Assessing Laboratory Risk Level and PEP

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Laboratory Exposures

Once a potential exposure is recognized, the first task is to determine the activities performed that may have led to the exposure. Then identify:

  1. who was in the laboratory during the suspected time(s) of exposure
  2. where they were in relation to the exposure
  3. what they did with the isolates

The identified individuals should be assessed for exposure risk using the descriptions in the three tables below.

Laboratory Risk Assessment and Post-Exposure Prophylaxis (PEP): Minimal (but not zero) Risk
Specimen Handling Exposure Scenario PEP Follow-Up/Monitoring
Routine clinical specimen (e.g., blood, serum, cerebrospinal fluid) Person who manipulates a routine clinical specimen (e.g., blood, serum, cerebrospinal fluid) in a certified Class II biosafety cabinet, with appropriate personal protective equipment (i.e., gloves, gown, eye protection). None N/A
Routine clinical specimen (e.g., blood, serum, cerebrospinal fluid) Person present in the lab while someone manipulates a routine clinical specimen (e.g., blood, serum, cerebrospinal fluid) in a certified Class II biosafety cabinet, or on an open bench where manipulation did not involve occurrence of aerosol- generating events (e.g., centrifuging without sealed carriers, vortexing, sonicating, spillage/splashes). None May consider symptom watch for following  scenarios:
  • Person who manipulates a routine clinical specimen (e.g., blood, serum, cerebrospinal fluid)  on an open bench with or without appropriate personal protective equipment  (i.e.,  gloves,  gown, eye protection), or in a certified Class II biosafety cabinet without appropriate personal protective equipment.
  • Person present in the lab while someone manipulates a routine clinical specimen (e.g., blood, serum,  cerebrospinal  fluid)  on an open bench, resulting in occurrence of aerosol-generating events (e.g., centrifuging without sealed carriers, vortexing, sonicating,  spillage/splashes).
Enriched material (e.g., a Brucella isolate, positive blood  bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) Person who manipulates enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) in a certified Class II biosafety cabinet, with appropriate personal protective equipment (i.e., gloves, gown, eye protection). None May consider symptom watch for following  scenarios:
  • Person who manipulates a routine clinical specimen (e.g., blood, serum, cerebrospinal fluid)  on an open bench with or without appropriate personal protective equipment  (i.e.,  gloves,  gown, eye protection), or in a certified Class II biosafety cabinet without appropriate personal protective equipment.
  • Person present in the lab while someone manipulates a routine clinical specimen (e.g., blood, serum,  cerebrospinal  fluid)  on an open bench, resulting in occurrence of aerosol-generating events (e.g., centrifuging without sealed carriers, vortexing, sonicating,  spillage/splashes).
Enriched material (e.g., a Brucella isolate, positive blood  bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) Person present in the lab while someone manipulates enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) in a certified Class II biosafety cabinet. None May consider symptom watch for following  scenarios:
  • Person who manipulates a routine clinical specimen (e.g., blood, serum, cerebrospinal fluid)  on an open bench with or without appropriate personal protective equipment  (i.e.,  gloves,  gown, eye protection), or in a certified Class II biosafety cabinet without appropriate personal protective equipment.
  • Person present in the lab while someone manipulates a routine clinical specimen (e.g., blood, serum,  cerebrospinal  fluid)  on an open bench, resulting in occurrence of aerosol-generating events (e.g., centrifuging without sealed carriers, vortexing, sonicating,  spillage/splashes).

Laboratory Risk Assessment and Post-Exposure Prophylaxis (PEP): Low Risk
Specimen Handling Exposure  Scenario PEP Follow-Up/Monitoring
Enriched material (e.g., a Brucella isolate, positive blood  bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) Person present in the lab at a distance of greater than 5 feet from someone manipulating enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic  fluid,  placental  products),  on an open bench, with no occurrence of aerosol-generating events (e.g., centrifuging without sealed carriers, vortexing,  sonicating, spillage/splashes). May consider if immunocompromised or pregnant. Discuss with health care provider (HCP).

Note: RB51 is resistant to rifampin in vitro, and therefore this drug should not be used for PEP or treatment courses.

 Regular symptom watch (e.g., weekly) and daily self-fever checks through 24 weeks post- exposure, after last known exposure.
Sequential serological monitoring at 0 (baseline), 6, 12, 18, and 24 weeks post- exposure, after last known exposure.
Note: no serological monitoring currently available for RB51 and B.  canis exposures in humans.

 

Laboratory Risk Assessment and Post-Exposure Prophylaxis (PEP): High Risk
Specimen handling Exposure scenario PEP Follow-Up/Monitoring
Routine clinical specimen (e.g., blood, serum, cerebrospinal fluid) Person who manipulates a routine clinical specimen (e.g., blood, serum, cerebrospinal fluid), resulting in contact with broken skin or mucous membranes, regardless of working in a certified Class II biosafety cabinet, with or without appropriate personal protective equipment (i.e., gloves, gown, eye protection).
  • Doxycycline 100mg twice daily, and rifampin 600 mg once daily, for three weeks.
  • For patients with contraindications to doxycycline or rifampin: TMP-
    SMZ, in addition to another appropriate antimicrobial, should be considered. Two antimicrobials effective against Brucella should be given.
  • Pregnant women should consult their obstetrician.
  • Regular symptom watch (e.g., weekly) and daily self-fever checks through 24 weeks post- exposure, after last known exposure.
  • Sequential serological monitoring at 0 (baseline), 6, 12, 18, and 24 weeks post-exposure, after last known exposure.
Enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) Person who manipulates (or is ≤ 5 feet from someone manipulating) enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products), outside of a certified Class II biosafety cabinet.
  • Doxycycline 100mg twice daily, and rifampin 600 mg once daily, for three weeks.
  • For patients with contraindications to doxycycline or rifampin: TMP-
    SMZ, in addition to another appropriate antimicrobial, should be considered. Two antimicrobials effective against Brucella should be given.
  • Pregnant women should consult their obstetrician.
  • Regular symptom watch (e.g., weekly) and daily self-fever checks through 24 weeks post- exposure, after last known exposure.
  • Sequential serological monitoring at 0 (baseline), 6, 12, 18, and 24 weeks post-exposure, after last known exposure.
Enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) Person who manipulates enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products), within a certified Class II biosafety cabinet, without appropriate personal protective equipment (i.e., gloves, gown, eye protection).
  • Doxycycline 100mg twice daily, and rifampin 600 mg once daily, for three weeks.
  • For patients with contraindications to doxycycline or rifampin: TMP-
    SMZ, in addition to another appropriate antimicrobial, should be considered. Two antimicrobials effective against Brucella should be given.
  • Pregnant women should consult their obstetrician.
  • Regular symptom watch (e.g., weekly) and daily self-fever checks through 24 weeks post- exposure, after last known exposure.
  • Sequential serological monitoring at 0 (baseline), 6, 12, 18, and 24 weeks post-exposure, after last known exposure.
Enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) All persons present during the occurrence of aerosol-generating events (e.g., centrifuging without sealed carriers, vortexing, sonicating, spillage/splashes) with manipulation of enriched material (e.g., a Brucella isolate, positive blood bottle) or reproductive clinical specimen (e.g., amniotic fluid, placental products) on an open bench.
  • Doxycycline 100mg twice daily, and rifampin 600 mg once daily, for three weeks.
  • For patients with contraindications to doxycycline or rifampin: TMP-
    SMZ, in addition to another appropriate antimicrobial, should be considered. Two antimicrobials effective against Brucella should be given.
  • Pregnant women should consult their obstetrician.
  • Regular symptom watch (e.g., weekly) and daily self-fever checks through 24 weeks post- exposure, after last known exposure.
  • Sequential serological monitoring at 0 (baseline), 6, 12, 18, and 24 weeks post-exposure, after last known exposure.

Notes:

  • RB51 is resistant to rifampin in vitro, and therefore this drug should not be used for PEP or treatment courses.
  • No serological monitoring is currently available for RB51 and canis exposures in humans.

Examples of aerosol generating procedures include, but are not limited to:

  • centrifuging without sealed carriers
  • vortexing
  • sonicating
  • accidents resulting in spillage or splashes (e.g., breakage of tube containing specimen)

Other manipulations may require further investigation. These may include:

  • automated pipetting of a suspension containing the organism
  • grinding the specimen
  • blending the specimen
  • shaking the specimen
  • other procedures for suspension in liquid to produce standard concentration for identification (i.e., inclusion of steps that could be considered major aerosol generating activities)
Page last reviewed: April 6, 2018
Content source: Centers for Disease Control and Prevention , National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) , Division of High-Consequence Pathogens and Pathology (DHCPP)