to traditional microbiology and clin-
out in specific facilities with preventive measures and the proper ical laboratory accidents and infections (Kimman et al., 2008).
training of laboratory personnel to avoid LAIs (Fonash, 2001). However, if the prevalence is so high in traditional microbiology
Specific training addressed to pathogenic organisms that are being and clinical laboratories, it indicates that potential infections exist
manipulated and studied must be carried out (Narasimharao, in new technological laboratories. In the near future of genetic
2009). Thus, the Certification Program for Biorisk Manage- science, the demand for new vaccines, antimicrobial drugs, or
ment Professionals proposed by the International Federation of treatments for emergent and re-emergent diseases will involve
Biosafety Associations should be an initial step to standardize new developments in biotechnology, and the risk of biological
the training and education of laboratory staff. In addition, a accidents will potentially increase. Consequently, specific training
proper immune control strategy for the laboratory staff should be and education programs for laboratory personnel in addition
implemented (Rusnak et al., 2004). to proper design and construction of laboratory facilities must
To avoid occupational infections, knowledge of the application be followed to avoid LAI and/or laboratory outbreaks (Mourya
of correct microbiological procedures and techniques and the et al., 2014). The scientific community needs to heed the lessons
use of containment devices, facilities, and protective barriers is learned from the past to anticipate future problems associated with
necessary. biological risks and LAIs.
Most risk group 4 pathogens, including certain arenaviruses
and hendraviruses, are zoonotic agents that often cause severe Acknowledgments
or fatal disease in infected humans (Lipsitch and Bloom, 2012).
Pathogens currently handled at biosafety level for risk group 3 and The work was supported by the strategic research project PEst-
biosafety level for risk group 4 present a serious risk to anyone who OE/AGR/UI0772/2014 financed by the Foundation for Science
works in a laboratory. Laboratories with biosecurity levels for risk and Technology (FCT). This study was supported by the Foun-
group 3 and 4 must conform to the most rigorous safety protocols. dation for Science and Technology of the Portuguese Ministry
Laboratory safety guidelines differ among laboratories, research of Education and Science (FCT Fundao para a Cincia e
institutions, or even by country, with a high heterogeneity in Tecnologia do Ministrio Portugus para a Educao e Cincia) by
the preventive measures and training required for working on a a research grant SFRH/BD/85118/2012 given to the author JGD.

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Wolfensohn, S., and Lloyd, M. (2013). Handbook of Laboratory Animal Management
ducted in the absence of any commercial or financial relationships that could be
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of Infectious Substances and Diagnostic Specimens. Geneva: Copyright 2015 Coelho and Garca Dez. This is an open-access article distributed
WHO/EMC/97/3/EN. under the terms of the Creative Commons Attribution License (CC BY). The use, dis-
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