On Dec. 9, 2019, a University of Wisconsin–Madison researcher was in a biosafety level 3-Ag laboratory suite when their powered air purifying respirator (PAPR) became disconnected for a matter of seconds.
The researcher, who was undergoing training, had been observing two senior scientists collecting nasal samples from ferrets involved in a transmission experiment of H5N1 avian influenza. During a pause in sample collection, when all ferrets were in HEPA-filtered containment cages, the biosafety cabinet had been decontaminated and Tyvek sleeves and outer gloves had been disinfected and changed, the observing scientist and one of the senior scientists noticed the observing researcher’s PAPR hose become detached from its base. The hose, disconnected for a matter of seconds, was immediately reconnected.
The researchers followed the lab’s emergency response procedure, which included immediately communicating what happened to the UW–Madison Responsible Official (RO). The RO notified the Federal Select Agent Program along with UW–Madison’s Biological Safety Officer (BSO).
The researcher was also directed to follow the lab’s quarantine procedure while the RO and BSO gathered the facts of what took place. The RO and BSO consulted with program medical providers, including experts in infectious disease who provided medical clearance, and determined the incident was not an exposure or potential exposure under the criteria set forth by the National Institutes of Health. As a result, it was not immediately reported to the NIH Office of Science Policy. The incident did not result in injury or illness.
They made this determination because all infectious agent was stored away from where the incident took place, infected animals were in HEPA-filtered containment cages, the biosafety cabinet where the sample collection took place had been disinfected and Tyvek sleeves and outer gloves had been disinfected and changed. The detachment was also so brief that the researcher would have continued to breath the filtered air still present in their PAPR.
Nonetheless, the lab voluntarily shared the incident with the project funding agency and took part in ongoing discussion about the incident with the Federal Select Agent Program and the NIH Office of Science Policy (NIH-OSP). Upon recommendation in late January from NIH-OSP, UW–Madison submitted a report of the incident to that agency on Feb. 10, 2020. In response to the report, UW–Madison received an email from NIH-OSP on March 27, 2020 that said, “the actions taken in response to this incident appear appropriate”. There was no further communication from NIH-OSP to the university about its approach to the incident.
UW–Madison followed approved emergency and reporting procedures in the wake of the incident, and the ongoing collaboration between the university and federal regulatory and oversight agencies illustrates the multiple layers of protection governing this kind of research. The laboratory and RO have reviewed the laboratory’s training and SOPs. Researchers have been reminded of the importance of checking PAPR connections, which has subsequently been emphasized during annual hands-on refresher trainings. The university continues to follow its institutional and federal oversight requirements and takes seriously the safe conduct of research involving pathogens.
View the incident report. (PDF)